School sun-protection policies: measure development and assessments in 2 regions of the United States

Sun Protection Policies and Practices in Preschool and Elementary Schools in Andalusia (Spain)

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.

Society of Behavioral Medicine Position Statement: promote sun-safety policies and practices for youth in educational, childcare, and recreational settings

Youth should be allowed and encouraged to engage in sun-safe behaviors in educational, childcare, and recreational settings, including use of sunscreen, wide-brimmed hats, other sun-protective clothing, and shade.

Health risk assessment of volatile organic compounds at daycare facilities

Children are particularly vulnerable to many classes of the volatile organic compounds (VOCs) detected in indoor environments. The negative health impacts associated with chronic and acute exposures of the VOCs might lead to health issues such as genetic damage, cancer, and disorder of nervous systems. In this study, 40 VOCs including aldehydes and ketones, aliphatic hydrocarbons, esters, aromatic hydrocarbons, cyclic terpenes, alcohols, and glycol ethers were identified and qualified in different locations at the University of Missouri (MU) Child Development Laboratory (CDL) in Columbia, Missouri. Our results suggested that the concentrations of the VOCs varied significantly among classrooms, hallways, and playground. The VOCs emitted from personal care and cleaning products had the highest indoor levels (2-ethylhexanol-1, 3-carene, homomenthyl salicylate with mean concentration of 5.15 µg/m³ , 1.57 µg/m³ , and 1.47 µg/m³ , respectively). A cancer risk assessment was conducted, and none of the 95th percentile dose estimates exceeded the age-specific no significant risk levels (NSRL) in all classrooms. Dimensionless toxicity index scores were calculated for all VOCs using a novel web-based framework called Toxicological Prioritization Index (ToxPi), which integrates multiple sources of toxicity data. According to the method, homomenthyl salicylate, benzothiazole, 2-ethylhexyl salicylate, hexadecane, and tridecane exhibited diverse toxicity profiles and ranked as the five most toxic indoor VOCs. The findings of this study provide critical information for policy makers and early education professionals to mitigate the potentially negative health impacts of indoor VOCs in the childcare facilities.

Economic Evaluation of an Intervention Promoting Adoption of Occupational Sun Protection Policies

OBJECTIVE

Economic evaluation of an intervention promoting adoption of occupational sun protection actions by Colorado public sector employers.

METHODS

Randomized controlled trial with 2-year follow-up conducted during 2010 to 2013. Thirty-three intervention and 30 attention-control worksites in final economic sample. Twenty-four-month intervention of personal contacts, training, and materials. Intervention delivery micro-costed. Costs of implemented actions from employer self-report.

RESULTS

Twenty-four-month intervention costs: $121,789, 51.8% incurred by project staff (per-worksite mean=$1,732). Worksite costs: $58,631 (mean = $1,777). Per-employee costs: $118 project staff, $56 worksites. Materials cost: $5990 (mean = $181). Intervention worksites implemented 72 nontraining sun protection actions post-Sun Safe Workplaces (SSW) (mean = 2.18). Control worksites implemented 39 actions (mean = 1.30). Total costs to intervention worksites of implementing the 72 post-SSW actions: $90,645 (mean = $2,747). Control worksite costs: $66,467 (mean = $2,216). Per-employee implementation costs are comparable to other worksite health interventions.

CONCLUSION

SSW expanded adoption of sun protection actions at a reasonable per-employee cost.

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.

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.

Sun Safe Workplaces: Effect of an Occupational Skin Cancer Prevention Program on Employee Sun Safety Practices

OBJECTIVE

Occupational skin cancer prevention is a priority because outdoor workers are exposed to high levels of ultraviolet radiation, the primary risk factor for skin cancer.

METHODS

A 2-year follow-up assessment of the impact of Sun Safe Workplaces (SSW), a workplace sun safety program that promoted policy adoption and education, on employee sun safety behavior was conducted. Sixty-three of 98 local government organizations from the original study participated.

RESULTS

Outdoor workers (n = 1724) completed surveys on personal sun protection practices. Employees' sun protection improved statistically significantly in the intervention group receiving the SSW program. SSW's effect was mediated by the number of workplace actions to implement elements of the policy, including sun protection messages and equipment and employee reports of sun safety training.

CONCLUSION

Policy promotion is a feasible approach to occupational skin cancer prevention.

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.

Sun Safety Practices Among Schools in the United States

Importance

Exposure to the sun's UV radiation is a leading cause of skin cancer. Positive attitudes and beliefs about sun safety behavior, which would make sun protective behavior more likely, could be promoted and supported by school policies and practices.

Objective

To identify school characteristics associated with having adopted practices that promote sun safety.

Design, Setting, and Participants

School-level data from the February 3 to July 23, 2014, School Health Policies and Practices Study's Healthy and Safe School Environment questionnaire were analyzed. The School Health Policies and Practices Study uses a 2-stage sampling design to select a nationally representative sample of schools. All public, state-administered, Catholic, and non-Catholic private schools with any of the grades from kindergarten through 12 were eligible for inclusion. All analyses were conducted using weighted data.

Main Outcomes and Measures

Prevalence of sun safety practices.

Results

In a nationally representative sample of 828 US schools, representatives of 577 schools (69.7%) responded. Overall, sun safety practices were not common among schools. The most frequent practice was having teachers allow time for students to apply sunscreen at school (47.6%; 95% CI, 42.4%-52.9%). Few schools made sunscreen available for students to use (13.3%; 95% CI, 10.2%-17.0%), almost always or always scheduled outdoor activities to avoid times when the sun was at peak intensity (15.0%; 95% CI, 11.4%-19.6%), or asked parents to ensure that students applied sunscreen before school (16.4%; 95% CI, 12.9%-20.6%). High schools were less likely than elementary schools and middle schools to adopt several practices: for instance, 37.5% of high schools (95% CI, 29.7%-46.0%), 51.6% of middle schools (95% CI, 43.3%-59.7%), and 49.5% of elementary schools (95% CI, 42.0%-57.0%) had teachers allow time for students to apply sunscreen at school, and 11.8% of high schools (95% CI, 7.7%-17.5%), 18.2% of middle schools (95% CI, 13.3%-24.4%), and 14.7% of elementary schools (95% CI, 9.6%-21.8%) almost always or always scheduled outdoor activities to avoid times when the sun was at peak intensity. Other school characteristics were either not significantly associated with the adoption of any of the sun safety school practices studied (eg, metropolitan status) or were inconsistently associated with such policies and practices (eg, region, percentage of students eligible for free or reduced-price lunch, and school enrollment).

Conclusions and Relevance

School practices that could protect children and adolescents from sun exposure and that could change norms about sun safety are not common. Interventions aimed at increasing the adoption of sun safety practices among schools are needed regardless of the level, location, size, and poverty concentration of the school. Such practices would cost little to implement and would support other messages targeted toward children, adolescents, adults, and parents, with an aim to reduce skin cancer morbidity and mortality.

Results of a Randomized Trial on an Intervention Promoting Adoption of Occupational Sun Protection Policies

PURPOSE

To evaluate an intervention promoting adoption of occupational sun protection policies by employers in a randomized trial.

DESIGN

A randomized pretest-posttest controlled design with 2-year follow-up was conducted in 2010 to 2013.

SETTING

Local government organizations in Colorado who had outdoor workers in public works, public safety, and/or parks and recreation.

PARTICIPANTS

Ninety-eight local government organizations (n = 51 municipalities, 10 counties, and 37 special districts).

INTERVENTION

Organizations were randomly assigned to receive a policy and education intervention comprised of personal contacts and theory-based training and materials or to an attention control group.

MEASURES

Occupational policy documents were coded for sun safety content by a trained research assistant blind to condition.

ANALYSIS

Policy scores were analyzed with logistic and Poisson regression models using imputation.

RESULTS

At posttest, more organizations in the intervention group had a sun protection policy than in the control group (odds ratio [OR] = 4.91, P < .05; intent to treat: OR = 5.95, P < .05) and policies were more extensive (χ² = 31.29, P < .01; intent to treat: χ² =73.79, P < .01) and stronger (χ² = 24.50, P < .01; intent to treat: χ² = 51.95, P < .01). Policy adoption was higher when the number of contacts and trainings increased ( P < .05).

CONCLUSION

The intervention had a large effect on adoption of formal sun protection policies, perhaps because of its fit with legal requirements to maintain safe workplaces. Personal contacts with managers were influential on adoption of occupational policy even in this age of communication technology and social media.

Sun-Protective Behaviors of Student Spectators at Inter-school Swimming Carnivals in a Tropical Region Experiencing High Ambient Solar Ultraviolet Radiation

Skin cancer is the most common cancer in humans and Australia (particularly in Queensland) has the highest incidence globally. Sunlight is a known skin carcinogen and reflects off water, exacerbating the risk of sunburn. In 1988, the "SunSmart Program" was developed to promote sun-protection to Australian children. Within a decade, it evolved to include a voluntary national accreditation program for schools, known as the SunSmart Schools (SSS) Program. Additionally, in 2008, it became compulsory for primary schoolchildren attending Queensland government-funded schools to wear a shirt during all water-based activities, except when competing. We observed the proportion of student spectators from 41 Townsville (latitude 19.3°S) primary schools (65.9% SSS) wearing hats at inter-school swimming carnivals in 2009-2011 and 2015 and the proportion wearing a shirt. Overall, a median of 30.7% student spectators from each school wore a hat [max 46.2% (2009); min 18% (2015)] and 77.3% wore a shirt [max 95.8% (2009); min 74.5% (2015)], suggesting that hats are under-utilized. Students from non-government (private) schools were twice as likely as students from government schools to wear a hat (41 vs. 18.2% p = 0.003). Neither the hat nor the shirt-wearing behaviors of student spectators were significantly influenced by their school's size (number of students), educational advantage, sun-protection policy score, or SunSmart status, indicating that other socioeconomic factors, not assessed here, may have influenced the results. Our findings suggest that the mandatory swim-shirt policy introduced in 2008 was very effective, especially initially. However, monitoring and feedback of results to schools may be needed to maintain high levels of compliance in the longer-term. Schoolchildren attending swimming carnivals should not rely on sunscreen or shade alone to protect against direct and reflected-sunlight, and need prompting to put a hat and shirt back on immediately after a race. This responsibility could be delegated to either a parent or a student prefect, if teachers are too busy to encourage and monitor sun-safety compliance among the students in their care.

Factors Associated With Occupational Sun-Protection Policies in Local Government Organizations in Colorado

IMPORTANCE

Skin cancer prevention remains a national priority. Reducing chronic UV radiation exposure for outdoor workers through sun-safety practices is an important step to help reduce the incidence of skin cancer.

OBJECTIVE

To determine the presence of occupational sun-safety policies at local government organizations in a single state.

DESIGN, SETTING, AND PARTICIPANTS

Of 571 potentially eligible local government organizations of Colorado cities, counties, and special tax districts, we enrolled 98 in a randomized pretest-posttest controlled experiment starting August 15, 2010, that evaluated an intervention to promote the adoption of sun-safety policies. We used a policy-coding protocol to evaluate personal sun-protection practices, environmental and administrative controls, and policy directives for sun safety starting February 10, 2011. We report the baseline assessment of the occupational sun-protection policies of these organizations.

MAIN OUTCOMES AND MEASURES

The presence of an occupational sun-safety policy.

RESULTS

Overall, 85 local government organizations (87%) had policies that required personal sun-protection practices, including the use of eyewear, hats, and protective clothing. However, of the 98 responding organizations, only 8 hat policies (8%), 10 eyewear policies (10%), and 7 clothing policies (7%) mentioned sun protection as the intent of the policy. Only cosmopoliteness, operationalized as proximity to an urban area, was associated with the presence of a sun-safety policy (odds ratio, 0.99 [95% CI, 0.98-1.00]; P = .02).

CONCLUSIONS AND RELEVANCE

Outdoor workers are at increased risk for skin cancer because of long-term exposure to solar UV radiation. Although organizational policies have the potential to increase sun protection in occupational settings, occupational sun-safety policies were uncommon among local governments. Opportunities exist for dermatologists and other physicians to influence occupational sun-safety practices and policies, which are consistent with other safety procedures and could easily be integrated into existing workplace practices.

School sun-protection policies-does being SunSmart make a difference?

Evaluate the comprehensiveness of primary school sun-protection policies in tropical North Queensland, Australia. Pre-determined criteria were used to assess publicly available sun-protection policies from primary schools in Townsville (latitude 19.3°S; n = 43), Cairns (16.9°S; n = 46) and the Atherton Tablelands (17.3°S; n = 23) during 2009-2012. Total scores determined policy comprehensiveness. The relationship between policy score, SunSmart status and demographic characteristics was explored. At least 96.6% of primary schools sampled had a sun-protection policy. Although policies of Cancer Council accredited 'SunSmart' schools addressed more environmental, curriculum and review-related criteria than those of 'non-SunSmart' schools, the overall median score for both groups was low at 2 from a possible 12 (48.5% of SunSmart schools [SSSs]: inter-quartile range [IQR = 2.0-9.0] versus 65.9% of non-SSSs: [IQR = 2.0-3.0], P = 0.008). Most policies addressed hat wearing, while criteria related to shade provision at outdoor events, regular policy review and using the policy to plan outdoor events were poorly addressed. Although most primary schools in skin cancer-prone North Queensland have written sun-protection policies, the comprehensiveness of these policies could be vastly improved. These schools may require further support and advice to improve the comprehensive of their policies and incentives to continually implement them to achieve and maintain exemplary sun-protection compliance.

Does being a "SunSmart School" influence hat-wearing compliance? An ecological study of hat-wearing rates at Australian primary schools in a region of high sun exposure

BACKGROUND

Childhood sun exposure is an important risk factor for skin cancer. Anecdotal evidence suggests that hats are under-utilized by Australian primary school students.

METHODS

The proportion of students and adult role-models wearing hats was observed at 36 primary schools (63.9% SunSmart schools [SSS]) in Townsville (latitude 19.3°S; high to extreme maximum daily UV-index year round), Queensland, Australia, from 2009 to 2011.

RESULTS

Overall, 52.2% of 28,775 students and 47.9% of 2954 adults were observed wearing a hat. Hat use (all styles) among SSS and non-SunSmart school (NSSS) students was similar before (24.2% vs 20.5%; p=0.701), after (25.4% vs 21.7%; p=0.775) and during school-hours (93.0% vs 89.2%; p=0.649) except SSS students wore gold-standard (broad-brim/bucket/legionnaire) hats during school play-breaks more often in the warmer months (October-March) than NSSS students (54.7% vs 37.4%; p=0.02). Although the proportion of adults who wore hats (all styles) was similar at SSS and NSSS (48.2% vs 46.8%; p=0.974), fewer adults at SSS wore them before school (3.7% vs 10.2%; p=0.035).

CONCLUSIONS

SunSmart status is not consistently associated with better hat-wearing behavior. The protective nature of hats and the proportion of school students and adult role-models wearing them could be improved, possibly by offering incentives to schools that promote sun-safety.