The POOL COOL Program was evaluated using a cluster randomized controlled design to assess the impact of the program on sun-protection habits and swimming pool environments. The POOL COOL Program was compared with a program similar in format, with injury prevention as the topic. Both educational and environmental strategies were tested in 28 swimming pools in Hawaii and Massachusetts. A total of 1,010 parents/caregivers completed baseline surveys regarding themselves and their children, aged 5-10 years (mean age 6.6 years), who were enrolled in swimming lessons. Children were 47.1% female and 52.9% male, and 57.2% of parents/caregivers identified themselves as Caucasian.
Parents completed surveys concerning themselves and their children about skin cancer risk factors, knowledge about skin cancer and sun-protection guidelines, attitudes, and policies for sun protection at the swimming pool. Surveys were completed at the beginning of the summer and approximately 8 weeks later, near the end of the swimming lessons season. POOL COOL research staff conducted observations at the beginning, middle, and end of the summer to ascertain structural and environmental changes, including the sun-safety environment (availability of sunscreen, shaded areas, and sun-safety signage) and lifeguard sun-safety practices (wearing hat, shirt). Findings for the main targeted outcomes are presented below.
Effects of the POOL COOL Intervention on Child Sun-Protection Habits and Sunburn
Parents of children who received the POOL COOL intervention reported significantly higher use of sunscreen (baseline M=3.09, follow-up M=3.15), shade (baseline M=2.12, follow-up M=2.16) and higher composite sun protection habits* scores (baseline M=2.29, follow-up M=2.30) for their children at follow-up than parents of children who received the injury prevention intervention.
*The composite sun protection habit score was created from five protective behaviors (using sunscreen, wearing a hat, wearing a shirt, seeking shade, and wearing sunglasses) on a 4-point scale ranging from 1 (rarely/never) to 4 (always), adding the responses for each behavior and dividing by the number of items answered to obtain a summary score, ranging from 1 to 4.
Parents of children at moderate or high risk for skin cancer who received the POOL COOL intervention reported a 23% reduction in children sunburns compared with the preceding summer, while parents of children at moderate or high risk who received the injury prevention intervention reported only a 1% reduction (p=.04).
Effects of the POOL COOL Intervention on Parents' Sun-Protection Habits, and Pool Sun-Protection Policies
Parents of children who received the POOL COOL intervention self-reported significantly more use of sunscreen (baseline M=2.52, follow-up M=2.56), hat use (baseline M=2.07, follow-up M=2.15), and higher composite sun protection habits scores (baseline M=2.45, follow-up M=2.52) at follow-up than parents of children who received the injury prevention intervention.
At follow-up, the POOL COOL group parent surveys showed substantially greater increases in sun-protection policies at their pools compared with the injury prevention group: 2.59 compared with 1.67, or 55.1% higher on a scale of 0 to 4 (p<.001).
Knowledge scores, relatively high at baseline, remained virtually unchanged in both groups at follow-up.
Observational Findings of Changes in Sun-Safety Environments and Lifeguard Sun Protection
Pools in the POOL COOL trial had greater improvements in posting of sun-safety signs (p<.01), availability of sunscreen (p<.05), and lifeguard shirt use (p<.01).
Dose-Response Effect of the POOL COOL Intervention
There was a significant dose-response effect on Sun Protection Habits for children receiving two or more lessons or activities compared with those whose parents reported that they received zero or one (p<.05).