Health Education Research, Vol. 17, No. 6, 715-731,
December 2002
© 2002 Oxford University Press
Current action for skin cancer risk reduction in English schools: pupils’ behaviour in relation to sunburn
School of Epidemiology and Health Sciences, Medical School, University of Manchester, Stopford Building, Manchester M13 9PT, UK
Correspondence to: A. Charlton
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Abstract |
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In a random sample of schools distributed throughout all areas of England, 2703 primary school pupils from 46 schools and 2692 secondary school pupils from 32 schools were surveyed regarding behaviour in the sun, and opinions and experience of sunburn. Seventy percent (1879) of primary and 36.5% (982) of secondary pupils recalled hearing about protecting themselves from the sun at school. Primary school pupils who recalled they were told to ‘stay in the shade’ were more likely say they did so; 27.3% (739) of primary and 20.7% (556) of secondary school pupils reported getting sunburnt; and 53.2% (393/739) primary school pupils and 52.5% (292/556) secondary school pupils reporting sunburn said their sunburn peeled. The most common time both primary and secondary pupils said they got sunburnt at school was at lunchtime (mid-day break); the next most common time was during sports day. Pupils saying they did not protect their skin because they wanted a tan were more likely to report sunburn (41.7% primary and 29.5% secondary) than those giving other reasons. Primary school pupils who said they used sun screen frequently (285/847) were more likely than ‘never users’ (178/813) to report sunburn, as were secondary school pupils (53/192 and 264/1565 for frequent and ‘never users’, respectively). Dark- and light-skinned pupils at primary school (27.3 and 27.4%, respectively) were equally likely to say they had been sunburnt. At secondary school, only 10.6% of dark-skinned compared with 22.3% of light-skinned pupils reported sunburn. The last two findings might be related to cultural behaviours and are discussed later. Pupils of all ages need encouragement to protect their skin at mid-day break, to use sunscreens correctly and be aware of alternative sun-protection methods. Education is needed which challenges the notion that a ‘tan is beautiful’ and uses social teaching methods to empower pupils to carry out sun protection in real life.
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Introduction |
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Ultraviolet (UV) radiation in sunlight is known to be a cause of skin cancer. Sun protection is important in childhood because that appears to be the time in our lives when our skin is most susceptible to sunburn damage. Cooke and Fraser found a link between childhood exposure to high levels of UV radiation in sunlight and elevated risk of skin cancer in later life (Cooke and Fraser, 1985
). Skin cancer is unusual among cancers because it attacks young adults. An increase in skin cancer deaths was observed in England and Wales from 1990 to 1995 (Office for National Statistics, 1998).
With a view to decreasing skin cancer incidence, the Health Education Authority (HEA)/Department of Health/British Association of Dermatologists (1995) produced a set of ‘Sun Awareness and Protection Guidelines for Schools’ to inform school safe sun policy in the following areas: education, uniform, shade, outdoor activities, sun screens, staff issues and alliances. Plans to reduce skin cancer are currently covered by the government’s general cancer target of reducing cancer in people aged under 65 years to 80% of the 1996 baseline level in Saving lives: Our Healthier Nation (Secretary of State for Health, 1998).
The research described in this paper (funded by the Department of Health) was carried out to investigate:
- To what extent the HEA/Department of Health/British Association of Dermatologists guidelines have been taken up by schools and assimilated into their practice.
- Whether or not behaviour and sunburn levels among the pupils was related to the number of guideline recommendations operating in the schools.
This paper is concerned with pupils’ self-reported sun behaviour, opinions and sunburn, and forms the second stage of the above work. The uptake of sun-awareness guidelines by schools was gauged from a headteachers’ questionnaire sent to 10% of English schools and was published in Horsley et al. (Horsley et al., 2000). An evaluation of teachers’ practice is currently being prepared for publication.
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Sample |
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Table I
shows the sample of schools and staff. Table II shows the sample of pupils.
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One hundred and twenty-eight primary and secondary schools were randomly selected from the schools which had participated in a headteachers’ survey. Because it was a random sample, urban and rural schools were represented, distributed over the whole of England. The response rate was 35.9% (46/128) for primary schools and 25.0% (32/128) for secondary schools. In primary schools, a total of 152 teachers and 43 lunchtime assistants were interviewed. In secondary schools, a total of 124 teachers and 31 lunchtime assistants were interviewed. In total, 2703 pupils from 46 primary schools and 2692 pupils from 32 secondary schools were surveyed regarding their behaviour in the sun, and their opinions and their experience of sunburn
The sample of schools
The sampling of schools was based on information provided by headteachers in a survey of a 10% sample of primary and secondary schools in England, reported in Horsley et al. (Horsley et al., 2000). Schools were grouped on the basis of the amount of sun awareness activity taking place there. Schools were randomly selected within these groups until 32 schools per group had been chosen. Schools were scored for their overall application of the HEA ‘Sun Awareness and Protection Guidelines’ and grouped as follows:
- GROUP 1 = low HEA guideline application (<25% of the maximum score).
- GROUP 2 = medium HEA guideline application (25–75% of the maximum score).
- GROUP 3 = high HEA guideline application (>75% of the maximum score).
The sample of teachers
Five members of staff were interviewed from each school. Four teachers were chosen: the pupils’ class teacher, the class teacher of a different class, a science specialist teacher and a PE specialist teacher. The fifth staff member interviewed was a lunchtime assistant because they would be in charge of the pupils during the teachers’ lunchbreak and be on duty in the outdoor break area.
The sample of pupils
Year 5 and 6 (age 10 and 11 years) in primary school and year 10 and 11 (age 15 and 16 years) in secondary school were chosen because they are the final years in each type of school, and so would be expected to have been subjected longest to their school’s policy. Power calculations showed that 769 pupils per group would have been necessary to investigate a difference in binary outcomes to within five percentage points of the true value with 95% confidence (Lemeshow et al., 1990).
Pupils were randomly selected from class registers of schools to provide a total of 800 pupils in each group. The actual number of pupils drawn in each group fell short of the power calculation total needed for five percentage points, but allowed investigation to within 10 percentage points, of the true value. In total, 2703 primary pupils (1374 boys and 1329 girls) and 2692 secondary pupils (1374 boys and 1318 girls) completed questionnaires which were included in the analysis. Thirty incomplete questionnaires (0.6%) were excluded from the analysis.
The sample of parents
Parents were asked about their recollection of their child’s sunburn, for the purpose of cross-checking the pupils’ self-reported sunburn. Parents of pupils who were to complete the survey were asked if they were willing to be contacted by phone. This was done using a note sent home with pupils, when seeking parental consent for children to participate in the survey. Forty-five parents of primary pupils and 20 parents of secondary pupils who had completed the pupils’ questionnaire gave their phone number on the permission slip and were asked about their child’s experience of sunburn.
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Methods |
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Permission slips were sent home with pupils to gain parental consent for pupils to complete the questionnaire. In participating schools, the selected pupils were gathered to complete the questionnaire under the supervision of researchers from Public Attitude Surveys. The researchers noted pupils who were absent on the day the questionnaire was carried out and these were followed up by mailing the questionnaire to their class teacher, who supervised its completion and returned it by post. The questionnaire was completed during January and February 1999. Pupils had the right to refuse to participate even if their parents had given permission, but none did so.
The questionnaires of pupils who were absent on the day when the researchers supervised the completion of questionnaires and were followed up were compared to those of their peers for key questions. As no statistically significant differences were found between the responses of pupils who completed the questionnaire under the supervision of their teachers and those who completed it under the supervision of researchers; all pupils’ responses were analysed together.
The pupils’ survey instrument—‘The Sunshine Questionnaire’
The survey was developed and piloted at a primary school with 10 Year 6 pupils (four girls and six boys) and at a secondary school with 14 Year 11 pupils (two girls and 12 boys). Revisions were made and a second pilot was conducted with eight Year 6 pupils (three girls and five boys) and with 12 Year 11 pupils (five girls and seven boys). Piloting ensured that the questions were understandable and answerable.
Questions were asked about sunburn, school clothing, PE kit, pupils’ recall of hearing about protecting themselves from the sun at school, if they had sought shade, use of sunscreen, protective clothing, skin type, and opinions on why young people in general and why the pupils themselves might not always protect their skin in the sun. The questions were generally closed in format, requiring ticks in boxes as answers. However, ‘other’ categories were provided in the closed questions which enabled respondents to write their own answer. Where opinions were sought, the questions were open-ended, e.g. ‘Why do you think young people of your age might not always take care to protect themselves from the sun?’.
A standard question on sunburn was compiled at an expert meeting. Many surveys in the past have asked about sunburn in different ways, so a standard outcome measure of sunburn was needed. Regarding their experience of sunburn, pupils were asked, ‘Can you remember your skin being red and sore after being in the sun at school before the summer holidays?’.
Skin type is important in determining susceptibility to sunburn damage, so a skin colour chart was adopted from the work of Scotto and Fears to gauge skin type (Scotto and Fears, 1978).
Parents
Due to time and financial limitations, few of the parents could be interviewed. Two Local Authority areas only were selected because of their proximity to UV Recording Units, which would permit comparison with actual levels of UV radiation and the reported times of sunburn if necessary. Parents were first contacted by letter and those who were willing to be interviewed were telephoned at a time to suit them. They were asked about their child’s experience of sunburn by researchers from Public Attitude Surveys. The standard question on sunburn from the pupils’ questionnaire was adapted for parents. Parents saying their child had been sunburnt were also asked whether their child’s sunburn peeled and what the circumstances surrounding their child’s sunburn were. The numbers were too few to carry out statistical analysis, such as whether they were mothers or fathers, parents of girls or boys and who reported more sunburn. More research on this topic would be valuable.
Data analysis
The data were analysed using the Statistical Package for the Social Sciences. Pearson’s 
2-test of association or Fisher’s exact test was used where appropriate to test for associations. Factors which tested as significant were further examined by entering them into a simple forward stepwise logistic regression analysis.
Background factors checked
No statistically significant differences were found between groups for catchment area or ethnicity of pupils.
Gender
There were no statistically significant differences in the proportions of boys and girls in the various school groups at primary school, but at secondary school there was a greater proportion of boys in Group 1 schools (2 = 9.996, d.f. = 2, P = 0.007). This was not due to sampling from single-sex schools. However, this difference did not seem likely to obscure the results of the survey because primary and secondary boys and girls did not differ significantly in their reported episodes of sunburn at school.
Skin colour
Pupils were asked to identify which skin colour from the chart of Scotto and Fears best matched the skin on their upper arm (Scotto and Fears, 1978). They were also asked whether their skin was actually the same colour or a bit lighter or darker. Most pupils said the skin colour they had chosen did not match their skin tone exactly, so the skin colour chart was split into two broad skin types: ‘light’ (ranging from colour 4 to colour 10) and ‘dark’ (ranging from colour 1 to colour 3), which would apply to pupils with a Mediterranean skin tone or darker. We are not able to report ethnicity or religion of the pupils, but it appears that cultural differences as well as skin tone could affect incidence of sunburn, which is discussed later.
The proportion of light-skinned primary pupils was higher in groups where school sun awareness was higher (2 = 24.371, d.f. = 2, P < 0.001). This would have been expected to contaminate the results of the survey if light-skinned pupils were more likely to report sunburn; however, no significant differences were observed between primary school pupils’ skin colour and experience of sunburn at school.
The proportion of light- and dark-skinned secondary pupils did not differ significantly between the three school groups.
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Results |
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What pupils remembered about sun protection
Seventy percent (1879) of primary and 36.5% (982) of secondary pupils recalled hearing about protecting themselves from the sun at school. At primary school, a greater proportion of pupils in Group 1 schools (low HEA Guidelines) recalled hearing about sun protection (
2 = 16.927, d.f. = 2, P < 0.001), but no clear trend was observed. In secondary schools the proportion of pupils recalling hearing about sun protection increased with school sun-awareness group (2 = 43.041, d.f. = 2, P < 0.001). The main messages which pupils recalled are summarized in Table III.
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Responses which were seldom given, i.e. in the open-ended ‘Other’ category of this question, included:
nothing more to tellsun can cause harm
told not to sunbathe often
don’t get too hot
drink plenty fluid
cover up/don’t take clothes off
Pupils’ experiences of sunburn
In response to the question, ‘Can you remember your skin being red and sore after being in the sun at school before the summer holidays?’, 27.3% (739) of primary and 20.7% (556) secondary school pupils said ‘yes.’ Of those pupils reporting sunburn, 53.2% (393/739) of primary and 52.5% (292/556) of secondary pupils said their sunburn peeled.
At primary school, 27.3% (620) of light skinned and 27.4% (117) of dark skinned pupils reported getting sunburnt. At secondary school, 22.3% (508) of light skinned and 10.6% (39) of dark skinned pupils reported getting sunburnt.
Pupils who reported getting sunburnt were asked ‘When was the worst time your skin was red and sore before the summer holidays?’. The majority replied that they had got sunburnt during lunchtime (mid-day break), as shown in Table IV.
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The question was a closed one, but an ‘Other’ category at the end provided the respondents with the opportunity to add situations which were not included in the boxed options. ‘Other’ responses included:
watching a cricket matchwatching a football game
at a sailing regatta
doing country dancing
at the district sports
on work experience
on a boat
on a trip at weekend—swimming outside
At primary school, the proportion of pupils saying they got sunburnt whilst walking to or from school, being outside at lunch, or during a sports lesson appeared to decrease with increasing school HEA guideline application group (2 = 49.089, d.f. = 24, P = 0.002). However, a greater proportion of primary pupils in higher HEA guideline application groups reported getting sunburnt because they had been sunbathing at lunch-time (mid-day break) (2 = 49.089, d.f. = 24, P = 0.002). No such patterns were evident across the three school groups for the circumstances of sunburn at secondary school.
Parents’ observations on their children’s sunburn
Parents’ and their children’s answers were compared on questions about the child’s sunburn and the circumstances in which it happened. Parents and children tended to have different opinions:
- 80% (52/65) of the pupils said they had not been sunburnt and 72.3% (47/65) parents gave the same answer.
- Out of the 13 pupils who said they had been sunburnt, 10 of their parents said their child had not been sunburnt.
- Eight parents said their child had been sunburnt, but only three of these children gave the same answer as their parent.
- Seven pupils said their sunburn peeled, but only two of their parents had noticed this was so.
- One pupil said they got sunburnt whilst walking home from school. The parent said their child had not been sunburnt.
- Seven pupils reported getting sunburnt whilst being outside at lunch break (mid-day). Two of their parents gave the same answer.
- Two pupils said they got sunburnt whilst sunbathing at lunchtime. Their parents said the children had not been sunburnt.
- Two pupils reported getting sunburnt during sports day. One parent gave the same answer.
- One pupil could not remember the circumstances surrounding getting sunburnt. The parent said their child had not been sunburnt.
- The parents of five pupils who said they had not got sunburnt said their children had been sunburnt: three parents said their child got sunburnt whilst outside at lunch (mid-day) one parent said their child got sunburnt during a sports lesson and one parent said their child got sunburnt on sports day.
Factors affecting pupils’ sunburn
Using a simple forward stepwise logistic regression model, we were unable to determine the characteristics that were risk factors for whether or not pupils burned. The variables tested were: pupils’ skin colour, recall of sun awareness main message, recall of the context of sun awareness advice, use of shade and use of suncream. However, univariate analysis revealed associations between pupils’ reported sunburn and their opinions, behaviour, skin colour and school environment. Some types of education also affected positively pupils opinions and behaviour, as has also been found in an evaluation of ‘Safe in the Sun’ (McWhirter et al., 2000). Our findings with regard to education effects will be reported in a separate paper currently under preparation.
School HEA guideline application group related to pupils’ reported sunburn
At primary school, no statistically significant differences were found between the three school groups for pupils’ reported sunburn.
A greater proportion of pupils in secondary schools in the higher HEA guideline application groups reported getting sunburnt, the opposite of what might be expected (2 = 13.628, d.f. = 2, P = 0.001). The proportions of secondary pupils reporting sunburn were: 16.8% (100) of secondary pupils in Group 1, 20.4% (310) of secondary pupils in Group 2 and 25.4% (146) of secondary pupils in Group 3
Sunburn related to pupils’ recall of the context of sun awareness advice
More sunburnt pupils could recall hearing about protecting themselves from the sun at school than pupils who said they had not been sunburnt.
- At primary school, 29.9% (561) of pupils who recalled hearing about sun protection at school reported sunburn, compared with 21.6% (178) of those not recalling hearing about sun protection (2 = 19.646, d.f. = l, P < 0.001).
- At secondary school, 22.9% (225) of pupils who recalled hearing about sun protection at school reported sunburn, compared with 19.4% (757) of those not recalling hearing about sun protection (2 = 4.812, d.f. = l, P = 0.028).
Circumstances surrounding pupils hearing about sun protection related to sunburn
Significantly fewer pupils at both primary (2 = 5.354, d.f. = l, P = 0.023) and secondary (2 = 6.971, d.f. = 1, P = 0.005) schools who recalled receiving leaflets about sun awareness reported having been sunburnt. This effect was not due to just one or two schools taking part in a leaflet campaign, as pupils who recalled receiving leaflets did not come from the same schools, but were scattered between 13 primary and 10 secondary schools.
More secondary pupils who recalled that sun protection was mentioned to them immediately before they went outdoors at mid-morning or mid-day break reported sunburn (2 = 4.672, d.f. = l, P = 0.036). No such association was evident for primary pupils.
Main messages recalled by pupils related to sunburn
Statistically significant associations were found between the main sun awareness messages primary pupils could recall and reported sunburn as Table V shows. No such relationship was observed for secondary pupils. More primary school pupils recalling the message ‘Sun can cause skin cancer’ reported getting sunburnt. Fewer primary pupils recalling the message ‘Stay in the shade’ reported getting sunburnt.
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Pupils’ claim always to protect themselves and experience of sunburn
At both primary and secondary school, pupils’ assertion that they always protect themselves in the sun was not significantly associated with their reported experience of sunburn.
Uniform and pupils’ sunburn
No statistically significant differences were found between pupils wearing long or short sleeves and reported sunburn at either primary or secondary school.
In both primary (2 = 13.273, d.f. = 1, P < 0.001) and secondary schools (2 = 4.357, d.f. = l, P = 0.042), reported hat wearing was associated with higher reported sunburn.
Shade and pupils’ sunburn
No statistically significant differences were observed between the availability of shade and reported sunburn at primary school. However, at secondary school, 25.2% (296) of those saying there was not enough shade available to them at school reported getting sunburnt, compared with 18.9% (385) of those saying there was enough shade available (2 = 12.913, d.f. = l, P < 0.001).
The relationship between reported shade use and primary school pupils’ reported sunburn is shown in Table VI. No clear pattern is evident, but pupils who said they ‘rarely seek shade’ and those who said they ‘always seek shade’ reported getting sunburnt more often than those who claimed ‘never to seek shade’. No statistically significant relationship was found between secondary school pupils’ use of shade and their reported sunburn.
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Of the 77 primary pupils who said they always seek shade and that they experienced sunburn, the majority [62.9% (44)] said they had got sunburnt whilst doing an activity of their choice, such as playing at lunch break (mid-day) [34.3% (24)] and 37.1% (26) said they got sunburnt during a school activity, e.g. sports day [22.9% (16)], on a school trip [7.1% (5)], during fieldwork [4.3% (3)] or during a PE lesson [2.8% (2)].
Pupils’ behaviour in the sun
When pupils were asked ‘Do you always take care to protect yourself in the sun?’, 76.2% (2057) of primary and 33.3% (893) of secondary pupils said they did (2 = 997.801, d.f. = l, P < 0.001).
Pupils’ use of suncream and their reported sunburn
Table VII shows that the more often primary pupils said they used suncream, the more likely they were to say they had experienced sunburn. A similar trend was seen at secondary school.
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Uniform and pupils’ behaviour
Pupils were asked what they usually wear outside at school in summer. Pupils ticked as many types of clothing as applied to them. Short sleeves were worn by 85.1% (2301) of primary and 70.8% (1905) of secondary pupils surveyed. Long sleeves were worn by 31.7% (857) of primary and 41.3% (1113) of secondary pupils. Sixty-nine percent (1806) of primary pupils said they wore hats, compared with only 18.4% (494) of secondary pupils.
Shade and pupils’ behaviour
The availability of shade to pupils and the extent to which they chose to seek shade is shown in Table VIII. A greater proportion of primary pupils said they were able to use shade and more primary pupils said they did so.
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More primary pupils who recalled being taught to seek shade reported that they did so, as shown in Table IX
. No such link was observed between sun awareness message recalled and shade use by secondary school pupils.
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Suncream and pupils’ behaviour
Table X
summarizes how often pupils claimed to use suncream on sunny days at school. More primary than secondary pupils said they used suncream at school.
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On the question of whether pupils were allowed to use suncream at school, 57% (1547) of primary and 59.8% (1611) of secondary pupils gave the same answer as their teacher. Twenty-seven percent (730) of primary and 35.4% (954) of secondary pupils did not know if they were allowed to use suncream at school or not.
Primary pupils who recalled being taught that ‘suncream is important’ reported using suncream more frequently than those who did not recall this message (2 = 43.114, d.f. = 4, P < 0.001). No such link between message recall and reported suncream use was seen for secondary school pupils.
Pupils’ opinions on why young people do not protect themselves from sunburn
As Table XI shows, when pupils were asked why they thought young people of their age might not always take care to protect themselves in the sun, the most common reason given by 24.7 % (635) of primary pupils was ‘people can’t be bothered’, but the most common reason given by 37.1% (991) of secondary pupils was that ‘people want a tan’. Wanting a tan was the equal second most common reason given by 17.0% (437) of primary pupils, together with people’s ignorance of the implications of sunburn. The second most common reason given by 33.0% (881) secondary pupils was ‘people can’t be bothered’ and the third most common reason given was people’s ignorance of the implications of sunburn (19.6% (524).
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Responses given to the open-ended ‘Other reasons’ category included:
I don’t like hats [Primary boy]People may not have caps, suncream and long-sleeved jumpers [Primary girl]
Some children my age take off their tops because it‘s too hot and they can’t help ourselves [sic] [Primary boy]
We hardly have any sun in Britain, and when we do, we make the best of it [Secondary boy]
Reasons why pupils do not always protect themselves from the sun
When pupils saying they did not always protect themselves in the sun were asked why that was so, some pupils gave more than one reason, others gave none. Responses are shown in Table XII. The most frequently given reason by 23.5% (151) of primary school pupils was ‘I forget’, whereas the most frequent reason given by 19.4% (346) of secondary pupils was ‘My skin rarely or never burns’. Wanting a tan was the fifth most common reason why 9.3% (60) of primary and 10.6% (190) of secondary pupils did not always protect themselves.
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Reasons given in the open-ended ‘Other reasons’ category included:
I don’t know when to [Primary]I did not know how much the sun was dangerous [Primary]
I did not know about skin cancer [Primary]
I come out of the sun when I have had enough [Secondary]
It depends on where I am [Secondary]
I protect myself when I‘m sunbathing but not if I‘m going shopping [Secondary]
I don’t use sun tan [cream] in normal sun but I do if there’s a heatwave [Secondary]
I usually wear tracksuit bottoms [Secondary]
There were no statistically significant differences in the reasons given by primary pupils for not always protecting themselves between the three school HEA guideline application groups. As Table XIII shows, significantly fewer secondary pupils in Group 3 schools said that they do not think about sun protection, but in this group more pupils said they don not protect themselves because they cannot be bothered or because they want a tan.
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Pupils’ opinions related to sunburn
More pupils who did not protect their skin because of wanting a tan reported sunburn:
- At primary school 41.7% (25) of pupils saying they do not always protect themselves because they want a tan reported sunburn, compared with 25.4% (143) of those giving other reasons (2 = 7.285, d.f. = l, P = 0.007).
- At secondary school 29.5% (56) of pupils saying they do not always protect themselves because they want a tan reported sunburn, compared with 18.7% (296) of those giving other reasons (2 = 12.478, d.f. = l, P < 0.001)
Fewer pupils saying they did not protect themselves because their skin rarely/never burnt reported sunburn:
- 9.1% (9) of primary pupils saying they did not protect themselves because their skin rarely or never burned reported getting sunburn, compared with 30.3% (159) of those giving other reasons (2 = 19.097, d.f. = l, P < 0.001).
- 9.2% (32) of secondary pupils saying they did not protect themselves because their skin rarely or never burned reported getting sunburn, compared with 22.4% (320) of those giving other reasons (2 = 30.218, d.f. = l, P < 0.001).
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Discussion |
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The prevalence of sunburn in school children was roughly one-quarter of primary pupils and one-fifth of secondary pupils. Half of all sunburnt pupils said their sunburn was severe enough to peel.
One of the most interesting findings was the difference between primary and secondary schools. Dark- and light-skinned pupils were equally likely to report sunburn at primary school, but fewer who said they had dark skin sunburnt at secondary school. It might be speculated that this is perhaps due to cultural differences, e.g. Muslim girls are protected by the veil and other clothing at secondary, but not at primary; primary school pupils are required to go outdoors more; younger dark skin is more sensitive to UV radiation. More research is needed on this topic. The difference in sunburn between dark- and light-skinned pupils might also underlie the finding that there was more sunburn in schools which applied more HEA guidelines, which also had more light-skinned pupils.
Many schools are to be commended for addressing the issue of sun protection, but sunburn incidence shows there is still room for improvement.
Parents and children differed in their recollections of the child’s sunburn. It would therefore seem prudent to raise parental awareness of the need to protect children of all ages from sunburn by including some form of parental involvement in future school-based sun protection education.
The majority of pupils who got sunburned said it happened at lunchtime (mid-day break). Most of the primary pupils who reported they sought shade but got sunburnt were burnt whilst doing an activity of their choice. The circumstances surrounding pupils’ sunburn indicate a need for education to encourage pupils to protect their skin from too much sun as a matter of routine (not just on special occasions like holidays) and to make them aware that they can get sunburnt even when they are not sunbathing. Positive messages giving specific action that can be taken, e.g. stay in the shade, were more effective than passive information, e.g. the sun causes skin cancer, or victim-blaming messages, e.g. people who want a tan are vain.
School sports day was the second most common occasion when pupils at both primary and secondary school reported getting sunburnt. School sports days need to be scheduled away from the hours of 11 a.m. to 3 p.m. when the sun is strongest, if at all possible, and pupils need to be allowed to take the protective measures of wearing hats, sports shirts with collars to protect the back of their neck (or at least T-shirts) and to be actively encouraged to use sunscreen on sports day.
More secondary pupils who said there was not enough shade reported getting sunburnt. This finding indicates a need for schools to provide shade for pupils, especially at mid-day break during sunny summer weather. No clear trend emerged for pupils’ use of shade and sunburn, even though many primary pupils recalled the message ‘seek shade’ and reported they did so. Perhaps primary pupils went into the shade only after they sensed their skin burning, by which time it was too late to prevent sunburn.
Local authorities could support schools in the matter of providing shade and could aim to include shade in community leisure facilities. The HEA produced ‘Skin Cancer Prevention: Policy Guidelines for Local Authorities’ in a revised form which contains action sheets differentiated for separate local authority departments. However, the action sheet on education and social services focuses solely on schools educating pupils about sun awareness and protection. No amount of sun-safe education will help pupils to avoid sunburn if the school environment is working against sun safety. Health-promoting schools must be at an advantage in addressing health issues with pupils and parents, but currently do not mention skin cancer risk reduction in their charter. As Nutbeam et al. showed, a supportive school environment which empowers pupils’ choices is needed for health education to be effective (Nutbeam et al., 1993). To this end, local education authorities could help schools to form alliances with helpful agencies by compiling a list of providers of shade structures, sunscreen and uniform, and could perhaps negotiate discount rates for local schools or large quantity purchases, say if two or three small schools were to order together. Although this study found no link between uniform and incidence of sunburn, it is an important issue. It seems likely that young people do not always wear the uniform as intended, e.g. roll up the sleeves. High protection factor materials and long sleeves are needed, but it needs to be attractive and comfortable enough for pupils to wear it correctly and they need to be encouraged to do so. A useful guide to architects which covers the practical aspects of shade planning and construction, health and safety standards, suitable materials, and case studies was produced by the HEA in conjunction with the Royal Institute of British Architects (New and McDonough, 1997).
Some local education authorities, e.g. Norfolk, have circulated teaching information packs based on ‘Sun Know How’ to help their schools. Others, e.g. Manchester, have advised schools to use uniform to protect pupils from the sun in summer. Sending a reminder to schools at the beginning of summer term about the scheduling of sports day would help to prevent children’s sunburn and any potential complaints from parents.
It is a matter of concern that those pupils who used suncream frequently were more likely to report they had been sunburned. It may be that the frequent suncream users are the pupils who are the most susceptible to sunburn anyway. However, this finding is the opposite of what would be expected if sunscreen of a high enough factor was being applied correctly by pupils. Susceptible pupils may be lulled into a false sense of security when they have applied some sunscreen and may not be using a high enough factor or reapplying the cream as the manufacturers recommend. The most frequently recalled sun-protection message was the importance of wearing suncream. Whilst suncream is protective, it is not the most protective measure available nor the cheapest for parents. Pupils would benefit from using a variety of protection methods. Future health education needs to make pupils, parents and school staff aware that covering up with clothing and seeking shade can be more protective than using suncream according to the UK Skin Cancer Prevention Working Party consensus statement (1995) which listed sun-protection methods in descending order of effectiveness as:
- Avoiding the sun from 11 a.m. to 3 p.m.
- Seeking natural shade.
- Wearing hats and covering up with clothing.
- Using sunscreen with a sun-protection factor (SPF) of 15+.
A clue as to why sunscreen users were more likely to burn may lie in the comment of one secondary school pupil who said, ‘I don’t use sun tan (cream) in normal sun, but I do if there’s a heatwave’. This person implies they use suncream in order to tan, not to protect their skin from sunburn. An HEA survey carried out on young people’s attitudes to sunbathing in 1995 (Howard, 1997) found that because of the desire to be tanned, ‘On the whole, young people seem to be aiming for the minimum degree of protection from the sun which allows them to avoid sunburn but does not slow down their rate of tanning too much’. They do this ‘because they feel that any type of sunscreen (and particularly one with a high SPF) reduces their chances of getting a really good tan’.
Secondary pupils who were dark skinned and those who said ‘My skin rarely or never burns’ were less likely to report getting sunburnt, as would be expected. However, since some dark-skinned pupils did report getting sunburnt, it is evident that pupils need to be made aware that all skin types can get sunburnt and so we all need sun protection when the UV radiation becomes intense enough.
In summer 1999 the Minister for Public Health launched the ‘Global Solar UV Index’ to be included in British summer weather forecasts to help people discern when they are at risk of getting sunburnt. The Index was developed by the WHO. The risk of sunburn depends upon the intensity of the sun’s rays which is given a value from 1 to 11+ and their natural level of UV protection due to their skin type. Education is needed to explain the index to children and parents so they will understand the numbers given on weather forecasts and recognize when they are at risk of burning. Those who are especially susceptible to sunburn because of their skin type need to be encouraged to recognize this fact. It is encouraging that the 17–25 year olds surveyed by Clarke et al. who had skin which easily burns did tend to protect themselves more than those who did not generally burn (Clarke et al., 1997).
The two most common reasons pupils gave why other people their age might not always protect themselves from sunburn were because they cannot be bothered or they want a tan. At both primary and secondary school, more pupils who said they did not always protect their skin because they wanted a tan reported getting sunburnt. Even at primary school, pupils appear to be conscious of their image, which is evident by the fact that similar proportions of primary secondary pupils said they wanted a tan. Similar proportions of primary and secondary pupils reported getting sunburnt due to sunbathing at lunchtime (mid-day break).
Clearly, education is needed to counter pupils’ desire to be tanned, which questions the glamour of tanned images portrayed by some of the media. Such education would also need to highlight that the true purpose of sunscreen is to protect the skin from sunburn damage and is not sun tan lotion to help people get a tan safely. There is no such thing as a safe tan according to dermatologists (McPhail, 1997).
Linked to self-image is the matter of vanity, found to be the most negative aspect of tanning by Miller et al. (Miller et al., 1990). People who actively sought a tan were perceived to be vain, although less so by women than by men. However, this aspect should not be used in an educational approach due to its victim-blaming message, as evidenced by the following study.
Jones and Leary trialed appearance-based admonition to university students not to tan which centred on the message that suntanning prematurely ages the skin (Jones and Leary, 1994). The intervention did have the desired effect of lessening the desire to be tanned in students who were not very image conscious, but actually backfired by strengthening the determination of highly appearance motivated students to work on getting a tan. This stands as a warning to health educators, and highlights the need to research and test sun-awareness education messages and manner of delivery with the target group.
In summary, pupils need encouragement to protect their skin at lunchtime, to use sunscreens correctly and be aware of alternative sun-protection methods. Education is needed which uses social teaching methods to empower pupils, including decision-making skills, building self-efficacy, raising self-esteem and understanding social pressures such as fashion and popular beliefs about the beauty and ‘healthiness’ of a tan. Information alone is insufficient as has been found in smoking control education (Battjes, 1985; Bruvold, 1993). For example, the ‘Safe in the Sun’ materials (McWhirter et al., 2000) and the new materials ‘Sunwise’ we have designed to meet these needs. The new National Healthy Schools Standard (Wired for Health, 1998) includes a section on sun awareness. There is scope to develop this topic in the context of healthy schools in the light of the findings of these two studies.
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Acknowledgments |
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The authors sincerely thank the following. The Department of Health for funding this research. The expert consulting group: Dr William Maton-Howarth of the Department of Health, Professor Rona MacKie of the University of Glasgow Dermatology Department and Dr Jane Melia of the Cancer Screening Evaluation Unit, Institute of Cancer Research. Dr Valerie Hillier for her help with statistical analysis. Dr David While for his help, Mrs Catherine Wiggett for her clerical work, and the researchers and staff of Public Attitude Surveys. The Directors of Education, Headteachers, teachers and school staff, pupils and parents without whom this research would not have been possible.
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Received on June 28, 2001; accepted on November 29, 2001
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