Dermatology: Practical and Conceptual Original Article | Dermatol Pract Concept. 2024;14(3):e2024127 1 Sun Exposure of Preschoolers, Parental Sun Protection Behavior, and Sun Protection Measures at Preschool in Bavaria—Comparison of Two Cross- Sectional Studies of 2010/11 and 2018/19 Christine Korbely1, Jonas Huß1, Caroline Quartucci1,2, Uta Nennstiel3, Rike Severin4,5, Burkhard Summer6, Eva Oppel6, Dennis Nowak2,7, Caroline Herr1,2, Stefanie Heinze1,2 and Susanne Kutzora1 1 Department of Occupational and Environmental Health and Epidemiology, Bavarian Health and Food Safety Authority, Munich, Germany 2 Institute and Clinic for Occupational, Social and Environmental Medicine, University Hospital, LMU Munich, Munich, Germany 3 Bavarian Health and Food Safety Authority (LGL), Oberschleißheim, Germany 4 Institute for Medical Informatics, Biometry and Epidemiology (IBE) at the Ludwig-Maximilians-Universität München, Munich, Germany 5 Pettenkofer School of Public Health, Munich, Germany 6 Department of Dermatology and Allergology, Ludwig-Maximilians-University Munich, Munich, Germany 7 Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany Key words: children, sun exposure, sun protection, skin cancer, UV index Citation: Korbely C, Huß J, Quartucci C, et al. Sun Exposure of Preschoolers, Parental Sun Protection Behavior, and Sun Protection Measures at Preschool in Bavaria—Comparison of Two Cross-Sectional Studies of 2010/11 and 2018/19. Dermatol Pract Concept. 2024;14(3):e2024127. DOI: https://doi.org/10.5826/dpc.1403a127 Accepted: January 12, 2024; Published: July 2024 Copyright: ©2024 Korbely et al. This is an open-access article distributed under the terms of the Creative Commons Attribution- NonCommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Christine Korbely, Department of Occupational and Environmental Health / Epidemiology, Bavarian Health and Food Safety Authority, Pfarrstr. 3, 80538 München, Germany. Email: christine.korbely@outlook.com Introduction: Children’s skin is particularly susceptible to the carcinogenic effects of ultraviolet radia- tion. Young children are dependent on sun protection measures taken by parents and other caregivers. Objectives: The aim of the study is to evaluate parental sun protection behavior and sun protection mea- sures at preschool at two points in time (2010/11 and 2018/19) in Bavaria and to test for a secular trend. Methods: Two cross-sectional surveys were carried out. For each survey, more than 4,000 parents of preschoolers completed a self-administered questionnaire about parental sun protection behavior and sun protection measures at preschool. To identify possible associations between parental sun protec- tion behavior and sociodemographic characteristics, logistic regression analysis was carried out. Results: In the survey of 2018/19, six out of eight sun protection measures are adequately applied by over two-thirds of the parents. Two out of eight sun protection measures are adequately applied ABSTRACT 2 Original Article | Dermatol Pract Concept. 2024;14(3):e2024127 Introduction Among almost all Caucasian population, the incidence rates for skin cancer worldwide have been mostly rising over the last decades [1-3]. The incidence rate of malignant melanoma has more than quintupled since the 1970s in Germany [4]. The most important exogenous risk factor for malignant mela- noma is ultraviolet (UV) radiation from the sun or sunbeds [4]. Children spend more time in the sun during leisure activ- ities than adults and thus are more exposed to UV radiation [5]. In addition, children’s skin is particularly susceptible to the carcinogenic effects of ultraviolet radiation, because it is structurally different to adult skin [6-8]. These structural dif- ferences lead to a strong association between UV exposure during childhood and risk of skin cancer in adulthood [9]. Avoiding or reducing exposure to UV radiation is the most important preventive measure for all children regard- less of skin type [10-12]. UV exposure can be reduced by physical barriers such as shade (going indoors, seeking shade outdoors), sun hats, clothing, and sunglasses. Parts of the body which cannot be covered by clothes, such as the face or hands, should be protected by applying sunscreen [13]. Young children depend on adults to provide sun pro- tection measures, as they are usually unable to adequately assess the consequences of sun exposure. Secondly, there is evidence that behavior which was internalized in early child- hood is more likely in adulthood [10,14-17]. Objectives The aim of the study is to evaluate sun exposure of pre- schoolers, parental sun protection behavior and sun protec- tion measures at preschool at two points in time (2010/11 and 2018/19) in Bavaria, and to test for a secular trend. Methods Data Collection As part of the School Entrance Examination (SEE)1, nine pa- rental surveys have been carried out at the health monitoring 1The school entrance examination is mandatory for all children who start primary school the following year. The SEE checks whether units (HMU)2 in Bavaria since 2004 [18]. Each time, the questionnaire contains different topics. In the 5th Survey of 2010/2011 (S5) and the 9th Survey of 2018/2019 (S9), sun exposure and sun protection measures were among the topics. During the mandatory school entrance examination (SEE) for preschoolers, paper questionnaires were handed out to all parents in the cities Bamberg, Ingolstadt and Mu- nich (the latter only in S5), as well as the districts Bamberg, Günzburg, and Schwandorf. Participation in the survey was voluntary and parental consent was obtained. HMU are ap- proved by the local ethics committee [18]. Sociodemographic Characteristics In order to compare the two study populations in terms of sociodemographic characteristics, the following vari- ables were analyzed: sex, marital status (married living together versus married living separated/divorced/single/ widowed), residence, family size (family with 1 child versus family with 2 children; family with 1 child versus family with 3 or more children), parental school education (low = 9 years of school or no graduation versus middle = 10 or 11 years of school versus high = 12 or 13 years of school), employment of parents (at least one person employed in the household versus no person employed in the house- hold), migration background (migrant = both parents born abroad/child born abroad and at least one parent born abroad/no German spoken at home/German and another language spoken at home versus no migrant), and health status (moderate/bad/very bad versus good/very good). In order to identify possible associations between parental sun protection behavior and sociodemographic characteristics, logistic regressions were performed. Skewed variables were subsequently excluded. children meet the requirements to cope with everyday school life. The SEE aims to detect impairments in e.g. vision or hearing, speech disorders, as well as vaccination gaps. 2Since 2004, the Bavarian Health and Food Safety Authority sup- ported by the Bavarian State Ministry of Health and Care have established health monitoring units (HMU) in Bavaria. The HMU surveys allow monitoring of health and living environment of chil- dren and identification of factors influencing the maintenance of health. The data collected is used to generate recommendations for promoting children’s health [18]. by less than one-third of the parents. Those two measures are aligning sun protection to actual UV index and preschoolers wearing sunglasses. The comparison of the study population of the survey of 2010/11 and of 2018/19 shows an improvement in parental sun protection behavior for seven out of eight sun protection measures. In both surveys more than 80% of parents state that preschool staff ensures preschoolers wear sun hats and sunscreen outside on sunny days. Conclusions: Future campaigns should focus on the use of sunglasses and promote the UV index, as these sun protection measures are used very little. Original Article | Dermatol Pract Concept. 2024;14(3):e2024127 3 Sun Exposure and Sunburn To estimate and compare the amount of sun exposure in S5 and S9, the daily average outdoor stay of preschool children between 10am and 5pm during summer (on weekdays/on weekends), and the number of visits of preschool children to open-air swimming pools/lakes during summer have been analyzed. The number of visits to open-air swimming pools/ lakes has been categorized into never, up to 20 times, more than 20 times, and pool at home. Regarding sunburn, the following data has been an- alyzed and compared for S5 and S9: Number of sunburns with and without blisters, and the age when the first sunburn occurred. Number of sunburns was categorized into 0, 1, 2, and more than 2, and age of the child at first sunburn into no sunburn, younger than 3 and 3 or older. Parental Sun Protection Behavior To estimate and compare the parental sun protection behav- ior, eight parental protection measures of the three topics sunscreen, physical barriers, and UV index were analyzed. Those eight variables were categorized into adequate and in- adequate parental sun protection behavior (shown in Table 1). The categorization of the variables into adequate and in- adequate was carried out according to sun protection recom- mendations of the Federal Office for Radiation Protection and WHO [13,19]. Table 1. Categorization of the variables for parental sun protection behavior Topic Variable Categorized Values Sunscreen Parents protect their children with sunscreen on sunny days Definition of sunscreen: “any preparation (such as creams, oils, gels, sprays) intended to be placed in contact with the human skin with a view exclusively or mainly to protecting it from uv radiation by absorbing, scattering or reflecting radiation” [26] inadequate: never; rare; sometimes adequate: often; always sun protection factor (SPF) of the sunscreen, which is commonly used at home Definition of SPF: “Sunscreen products found on the market are characterized by a Sun Protection Factor (SPF). The SPF can be defined as the numerical ratio between the minimal erythemal dose with photo protection and the minimal erythemal dose without. SPF is equivalent to a standardized degree of protection against UVB and UVA radiation: low protection for a labelled SPF equal to 6 or 10, medium protection for a labelled SPF equal to 15, 20 or 25, high protection for a labelled SPF equal to 30 or 50 and very high protection for a labelled SPF equal to 50+. […] the amount of sunscreen applied when testing SPF is 2 mg/cm” [27] inadequate: SPF 6-10 adequate: SPF 15 – 25; SPF 30 – 50; SPF 50+ (SPF of the sunscreen, which is commonly used on holiday) inadequate: SPF 6-10 adequate: SPF 15 – 25; SPF 30 – 50; SPF 50+ Time period between parental application of sunscreen and exposure inadequate: not at all; just before adequate: about 15 minutes before; at least 30 minutes before Physical barriers Child wears hat on sunny days inadequate: never; rare; sometimes adequate: often; always Child wears clothes on sunny days inadequate: never; rare; sometimes adequate: often; always Child wears sunglasses on sunny days inadequate: never; rare; sometimes adequate: often; always UVI Parents align sun protection to actual UV index on sunny days Definition of UV index: The UV index describes the expected daily peak level of the erythemal UV irradiance at ground level. The higher the UV index, the faster a sunburn can occur when skin is not protected. The UV index is a guide to answering the question what sun protection measures should be taken and when [28,29]. inadequate: no; do not know the UV index adequate: yes 4 Original Article | Dermatol Pract Concept. 2024;14(3):e2024127 Preschoolers of study population S9 stay outside during noon more often (often-always) at preschool (34.4%) than at other places (22.7%). No data was collected for study population of S5. Detailed information is available in Sup- plementary Table S1. Sunburn Preschoolers of study population S9 get less sunburned than preschoolers of study population S5 (S9: 83.3% preschool- ers with zero sunburn in life, + 3,9pp compared to S5). Fur- thermore, they are older when getting sunburned for the first time (S9: 3.69 years, +0.09 years, Table S1). Parental Sun Protection Behavior Parents of study population S9 apply seven out of eight sun protection measures more adequately than parents of study population S5 (as shown in Figure 2: sunscreen + 2.7pp, SPF at home +2.9pp, SPF on holiday +5.5pp, hat +5.7pp, clothes +1.1pp, sunglasses +4.8pp, UV index +4.4pp). For the variable child wears clothes on sunny days, the change is not significant. The only sun protection measure applied less adequately is Time period between parental application of sunscreen and exposure (time pe- riod –2.2 pp, Figure 2). There are differences regarding the number of parents who adequately apply those eight sun protection measures. In S9, six out of eight parental sun protection measures are applied adequately by 68.9% or more parents (SPF at home 94.0%, sunscreen 90.6%, SPF on holiday 89.7%, hat 87.6%, clothes 79.2%, time period 68.9%, Figure 2 and Ta- ble S2). However, two out of eight sun protection measures are applied adequately by 24.6% or less in S9 (sunglasses 24.6%, UV index 11.8%, see Figure 2, Table S2). Since information is lost when the categories adequate and inadequate are formed, Figure 2 (detailed information in Table S2) shows all values of the variables. For some vari- ables, the values within the categories show opposing trends when comparing the two study populations or show partic- ularly strong developments for one value: • In S9, more parents use sunscreen adequately (+2.7pp), but the values within the categories show opposite trends (always: +5.2pp, often: -2.5pp). • The increase in the number of parents using an adequate SPF (SPF at home +2.9pp, SPF on holiday +5.5pp) is particularly generated by an increased use of SPF 50+ at home and during holidays (at home: +22.8pp, on holiday: +25.4pp). However, sunscreen with a SPF 15-25 (at home: -16.3pp, on holiday: -6.5pp) and SPF 30-50 (at home: -3.6pp, on holiday: -13.5pp) is used less frequently in S9. In S9, a higher SPF is used on holidays than at home (SPF at home = 30-50; SPF on holiday = 50+). Sun Protection Measures at Preschool To estimate and compare sun protection measures at pre- school, parents were asked whether: • preschool staff ensures that children wear sun hats and sunscreen outside on sunny days. • shade was available in the garden of the preschool. For S9 we also analyzed whether: • shade was ensured by trees, sunshades, sun sails, awnings, or other measures. • preschool staff ensures that preschoolers stay in the shade on sunny days at noon (11 am – 3 pm). • the UV index is displayed at preschool. • preschool staff aligns sun protection to actual UV index. • parents are informed about sun protection measures at preschool. Statistical Analysis The arithmetic mean was calculated for metric variables. To check whether the variables in S5 and S9 are independent, a Chi-square test was performed. The following null hypoth- esis H0 was established: the variables in S5 and S9 are sto- chastically independent. All requirements for the Chi-square test were met. For five of the previously mentioned sociodemographic variables and for six parameters of parental sun protection behavior, Odds Ratios (OR) and 95% confidence interval (CI) were calculated [20]. Statistical analyses were performed using Statistical Analysis Software Version 9.4 (SAS Institute Inc.). Results Study Population A total of 7491 children took part in S5. Parents completed the questionnaires for 4579 children, which corresponds to a response rate of 61.1%. A total of 5986 children took part in S9, and parents completed a questionnaire for 4009 chil- dren, which corresponds to a response rate of 67.0%. In S5, 23.9% of the surveys were filled out by parents in Munich. In S9, Munich has not been part of the survey which was com- pensated by additional surveys in Bamberg (+13.6pp [percent points] of surveys completed by Bamberg in S9) and Schwan- dorf (+8.1pp). There are no significant changes regarding sex, marital status and family size comparing both study popula- tions. Detailed information is available in Table 2. Sun Exposure As Figure 1 shows, preschoolers of study population S9 are less exposed to the sun compared to preschoolers of study population S5. Original Article | Dermatol Pract Concept. 2024;14(3):e2024127 5 Table 2. Sociodemographic Characteristics Survey S5 N = 4579 S9 N = 4009 Mean n SD (%) Mean n SD (%) Age of children, years 5.49 0.52 5.31 0.48 Residencea Missing . . 73 (1.8) Bamberg 835 (18.2) 1274 (31.8) Günzburg 940 (20.5) 803 (20.0) Ingolstadt 990 (21.6) 904 (22.5) Schwandorf 720 (15.7) 955 (23.8) Munich 1094 (23.9) . . Sexc Missing 2 (0.0) 5 (0.1) Girl 2134 (46.6) 1914 (47.7) Boy 2443 (53.4) 2090 (52.1) Marital statusc Missing 79 (1.7) 77 (1.9) Parents married living together 3756 (82.0) 3246 (81.0) Parents not living together (married/divorced/single/widowed) 744 (16.2) 686 (17.1) Family sizec Missing 3 (0.1) 5 (0.1) Family with 1 child 997 (21.8) 834 (20.8) Family with 2 children 2531 (55.3) 2154 (53.7) Family with 3 or more children 1048 (22.9) 1016 (25.3) Parental educationb,d Missing 146 (3.2) 125 (3.1) High 1885 (41.2) 1816 (45.3) Medium 1597 (34.9) 1319 (32.9) Low 951 (20.8) 749 (18.7) Employment of parentsb Missing 152 (3.3) 95 (2.4) At least one person employed in the household 4175 (91.2) 3759 (93.8) No person employed in the household 252 (5.5) 155 (3.9) Migration backgrounda,e Missing 20 (0.4) 1 (0.0) Migrant 1502 (32.8) 1122 (28.0) Not migrant 3057 (66.8) 2886 (72.0) Health statusa Missing 57 (1.2) 34 (0.8) Mediocre, bad or very bad 232 (5.1) 114 (2.8) Good or very good 4290 (93.7) 3861 (96.3) SD = standard deviation. a The difference between survey 2010/11 and survey 2018/19 is significant (P < 0.0001). b The difference between survey 2010/11 and survey 2018/19 is significant (P < 0.0004). c The difference between survey 2010/11 and survey 2018/19 is not significant. d Parental education: high = school type with 12 years of education (“Gymnasium”); middle = school type with 10 to 11 years of education (“Realschule” and “Wirtschaftsschule”); low = school type with 9 years of education (“Hauptschule”) and school for children and young adults who have special learning needs. e Migration background: migrant = (both parents born abroad) or (child born abroad and at least 1 parent born abroad) or (no German spoken at home) or (German and other language spoken at home). 6 Original Article | Dermatol Pract Concept. 2024;14(3):e2024127 Sun Protection Measures at Preschool Figure 5 (detailed information in Table S3) shows the infor- mation provided by parents on the questions regarding sun protection in preschool. Since parents are supposed to make statements about sun protection measures at preschool, the questions are often answered with “do not know” or are not answered at all. Conclusions It could be shown that most of the defined parental sun pro- tection measures are carried out adequately. This finding was also reported by another study of 2011 in Bavaria [21]. In S9, sunscreen was the most common sun protection measure used by parents. According to the WHO, children should be particularly protected from the sun by physical barriers, and sunscreen should only be used on parts of the body that cannot be covered, such as face and hands. There- fore, future campaigns should also promote physical barriers as sun protection measures. Two out of eight sun protection measures are adequately applied by less than one third of the parents: Aligning sun protection to actual UV index and children wearing sun- glasses on sunny days. Similar to our findings, a study on sun protection for Ba- varian children in 2016 proves using sunscreen with a high SPF, and wearing sun hats as very common sun protection • In both surveys, most parents apply sunscreen to their children 15 minutes before sun exposure (S5: 45.5%, S9: 50.7%). The values within the categories show opposite trends (about 15 minutes before: +5.2pp, at least 30 min- utes before: -7.4pp). • In S9, more preschoolers wear hats adequately (+5.7pp), but the values within the categories show opposite trends (always: +9.1pp, often: -3.4pp). • In S9, less parents do not know the UV index (-15.3pp), nevertheless, more parents do not align sun protection to actual UV index on sunny days (+11.7pp). Not all sun protection measures and sociodemographic characteristics were included in the logistic regression be- cause certain values of variables occur in too small numbers. For the dependent variables, two of the sun protection mea- sures are excluded: SPF at home and SPF on holiday, since in both surveys 1.7% or less of the interviewed parents show an inadequate SPF of commonly used sunscreen at home and on holiday. For the independent variables, two of the sociodemographic characteristics are excluded: employment of parents since in 5.5% or less households no person is em- ployed; health status since 5.1% or less preschooler have a mediocre, bad or very bad health status. Certain sociodemographic characteristics increase the likelihood of inadequate sun protection measures in both surveys, especially increasing family size (Figures 3 and 4). 2010/2011 2018/2019 2010/2011 2018/2019 3.3 3.0 5.0 6.31.0 1.1 0.4 0.63.9 5.1 1.3 1.7 18.3 20.9 5.7 7.7 48.6 47.6 28.3 31.9 24.9 22.3 59.2 51.8 Nu m be r o f p re sc ho ol er s i n pe rc en t 4 hours or more 2 - below 4 hours 1- below 2 hours 30 min to 1 hour less than 30 minutes missings Figure 1. Child avrage outdoor stay between 10 am and 5 pm during summer. Original Article | Dermatol Pract Concept. 2024;14(3):e2024127 7 nowadays, applying sunscreen before sun exposure is less stressed than it was in the past. Gefeller et al could show in a German study of combined data from four large popula- tion-based surveys that knowledge of the need for sun pro- tection has increased significantly overall among parents of 3 to 6-year-old children [17]. Our results show a continuation of this positive development. The positive development of parental sun protection be- havior may have also been favored by a change in the so- ciodemographic characteristics of study population S9. The measures and shows deficits in wearing sun-protective cloth- ing, and sunglasses [21]. The comparison of both cross-sectional data shows a slight improvement in parental sun protection behavior for seven out of eight sun protection measures (improvement of Child wears clothes on sunny days is not significant). The only sun protection measure applied significantly less ade- quately is Time period between parental application of sun- screen and exposure. However, the decrease from S5 to S9 is very small and could also be explained by the fact that Figure 2. Parental sun protection behavior. Figure 3. Adjusted odds ratios. Associations between inadequate use of sunscreen/UV index and sociodemographic characteristics. 8 Original Article | Dermatol Pract Concept. 2024;14(3):e2024127 parents in S5 and S9 report that preschool staff ensures that preschoolers wear sun hats and sunscreen outside on sunny days. This finding is in line with a survey of 246 preschools in southern Germany in 2014/2015 [10]. Similar to parents, preschool staff hardly aligns sun protection to the UV index. A study on sun protection measures in daycare facilities in the USA in 2018 also shows that the majority of daycare staff is not aware of the UV index [24]. The results regarding sun protection at preschool are to be interpreted with caution because they were collected by parental reporting and not by the preschools themselves. The development from S5 to S9 regarding preschool staff ensures that preschoolers wear sun hats and sunscreen on sunny days and shadow in the garden of preschool available shows a decline (sun hats and sunscreen: S5 = 89.8%, S9 = 82.7% - > -7.1 pp; shadow: S5 = 96.0%, S9 = 91.3% -> -4.7 pp). The strength of our study is that data from identical questions of 2 HMU surveys were compared. This is cur- rently the only study in Germany that shows a development of parental sun protection behavior over the last 9 years. Further strengths were the high number of participants as more than 4000 participants for each survey were available as well as relatively high response rates (>60%) compared to similar studies [25]. Selection bias was not assessed due to lack of information on non-responders. However, due to the high response rate and the survey of all social strata within the SEE, the study population is representative for Bavarian preschoolers [18]. A limitation of our study is the collection following variables show significant slight increases (≤ 5.2 pp) from S5 to S9 which may imply a higher social status of study population of S9: more preschoolers without migra- tion background, higher educated parents, more preschoolers with good to very good health status, and more households with at least one person employed. However, the multivari- able analysis did not show a clear trend that a higher social status is associated with improved parental sun protection behavior. Living in a family with three or more children com- pared to living in a family with one child is a risk factor for four out of six sun protection measures in both surveys. Regarding the migration background, there are opposing associations. On the one hand, migrants are at higher risk for inadequately using three sun protection measures: use of sunscreen, and the time period before applying the sunscreen and exposure and wearing a hat. On the other hand, wearing sunglasses and aligning sun protection to UV index is more common in migrant families. That migrant children are more likely to wear sunglasses could be explained as follows. The majority of migrants in Germany is from southern countries. In southern countries wearing sunglasses is more common as shown by a study about sun protection behavior of primary students in coastal area of Greece of 2012 [22]. The aim of the study was also to analyze sun protection measures taken at preschool. Sun protection behavior re- hearsed in peer groups at preschool is often better received by the children themselves than by the parents, and is sooner perceived as normal [10,14,23]. More than 80 percent of Figure 4. Adjusted odds ratios – associations between inadequate use of physical barriers and sociodemographic characteristics. Original Article | Dermatol Pract Concept. 2024;14(3):e2024127 9 The comparison of the survey of 2010/11 and of 2018/19 shows an improvement in parental sun protection behav- ior for seven out of eight sun protection measures. The use of physical barriers should be emphasized in future sun of data by interviewing parents, as recall or social desirabil- ity bias is possible. The questionnaire is only available in German, which can pose a language barrier for non-German parents and lead to problems of understanding. 4 16.0 13.7 34.5 59.6 80.1 awnings* other* sunshades* sun sails* trees* 2018/2019 7.4 9.2 9.8 9.0 19.2 35.6 44.8 16.9 5.3 50.3 38.4 23.3 68.1 4.9 7.0 50.8 Preschool staff ensure that preschool children stay in the shade on sunny days at noon (11 am - 3 pm) UV-index displayed at preschool Preschool staff align sun protection to actual UV-index Parents being informed about sun protection measures at preschool yes no do not know missing Preschool staff ensures that preschoolers stay in the shade on sunny days at noon (11 am - 3 pm) UV-index displayed at preschool Preschool staff align sun protec�on to actual UV-index Parents being informed about sun protec�on measures at preschool (11 am - 3 pm) * The difference between survey 2010/11 and survey 2018/19 is significant (p < 0.0001) ** The difference between survey 2010/11 and survey 2018/19 is significant (p < 0.0335) Survey 2019/20: Percentage of parents who state that shade in preschool is provided by... *Missing 7.7% 96.0 91.3 89.8 82.7 1.6 1.0 6.2 3.4 2.4 7.7 4.0 13.9 yes no missing Percentage of parents who state… Percentage of parents who state… 2018/19 2018/19 2010/11 2010/11 Preschool staff ensures that preschoolers wear sun hats and sunscreen outside on sunny days* Shadow in the garden of preschool available** Figure 5. 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Lingham G, Milne E, Cross D, et al. Investigating the long-term impact of a childhood sun-exposure intervention, with a focus on eye health: protocol for the Kidskin-Young Adult Myopia Study. Clinical Trial Research Support, Non-U.S. Gov’t. BMJ open. Jan 31 2018;8(1):e020868. doi:10.1136/bmjopen-2017-020868. PMID: 29391375. PMCID: PMC5829843. 16. Gefeller O, Li J, Uter W, Pfahlberg AB. The impact of parental knowledge and tanning attitudes on sun protection practice for young children in Germany. Int J Environ Res Public Health. May 5 2014;11(5):4768-81. doi:10.3390/ijerph110504768. PMID: 24802677. PMCID: PMC4053880. 17. Gefeller O, Uter W, Pfahlberg AB. Long-term development of parental knowledge about skin cancer risks in Germany: Has it changed for the better? Prev Med. Aug 2016;89:31-36. doi:10.1016/j.ypmed.2016.05.016. PMID: 27211108. 18. Bolte G, Heissenhuber A, Von Kries R, et al. Health monitor- ing units in Bavaria. Concept, aims and thematic focus of the first survey on children’s environment and health. Bundesge- sundheitsblatt, Gesundheitsforschung, Gesundheitsschutz. 2007;50(4):476-483. doi: 10.1007/s00103-007-0191-0. PMID: 17387440. 19. Protection of man against the hazards of solar UV radiation and UV radiation in solaria. Recommendation by the German Com- mission on Radiological Protection. 2016. protection campaigns, as our study shows sunscreen being the most used sun protection measure. In addition, future campaigns should pay particular attention on sunglasses and the promotion of the UV index as a tool to improve sun protection behavior. The data on sun protection mea- sures at school were neither collected directly at preschool nor by preschool staff. In further studies, the assessment of sun protection measures in preschools could be of interest, as pre-school has a role model function and contributes to educating preschool children and their parents about sun protection. Acknowledgement: Susanne Kutzora for the GME Study Group: Health Authority of the District Office of Bamberg (Wiltrud Doerk, Angelika Pfister, Heike Seidler, Rosema- rie Sittig, Winfried Strauch, Heidi Thamm, Anita Wunder); Health Authority of the District Office of Günzburg (Tatjana Frieß-Hesse, Monika Jung, Franziska Lang, Dagmar Rudolph, Gabriele Schick, Roland Schmid, Gudrun Winter); Health Authority of the City Ingolstadt (Ursula Becker, Isa- bella Bockmann, Christine Gampenrieder, Margot Motzet, Elisabeth Schneider, Traudl Tontsch, Gerlinde Woelk); Health Authority of the District Office of Schwandorf (Kornelia Baranek, Gitte Koch-Singer, Maximilian Kühnel, Roswitha Stangl); Institute of Social Pediatrics and Adolescent Med- icine, Ludwig-Maximilian-University Munich (Rüdiger von Kries); Bavarian Health and Food Safety Authority, Munich and Oberschleißheim (Annette Heißenhuber, Stefanie Heinze, Caroline Herr, Gabriele Hölscher, Jonas Huß, Bernhard Liebl, Franziska Nairz, Uta Nennstiel, Alisa Weber, Manfred Wildner). 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