Sun Protection Policies and Environmental Features in US Elementary Schools

STUDY

Sun Protection Policies and Environmental Features in US Elementary Schools David B. Buller, PhD; Alan C. Geller, RN, MPH; Maura Cantor, MA; Mary Klein Buller, MA; Kevin Rosseel, MS; Drusilla Hufford, MBA; Lori Benjes, MD; Robert A. Lew, PhD

Objective: To assess current sun protection policies and the receptiveness to new policies at elementary schools in the United States. Design: A cross-sectional telephone survey. Setting: General educational community. Patients or Other Participants: In1998,arandomsample of 1000 public elementary schools in the United States was selected (proportional to population size) from 27 metropolitan areas chosen from the 58 US cities regularly reporting the UV index in 1997. A final sample of principals from 412 elementary schools completed the survey.

for not having a policy included the principal’s lack of awareness (n = 113) or organizational barriers in the school districts (n = 77). Most principals (84.2%) said that students were outdoors during midday hours. Many principals (48.3%) were willing to adopt a sun protection policy. Most schools (72.8%) had shade structures but the majority (67.3%) reportedly covered less than one fifth of the grounds. Most principals (76.4%) were willing to increase the amount of shade structures.

Intervention: None.

Conclusions: The low frequency of sun protection policies and shade structures calls for national efforts to change policies and environments to increase sun protection at US schools. Research is needed to demonstrate the efficacy of these changes.

Main Outcome Measures: Only 3.4% of schools had a sun protection policy. The most common reasons

Arch Dermatol. 2002;138:771-774

N

From the AMC Cancer Research Center, Denver, Colo (Dr Buller); Boston University School of Medicine, Department of Dermatology, Boston, Mass (Mr Geller); Environmental Protection Agency, Washington, DC (Mss Cantor and Hufford and Mr Rosseel); Partners for Health Systems Inc, Denver (Ms Buller); and Argose, Inc, Waltham, Mass (Dr Lew). Dr Benjes is in private practice in Wellesley, Mass.

EW STRATEGIES are needed in the United States to combat the increasing rates of melanoma and other skin cancers caused by exposure to UV radiation (UVR) in sunlight.1 Severe sunburns occur during childhood, which may promote melanoma later.2,3 Reducing sun exposure in childhood seems to reduce the development of nevi.4,5 Policies that facilitate environmental change and personal protection should be an essential part of efforts to improve childhood sun safety.6 Broad social environment changes, including adoption of policies at schools, have influenced child health care behavior, most notably to reduce smoking.7

RESULTS

There was an average±SD of 517±253 students per school, which is only slightly higher than the average size for schools nationally in 1997 and 1998.6 Schools com-

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pleting the survey contained kindergarten (K) to fifth grade (46%), K to sixth grade (38%), or K to eighth grade (16%). National comparison data showed 42% of schools having K to fifth grade; 24%, K to sixth grade; 7%, K to eighth grade; 18%, fourth, fifth, or sixth grade to sixth to eighth grade; and 9%, other grade spans.8 On average, principals estimated that 61% of their students were non-Hispanic white; 17%, African American; and 15%, whiteHispanic. Data are identical to national estimates for 1998 and 1999.9 Thirty-seven percent of schools were in cities with high year-round UV intensity, including the Southeast, Southern California, and the Southwest (UV index range, 7-9) and 63% were in cities with lower UV intensity (UV index range, 4-6). Only 3.4% of schools (n=14) had a policy with rules or recommendations for students, teachers, staff, or parents designed to improve sun protection, for instance, scheduling outdoor activities to avoid having children outside during daily

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PARTICIPANTS AND METHODS In 1998, a survey on sun protection policies was conducted with elementary school principals in the United States. A sample of 1000 public elementary schools was randomly selected in 27 metropolitan areas (proportional to population size) from a list obtained from the National Center for Education Statistics. The cities were chosen from the 58 US cities regularly reporting the UV index in 1997 in 9 regions defined by UV intensity. After receiving an introductory letter, principals were contacted by telephone by professional interviewers from the AMC Cancer Research Center’s Survey Research Center to complete the survey. Of the 800 eligible schools identified by the interviewers (199 listings did not have a valid telephone number; 1 of the calls was terminated owing to inability to speak English), 387 surveys were completed with school principals (48.4%); 321 (40.1%) refused to be interviewed; and 92 (11.5%) were not reached. Bias caused by nonresponse seemed small: later responding principals, who might be more similar to nonresponding principals, were in larger schools than earlier responding principals (r=0.12, P⬍.02), but no other correlations of school characteristics or sun protection policy measures with date of interview were significant. The National Center for Education Statistics list was the most comprehensive sampling frame available, but it did not contain newly opened schools. To provide newly opened schools with a probability of being selected, participating principals were asked to identify newly opened schools in their school districts. Another 80 new schools

peak UVR (n=9); requiring children to wear shirts with sleeves (n = 4), hats with a brim (n = 6), or sunglasses (n=3); or requiring children to wear sunscreen during outdoor times (n=2) (multiple rules were listed by some schools). There were no differences in the proportion of schools with a sun protection policy by the average UV intensity in the metropolitan areas (P = .45). Of the 503 reasons given for not having such a policy, principals most commonly said that they were unaware of a skin cancer problem or that it had yet to become an issue in their school (n=113; unweighted, 22.4%) or organizational barriers to policy creation existed, including policy decisions being made elsewhere (n = 77; 15.3%); they were only able to suggest changes but not require them (n=53; 10.5%); and legal issues existed regarding policy adoption (n=38; 7.6%). Sixty-six principals thought that such a policy was unimportant (13.1%) or that other health care issues were more important (4.0%). Weather conditions precluding a policy, sun safety already being taught in school, no time available for policy development, lack of support by parents, staff, or children, and financial burden comprised in total less than 10% of replies. Some existing policies discouraged the use of personal sun protection by students (Table 1). Less than 5% of schools provided sunscreen for students, more than two thirds prohibited staff from applying sunscreen to students in general, and nearly half required a physician’s prescription before staff could apply sunscreen to students. Hats were prohibited at some schools, al(REPRINTED) ARCH DERMATOL / VOL 138, JUNE 2002 772

were identified, and interviews were successfully completed with 25 principals. Only school size differed between newly opened schools (mean, 668 students) and schools from the National Center for Education Statistics list (mean, 507 students; P⬍.02) (which may account for the correlation above), suggesting little bias due to this limitation in the sampling frame. The final sample was 412 principals from public elementary schools. The proportion of completed interviews in each metropolitan area was similar to the original proportionate sampling procedure (deviations ranged from −0.04 to +0.03); the latter was used in a weighted analysis to balance the sample with respect to metropolitan area population. Since there were few differences between the weighted and unweighted responses, we report only the unweighted responses. The 94-item survey assessed whether (1) schools had a sun protection policy, (2) what was included in the content of any such policies, (3) whether such policies prohibited personal sun protection (eg, sunscreen, sunglasses), and (4) whether principals at schools were willing to develop a sun protection policy where no such policy existed. The time scheduled for outdoor activities by children, the presence and extent of outdoor shade, and the willingness to increase outdoor shade was measured. Time of school session, size of school, ethnic composition of students, and student’s grades were reported by principals. Finally, principals were asked to cite the reasons why they did not have a sun protection policy. ␹2 Tests were used to compare differences in policies by areas of low and high UV intensity.

though less commonly at schools in areas with higher UV intensity (P⬍.01). Nearly two thirds of schools prohibited students from wearing sunglasses. Almost half of principals at schools without sun protection policies (48.3%) were willing to create a policy for their school. They were most willing to require hats with a brim (35.2%), shirts with sleeves (28.1%), and sunscreen with a sun protection factor of 15 or more (24.6%). They were less willing to require sunglasses (19.6%) and to schedule outdoor activities at nonpeak hours of daily UVR (13.6%). Many principals noted that the following educational tools could be helpful or very helpful in developing policies: printed materials for teachers and staff explaining sun safety (91.5% [unweighted]), an example of a school sun protection policy (88.4%), printed messages for parents explaining why sun protection of their children is important at school (87.0%), and printed step-by-step instructions on creating such a policy (77.9%). Some desired a qualified person to present a seminar on sun protection for parents (60.9%), tools to evaluate the school’s current sun protection policy and environment (53.3%), and consultants to draft a policy or present a seminar on how to develop one (46.7%). Most principals (84.2%) reported that students were outdoors between 10:00 AM and 2:00 PM, the daily period of peak UVR (Table 2). Schools in areas of high UVR intensity were more likely than schools in low intensity areas to have outdoor activities before 10:00 AM (P = .02). Almost three quarters of schools have strucWWW.ARCHDERMATOL.COM

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Table 1. Existing School Policies That Discourage Use of Personal Sun Protection by Students

School Policies on Sunscreen Sunscreen provided by school or school staff for students while outdoors Staff are permitted to apply sunscreen to students Staff not permitted to apply sunscreen Do not know A physician’s prescription is required for staff to apply sunscreen to students School policy on hats Use prohibited anywhere at school Use prohibited indoors only Use not prohibited School policy on sunglasses Use prohibited anywhere at school Use prohibited outdoors No policy

Unweighted Response, %* 4.6 28.5 68.7 2.9 44.8

13.9 60.3 25.7 10.0 54.6 35.4

*Responses from principals from 412 schools.

tures that provide shade (most commonly planted trees), but two thirds of principals reported that one fifth or less of the school grounds were shaded. A quarter of principals reported that shade existed on 40% of their grounds. Three quarters of principals indicated that they were willing to make structural changes to increase the amount of shade available at school if funds were available. Three fifths of the schools had made improvements to their playground or play fields in the past 5 years, but most said that the funding process was involved and complicated. These responses did not differ by regional UV intensity (P=.70).

Table 2. Environmental Features Promoting Sun Protection in US Schools

Query Hours during which most outdoor activities occur at school (n = 412) Before 10 AM 10 AM to 2 PM After 2 PM School has any structures that provide shade and/or shelter during students’ outdoor time (n = 412) Type of shade structure or shelter (n = 300)† Outdoor shelters Awnings Umbrellas on lunch tables Planted trees Other items % of outdoor space shaded and/or sheltered (n = 300) 0-20 21-40 41-60 61-80 81-100 Willing to make structural changes to increase the amount of shade available at school, if funds for changes were available (n = 412) School or school district has funded playground or playfield improvement at your school in past 5 y (n = 412) How complicated was the procedure for obtaining funding for improvements in playground or playfield? (n = 257) Very involved Somewhat involved Neither involved nor uninvolved Somewhat uninvolved Very uninvolved Do not know

Unweighted Response, %*

15.1 84.2 0.7 72.8

23.0 15.7 4.7 80.3 26.7

67.3 25.3 5.7 1.7 0 76.4

61.3

45.1 28.8 7.4 8.2 8.2 2.3

COMMENT

Currently, few schools in the United States have sun protection policies; consequently, many children and school staff when outside are unprotected from the sun. Many school principals are willing to develop such policies but were unaware of skin cancer as a health problem or the role that their school could play in preventing adverse sun exposure. Less common obstacles include decisionmaking powers often beyond the scope of the individual principal. While there are validity concerns with all self-report measures, the very low frequency of sun safety policies and shade structures suggest that little bias is present in these data. Greater public awareness and concern regarding the dangers of excessive sun exposure, coupled with educational forums for school principals, administrators, and teachers, might stimulate schools to implement sun protection policies. In the short term, efforts need to be directed at changing some school policies. Requiring a physician’s prescription for sunscreen is especially detrimental, as sunscreen is not dispensed by prescription and it is difficult to specify the appropriate “dose” to be applied. State and local health departments may need to change this requirement, or if a prescription is not required by state policy, health officials should make sure that school officials are aware that a prescription requirement ex(REPRINTED) ARCH DERMATOL / VOL 138, JUNE 2002 773

*Responses from principals from 412 schools. †School principals could provide more than 1 response to this question.

ceeds state regulations. Changes that permit hats and sunglasses to be worn while outdoors would be beneficial in reducing skin and eye exposure to UVR.10,11 However, these changes must be balanced against efforts to control other problems, including preventing gang insignias and head lice transmission. It may be more practical to routinely ask parents to apply sunscreen to children before school and to have them wear protective clothing. However, sunscreen should not be the primary means of protection because people often do not adequately apply and reapply it to achieve its maximum protection.12 Longer-term goals such as policy alternatives that change structural and environmental features (eg, trees, shade covering) and those that reschedule outdoor activities to times when less sun exposure will occur might help overcome the reluctance of school administrators to require personal sun protection of children who are unable to take these actions. Schools should first perform an audit of existing outdoor shade (amount, usability, reflection) and schedules13 and develop plans to increase shade, especially in high use areas (eg, lunch arWWW.ARCHDERMATOL.COM

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eas, walkways, bus stops, assembly areas, playground equipment), and decrease sun exposure during the midday. School personnel also will need information on the shading properties of various materials and trees and on effective and affordable shade structure designs. For instance, shade structures should (1) be designed to cover more of the sky, not just block direct sunlight, by decreasing height and increasing width or overhang; (2) be carefully placed relative to the sun’s angle to create maximum usable shaded area; and (3) include side barriers as well as overhead protection to block indirect UVR.14,15 Also, darker colored soils and paints should be used to reduce sun reflection.14 Data on the efficacy of these policy and environmental changes in reducing sun exposure are currently limited. Recently, there has been a call for national recommendations on the prevention of skin cancer.6 These would undoubtedly help sun protection become an item on school districts’ agendas. However, creating local support for sun protection among parents is essential because local entities determine whether national recommendations are implemented. Thus, recommendations to schools and education of school officials and the public are needed to convince administrators to reallocate resources to increase shade and change the traditional school day schedule to avoid midday exposure. It is also necessary to work with parents to increase personal protection behavior for children. Researchers in Australia, where strong behavioral changes for sun protection have been implemented, have observed that school-based programs may be most successful when they are aligned with other community activities and complemented by structural changes.16 Further studies are needed to identify the vital components for behavior change in the United States. Accepted for publication September 26, 2001. The survey was sponsored by grant X826339-01-0 from the Environmental Protection Agency to Boston University. Institutional review board approval was provided by the Boston University School of Medicine.

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Corresponding author and reprints: David B. Buller, PhD, Center for Health Communication, AMC Cancer Research Center, 1600 Pierce St, Denver, CO 80214. REFERENCES 1. American Cancer Society. Skin Cancer Melanoma Resource Center Web site. Atlanta, Ga: American Cancer Society; 2000. Available at: http://www3.cancer.org /cancerinfo/load_cont.asp?ct=50&prevURL=load_cont.asp&language=ENGLISH. Accessed July 19, 2000. 2. Buller DB, Borland R. Skin cancer prevention for children: a critical review. Health Educ Behav. 1999;26:317-343. 3. Koh HK, Kligler BE, Lew RA. Sunlight and cutaneous malignant melanoma: evidence for and against causation. Photochem Photobiol. 1990;51:765-799. 4. Autier P, Dore JF, Cattaruzza MS, et al. Sunscreen use, wearing clothes, and number of nevi in 6- to 7-year-old European children. J Natl Cancer Inst. 1998;90: 1873-1880. 5. Gallagher RP, Rivers JK, Lee TK, Bajdik CD, McLean DI, Coldman AJ. Broadspectrum sunscreen use and the development of new nevi in white children: a randomized controlled trial. JAMA. 2000;283:2955-2960. 6. Emmons KM, Colditz GA. Preventing excess sun exposure: it is time for a national policy. J Natl Cancer Inst. 1999;91:1269-1270. 7. California Department of Health Services Tobacco Control Section. A Model for Change: The California Experience in Tobacco Control. Sacramento: California Dept of Health Services Tobacco Control Section; 1999. 8. Department of Education National Center for Education Statistics. Common Core of Data Survey. Washington, DC: Dept of Education; 1999. 9. Department of Education National Center for Education Statistics. Education Statistics Quarterly [serial online]. Common Core of Data; “State Nonfiscal Survey of Public Elementary/Secondary Education,” 1998-1999. Available at: http: //nces.ed.gov/pubs2000/quarterly/summer/2feat/q2-6.html. Accessed November 7, 2000. 10. Rosenthal FS, Phoon C, Bakalian AE, Taylor HR. The ocular dose of ultraviolet radiation to outdoor workers. Invest Ophthalmol Vis Sci. 1988;29:649-656. 11. Wong JCF, Airey DK, Fleming RA. Annual reduction of solar UV exposure to the facial area of outdoor workers in southeast Queensland by wearing a hat. Photodermatol Photoimmunol Photomed. 1996;12:131-135. 12. Stokes R, Diffey B. How well are sunscreen users protected? Photodermatol Photoimmunol Photomed. 1997;13:186-188. 13. Cancer Foundation of Western Australia. Shade for the Public: Guidelines for Local Government in Western Australia. Subiaco, Western Australia, Australia: Cancer Foundation of Western Australia; 1999. 14. Moise AF, Aynsley R. Ambient ultraviolet radiation levels in public shade settings. Int J Biometeorol. 1999;43:128-138. 15. Parsons PG, Neale R, Wolski P, Green A. The shady side of solar protection. Med J Aust. 1998;168:327-330. 16. Hill D, Dixon H. Promoting sun protection in children: rationale and challenges. Health Educ Behav. 1999;26:409-417.

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