Background
The incidence of both melanoma and nonmelanoma skin cancer types among fair-skinned populations is increasing rapidly worldwide [
1‐
4]. Factors that have been associated with these increased incidence rates are all related to Ultraviolet Radiation (UVR) exposure. Increased sun exposure behaviors during leisure-time activities, the preference for wearing less covered clothing and increased exposure to tanning beds, influenced by changed attitudes in which people are more in favor of getting a tan and enjoying the sun are important factors related to increasing skin cancer types [
3,
5]. Moreover, sun exposure and sunburns during the first 10 to 15 years of life have proven to play an important role in the etiology of all skin cancer types [
6,
7] and especially melanoma [
8‐
11] since children’s skin is more sensitive to UVR. Even though sun exposure seems to be distributed equally over a person’s lifetime, prevention of excessive sun exposure and sunburns during childhood is ought to start during early childhood [
12]. Children are largely dependent of their parental sun protection, which makes them a particular vulnerable group [
13]. Moreover, childhood is an important phase in which health behaviors such as sun protection should be established [
14], to increase the likelihood of habitual behavior in later life [
15]. To prevent children from getting sunburnt, various precautions can be taken, in which parents play an important role. Application of sunscreen, wearing UV-protective clothing (including a hat and sunglasses) and seeking shade are the most important and recommended sun safe behaviors [
5,
16,
17].
Although clear guidelines exist with regard to sun protection of children, the prevalence of sunburns is still high, with studies reporting 28 to 52% of children suffering one or multiple sunburns during the past 12 months [
16,
18‐
20]. Although children in general are at high risk of getting sunburnt, several subgroups need specific attention. Boys in general seem to be more exposed to UVR [
21], use less sun safe measures [
22,
23] and have more reported sunburns during childhood [
24,
25] than girls. Moreover, older children, primarily from the age of 8, are often less protected against UVR than younger children, and more sunburns are reported [
16,
17,
23,
26‐
28]. Possible explanations for the finding that children are less protected as they get older is that older children spend more unsupervised time outside the house and gain self-responsibility and independence, which makes parental influence on children’s behavior less probable [
15,
16,
29,
30]. Furthermore, positive sun-protective attitudes and behaviors of children seem to weaken when children reach adolescence [
28]. However, parental sun safe attitudes, beliefs and behavior are considered of great influence, even when a child grows older [
30‐
32]. For example, Behrens and colleagues [
33] found that parental attitudes favoring a tanned skin accounted for an 85% increase in sunburn risk of children aged 13 and above, while this effect was not seen among children aged between 0 and 6 years old. Even though parental influences seemingly play a vital role in sun safety behavior, specific insight in the occurrence of sun safety behavior of children themselves as they grow older are lacking. Although alterations in children’s behavioral responsibility seem to occur within other health behaviors such as medicine use, healthy food intake or tooth brushing [
34‐
37], occurrence of possible behavioral shifts concerning sun safety behavior have not yet been investigated.
The primary school age is an important period in which children start to adopt and develop self-responsibility and autonomy over their health behavior, a process that is continued throughout adolescence and is thought to result in the formation of habitual behavior [
38,
39]. During this phase children learn that the environment expects them to start controlling their own behavior and that their individual freedom expands [
29,
40]. Given the fact that sunburn incidence rates are high among older children, gaining insight in possible behavioral shifts from parental executive to children’s own executive behavior is imperative for targeting interventions towards specific age groups and developing tailored content. Furthermore, based on existing differences in UVR exposure and sunburn incidence between boys and girls, examining the role of gender in the occurrence of sun safe behaviors of both parents and children as the child grows older is of great importance and can contribute to developing tailored sun safety interventions. This study therefore aims to gain insight in executive sun safe behaviors of parents and their child and investigates: 1. the relations between children’s age and sex and the occurrence of extensive sun safe behaviors of both parents towards their child and children themselves in the age range of 4 to 13 years; and 2. the relations between children’s age and sex on the one hand and the differences in execution of these behaviors between parents and their child on the other hand (i.e. investigation of when and how a possible behavioral shift takes place).
Discussion
This study examined the differences between parents and their child concerning the execution of sun safe behaviors in the context of an increasing age of the child. Furthermore, effects of sex and age of the child on the development of these behaviors were investigated. When comparing sun safety behaviors, for both parents and children sunscreen use appeared the most frequently applied, followed by wearing UV-protective clothing and seeking shade, which corresponds with previous studies [
46‐
48]. In addition, parents with young children applied sun safety measures significantly more often than parents with older children, which also corresponds with earlier work [
17,
23]. Additionally, older children were more likely to execute sun safe behaviors themselves. Interestingly, these results contrast with previous work, which state that sun protection of children themselves declines as children grow older [
13,
23,
28]. Weakened parental encouragement towards the children as they grew older was mentioned as an important cause for this decline. In our study, supportive behavior of parents remained relatively stable throughout the age range studied, which could have stimulated older children’s sense of their own behavioral responsibility.
Furthermore, a possible effect of children’s sex on sun safety behaviors was examined. Parents seem to apply sunscreen less frequently on older boys than younger ones in both planned and incidental situations, while age group differences for girls were only observed in incidental situations. Moreover, girls themselves executed all sun safety behaviors more often than boys in both situations. For shade-seeking behavior, older girls more often stayed in the shade than younger girls, which is interesting since literature concerning sun safety behavior among adolescents reveals that especially girls gain a desire to tan and are more likely to use tanning beds than boys, occurring around the age of 13 to 16 [
19,
46,
49]. Based on these results, stimulating sun safety behavior for boys during early childhood deserves specific attention.
The overall results concerning the development of parental and child’s sun safe behavior indicate that during the age of 4 to 13 years, children increasingly apply sun safety behaviors, but largely depend on their parents’ protection. The fact that children’s sun safety is strongly related to adequate parental sun safety practices during early childhood is in line with previous studies [
17,
26]. Additionally, we found a shift in which children put on UV-protective clothing more often than parents do for them before the age of 13 in planned sun exposure situations. Shifts in other sun safety behaviors were subsequently mostly predicted after the age of 13, when children transition into adolescence [
50]. Intervening on enhancing sun safety behaviors during this stage and some time before may be imperative for establishing sun safety behaviors in later life. This is accentuated by the fact that, at the onset of adolescence, increased levels of self-consciousness and internalization of norms and values develop [
51], children start to form their own personal identity, and start to differentiate from their families [
52]. Moreover, before children reach adolescence, they are still prone to adopting their parents’ values, which makes this specific age even more important to take into account [
33]. Nonetheless, children in the age of 4 to 12 years frequently get sunburnt, spend more time outdoors than adolescents and, from the age of 8, gain understanding in the influence they have on their own behavior [
14,
29], which makes them an important target group as well. Additionally, from a behavioral development perspective, it is important that children learn how to execute sun protective measures at an early age, rather than get familiar with these behaviors in later life, since unhealthy habits then may already have been established [
15,
53]. During the primary school years, stimulating an internal locus of control concerning health behaviors can enhance self-responsibility [
54,
55]. Sun safety interventions should therefore target both parents and children during the primary school age with a specific focus on boys. Parental influence is significant and life-long habits start to form, and children start gaining insight in their own health behaviors and can therefore be made aware about importance of sun safety. Additionally, when children transition into adolescence, interventions are of equal relevance, with a strong emphasis on self-responsibility.
There are a few limitations to this study that should be mentioned. First, children’s own sun safety behavior in this study consisted of parental perception of their execution, which may lower the validity of the outcome measure, even though parental perceptions of executive behaviors of their children is the most commonly used method in measuring sun safety behavior [
28]. Moreover, frequency of sun safe behaviors was measured using retrospective self-report questions, which may limit the accuracy of behavioral outcomes because of social desirability and the possibility of recall bias [
31,
56]. To enhance objectification of sun safety behaviors, future studies should include personal dosimetry measures, preferably together with behavioral diaries [
57]. Moreover, combining objective measures with self-reported data allows for detecting risk situations regarding UVR exposure. Nevertheless, self-report measures remain a commonly used method for sun safety behaviors, with correlations among actual sun safe behaviors ranging from low to moderately positive [
57,
58]. A further limitation is that children’s age in this study was limited to 13 years, while important behavioral shifts seemed to occur after this age. Even though statistical analyses allowed for prediction of these shifts, extrapolation based on cross-sectional data is less valid compared to time-series data. For future research, a within-subjects design using longitudinal data is essential to investigate behavioral changes of both parents and their child over time. Since findings about sun protection behavior are weather dependent [
45] and questions were asked regarding the past summer season, future studies are necessary to allow for seasonality. Additionally, elaborate data about objective UVR exposure of both parents and children in the Netherlands over time, is needed to target childhood sun safety interventions more accurately. Moreover, since children can be influenced by their caretaker’s health behaviors and tend to imitate what they see [
13,
27,
59], future studies might also include questions regarding parental modelling and its effects on children’s own executive behavior.
The findings in this study concerning sun safe behaviors of children suggest that parental behavior declines whereas children’s own executive behavior increases as a child grows older. Moreover, girls seem to protect themselves better than boys and parents apply sunscreen less on older boys than younger ones. However, children are not yet taking main responsibility for their sun safe behavior during the assessed time interval (4–13 years), given the fact that a behavioral shift was only apparent in wearing UV-protective clothing during planned situations. These results lead to the recommendation that sun safety interventions during the primary school years should be focusing on both parents and their children, in which specific stimulation of sun protection among boys is warranted. In addition, since we predicted behavioral shifts after the age of 13, the age from which children reach adolescence suggests that this is an important target group as well for emphasizing that children take self-responsibility by providing them with advice and suggestions. However, follow-up data is imperative to consolidate the findings from this study and examine possible short-term developments.
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