Women and Birth
Volume 21, Issue 3 , Pages 107-111, September 2008

Building capacity of maternity staff to discourage the use of sunlight therapy in the post-partum period and infancy

School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University, Townsville, Queensland 4811, Australia

Received 3 December 2007; received in revised form 30 May 2008; accepted 30 May 2008.

Article Outline

Summary 

Purpose

To describe the development, implementation and evaluation of an educational intervention that addresses risky beliefs held by midwives and nurses working in maternity areas and new mothers about therapeutic sun exposure.

Procedure

In 2002–2003, 59 midwives and nurses from a hospital in northern Queensland participated in an educational intervention to discourage mothers from exposing themselves and their infants to sunlight for therapeutic reasons. Intervention staff attended an educational workshop and/or received educational resources. Resources (posters, pamphlets and bookmarks) were developed for the staff to use for educating mothers. Process evaluation of the quality and usefulness of the workshop and resources was conducted immediately after the workshop and 12 months later.

Findings

Intervention staff indicated that the workshop was relevant to their work, and increased their knowledge and confidence in talking to mothers about sunlight exposure. Ninety percent of the 59 participants indicated they had used the workshop information in their interactions with post-partum mothers. Of the resources, pamphlets and bookmarks were used most often.

Conclusions and implications for practice

The educational intervention was successful in developing the knowledge of midwives and nurses to provide sound advice to new mothers about therapeutic sun exposure and in developing resources to support them in their education. Although workshops and resources are useful in the short term, they are impractical to sustain. To improve sustainability, content on this topic needs to be incorporated into midwifery and nursing curricula across Australia.

Keywords: Sun exposure, Maternity staff, Education, Infancy, Post-partum period

 

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Introduction 

Australia has the highest incidence rates of skin cancer in the world1, 2 with the greatest problem in Queensland, where the incidence of non-melanocytic skin cancer (NMSC),3 cutaneous malignant melanoma (CMM)4 and pigmented moles5, 6 are all extremely high. Because the development of CMM and pigmented moles are both related to early childhood sun exposure,5, 7, 8 sensible sun protection should begin at birth in at-risk populations.

Although sun protection is now almost universally recommended, our research has shown that inappropriate beliefs about the perceived therapeutic benefits of sun exposure prevail in Australia both in health professionals and in post-partum women.9, 10 There is evidence that a considerable proportion of the health professionals working in tropical Australia who care for women in the immediate post-partum period not only believe in the therapeutic value of sun exposure but also recommend it to post-partum women.9, 10, 11 There is also evidence that parents may be intentionally exposing their infants to sunlight for a range of health reasons, including treatment for newborn infants who have mild neonatal jaundice or nappy rash. Some mothers also expose themselves to sunlight to treat cracked nipples from breastfeeding on the advice of midwives and other nurses.9, 10, 11

Nurses are recognised as one of the most trustworthy groups of health professionals in Australia,12 and it is essential that they are able to provide accurate and consistent advice and information to post-partum women and the staff with whom they work. Our previous research shows that post-partum women depend on midwives and nurses to provide them with safe, consistent and explicit evidence-based advice about a wide spectrum of health issues in the immediate post-partum period.9 Given the potential for one-on-one education with new mothers, it is important that midwives and nurses have access to the latest available evidence about the risks associated with therapeutic sun exposure in infancy, together with high quality resources that support and reinforce the advice they give to new mothers.

Although health education resources on general skin cancer are abundant, no specific resources relating to therapeutic sun exposure were found prior to developing this intervention. It was clear that developing resources about therapeutic sun exposure would be useful in supporting education given by midwives and nurses.

This paper describes the development, implementation and process evaluation of an educational intervention to address the issue of ‘inappropriate’ beliefs and practices about sun exposure held by midwives and nurses working in maternity areas and post-partum women in tropical North Queensland.

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Methodology 

Study design 

Ethical approval was granted by the James Cook University Human Ethics committee on 01.03.02 (No. H1333) prior to conducting an educational intervention with midwives and nurses involved in maternity care in North Queensland. All participants in the study provided written informed consent and all data was de-identified to ensure confidentiality.

Midwives and nursing staff of the maternity units of the three largest public hospitals situated on the coast, north of the tropic of Capricorn (Cairns 16°51′S, population (pop) 131,000; Townsville13 19°16′S, pop 146,000 and Mackay lat 21°10′S, pop 78,000) were recruited into a settings-based educational intervention designed to correct inappropriate beliefs about therapeutic sun exposure during the post-partum period and infancy. In 2005 there were 2648 deliveries in Cairns, 1394 in Mackay and 2134 in Townsville.14 The Townsville Hospital is a level 5/6 tertiary referral centre for North Queensland. One hospital was assigned to the intervention group, and the other two hospitals were assigned to the control group.

The intervention consisted of two main parts. Part one was the development and delivery of an educational intervention that aimed to provide hospital-based midwives and nurses working in maternity areas with: (1) relevant information about the risks of recommending therapeutic sun exposure; (2) suitable treatment alternatives for dealing with common ailments which occur in the immediate post-partum period and in infancy for which therapeutic sun exposure might inappropriately be advised (e.g. mild neonatal jaundice; nappy rash; cracked nipples; acne; wet wound healing). The second part was the development of health education resources to be used by staff in discussions with parents regarding sun exposure. The development of the educational intervention and resources was informed by aspects of the Communication-Behaviour Change Model15 (Fig. 1).

Educational intervention with midwives and nurses 

In the intervention hospital all 68 midwives and nurses who worked in maternity areas (birth suite, antenatal clinic and post-natal ward) were invited to participate in an educational intervention. The intervention consisted of a 1h workshop (or a one-on-one educational session for those who could not attend the workshop) and distribution of an accompanying resource package, entitled “The Myths and Facts of Therapeutic Sun Exposure.” A total of seven in-service workshops and eleven individual educational sessions were conducted over a one-month period (19 February–19 March 2003).

The content of the educational workshop and the resource package was developed in consultation with a paediatrician and a skin cancer epidemiologist (SLH). All participants received the resource package which included: (1) a detailed background paper based on current published literature complete with references to provide the staff with the relevant material to inform their understanding of the issues; (2) a one-page fact sheet that covered the key facts without extraneous information for those who wanted less in-depth information; (3) a copy of the health education resources to be used with new mothers.

Maternal health education resources 

Written materials including pamphlets, bookmarks and posters were developed to reinforce the verbal information provided to new mothers by midwives and nurses. Such materials have been found to be useful instructional tools and also allow post-partum women to refer to them at a later stage to reinforce the content.16 In line with recommendations made by Paul et al.,17 the target group were active participants in the resource development process and the choice of resources was also made on the advice of mothers who participated in the focus groups described below.

Resource design process 

A reference group consisting of a paediatrician, (SLH), midwives and playgroup mothers was established. A participatory approach was used for the development of the pamphlet, bookmark and posters. A series of three focus groups were conducted with playgroup mothers who actively participated in the decision making about the pamphlet, bookmark and poster content and design. Paul et al. checklist of content and design characteristics17 was used as an additional guide for the development and design of the pamphlet. All content was checked by (SLH) to ensure that it was based on current evidence and the Simplified Measure of Gobbledygook (SMOG) Grading18 was used to determine the reading level of printed materials aimed at new mothers. SMOG is a readability formula that is widely used for checking health messages.19

Resource distribution 

Posters were framed and put on permanent display in areas within the intervention hospital frequented by antenatal and post-partum women. Bookmarks were inserted into the Queensland Health Maternal Record book given to all new mothers and the pamphlets were included in the take home baby sample packs (Bounty New Mother Bags).20 Pamphlets were also included in a resource file placed at the end of each bed in the maternity ward of the intervention hospital.

Process Evaluation 

All resources were pre-tested with members from the target group and with other health professionals to check appeal and comprehension of messages. All workshop attendees (n=48) were asked to complete an anonymous workshop evaluation form by indicating whether they strongly agreed; agreed; disagreed; or strongly disagreed, with each of the six statements about the workshop. Twelve months after attending the workshop, workshop attendees and those who had attended the one-on-one education session (n=11), were surveyed to see if they had used the workshop information and resources in discussions with post-partum women. Pre- and post-questionnaires were also conducted with control hospital staff and post-partum women to assess changes in their beliefs about therapeutic sun exposure and to document the advice given to mothers, however these findings will be reported elsewhere.

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Results 

Resource Pre-testing 

The therapeutic sun exposure resources (pamphlets, bookmarks and posters) were tested on two midwives and two other health professionals (health promotion professionals) to seek their opinion and to ensure attraction, acceptability and comprehension. Eight members of the playgroup who had not been involved in the initial resource development focus groups, were members of the pre-testing audience and were interviewed individually by the first author. Feedback indicated that the resources were visually appealing and eye catching, that the messages were clear and easily understood and that the graphics were attractive. Feedback from one-to-one interviews with health professionals also indicated that the resources were appealing and that the content was clear. SMOG analysis of the pamphlet was nine, and in line with recommendations from McLaughlin,18 were seen to be at an appropriate level.

Description of education session attendees 

A total of 59 staff participated in the educational intervention (86.8% response). Of these, 48 (81.5%) attended one of the seven in-service workshops, and 11 (18.5%) received the individual one-to-one educational session. Nine of the 68 eligible staff were unable to attend due to unavailability at the specified time (i.e. on days off, recreational leave or completing work commitments). Of the 59 staff who did attend the workshop or individual session, 59.5% were midwives, 37% were registered general nurses and 3.5% were enrolled nurses.

Evaluation of the workshop & educational materials by midwives and nurses 

Thirty-nine (81%) of the 48 workshop attendees returned a completed workshop evaluation form. All respondents agreed or strongly agreed that the topic was relevant to their work, had increased their knowledge about the inappropriateness of recommending therapeutic sun exposure for infants and mothers, and increased their confidence in discussing this topic with mothers (Table 1). Participants indicated that the workshop material was well organized, presented in a logical manner, was interesting and current and that the workshop was worth the time they invested in it (Table 1).

Table 1. Evaluation completed by workshop attendees (n=39) in the intervention hospital
Evaluation questionStrongly agree, n (%)Agree, n (%)Disagree, n (%)Strongly disagree, n (%)
1The topic was relevant to my area of work19 (48.7)20 (51.3)00
2The in-service has increased my knowledge of the topic22 (56.4)17 (43.6)00
3The in-service has helped me feel more confident in talking to mothers about therapeutic sun exposure20 (51.3)18 (46.1)01a (2.6)
4The in-service material was well organised and presented in a logical manner28 (71.8)11 (28.2)00
5The material was interesting and current27 (69.2)12 (30.8)
6The in-service was worth the time I invested in it28 (71.8)11 (28.2)

aParticipant wrote, “I only said I disagree about the in-service making me feel more confident because I already feel confident in talking to mothers – much of this is what I always say – airing and not deliberate exposure to the sun”.

One year after the workshop, self-administered questionnaires were sent to all 59 midwives and nurses who completed the educational intervention. Forty-two (71.2%) of the original intervention hospital staff were available for follow-up and completed the questionnaire. Ninety percent of respondents indicated that they had made use of the in-service information in their work, and the four who did not were Neonatal Intensive Care Unit staff. Of the resources, the pamphlets had the greatest impact with 49 (83%) of intervention staff using them in the workplace, followed by bookmarks with 45 (75.5%) using them. The four posters had less of an impact, with 38 (65%) intervention staff noticing one or more of the posters on display in the year since the intervention.

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Discussion 

The results of this study demonstrate that midwives and nurses working in maternity areas view myths and facts about therapeutic sun exposure to be an area of importance and relevance. Given the high incidence of skin cancer1, 2 and the proportion of health professionals11 and post-partum women with inappropriate beliefs about the therapeutic uses of sunlight,9, 10, 11 the need for education in this area is clear.

Best practice approaches in developing educational interventions and resources need to be taken to ensure quality and usability. In developing this educational intervention, aspects of the Communication-Behaviour Change Model15 were used. This model is used to guide public education campaigns and was adapted in this situation to guide development of the intervention. A number of points described by McGuire were considered. Firstly, the person who delivers the message is important.15 Previous research indicating that nursing professionals are credible sources of information12 reinforced the importance of ensuring that they had access to the latest evidence about the adverse effects of sun exposure. Thus, up-to-date information and quality health education resources were needed to supplement verbal education. Our results demonstrate that midwives and nurses found the educational resources useful in educating mothers. Secondly McGuire emphasizes the importance of the content and form of the message.15 In designing this intervention the authors used participatory processes in which target groups were actively involved in the resource development. The application of a simple readability formula provided an objective, systematic and quantifiable way of assessing the content of written materials. The SMOG readability formula18 assisted in making the messages in the resources simple and readable. Results of the resource pre-testing reinforce the benefits of this process and demonstrated that the resources we developed were appealing, attractive and understandable. Thirdly, McGuire emphasizes the importance of selecting the correct channel for delivering the message15 Egger et al. discuss how resources such as pamphlets are useful in backing up more active education21 and in this situation it was felt that pamphlets and bookmarks would be suitable to reinforce verbal information provided by midwives and nurses involved in maternity care. This was also supported by the target audience. It was felt that posters would further reinforce key messages.

Despite the many public health interventions about sun protection and the improvements in sun protection behaviour seen in some groups,22 it is clear that confusion remains as to the benefits and uses of therapeutic sun exposure, at least in the post-partum period and infancy.9, 10, 11 This intervention describes one way to address this issue but there are a number of limitations to this approach that make sustaining the appropriate level of knowledge within an organisation difficult.

Although the workshops were rated highly in terms of interest, relevance and importance, such delivery approaches are time-consuming and may not reach the entire audience, particularly shift-workers. A more sustainable approach would be to incorporate therapeutic sun exposure content into midwifery and nursing curricula across Australia to ensure greater reach of the information and to combat the problem of high staff-turnover rates in hospital maternity wards. Similar content on this topic should also be covered in orientation sessions and/or packages for all new hospital maternity ward employees in order to reach midwives and nursing staff who trained abroad or completed their training prior to this education being available.

Approaches such as these will continue to be limited unless other organisations also embrace the research about therapeutic sun exposure. For example, it might be appropriate for professional bodies to develop clinical evidence-based guidelines for the treatment of conditions such as neonatal jaundice.

To achieve a broader reach it is also important to establish partnerships between researchers, midwifery and nursing organizations, health departments and other professional organizations. As a result of this intervention, Queensland Health has adopted our “Sun Exposure and Your Baby: What parents must know” pamphlet and made it available, both in print form across the state and online,23 as part of a collaborative partnership with the authors at James Cook University. The pamphlet23 and related resources could also be adopted by other agencies.

A final consideration is that midwives and nurses working in maternity areas are not the only people who give advice to new mothers. Further exploration of external forces (such as advice from family, general practitioners, pharmacists, media, etc.) still needs to be examined and unless all these areas are addressed, mothers may continue to receive conflicting advice.

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Conclusion 

Changing sun safety behaviour is complex. This study describes one facet of the broad multi-strategy approach that is needed to address this problem. In this paper the authors have described an educational intervention that targets the important topic of inappropriate beliefs about therapeutic sun exposure in the post-partum period and infancy. The authors have described the process of developing targeted resources to support education in this area and highlighted the principles that should be followed when developing written resources. This is valuable not only for those who design resources but also assists the users of resources to assess their quality. Addressing inappropriate beliefs about therapeutic sun exposure using the strategies suggested should help to discourage the use of sunlight therapy in infants. This is important as over-exposure to sunlight during infancy may increase their risk of developing skin cancer in the future. The influence that midwives and nurses working in maternity areas have on clients as credible sources of information is strong and cannot be undervalued on this topic.

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Acknowledgements 

The authors wish to acknowledge the following people who played an integral part in this study: Dr. William Frischman (Paediatrician) for his expert medical advice; Ms. Judy Woosnam, Margot Morrison and Vicki Saunders for data collection and data entry, mums from the Fun Days Playgroup who enthusiastically gave up their time to participate in the design of the resources for this study, and Fiona Devine for sharing her expertise in graphic design and printing.

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References 

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PII: S1871-5192(08)00050-4

doi:10.1016/j.wombi.2008.05.002

Women and Birth
Volume 21, Issue 3 , Pages 107-111, September 2008

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