Sun Protection Policies in Public School Districts With Elementary Schools in California

The Sunscreen for Kindergarteners (SKIN) Study trial protocol

BACKGROUND

Exposure to ultraviolet radiation (UVR) is the major modifiable risk factor for skin cancers. The majority of lifetime UVR exposure occurs before age 20, underscoring an important window for risk reduction. Incorporation of skills-based sunscreen education into school health curricula may foster the development of consistent and effective use of sunscreen among children and youth. We describe the study protocol for a first-of-its-kind study that examined the feasibility of bringing skills-based sunscreen education into kindergarten classrooms.

METHODS

Participants were 96 kindergarten students across four classrooms in a single elementary school. A single-blind open-label trial design was used to evaluate the feasibility of incorporating a song-based, video-guided intervention for independent application of sunscreen into the kindergarten curriculum. Students first completed a 10-day no-intervention baseline period, followed by a 10-day intervention period, and then a 10-day randomized follow-up period where students were randomly assigned to continue with the intervention or to revert to the no-intervention condition.

OUTCOMES

Feasibility metrics associated with study process, resources, management, scientific outcomes and safety were gathered. The primary outcome was pre-to-post intervention changes in student engagement in the sunscreen task. The secondary outcome was pre-to-post intervention changes in the proportion of exposed skin to which a student applies sunscreen. Teacher and student perceptions of intervention value and utility were also evaluated.

DISCUSSION

This is the study protocol for a clinical trial designed to determine the feasibility of implementing a skills-based sunscreen curriculum in kindergarten classrooms. Next steps include evaluation of the intervention for efficacy and effectiveness.

CLINICAL TRIAL REGISTRATION

NCT03752736.

Economic Evaluation of a Sun Protection Promotion Program in California Elementary Schools

BACKGROUND

An economic evaluation of Sun Safe Schools intervention designed to aid California elementary schools with implementing sun safety practices consistent with local board-approved policy.

DESIGN

Program cost analysis: intervention delivery and practice implementation.

SETTING

California elementary schools (58 interventions and 60 controls). Principals at 52 intervention and 53 control schools provided complete implementation data.

PARTICIPANTS

Principals completing pre-/postintervention surveys assessing practice implementation.

INTERVENTION

Phone-based 45-minute session with a project coach on practice implementation, follow-up e-mails/phone contacts, $500 mini-grant. Schools chose from a list of 10 practices for implementation: ultraviolet monitoring, clothing, hats, and/or sunscreen recommendations, outdoor shade, class education, staff training and/or modeling, parent outreach, and resource allocation. The duration of intervention was 20 months. Rolling recruitment/intervention: February 2014 to December 2017.

MEASURES

Intervention delivery and practice implementation costs. Correlations of school demographics and administrator beliefs with costs.

ANALYSIS

Intervention delivery activities micro-costed. Implemented practices assessed using costing template.

RESULTS

Intervention schools: 234 implemented practices, control schools: 157. Twenty-month delivery costs: $29 310; $16 653 (per school: $320) for project staff, mostly mini-grants and coaching time. Administrator costs: $12 657 (per school: $243). Per-student delivery costs: $1.01. Costs of implemented practices: $641 843 for intervention schools (per-school mean: $12 343, median: $6 969); $496 365 for controls (per-school mean: $9365, median: $3123). Delivery costs correlated with implemented practices (0.37, P < .01) and total practice costs (0.37, P < .05). Implemented practices correlated with principal beliefs about the importance of skin cancer prevention to student health (0.46, P < .001) and parents (0.45, P < .001).

CONCLUSION

Coaching of elementary school personnel can stimulate sun safety practice implementation at a reasonable cost. Findings can assist schools in implementing appropriate sun safety practices.

Randomized controlled trial evaluating an intervention supporting implementation of sun safety policies in California public elementary schools

Solar ultraviolet radiation (UV) exposure is the primary risk factor for skin cancer and children receive about one-quarter of lifetime UV exposure before age 18. Thus, skin cancer prevention is essential for children. The objective of this study was to test an intervention to facilitate implementation of district sun safety policies. Elementary schools (N = 118) from 40 California public school districts with a school board-approved policy for sun safety were recruited along with one principal and teacher from each school. Elementary schools were randomly assigned to receive the 20-month Sun Safe Schools intervention (N = 58) or to a minimal informational control condition (N = 60). Principals were 47.8 and teachers 44.3 years of age and were predominately female (principals 72.7%; teachers 86.7%) and White (principals 72.0%; teachers 68.2%). The 20-month Sun Safe Schools intervention was delivered to principals and included a coaching session, telephone and email contacts, provision of resources for practice implementation, and a small grant program. The principal (N = 118) and a teacher (N = 113) at each school reported on school sun protection practices 20-months post-baseline. The schools were diverse in student characteristics (M = 64.1% free/reduced price meals; M = 54.5% Hispanic). Intervention principals reported implementing more sun safety practices overall (control M = 2.7, intervention M = 4.2, p < .005) and more practices not present in the district's policy (control M = 0.4, intervention M = 0.9, p = .005). Principals and teachers combined replicated these findings and also reported implementing more practices present in the district policy (control M = 0.9, intervention M = 1.3, p = .005). In sum, the intervention increased sun safety practices in public elementary schools. Trial Registration. This study is registered in ClinicalTrials.gov, www.clinicaltrials.gov, with the identification number of NCT03243929.

Parent reports of sun safety communication and behaviour for students in a randomised trial on a school policy implementation intervention

OBJECTIVE

Schools are an important setting for skin cancer prevention. An intervention for implementation of school sun safety policy, Sun Safety Schools (SSS), was evaluated.

METHODS

Primary schools (n=118) in California school districts that had already adopted a sun safety policy were enrolled in a study with a randomised controlled design. Half of the schools were randomised to SSS intervention (N=58). Parents completed an online post-test.

RESULTS

More parents in intervention schools received information about sun safety (mean=26.3%, sd=3.1%, p=0.017) and children more frequently wore sun-protective clothing when not at school (mean=2.93, sd=0.03, p=0.033) than in control schools (mean=18.0%, sd=2.5%; mean=2.83, sd=0.03, respectively). In schools where principals reported implementing sun safety practices, parents reported that children spent less time outdoors at midday (mean=14.78 hours, sd=0.25, p=0.033) and fewer were sunburned (mean=12.7%, sd=1.1%, p=0.009) than in non-implementing schools (M=16.3 hours, sd=0.67; mean=21.2%, sd=3.8%, respectively). Parents who received sun safety information (mean=3.08, sd=0.04, p=0.008) reported more child sun protection than parents not receiving information (mean=2.96, sd=0.02).

CONCLUSIONS

A school district sun protection policy and support for implementation increased dissemination of sun safety information to parents and student sun safety. Implications for public health: Technical assistance for sun safety policies may increase sun protection of children.

School-Level Factors Associated with Sun Protection Practices in California Elementary Schools

BACKGROUND

This study examined implementation of district sun safety policy in schools and tested correlates of implementation in California public school districts.

METHODS

Principals (N = 118) and teachers (N = 113) in California public elementary schools (N = 118) were recruited and completed a survey on sun protection policies and practices. The sample contained schools whose districts subscribed to the California School Boards Association and adopted Board Policy 5141.7 for sun safety. Principals and teachers reported on implementation of 10 school practices related to BP 5141.7 indicating which practices were implemented in the school.

RESULTS

Years in public education (Exponentiated Score (ES) = 0.51, p < .001), years worked in the current district (ES = 0.49, p < .001), perception that parents should take action to protect children from the sun (ES = 0.43, p < .01), and personal skin phenotype (Low Risk ES = 0.55; High Risk ES = 0.09, p < .05) were associated with number of practices implemented in the school using multiple Poisson regression.

CONCLUSIONS

Policy implementation is more likely among schools with experienced faculty, when parents are seen as important partners in student skin cancer prevention, and when school principals and teachers have a lower personal risk phenotype.

Accuracy of Principal and Teacher Knowledge of School District Policies on Sun Protection in California Elementary Schools

Introduction

Policy is a key aspect of school-based efforts to prevent skin cancer. We explored the extent and accuracy of knowledge among principals and teachers in California public school districts about the elements specified in their district’s written sun safety policy.

Methods

The sample consisted of California public school districts that subscribed to the California School Boards Association, had an elementary school, adopted Board Policy 5141.7 for sun safety, and posted it online. The content of each policy was coded. Principals (n = 118) and teachers (n = 113) in elementary schools were recruited from September 2013 through December 2015 and completed a survey on sun protection policies and practices from January 2014 through April 2016.

Results

Only 38 of 117 principals (32.5%) were aware that their school district had a sun protection policy. A smaller percentage of teachers (13 of 109; 11.9%) than principals were aware of the policy (F₁₀₈ = 12.76, P < .001). We found greater awareness of the policy among principals and teachers who had more years of experience working in public education (odds ratio [OR] = 1.05, F₁₀₆ = 4.71, P = .03) and worked in schools with more non-Hispanic white students (OR = 7.65, F₁₀₉ = 8.61, P = .004) and fewer Hispanic students (OR = 0.28, F₁₀₉ = 4.27, P = .04).

Conclusion

Policy adoption is an important step in implementing sun safety practices in schools, but districts may need more effective means of informing school principals and teachers of sun safety policies. Implementation will lag without clear understanding of the policy’s content by school personnel.