ARTICLE
Auteur(s) : Talia Kakourou, Alexandra Klimentopoulou,
George Kavadias, Alexandra Veltsista, Xenofon Krikos, Chryssa Bakoula
First Department of Paediatrics, University of Athens, “Aghia
Sophia” Children’s Hospital, Thivon and Levadias Street, 11527,
Athens, Greece
accepté le 15 Novembre 2005
Greece is a Mediterranean country with a very warm climate during
the summer and a mild winter. Taking into consideration the
mounting evidence about the risks of UV exposure, including skin
cancer and premature ageing, appropriate sun protective measures
are necessary all year round [1, 2]. Both adults and children can
benefit from protection against sunburn, although most forms of
skin cancer are associated with sunlight exposure during childhood
[3, 4]. There are indications that more than 80% of an individual’s
exposure to UV in a lifetime occurs before 18 years. Therefore,
childhood sunscreen use is essential, for children are more
susceptible to UV damage. Sunscreen use by children decreases the
risk of non-melanoma skin cancer by 78% [5].A survey conducted in
1993 on Greek children’s sun protection behaviour and their
mothers’ sun awareness showed rather disappointing results. Only
63.7% of the children and 52.5% of the mothers always applied
sunscreen while on the beach. More than 90% of the participants did
not reapply sunscreen after swimming and over 60% did not avoid the
sun between 11 a.m. and 3 p.m. [6].This raised a challenge for
community efforts and educational activities to inform and guide
the public, in an aim to educate them on the hazardous effects of
the sun and promote sun protective measures. Mass media campaigns
have often been used in public health programmes with positive
results, although evaluation of this association is often difficult
[7]. In particular, countries with year round sunshine ought to
continuously examine the trends in sun protection in order to
potentially provide a clearer understanding of the contribution of
the campaigns conducted and aid in the establishment of future
preventive measures. Nonetheless, current sun protective practice
and the impact of such efforts remain unknown for many countries,
including Greece.The purpose of this study was to present and
compare the level of Greek mothers’ sun awareness, as well as
mothers’ and their children’s sun protection behaviour during a
period from 1993 to 2002 and to examine possible associations
between them.
Methods
Participants
The study population consisted of a random sample of children and
their mothers visiting the outpatient department of the ‘Aghia
Sophia’ Children’s Hospital in Athens during two survey years (1993
and 2002). The participants in both surveys were selected from one
out of three consecutive visitors to the above department [6].
Prior to acceptance, the parents and their children were fully
informed about the objectives and methods of the study. They gave
their verbal consent. For reasons of comparison, care was taken so
that all procedures in 2002 closely matched those in 1993 [6]. A
total of 295 mothers and their 491 children (56% boys, 44% girls,
mean age ± SD: 6.6 ± 3.7 years) comprised the 2002 study
population. The individuals in 1993 were 315 mothers and their 649
children (56% boys, 44% girls, mean age ± SD: 6.2 ± 4.3 years) [6].
The study was approved by the Scientific Committee of the
participating hospital.
Data collection
In both surveys the mothers completed a standardized questionnaire
during interviews conducted at the outpatient department of the
hospital. The interviewers were appropriately trained and followed
a written protocol to ensure consistency between data collection.
The questionnaire consisted of three sections. The first section
assessed parents’ and children’s demographic data (age, sex, place
of residence). The second section aimed to assess sun knowledge
using questions corresponding with maternal awareness of sun risks.
Finally, the third section assessed mothers’ and children’s
attitudes and behaviour in the sun. Table 1( Table 1 ) sets out the questions used to define
maternal sun awareness and maternal and children’s sun protection
practices.
Table 1 Definition of questions used to assess
sun-related knowledge and sun protection practice
|
Main category
|
Questions
|
|
Sun related knowledge
|
- Is excessive sunlight exposure hazardous to the skin or not?
|
|
- What are the harmful effects of sunlight on the skin?
|
|
- What protective measures should be taken?
|
|
- What does the sun protective factor of a sunscreen indicate?
|
|
- Does 11am-3pm in summer have the greatest hazard of sunlight
exposure?
|
|
Sun-protection practice
|
- Do you use a sunscreen? When and how often?
|
|
- What time do you usually go to the beach?
|
|
- What is your schedule of sunscreen use while on the beach?
|
|
- How long before exposure, on which parts of the body,
reapplications, etc?
|
|
- What other sun-protective measures do you take when on the beach
and when outdoors, but not on the beach?
|
Statistical analysis
Background differences between both populations were examined by
unpaired t-test and χ2-test of independence.
Distributions of the positive responses across the questionnaire
are reported as proportions (%) and were analysed by the
nonparametric χ2-test.
A total index score was calculated from the participant’s
responses to the questions assessing sun knowledge and sun
protection practice. The value given to each response was based on
the current knowledge of sun exposure effects and the sun
protection practice recommendations [8, 9]. ‘Correct’ responses
were given one point, while failure to answer and ‘incorrect’
responses gained no points. The responses concerning mother’s sun
knowledge, maternal sun protection practice and children’s sun
protection practice were grouped separately. The internal
consistency of each of the above groups was examined with the
Cronbach a value and was satisfactory (0.65 for mothers’ knowledge,
0.73 for mothers’ practice and 0.27 for children’s practice). The
index score was adjusted for the number of items used to assess
knowledge (10 items) and protection practice (8 items for mother
and her children), so as the maximum value for rating each group
was ten. Five levels were computed varying from ‘poor’ (score 1-2),
‘moderate’ (score 3-4), ‘good’ (score 5-6), ‘very good’ (score 7-8)
to ‘excellent’ (score 9-10).
Since the participants differed in both surveys, we were unable
to link responses in 1993 and 2002. Therefore, the distributions
across the five levels of sun knowledge and sun protection practice
were analysed by the nonparametric χ2- test of
independence.
Finally, the association between mother’s knowledge and sun
protection performance was examined for each survey using
nonparametric Spearman rank order correlation coefficient.
Statistical significance was set at p < 0.05. The statistical
analysis data was carried out using SPSSv10 for Windows.
Results
Characteristics of the two study populations
The characteristics of the groups investigated are reported in
table 2( Table 2 ). No significant
differences were observed between individuals who participated in
the present study and those who participated in 1993 in terms of
gender, maternal and children’s age, maternal education and place
of residence (table 2).
Table 2 Characteristics of participants in both
surveys
|
Year of data collection:
|
1993
|
2002
|
|
|
(mothers/ children)
|
(315/649)
|
(295/491)
|
p-value
|
|
Children’s gender (M/F)
|
363/286
|
275/216
|
0.98
|
|
Maternal age (years)*
|
32.5 ± 5.6
|
31.3 ± 6.7
|
0.18
|
|
Children’s age (years)*
|
6.2 ± 4.3
|
6.6 ± 3.7
|
0.09
|
|
Mother’s education (%)
|
|
|
0.17
|
|
< 10 years
|
42.2
|
49.2
|
|
|
10-12 years
|
32.6
|
30.8
|
|
|
≥ 13 years
|
25.2
|
20.0
|
|
|
Urban residence (%)
|
81.5
|
90.0
|
0.80
|
Sun knowledge
A statistically significant higher proportion of mothers in 2002
were aware of the hazards of sun exposure. Table 3( Table 3 ) shows that more mothers in 2002 compared
to 1993 reported that excessive sun exposure may cause skin cancer
(90.5% versus 66%, p < 0.001), sunburn (95.7% versus 23%, p <
0.001) and premature aging of the skin (17.8% versus 5%, p = 0.004)
and that the hazard of sunlight exposure is higher between 11 am-3
pm (97% versus 40%, p < 0.001). In contrast, only 25% knew what
the sun protective factor (SPF) on sunscreen containers indicates
(table 3).
Table 3 Percentages of mothers’ ‘correct’ responses to
questions that assessed sun knowledge in both surveys
|
Year
|
1993 N (%)
|
2002 N (%)
|
p-value*
|
|
Excessive sun exposure may cause
|
|
Skin cancer
|
208 (66.0)
|
267 (90.5)
|
< 0.001
|
|
Sunburn
|
72 (23.0)
|
282 (95.7)
|
< 0.001
|
|
Premature aging of the skin
|
16 (5.0)
|
53 (17.8)
|
0.004
|
|
Sun protective measures that should be taken
|
|
Sit in the shade
|
247 (78.3)
|
273 (92.5)
|
0.005
|
|
Wear sunscreen
|
155 (49.2)
|
273 (92.5)
|
< 0.001
|
|
Wear sunglasses
|
54 (17.0)
|
253 (85.8)
|
< 0.001
|
|
Wear suitable clothing
|
30 (9.6)
|
159 (53.8)
|
< 0.001
|
|
What SPF indicates
|
74 (23.6)
|
74 (25.0)
|
0.647
|
|
Hazard of sunlight exposure in summer is greatest between
11 a.m.-3 p.m.
|
126 (40.0)
|
286 (97.0)
|
< 0.001
|
Sun protection practice
In 2002 compared to 1993, there was a statistically significant
improvement in six out of nine items assessing mothers’ practice of
sun protection and in seven out of 13 items assessing children’s
behaviour under the sun.
Generally reported sunscreen use during the previous summer did
not differ significantly between both surveys. Yet, more mothers
(66.5% versus 52.5%, p < 0.001) and children always applied
sunscreen while on the beach (83.9% versus 63.7%, p < 0.001).
Reapplication of sunscreen after swimming was significantly higher
in 2002 for both mothers (69.7% versus 8.6%, p < 0.001) and
children (80.6% versus 10%, p < 0.001), while the rates of
remaining at the beach between 11 a.m. and 3 p.m. were
significantly lower among mothers (8.8% versus 64.3%, p < 0.001)
and their children (8.4% versus 64.3%, p < 0.001) in 2002 ((
figure 1 )).
In 2002 significantly more children sat in the shade, while
playing on the beach, than in 1993 (40% versus 21.6%, p <
0.001). The respective differences for wearing a hat (49% versus
44%, p = 0.09), a T-shirt (4% versus 3.4%, p = 0.54), or both (7%
versus 6%, p = 0.53), failed to reach statistical significance.
Finally, sun protective measures during other outdoor activities
among all participants were significantly higher in 2002, except
for the use of suitable clothing (( figure 2 )).
Index scores
The ( figure 3 )
shows that significantly more mothers in 2002 had ‘good’ (58.9%
versus 16%) and ‘excellent’ (28% versus 6%) levels of sun
knowledge, as determined by the index score (p < 0.001). In
addition, mothers’ and children’s sun protection practice were also
significantly improved in 2002 compared to 1993 (p < 0.001). 40%
of the mothers and children (versus 27% and 30% each in 1993) had
‘good’ levels of sun protection practice, while 28% of the mothers
and 26% of the children (versus none in 1993) reported ‘excellent’
levels (( figure
3 )).
Association of sun knowledge and sun protection practice
Correlation analysis for levels of knowledge and sun protection
practice revealed significant positive associations (p < 0.001).
The relationship between mothers’ knowledge and her protection
practice was higher in 2002 than in 1993 (rs = 0.457, p < 0.001
versus rs = 0.26, p < 0.001). The association of mothers’
knowledge with children’s sun protection practice was slightly
higher in 2002 (rs = 0.363, p < 0.001 versus rs = 0.296, p <
0.001). The association between mothers’ and children’s sun
protection practice was slightly lower in 2002 (rs = 0.771, p <
0.001 versus rs = 0.85, p < 0.001).
Discussion
Greek mothers’ awareness of sun exposure highly improved from 1993
to 2002. In the latter year, more than 90% of the mothers knew that
excessive sun exposure may cause skin cancer and sunburn. However,
the proportion who knew that it causes photo-ageing or that
suitable clothing is an effective sun protective measure continued
to be very low (table 3). In addition, 75% of mothers did not know
what the sun protective factor (SPF) on a sunscreen container
indicates, which, by comparison to a 35% rate reported in a Swedish
adult population, demonstrates a considerable lack of information
[10]. Therefore, our observations indicate that, although Greek
mothers’ sun knowledge may have broadened from the 1990s to 2002,
it is unlikely to be sufficient and efforts must be continued.
Surprisingly, about one out of three mothers do not use
sunscreens as recommended. While sunscreen use was high (81.8%),
only 66.5% always applied sunscreen while on the beach and only
69.7% reapplied sunscreen after swimming. This finding implies that
Greek women have a positive attitude towards sunbathing, a finding
consistent with those for other adult women [10, 11]. Cultural
influences in modern Western society often lead women to expose
themselves to excessive UV radiation in order to obtain an
unrealistic tan during the summer. This behaviour, however,
contradicts with the increase in mothers’ sun-related knowledge,
and suggests, moreover, that perceptions towards sunbathing have
not changed during this period [11].
It is worth noting, however, that children’s sunscreen use while
on the beach showed great progress between both surveys, as more
than 80% of the Greek children reported they used sunscreen while
on the beach, reapplied sunscreen after swimming and avoided
staying at the beach between 11 a.m. and 3 pm (( figure 1 )). The 83.9% rate
of sunscreen use among Greek children was similar to the 87% rate
achieved in Maltese children after intense campaigns promoting sun
protection [12]. By contrast, sunscreen use was much less frequent
among children during other outdoor activities (( figure 2 )). Yet, parents
have to realize that children are at high risk to UV exposure when
outdoors and they should modify their use of sunscreens on sunny
days.
Aside from this, parents must keep in mind that other measures
are not only effective, but necessary in order to achieve greater
protection, as sunscreens often allow extended exposure [13]. Our
data, in agreement with previous studies, demonstrate that, while
some sun-protective measures are becoming more common, the use of
suitable clothing is underestimated [14, 15]. Less than 10% of the
children wore suitable clothing, while on the beach or outdoors ((
figure 2 )).
Even more, only 66% of the Greek children wore a hat during outdoor
activities and 49% while playing on the beach, which was lower than
the 78% rate of Maltese children [12]. Despite earlier implications
that these measures, together with the application of sunscreen on
the parts of the body that remain exposed, provide the best
protection for children [8, 9], it is unlikely that they were made
clear. Interestingly, since prevention programmes in Australia the
majority of children younger than ten years wear Rash shirts on the
beach and hats at school breaks [13]. In an attempt to achieve
consistent broad protection, not necessarily using sunscreens,
optimal interventions must emphasize the use of sun-protective
clothing [16, 17].
An interesting comment concerns the relationship between
children’s sun protection practice, mother’s sun protection
practice and knowledge. The association of children’s sun
protection practice with mothers’ knowledge is indeed demonstrative
but with low correlation coefficients, whereas mothers’ actual
practice makes a greater contribution. The latter can be explained
by the fact that mothers who apply protective measures to
themselves are more likely to apply the same to their children.
Parents are also role-models for their children [7]. Thus, they
bear a heavy burden as they influence their youngsters’ behaviour
under the sun and their future health [18]. Parents must keep in
mind that those children who establish adequate sun protection
habits early in life are likely to continue to practice them for a
long period of time [19].
On the other hand, the weak association between mothers’
knowledge and sun protection practice suggests that poor protection
practice is partly, but not adequately, explicable on the basis of
poor sun-related knowledge. Likewise, there is evidence suggesting
that information alone is inappropriate to change behaviour [10,
20], whereas public perceptions and attitudes have the strongest
association with sun-protection practice [10, 21]. Consequently,
behaviour-based intervention strategies are necessary as a new
approach to sun protection promotion [21].
To our knowledge, the changes observed in the Greek population
from 1993 to 2002 can be attributed to information campaigns
conducted after the first survey in 1993 [6]. Promotion of sun
protection with mass media strategies such as posters, badges,
leaflets and television spots were attempted. At the same time,
educational sessions were organized to increase awareness of
melanoma-related knowledge, sun exposure and sun protection. This
attempt included lectures to parents and pupils, performances in
schools on sun-related issues by actor groups and provision of
relevant books to school libraries. Finally, Athens’ municipal
authorities and those of other cities too, organized a week of sun
awareness each year directed to the public, which included lectures
on skin cancer prevention and sun protection. The beneficial
influence of educational session interventions at schools and
public health promotions on sun knowledge have been shown in the
literature [22-25].
Limitations
Certainly, there are potential limitations associated with our
observations. A primary limitation of this study was the lack of a
control group, which is difficult to obtain when examining the
influence of educational campaign interventions directed to the
public, due to size and expense. A second limitation was that the
data was self-reported creating recall bias. Still, the
questionnaires were gathered during summer and autumn of the same
year and recalling their recent behaviour could not have been that
difficult. A final limitation of this study was that, although
participants were recruited by methods of random selection, there
is no available information on those who refused to participate.
Thus, a selection bias may exist. Nevertheless the relatively high
participation rate in both surveys and the identical methodology
used, secured, up to a certain extent, no methodological variations
between the surveys that were compared. Therefore, the changes
recorded in the present study reflect ‘true’ changes of a Greek
paediatric and parental population.
Conclusion
In summary, the present study was carried out to examine changes in
sun-related knowledge and protection practice in Greece during
1993-2002. The rise in awareness of the hazardous effects of sun
exposure is consistent with information campaigns conducted during
the same period. However, increased efforts to promote healthier
behaviour under the sun are required. Along this line, it is
important to motivate change of attitude towards sun exposure;
otherwise it filters down to the younger populations.
Sun-protective measures, such as the use of suitable clothing and
sunscreen when outdoors, need to be intensified. Families ought to
be guided and encouraged to incorporate relevant practices as part
of a healthy lifestyle. All the above implications could be
accomplished by systematically continuing well-designed,
educational campaigns.
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