Parents’ knowledge, attitudes and beliefs regarding sun protection in children: a qualitative study

It is well-established that overexposure to ultraviolet (UV) radiation is a major risk factor for melanoma skin cancer [1]. Protecting the skin from the harmful effects of the sun, the principal source of UV radiation, is therefore a key public health priority in the prevention of this disease, the incidence of which has increased by 119% in the UK since the early 1990s and continues to rise [2].

Despite the implementation of several campaigns throughout the last decade [3], evidence suggests that sun protection behaviour in the UK is still inadequate. In a recent survey, it was reported that 50% of individuals had experienced sunburn at least once in the previous year [4].

Childhood is a particularly crucial period for sun protection. Ecological studies demonstrate that sun exposure during early life, especially childhood and adolescence, is a strong determinant of future risk of melanoma, suggesting that the skin at this age is at increased susceptibility to the carcinogenic effects of ultraviolet radiation [5‐7]. It is thus recommended that children’s skin be protected from the sun from March until October in the UK through the use of sunscreen, shade, suitable hats and clothing [8]. Given that young children are unable to understand the consequences of excess sun exposure or adopt sun protective practices independently, they are dependent upon their parents or carers to implement such protection.

Despite the importance of sun protection in children, a Met Office survey has highlighted a shortfall in parents’ knowledge and protective practices [9]. Of 1000 parents with children aged 11 and under, 7% failed to understand the strong link between UV radiation and cancer, 21% revealed that their children would typically be visibly burnt before protective measures were taken and 40% of children had experienced sunburn in the past 2 years. Evidently, there remains considerable room for improvement in children’s sun protection.

Adolescents’ sun protection behaviours are difficult to target due to negative attitudes towards the use of sun protection, significant peer influences and a common desire to be tanned [10]. With this in mind, it has been suggested that targeting children may be more achievable and confer longer lasting benefits, as health behaviours and habits established during childhood are often seen to continue into adulthood [6].

The majority of literature regarding children’s sun protection is based on population based surveys and questionnaires. These show considerable awareness amongst parents about sun exposure, skin cancer, and appropriate protection [11, 12]. Quantitative literature also demonstrates how parents’ knowledge and attitudes influence these protective behaviours. Parents with greater awareness of the risks of sun exposure more effectively protect their children [13‐16], whilst for those with positive attitudes towards tanning, the converse is true [10, 11, 13, 17].

Qualitative methods allow a richer understanding to be brought to this matter, accommodating the complexities and nuances of parents’ beliefs and attitudes in a way that quantitative methods are unable to do [18]. Qualitative research with parents on this topic from the UK is limited to a summary of findings from focus groups with mothers carried out on behalf of Cancer Research UK [19]. The study itself is unpublished, however the summary illustrates that mothers are generally receptive to advice about children’s sun protection. It also found that parents were far less vigilant about their own sun protection than their children’s. A similar phenomenon was reported in an Australian thesis study [20].

Hamilton et al. conducted focus groups with parents in Australia [21], finding that they were well-equipped with sun protective knowledge, applying this in practice to varying degrees throughout the year. Parents associated numerous advantages with children’s protection, including health benefits, the instilment of positive sun safe attitudes, and parental peace of mind. Disadvantages included the loss of sun exposure benefits such as vitamin D absorption. Although parents described general societal approval regarding sun protection in children, often other adults or family members would make this difficult to achieve by setting a poor example through their own protection.

Although qualitative research with parents is limited, research has been carried out amongst other demographic groups, including university students [22, 23], female adults [24], and female adolescents [25]. A systematic review of qualitative studies including both male and female participants from several countries including the UK has also been done [26]. A common finding is that risks of UV exposure are well known, but this knowledge alone is often insufficient to motivate safe practices. Other influential factors play a role, including a sense of ‘unrealistic optimism’, due to a low perceived susceptibility to skin cancer [22, 23, 26]. Several benefits associated with sun exposure, including the desire to be tanned, feeling healthier, and getting enough vitamin D, also act as barriers to sun protection. [22‐26]. Sun protection tends to be adopted when abroad rather than in the UK, especially when on holiday or at the beach [22, 24, 26]. Relevant to this study, family members are often influential in sun protection attitudes and behaviours, with Mothers often taking the lead role [22, 24, 26]. This further highlights the importance of carrying out research within this group specifically.

The existing body of qualitative research with parents comes from Australia [20, 21]. Having the highest global incidence rate of melanoma [2], Australia has implemented widespread sun protection awareness campaigns such as the ‘Slip, Slap, Slop’ programme [27]. Given these facts, it is probable that certain differences will exist within a UK population, and conducting UK specific research with parents is therefore of value.

The risk of melanoma is more than twice as high in individuals with the fairest skin type (Fitzpatrick type 1, see Table 1) compared to those with light brown skin (type 4), and risk is again lower amongst individuals with darker skin types (types 5 and 6) [28, 29]. For this reason, existing qualitative research has used predominantly Caucasian samples and has thus been unable to consider the impact, if any, of ethnicity and skin type on children’s sun protection. The majority of public health messaging adopt a ‘one size fits all’ approach, despite the fact that 14% of the UK population are of non-white skin type [3, 30]. This leads to a degree of uncertainty, whereby individuals with darker skin types experience greater confusion about their risk of skin cancer [3]. Whilst it is reasonable to focus on those at greatest risk, melanoma can occur in any skin type and other groups should not be neglected. By including parents of non-white children in this study, it is hoped that public health campaigns might be better able to target this issue in the future.

This study is, to the best of the authors’ knowledge, the first UK based qualitative interview study investigating parents’ sun protection of their children. It aims to explore, amongst UK parents: (1) the degree of knowledge and understanding of sun protection in children, (2) the specific factors which motivate and challenge parents to adequately protect children, and (3) the impact of ethnicity and skin type on parents’ knowledge, attitudes and beliefs. A more thorough understanding of the factors that guide and influence parents’ sun protection for children can then be used to underpin future health campaigns by highlighting key messages which should be targeted.

Twenty-two mothers (n = 17) and fathers (n = 5) were interviewed, five of whom had at least one child with type 4–6 skin. The age of participants ranged from 29 to 42 years, with an average age of 36.5. Participants were asked about their occupation to provide context only and this was not used in analysis. Participants occupations are not listed due to confidentiality. They worked in a range of managerial and professional occupations reflected by categories 1 and 2 of the National Statistics Socio-economic Classification [40], and 13 worked in a university setting.

Four main themes emerged: attitudes towards sun protection in children, sun protection behaviours, sun safety knowledge, and motivating and facilitating factors. Themes are broken down into sub-themes, which are shown alongside brief explanations in Fig. 2.

These findings provide insights into the practices adopted by parents in protecting children from the sun, their sun safety knowledge and attitudes that inform and influence these behaviours, and factors which motivate and facilitate them in doing this. Sun protection in children was universally an important matter for the parents in this study, who had good knowledge of appropriate precautions and adopted these in practice for their children. This is especially the case when parents’ are abroad, echoing findings from previous studies in other groups [22, 24, 26].

Although findings from this sample cannot be extrapolated to all parents, the diligence of these parents’ sun protection is generally dissonant with the fact that the incidence of skin cancer in the UK is rising [2]. It is possible that other social and cultural factors such as sun protection practices later in life, the ageing population and increasing foreign travel are more important causative factors in this trend. Nevertheless, certain areas were identified in this study which might have the potential to further improve sun protection early in life.

It can be useful to consider findings from qualitative research in the context of pre-existing theory [41]; in this case using the Health Belief Model (HBM) [35]. The HBM states that an individual is inclined to take health protective behaviour (in this context sun protection), if certain criteria are fulfilled. Firstly, parents must perceive that children are susceptible to the condition (skin cancer), and that the condition would have serious consequences [36]. Although the severity of skin cancer was not discussed specifically in this research, perceived susceptibility was implied as skin cancer prevention was a major motivation for implementing sun protective behaviours.

Perceived benefits of a health behaviour must outweigh the barriers [36]. In this case, a number of benefits to sun protection were discussed. Some related to health outcomes; namely reducing the risk of skin cancer and sunburn in children. Other reasons included teaching children good habits, reducing guilt in parents, and ensuring social approval. These findings are consistent with sun protection benefits identified by parents in Australian qualitative research [21].

Several barriers to sun protection related specifically to sunscreen. These included a perceived unpleasantness associated with it amongst some parents, its tendency to discolour darker skin, difficulty trusting the properties that it claims to have, and uncertainty about sunscreen labelling.

Vitamin D was commonly cited as a benefit of sun exposure, echoing findings from previous qualitative research [23, 24, 26]. As a result, participants experienced difficulties in making decisions regarding vitamin D requirements and the need for sun protection, especially when in the UK. These findings are consistent with previous research, in which participants were confused by conflicting messages regarding vitamin D and sun protection, and thus achieving this balance was challenging [42, 43].

Previous research has highlighted how a desire to be tanned can influence personal choices about sun protection [22, 25, 44]. Conversely, in this study it was found that parents’ tanning attitudes did not appear to influence or act as a barrier to their children’s sun protection. Protecting children from the harms of UV exposure was the main priority amongst parents, and none in this study were motivated to get their children tanned. Despite this, some parents considered tanning to be an inevitability in summer, even with appropriate protection. This was especially the case amongst children with darker skin types which tan more easily [29], in which cases tanning was not necessarily viewed as a harmful or negative outcome.

Parents often adopted lower standards for their own sun protection, making them poor role models for their children. This finding echoes results from existing qualitative research [19, 20]. Although this was not identified as a barrier by parents, research has demonstrated that this has a negative effect on children’s sun protection. Use of sun protection in parents is a predictor of sun protection in children [45, 46], and sunburnt parents are more likely to have sunburnt children [10]. This discrepancy in standards may be due to the principle of ‘unrealistic optimism’ as identified amongst adolescents and adults in previous research [22, 23, 26], whereby parents don’t perceive themselves to be at serious risk of skin cancer, whilst children are viewed as being more vulnerable to the harmful effects of the sun.

Modifying variables are individual factors, such as ethnicity, which indirectly influence perceptions of health behaviours and outcomes [36]. Although skin type was considered throughout the analysis, too few participants with type 4–6 skin were recruited to gain sufficient data to answer this research question and no difference was observed between these parents and the rest of the participants in terms of sun protection concern, motivation and methods. Skin type was seen to influence perceived susceptibility to cancer in some cases, although there was some uncertainty regarding this issue.

Self-efficacy refers to an individual’s confidence to take action [36]. In this research, parents were mostly confident and well informed about sun protection. For some parents, sun protection was a cause of fear and anxiety, suggesting that their sense of self-efficacy was lower.

A cue to action is something which can help to trigger a health behaviour [36]. In this study, the nursery could be thought of as such, as their sun protection policy helped to remind parents and aided them in developing sun protective habits. The nursery also provided wider benefits, helping to educate children and normalise use of sun protection. The benefit which childcare facilities can have in sun protection has previously been recognised, and as such current UK guidelines recommend that all educational environments implement a sun protection policy [8].

Parent’s in this qualitative research, regardless of children’s ethnicity, were found to be well equipped with knowledge of sun protection methods, and motivated to apply this knowledge in protecting their children. It identifies key areas of uncertainty such as vitamin D needs, sunscreen properties and the need for protection in the UK, which might be targets of future campaigns. Potential areas for future research have also been identified and highlighted.

Whilst it is appropriate that sun protection is a priority for parents, it should not be a significant source of anxiety. Clearer and more widespread sun protection guidance focussing on specific areas of uncertainty might reduce this anxiety, as well as increasing sun protection knowledge and confidence amongst parents generally.