Cluster Randomized Trial: Sun Protection Intervention ‘Clever in Sun and Shade for Preschools’—Effectiveness and Dissemination
Abstract
:1. Introduction
2. Methods
2.1. Trial Design
2.2. Participants
2.3. Interventions
2.4. Measures
Scale | Reliability 1 | Item | Reference |
---|---|---|---|
Sunscreen Use 2 | 0.63 | I put sunscreen on my students when we go outside. | [61] |
I take sunscreen along when we go on field trips. | [61] | ||
I use sunscreen with an UV-protection factor of 30+ for my students. | [61] | ||
I reapply sunscreen on my students every 2 h when we are outside between 11 a.m. and 3 p.m. | [61] | ||
I put sunscreen on myself when I go outside with my students. | (role model) | ||
Sun-Avoidance 2 | 0.34 | My students wear hats or caps when they go outside. | [61] |
My students wear tank tops or halter tops when they go outside. 5 | [61] | ||
My students wear long shorts or skirts when they go outside. | [61] | ||
I take sun shade sails or parasols outside and on field trips so that I can set up shaded areas. | [61] | ||
When I go outside with my students, I keep to shaded areas myself and wear protective clothing. | (role model) | ||
Psychosocial Outcomes | |||
Sunscreen Use Self-Efficacy 3 | 0.62 | I am confident of being able | |
… to properly apply sunscreen on my students. | [61] (task) | ||
… to ensure that my students’ parents support me in the provision or use of sunscreen. | (task) | ||
… to take sunscreen with me on any occasion when my students may be outside. | [61] (maintenance) | ||
… to get more sunscreen for my students whenever necessary. | [61] (maintenance) | ||
Sun-Avoidance Self-Efficacy 3 | 0.58 | I am confident of being able | |
… to ensure that my students’ parents provide them with protective clothing. | (task) | ||
… to decide if an area is sufficiently shaded to protect my students from the sun. | [61] (task) | ||
… to check that my students are wearing protective clothes before they go outside. | [61] (maintenance) | ||
… to provide spare clothes in case the students‘ parents have forgotten suitable clothes. | (maintenance) | ||
Health-Related Outcome Expectancies 3 | 0.74 | Avoiding overexposure to the sun protects from premature skin-aging. | [65] |
Avoiding overexposure to the sun decreases the risk for skin cancer. | [65] | ||
Appearance-Related Outcome Expectancies 3 | 0.58 | Tanning makes me look better. 5 | [37] |
Tanned skin is healthy skin. 5 | [37] | ||
Impediments to Sunscreen Use 3 | 0.78 | Putting on sunscreen on my students takes too much time. | [61] |
Putting on sunscreen on my students is always messy. | [61] | ||
Impediments to Sun-Avoidance 3 | 0.40 | We do not have enough shade from trees, sun-shade sails, or parasols. | |
Preventing students from taking off protective clothing outdoors is difficult. | |||
Necessity of Sun protection 3 | 0.68 | I think it is important to protect oneself from the sun in the following situations … at the beach. … at noon. … on sunny evenings. … on cloudy summer days. … during outdoor sports activities. | [31] |
Sun protection Policy 4 | 0.76 | Is it recorded in writing in the facility concept or other documents, that parents are requested … to bring hats or protective clothing? … to provide sunscreen or if the preschool supplies sunscreen? … to provide a written permission for the use of sunscreen? | [14] |
2.5. Sample Size
2.6. Randomization
2.7. Statistical Methods
3. Results
3.1. Participant Flow
3.2. Recruitment
3.3. Baseline Data
3.4. Outcomes
3.4.1. Program Exposure
3.4.2. Intervention Effects
3.4.3. Dissemination and Implementation of CLEVER
4. Discussion
4.1. Effectiveness
4.2. Dissemination
4.3. Limitations
5. Conclusions
Supplementary Materials
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Acknowledgments
Conflicts of Interest
References
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Type of Measure | Recommendation |
---|---|
Knowledge-related | Educational measures on UV radiation and protective measures in kindergarten/preschools and schools can improve knowledge about sun protection. |
UV-risk communication should address aspects relevant to everyday life, the subjective perception of gain by UV exposure and the ideal of beauty of tanned skin. An important starting point for communication should be social ideals and behavioral routines with regard to tanned skin and sunbathing. | |
The range of media information on skin cancer prevention should be expanded qualitatively and quantitatively, since the media are the most important source of information for adults. | |
Digital media literacy as part of the population’s health literacy should be promoted in order to be able to find, understand, and assess the quality of information on skin cancer and skin cancer prevention in a more targeted manner. | |
Parents with children in kindergarten/preschool as well as educators, teachers, and daycare center/preschool managers should be informed about UV radiation as a risk factor for skin cancer and about the inadequate protective function of clouds against UV radiation. | |
Behavioral | Interventions aimed at influencing behavior over the long term should consist of several components, be intensive, and designed to be repeated. |
Behavioral change interventions should be based on behavioral theories and should take available evidence into account. | |
Measures to convey primary prevention of skin cancer should be multimedia-based as well as interactive and integrate several communication channels. | |
Information can be provided through parents, teachers, educators, peers, and other multipliers. | |
Skin cancer prevention interventions that also address external appearance are a promising strategy for changing sun protection behavior. | |
Measures for primary prevention of skin cancer should be designed with a focus on the target group and take the target group’s needs into account. | |
In order to reach people where they shape their everyday lives, measures for primary prevention of skin cancer should be setting-related. | |
Sun protection interventions for children and adolescents should be conducted in preschools and schools. | |
The UV Index should be more intensively communicated and used in sun protection recommendations and programs. | |
Environmental | A sufficient amount of shaded areas should be provided in kindergartens, preschools, and schools. |
Technical and organizational measures to avoid excessive UV exposure, especially during the midday hours (e.g., provision of shaded areas, consideration of sun protection when scheduling sporting events for example) should be an essential part of primary prevention. | |
Evaluation: Primary skin cancer prevention interventions should be evaluated formatively and summatively. The evaluation parameters used should be derived from a theoretically proven model. |
Scope | Content | Methods for Change |
---|---|---|
Promoting staff’s knowledge, attitudes and behavior | Information about effects of the sun and sun protection recommendations: Background and recommendations on the prevention of skin cancer in children | Tailoring: information designed to meet staff’s stated needs of sun protection measures Facilitation: pointing at barriers to adequate sun protection and advice on overcoming these barriers Persuasive communication: Appeal to staff’s vocational goal of caring for children’s health and well-being Framing: emphasizing risks of inappropriate sun protection Consciousness raising: providing scientific background information about consequences of UV exposure Active learning: presentation of information is combined with opportunities for staff members to discuss experiences and habits |
Group discussion on consequences of excessive UV exposure and tanning attitudes | Discussion: Staff members are encouraged to discuss their attitudes and behavior in an open debate Self-reevaluation: encouraging reflection on knowledge and attitudes | |
Joint planning of suitable sun- protection measures on behavioral and environmental level | Participation: joint discussion assures high level of engagement of staff members, which helps to promote changes in attitudes and behavior (individual level) Goal setting/implementation intentions: discussing and fixing goals and concrete behaviors for sun protection | |
Environmental changes in preschool | Development of an individual sun protection strategy | Participatory problem solving: staff team identifies current sun protection measures and develops a strategy for future measures Structural redesign: staff team reflects on organizational and technical elements that impede sun protection and finds ways to change them Public commitment: sun protection strategy is displayed in preschool, visible for staff and parents |
Providing material for educational measures | Presentation and distribution of the CLEVER project week material | Facilitation: easy-to-use materials reduce barriers to sensitize children for sun protection |
Intervention (n = 146) | Control (n = 127) | |
---|---|---|
Demographic characteristics | ||
Age, mean (SD) | 42.5 (12.43) | 43.7 (12.52) |
Gender, N females (%) | 140 (96.6) | 123 (96.9) |
Education, N (%) | ||
Less than 10th grade | 1 (0.7) | 0 (0.0) |
10th grade | 85 (61.6) | 76 (60.8) |
Higher than 10th grade | 52 (30.2) | 49 (39.2) |
Baseline outcome scores | ||
Behavioral outcomes, mean (SD) | ||
Sunscreen use | 2.40 (0.81) | 2.21 (0.81) |
Sun avoidance | 2.80 (0.51) | 2.82 (0.43) |
Psychosocial outcomes, mean (SD) | ||
Sunscreen use self-efficacy | 3.11 (0.62) | 3.06 (0.73) |
Sun avoidance self-efficacy | 3.03 (0.61) | 3.11 (0.61) |
Health-related outcome expectancies | 3.40 (1.00) | 3.26 (1.08) |
Appearance-related outcome expectancies | 2.50 (0.90) | 2.53 (1.03) |
Impediments to sunscreen use | 0.73 (0.94) | 0.97 (1.23) |
Impediments to sun avoidance | 1.65 (0.92) | 1.41 (1.01) |
Necessity of sun protection | 3.08 (1.07) | 3.07 (0.62) |
Sun protection policy, mean (SD) | 1.50 (1.18) | 1.73 (1.23) |
Scale | Within Group Difference Intervention Group | Within Group Difference Control Group | Between Group Difference in Changes | |||||
---|---|---|---|---|---|---|---|---|
Score Range | Baseline–1 Month Mean (95% CI) 1 | Baseline–1 Year Mean (95% CI)1 | Baseline–1 Month Mean (95% CI)1 | Baseline–1 Year Mean (95% CI) 1 | Mean (95% CI) 1 | Test for Significance | Effect Size Hedges’ dB (95% CI) | |
Behavioral Outcomes | ||||||||
Sunscreen Use | 0–4 | 0.47 (0.25, 0.69) | 0.46 (0.24, 0.68) | −0.01 (−0.40, 0.37) | F(1, 12.6) = 0.01, p = 0.95 | −0.01 (−0.43, 0.40) | ||
Sun-Avoidance | 0–4 | 0.17 (0.05, 0.29) | −0.02 (−0.15, 0.10) | 0.19 (0.02, 0.37) | F(1, 140) = 4.93, p ˂ 0.05 | 0.70 (0.04, 0.71) | ||
Psychosocial Outcomes | ||||||||
Sunscreen Use Self-Efficacy | 0–4 | 0.40 (0.26, 0.54) | 0.08 (−0.07, 0.23) | 0.30 (0.02, 0.57) | F(1, 18.2) = 5.12, p ˂ 0.05 | 0.71 (0.03, 0.88) | ||
Sun-Avoidance Self-Efficacy | 0–4 | 0.29 (0.15, 0.43) | −0.20 (−0.35, −0.05) | 0.49 (0.26, 0.72) | F(1, 9.8) = 22.38, p ˂ 0.001 | 1.09 (0.39, 1.07) | ||
Health-Related Outcome Expectancies | 0–4 | 0.24 (−0.03, 0.52) | 0.39 (0.10, 0.68) | 0.21 (−0.22, 0.65) | F(1, 15.7) = 0.40, p = 0.54 | 0.24 (−0.23, 0.69) | ||
Appearance-Related Outcome Expectancies | 0–4 | 0.01 (−0.21, 0.22) | 0.00 (−0.22, 0.22) | 0.00 (−0.35, 0.36) | F(1, 16.3) = 0.00, p = 0.99 | 0.00 (−0.29, 0.30) | ||
Impediments to Sunscreen Use | 0–4 | −0.17 (−0.37, 0.03) | −0.15 (−0.36, 0.06) | −0.15 (−0.43, 0.13) | F(1,18.2) = 0.00, p = 0.97 | −0.20 (−0.50, 0.15) | ||
Impediments to Sun Avoidance | 0–4 | −0.32 (−0.52, −0.12) | 0.11 (−0.09, 0.32) | −0.43 (−0.72, −0.15) | F(1,141) = 9.27, p < 0.01 | −0.56 (−0.82, −0.17) | ||
Necessity for Sun protection | 0–4 | 0.36 (−0.07, 0.33) | - | 0.23 (0.08, 0.37) | - | 0.14 (−0.09, 0.36) | F(1,18.6) = 1.62, p = 0.22 | 0.35 (−0.14, 0.57) |
Sun protection Policy | 0–3 | 0.72 (0.38, 1.06) | 0.59 (0.26, 0.91) | 0.13 (−0.34, 0.60) | F(1,118) = 0.31, p = 0.58 | 0.08 (−0.26, 0.46) |
Scales and Items | Scale Mean (SD) | Item Median (Range) |
---|---|---|
Behavioral outcomes | ||
Sunscreen Use | 2.31 (0.82) | |
Put sunscreen on students when outside | 3 (4) | |
Take sunscreen along on field trips | 2 (4) | |
Use sunscreen for students UPF 30+ | 4 (4) | |
Reapply sunscreen every 2 h | 2 (4) | |
Put sunscreen on myself when outside with students | 4 (4) | |
Sun-Avoidance | 2.81 (0.47) | |
Students wear hats/caps when outside | 2 (3) | |
Students wear tank tops/halter tops when outside1 | 2 (4) | |
Students wear long shorts/skirts when outside | 2 (4) | |
Set up shaded areas outside and on field trips | 4 (4) | |
Keep to shaded areas themselves and use protective clothing, when outside with students | 3 (4) | |
Psychosocial outcomes | ||
Sunscreen Use Self-Efficacy | 3.09 (0.67) | |
Properly apply sunscreen | 4 (4) | |
Ensure parents support provision/use of sunscreen | 3 (4) | |
Take sunscreen on any occasion | 3 (4) | |
Get more sunscreen when necessary | 3 (4) | |
Sun-Avoidance Self-Efficacy | 3.07 (0.61) | |
Ensure parents provide protective clothing | 3 (4) | |
Decide if area is sufficiently shaded | 4 (4) | |
Check students wearing protective clothing | 2 (4) | |
Provide spare clothes | 4 (3) | |
Health-Related Outcome Expectancies | 3.34 (1.04) | |
Decreased risk for premature skin-aging | 4 (4) | |
Decreased risk for skin cancer | 4 (4) | |
Appearance-Related Outcome Expectancies | 2.51 (0.96) | |
Tanning makes me look better 1 | 2 (4) | |
Tanned skin is healthy skin 1 | 3 (4) | |
Impediments to Sunscreen Use | 1.14 (0.84) | |
It takes too much time | 0 (4) | |
It is always messy | 0 (4) | |
Impediments to Sun-Avoidance | 1.29 (0.88) | |
We do not have enough shade | 0 (4) | |
Preventing taking of protective clothing is difficult | 2 (4) | |
Necessity of Sun protection | 3.08 (0.67) | |
At the beach | 4 (4) | |
At noon | 4 (4) | |
On sunny evenings | 2 (4) | |
On cloudy summer days | 2 (4) | |
During outdoor sports activities | 4 (4) | |
Sun Protection Policy | 1.60 (1.20) | |
Parents are requested to bring hats or protective clothing | 1 (1) | |
Parents are requested to provide sunscreen or preschool supplies sunscreen | 1 (1) | |
Parents are requested to provide permission for the use of sunscreen | 0 (1) |
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Seidel, N.; Fieber, V.; Breitbart, E.W.; Bornhäuser, M.; Stölzel, F. Cluster Randomized Trial: Sun Protection Intervention ‘Clever in Sun and Shade for Preschools’—Effectiveness and Dissemination. Children 2021, 8, 651. https://doi.org/10.3390/children8080651
Seidel N, Fieber V, Breitbart EW, Bornhäuser M, Stölzel F. Cluster Randomized Trial: Sun Protection Intervention ‘Clever in Sun and Shade for Preschools’—Effectiveness and Dissemination. Children. 2021; 8(8):651. https://doi.org/10.3390/children8080651
Chicago/Turabian StyleSeidel, Nadja, Vera Fieber, Eckhard Wilhem Breitbart, Martin Bornhäuser, and Friederike Stölzel. 2021. "Cluster Randomized Trial: Sun Protection Intervention ‘Clever in Sun and Shade for Preschools’—Effectiveness and Dissemination" Children 8, no. 8: 651. https://doi.org/10.3390/children8080651