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García-Harana C, Blázquez-Sánchez N, Rodríguez-Martínez A, Rivas-Ruiz F, Aguilar-Ortega D, Rodríguez-Martínez AG, Cambil-Martín J, de Gálvez MV, de Troya-Martín M. Positive impact of Distintivo Soludable on implementation of sun protection policies and practices in schools of Andalusia, Spain. J Public Health Policy 2024; 45:471-483. [PMID: 38858538 DOI: 10.1057/s41271-024-00495-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/06/2024] [Indexed: 06/12/2024]
Abstract
The incidence of skin cancer is increasing worldwide even though its main risk factor is preventable. This study evaluated the impact of the Distintivo Soludable pilot intervention on implementation of photoprotection policies and practices in preschool and primary schools in Andalusia, Spain. We completed two rounds of a Sun Protection Policies and Practices Survey (SPPPS) nine months apart. At baseline, 67 Andalusian schools earned a median score of 3/12 points (range 0-8; IQR: 2). Ten schools involved in Distintivo Soludable intervention group significantly increased their scores from 4 to 7.5/12 points (p = 0.014). We also detected a modest positive effect in 57 control group schools, an increase from 2 to 3 points (p = 0.002). This pilot study demonstrated that the main achievement of the Distintivo Soludable intervention was implementation of organizational policies regarding sun protection, an essential starting point for establishing positive attitudes toward sun protection in school communities.
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Affiliation(s)
- C García-Harana
- Dermatology Department, Hospital Universitario Costa del Sol, Marbella, Spain
- Department of Medicine, University of Málaga, Málaga, Spain
| | - N Blázquez-Sánchez
- Dermatology Department, Hospital Universitario Costa del Sol, Marbella, Spain.
- Hospital Costa del Sol, Autovía A7, KM 187, 29603, Marbella, Spain.
| | - A Rodríguez-Martínez
- Research and Innovation Unit, Hospital Universitario Costa del Sol, Marbella, Spain
| | - F Rivas-Ruiz
- Research and Innovation Unit, Hospital Universitario Costa del Sol, Marbella, Spain
- Research Network on Health Services in Chronic Diseases (REDISSEC), Barcelona, Spain
| | - D Aguilar-Ortega
- Research and Innovation Unit, Hospital Universitario Costa del Sol, Marbella, Spain
| | | | - J Cambil-Martín
- Nursing Department, Faculty of Health Science, University of Granada, Granada, Spain
| | - M V de Gálvez
- Photobiological Dermatology Laboratory Medical Research Center, Department of Dermatology and Medicine, Faculty of Medicine, University of Málaga, Málaga, Spain
| | - M de Troya-Martín
- Dermatology Department, Hospital Universitario Costa del Sol, Marbella, Spain
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Peconi J, Lanyon K, Tod D, Driscoll T, Prathap S, Watkins A, Abbott RA. Are Welsh primary schools Sunproofed? Results of a national survey, part 1: scoping the landscape of sun safety policies in Wales. Clin Exp Dermatol 2024; 49:566-572. [PMID: 38173274 DOI: 10.1093/ced/llad458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2023] [Revised: 12/08/2023] [Accepted: 12/19/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Schools with formal sun safety polices generally show better sun safety practices than schools without. OBJECTIVES To understand the extent to which Welsh primary schools have sun safety policies; to identify the key characteristics of policies; to assess whether policy adoption varies by school characteristics; and to consider what support schools need to develop sun safety policies. METHODS An online multiple-choice survey on sun safety was distributed to all 1241 primary schools in Wales. RESULTS In total, 471 (38.0%) schools responded. Of these, 183 (39.0%) reported having a formal sun safety policy. Welsh medium schools (P = 0.036) and schools in North Wales (P = 0.008) were more likely to report having a policy. Schools with a higher percentage of pupils receiving free school meals (P = 0.046) and with lower attendance rates (P = 0.008) were less likely to report having a sun safety policy. The primary reasons for schools not having a policy included being 'not aware of the need' (34.6%); 'need assistance with policy or procedure development' (30.3%); and 'not got around to it just yet' (26.8%). CONCLUSIONS With less than half of schools reporting a sun safety policy and variation in the presence/absence of a policy by school characteristics, our survey revealed inconsistency in formal sun safety provision in Welsh schools. The findings also suggest that schools are unaware of the importance of sun safety and need support to develop and implement policies. This snapshot of the current situation in primary schools in Wales provides a basis upon which the comprehensiveness, effectiveness and implementation of sun safety policies can be further evaluated.
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Affiliation(s)
- Julie Peconi
- Swansea Trials Unit, Faculty of Medicine, Health and Life Science, Swansea University, Swansea, UK
| | - Kirsty Lanyon
- Swansea Trials Unit, Faculty of Medicine, Health and Life Science, Swansea University, Swansea, UK
| | - Daniel Tod
- Swansea Trials Unit, Faculty of Medicine, Health and Life Science, Swansea University, Swansea, UK
| | - Timothy Driscoll
- Swansea Trials Unit, Faculty of Medicine, Health and Life Science, Swansea University, Swansea, UK
| | - Swetha Prathap
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Alan Watkins
- Swansea Trials Unit, Faculty of Medicine, Health and Life Science, Swansea University, Swansea, UK
| | - Rachel A Abbott
- Dermatology Department, Cardiff and Vale University Health Board, Cardiff, UK
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Scott JJ, Johnston RS, Darby J, Blane S, Strickland M, McNoe BM. A novel skin cancer prevention strategy: Preservice teachers' perceptions of a sun safety intervention and experiences in schools. Health Promot J Austr 2023; 34:255-263. [PMID: 35833309 PMCID: PMC10084111 DOI: 10.1002/hpja.638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Accepted: 06/20/2022] [Indexed: 01/27/2023] Open
Abstract
ISSUE ADDRESSED Teachers play a vital role in developing children's sun protection routines however upskilling preservice teachers (PSTs) while at university has not yet been trialled as a targeted skin cancer prevention strategy. Hence, this study investigated PSTs perceptions and experiences of sun safety following a brief pilot intervention and placement in primary schools in Western Australia. METHODS This study used a triangulation mixed methods design. Participants (n = 161) completed a post intervention survey which was analysed quantitatively. A random sub-sample was invited to participate in focus groups (three groups, n = 21) and one-on-one interviews (n = 4). This data was transcribed and uploaded in NVIVO software for thematic analysis. RESULTS Participants felt the intervention increased their awareness of the dangers of overexposure to ultraviolet radiation (UVR) with many feeling more knowledgeable, skilled and confident to teach sun safety in school settings. Most reported clear sun safety messages in their placement schools. However, only 34.4% reported they had been briefed on the school's sun safety procedures. There was consensus among PSTs that sun protection in primary schools needs to be improved to maximise the protection of children from harmful UVR overexposure. Participants supported a need for consistent sun protection messaging across primary schools with greater emphasis on education rather than compliance management to sun protection. CONCLUSION Enhancing existing teacher education programs to include more rigorous curriculum content and pedagogical approaches to sun protection education is a novel skin cancer prevention strategy and could feasibly support PSTs self-efficacy to effectively deliver sun safety curriculum in Australian schools.
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Affiliation(s)
- Joseph J Scott
- School of Education and Tertiary Access, University of Sunshine Coast, QLD, Australia.,School of Education, Edith Cowan University, WA, Australia
| | - Robyn S Johnston
- Telethon Kids Institute and University of Western Australia, WA, Australia.,School of Medical and Health Sciences, Edith Cowan University, WA, Australia
| | - Jill Darby
- School of Medical and Health Sciences, Edith Cowan University, WA, Australia
| | - Sally Blane
- Cancer Council Western Australia, WA, Australia
| | | | - Bronwen M McNoe
- Social and Behavioural Research Unit, University of Otago, New Zealand
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García-Harana C, de Gálvez Aranda MV, Blazquez-Sanchez N, Rivas-Ruiz F, Rodriguez-Martinez A, de Troya-Martín M. Sun Protection Policies and Practices in Preschool and Elementary Schools in Andalusia (Spain). JOURNAL OF CANCER EDUCATION : THE OFFICIAL JOURNAL OF THE AMERICAN ASSOCIATION FOR CANCER EDUCATION 2022; 37:819-828. [PMID: 33025452 DOI: 10.1007/s13187-020-01889-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/28/2020] [Indexed: 06/11/2023]
Abstract
Sun exposure in childhood is a major risk factor for the development of skin cancer as an adult. School children spend much of their time outdoors exposed to ultraviolet radiation during recreational and sports activities. Skin cancer incidence tripled from 1978 to 2002 in Spain. Andalusia, the largest and sunniest region of Spain, lacks data on the sun protection measures taken in schools. To address this deficit, the aim of this study was to determine photoprotection practices and policies in preschools and primary schools in Andalusia. This descriptive study involved the administration of an online questionnaire completed by principals regarding school sun protection policies and practices. Preschool and primary schools were selected from the database of the Ministry of Education of the Andalusian Regional Government. Information of interest included photoprotection policies, students' sun protection knowledge, sun protection measures, relevant curricular content, and availability of shade at the school. A total of 2425 schools were contacted. Of them, 420 schools responded (17.31%), with the highest number of responses received from Malaga (23.8%) and Seville (19.5%) provinces. Of those responding, 67.1% of the schools did not have written sun protection policies. The photoprotection measures reported included mandatory use of a cap or hat (3.3%), use of sunglasses in outdoor areas (30%), and active encouragement of students to use sunscreen (50.7%). Roughly 24% of schools evaluated their shaded areas, with 52.9% reporting insufficient protection for most activities. The study results showed that photoprotection policies and practices in Andalusian schools were mostly insufficient. Given that skin cancer incidence has increased considerably over the last decade, it is important to concentrate on improving primary prevention practices. Additionally, photoprotection programs in schools have been shown to improve children's knowledge, attitudes, and habits regarding photoprotection. Thus, it is essential for Andalusian preschools and primary schools to develop policies and strategies to help reduce children's sun exposure while at school.
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Affiliation(s)
- Cristina García-Harana
- Dermatology Department, Hospital Costal del Sol, Marbella, Spain.
- Medicine Department, University of Málaga, Málaga, Spain.
| | | | | | - Francisco Rivas-Ruiz
- Research Unit, Hospital Costal del Sol, Marbella, Spain
- Research Network on Health Services in Chronic Diseases (REDISSEC), Barcelona, Spain
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Reducing the Incidence of Skin Cancer through Landscape Architecture Design Education. SUSTAINABILITY 2020. [DOI: 10.3390/su12229402] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
There is a high and growing incidence of skin cancer associated with overexposure to the sun. Most of a person’s exposure occurs during their first eighteen years of life. While many children are taught to wear hats and sunscreen, studies indicate these are inadequate. There is a pressing need to improve the design of our landscapes to reduce exposure. Landscape architects can play a key role in driving this process, but only if they understand the factors determining sun protection behaviours among children in the landscape, and how to design for these. We introduced a systematic evidence-based teaching approach to landscape architecture students in New Zealand where the incidence of skin cancer is one of the highest in the world. In this paper, we describe the methods we used to integrate scientific information into a creative design process that included four design phases: (1) review, summary and translation of evidential theory into design guidelines; (2) inventory and analysis of existing schoolyard; (3) redesign of schoolyard; and (4) final design evaluation. We found this process was effective in developing student appreciation for the need to improve sun protection through design, for increasing their understanding of the evidential science, in addition to developing their ability to translate, often inaccessible, evidential data into its spatial form implications. Furthermore, the process led to a high degree of confidence and pride among many students as their resulting design solutions were not only supported by evidence but were often highly creative. Such evidence-based design courses are essential for preparing future landscape architects to design landscapes that significantly reduce the incidence and health effects of skin cancer.
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Scott JJ, Johnston R, Blane S, Strickland M, Darby J, Gray E. Investigating primary preservice teachers' ultraviolet radiation awareness and perceived ability to teach sun safety. Health Promot J Austr 2020; 32 Suppl 2:178-184. [PMID: 32770684 PMCID: PMC8596547 DOI: 10.1002/hpja.401] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2019] [Revised: 07/23/2020] [Accepted: 08/04/2020] [Indexed: 12/24/2022] Open
Abstract
Issue addressed Sun protection practices in Australian primary schools remain inconsistent. Therefore, this study investigates primary PSTs sun protective sun behaviours, ultraviolet (UV) radiation awareness and perceived ability to teach sun safety. Methods A convenience sample of undergraduate PSTs (N = 275; mean age = 23.13 years) enrolled at one Western Australian university completed an online survey. Descriptive analyses provided features of the data. Factors associated with sun protection behaviours and perceived knowledge and skill to teach sun safety were explored using multivariable logistic regression models. Results Lesser than 10% of participants reported using sun protective measures daily (midday shade use: 6.5%; sunscreen: 7.6%; hat: 4.4%). Only 56.3% reported they understand the UV index, with 68.0% rarely/never using it to aid sun protection. Under half the participants reported they felt they had the knowledge (38.5%) or skills (40%) to effectively teach sun safety in primary schools. Regression analysis revealed gender, undergraduate, year and skin sensitivity were not predictors of UV index use (P > .05) or perceived knowledge of sun safety (P > .05). Skin sensitivity was the strongest predictor for shade usage (P = .02), hat usage (P = .05) and perceived skill to teach sun safety (P = .02). Conclusions Survey data indicate UV radiation is inconsistently understood by PSTs. Many felt that they did not have the required knowledge or skill to teach sun safety effectively. So what? Improving PSTs UV radiation knowledge while at university is a potential opportunity to improve sun safety delivery in primary schools. A targeted intervention for PSTs is warranted.
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Affiliation(s)
- Joseph J Scott
- School of Education, Edith Cowan University, Joondalup, WA, Australia
| | - Robyn Johnston
- School of Education, Edith Cowan University, Joondalup, WA, Australia
| | - Sally Blane
- Cancer Council Western Australia, Subaico, WA, Australia
| | | | - Jill Darby
- School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
| | - Elin Gray
- Melanoma Research Group, School of Medical and Health Sciences, Edith Cowan University, Joondalup, WA, Australia
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SunSmart Accreditation and Use of a Professional Policy Drafting Service: Both Positively and Independently Associated with High Sun Protective Hat Scores Derived from Primary School Policies. J Skin Cancer 2020; 2020:9695080. [PMID: 32665864 PMCID: PMC7345958 DOI: 10.1155/2020/9695080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 06/05/2020] [Indexed: 12/05/2022] Open
Abstract
Background The head and neck are exposed to the highest solar ultraviolet radiation levels and experience a disproportionate skin cancer burden. Sun protective hats can provide an effective barrier. Since early life exposure contributes to skin cancer risk, the World Health Organisation recommends prevention programmes in schools. The New Zealand SunSmart Schools programme is one example. Two criteria concern wearing hat outdoors: students are required to wear a hat providing protection for the face, neck, and ears; if a suitable hat is not worn, students must play in shaded areas. Objectives To investigate two internationally relevant interventions as plausible statistical predictors of hat policy strength: (1) skin cancer primary prevention programme membership, (2) use of a professional policy drafting service. Methods Of 1,242 (62%) eligible schools participating in a 2017 national survey, 1,137 reported a sun protection policy and 842 were available for categorising and allocating protective scores (0–3). Results In multinomial (polytomous) logistic regression models of cross-sectional association, adjusted for school characteristics, SunSmart accredited schools and those utilising a policy drafting service were independently significantly more likely than their counterparts to obtain the most protective compared to the least protective hat score (respectively, RRR 6.48: 95% CI 3.66, 11.47; 7.47: 3.67, and 15.20). For the dichotomous shade measure, similar associations were found using adjusted logistic regression (OR 3.28: 95% CI 2.11, 5.09; 2.70: 1.54, 4.74). Conclusions Our findings provide support for two plausible interventions that could potentially be implemented beneficially in primary schools via established infrastructure in any jurisdiction, internationally.
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Reynolds KD, Buller DB, Berteletti J, Massie K, Ashley J, Buller MK, Meenan RT, Liu X. School-Level Factors Associated with Sun Protection Practices in California Elementary Schools. THE JOURNAL OF SCHOOL HEALTH 2020; 90:386-394. [PMID: 32141621 PMCID: PMC7127930 DOI: 10.1111/josh.12884] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Revised: 03/15/2019] [Accepted: 05/04/2019] [Indexed: 06/10/2023]
Abstract
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.
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Affiliation(s)
- Kim D. Reynolds
- Professor, School of Community & Global Health, Claremont Graduate University. 675 W. Foothill Blvd., Ste. 310, Claremont, CA 91711, USA
| | - David B. Buller
- Director of Research and Senior Scientist, Klein Buendel, Inc. 1667 Cole Boulevard, Suite 225, Golden, CO 80401, USA
| | - Julia Berteletti
- Research Program Manager, Klein Buendel, Inc. 1667 Cole Boulevard, Suite 225, Golden, CO 80401, USA
| | - Kim Massie
- Project Manager, School of Community & Global Health, Claremont Graduate University. 675 W. Foothill Blvd., Ste. 310, Claremont, CA 91711, USA
| | - Jeff Ashley
- President, Sun Safety for Kids. 2625 W. Alameda Ave., Suite 517, Burbank, CA 91505, USA
| | - Mary Klein Buller
- President, Klein Buendel, Inc. 1667 Cole Boulevard, Suite 225, Golden, CO 80401, USA
| | - Richard T. Meenan
- Senior Investigator, Kaiser Permanente Center for Health Research. 3800 N. Interstate Ave, Portland, OR 97227, USA
| | - Xia Liu
- Biostatistical Manager, Klein Buendel, Inc. 1667 Cole Boulevard, Suite 225, Golden, CO 80401, USA
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Islami F, Sauer AG, Miller KD, Fedewa SA, Minihan AK, Geller AC, Lichtenfeld JL, Jemal A. Cutaneous melanomas attributable to ultraviolet radiation exposure by state. Int J Cancer 2020; 147:1385-1390. [DOI: 10.1002/ijc.32921] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 01/24/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Farhad Islami
- Surveillance and Health Services Research Program American Cancer Society Atlanta GA
| | - Ann Goding Sauer
- Surveillance and Health Services Research Program American Cancer Society Atlanta GA
| | - Kimberly D. Miller
- Surveillance and Health Services Research Program American Cancer Society Atlanta GA
| | - Stacey A. Fedewa
- Surveillance and Health Services Research Program American Cancer Society Atlanta GA
| | - Adair K. Minihan
- Surveillance and Health Services Research Program American Cancer Society Atlanta GA
| | - Alan C. Geller
- Department of Social and Behavioral Sciences Harvard T.H. Chan School of Public Health Boston MA
| | | | - Ahmedin Jemal
- Surveillance and Health Services Research Program American Cancer Society Atlanta GA
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de Troya Martín M, Blázquez Sánchez N, García Harana C, Fernández Morano T, Toribio Montero J, Jabalera Mesa L, Rivas Ruiz F, Delgado Sánchez N, Rodríguez Martínez A, Santana López V, de Gálvez Aranda M. Creation of the «soludable» sun protection accreditation program for schools. ACTAS DERMO-SIFILIOGRAFICAS 2019. [DOI: 10.1016/j.adengl.2019.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Hunkin H, Pollock K, Scupham R. The National SunSmart Schools Program: Impact on sun protection policies and practices in Australian primary schools. Health Promot J Austr 2019; 31:251-257. [PMID: 31466123 DOI: 10.1002/hpja.291] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 08/21/2019] [Indexed: 11/09/2022] Open
Abstract
ISSUE ADDRESSED Overexposure to ultraviolet radiation during childhood is a significant determinant of lifetime skin cancer risk, but can be mitigated through primary schools' adoption of appropriate sun protection policies and practices. The present study aimed to evaluate the changes in these policies and practices in Australia, and to assess the impact of the National SunSmart Schools Program. METHODS A random sample of primary schools were selected in 2011 and 2016 (N = 1577, 1533), and asked to complete a survey describing their current sun protection policies and practices. Significant changes across the study period, and relative to previously reported data from 2005, were identified. RESULTS Sun protection policies and practices remained relatively stable over the period, although there was a notable decrease in incorporating sun protection material into the curriculum. SunSmart membership was associated with a significantly greater likelihood of several policies and practices being employed. The launch of the SunSmart program in New South Wales was linked with significant improvements to sun protection practices, relative to other states and territories. CONCLUSION The National SunSmart Schools program continues to have a substantial impact in supporting the adoption of appropriate sun protection policies and their practical implementation. SO WHAT?: Even small changes to sun protection practices in Australian primary schools can have a major positive impact on long-term health outcomes. SunSmart membership can be leveraged to broaden existing policies and practices, targeting priority areas such as shade provision and the incorporation of sun protection into school curriculum.
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Affiliation(s)
- Hugh Hunkin
- Behavioural Research and Evaluation Unit, Cancer Council SA, Eastwood, SA, Australia
| | - Kate Pollock
- Behavioural Research and Evaluation Unit, Cancer Council SA, Eastwood, SA, Australia
| | - Rebecca Scupham
- Behavioural Research and Evaluation Unit, Cancer Council SA, Eastwood, SA, Australia
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de Troya Martín M, Blázquez Sánchez N, García Harana C, Fernández Morano T, Toribio Montero JC, Jabalera Mesa L, Rivas Ruiz F, Delgado Sánchez N, Rodríguez Martínez AG, Santana López V, de Gálvez Aranda MV. Creation Of The «Soludable» Sun Protection Accreditation Program For Schools. ACTAS DERMO-SIFILIOGRAFICAS 2019; 110:830-840. [PMID: 31399150 DOI: 10.1016/j.ad.2019.06.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2019] [Revised: 06/02/2019] [Accepted: 06/03/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Sun exposure during childhood is the main risk factor for skin cancer in later life. School-based sun protection policies and practices have proven to be the most effective and cost-effective strategies for preventing skin cancer. OBJECTIVE To develop a sun protection accreditation program known as «Soludable» (a play on the Spanish words sol [sun] and saludable [healthy]) to objectively identify schools that actively promote sun protection behaviors among students. METHODS The consensus method used was a 2-round Delphi technique with input from a panel of experts. We then calculated the median scores for the importance and feasibility of each of the recommendations proposed and the level of complexity assigned to each recommendation by counting the percentage of experts who chose each difficulty category. RESULTS The resulting accreditation model consists of 14 recommendations with corresponding evaluation criteria divided into 7 domains: 1) organizational leadership (5 recommendations), 2) effective communication (2 recommendations), 3) structural elements (2 recommendations), 4) training of professionals (1 recommendation), 5) school curriculum (1 recommendation), 6) behavioral models (2 recommendations), and 7) student habits (1 recommendation). A high level of agreement among experts was observed for all recommendations, in terms of both their perceived importance and feasibility and their categorization by levels of complexity. CONCLUSIONS This is the first sun protection accreditation program developed for Spanish schools. Studies are needed to evaluate how this program is received and how it affects students' sun protection behaviors.
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Affiliation(s)
- M de Troya Martín
- Servicio de Dermatología, Hospital Costa del Sol, Marbella (Málaga), España.
| | - N Blázquez Sánchez
- Servicio de Dermatología, Hospital Costa del Sol, Marbella (Málaga), España
| | - C García Harana
- Servicio de Dermatología, Hospital Costa del Sol, Marbella (Málaga), España; Universidad de Málaga, Málaga, España
| | - T Fernández Morano
- Servicio de Dermatología, Hospital Costa del Sol, Marbella (Málaga), España
| | - J C Toribio Montero
- Unidad de Enfermería, Hospital Costa del Sol de Marbella, Marbella (Málaga), España
| | - L Jabalera Mesa
- Unidad de Enfermería, Hospital Costa del Sol de Marbella, Marbella (Málaga), España
| | - F Rivas Ruiz
- Unidad de Investigación, Hospital Costa del Sol, Marbella (Málaga), España
| | - N Delgado Sánchez
- Unidad de Educación para la Salud, Distrito Sanitario Costa del Sol, Málaga, España
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Nicholson AK, Hill J, Walker H, Heward S, Dobbinson S. Teacher perceptions of sun protection practices in the secondary school setting: Barriers, enablers and recommendations for future. Health Promot J Austr 2019; 31:258-267. [PMID: 31269302 DOI: 10.1002/hpja.273] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2018] [Accepted: 06/26/2019] [Indexed: 11/08/2022] Open
Abstract
OBJECTIVE This qualitative study aimed to explore sun protection barriers and enablers in secondary schools in Victoria. METHODS Five focus groups were conducted with nominated Health or Physical Education (PE) Coordinators (or other staff representatives) from schools in metropolitan and regional Victoria. Discussions were audio-recorded, transcribed and coded thematically. RESULTS Participants identified the need for regulatory influences that included minimum standards for sun protection policy, training and shade in the built environment. Participants perceived that sun protection is not always acknowledged to be a duty of care in secondary schools. A crowded health and well-being curriculum, a focus on fostering independence, and challenges overcoming peer norms were perceived to be important contextual influences. At an organisational level, strong leadership and a united approach among staff were identified as critical ingredients for successful policy implementation and organisational change. Several potentially effective strategies were proposed, including increased shade, leveraging from student leaders, normalising sun protection practices and prioritising staff role modelling. CONCLUSIONS A cultural shift is required for many schools to accept and act on sun protection as a duty of care. A comprehensive approach that includes regulatory action, healthy school policies and leading by example may help protect students and staff from harmful UV exposure during school hours. SO WHAT?: Without regulatory support, strong leadership is required to implement and enforce sun protection practices within schools. Health promotion programs could assist schools to trial and evaluate the sun protection strategies that involve student-led solutions, role modelling and increasing shade.
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Affiliation(s)
- Anna K Nicholson
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Jane Hill
- SunSmart Victoria, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Heather Walker
- SunSmart Victoria, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Sue Heward
- SunSmart Victoria, Cancer Council Victoria, Melbourne, Victoria, Australia
| | - Suzanne Dobbinson
- Centre for Behavioural Research in Cancer, Cancer Council Victoria, Melbourne, Victoria, Australia
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Lucas RM, Yazar S, Young AR, Norval M, de Gruijl FR, Takizawa Y, Rhodes LE, Sinclair CA, Neale RE. Human health in relation to exposure to solar ultraviolet radiation under changing stratospheric ozone and climate. Photochem Photobiol Sci 2019; 18:641-680. [PMID: 30810559 DOI: 10.1039/c8pp90060d] [Citation(s) in RCA: 99] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The Montreal Protocol has limited increases in the UV-B (280-315 nm) radiation reaching the Earth's surface as a result of depletion of stratospheric ozone. Nevertheless, the incidence of skin cancers continues to increase in most light-skinned populations, probably due mainly to risky sun exposure behaviour. In locations with strong sun protection programs of long duration, incidence is now reducing in younger age groups. Changes in the epidemiology of UV-induced eye diseases are less clear, due to a lack of data. Exposure to UV radiation plays a role in the development of cataracts, pterygium and possibly age-related macular degeneration; these are major causes of visual impairment world-wide. Photodermatoses and phototoxic reactions to drugs are not uncommon; management of the latter includes recognition of the risks by the prescribing physician. Exposure to UV radiation has benefits for health through the production of vitamin D in the skin and modulation of immune function. The latter has benefits for skin diseases such as psoriasis and possibly for systemic autoimmune diseases such as multiple sclerosis. The health risks of sun exposure can be mitigated through appropriate sun protection, such as clothing with both good UV-blocking characteristics and adequate skin coverage, sunglasses, shade, and sunscreen. New sunscreen preparations provide protection against a broader spectrum of solar radiation, but it is not clear that this has benefits for health. Gaps in knowledge make it difficult to derive evidence-based sun protection advice that balances the risks and benefits of sun exposure.
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Affiliation(s)
- R M Lucas
- National Centre for Epidemiology and Population Health, Research School of Population Health, Australian National University, Canberra, Australia. and Centre for Ophthalmology and Visual Science, University of Western Australia, Perth, Australia
| | - S Yazar
- Centre for Ophthalmology and Visual Science, University of Western Australia, Perth, Australia and MRC Institute of Genetics and Molecular Medicine, University of Edinburgh, Edinburgh, UK
| | | | - M Norval
- Biomedical Sciences, University of Edinburgh Medical School, Edinburgh, Scotland, UK
| | - F R de Gruijl
- Department of Dermatology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Y Takizawa
- Akita University School of Medicine, National Institute for Minamata Disease, Nakadai, Itabashiku, Tokyo, Japan
| | - L E Rhodes
- Centre for Dermatology Research, School of Biological Sciences, Faculty of Biology, Medicine, and Health, The University of Manchester and Salford Royal NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
| | | | - R E Neale
- QIMR Berghofer Institute of Medical Research, Herston, Brisbane, Australia and School of Public Health, University of Queensland, Australia
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15
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Shedding Light on the Shade: How Nurseries Protect Their Children from Ultraviolet Radiation. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2018; 15:ijerph15091793. [PMID: 30134509 PMCID: PMC6163746 DOI: 10.3390/ijerph15091793] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2018] [Revised: 08/11/2018] [Accepted: 08/14/2018] [Indexed: 11/26/2022]
Abstract
Minimizing exposure to ultraviolet radiation (UVR) is strongly recommended as the most important primary prevention measure regarding skin cancer. The responsibility for adequate sun protection of young children lies with their parents and external caregivers. Since a high proportion of 3- to 6-year-old children in Germany attend nurseries, the practice of sun protection in this setting was assessed. A survey was conducted in 246 nurseries in southern Germany during spring and summer of 2014 and 2015. Shade coverage in the outdoor area of the nursery was assessed by study team members and UVR protective behavior of staff was assessed by an interview with the directors. On average, 52% of the entire outdoor area and 65% of the children’s outdoor play area were covered by shade, with a significant difference between nurseries of different sizes, pointing to a better shade coverage in larger nurseries. The daily outdoor stay was not regularly scheduled before or after peak sun intensity hours around noon to avoid intense UVR exposure. General sun protection rules were present in the majority of the nurseries and addressed predominantly wearing sunhats and applying sunscreen. Our findings show that current sun protection recommendations for children are only partially met in nurseries and indicate a lower level of sun protection in small institutions. Especially, avoidance of excessive exposure to UVR around noon and the importance of shade provision over play structures needs to be emphasized in future information campaigns.
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16
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Wright B, Winslade M, Dudley D, Cotton W, Hamer A. Protect your skin and let the fun begin: The results of an intervention to improve NSW primary schools' implementation of the SunSmart Program. Health Promot J Austr 2018; 30:267-271. [PMID: 30972900 DOI: 10.1002/hpja.27] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2017] [Accepted: 12/04/2017] [Indexed: 11/05/2022] Open
Abstract
ISSUE ADDRESSED The SunSmart Policy Support and Intervention Study (SSPSIS) (ACTRN12614000926639) investigated the feasibility of improving schools' implementation of the SunSmart Program, which is a resource for primary school communities to support their development of a comprehensive sun protection policy. METHODS A cluster randomised controlled trial (RCT) was used to evaluate the SSPSIS, which was conducted in NSW SunSmart schools (n = 20). Objective measurements of students' sun-safe hat-wearing behaviours and sunscreen application, and teachers' role-modelling behaviours, were collected for baseline, post-test and follow-up data. Interviews with school community stakeholders, including students (n = 103), parents (n = 31), teachers (n = 11) and executive staff (n = 4), were conducted to inform the intervention design, which was implemented following baseline data collection. RESULTS The results of baseline observations and interviews have been published previously. The intervention design aimed to combat negative perceptions of hat-wearing policy and create a trigger for sunscreen application by rewarding students practising these sun protection behaviours with play-based incentives. Although this intervention had no significant effect on the wearing of sun-safe hats among students or teachers, it did have a large effect on the consumption of sunscreen. CONCLUSIONS Associating sunscreen and play-based incentives can create an effective trigger for students' sunscreen application behaviours. However, further evidence is needed to investigate how students' and teacher role models' hat-wearing behaviours could be increased. SO WHAT?: While combining a play-based incentive with a trigger for behaviour can promptly increase students' sunscreen application, it was unable to increase students' or teacher role models' hat-wearing behaviours.
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Affiliation(s)
- Bradley Wright
- School of Teacher Education, Charles Sturt University, Bathurst, NSW, Australia
| | - Matthew Winslade
- School of Teacher Education, Charles Sturt University, Bathurst, NSW, Australia
| | - Dean Dudley
- School of Education, Macquarie University, Sydney, NSW, Australia
| | - Wayne Cotton
- Faculty of Education and Social Work, University of Sydney, Camperdown, NSW, Australia
| | - Alexandra Hamer
- Cancer Council New South Wales, Woolloomooloo, NSW, Australia
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17
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Validation of the ‘CHRESI’ questionnaire on habits related to sun exposure during childhood. Eur J Cancer Prev 2018; 27:54-61. [DOI: 10.1097/cej.0000000000000275] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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18
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Gage R, Leung W, Stanley J, Reeder A, Mackay C, Smith M, Barr M, Chambers T, Signal L. Sun Protection Among New Zealand Primary School Children. HEALTH EDUCATION & BEHAVIOR 2017; 45:800-807. [PMID: 29199473 DOI: 10.1177/1090198117741943] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Schools are an important setting for raising skin cancer prevention awareness and encouraging sun protection. We assessed the clothes worn and shade used by 1,278 children in eight schools in the Wellington region of New Zealand. These children were photographed for the Kids'Cam project between September 2014 and March 2015 during school lunch breaks. Children's mean clothing coverage (expressed as a percentage of body area covered) was calculated. Data on school sun-safety policies were obtained via telephone. Mean total body clothing coverage was 70.3% (95% confidence interval = 66.3%, 73.8%). Body regions with the lowest mean coverage were the head (15.4% coverage), neck (36.1% coverage), lower arms (46.1% coverage), hands (5.3% coverage), and calves (30.1% coverage). Children from schools with hats as part of the school uniform were significantly more likely to wear a hat (52.2%) than children from schools without a school hat (2.7%). Most children (78.4%) were not under the cover of shade. Our findings suggest that New Zealand children are not sufficiently protected from the sun at school. Schools should consider comprehensive approaches to improve sun protection, such as the provision of school hats, sun-protective uniforms, and the construction of effective shade.
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Affiliation(s)
- Ryan Gage
- 1 University of Otago, Wellington, New Zealand
| | - William Leung
- 1 University of Otago, Wellington, New Zealand.,2 University of Auckland, Auckland, New Zealand
| | | | | | | | - Moira Smith
- 1 University of Otago, Wellington, New Zealand
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19
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Winslade M, Wright B, Dudley D, Cotton W, Brown A. Australian primary school communities' understandings of SunSmart: a qualitative study. Aust N Z J Public Health 2017; 41:483-489. [PMID: 28664586 DOI: 10.1111/1753-6405.12677] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 12/01/2016] [Accepted: 03/01/2017] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVES Skin cancer represents a major health issue for Australia. Childhood sun exposure is an important risk factor and evidence suggests the use of sun protection measures by Australian school children could be improved. This study examines how the SunSmart Program, a school-based skin cancer prevention resource, can be supported to further increase sun protection behaviours to assist in lowering skin cancer incidence. METHODS The Health Promoting Schools (HPS) framework was adopted to select key stakeholders from a convenience sample of five school communities. Students, teaching staff and parents participated in semi-structured focus group and individual interviews. A thematic analysis was used to extract key themes from the data. RESULTS Although these school communities were aware of sun protection practices and the risks associated with sun exposure, their understandings of the SunSmart Program were limited. Sun protection policy implementation was inconsistent and students were unlikely to engage in sun protection practices beyond the school setting. CONCLUSION AND IMPLICATIONS School communities require additional support and engagement to holistically enforce the principles of the SunSmart Program.
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Affiliation(s)
| | - Bradley Wright
- Faculty of Education, Charles Sturt University, New South Wales
| | - Dean Dudley
- School of Education, Macquarie University, New South Wales
| | - Wayne Cotton
- Faculty of Education and Social Work, University of Sydney, New South Wales
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20
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Harrison SL, Garzón-Chavez DR, Nikles CJ. Sun protection policies of Australian primary schools in a region of high sun exposure. HEALTH EDUCATION RESEARCH 2016; 31:416-428. [PMID: 27093982 DOI: 10.1093/her/cyw020] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 03/17/2016] [Indexed: 06/05/2023]
Abstract
Queensland, Australia has the highest rates of skin cancer globally. Predetermined criteria were used to score the comprehensiveness of sun protection policies (SPP) of primary schools across Queensland. SPP were sought for schools in 10 regions (latitude range 16.3°S-28.1°S) from 2011 to 2014. Of the 723 schools sampled, 90.9% had a written SPP available publicly. Total SPP scores were low {mean 3.6 [95% CI: 3.4-3.9]; median 2 [interquartile range (IQR) 2, 4]}, with only 3.2% of schools achieving the maximum score of 12. Median SPP scores were higher in Northern and Central Queensland [both 2 (IQR 2, 6) and (IQR 2, 5), respectively] than in Southern Queensland [2 (IQR 2, 3); P = 0.004]. Clothing and hat-wearing were addressed in most policies (96% and 89%) while few schools used their SPP to plan outdoor events (5.2%) or reschedule activities to minimize sun exposure (11.7%). The SunSmart Schools program has been operating in Queensland for 17 years, and while most primary schools now have a written SPP, most are not comprehensive. Incentive-based approaches (5-star-rating award scheme and grants) may assist in addressing this issue, to reduce sun exposure of students and teachers. These data provide a baseline from which improvements in the comprehensiveness of school SPPs can be evaluated.
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Affiliation(s)
- S L Harrison
- JCU Skin Cancer Research Unit, College of Public Health, Medical & Veterinary Sciences, Room Eg-083 Ground Floor, The Townsville Hospital Education Wing, James Cook University, Townsville, QLD 4811, Australia The Anton Breinl Research Centre for Health Systems Strengthening, Australian Institute of Tropical Health and Medicine (AITHM), James Cook University, Townsville, QLD 4811, Australia
| | - D R Garzón-Chavez
- JCU Skin Cancer Research Unit, College of Public Health, Medical & Veterinary Sciences, Room Eg-083 Ground Floor, The Townsville Hospital Education Wing, James Cook University, Townsville, QLD 4811, Australia
| | - C J Nikles
- JCU Skin Cancer Research Unit, College of Public Health, Medical & Veterinary Sciences, Room Eg-083 Ground Floor, The Townsville Hospital Education Wing, James Cook University, Townsville, QLD 4811, Australia
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21
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Wright CY, Reeder AI, Albers PN. Knowledge and practice of sun protection in schools in South Africa where no national sun protection programme exists. HEALTH EDUCATION RESEARCH 2016; 31:247-259. [PMID: 26936482 DOI: 10.1093/her/cyw005] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 02/03/2016] [Indexed: 06/05/2023]
Abstract
Interventions in primary schools that increase sun-protective behaviours and decrease ultraviolet radiation exposure, sunburn incidence and skin cancer risk can be effective. SunSmart School Accreditation Programmes (SSAP) are recommended. Prior to SSAP implementation in South Africa, we explored the feasibility of obtaining national baseline information and investigated possible associations between strategies regarding sun protection in schools and students' responses to a questionnaire. Principals from randomly selected urban government schools in all nine South African provinces completed a questionnaire and 679 students were surveyed. The mean sun-related knowledge and behaviour scores of students were 4 (range: 1-7) and 3 (range-0-8) out of 9, respectively. The mean school sun protection effort score was 4 out of 14. There were no statistically significant correlations between students' knowledge or behaviour scores and their school score. The World Health Organization recommends an SSAP to address policy, practice and curriculum changes to support sun protection of students. This cross-sectional study demonstrates the feasibility of, and need for, a larger baseline study with longitudinal, multi-variable follow-up which includes other influential factors, such as parent support. Such research could quantify the impact of the SSAP and identify which key factors influence the sun-related knowledge and behaviours of students.
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Affiliation(s)
- Caradee Y Wright
- Environment and Health Research Unit, South African Medical Research Council, 1 Soutpansberg Road and Department of Geography, Geoinformatics and Meteorology, University of Pretoria, Pretoria 0028, South Africa,
| | - Anthony I Reeder
- Cancer Society Social & Behavioural Research Unit, Department of Preventive and Social Medicine, Dunedin School of Medicine, University of Otago, PO Box 913, Dunedin 9054, New Zealand and
| | - Patricia N Albers
- Environment and Health Research Unit, South African Medical Research Council, 1 Soutpansberg Road, Pretoria, South Africa
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22
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Reeder AI, McNoe BM, Iosua EE. Sun protection practices in New Zealand secondary schools: a 2014 baseline study. Prev Med Rep 2016; 3:257-63. [PMID: 27486557 PMCID: PMC4962859 DOI: 10.1016/j.pmedr.2016.03.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2015] [Revised: 02/02/2016] [Accepted: 03/07/2016] [Indexed: 11/28/2022] Open
Abstract
Objective Guided by the established primary school SunSmart programme,
a survey of secondary schools' sun protection policies, planning, behavioural
expectations, curriculum content and environment was undertaken in order to establish
a baseline to inform advocacy and secondary level programme
development. Methods All 448 principals of state or state integrated public
secondary schools identified from the Ministry of Education database were mailed a
hard copy questionnaire. School sun protection practices were assessed and a
summative, non-weighted, 11-item Total Sun Protection Score (TSPS) was created.
Associations between TSPS and socio-demographic factors, as well as school sun
protection policy, were investigated using unadjusted and multiple linear
regressions. Results Usable responses received from 211 of the 448 schools (47%
participation) indicated reasonable representativeness of eligible schools, but
under-representation of low socioeconomic decile institutions
(p = 0.003) and those
with the smallest roll size (p = 0.004). Only 50% of schools reported having a sun protection policy.
The least attained TSPS components were outdoor event planning (17.1%), student
breaks (16.6%), sun-protective clothing (8.5%) and shade provision (6.2%). The mean
(SD) TSPS was 4.58 (2.06). In multivariable analysis, TSPS was statistically
significantly positively associated with having a sun protection policy
(p < 0.001) and the
presence of primary level classes (p < 0.001) — the latter suggesting a possible influence of
programme continuity, but negatively associated with integrated school status
(p = 0.036). Conclusion A standard SunSmart programme could be promoted to all
schools, irrespective of socioeconomic decile, overall roll size, gender status or
regional population density. Low attainment of some TSPS components indicates
targeting priorities. Sun-protection practices of 211 secondary schools were
assessed. Event planning, breaks, clothing and shade criteria were
least likely met. A summative, non-weighted Total Sun Protection (TSP) score
was created. TSP score was associated with having a sun protection
policy and primary classes. A standard SunSmart programme could be promoted
irrespective of school demographics.
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Affiliation(s)
- A I Reeder
- Cancer Society of New Zealand Social & Behavioural Research Unit, Department of Preventive & Social Medicine, University of Otago School of Medicine, Dunedin, New Zealand
| | - B M McNoe
- Cancer Society of New Zealand Social & Behavioural Research Unit, Department of Preventive & Social Medicine, University of Otago School of Medicine, Dunedin, New Zealand
| | - E E Iosua
- Department of Preventive and Social Medicine, University of Otago School of Medicine, Dunedin, New Zealand
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