printed by Natural History of Sun Protection Behaviors in a Cohort of Children in Colorado Nancy L. Asdigian PhD,* Lori A. Crane PhD MPH,* Alfred C. Marcus PhD,**, Anna E. Baron PhD,* Chan Zeng PhD* * University of Colorado Denver, School of Medicine ** University of Colorado Comprehensive Cancer Center   Melanoma, the most serious form of skin cancer, is the fastest rising cancer in the U.S.   In 2007, nearly 60,000 men and women will be diagnosed with melanoma and more than 8,000 will die.   Childhood exposure to ultraviolet radiation is the single most important preventable risk factor for melanoma.   Prevention behavior remains inadequate despite increasing awareness of risk factors.   Understanding the determinants of sun protection behavior is key to developing effective interventions and to reversing unfavorable trends in skin cancer incidence.   The purpose of this study was to identify predictors of change in a parent’s stage of behavior for two sun protection practices: limiting a child’s time in the mid-day sun and dressing a child in long clothes. ,  The findings do not support PAPM-based predictions that perceptions of threat and effectiveness should be emphasized for individuals in earlier behavioral stages, while barriers reduction should be emphasized in later stages. Our results suggest that all individuals, regardless of behavioral stage, may benefit from interventions that reduce sun protection barriers.   Reducing barriers can take many forms, including: a) providing sun protection items directly to families, b) promoting the availability of protective clothing and accessories in a community, c) advising parents on strategies for mid-day sun avoidance or sunscreen products (foam, spray, sticks) that are more acceptable to children, and d) incorporating sun protective elements (e.g., shade trees) into the places where children play. BACKGROUND THEORETICAL FRAMEWORK METHODSANALYSIS & RESULTS CONCLUSIONS   The Precaution Adoption Process Model (PAPM) suggests that people move through a series of seven stages as they adopt a new health behavior (Weinstein et al., 1998).   Movement through the early stages is believed to be influenced by increases in perceptions of disease risk, disease severity and the effectiveness of the new behavior.   Movement through the latter stages is believed to be influenced by decreases in the perceived barriers to engaging in the new behavior. Study Sample   381 adults in the non-intervention arm of a longitudinal, randomized controlled trial evaluating the effectiveness of a sun protection newsletter intervention.   Study participants were recruited in 2003 and 2004 from pediatric practices and other community settings in the Denver, Colorado metropolitan area.   Parents who had a child born between January 1, 1998 and September 30, 1998 and who lived in Colorado at the time of enrollment were eligible for the study. Statistical Analysis and Study Hypotheses   We calculated difference scores to represent change between 2004 and 2006 in PAPM stage, and perceptions of melanoma threat, non-melanoma threat, effectiveness, and barriers to mid- day sun avoidance and long clothes.  change),  Positive difference scores reflect movement from a lower PAPM stage in 2004 to a higher PAPM stage in 2006 (i.e., positive stage change), and 2004 to 2006 increases in perceptions of effectiveness, disease threat, and barriers.   Multiple linear regression (backwards selection) was used to predict change in PAPM stage for mid-day sun avoidance and long clothes from: a) baseline (2004) stage, b) change in measures of threat, effectiveness and barriers, and c) parent demographics.   We tested PAPM hypotheses by evaluating interactions between baseline stage (early stage - 1,2,3 vs. later stage - 4,5) and change in threat, effectiveness and barriers.   We hypothesized that increases in threat and effectiveness would predict positive stage change for participants who were in an early PAPM stage at baseline. We also hypothesized that decreases in barriers would predict positive stage change for participants who were in a later PAPM stage at baseline. Measures   Data were collected during three annual telephone interviews conducted between June and September of 2004, 2005 and Response rates were 96%, 93% and 91%.   PAPM stage was assessed each year for two sun protection behaviors: 1) dressing the index child in long clothes, and 2) limiting time in the mid-day sun (see Figure 1).   Other measures collected in each year include:   Perceived threat (disease risk X disease severity) of melanoma and non-melanoma skin cancer (4-item index with a range of 1-35; higher scores reflect greater threat).   Perceived effectiveness of mid-day sun avoidance and long clothes (Single item for each behavior, with a range of 0-10; higher scores reflect greater effectiveness).   Perceived barriers to mid-day sun avoidance and long clothes (2-item index for each behavior, with a range of 1 to 4; higher scores reflect more barriers).   Participant demographics – household income, educational attainment, age, race/ethnicity (non-Hispanic white vs. other). Trends in PAPM Stage and Other Measures In each year, parents’ PAPM stage for mid-day sun avoidance was more advanced than their stage for long clothes. In addition, perceived barriers were higher for clothes than for mid-day sun avoidance. PAPM stage increased over the study period for mid- day sun but not for clothes. Clothes barriers increased from 2004 to 2005, but fell again by Perceived threat of non-melanoma skin cancer decreased over the study period. Table 2. Trends in Stage and Cognitions Measure Clothing Stage M sd Mid-Day Sun M Stage* sd Melanoma M Threat sd Non-Melanoma M Threat* sd Clothing M Effectiveness sd Mid-day Sun M Effectiveness sd Clothing M Barriers* sd Mid-day Sun M Barriers sd * p <.05. GLM repeated-measures analysis testing trends over time. Sample Characteristics 85% non-Hispanic white Median age in 2006 = 40 years old 73% with college or post-graduate degree 55% with an annual HH income of $75,000 or higher Predictors of PAPM Stage Change Positive change in mid-day sun stage was predicted by a lower stage at baseline, barriers reduction from 2004 to 2006, and lower income. Positive change in clothes stage was predicted by a lower stage at baseline, barriers reduction from 2004 to 2006, older age and other race/ethnicity. Perceived threat and effectiveness were not significant predictors of positive stage change. None of the interaction terms involving baseline stage and changes in cognitions were significant predictors of positive stage change. Table 3. Final Linear Regression Models Predicting Stage Change from 2004 to 2006 a. Change in Clothing Stage Predictor b p Baseline (2004) Stage (1,2,3=0 / 4,5=1)-1.22<.0001 Change in Clothing Barriers-0.58<.0001 Parent Age Parent Race (Other=0/NHW=1) Adj R 2 =.20, F (3, 256) = 21.97, p <.0001 b. Change in Mid-day Sun Stage Predictor b p Baseline (2004) Stage (1,2,3=0 / 4,5=1)-1.08<.0001 Change in Mid-day Sun Barriers-0.56<.0001 Annual HH Income Adj R 2 =.19, F (4, 232) = 14.83, p <.0001 Table 1. PAPM Stage by Time % (n) % (n) % (n) Clothing __________________________________________________ Decided Not to Act (0) 6.0 (23)13.6 (52) 9.4 (36) Unaware (1) 3.4 (13) 0.8 (3) 0.5 (2) Aware/Unengaged (2)37.3 (142)29.1 (111) 35.7 (136) Engaged/Deciding (3) 7.9 (30) 5.8 (22) 3.7 (14) Intend to Act (4) 16.0 (61)18.6 (71)22.3 (85) Action – Inconsistent (5)13.9 (53)18.4 (70) 15.0 (57 Action – Consistent (6)15.5 (59)13.6 (52)13.4 (51) Mid-day Sun ___________________________________ Decided Not to Act (0) 4.7 (18) 7.3 (28) 6.0 (23) Unaware (1) 5.5 (21) 0.8 (3) 0.0 (0) Aware/Unengaged (2) 24.4 (93)18.6 (71)20.5 (78) Engaged/Deciding (3) 4.5 (17) 5.5 (21) 3.4 (13) Intend to Act (4) 18.1 (69) 22.3 (85)20.7 (79) Action – Inconsistent (5) 27.0 (103) 26.2 (100) 28.3 (108) Action – Consistent (6) 15.7 (60) 19.2 (73)21.0 (80)