Health Education Research, Vol. 15, No. 2, 203-217,
April 2000
© 2000 Oxford University Press
Evaluating `Safe in the Sun', a curriculum programme for primary schools
Health Education Unit, School of Education, University of Southampton, Southampton, SO17 1BJ,
1 Adult Continuing Education, University of Southampton New College, Southampton, SO17 1BJ and
2 ICRF Medical Research Unit, St James University Hospital, Beckett Street, Leeds LS9 7TF, UK
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Abstract |
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Eleven schools in the south of England took part in a trial of `Safe in the Sun', a curriculum programme for primary school aged pupils. Case study methodology and the `draw and write' technique were combined to evaluate changes in pupils' perceptions of the effects of the sun on their skin. Teachers were free to use the materials, consisting of a teacher's handbook and video, as they wished. Pupils in all schools showed higher levels of awareness of sun-safety measures in post-intervention studies compared with the levels recorded 4 months earlier. Chi-square analysis revealed that those pupils whose teachers had used the materials as recommended by the authors had significant increases in awareness and knowledge about keeping safe in the sun, compared with other levels of intervention. More pupils also appeared able to transfer their awareness to the context of the school playground, although the differences were not significant for any level of intervention. The discussion focuses on the value of the `draw and write' technique as a tool for illuminative evaluation, on the factors which contributed to the pupils increased awareness of sun safety and on the importance of a whole school approach to sun safety.
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Introduction |
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This century has seen an increase in the incidence of skin cancer amongst white-skinned populations which has been widely reported (McKie, 1992
; Armstrong and Kricker 1993). In Norway the increase in malignant melanoma is rising by 6–7% per annum (Winchstrom, 1994), and in the UK and Germany the approximate lifetime risk for this frequently fatal form of skin cancer is 1 in 200 (Boyle et al., 1995). Skin cancer is the commonest form of cancer in the US and Australia has the highest incidence worldwide (Peters and Paulussen, 1997).
The increase in incidence amongst northern Europeans is attributed to excessive sun exposure due to increased travel and recreation. Environmental factors also play a part. It is predicted that the risk of skin cancer will increase by 3–6% for every 1% decrease in the ozone layer (Weston, 1996).
Reducing the incidence of skin cancer has become a priority for health promotion but requires a behaviour change on a large scale. Newton (Newton, 1993) suggests that this can be achieved by the collaborative action of a wide range of personnel, including health promoters, the travel industry, primary care teams, the cosmetics industry and teachers. Weston (Weston, 1996) and others have emphasized the importance of tailoring interventions to specific populations.
Young children, particularly those under the age of 15, form an important target group, since epidemiological evidence suggests that sunburn in childhood may be more harmful than later in life, increasing the risk of skin cancer (Zanetti, 1992; Osterlind et al., 1998). In a study of children's perceptions of sun, skin and skin cancer (Wetton and Collins, 1993; Hughes et al., 1996), a team of educationalists and dermatologists examined the beliefs and knowledge of 2857 primary school aged children from five northern European countries, using a `draw and write' technique, and compared these with the perceptions of children in Australia, where public health and education campaigns have been implemented since the 1980s. The findings suggested that the level of awareness of the dangers of sun exposure was lower amongst northern European children compared with Australian children. Levels of knowledge about the means of sun protection were also lower and European children were much less likely to mention skin cancer as something which results from too much sun. Almost 80% of the European children perceived suntan or sunburn as evidence of a good holiday. Rademaker et al.(Rademaker et al., 1996) found similar differences between the English subgroup of the European study and New Zealand primary school pupils, using the same methodology.
In view of these findings and evidence that pupils aged 11–15 are more resistant to skin cancer prevention messages (Peters and Paulussen, 1997), Wetton et al.went on to develop classroom materials to help European primary school teachers to incorporate safe sun messages into the curriculum.
`Safe in the Sun' consists of a book for teachers and a video with two programmes, one for teachers/health promoters and the other for pupils to watch with their teacher. A key principle of the approach of the classroom activities suggested in the teacher's book is that of `starting where children are', offering teachers a way to discover what the children already know, understand and misunderstand before planning their classroom activities (Bruner, 1960).
Pupils are actively involved in topics which span different areas of the curriculum over a number of lessons. This approach is supported by the findings of a review of sun-safety programmes (Peters and Paulussen, 1997) which concluded that the most effective interventions were targeted at the primary school age group and involved pupils in a series of active sessions rather than a single didactic intervention.
A pre-publication version of these materials was trialed in the summer term of 1995 and this paper is a report of the evaluation of the materials.
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Methods |
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There are well-known difficulties in evaluating classroom materials. If the materials are to be trialed in realistic classroom circumstances, researchers have limited control over the way the materials are used. This study has adopted the philosophy of Stenhouse (Stenhouse, 1975
) who emphasized the importance of examining the process of implementation of a curriculum as well as the outcomes. For these and ethical reasons no control group was designated. Teachers were given a standardized verbal introduction to the materials and invited to use them as they wished. Pupils whose teachers chose not to use the materials formed a non-intervention comparison group.
In this study, which is essentially formative and illuminative (Tones, 1997), we have combined some elements of a case study approach, to examine how the materials were used in a range of schools, with the use of the `draw and write' technique to study outcomes in terms of the children's awareness, knowledge and in the application of their knowledge. A more direct study of children's behaviour in the playground, as in studies of beach behaviour in Australia (Foot et al., 1993), was considered. It was thought unlikely, however, that weather conditions in England would be sufficiently constant for such a study to provide reliable data. Our approach may be compared with others cited in a recent review (Morris and Elwood, 1996) and with a study by Thornton and Piacquadio (Thornton and Piacquadio, 1996), who used a closed-ended questionnaire to test children's knowledge of sun protection strategies before and after a standardized classroom intervention.
The `draw and write' technique is primarily a qualitative tool for understanding how children explain and construct ideas and concepts. The researcher invites children to draw a simple scenario and to write what is happening. Only the written statements are analysed and children as young as 4 years can participate through the use of adult scribes. The technique is open ended, but increasingly focuses on the issue under consideration (Figure 1).
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The technique was devised as a tool for curriculum development (Williams et al., 1989a
, b) and is increasingly used in research into children's perceptions of health issues (Coombes, 1991; McWhirter, 1993; Box and Landman 1994; McWhirter and Wetton, 1994; Zivkovic, 1994; Oakley et al., 1995; Wetton and McWhirter, 1998). Since the teaching materials to be evaluated were based on an earlier survey of pupils' perceptions of the effects of the sun on skin, it seemed appropriate to carry out a before and after study of the effectiveness of the curriculum using the same technique. The materials were evaluated in 11 schools in the south of England, selected from a list of 63 volunteers where headteachers claimed sun safety was to be part of their planned curriculum for the summer term. Schools were chosen to represent urban, inner city, rural and seaside communities, and not on the basis of previous work in sun safety. Children in Year Groups 1, 3 and 5 in the summer term of 1995 (aged 5–6, 7–8 and 9–10 years) participated in the study.
Schools were visited in June and early July 1995, and pre-intervention data collected using a modified version of the `draw and write' technique used by Hughes et al.(Hughes et al., 1996). Teachers were asked to provide examples of school policies or other evidence, such as letters to parents, about the school's approach to sun safety, and were encouraged to keep records and examples of work done by children based on the materials.
Post-intervention data were collected in September/October of the new academic year when the pupils were in Year Groups 2, 4 and 6. Pupils repeated the `draw and write' activity and took part in a discussion about the sources of their knowledge.
Structured interviews with teachers sought information about how the materials were used, their opinions of the materials, their approach to sun safety and demographic information about the schools. Teachers' responses were recorded in note form during the interviews. Intervention groups were constructed on the basis of the teachers' accounts of how they used the materials. Once again teachers were asked to provide evidence of the school policies and approaches to sun safety.
Special care was taken to discourage the teachers from preparing the children in any way for either the pre- or post-intervention visits. Teachers were asked not to tell the children the reason for the researchers' visits or to do any specific teaching about sun safety in the days leading up to either visit.
The researchers each visited different schools, using a script, so that each class was given the same introduction and instructions. The children were encouraged to work independently and to use an adult scribe if they felt unable or reluctant to write for themselves. Children were told that they could write `I don't know' if they were unable or unwilling to respond to any of the Invitations.
The detailed invitations to take part in the `draw and write' investigation used in this study are shown in Figure 1
. Each invitation provided the pupils with opportunities to express their awareness, knowledge or beliefs about the sun and about how to keep safe in the sun.
These invitations were identical to those used in the earlier studies with the exception of Invitation 6 which was modified.
In the study by Hughes et al.(Hughes et al., 1996), Invitation 6 was the only invitation in the series to ask children about their own behaviour. Children were asked to draw themselves outdoors on a hot and sunny day, and to write about what they were wearing and what they were doing because it was hot and sunny. In the modified version children were asked to draw themselves in the school playground (which was pre-printed on the response sheet) during the lunch break on a hot and sunny day, and to write what they were doing and wearing (see Figure 6a and b). This invitation provided an opportunity for pupils to relate their understanding of sun safety to the context of school, without the overt prompt to link behaviour to the sun. By modifying Invitation 6 we hoped to focus the children's responses on their own behaviour in the school playground and discover how much of the knowledge they displayed in earlier responses would be transferred to this more commonplace situation.
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In the pre-intervention phase pupils were asked to respond to all six invitations used in the earlier curriculum development study. Analysis of these responses revealed that Invitations 3 and 5, although useful for the original purpose (exploring feelings associated with damage to the skin and sunburn), did not provide greater insights into the children's levels of awareness, knowledge or attitudes than was apparent from Invitations 1, 2 and 4. The redundant invitations were therefore omitted in the post-intervention phase.
With respect to Invitations 1–5, only written statements were analysed, since pictures alone can be ambiguous. This practice was varied in Invitation 6 to allow for children who had clearly drawn themselves in the shade, but had not written this on their papers. This did not affect the significance of the results. The papers were analysed using categories similar to those determined in the earlier, curriculum development study and a sample was reanalysed by a second researcher. There was complete agreement about the categories scored.
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Results |
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A total of 998 children from all schools enrolled in the study participated in both phases of the `draw and write' investigation (Tables I and II
). Responses from children who dropped out of or into the study at different stages were omitted from the analysis of pre- and post-intervention data.
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Approximately 60% of the classes used the materials in some way. With the exception of one school, the decision to use or not to use the materials seems to have been taken by individual teachers. In one small seaside school the head teacher decided that the materials would be used as part of a whole school project to promote sun safety. Teachers of pupils in Years 1 and 3 were most likely to use the materials. Those who chose not to use them gave a variety of reasons, including other priorities and lack of planning time, suggesting sun awareness had not after all been part of their planned programme.
Other teachers used the materials provided in a variety of ways. Table IIIshows the five different levels of intervention which the teachers chose. Teachers of all age groups reported that the materials were appropriate for use with primary school pupils. It is interesting to note that none of the teachers used the classroom materials without using the video, although these could be used independently.
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As on previous occasions the `draw and write' technique provided a wealth of qualitative data about children's perceptions of a health related issue. In this study the responses to Invitations 1 and 6 proved to be the most valuable for quantitative analysis.
Children's responses could be divided into two broad categories: useful and not useful. Useful responses included all those examples of appropriate ways to keep safe in the sun, including use of sun creams, specific clothing, wearing hats and staying in the shade. Children frequently made more than one useful response and these were further subdivided (see Tables IV–VII).In addition to these categories, references to cancer were recorded separately.
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- Invitation 1. During the pre-intervention phase the majority of pupils made no mention of keeping safe in the sun in response to Invitation 1. The majority of their responses were not useful in the context of this study but included many other appropriate ways in which an adult takes care of a child on the beach, e.g. staying away from the water, holding the child's hand, telling them not to wander off or go with strangers, or buying them an ice cream (Figures 2 and 3). During the second phase of data collection fewer children in all age groups made no useful response to Invitation 1 (P= 0.05) (see Table IV). The most frequently mentioned strategy for keeping safe in the sun in response to Invitation 1 was using sun creams or lotions, with hats and shade less common. The numbers of these responses were higher following the interventions, with the distribution being significantly different (P= 0.05)
- Invitation 2. It is interesting to note that the number of useful responses to Invitation 2 did not change significantly after the intervention. An examination of individual responses shows that some pupils who made a useful response to Invitation 1 chose to `draw and write' about other ways to protect the skin outdoors, e.g. from frost bite or sharp implements (Figure 4). Since Invitation 2 did not specifically refer to hot, sunny weather this was a valid response, but not useful in terms of the research focus. Invitation 2 prompted most mentions of the word cancer, however. Overall during the pre-intervention phase, cancer was mentioned by 21 pupils (2%), while in the second phase cancer was mentioned by 43 pupils (4%). This may be compared with the earlier European study where 10% of the pupils mentioned skin cancer and with the Australian study where 25% of the pupils included cancer in their responses to the same invitations. Also revealed by Invitation 2 was the misconception that sunbathing was a strategy for taking care of the skin outdoors. The number of these responses fell following the interventions, although total numbers were too small to test for significance (Figure 5).
- Invitation 4. Invitation 4 revealed that 60% of the pupils thought having a sun tan or sun burn was a sign of a good holiday. Following the intervention the number of pupils who perceived a sun tan as a sign of a good holiday fell while those referring to sun burn rose (Table VI). These differences were not significant. Children frequently described people returning from a really good holiday as miserable and cold without reference to sun tan or sun burn.
- Invitation 6. More pupils of all age groups responded with some appropriate clothing or behaviour to the playground scenario when comparing the pre and post-intervention data, although this change was not statistically significant. In contrast to Invitation 1, however, the most frequently mentioned strategy for sun safety in the playground was to play in the shade (Figures 6 and 7). The pre-intervention data and the findings of the earlier study in northern Europe (Hughes et al., 1996) are similar, with a low level of unprompted awareness amongst primary school aged children of the need for skin protection and few references to cancer. The most common strategy for protecting the skin on the beach is use of sun cream, with shade the next most common. We have shown, however, that the context can alter this distribution. Modified Invitation 6 revealed that in the school playground pupils were most likely to describe shade and hats as ways of keeping safe in the sun.
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The data obtained in the second phase of the study suggest that children in the 11 schools were more aware of the importance of protecting their skin from the effects of the sun than in the first phase. In all groups, including Group E, where no follow-up activity was carried out by teachers, the number of pupils who mentioned sun cream in response to Invitation 1 rose. Further analysis was required to determine if this trend was related to the intervention, to other health promotion activities, to the test–re-test phenomenon or to some other confounding variable.
Tables VI, V and VIIshow the effects of the different levels of intervention on the responses children gave to Invitations 1, 2 and 6. With the exception of the `no useful response' category for Invitations 1 and 6, most of the categories were too small to draw valid statistical conclusions about the effect of the different levels of intervention, however. Chi-square analysis reveals that when teachers used the materials as recommended by the authors (Group A) fewer pupils made no useful response to Invitation 1 than pupils in any of the other groups. This difference was significant when compared with Groups B, C and E at P= 0.05.
The responses to Invitation 6 suggest that children in Group A made fewer non-useful responses when compared with responses from children in Group C (P= 0.1), but the differences were not statistically significant.
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Discussion |
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Significance of the quantitative data
It is apparent from this study that data obtained from a `draw and write' investigation can be used both qualitatively and quantitatively, at the level of nominal data. While the study design created some unavoidable difficulties with sample size, achieved samples were sufficient for some statistically significant differences to be detected, despite the dropping in and out of some pupils and the high background effects due to other initiatives. We do not believe the analysis was compromised by pre-intervention differences in responses. While the test–re-test phenomenon may have contributed to fewer pupils making no useful response to Invitation 1 in the post-intervention phase, this effect can be presumed to be the same for all groups, since all responses analysed were from pupils who carried out the task twice.
It is clear from this study that the pupils were aware of a wide range of strategies for keeping safe in the sun. These strategies included the misconception that sunbathing was a way to take care of the skin in the sun. The level of this misunderstanding was reduced following the intervention. Such misconceptions are more likely to be revealed by open-ended techniques such as `draw and write', than by closed-ended techniques such as forced choice questionnaires.
It is also clear that pupils were more aware of the need to protect the skin from the sun in the second phase of data collection than in the first. Furthermore, pupils whose teachers used the `Safe in the Sun' materials as recommended had higher levels of awareness and were more knowledgeable about strategies for keeping safe in the sun than pupils whose teachers followed up the initial visit with other unspecified activities.
Usefulness of the materials to the target group
Teachers of all age groups reported that the materials were suitable for use with their pupils. However, the data reveals that the teachers were most likely to use the materials with pupils in Years 1 and 3 (7- to 9-year-old pupils). Only one-third of Year 5 pupils had access to the video and/or teaching materials. This may be due to the additional pressure on the timetable for older pupils.
The readiness of the teachers to use the video, whether with the `Safe in the Sun' teaching materials, with their own follow-up or unsupported is noted. Only one-third of the teachers used both teaching materials and the video, as recommended by the authors. A recent review (Eiser and Eiser, 1996) is critical of the use of videos to promote health, without related follow-up activities. The final version of the materials was modified to include suggestions for classroom activities to use before watching the video, to focus the children's attention on the health messages.
Confounding factors
The general increase in awareness of sun-safety measures, even amongst the non-intervention comparison group, suggests factors other than the curriculum intervention may have influenced pupils' responses.
One strongly confounding factor in this study was the impact of other sun awareness campaigns, such as the HEA Sun-Know How campaign which was in its second year during the study period (Health Education Authority, 1995/96). In addition the summer months of 1995 were characterized by high levels of sunshine, particularly in the South of England, where an exceptionally hot and dry summer was recorded [(Royal Meteorological Society, 1995), Weather Log: June, Julyand August]. September and October 1995 were also warm and sunny in the south of England providing the benefits of an `Indian Summer' [(Royal Meteorological Society, 1995), Weather Log: Septemberand October). An insight into the impact of these factors can be gained by considering the responses to Invitations 1 and 6 of the pupils who participated only in the post-intervention phase of the study which shows that the level of awareness of these pupils was higher than for those pupils who took part in the pre-intervention phase (not statistically significant). These children had not taken part in the `draw and write' activity before and (we suppose) were exposed to the same background effects as all the other children in the study. We cannot know the extent to which these children learned about keeping safe in the sun from their teachers, since we only know that they were absent from Phase 1 of the data collection.
Further evidence for the impact other health promotion activities came from classroom discussions held with the pupils after the post-intervention responses had been recorded. The researchers invited the pupils in each class to compare their pre- and post-intervention responses for Invitations 1 and 6. The raw scores were recorded on the board or flip chart and it was clear that in each class the number of children able to give useful responses had risen. Pupils were congratulated on their knowledge and asked why they knew so much more about keeping safe in the sun.
Children most frequently recalled being warned about the sun by their mothers, aunts, sisters and grannies. Many children mentioned the burn-time and similar warnings given on the weather forecast and some pupils concluded that as they were older `...we are more sensible'. Teachers were least frequently mentioned as a person who had told children how to keep safe in the sun. Thornton and Piacquadio (Thornton and Piacquadio, 1996) also found that pupils reported parents as the most likely people to educate them about sun safety.
Multi-level interventions in health promotion
This observation reflects the success of a wide range of health promotion measures. There is evidence from other areas of health promotion (e.g. cycle helmet and seat belt use) that multi-level interventions are more likely to be successful than single interventions (Thompson et al., 1989Thompson et al., 1993). Indeed, what were described earlier in this paper as confounding factors might more appropriately be termed compounding factors, with community-wide and school-based interventions apparently having additive value.
Our findings suggest that the teacher can also be an effective communicator of messages about keeping safe in the sun. The teachers who used the `Safe in the Sun' materials as recommended by the authors (Group A) were most effective in helping children to be more aware of the importance of keeping safe in the sun, both on the beach and in the school playground on a hot and sunny day, but as we have observed, the pupils did not credit their teachers with this skill.
Whole school approaches to sun safety
The `draw and write' technique provided an increasing number of prompts to the children that the whole activity was about the skin and the sun. It is perhaps surprising then that more pupils did not transfer this awareness to themselves in the final Invitation, the playground scenario.
This result may reflect the lack of school policies about safety in the sun. Only one school provided an example of a letter to parents, and a copy of the health and safety policy. When examined it was found that the policy made no mention of the sun.
As well as the absence of written policies there was further evidence from the structured interviews to indicate that the schools in this study did not consider safety in the sun a priority. Only one school allowed pupils indoors when it was hot and sunny, although in other schools individual teachers did appear to use their discretion. Reasons for not allowing pupils to remain indoors included the high temperature in classrooms with a lot of glass and problems of supervision.
It is ironic, in view of the pupils' responses to Invitation 6 where shade was the dominant strategy for keeping safe in the sun, that five of the 11 schools in the study reported little shade in the play areas. Those with shade said it was not sufficient for all the children.
In the light of these findings it was recommended that the teachers' materials be modified to emphasize the importance of a whole school approach to sun safety, and to include policy guidelines and practical recommendations for providing shade through planting schemes (Wetton et al., 1996). This reflects the philosophy of the health-promoting school movement (Tones and Tilford, 1994; WHO, 1997) in which it is proposed that curriculum, policy and community actions can work synergistically to promote the health of pupils and staff. A recent review (Lynagh et al., 1997) suggests too few interventions have addressed these important aspects of health promotion in schools. Formative evaluation of these materials was thus valuable in enabling the authors to redress the balance between curriculum, policy and community aspects of the advice in the teachers' handbook.
Through such a whole school approach it is hoped teachers, health professionals and parents will be more able to help children make the conceptual links between sun safety on the beach, in the playground and in other settings.
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Conclusion |
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This study suggests that `Safe in the Sun', developed as a result of research with primary school children, can be effective in raising children's awareness and increasing or modifying their knowledge about sun safety, but underlines the importance of teachers using the materials as they were designed. Many health promotion packages include videos and these are an attractive teaching tool, but specific, well-designed teaching materials can make the difference between an effective and an ineffective intervention.
The study also underlines the value of the `draw and write' technique as both a qualitative and quantitative tool for curriculum researchers and evaluators. In this study the gradual focusing of Invitations on a specific issue to reveal the level of awareness and knowledge, followed by a shift to a new context provided valuable insights into the transferability of the concept of sun safety.
In circumstances where studies of behaviour change are impractical or too expensive, measuring the extent to which health concepts are transferable provide valuable additional information to evaluators of classroom materials. In this study the transferability of pupils' knowledge may have been hindered by the lack of a whole school approach to the subject of safety in the sun. It is suggested that curriculum developers should include specific recommendations for school policy and community links when planning health education materials.
Finally, formative evaluation of curriculum materials can provide valuable insights into the usefulness of the materials in the classroom and help to improve their effectiveness.
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Acknowledgments |
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The authors wish to thank all the staff and pupils of the schools which took part in this study. Europe Against Cancer and the Imperial Cancer Research Fund are also gratefully acknowledged for their support.
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References |
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Armstrong, B. K. and Kricker, A. (1993) How much melanoma is caused by sun exposure? Melanoma Research, 3, 395–401.[Web of Science][Medline]
Bruner, J. S. (1960) Readiness for learning. Collected in Bruner, J. S. and Anglin, J. (1973) Beyond the Information Given.George Allen and Unwin, London, pp. 413–425.
Box, V. and Landman, J. (1994) A breakfast survey of primary schools in low income families in inner city areas of Southampton. Health Education Journal, 53, 249–261.
Boyle, P., Veronesi, U., Tubiana, M., Alexander, F. E., Clais da silva, F., Denis, L. J. and Freire, J. M. (1995) European School of Oncology advisory report to the European Commission for the Europe Against cancer programme European Code Against Cancer. European Journal of Cancer, 31A, 1395–1405.
Coombes, G. (1991) You Can't Watch Them 24 Hours a Day. CAPT, HEA, Health Education Board for Scotland, Community Education Development Centre and Northern Ireland Department of Health and Social Services.
Eiser, J. R. and Eiser, C. (1996) Effectiveness of Video for Health Education: A Review.HEA, London.
Foot, G., Girgis, A., Boyle, C. and Sanson-Fisher, R. (1993) Solar protection behaviours: a study of beachgoers. Australian Journal of Public Health, 20, 275–287.
Health Education Authority (1995/96) Annual Report. HEA, London.
Hughes, B., Wetton, N. M., Collins, M. and Newton Bishop, J. (1996) Health education about sun and skin cancer: language ideas and perceptions of young children. British Journal of Dermatology, 134, 412–417.
Lynagh, M., Schofield, M. J. and Sanson Fisher, R. W. (1997) School health promotion programs over the last decade: a review of the smoking, alcohol and solar protection literature. Health Promotion International, 12, 43–60.
McKie, R. M. (1992) Preventable cancers. In Heller, T. (ed.), Preventable Cancers. Open University Press, Milton Keynes.
McWhirter, J. M. (1993) A teenager's view of puberty. Health Education, May, 9–11.
McWhirter, J. M. and Wetton, N. M. (1994) Children's perceptions of risk. Journal of Health and Safety, 10, 21–29.
Morris, J. and Elwood, M. (1997) Sun exposure modification programmes and their evaluation: a review of the literature. Health Promotion International, 11, 321–332.
Newton, J. (1993) Education and action for skin care. In Dickinson, L., Pizzala, D. (eds), Safe in the Sun: Conference Proceedings.South East Thames Regional Health Authority.
Osterlind, A., Tucker, M. A., Stone, B. J. and Jenson, O. M. (1988) The Danish case control study of cutaneous malignant melanoma: the importance of UV light exposure. International Journal of Cancer, 42, 319–322.
Peters, L. and Paulussen, T. (1997) A review of international effect research on skin cancer prevention. In School Health Promotion and Cancer Prevention.Netherlands Institute for Health Promotion and Disease Prevention, The Netherlands.
Oakley, A,, Bendelow, G., Barnes, J., Buchanan, M. and Husain, O. A. N. (1995) Health and cancer prevention: knowledge and beliefs of children and young people. British Medical Journal, 310, 1029–1033.
Rademaker, M., Wyllie, K., Collins, M. and Wetton, N. (1996) Primary school children's perceptions of the effects of sun on skin. Australasian Journal of Dermatology, 37, 30–36[Medline]
Royal Meteorological Society (1995) Weather Log: June–October 1995. Reading, UK.
Stenhouse, L. (1975) An Introduction to Curriculum Research and Development. Heinemann, London.
Thompson, R. S., Rivera, F. P. and Thompson, D. C. (1989) A case control study of the effectiveness of bicycle helmets. New England Journal of Medicine, 320, 1361–1367[Abstract]
Tones, K. (1997) Beyond the randomized controlled trial: a case for `judicial review'. Health Education Research, 12, i–iii.
Tones, K. and Tilford, S. (1994) Health Education: Effectiveness, Efficiency and Equity.Chapman & Hall, London
Thornton, C. M. and Piacquardio, D. J. (1996) Promoting sun awareness: evaluation of an educational children's book. Pediatrics, 98, 52–55.
Wetton, N. M. and Collins, M. (1993) Children's perceptions of the sun on the skin: the missing link. In Dickinson, L. and Pizzala, D. (eds), Safe in the Sun: Conference Proceedings.South East Thames Regional Health Authority.
Wetton, N. M. and McWhirter, J. M. (1998) Image based research and curriculum development in health education. In Prosser, J. (ed.), Image Based Research: A Source Book for Qualitative Researchers. Falmer Press, Brighton.
Wetton, N. M., Collins, M. and Newton Bishop, J. (1996) Safe in the Sun. University of Southampton, Southampton.
Weston, R. (1996) Have fun in the sun. In Clift, S. and Page, S. J. (eds), Health and the International Tourist.Routledge, London, pp. 235–259.
WHO (1997) Promoting Health Through Schools. Report of a WHO Expert Committee on Comprehensive School Health Education and Promotion. WHO, Geneva.
Winchstrom, L. (1994) Predictors of Norwegian adolescents' sunbathing and use of sunscreen. Health Psychology, 13, 412–420.[Web of Science][Medline]
Williams, D. T., Wetton, N. M. and Moon, A. (1989a) A Picture of Health. HEA, London.
Williams, D. T., Wetton, N. M. and Moon, A. (1989b) A Way In. HEA, London
Zanetti, R., Fracheschi, R. and Rosso, S. (1992) Cutaneous melanoma and sunburn in childhood in a southern European population. European Journal of Cancer, 28A, 1172–1176.
Zivkovic, M., Marinkovic, J., Legetic, B., Paunovic, P. and Vidanovic, A. (1994) Evaluation techniques for the healthy school project in Yugoslavia. Health Promotion International, 9, 73–79.
Received on February 1, 1998; accepted on June 23, 1998
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 T. Hedges and A. Scriven Sun safety: what are the health messages? Perspectives in Public Health, July 1, 2008; 128(4): 164 - 169. [Abstract] [PDF]
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 J. M McWhirter, A. J Young, and N. Wetton In a class of its own: Introducing a new tool for understanding adolescents' perceptions of the world of drugs Health Education Journal, January 1, 2004; 63(4): 307 - 323. [Abstract] [PDF]
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B. Jansson, C. Boldeman, H. Dal, and H. Ullen Skin cancer prevention in early childhood: An evaluation of a health education intervention among students in a preschool vocational programme Health Education Journal, January 1, 2003; 62(3): 198 - 209. [Abstract] [PDF]
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 L. Horsley, A. Charlton, and C. Waterman Current action for skin cancer risk reduction in English schools: pupils' behaviour in relation to sunburn Health Educ. Res., December 1, 2002; 17(6): 715 - 731. [Abstract] [Full Text] [PDF]
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P. M. Lund and R. Gaigher A health intervention programme for children with albinism at a special school in South Africa Health Educ. Res., June 1, 2002; 17(3): 365 - 372. [Abstract] [Full Text] [PDF]
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