6 February 2009

Dear Editor,


We read with interest the recent article ‘Child sun protection: sun-related attitudes mediate the association between children's knowledge and behaviours’ by Wright, Reeder, Gray and Cox.1 The authors addressed a very essential topic, as children's sun protection behaviour is an important factor in the prevention of skin cancer.

The model depicted by Wright et al. suggests no direct link between children's sun protection-related knowledge and sun protection-related behaviour. Only an indirect path via sun protection-related attitudes towards behaviour was found to be significant. Therefore, the authors state in their conclusion that when targeting child sun protection and skin cancer prevention programmes, a focus on attitudes towards sun exposure and a suntan is important. We believe, however, that this conclusion might be different for different subgroups of the sample. For 12-year-olds there might well be a direct association between knowledge and behaviour, whereas for eight-year-olds there might not. In our opinion the behaviour of eight-year-olds is greatly influenced by their parents and not by their knowledge about sun protection. Including these eight-year-olds in the sample when testing the model will therefore probably weaken the association for the whole sample. For that reason, eight-year-olds and 12-year-olds should not be considered one group when assessing associations between knowledge, attitudes and behaviour in child sun protection. A study by O'Riordan, Geller, Brooks, Zhang and Miller (2003) showed that differences in sun protection-related behaviour indeed exist between eight-year-olds and 12-year-olds. They found a difference in the behaviour of five- to nine-year-olds and 10–12 year-olds in their study of sun protection. Children of 10–12 years of age had a lower sun protection behavior index (SPBI), which means that 10- to 12-year-olds were less inclined to wear a hat, wear a shirt with sleeves, use sunscreen SPF 15+, limit time outside between 10 am and 4 pm, and use shade.2

It is also conceivable that knowledge is a moderator in the relationship between attitudes and behaviour. Further research about the nature of the associations is necessary. Meanwhile, when targeting child sun protection, a focus on sun protection-related knowledge remains important.

Moreover, even though the relationship between knowledge, attitudes and behaviour is called an association, the single arrows in the model suggest causality. This cannot be supported by the cross-sectional design of the study.

Furthermore, we feel the authors have left out some important factors in assessing child sun protection. For example, the literature suggests that parents greatly influence child sun protection.2 Another important factor in child sun protection is skin colour. Children with a darker skin get sunburned less easily than their white counterparts and therefore might deal with sun protection in a different way. Also, children with a family history of skin cancer might address sun protection in a different way than children with no family history of skin cancer. Therefore, we think that future studies that address the associations between sun protection behaviour, attitudes or knowledge should take into account these others factors.


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