The Raybusters Program: Early Interventions for Creating Sun Smart Behavior

Skin cancer, the most common form of cancer in the United States, affects over one million Americans each year, equaling all other cancers combined.  Research has shown that many of the 1.3 million cases of skin cancer in the United States are caused by unprotected sun exposure.  Therefore, skin cancer, like lung cancer, should be largely preventable through public education and behavior change.

It is estimated that up to 80% of an individual's cumulative sun exposure occurs before age 18. While the numbers of fatal skin cancers are rapidly rising, children are still sunbathing. Because most skin cancer is the result of childhood sun exposure, there is a need to educate families early on about the importance of sun protection. 

Skin cancer is preventable: Incorporating safe sun practices into the early years can reduce nearly 80% of skin cancers. Most sun protection messages delivered to date, however, have targeted older children, with few messages aimed directly at parents of neonates, infants, and toddlers. At this early stage, most parents have not yet instilled health habits in their child. With an early start, parents can help their children to develop lifelong sun protection habits. 

Raybusters is a sun protection education program targeted at mothers of at least one child under 2 years of age. The program encourages mothers to practice sun protection for their infant/toddler, themselves, and other young children in the family. The program consists of a single telephone counseling session and two personalized mailings. 

Raybusters is designed to promote sun protective behaviors with-

• A single session of telephone counseling facilitated by a health educator
• Two four-page color Raybusters newsletters containing information on sun protective practices, tailored to address participants' educational needs identified in the baseline survey

The Implementation Guide is a resource for implementing this program. It provides important information about the staffing and functions necessary for administering this program in the user's setting. Additionally, the steps needed to carry out the research-tested program, relevant program materials, and information for evaluating the program are included. The Implementation Guide can be viewed and downloaded in the Products page.

This program is an example of interventions targeting children's parents and caregivers (Sun Safety) which has an insufficient evidence finding from the Community Preventive Services Task Force, as found in the Guide to Community Preventive Services. Insufficient evidence means the available studies do not provide sufficient evidence to determine if the intervention is or is not effective. This does not mean that the intervention does not work. It means that additional research is needed to determine whether the intervention is effective. To expand understanding of this intervention category consider communicating with members from NCI’s Research to Reality (R2R) community of practice who may be able to help you with your research efforts. Following is a link to start an online discussion with the R2R community of practice, after completing registration on the R2R site: https://researchtoreality.cancer.gov/discussions.

The Raybusters program requires administration of the baseline survey via phone, creating, assembling, and mailing the customized newsletters, and a single telephone counseling session, taking at least 15 minutes, provided by a health educator. 

Mothers of children aged 2 years and younger.

The Raybusters program is designed to be introduced to new parents post-delivery in the hospital, with the actual administration of the program taking place at home via telephone calls and mailings. 

The Raybusters toolkit includes-

• Baseline questionnaire for determining individual's stage of change
• Telephone script for the counseling session (to be administered by a health educator)
• Two Sun Safety Bulletins
• Implementation Guide

Mothers giving birth in Falmouth Hospital, Falmouth, Massachusetts, during the first 6 months of 1998 were approached to participate in a study testing the effectiveness of sun protection education during the following 12 months. At that time, all new mothers were counseled by maternity nurses on sun protection for their newborns. Mothers who agreed to participate were randomly selected to receive hospital education alone or hospital education plus tailored materials and telephone counseling.

Participating mothers completed baseline surveys conducted by the health educator in September and October 1998 to determine their sun-protective practices and attitudes toward sun exposure and tanning. Their infants ranged in age from 3 to 9 months at that time. Participants were then randomized to intervention and control groups. Beginning in the spring of 1999, mothers in the intervention group received a 15 minute telephone call from the health educator and were mailed two newsletters, which were customized to address the mother's educational needs identified in the baseline survey. The telephone call and newsletters addressed: the health benefits of sun protection; specific instructions for use of sunscreen and protective clothing; solutions to mothers' specific questions about sun protection; and personalized sun protection suggestions.  One year after completing the baseline surveys, mothers in both groups completed follow-up surveys assessing their experiences during their child's second summer.

Effect on Mothers' Vigilance in Sun Protection
Vigilant sun protection,* measured only at follow-up, was 82% in the intervention group compared with 61% in the control group (p<.05). 

Additional Effects of the Raybusters Intervention
While higher vigilance scores in the intervention group indicate that the intervention had positive effects, some individual sun protection behaviors showed null or negative results from baseline to follow-up.  However, it is possible that this is due to the developmental stage of the children from baseline to follow-up - mothers have greater control over the sun protection process when their children are infants as opposed to when they are toddlers.  As the researchers point out, these findings may be due to their toddlers being mobile and more independent, contributing to mothers' difficulties in keeping sun-protective clothing on their children.

Given this, although not significant, the following results are reported:

Effects on Mothers' Change in Use of Sun Protection From First Summer to Second Summer
Change in use of sun protection was not significantly different for those receiving the Raybusters program as compared to the control group. Use of shade decreased for both the intervention group (baseline 89%, follow-up 56%) and control group (baseline 83%, follow-up 57%). Use of sunscreen increased for both the intervention group (baseline 36%, follow-up 98%) and the control group (baseline 33%, follow-up 89%). Mothers' reports of child sunburn increased for both the intervention group (baseline 7%, follow-up 14%) and control group (baseline 7%, follow-up 28%). Any skin damage (tanning or burning) also increased for both the intervention group (baseline 20%, follow-up 52%) and the control group (baseline 20%, follow-up 63%).

Effects on Mothers' Sun Protection Knowledge Scores
Sun protection knowledge scores at follow-up were 46% among intervention mothers compared with 35% of the control mothers.

Steinberg Benjes, L. S., Brooks, D. R., Zhang, Z., Livstone, L, Sayers, L, Powers, C., Miller, D. R., Heeren, T., & Geller, A. C. (2004). Changing patterns of sun protection between the first and second summers for very young children. Archives of Dermatology, 140, 925-930.