Health Education Research, Vol. 15, No. 3, 249-259,
June 2000
© 2000 Oxford University Press
Current action for skin cancer risk reduction in English schools: a report on a survey carried out for the Department of Health
Epidemiology and Health Sciences, The University of Manchester, Stopford Building, Manchester M13 9PT, UK
Correspondence to: A. Charlton
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Abstract |
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The objective of this study was to identify current action for skin cancer risk reduction in English schools and thus set a baseline for future skin cancer risk reduction interventions. A postal questionnaire survey was sent to 1295 primary, 59 middle and 216 secondary school headteachers, a 10% sample of schools in England in 1998. Since the Health Education Authority/Department of Health/British Association of Dermatologists introduced the Sun Awareness Guidelines for Schools in 1995, seven items from the Guidelines, i.e. education, uniform, shade, outdoor activities, sunscreens, staff awareness, and parent and governor alliances were chosen as outcome measures. The results of the survey showed that most schools had taken at least one of the seven actions (mean 2.67, SD 0.88). Of the schools which addressed sun protection, the majority started to do so after the release of the Sun Awareness Guidelines in 1995. Judging from the length of time schools had been covering sun awareness issues, the proportion of schools which were just beginning to implement sun protection in 1995 was greater than those who began in the previous year. Teaching in the curriculum was the most frequent action taken, but the approach used was usually information giving. Brimmed hats and long sleeves were rarely part of summer school wear. Most schools had less than 25% of their outdoor break areas in shade, but action was being taken to increase this. Sports days were usually scheduled for the afternoon. Sunscreen use was allowed in over 80% of schools, but its application presented teachers with a dilemma. Few staff manuals contained sun awareness issues; few staff had attended in-service courses on the subject; two-thirds of headteachers would support their staff attending them. Few schools had developed parent and governor alliances. We conclude that help is needed for schools in the form of materials, courses, funds and clear Government policy if their action is to play a major role in reducing the incidence of skin cancer.
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Introduction |
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The current Government cancer target, `to reduce the death rate from cancer amongst people aged under 65 years by at least a further fifth (20%) by 2010 from a baseline at 1996', includes action to prevent malignant melanoma (Secretary of State for Health, 1998
). The death rates for malignant melanoma and skin cancers in general rose between 1990 and 1995. Malignant melanoma rose from 20 per million in males and 23 per million in females to 25 per million in both sexes. All skin cancer deaths rose from a rate of 30 per million in both sexes to 35 per million in males and 32 per million in females (Office for National Statistics, 1998).
The link between exposure to ultraviolet radiation from the sun and the development of skin cancer has long been known, but it is now reaching critical importance. Moseley and Mackie (Moseley and Mackie, 1997) report that ultraviolet B radiation increases at ground level in the UK at times of ozone depletion as it does in Australia, which is likely to be followed by an increased risk of skin cancer in the foreseeable future.
Excessive exposure to the sun during the first 10–20 years of life greatly increases the risk of melanoma (Elwood and Jopson, 1997). Armstrong (Armstrong, 1988) showed that non-melanoma skin cancer is also associated with cumulative sun exposure in that period of life. People living in New Zealand and Australia who had spent their childhood in a less sunny country of the northern hemisphere were found to be at lower risk of skin cancer than people who were born and brought up in Australasia (Cooke and Fraser, 1985). Sunburn in childhood causes a greater risk of melanoma than sunburn later in life (Cooke and Fraser, 1985). These facts indicate the need for skin cancer risk reduction to begin early. Given the causal link between sunburn and skin cancer, the success of the multi-faceted Australian SunSmart program in reducing sunburn incidence among women proves the worth of a holistic approach to skin cancer prevention (Hill et al., 1993). Since skin cancer takes 15–20 years to develop after sunburn damage, even the longest running Australian skin cancer education initiatives are as yet unable to demonstrate a reduction in skin cancer incidence and mortality. Each summer in Britain, the Health Education Authority runs the Sun Know How campaign, targeting the general population with sun awareness messages. Sun Awareness Week activities are organized locally by Skin Cancer Co-ordinators, supported by the British Association of Dermatologists.
Young people spend a considerable proportion of their life at school, where there is the opportunity for a holistic approach to sun protection to be taken. To facilitate this action, the Department of Health, the Health Education Authority and the British Association of Dermatologists produced a list of seven Sun Awareness Guidelines for Schools which was distributed in 1995. The guidelines covered education, uniform, shade, outdoor activities, sunscreens, staff awareness, and alliances with parents and governors.
The study reported in this paper was commissioned by the Department of Health to identify the types and extent of sun protection action being taken by schools at present. The seven Guidelines were used as a framework for this survey. It is hoped that the findings will not only inform current policy, but will also provide a baseline of information to which future epidemiological studies on skin cancer can refer.
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Method |
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A 10% sample of primary, middle and secondary schools was selected by entering into the study every tenth state school listed in the Primary Education Directory (Anonymous, 1997a
) and the Education Authorities Directory and Annual (Anonymous, 1997b). Chief Education Officers of each Local Education Authority were approached for permission to write to headteachers of the schools selected to invite their participation in the survey. Four Chief Education Officers refused permission, which slightly reduced the sample numbers, from 1813 to 1776 primary and from 336 to 327 secondary schools. No middle schools were affected at this stage.
The response rate after two reminders was 75% (1325) for primary, 72% (60) for middle and 72% (235) for secondary schools. Some of the respondents declined to participate and a few questionnaires had to be excluded from the analysis due to major omissions. A total of 73% (1295) primary, 71% (59) middle and 66% (216) secondary responses were entered into the analysis.
A postal questionnaire was chosen as the method of data collection in order to survey a large number of respondents. For the purpose of this study, the actual numbers of schools taking particular types of action were of more interest to us than qualitative data from a small group of respondents. The second phase of the study now nearing completion is adding this more detailed dimension to the information obtained in the baseline survey.
The topics covered in the questionnaire were closely based on the aims and objectives of the study, i.e. the current action being taken in schools with regard to the seven areas recommended in the Guidelines: education types, methods and place in the school curriculum; items of school uniform and the extent to which they are worn; the amount of shade available in the outdoor leisure areas of the school and whether or not new shade is being created. Outdoor activities were also covered, especially with regard to the times of day when they usually take place. Questions on sunscreen use for both pupils and teachers led to a set of questions which examined teachers' behaviour in more detail. Alliances established within and outside the schools enabled coverage of general health education issues and policies to be gained. Questions on the school type, size, population and catchment area were also included.
The educational approach question was based on the categories devised by Battjes (Battjes, 1985) and used by Bruvold in the context of smoking education in 1993 as follows (Bruvold, 1993):
- Rational: information-giving delivered in a formal manner.
- Developmental: affective education to increase self-esteem making informed decisions; but with no particular focus on the health issue in question.
- Social norms: to reduce alienation and boredom and to increase self-esteem.
- Social reinforcement: to recognize and resist social pressures by pupil-involvement activities.
The question was asked in the following manner. Which is/are the main approach(es) used for teaching about sun awareness in your school? Information about skin cancer risk and prevention (rational); skills in making informed decisions (developmental); awareness of social pressure, i.e. fashion, advertising (social reinforcement); resisting peer pressure, i.e. refusal skills (social reinforcement); building a positive self-image (social norms).
Questions were generally closed in format, but feedback from two pilot study phases enabled us to make the choices as relevant and appropriately worded as possible. In order to provide some freedom for any teacher who did not find a suitable response to tick or who wanted to add further details and specify alternative factors, most questions had an open-ended section (Fink, 1995).
Schools could be identified by reference number for the next stage of the study, but the questionnaires carried no names of respondents or schools.
The next phase of the study is investigating behaviour and outcome related to action being taken in a subsample of these schools.
The first mailing took place on February 2, 1998, with reminders on February 17 and March 18, 1998. Two reminders were sent as the efficiency of follow-ups usually peaks at about three or four attempts and these are best carried out at intervals of 2 weeks or more (Bourque and Fielder, 1995).
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Results |
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Thirty-nine percent (486) of primary, 31% (18) of middle and 25% (54) of secondary respondents said they had seen the Sun Awareness Guidelines. Out of those respondents, 75% (315), 86% (12) and 60% (25) from primary, middle and secondary schools, respectively, had found them useful.
The respondents were asked how many years each of the actions recommended in the Guidelines had been implemented in their school. Relatively few had been in operation for more than 3 years, but concurrent with the circulation of the Sun Awareness Guidelines in 1995 there was a sudden upsurge in the implementation of all except the establishment of alliances. The following year, 1996, saw an even higher number of schools taking up the actions recommended in the Guidelines. Whilst these schools which had already established action did not abandon it, few other schools instituted new sun protection measures in 1997 and 1998.
Education
Sixty-two percent (804) of the primary, 51% (30) of middle and 63% (137) of secondary respondents said they included aspects of sun awareness in their curriculum. Table I shows the topics covered.
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Seventy-nine percent (1023) of primary, 70% of (41) middle and 39% (84) of secondary schools covered some aspects of sun awareness in their pastoral care.
Of those schools where sun awareness was taught in the curriculum, primary schools used Health Education as the most frequent place for sun awareness education [74% (596)] or covered it `as the need arises' [72% (579)], or in assembly [67% (537)]. Middle schools favoured Personal and Social Education [83% (25)] and secondary schools most often included the topic in Science [67% (92)] followed by Personal and Social Education [58% (79)].
Table I
shows that the `rational approach' of giving information was the lesson content most often used in all school types. The developmental approach of informed decision making and the social norms approach of building a positive self-image were used less frequently. Social reinforcement approaches teaching awareness of social pressure and skills to resist negative peer pressure were used least of all.
Table II shows the reasons why some schools were not including sun awareness in their curriculum. The most frequent reason why primary [51% (243)] and secondary [58% (42)] schools did not teach sun awareness was pressure of time. Whilst a large proportion of middle schools also said that pressure of time prevented them from teaching sun awareness [41% (11)], the most common reason why middle schools did not teach sun awareness was that they preferred to cover it in assembly [52% (14)]. A large proportion of secondary schools where sun awareness is not taught complained that they have no suitable teaching materials to draw upon [52% (38)]. A surprisingly large number of respondents expressed other reasons why they did not include sun awareness in their curriculum. These factors did not emerge in the pilot studies and were therefore not added to the closed questions. The most frequently given other reason why 27% (345) of primary, 29% (17) of middle and 26% (56) of secondary schools did not teach sun awareness was that they had `not considered it' before. Other reasons included: the school nurse deals with this; it is not in the National Curriculum; covered on trips; included in letters home; covered as the need arises; considered to be a pastoral matter.
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Uniform
Only 36% (463) primary schools had a compulsory summer uniform, but a further 59% (759) gave guidelines to parents on school wear. More middle schools [73% (43)] and secondary [91% (197)] had compulsory summer uniforms. Table III
shows in how few schools more than three-quarters of the pupils wore hats and other protective clothing in summer. The attitude to hats was a widely varied one. While 87% (1122) primary and 71% (42) middle schools recommended that their pupils wear hats in summer, only 20% (43) of secondary schools did this and 13% (28) even discouraged the bringing of hats to school. Short sleeves were the most common type of sleeves worn in all school types.
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Eighty-one percent (1048) of primary, 95% (56) of middle and 97% (210) of secondary schools had a compulsory PE kit. Tracksuits and sweatshirts allow pupils to cover-up, but a proportion of schools had sleeveless tops for PE in summer: 13% (166) primary, 17% (10) middle and 25% (54) secondary. The most commonly worn items of PE kit in all school types were T-shirts and shorts, as might be expected.
Shade
Most schools, 81% (1054) primary, 92% (54) middle and 68% (147) secondary, had less than 25% of their outdoor break areas in shade at lunchbreak. However, 45% (582), 29% (17) and 15% (33) primary, middle and secondary schools, respectively, had taken recent action to create more shade.
Table IV shows the actions taken. Some teachers commented that it would be some time before the saplings planted now would provide shade. Artificial shade had a more immediate effect. Changing behaviour included allowing pupils to go into areas such as gardens where they were not normally permitted, placing seats under trees to encourage use of shade and shortening lunchbreaks. Education for behaviour change could also play a part.
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In 87% (1125) of the primary and 78% (46) of the middle schools it was compulsory for pupils to go outdoors during the lunchbreak, but only 32% (70) of the secondary schools insisted on this. Only 28% (363) primary, 15% (nine) middle and 2% (four) secondary respondents said that pupils would be kept indoors on an exceptionally sunny day. The most common reason why secondary pupils were allowed inside was cold, wet weather [9% (19)], whilst in 22% (289) of primary and 17% (10) of middle schools exceptions were most frequently made on medical grounds.
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Outdoor activities |
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Many outdoor activities such as excursions, fieldwork and sports days were held in the afternoon when the sun is strongest. Eighty percent (1031) of primary, 86% (51) of middle and 78% (169) of secondary respondents said their sports days took place in the afternoon.
Sunscreens
Table V shows the schools' policies on sunscreen use for pupils. Schools are rightly very wary of recommending or providing sunscreens for pupils. Teachers are not legally allowed to administer medicines or even to apply antiseptics or plasters to children in case they cause adverse effects. Moreover, accusations of child abuse are now major anxieties faced by teachers and the application of sunscreens has been raised in the media in this context.
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Staff awareness
Three main issues were covered in this context: staff as role models, staff training and information, and PE staff. Concerning staff as role models, as can be seen in Table V
, teachers were acting as both negative and positive examples. Few staff manuals contained any information on sun awareness and very few of the respondents had attended in-service training on the subject. Nevertheless two-thirds of the headteachers would support staff attendance on such courses. PE staff, who spend much of summer school hours out of doors, present a special case. Few schools appear to have addressed this specific issue.
Alliances
Of the seven Sun Awareness Guidelines, this was the least frequently implemented and showed the smallest increase in 1995 concurrent with their distribution. Eighty-four percent (1085) of primary, 75% (44) of middle and 70% (152) of secondary schools indicated that the school nurse was a part of their support team, and 36% (463), 51% (30) and 65% (140) primary, middle and secondary respondents, respectively, said outside agencies were involved in supporting their health education. However, there was little evidence of parent and governor alliances having been formed in this context.
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Discussion |
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In some ways the findings of this survey are very encouraging. Most schools are now implementing at least one or two of the Guidelines to some extent and the publication of the Guidelines themselves appears to have provided an effective trigger to action.
However, there are a number of specific aspects which would benefit from further consideration and, in some cases, further action.
Teaching about sun awareness in the curriculum was the most widely implemented action, perhaps not surprisingly because teaching is the role of schools. However, education with regard to sun behaviour is not merely a matter of giving information, as has been shown by the fact that people who know of the dangers of sun exposure do not tend to take protective measures if they believe that a tan is healthy and attractive or that skin cancer only happens to other people (Arthey and Clarke, 1995). Since a tan is still seen as healthy and attractive, changing attitudes and behaviour involves just as complex a process as preventing smoking. Transfer-of-learning between health topics is needed to prevent the wheel being reinvented.
It is, therefore, from the well-researched context of smoking interventions that we must draw examples of successful behaviour-change education. Research in the context of school-based smoking interventions has shown that social reinforcement approaches to a health issue are the most effective in promoting healthy behaviour (Bruvold, 1993). Information giving is classified by Battjes (Battjes, 1985) as a rational approach, and the kind of teaching methods involved in this approach include didactic, teacher-led question and answer sessions, and lecture-style presentations of facts about sun exposure, health consequences and protection methods. Such teaching requires children to be passive listeners only, and performed poorly in changing pupils' attitudes and behaviour in the field of smoking prevention.
Informed decision making is a developmental approach according to Battjes (Battjes, 1985). Class activities may involve lectures, but more importantly they involve discussion groups and problem-solving activities to engage pupils in active learning. Pupils would be encouraged to weigh up the arguments for and against sun exposure and various protection methods, and in the process of reasoning on the facts to develop a positive attitude toward safe sun behaviour. Class discussions at all ages could be used to challenge the notion that `tan is beautiful'. Such teaching approaches have produced moderate improvements in pupils' attitude in the context of smoking and non-smoking behaviour.
The teaching approaches which yielded the best effects on pupils' attitudes and behaviour in smoking prevention programmes were those which addressed the social reinforcement which pupils are subject to by virtue of their environment (Bruvold, 1993). Teaching children to be aware of social pressures and to resist negative peer pressure are classified as `social reinforcement' approaches by Battjes (Battjes, 1985). Class activities using this approach may include discussions and role play behaviour modelling exercises to provide pupils with opportunities to develop or extend resistance skills. Sun awareness taught in this way at primary school might involve teachers discussing with pupils how to avoid being picked on or made to feel foolish in front of others if they wanted to sit in the shade when their friends were wanting to sunbathe, then letting pupils develop their refusal skills by role play to put ideas into their own words. At secondary school an assignment could be set to evaluate the fashion images used in advertisements which give out `tan is beautiful' messages and to question those messages. Building a positive self-image is a social norms teaching approach which should focus away from skin cancer, and is appropriate for class discussions at primary and secondary school.
Relatively few evaluations of school-based interventions to reduce skin cancer risk have been carried out. Thirteen studies involved children being taught lessons about sun protection at school. Over half of children's lessons were focused on knowledge and information giving, and did increase children's knowledge (Katz and Jerrigan, 1991; Fork et al 1992; Kamin et al., 1993; Hughes, 1994; Fidler and Lambert, 1995; Reding et al, 1995; Thornton and Piacquadio, 1996; Novick, 1997; Vitols and Oates, 1997). The only one of these studies which considered children's behaviour at all, Hughes (Hughes, 1994), failed to find any improvements in sun protection behaviour. By contrast three of the four school lesson interventions which addressed knowledge, attitudes and behaviour claimed success in promoting improved sun protection behaviour (Ramstack et al., 1986; Hughes et al., 1993; Buller et al., 1994).
Of the 11 studies located by the authors which gave any consideration to physical effects of sunshine in their analysis, only three found significant differences. Hill et al (Hill et al., 1993) report that Australian SunSmart caused a reduction in sunburn among women. Theobald et al. (Theobald et al., 1991) found that the Australian mass media broadcast of `Goodbye Sunshine' raised public awareness causing people to seek earlier medical advice which resulted in a significant decrease in melanoma thickness. However, Robinson et al. (Robinson et al., 1997) found that following an American mass media intervention sunburn significantly increased despite increased use of sunscreen.
Teaching also needs to be supported by the creation of a supportive environment, as teaching young people cannot in itself bring about healthy behaviour if the environment either obstructs or fails to empower young people to act in the desired healthy way (Nutbeam et al., 1993). Health-promoting schools which are already implementing actions in such areas as nutrition and smoking prevention can be encouraged to transfer their expertise to sun awareness issues also. However, reduction of skin cancer risk is not specifically mentioned in the healthy schools charter. Perhaps this could be included when the charter is reviewed in the light of Our Healthier Nation (Secretary of State for Health, 1998). It is of concern that the setting of a general cancer target in Our Healthier Nation may tend to detract from focusing on specific cancers, so education for the prevention of skin cancer may be neglected.
Most schools which teach sun awareness adopt a rational, information-giving approach which is not likely to affect pupils' sun behaviour, therefore user-friendly teaching materials taking the social influences approach are urgently needed, as are in-service courses to help teachers to understand the issues involved. Materials and courses must also match the requirements of the National Curriculum and the developmental stage of the pupils, and at primary school level must also address issues to do with the recently introduced Literacy Hour. However, the National Curriculum is due to change in the year 2000, so existing sun awareness materials will need to be updated in line with the new orders. Many Local Education Authorities have developed their own information packs as teaching resources for sun awareness along the lines of Sun Know How, so perhaps they could be encouraged to develop further materials taking a social influence approach to help teachers promote sun awareness most effectively.
The UK Skin Cancer Prevention Working Party agreed a consensus statement in 1995, placing in order of effectiveness skin protection measures. First was `Avoiding the noon-day sun between 11 a.m. and 3 p.m.', which has strong implications for schools with regard to shade at break times, including lunchbreak consideration to keeping children indoors if shade is not available and the sun is very strong, and to the scheduling of outdoor activities as well as changing pupils' own behaviour.
The second most protective measure in the consensus statement is `seeking natural shade in the form of trees or other shelter' which gives better sun protection than clothing or sunscreen. It is clear from the findings of this survey that, in most school outdoor break areas it is, at present, very difficult for pupils to seek shade, despite the planting of trees and gardens in many schools. Parasols could provide instant shade whilst sapling trees are maturing to provide long-term shade. Local Education Authorities could support schools in increasing shade available to pupils by providing funds and guidance on options for increasing shade which best suit their area. For example, long-term shade from planting trees or erecting permanent canopies may be the best option for one school, but another school in an area where vandalism is a problem may prefer to invest in parasols because they can be taken in at the end of the school day, whereas new trees and shelters could soon be spoiled. This would be a area where parent and governor alliances could help by raising needed funds for improving shade in school grounds or contacting local companies for sponsorship.
The third recommendation in the consensus statement relates to summer school wear and PE kit. It advocates `use clothing as a sunscreen, including T-shirts, long sleeves, shirts and hats'. Summer school wear has changed drastically over the past two decades. Brimmed hats and long sleeves have virtually disappeared and new items such as sleeveless vests have become common in PE kit. Cost is a major factor in changing school dress codes. Parents cannot be expected to buy a major range of new items. Added to the problem of cost is one of the acceptability of sun-safe clothes to fashion conscious pupils, even those at primary school nowadays. Sun-safe clothes therefore need to be fashionable enough for pupils to want to wear them.
Using `a broad spectrum sunscreen with a SPF of 15 or higher to protect against UVB with additional UVA protection' is ranked last in the list of four recommendations in the consensus statement. Not only does sunscreen offer less protection than either shade or clothing, but it is also potentially the most problematic sun protection measure for schools. Sunscreens are still relatively untested with regard to allergenic or even possibly carcinogenic properties, and teachers are likely to be extremely cautious about using them on pupils.
Staff issues with regard to sun protection are rarely covered in staff manuals as the study shows but such policy is very much needed as are in-service courses. Teachers have the potential to be very positive role models in children's social learning (Bandura, 1977), and they need to feel confident in their teaching and own behaviour with regard to pupils' behaviour in the sun.
Alliances with parents and governors could enable the responsibility for potentially difficult decisions to be shared. Parents and governors have the authority to make decisions on potentially problematic actions, e.g. to agree changes in uniform, school policy regarding sunscreen and other issues for which staff cannot take sole responsibility. However, as yet few such alliances with regard to sun awareness have been established. A set of guidelines on how to set up and use such alliances would be invaluable to headteachers, such as are presented in the Sun Safety Guidelines for Schools 1998 produced by the Health Education Authority as part of Sun Know How.
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Conclusion |
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Sun awareness is the first health topic which, from its outset, has been planned as a holistic approach in schools. If the policy can be established, the health value to present day children should be reflected in a fall in skin cancer incidence in years to come.
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Acknowledgments |
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The authors sincerely thank the Department of Health for funding this survey, Dr William Maton-Howarth and Dr David While for their help, and all the Directors of Education and headteachers without whom this research would not have been possible.
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Received on March 17, 1999; accepted on July 20, 1999
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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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M. Hewitt, S. Denman, L. Hayes, J. Pearson, and C. Wallbanks Evaluation of `Sun-safe': a health education resource for primary schools Health Educ. Res., October 1, 2001; 16(5): 623 - 633. [Abstract] [Full Text] [PDF]
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