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Sun Protection Counseling for Children
Primary Care Practice Patterns and Effect of an Intervention on Clinicians
Allen J. Dietrich, MD;
Ardis L. Olson, MD;
Carol Hill Sox, Engr;
Charlotte Woodruff Winchell;
Jennifer Grant-Petersson, MS;
Daniel W. Collison, MD
Arch Fam Med. 2000;9:155-159.
ABSTRACT
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Objectives To describe current primary care sun protection advice for children and assess the effect on clinicians of an intervention to enhance their sun protection advocacy.
Setting Primary care practices caring for children in New Hampshire with special attention to clinicians serving 10 towns that were involved in a randomized controlled trial of the multicomponent SunSafe intervention involving schools, recreation areas, and primary care practices.
Design/Intervention A statewide survey of all primary care clinicians serving children addressed their self-reported sun protection advocacy practices. Clinicians in 10 systematically selected rural towns were involved in the subsequent intervention study. The primary care intervention provided assistance to practices in establishing an office system that promoted sun protection advice to children and their parents during office visits.
Main Outcome Measures Sun protection promotion activities of primary care clinicians as determined by their self report, research assistant observation, and parent interviews.
Results Of 261 eligible clinicians responding to the statewide survey, about half provide sun protection counseling "most of the time" or "almost always" during summer well care visits. Pediatricians do so more often than family physicians. Clinicians involved in the intervention increased their use of handouts, waiting room educational materials, and sunscreen samples. Compared with control town parents, parents in intervention towns reported an increase in clinician sun protection advice.
Conclusions The SunSafe primary care intervention increased sun protection counseling activities of participating clinicians. A single-focus preventive service office system is feasible to include in community interventions to promote sun protection.
INTRODUCTION
SKIN CANCER rates are rising.1 Increased sun exposure due to ozone depletion and more time spent outdoors have been implicated as contributing factors.2 The incidence rate of squamous cell skin cancer in New Hampshire has increased by more than 300% in the past 20 years.3
While the value of routine total skin examinations for early detection is controversial,4 sun protection has been endorsed by influential experts. Healthy People 2000 identifies as desirable an "increase to at least 60% the proportion of people of all ages who limit sun exposure, use sunscreens and [use] protective clothing when exposed to sunlight."5
Primary care physicians can contribute to promoting sun protection. The Guide to Clinical Preventive Services states that "Counseling patients at increased risk of skin cancer to avoid excess sun exposure is recommended."6 Children and their parents provide an important risk group and target for counseling. Stern et al7 developed a model that suggests a 78% reduction in lifetime incidence of nonmelanoma skin cancer if children regularly used sunscreen during the first 18 years of life.
What counseling do primary care physicians provide currently? A survey of Texas parents showed that 18% recalled receiving sun protection information from their child's primary care physician.8 A survey of Massachusetts pediatricians found that almost 70% report counseling most of their patients and parents about sun protection during summer months.9 Whether pediatricians elsewhere or family physicians provide similar counseling is not known.
Can primary care physician counseling alone actually result in more sun protection? Of the few interventions shown to promote sun protection, most have been delivered through schools, such as the Slip! Slop! Slap! and the SunSmart programs in Australia10-11 and the Sunny Days, Healthy Ways12 program in Arizona. The US Preventive Services Task Force notes that while risk reduction through sun protection is efficacious, the effectiveness of physician counseling has not been well-established.6
Rossi et al13 have observed that multicomponent interventions promoting sun protection are more likely to effect actual behavior than single-component programs. Building on this premise, we designed a community-wide intervention called SunSafe, with components directed at schools, child care settings, freshwater beach areas, and primary care practices. One year after the intervention, use of sun protection by children increased in intervention towns compared with control towns.14 The school/day care component of SunSafe is described in detail elsewhere.15 This report describes primary care practice patterns regarding sun protection counseling, the primary care component of the SunSafe intervention, and the effect of SunSafe on clinician behavior.
MATERIALS AND METHODS
In the first phase of the New Hampshire Children's Sun Protection Project, a statewide survey of primary care clinicians caring for children assessed their self-reported sun protection promotion activities prior to any intervention. The second phase of the project tested a multicomponent intervention in 10 rural communities. The intervention, called SunSafe, worked through elementary schools and day care centers, freshwater beach recreation areas, and primary care practices in the 5 towns that were randomly assigned to intervention status. The remaining 5 towns served as controls. The remainder of this section is divided into 2 parts, the first describing the methodology used in the 1995 statewide survey and the second describing the assessment of the effect of the primary care component of SunSafe.
1995 PRIMARY CARE CLINICIAN SURVEY
Specialty societies provided lists of family physicians, pediatricians, and nurse practitioners in current practice. To be eligible, clinicians had to spend at least half their time in primary care, see at least 10 patients aged 16 years or younger each week, and have been in practice for 1 year or more. After an initial mailing, clinicians received 2 follow-up mailings and finally a telephone call from one of the investigators.
The survey instrument included 29 items addressing clinician demographic and practice characteristics, the proportion of patients seen from May to August, sun protection advice given according to visit type (well care or sick care), and the practice approach to promoting sun protection. Respondents were asked to indicate if they never (0%), seldom (1%-20%), sometimes (21%-40%), about half the time (41%-60%), often (61%-80%), or almost always (more than 80% of the time) provided various sun protection promotion services. Results of the survey were analyzed using t tests for continuous variables and  2 tests for categorical variables.
THE SUNSAFE PRIMARY CARE INTERVENTION AND ITS EFFECT ON CLINICIANS
Ten New Hampshire communities with populations between 5000 and 15,000, a community freshwater beach, and at least 1 primary care practice serving children provided the setting for the intervention study. To assure that communities were representative, a list of all New Hampshire communities meeting these eligibility criteria were compiled.14 Towns were ordered according to their proportion of low-income families, with the towns with the largest proportion listed first. Starting from the top of the list, the 10 towns with the largest proportion of low-income families were identified for the study, excluding towns that were near towns that had already been selected. Towns with large low-income populations were targeted because low-income populations may face more barriers to sun protection and may thus have the most to gain from an intervention.
The primary care component of SunSafe consisted of a continuing education meeting at local hospitals on sun protection education followed by 2 visits to each participating practice by a research assistant. The research assistant offered free materials related to sun protection of children as well as assistance in establishing a sun protection office system. As in our previous work with preventive service office systems,16-18 the office system included enhanced practice routines to promote preventive service goals, shared responsibility among clinicians and office staff for achieving these goals, and use of handouts, posters, and other materials to promote sun protection.
The procedure to establish the system followed the preventive goals, assessment, planning, and start-up approach used previously to support a broad range of preventive services.19 Here it was focused specifically on sun protection advocacy. In applying goals, assessment, planning, and start-up, the research assistant helped the practice set a target number of children to reach during well care and sick care visits, assess current practice activities related to sun protection, plan changes to enhance these activities, and start implementing the planned changes.
At the beginning of the first visit, the research assistant described the rationale for sun protection of children to clinicians and office staff and asked about current sun protection counseling. The remainder of the first visit and the entire second visit were devoted to helping the practice establish sun protection goals and to divide responsibilities among clinicians and office staff to ensure that these goals would be addressed routinely. Practices could select from among various free materials, called tools, available from the project. Research assistant visits typically required 30 to 45 minutes each, with the second visit typically involving 1 to 2 key office staff but no clinicians.
Available tools included free sunscreen samples, patient brochures on sun protection, posters, reward stickers or removable tattoos for children, and, for use as clinician reminders, adhesive chart identifiers and a preventive services flowsheet developed through the Put Prevention Into Practice program.20 A consumer-oriented article and a laminated chart rating sunscreen products were included as well. Additional support, if needed, was provided by the research assistant through 1 or 2 follow-up telephone calls. The research assistant visited each cooperating practice in intervention towns once immediately prior to the second follow-up summer (1997), at which time an additional supply of tools was offered. The cost of requested materials and research assistant time helping practices were tracked.
To assess the effect of the primary care intervention on sun protection activities in practices, clinicians in control and intervention towns were asked to complete a survey regarding their sun protection counseling practices in 1996 and 1997. This survey was similar to the 1995 statewide survey. Responses from these clinicians were linked across years so changes in the self-reported behavior could be tracked for individual clinicians.
Analysis using 2 tests explored whether clinicians in intervention towns were more likely than those in control towns to "improve" in terms of addressing sun protection during well care and sick care visits as well as in providing patient education materials and sunscreen samples. Clinicians who gave any of the following responses in their 1995 preintervention survey were considered to be already providing adequate care and thus could not improve on those specific items in subsequent years: sun protection addressed "often" or "almost always" during well care visits; sun protection addressed "most of the time" or more frequently during sick care visits; and sun protection educational materials or sunscreen samples provided during visits.
Each summer, parents who lived in the 10 towns were queried about the sun protection advice they had received from various sources during the preceding year, including advocacy by their primary care clinicians. These interviews took place while these parents were visiting local beaches with their children. The methodology is described in detail elsewhere.14 In summary, all adults caring for children aged 2 to 9 years were approached and, if willing, interviewed. More than 90% of those approached agreed to be interviewed. The proportions of intervention vs control town parents reporting clinician advice in the previous year were compared using the Fisher exact test.
RESULTS
STATEWIDE SURVEY
Of 508 surveys mailed, 131 were returned with responses indicating that the clinicians did not meet eligibility requirements, most commonly because they were seeing too few children or practicing primary care less than 50% of the time. One hundred sixteen declined to participate or did not respond. Usable data were provided by 261 (69.2%) of 377 eligible clinicians.
Respondents had a mean age of about 44 years, averaged 10 years in their current practice, and saw a mean of almost 100 patients a week. Among those in family practice, three quarters were men, whereas the proportions of men and women were about equal in pediatrics (P = .01). Of the nurse practitioners, 22 were based in family practice offices and 21 were in pediatric offices.
Table 1 describes the sun protection activities of the statewide sample prior to the intervention. Pediatric clinicians were more likely to indicate that they promoted sun protection during well care visits from May to August than family practice clinicians. Both groups were less likely to provide sun protection information during sick care visits, with no significant difference between them. Pediatric clinicians were more likely to have educational materials on sun protection available in the waiting room for patients to select, to hand out materials themselves during well care visits, and to provide sunscreen samples.
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Table 1. Sun Protection Services Provided From May to August by 261 Eligible Clinicians Who Responded to the Survey in 1995*
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THE SUNSAFE PRIMARY CARE INTERVENTION AND EFFECT
Eighty-six clinicians practiced in the 10 communities involved in the intervention trial. Fifty-one (59%) completed both the 1995 preintervention survey and at least one follow-up survey. Fifteen of the 21 intervention town practices (71%) agreed to cooperate with the intervention. Demographic characteristics of the clinicians did not differ between intervention and control towns and were similar to the demographic characteristics reported for the respondents to the statewide survey.
Table 2 compares adaptation of various office system activities between control town clinicians and clinicians cooperating with the intervention who returned both baseline and follow-up surveys. Some of these intervention town clinicians were in practices that did not cooperate with the intervention. At baseline, providing educational materials actively in the context of a well care visit was not common. Only 4 (14%) of 29 intervention town clinicians and 1 (8%) of 12 control town clinicians indicated that they did so. More common was availability of sun protection brochures in the waiting room and provision of free sunscreen. Among responding clinicians cooperating with the intervention, all 3 of these activities increased significantly in follow-up compared with clinicians from control towns.
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Table 2. Performance of Recommended Sun Protection at Baseline and Follow-up Reported by Responding and Cooperating Physicians in Participating Communities*
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About half the responding clinicians from the 10 towns said at baseline that they addressed sun protection "often" or "almost always" during summer well care visits, which is similar to statewide results reported in Table 1. Sun protection advocacy was less during sick care visits at baseline and also similar to statewide survey results. Between baseline and follow-up, clinician counseling behavior during well care and sick care visits increased for both intervention and control town clinicians with no significant difference between them.
Table 3 summarizes tool selection and continued tool use among the 15 practices that cooperated with the intervention. These data are based on the observations of research assistants and tool orders received. Posters, patient education pamphlets, and patient rewards such as SunSafe stickers and removable tattoos were the most frequently selected and used tools in both summers after the intervention. Laminated cards ranking the quality of sunscreens were selected by many of the practices but were dropped by most after the initial use. Fewer selected to use the consumer article rating specific sunscreen products and most dropped its use the second summer. Flowsheets and chart stickers to prompt counseling by clinicians and staff were rarely selected. The average cost of materials selected per practice was about $25. Manufacturers donated the sunscreen samples.
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Table 3. Tool Use by Participating Intervention Town Practices (n = 15)
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Previous data reported in this section have been based on clinician self report and research assistant observation. Did parents experience any change in primary care clinician behavior following the SunSafe intervention? In 1995, 93 (25%) of 375 control town parents interviewed at the beach indicated that they had received sun protection information from a clinician in the prior year compared with 103 (26%) of 394 in intervention towns (P = .68 by Fisher exact test). In 1997, 148 (34%) of 437 parents interviewed at intervention town beaches indicated that they had received this information from a clinician in the prior year compared with 119 (27%) of 440 at control town beaches (P = .03). This represents an increase of about 30% in clinician counseling in intervention towns.
COMMENT
Based on the statewide survey, about half of New Hampshire primary care clinicians typically address sun protection during summer well care visits. Pediatricians report levels of activity similar to their Massachusetts colleagues9 and much more activity than New Hampshire family physicians. The SunSafe primary care intervention increased availability and active use of educational materials and increased provision of sunscreen samples. In intervention towns, an increased proportion of parents interviewed at the beach reported that a clinician had provided them with sun protection information in the past year.
Along with relevance to sun protection, these results add to the evidence that supports use of preventive service office systems. In our earlier work,16 we established that office systems can increase age- and sex-appropriate preventive services, but such interventions are time consuming and can be challenging to implement in some settings.18 This current report provides evidence that a single-focus system, though less complex to implement, can increase the target clinician behavior. Application of this single-focus office system approach may be warranted to other preventive services needing a performance boost.
American Cancer Society (Atlanta, Ga) volunteers can be trained to help practices implement a comprehensive preventive services office system.21 In the current study, the requirements and challenges faced by research assistants were more modest, suggesting that volunteers could be trained in the SunSafe primary care context as well. The SunSafe office system may be useful to motivated clinicians without external help. Materials related to the SunSafe intervention are available free through the Web site of the Norris Cotton Cancer Center, Lebanon, NH (http://nccc.hitchcock.org/sunsafe.htm), or by contacting the corresponding author.
Clinician choices regarding tools deserve comment. Sunscreen samples and patient education materials were commonly chosen and used over time. Flowsheets and stickers were rarely chosen. These findings are at odds with our previous experience with comprehensive preventive services in which a flowsheet and chart stickers were adopted by almost all practices.17 Perhaps for a single-focus office system such as SunSafe, tools that are simple to implement are better. Educational materials, posters, and sunscreen samples are ready to use "off the shelf." Flowsheets and chart stickers require more effort to implement and the effort required may exceed the benefit expected from a single-focus preventive service.
What about generalizability? This study involved independent practices in rural New England towns. While skin cancer is a growing problem in New Hampshire,3 clinicians in warmer states may benefit from the intervention as well. The Texas study cited7 found similar or even lower rates of primary care sun protection advice reported by parents. How the SunSafe approach would apply in other states or in less rural settings deserves exploration.
Certain limitations of this study should be recognized. Only 69% of clinicians responded to the statewide baseline survey, so we cannot comment on the activities of the others. Some results are based on clinician self report. However, research assistant observations and parent interviews provide some assurance that changes in clinician behavior actually occurred in intervention towns. Random assignment to study groups was by town, not by clinician or by practice. Thus, clinicians serving intervention and control towns may have differed in baseline attitudes and skills. However, their self-reported baseline activity was similar between groups.
Certain strengths should be noted as well. The demands on practices to learn about and adopt the intervention were modest, involving routine local grand rounds, one brief lunch meeting of all practice personnel, and a second meeting involving 1 or 2 office staff. Demands on practices to provide increased sun protection advocacy during well care were similarly modest because of the tools selected by practices. Posters, educational pamphlets, and sunscreen samples required placement and periodic restocking or changing, but more demanding tools such as flowsheets were seldom selected.
In conclusion, this report provides evidence that a single-focus office system addressing sun protection can change the behavior of primary care clinicians regarding sun protection promotion to their patients. This office system can be implemented with modest external assistance and could play a role in promoting sun protection of children when joined with intervention components directed at schools, day care centers, and beach areas.
AUTHOR INFORMATION
Accepted for publication March 8, 1999.
This project was supported by grants CA63029 and CA23108 from the National Cancer Institute, Bethesda, Md. We thank Angelica Barrett for support and coordination for field assistants, and Susanna Reed for assistance with the preparation of the manuscript. We also thank the following companies for their generous donations of sunscreen: Schering-Plough HealthCare Products Inc, Madison, NJ (Coppertone); Hawaiian Tropic, Daytona Beach, Fla; Pfizer Inc, New York, NY (Bain De Soleil); and Johnson & Johnson Consumer Products Inc, New Brunswick, NJ (Johnson's Baby Sun Block).
Reprints: Allen J. Dietrich, MD, Department of Community and Family Medicine, Dartmouth Medical School, Hanover, NH 03755 (e-mail: Allen.J.Dietrich{at}Dartmouth.edu).
From the Departments of Community and Family Medicine (Dr Dietrich, Prof Sox, and Mss Winchell and Grant-Petersson), Pediatrics (Dr Olson), and the Section of Dermatology (Dr Collison), Dartmouth Hitchcock Medical Center, Lebanon, NH.
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