Background. Excessive sun exposure during childhood has been associated with subsequent development of skin cancers. Children have been advised to avoid sun exposure, use protective clothing, and apply sunscreen lotions, but how completely these recommendations are followed has not been studied.

Objective. To determine the extent of sun protection among children visiting lake beaches, the methods used, and the characteristics associated with more protection.

Design. Direct observations of children were linked with concurrent care giver/parent interviews.

Subjects/Setting. A total of 871 children 2 to 9 years of age and their parents/care givers at freshwater beaches in 10 small New Hampshire towns during July and August 1995.

Outcome Measures. Protection of the head, torso, and legs according to method used (hats, shirts, pants, sunscreen, or shade).

Results. Fifty-four percent of children were protected by at least one method for all three body surface regions, although 17% had no protection for any region. Sunscreen was used either alone or in combination with clothing for at least one region in 79%. Hats were used by 3%, shirts by 22%, and pants to the knee by 49%. Only 12% of observed children were in the shade. The region that was protected most often was the legs for boys (due to swim suit styles) followed by the torso for both sexes. The region most often unprotected was the legs for girls followed closely by the face for both boys and girls. Girls were significantly more likely to have no protection (31.2% female vs 7% male, χ2 83.3) due to better leg protection from swim trunks to the knees popular with boys. Full protection of all three regions was more common for children younger than 5 (odds ratio [OR] = 1.8, 95% confidence interval, [CI] 1.3–2.5), for children perceived to usually or always burn (OR = 2.0, 95% CI 1.4–2.7), for children whose parents had more than a high school education (OR = 1.8, 95% CI 1.3–2.5), and if the parents indicated receiving sun protection information from a school or clinician during the previous year (OR = 1.7, 95% CI 1.2–2.3). Approximately 51.6% of parents recalled receiving childhood solar protection advice in the past year from either their physician, a nurse, or a school/day care setting.

Conclusions. Sunscreen provided the most common form of solar protection. Hats and shade were used rarely, and shirts were also underused. Although the sun protection of these children visiting the beach was substantial, nearly half were still not fully protected. Clinician advice within the past year was associated with better protection. Clinicians could increase their influence by providing more specific counseling about how to achieve full protection. Use of multiple methods of protection rather than just sunscreen and full protection rather than protection for just one or two body regions should be emphasized. It is helpful to remind families to protect the regions most frequently omitted from protection: girls’ legs and boys’ and girls’ faces. Advice can be enhanced with patient education materials such as included in the “Slip” (on a shirt), “Slop” (on sunscreen), and “Slap” (on a hat) program developed in Australia and available through the American Cancer Society. solar protection, skin cancer, primary prevention, preventive health services, counseling, primary health care.

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