LETTER RESEARCH Attitudes, knowledge, and practices regarding sun safety among third to fifth graders from Chicago-area schools To the Editor: Exposure to ultraviolet radiation and childhood sunburns are linked to increased risk for developing melanoma later in life. Sun-safe behaviors from an early age may help reduce the risk of future skin cancer.1 To effectively teach proper sun-safe practices, it is essential to understand children’s existing perceptions and behaviors. We examined differences in sun safety between different Fitzpatrick skin type in 173 third, fourth, and fifth graders at 3 Chicago-area schools. Schools were chosen based on availability to host the SunWise program and had not participated previously. Children were administered a 20- to 25-minute, multiple-choice, validated SunWise questionnaire,2 including 4 questions from the sun-exposure subscale of the Fitzpatrick skin type questionnaire. All data were analyzed using software (SAS, Version 9.4, SAS Institute, Cary, NC). The 2 and Fisher exact tests were used to compare categorical variables. We created an empiric weighting system for all the questions to allow for overall assessment of sun safety (Table I, available at http://www.jaad.org). We constructed multivariate mixed models of weighted SunWise scores including the school as a random effect, and grade, gender, and modified Fitzpatrick skin type as covariates. No students reported difficulty comprehending or answering the questions. There were no differences between schools with regard to Fitzpatrick skin type (P ¼ .49) or gender

LETTERS (P ¼.61). Only 1 school enrolled third graders for this study. There were significant differences of weighted SunWise scores between Fitzpatrick skin type (Table II). Fitzpatrick skin type V to VI was associated with lower overall score (adjusted 5.96; 95% confidence interval [CI] 10.88 to 1.04; P ¼.01) and lower sun-safety knowledge (adjusted 2.71; 95% CI 4.51 to 0.92; P ¼.002) than Fitzpatrick skin type I to II. Fitzpatrick skin type III to IV was associated with lower knowledge (adjusted 1.13; 95% CI 1.87 to 0.38; P ¼ .002) and poorer sun-safe attitudes (adjusted 0.72; 95% CI 1.40 to 0.05; P ¼ .018) than Fitzpatrick skin type I to II (Table II). Children with Fitzpatrick skin type V to VI were less aware of the need to apply sunscreen away from the beach or poolside, frequency of sunscreen reapplication, ability to get a sunburn in the winter, and the need for photoprotection even when their skin does not sunburn (Table I). Children with Fitzpatrick skin type V to VI believed that sun safety is easy to do and sunscreen and sun-protective clothing are not important. Further, they were less likely to wear sunscreen or a protective hat, had fewer sunburns, and did not intend to apply sunscreen or play in the shade. Some scores are similar to pretest scores reported by Geller et al2: 65.3% versus 59.1% had knowledge that wearing a shirt or hat outside is sun protective; 14.5% versus 23.6% believed that having a suntan is good; and 59.0% versus 54.9% reported intention to put on sunscreen during the upcoming summer, respectively. The study has some limitations. Socioeconomic status may impact the results of this study; 1 school

Table II. Mixed models of SunWise weighted scores Total Adjusted b (95% CI)

Variable

Fitzpatrick skin type I-II 0.00 (reference) III-IV 0.26 (2.35 to 1.90) V-VI 5.96 (10.88 to 1.04) Gender Male 0.00 (reference) Female 0.77 (2.47 to 0.93) Grade level Third 0.00 (reference) Fourth 0.84 (4.44 to 2.77) Fifth 0.72 (4.26 to 2.83)

Knowledge P

Adjusted b (95% CI)

Attitudes P

Adjusted b (95% CI)

P

e 0.00 (reference) e 0.00 (reference) e .96 1.13 (1.87 to 0.38) .002 0.72 (1.40 to 0.05) .018 .01 2.71 (4.51 to 0.92) .002 1.40 (3.00 to 0.19) .10 e .37

0.00 (reference) 0.50 (0.09 to 1.10)

e .10

e .76 .81

0.00 (reference) 1.38 (0.07 to 2.69) 1.33 (0.003 to 2.65)

e .04 .05

0.00 (reference) 0.59 (1.15 to 0.04)

e .033

0.00 (reference) 0.25 (1.54 to 1.04) 0.59 (0.71 to 1.89)

e .82 .43

Bold indicates significant P values. CI, Confidence interval.

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was located in an urban area, whereas 2 were in wealthier suburbs. The sun-exposure subscale was not validated as a predictor of Fitzpatrick skin type in children. These results highlight shortcomings in current and intended practices, knowledge, and attitudes regarding sun protection in third to fifth graders with higher Fitzpatrick skin type. Darker-skinned children’s families may be less likely to include sun-safe behaviors because of a lack of awareness or misperceptions regarding skin cancer.3 Lack of access to sunscreen may also contribute, as found in a recent study that showed Hispanics had less access to sunscreens.4 Although patients with higher Fitzpatrick skin type have a lower incidence of skin cancer, they are not immune to these disorders. Moreover, when skin cancer occurs in higher Fitzpatrick skin type, the diagnosis is often delayed and mortality is higher.3 This study suggests that young children with higher Fitzpatrick skin type are an important target for sun-safety education. Tanya Bhattacharya, MD,a Girish C. Mohan, MD,a and Jonathan I. Silverberg, MD, PhD, MPHa,b,c Departments of Dermatology,a Preventive Medicine,b and Medical Social Sciences,c Northwestern University Feinberg School of Medicine, Chicago, Illinois Drs Bhattacharya and Mohan contributed equally as first authors. Funding sources: None. Conflicts of interest: None declared. Correspondence to: Jonathan I. Silverberg, MD, PhD, MPH, Department of Dermatology, Northwestern University, 680 Lakeshore Dr, Suite 1400, Chicago, IL 60611 E-mail: [email protected] REFERENCES 1. Oliveria SA, Saraiya M, Geller AC, Heneghan MK, Jorgensen C. Sun exposure and risk of melanoma. Arch Dis Child. 2006;91: 131-138. 2. Geller AC, Rutsch L, Kenausis K, Selzer P, Zhang Z. Can an hour or two of sun protection education keep the sunburn away? Evaluation of the Environmental Protection Agency’s SunWise School Program. Environ Health. 2003;2:13. 3. Battie C, Gohara M, Verschoore M, Roberts W. Skin cancer in skin of color: an update on current facts, trends, and misconceptions. J Drugs Dermatol. 2013;12:194-198. 4. Hernandez C, Calero D, Robinson G, Mermelstein R, Robinson JK. Comparison of sunscreen availability in Chicago Hispanic and non-Hispanic neighborhoods. Photodermatol Photoimmunol Photomed. 2012;28:244-249. http://dx.doi.org/10.1016/j.jaad.2014.11.007

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Teledermatology as pedagogy: Diagnostic and management concordance between resident and attending dermatologists To the Editor: Teledermatology may serve as a platform for the education of dermatology residents.1-3 A few studies have measured diagnostic1,2 and management1 concordance between residents evaluating patients in-person and attending dermatologists supervising residents via teledermatology. We report diagnostic and management concordance between resident and attending dermatologists responding to store-and-forward teledermatology consults submitted by primary care providers and discuss implications for resident education. We performed a prospective study between January and November 2013 with inclusion of 84 consults encompassing 90 dermatologic conditions. This study received approval from the Philadelphia Field Initiating Group of Human Immunodeficiency Virus Trials, Philadelphia Department of Public Health, and University of Pennsylvania institutional review boards. Verbal informed consent and Health Insurance Portability and Accountability Act authorization were obtained from patients; written informed consent was obtained from providers. Consults were submitted to the University of Pennsylvania by 25 primary care providers at the Jonathan Lax Center, the Dr Bernett L. Johnson Jr Sayre Health Center, and 8 Philadelphia Department of Public Health centers using the AccessDerm (Vignet Corporation, Fairfax, VA) mobile platform.4 Diagnoses and management plans, initially drafted by dermatology residents, were reviewed, edited, and submitted by attending dermatologists. Nine residents and 9 attending dermatologists responded to consults. For each dermatologic condition, 2 investigators (C.A.N. and J.T.) independently determined the concordance of differential diagnoses and management plans between resident and attending dermatologists. Cohen’s kappa assessing interrater reliability (95% confidence interval) for diagnostic and management concordance between the 2 investigators were 0.94 (0.91-0.98) and 0.87 (0.78-0.90), respectively. Statistical analyses were performed in Stata 12.1 (StatCorp LP, College Station, TX). Each resident responded to a median (interquartile range) of 9 (4-15) consults. The number of responses stratified by dermatology training year was: 10 (12%) first-, 29 (34%) second-, and 45 (54%) third-year residents. Based on the leading diagnosis of the attending dermatologist or definitive diagnosis when available, dermatologic

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Table I. Differences of sun knowledge, attitudes, and practices by Fitzpatrick skin type Fitzpatrick skin type Question, no. (%)

Knowledge You only need to wear sunscreen when you are at the beach or pool. True False After you put on sunscreen once, how often should you put it on again that day? If you put it on once, you don’t have to put it on again that day Every 8 h Every 2 h You cannot get a sunburn in the winter. True False If my skin doesn’t get sunburned, I don’t need to worry about protecting myself from the sun: True False Attitudes Keeping your skin safe from the sun is: Hard to do Not too hard, not too easy Easy to do How important is wearing clothes that block the sun? Very important Somewhat important Not important How important is it to wear sunscreen when you are outside? Very important Somewhat important Not important Practices Why I don’t always wear sunscreen when I’m outside: It takes too long to put on sunscreen I forget to put on sunscreen or I don’t even think about sunscreen It stings my eyes Sunscreen feels greasy on my skin It’s hard to put sunscreen on my whole body I don’t have any sunscreen None of the above. I always wear sunscreen! Why I don’t always wear a hat when I’m outside: I forget to bring a hat or I don’t even think about wearing a hat It’s too hot to wear a hat I don’t like to wear a hat I don’t have a hat None of the above. I always wear a hat! When you wear a bathing suit outside, where do you put on sunscreen? My face My arms My ears My shoulders

Overall

I-II

III-IV

P value

V-VI

.003 68 (39.3) 104 (60.1)

13 (25.0) 39 (75.0)

49 (43.4) 64 (56.6)

6 (85.7) 1 (14.3) .005

70 (40.5)

13 (24.5)

53 (46.9)

4 (57.1)

51 (29.5) 52 (30.1)

23 (43.4) 17 (32.1)

25 (22.1) 35 (31.0)

3 (42.9) 0 (0.0)

90 (52.0) 83 (48.0)

20 (37.7) 33 (62.3)

65 (57.5) 48 (42.5)

5 (71.4) 2 (28.6)

.036

.002 49 (28.3) 121 (69.9)

8 (15.4) 44 (84.6)

36 (32.4) 75 (67.6)

5 (71.4) 2 (28.6)

15 (8.7) 92 (53.2) 61 (35.3)

12 (23.1) 25 (48.1) 15 (28.9)

3 (2.8) 65 (59.6) 41 (37.6)

0 (0.0) 2 (28.6) 5 (71.4)

63 (36.4) 92 (53.2) 17 (9.8)

27 (50.9) 24 (45.3) 2 (3.8)

34 (30.4) 65 (58.0) 13 (11.6)

2 (28.6) 3 (42.9) 2 (28.6)

79 (45.7) 76 (43.9) 18 (10.4)

37 (69.8) 16 (30.2) 0 (0.0)

41 (36.3) 59 (52.2) 13 (11.5)

1 (14.3) 1 (14.3) 5 (71.4)

47 (27.2) 104 (60.1)

16 (30.2) 26 (49.1)

30 (26.6) 72 (63.7)

1 (14.3) 6 (85.7)

.74 .09

8 20 13 5 16

14 45 21 14 10

2 4 3 2 0

.32 .64 .20 .27 .002

.0004

.028

\.0001

24 69 37 21 26

(13.9) (39.9) (21.4) (12.1) (15.0)

(15.1) (37.7) (24.5) (9.4) (30.2)

(12.4) (39.8) (18.6) (12.4) (8.9)

(28.6) (57.1) (42.9) (28.6) (0.0)

82 (47.4)

22 (41.5)

56 (49.6)

4 (57.1)

.55

67 69 21 25

(38.7) (39.9) (12.1) (14.5)

20 19 10 13

(37.7) (35.9) (18.9) (24.5)

44 47 9 11

(38.9) (41.6) (8.0) (9.7)

3 3 2 1

(42.9) (42.9) (28.6) (14.3)

.99 .75 .037 .033

147 150 75 132

(85.0) (86.7) (43.4) (76.3)

48 50 28 48

(90.6) (94.3) (52.8) (90.6)

95 96 45 91

(84.1) (85.0) (39.8) (71.7)

4 4 2 3

(57.1) (57.1) (28.6) (42.9)

.07 .02 .20 .002

Continued

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Table I. Cont’d Fitzpatrick skin type Question, no. (%)

My neck My stomach My legs My back I don’t put any sunscreen on In the last 12 mo, how many times did you have a painful or red sunburn that lasted a day or more than a day? 0 1 2 3 4 $5 Intended practices When you are outside this summer, will you try to play in the shade instead of the sun? Yes Most likely Probably not No When you are outside this summer, will you put sunscreen on? Yes Most likely Probably not No

Overall

I-II

III-IV

V-VI

132 112 138 117 17

(76.3) (64.7) (79.8) (67.6) (9.8)

48 38 49 42 0

(90.6) (71.7) (92.5) (79.3) (0.0)

82 71 86 71 14

(72.6) (62.8) (76.1) (62.8) (12.4)

2 3 3 4 3

(28.6) (42.9) (42.9) (57.1) (42.9)

87 36 23 14 8 5

(50.3) (20.8) (13.3) (8.1) (4.6) (2.9)

7 9 13 13 7 4

(13.2) (17.0) (24.5) (24.5) (13.2) (7.6)

74 26 10 1 1 1

(65.5) (23.0) (8.9) (0.9) (0.9) (0.9)

6 1 0 0 0 0

(85.7) (14.3) (0.0) (0.0) (0.0) (0.0)

P value

.004 .24 .002 .08 .0004 \.0001

\.0001 23 51 61 32

(13.3) (29.5) (35.3) (18.5)

16 23 9 4

(30.8) (44.2) (17.3) (7.7)

6 28 49 25

(5.6) (25.9) (45.4) (23.2)

1 0 3 3

(14.3) (0.0) (42.9) (42.9) \.0001

46 56 47 23

(26.6) (32.4) (27.2) (13.3)

22 20 8 3

(41.5) (37.7) (15.1) (5.7)

24 36 37 15

(21.4) (32.1) (33.0) (13.4)

0 0 2 5

(0.0) (0.0) (28.6) (71.4)

Fitzpatrick skin type was determined using the sun-exposure subscale of the original Fitzpatrick skin type questionnaire. Responses from the questions regarding skin response to the sun, skin tan, depth of tan, and facial sensitivity to the sun were weighted from 0-4 corresponding to A-E. Weighted scored were divided into Fitzpatrick skin types (I-II: 0-6; III-IV: 7-12; V-VI: 13-16). Bold indicates significant P values.

Attitudes, knowledge, and practices regarding sun safety among third to fifth graders from Chicago-area schools.

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