Health Education Research, Vol. 19, No. 1, 98-109,
February 1, 2004
© 2004 Oxford University Press
Creating SunSmart schools
1 School of Population Health, University of Western Australia, Crawley, Western Australia 6009 and 2 Western Australian Centre for Health Promotion Research, School of Public Health, Curtin University of Technology, Bentley, Western Australia 6148, Australia 3 Correspondence to: B. Giles-Corti; e-mail: billie@cyllene.uwa.edu.au
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Kidskin was a sun-protection intervention study involving 1776 children attending 33 primary schools in Perth, Western Australia. There were three study groups: a control group, a moderate intervention group and a high intervention group. In addition to receiving a specially designed curricular intervention (1995–1998), the moderate and high intervention groups received an environmental intervention aimed at creating SunSmart schools (1996–1998). The environmental intervention focused on encouraging implementation of ‘No hat, no play’ policies and reducing sun exposure at lunchtime. In 1995 and 1998, observational methods were used to measure children’s lunchtime sun exposure (i.e. polysulfone film badges) and hat wearing (i.e. video-taping of children). The proportion of children wearing broad-brimmed hats or legionnaire caps increased in seven of the eight high intervention schools between 1995 and 1998. In three schools, however, the impact was very positive with almost all children wearing these hats in 1998. There was no improvement in wearing these types of hats in either the moderate intervention group or the control group. In terms of sun exposure, there were only small non-significant differences among the three groups in terms of lunchtime sun exposure. The Kidskin program had a positive effect on hat wearing in the playground, but did not change children’s use of shade at lunchtime. In this study, disseminating policy guidelines to schools using a mail-only strategy was ineffective, even when combined with an awards program. More information on ‘champions’ who bring about change in schools is required.
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Introduction |
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Australia has the highest rate of melanoma and other skin cancer in the world (Parkin et al., 1997
; Staple et al., 1998), although increased rates of melanoma are now recognized as an international public health problem (Koh and Geller, 1998; Emmons and Colditz, 1999). Case control and migrant studies suggest that childhood sun exposure is a particularly important cause of melanoma (Amstrong and English, 1996). Thus, reducing childhood exposure is a priority.
Schools have an important part to play in reducing sun exposure in children since for 5 days a week children are at school during the high-risk period of the day (i.e. 10 a.m.–3 p.m. in Western Australia) (Schofield et al., 1991). Schools may influence children’s behavior both indirectly (e.g. by using the school curriculum and positive role modeling to encourage sun-protective behavior) or directly (e.g. by restricting exposure to the sun and strictly enforcing ‘No hat, no play’ policies) (Hill and Dixon, 1999). For example, research in New South Wales found that primary school children spent nearly 8 hours weekly in outdoor activities. About half of this time was during the lunchtime period, when ultraviolet radiation is most intense (Schofield et al., 1991). The implementation of school policies has the potential to reduce this level of sun exposure.
Kidskin was an intervention study involving 1776 children attending 33 primary schools in Perth, Western Australia. The aim of the study was to design, implement and evaluate an intervention to reduce sun exposure and improve sun-protection behaviors in children. The subjects were 5 or 6 years old when they commenced school in February 1995 and were followed until 2001. The study design has been described fully elsewhere (Milne et al., 1999a–c). Briefly, the study was a non-randomized, community intervention trial with schools as the units of intervention. Three groups were included: a control group of 14 schools, a ‘moderate intervention’ group of 11 schools and a ‘high intervention’ group of eight schools. Schools were not randomly assigned to treatment groups because of concerns about contamination and because costs were reduced by designating schools closest to the center of Perth as eligible for the high intervention group. Schools located farthest from the center of Perth were designated as control group clusters. Schools were randomly selected from within clusters, after stratification by social disadvantage (Milne et al., 1999c). Between 1995 and 1998, the control schools received the standard health education curriculum, while schools in the other two groups received a multi-component intervention comprising school- and home-based activities. As part of the education program, children were encouraged to stay indoors during the middle of the day when solar UV radiation is highest, and to protect themselves when outdoors by using shade, clothing, hats and sunscreen (in that order of priority). In addition to a classroom curriculum program, schools in the moderate and high intervention groups received an intervention aimed at creating a sun-protective school environment. The focus of this paper is on the latter intervention.
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Methods |
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The study was approved by the Committee of Human Rights at the University of Western Australia and the Human Research Ethics Committee at Curtin University of Technology.
The Intervention
The aims of the environmental intervention were:
(1) To introduce a Gold Standard ‘No hat, no play’ policy whereby children were required to wear broad-brimmed hats or ‘legionnaire’s hats’ (peaked caps with a flat covering the back of the neck).
(2) To reduce children’s sun exposure by asking schools to actively encourage them to use available shade.
(3) To increase shade provision in the playground.
After collection of baseline data, aim (3) was abandoned because it was recognized that it would be difficult to increase shade in the playground without additional funding. The focus became encouraging the use of existing shade.
The environmental intervention was based on Social Cognitive Theory (Bandura, 1986) and the Diffusion of Innovations Theory (Rogers, 1983). A framework developed by Parcel et al. for the dissemination of curriculum materials into schools (Parcel et al., 1989) was used to conceptualize the policy-related intervention. Table I shows the components of the intervention received by each group and each component is discussed below.
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Sun-protection policy guidelines
Schools in the moderate and high intervention group received guidelines on how to improve sun protection at schools. The guidelines were developed in consultation with the Cancer Foundation of Western Australia and were based on those produced by the Anti-Cancer Council of Victoria (Anti-Cancer Council of Victoria, 1994
). They included five sections: a rationale for creating a SunSmart school, strategies for creating a SunSmart school, legal obligation of schools, the steps involved in developing a school SunSmart policy and a series of appendices with resources materials. The Education and Health Departments of Western Australia contributed to the development of the guidelines. In addition, as part of a formative evaluation, principals from three pilot primary schools reviewed the draft guidelines. The guidelines were posted to the school principals and Presidents of the Parents’ Associations with a covering letter encouraging schools to participate by developing and implementing sun-protective policies. Mail-only strategies are commonly used by health agencies to disseminate materials to schools and other groups.
SunSmart Awards
The SunSmart Awards were offered annually. They were designed as an incentive to encourage adoption of the SunSmart Guidelines, and to assist in maintenance of the policy implementation by providing recognition and feedback on performance (Bandura, 1986; Parcel et al., 1989). The awards were developed in consultation with principals from three pilot primary schools.
Applications were posted to the principals of the moderate and high intervention group schools at the end of each year. The application form enquired about the types of sun-protection policies in the school using a five-point scale from ‘written and implemented’ to ‘planned’. This information was used to provide feedback to the schools to enable them to achieve a higher award the following year. Where possible, the awards (either Bronze, Silver or Gold) were presented to each school at a school assembly early the following year. The presentations were used to recognize the school for its achievements (Parcel et al., 1989), to raise the issue of sun protection at a whole-of-school activity and to encourage further sun-protection policy development.
In 1996/97, eight schools participated in the awards (five of 11 schools from the moderate group and three of eight schools from the high intervention group). In 1997/98, 12 schools participated (eight of 11 schools from the moderate group and four of eight schools from the high intervention group).
Community organization
Schofield et al. (Schofield et al., 1997) found that simply mailing policy guidelines to schools (i.e. a mail-out strategy) was insufficient to encourage policy development and that in primary schools, a mail-only strategy coupled with staff support was more effective. Thus, in this study, we compared the mail-out strategy plus the SunSmart Awards in the moderate group with the mail-out strategy, SunSmart Awards and a range of community organization activities in the high intervention group (see Table I). The community organization activities aimed to identify someone who would ‘champion’ further development and implementation of sun-protection policies within the school.
One of us (C. C.) made contact with school principals and Presidents of Parent Associations in the high intervention schools. During the telephone contact, C. C. encouraged implementation of the SunSmart Guidelines, encouraged participation in the SunSmart Awards, and offered separate seminars to staff and Parents’ Associations. Parent Association seminars were presented at seven of eight high intervention schools and staff seminars at all schools. Telephone contact to each school in relation to the community organization intervention was limited to booking appointments for seminars. Any requests to assist with the policy development were referred to the Cancer Foundation of Western Australia.
A school newsletter was sent twice per year to the high intervention schools as part of the community organization activities. The aims of the newsletter were to encourage adoption, implementation and maintenance of the SunSmart Guidelines (Rogers 1983), to increase school self-efficacy by providing ideas for simple and low cost sun-protective strategies, to increase outcome expectations by using other schools as role models, and to reinforce positive changes in schools by providing recognition and feedback these schools (Bandura, 1986; Parcel et al., 1989).
Evaluation
Observational methods were used to assess the extent of shade use and hat wearing at the school.
Data collection
Policy implementation. In 1995 and 1998, the principals at each school were sent a self-completed questionnaire on school policy. The questionnaire enquired about the schools’ sun-protection practices and policy. The instrument was pilot tested with principals from three pilot schools prior to being finalized. Pilot school principals were consulted regarding the ease of completing the pilot instrument and advice about how to improve response rates when the main study commenced.
Shade use. Personal solar ultraviolet radiation (UVR) exposure was assessed using polysulfone film badges. These badges provide an inexpensive method of dosimetry of personal UVR exposure and have been used successfully for this purpose since the mid-1970s [see (Milne et al., 1999a) for a more detailed overview]. In this study, badges worn by children at lunchtime were compared with badges exposed to full sun over the same period to calculate the proportion of the potential UVR that the children actually received.
Full details of the pilot testing and protocol adopted were published previously (Milne et al., 1999a). Briefly, the polysulfone badges were pinned on the children’s clothing at the left shoulder just after morning recess. At each school, four badges were used as ‘ambient badges’ in the school grounds over the same exposure period as the badges worn by the children. The ambient badges were mounted horizontally on a padded tile in full sun in an area out-of-bounds to children and were uncovered when the lunch bell rang. After the lunch period, the badges were removed from the children’s clothing and the ambient badges were covered. After recording the time of exposure, the badges were packaged and sent to the Australian Radiation Laboratory for blind analysis.
In 1998, the sun exposure surveys were conducted over 12 days (6 days in common to all three groups) over 6 November–2 December 1998 and 12 days (2 days in common to all three groups) over 13–29 November 1995. Where possible, 30 children in each of school Years 1, 4 and 7 were randomly selected from each school, except that in two schools with no Year 7 children, children in Year 6 were selected. In 1995, 30 children in Year 1 were randomly selected from each school. Similar numbers of boys and girls were selected in each school in each year. Schools were randomly assigned days on which the observations took place. An attempt was made to restrict these to typical Perth spring days (i.e. maximum temperatures between 22 and 32°C, little or no rain, variable winds and high, scattered cloud) and, where possible, to select alternative days on atypical spring days. However, this was not possible in 1998 when the temperatures, during this period, ranged from 18.1 to 37.7°C.
Hat wearing. The method adopted to assess hat wearing is described elsewhere (Milne et al., 1999a,b) and involved video-recording children in the playground. The observations were made on the same day as the measurements of shade use. Members of staff were told that the purpose of the video study was to observe children’s behavior in the playground. Hat wearing was not mentioned.
The play areas video-recorded were selected in consultation with the principal who indicated main areas used by each age group, as well as areas used by children of all ages. One of four trained observers attended each school. The observer familiarized herself with each selected play area and identified the most suitable vantage point from which to film the children. The level of reactivity to the video camera was recorded at each school.
In 1995, we assessed (1) the stability over time of hat-wearing behavior within play areas at each school, and (2) the reliability of observers counting and recording the number of children in the area, and the type of hat worn by each child. The results indicated a very high level of stability of hat wearing [intraclass correlation (ICC) 0.95] when filmed twice by the same observer, and a very high level of intra- (ICC 0.98) and inter-rater reliability (ICC 0.98) in estimating the proportion of children wearing Gold Standard hats.
Data analysis
All analyses presented are school-level analyses in which each school contributed one observation only.
Policy implementation. The self-reported policy implementation data from the principals’ survey was cross-tabulated by intervention group. Due to the small number of schools in each group, Fisher’s exact test was used to assess statistical significance.
Shade use. For each school, the mean proportion of ambient exposure (PAE) received by the children was calculated from the individual badge recordings. The UVR exposure for each polysulfone badge reading was expressed as ‘effective erythemal dose’ (EED) and measured in joules per square meter (J/m2). For each child’s badge, the PAE was calculated by dividing the individual badge’s EED reading by the school’s average ambient reading. The PAE is the best measure of the use of shade by the children. Theoretically, if a child spent the whole lunch period in the sun, the value would be 100%; if he or she were inside, the value would be 0%. A logistic transformation of the PAE was used to analyze the data. Means and confidence intervals were calculated by back transformation. The logistic transformed data were approximately normally distributed.
Regression analysis, with adjustment for maximum daily temperature, was performed on the 33 school means. We adjusted for the maximum daily temperature because it was distributed differently among the groups and, in Australia, is a strong determinant of where children play. On the hottest days, children are more likely to play indoors or in the shade. Three analyses were performed using the 1998 data only, using the data for children in school Year 1 on each occasion and using the children in the Kidskin cohort (i.e. school Year 1 in 1995 and school Year 4 in 1998). In the latter two analyses, the 1998 school mean PAEs were adjusted for the equivalent 1995 mean and for the 1995 and 1998 temperatures. In all cases, the residuals from the regression analysis were approximately normally distributed. We report tests for trend across the three groups. Tests for trend were used because we hypothesized that any effect of the intervention would be greater in the high intervention schools.
Hat wearing. The content analysis of the video-recordings was conducted by a trained research assistant using high-quality editing equipment and following a standard protocol. For each school we estimated the whole-school prevalence of hat wearing by calculating, in each play area, the number of children in each school year (total and by type of hat), adding these across the three play areas in each school, then weighting by the number of children in the relevant age group at that school. We performed a non-parametric test for trend across the three groups (Cuzick, 1985) on the differences between the 1998 and 1995 prevalence in each school.
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Results |
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Overall, in both 1995 and 1998, almost all principals returned questionnaires (100 and 91%, respectively), although not all questions were answered. In 1998, only 36.4% of principals claimed to be the principal at the same school in 1995.
By 1998, the majority of schools in each group reported having a general policy encouraging sun protection (see Table II). Between 1995 and 1998, there appeared to be more than a two-fold increase in the proportion of schools in the control group reporting having a general policy to encourage sun protection. This increase was not statistically significant and was not reflected in each of the specific policies that we enquired about.
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All schools in the moderate and high intervention groups claimed that their school policy was to recommend a hat as part of the school uniform from September to May. This represented an increase from 1995 that was not observed in schools in the control group; however, none of the results was statistically significant. In 1995, the majority of schools in each group reported having a written ‘No hat, no play’ policy (i.e., 75% or more). In 1998, the question was changed and schools were asked about whether they had a written ‘No hat, no play’ policy that enforced the wearing of Kidskin’s ‘Gold Standard’ hats, i.e. broad-brimmed or legionnaire hats. As shown in Table II, the proportion of schools that reported a ‘Gold Standard’ ‘No hat, no play’ policy declined in the control and moderate intervention group schools. Only in schools in the high intervention group was there an increase in the proportion of schools with written ‘No hat, no play’ policies (75.0–85.7%). The result was not, however, statistically significant.
Between 1995 and 1998, there appeared to be an increase in the proportion of schools in the high intervention group reporting school policies that included organizing sports and PE lessons to minimize sun exposure. Similarly, there appeared to be an increase in the proportion of schools in the moderate and high intervention groups reporting a policy to provide shade at sports carnivals. While these changes were not observed in the control schools, none of the results was statistically significant.
In 1998, principals were asked an open-ended question about whether they experienced obstacles to implementing specific policies. Overall, 83.3% of the principals responded to this question. The main obstacles to increasing the amount of shade available in schools were the cost (40%) and potential vandalism to the shade structures (20%). Although many principals reported no specific obstacles in recommending or enforcing the broad-brimmed or legionnaire hats as part of the school uniform, the main obstacles reported related to fashion considerations and lack of parental support for both recommending (28 and 20%, respectively) and enforcing (16 and 28%, respectively) the policy.
Shade use
In 1995, 938 children participated in the lunch-time shade use survey. Gender was not recorded in 1995. In 1998, 2598 children participated, including 1331 boys and 1267 girls (n = 1141 in the control group, 846 in the moderate intervention group and 611 in the high intervention group). Two badges gave negative readings of EED and another 20 gave PAEs of greater than 100%. These were excluded from the analysis, leaving 2576 individual badges.
The median of the daily maximum temperatures was similar for the three groups in 1998, although the two intervention groups had a wider range of temperatures on the days on which measurements were taken (Table III). The two intervention groups had lower median temperatures in 1995, but the ranges were similar for all groups.
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All three groups had similar median ambient EED readings in 1998, while the median for the high intervention group in 1995 was lower than for the other two groups (see Table III). In 1998, measurements were made at some control schools on a day with low ambient EED. Maximum temperature and mean ambient EED were positively correlated (Spearman correlation 0.32 in 1998 and 0.65 in 1995), indicating that on days with higher temperatures, there were higher UVR levels, presumably due to less cloud cover. Maximum temperature and the mean within-school PAEs were negatively correlated: –0.29 in 1995 and –0.46 in 1998, indicating that on hotter days, children received less sun exposure.
Differences among the study groups in mean PAE were small and not statistically significant, regardless of whether the analysis included the whole school in 1998, Year 1 children only or Year 4 children only (Table IV).
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Hat wearing
Reactivity to the video was recorded as negligible, mild, moderate or severe. In 1998, the levels of reactivity to the video camera were recorded for each shoot and were similar in all three groups: negligible reactivity was noted for 61% of control group shoots, 64% of moderate intervention group shoots and 54% of high intervention group shoots. Almost all the remaining shoots had mild reactivity only. Reactivity was recorded at school level in 1995. Mild reactivity was the most common, occurring in 71% of control schools, 45% of moderate intervention schools and 25% of high intervention schools. Most of the remaining schools showed moderate reactivity.
In both years, almost all children wore a hat, with little change over time and only small differences among groups (Table V). However, in the high intervention group there was a 14% increase in the median proportion of children wearing Gold Standard hats. There was no such increase in the moderate group and a slight decrease in the control group (test for trend across groups, P < 0.001).
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These overall results mask large changes in some schools that are shown in Figure 1. The prevalence increased in three of the eight schools in the high intervention group from 16% or less in 1995 to 85% or more in 1998 and four of the remaining five schools showed some improvement. Six of the 11 moderate intervention schools and six control schools showed some improvement, although the largest increases were only 11% in the moderate group and 7% in the control group.
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Discussion |
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The results showed that Kidskin had an impact on the introduction of Gold Standard hat ‘No hat, no play’ policies in the high intervention group, but little impact on sun exposure during lunchtime. Consistent with Schofield et al. (Schofield et al., 1997
), we found that disseminating materials to schools using a mail-out only strategy was ineffective to increase the implementation of policies, even when combined with an awards program. The results suggest that, in primary schools, a more intense strategy that includes support for policy development is required.
Intervention components
Health-promotive environments complement and reinforce individual behavior change (Stokols, 1996). Thus, implementing policies to create health-promotive environments has the potential to increase the sustainability of behavioral interventions by facilitating behavior change after the behavioral intervention is over. However, in a study of childcare centers, Schofield et al. concluded that a ‘policy may be a necessary but not sufficient condition for achieving solar protection’ (Schofield et al., 1993). Effective policy needs more than a simple policy statement. It requires the ongoing support and commitment of students, staff and parents to ensure that the policy is implemented and enforced (Schofield et al., 1993). Engaging all stakeholders in policy development and gaining ongoing commitment to its implementation is therefore critical to the success of policy.
One of the objectives of the organizational development activities used in high intervention schools in the Kidskin program was to identify an individual who could champion the development of sun-protection policies in the school. In New South Wales (Schofield et al., 1997) researchers successfully pre-selected the student welfare coordinator as that champion. The coordinators were provided with comprehensive information including a staff development training module, articles to raise community awareness, and advice on methods for gaining support from staff, parents and students. Follow-up letters to the coordinators were included as part of the dissemination strategy. From a health agency perspective, this dissemination strategy is likely to be more practical than involving agency staff to visit schools as was the case in Kidskin. However, it is clear that health agency support is beneficial and Schofield et al. (Schofield et al., 1997) concluded that additional components to the dissemination strategy could include training workshops, personal visits by sun-protection experts and incentives.
Clearly, one aspect of successful dissemination of policy development materials to schools is identifying a champion, or champions, who will drive policy development (Rogers, 1983). The most appropriate champions may vary from region to region or even between schools. One of the limitations of the current study was that no attempt was made to collect information about the champions who attempted to implement policies in the schools. This information may have, for example, helped explain why some schools were more effective in enforcing Gold Standard hat policies. Thus, future research and practice should consider investing in formative evaluation to identify the most appropriate champions with whom to communicate and follow-up, as well as process measures about their motivation to promote policy development and implementation. In addition, future practice might consider developing training for champions based on the Diffusion of Innovation Theory. This theory seeks to identify official and unofficial opinion leaders who have the potential to influence others in a social group (Rogers, 1983). Including training based on Diffusion theory will help enthusiastic champions understand the process of organizational change, including the need to engage principals as well as other unofficial ‘opinion leaders’ in the school, thus ensuring effective and timely policy development (Rogers, 1983).
Kidskin’s SunSmart Award program was successful in attracting schools to participate, but not all schools participated. Moreover, compared with high group schools, schools in the moderate group were more likely to participate in the SunSmart Award program. This did not appear to increase the uptake or implementation of policies in the moderate schools, however.
The SunSmart Awards program had a number of limitations. First, the awards themselves were modest (i.e. presentation of a certificate at a school assembly). Second, although one of the goals of the awards program was to provide recognition for becoming SunSmart (Parcel et al., 1989), the recognition had limited reach. For example, we were unable to publicly recognize schools with major signage or publicity in local newspapers because of concern of contamination of the other schools in the study. Finally, there were only 33 schools in the study. This resulted in a small number of schools in each group.
Barriers to implementing policy
Qualitative data collected from school principals suggested that a major obstacle to implementing policy was gaining parental support, particularly support to enforce wearing the Gold Standard hat. Consistent with previous research, we found that lack of parental support was a barrier to implementing sun-protection policies (Schofield et al., 1993). This highlights the importance of incorporating complementary strategies that target parents. For example, the Kidskin study used presentations to the Parents’ Associations. Similarly, in their package of materials to school welfare coordinators, Schofield et al. (Schofield et al., 1997) included articles for inclusion in newsletters to gain community support for policy implementation.
Clearly, for Australian schools, there is a conflict between public health messages about encouraging children to be physically active (CDC, 1997), and the need to reduce sun exposure between 10 a.m. and 3 p.m. Only a minority of schools in this study reported any attempt to reduce sun exposure or provide shade during sport or physical education lessons and sports carnivals. The provision of shade offers increased protection, regardless of individual behavior (Schofield et al., 1993) and thus is a priority in Australian schools. However, the cost of buying additional shade and the potential for vandalism for temporary shade structures are both concerns to principals, and alternative strategies are required. For example, schools could re-schedule sport and PE classes for the first lesson of the morning, organize indoor sport or PE lessons and hold sport carnivals in the evening. In addition, they could reduce regular sun exposure at lunchtime by increasing the length of the morning recess period, while reducing the length of the lunch break. Creative, cost-effective strategies are required to reduce sun exposure in the middle of the day in the spring and summer (CDC, 1997), while at the same time ensuring children are physically active at school.
On average, Kidskin children received 19–26% of the ambient UVR over the lunch break at school and the intervention had no impact on exposure. The negative correlation between proportion of ambient exposure and temperature indicates that on warmer days, children were less likely to spend time in the sun. This reduction in sun exposure was either self-moderated because it is unpleasant in the sun on warmer days, or because the children were actively encouraged by the school to stay indoors or use shade. However, this finding suggests that there is still a lack of awareness of the need to reduce sun exposure during spring and summer, regardless of the temperature (Milne et al., 1999b). Even on cooler or less sunny days, UVR remains high through spring and summer, and this needs to be addressed in school policies.
Research
Although previous studies have found that principals are a reliable source of information on policy and practice (Schofield et al., 1997), we found that the observational methods were a more reliable indicator of practice (Milne et al., 1999b). While a large proportions of principals reported that the Gold Standard hat was part of the school’s ‘No hat, no play’ policy, our observational findings showed that it was implemented in only a minority of schools. This highlights the value of observational methods as a valid means of evaluating the implementation of policy. The use of video was an effective and reliable means of observing children in the playground (Milne et al., 1999a). While the children appeared more likely to react to the video in 1995, the overall reaction was relatively modest and, in any event, is unlikely to have affected their hat-wearing behavior. We collected no information on the effectiveness of champions who were recruited to implement policies in schools, which is a limitation of this study. Future studies might consider collecting information that could help explain why some schools change and others do not.
Conclusion
Schools have the potential to reduce sun exposure in children during spring, summer and autumn, and are therefore an important target for policy-related interventions. Our findings suggest that it is possible to change school policy, but that mail-only strategies are ineffective. Schools require support to develop and implement policies that have the support of the whole school community, including parents. Because of the gap in policy and practice, future studies that evaluate school-based policy interventions should consider using observational methods rather than simply asking school principals about policy implementation. They should consider also collecting information on change agents in school who bring about policy change.
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Acknowledgements |
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‘Kidskin’ was funded by a Development Program Grant (no. 954601) from the Public Health Research and Development Committee of the National Health and Medical Research Council, and by the Cancer Foundation of Western Australia. Initial pilot funding was provided by the Western Australian Health Promotion Foundation. Dr Ron Borland (Centre for Behavioural Research in Cancer, Anti-Cancer Council of Victoria) contributed to the design of the environmental intervention. We thank Ms Tommy Cordin for assistance with study coordination and video content analysis. Ms SeongHee Kwon undertook some of the initial statistical analyses. Mrs Melodie Kevan, Ms Derry Houston, Ms Terri Pikora and Ms Tommy Cordin assisted with the data collection at the schools. The polysulfone film badges were supplied and analyzed by Dr Peter Gies at the Australian Radiation Laboratory.
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Received on May 8, 2002; accepted on November 26, 2002
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