An objective and cross-sectional examination of sun-safe behaviours in New South Wales primary schools

Are Welsh primary schools Sunproofed? Results of a national survey, part 2: sun protection practices in primary schools in Wales

BACKGROUND

Skin cancer rates are on the rise globally. School sun safety programmes are recommended by the World Health Organization to reduce the risk of future skin cancer at the population level; however, these are encouraged but not mandated in Wales.

OBJECTIVES

To explore current sun protection practices and sun safety education in primary schools in Wales and whether these are linked to the existence of a formal sun safety policy.

METHODS

An online survey to all 1241 Welsh primary schools asking about sun safety practices, education and formal policies was undertaken.

RESULTS

In total, 471 (38.0%) schools responded. A minority (22/469, 4.7%) of responding schools reported they had sufficient shade for most activities. In the spring and summer terms, almost two-thirds of schools encourage hat wearing (304/469, 64.8%) and sunscreen (296/468, 63.2%). Although nearly all schools reported that parents were encouraged to apply sunscreen to students before school (449/469, 95.7%), there was wide variation in other sunscreen application practices. Less than one-third of schools (129/445, 29.0%) reported that they include sun protection education in the curriculum in every year group, with 11.7% (52/445) including this in certain years only. Schools with a formal policy were more likely to report more comprehensive sun protection practices, including having sufficient shade [odds ratio (OR) 1.51, 95% confidence interval (CI) 1.04-2.19; P = 0.03], having spare hats for pupils to wear (OR 1.59, 95% CI 1.07-2.37; P = 0.02), providing guidance for staff (OR 5.87, 95% CI 3.05-11.28; P < 0.001), encouraging them to model sun safe behaviours (OR 1.82, 95% CI 1.18-2.80; P = 0.007) and teaching sun protection education as part of the curriculum in every year group (OR 2.56, 95% CI 1.76-3.71; P < 0.001). With respect to sunscreen, the existence of a formal policy did not seem to affect a school's practice.

CONCLUSIONS

Although in most cases, the existence of a formal policy suggests more comprehensive sun protection practices and education in schools, sun protection measures and education need improvement across the primary school sector in Wales to reverse rising skin cancer rates.

The formative evaluation and pre-testing of a SunSmart policy implementation support toolkit targeting sun safe hat-wearing in NSW primary schools

ISSUE ADDRESSED

Strategies that support the implementation of the SunSmart program in primary schools are essential to optimising policy uptake. Evidence outlining the type of support required, however, is lacking. This project explored the usefulness of an implementation support approach to sun safe hat-wearing in schools.

METHODS

Formative research was undertaken with 16 primary schools in Greater Western Sydney to explore current sun protection behaviours and practices, perceived barriers and motivators of sun safe hat-wearing, and resource needs. Based on these insights, a resource toolkit was developed and tested in 14 demonstration sites. Follow-up interviews evaluated the usefulness of the toolkit and implementation support approach.

RESULTS

Sun safe hat-wearing practices varied among schools. Commonly reported motivators included school policies, role modelling, incentives and knowledge. Commonly reported barriers included negative social norms, forgetfulness, cost and lack of understanding. Formative insights informed the development of the 'Motivation, Access, Triggers' Model and a 23-resource toolkit. Following toolkit rollout, champions reported that the ability to select resources according to local needs was useful, and most found that the toolkit supported their school with sun safe hat-wearing.

CONCLUSIONS

A toolkit with local champions and leadership buy-in has the potential to improve policy implementation. The opportunity to prioritise resource selection enables schools to address their specific needs in line with their sun protection policy. SO WHAT?: The provision of policy implementation support can help schools overcome the challenges of transforming a written SunSmart policy into practice.

A novel skin cancer prevention strategy: Preservice teachers' perceptions of a sun safety intervention and experiences in schools

ISSUE ADDRESSED

Teachers play a vital role in developing children's sun protection routines however upskilling preservice teachers (PSTs) while at university has not yet been trialled as a targeted skin cancer prevention strategy. Hence, this study investigated PSTs perceptions and experiences of sun safety following a brief pilot intervention and placement in primary schools in Western Australia.

METHODS

This study used a triangulation mixed methods design. Participants (n = 161) completed a post intervention survey which was analysed quantitatively. A random sub-sample was invited to participate in focus groups (three groups, n = 21) and one-on-one interviews (n = 4). This data was transcribed and uploaded in NVIVO software for thematic analysis.

RESULTS

Participants felt the intervention increased their awareness of the dangers of overexposure to ultraviolet radiation (UVR) with many feeling more knowledgeable, skilled and confident to teach sun safety in school settings. Most reported clear sun safety messages in their placement schools. However, only 34.4% reported they had been briefed on the school's sun safety procedures. There was consensus among PSTs that sun protection in primary schools needs to be improved to maximise the protection of children from harmful UVR overexposure. Participants supported a need for consistent sun protection messaging across primary schools with greater emphasis on education rather than compliance management to sun protection.

CONCLUSION

Enhancing existing teacher education programs to include more rigorous curriculum content and pedagogical approaches to sun protection education is a novel skin cancer prevention strategy and could feasibly support PSTs self-efficacy to effectively deliver sun safety curriculum in Australian schools.

Knowledge, Perceptions and Photoprotective Behaviors Against the Damaging Effects of Direct, Indirect, and Blue Light: There Are No "Cheat Days"

OBJECTIVE

We sought to evaluate the impact of the coronavirus-19 (COVID-19) pandemic on sun-seeking and sun-safe behaviors.

METHODS

We conducted an online, cross-sectional, population-based survey.

RESULTS

In total, 1,001 respondents participated in the survey and reported being exposed to 12 or more hours of sunlight (i.e., direct and indirect ultraviolet light, and blue light) each day. Participants self-reported a net increase in all types of light exposure since the onset of the COVID-19 pandemic, especially to blue light (+38%). Notably, while the effects of direct sunlight were well known among survey respondents, they were less aware of the potential damaging impact of indirect sunlight and blue light.

LIMITATIONS

As the survey was only conducted among residents of the United States, results might not be generalizable to all geographical regions.

CONCLUSION

Social outreach strategies are required to improve sun-safe behaviors. Future behavioral interventions should encourage the implementation of broad-spectrum sun protection.

Keratinocyte skin cancer risks for working school teachers: Scenarios and implications of the timing of scheduled duty periods in Queensland, Australia

Relative keratinocyte skin cancer risks attributable to lifetime occupational and casual sunlight exposures of working school teachers are assessed across the state of Queensland for 1578 schools. Relative risk modeling utilizing annual ultraviolet exposure assessments of teachers working in different geographic locations and exposed during periods of measured daily playground duty times for each school were made for local administrative education districts by considering traditional school opening and closing hours, and playground lunchtime schedules. State-wide, basal cell carcinoma (BCC) and squamous cell carcinoma (SCC) relative risk estimates varied by 24% for BCC and 45% for SCC. The highest relative risk was calculated for the state's north (sunshine) coast education district which showed that risk could increase by as much as 32% for BCC and 64% for SCC due to differences in teacher duty schedules. These results highlight the importance of playground duty scheduling as a significant risk factor contributing to the overall burden of preventable keratinocyte skin cancers in Queensland.

Investigating primary preservice teachers' ultraviolet radiation awareness and perceived ability to teach sun safety

Issue addressed

Sun protection practices in Australian primary schools remain inconsistent. Therefore, this study investigates primary PSTs sun protective sun behaviours, ultraviolet (UV) radiation awareness and perceived ability to teach sun safety.

Methods

A convenience sample of undergraduate PSTs (N = 275; mean age = 23.13 years) enrolled at one Western Australian university completed an online survey. Descriptive analyses provided features of the data. Factors associated with sun protection behaviours and perceived knowledge and skill to teach sun safety were explored using multivariable logistic regression models.

Results

Lesser than 10% of participants reported using sun protective measures daily (midday shade use: 6.5%; sunscreen: 7.6%; hat: 4.4%). Only 56.3% reported they understand the UV index, with 68.0% rarely/never using it to aid sun protection. Under half the participants reported they felt they had the knowledge (38.5%) or skills (40%) to effectively teach sun safety in primary schools. Regression analysis revealed gender, undergraduate, year and skin sensitivity were not predictors of UV index use (P > .05) or perceived knowledge of sun safety (P > .05). Skin sensitivity was the strongest predictor for shade usage (P = .02), hat usage (P = .05) and perceived skill to teach sun safety (P = .02).

Conclusions

Survey data indicate UV radiation is inconsistently understood by PSTs. Many felt that they did not have the required knowledge or skill to teach sun safety effectively.

So what?

Improving PSTs UV radiation knowledge while at university is a potential opportunity to improve sun safety delivery in primary schools. A targeted intervention for PSTs is warranted.

Parent reports of sun safety communication and behaviour for students in a randomised trial on a school policy implementation intervention

OBJECTIVE

Schools are an important setting for skin cancer prevention. An intervention for implementation of school sun safety policy, Sun Safety Schools (SSS), was evaluated.

METHODS

Primary schools (n=118) in California school districts that had already adopted a sun safety policy were enrolled in a study with a randomised controlled design. Half of the schools were randomised to SSS intervention (N=58). Parents completed an online post-test.

RESULTS

More parents in intervention schools received information about sun safety (mean=26.3%, sd=3.1%, p=0.017) and children more frequently wore sun-protective clothing when not at school (mean=2.93, sd=0.03, p=0.033) than in control schools (mean=18.0%, sd=2.5%; mean=2.83, sd=0.03, respectively). In schools where principals reported implementing sun safety practices, parents reported that children spent less time outdoors at midday (mean=14.78 hours, sd=0.25, p=0.033) and fewer were sunburned (mean=12.7%, sd=1.1%, p=0.009) than in non-implementing schools (M=16.3 hours, sd=0.67; mean=21.2%, sd=3.8%, respectively). Parents who received sun safety information (mean=3.08, sd=0.04, p=0.008) reported more child sun protection than parents not receiving information (mean=2.96, sd=0.02).

CONCLUSIONS

A school district sun protection policy and support for implementation increased dissemination of sun safety information to parents and student sun safety. Implications for public health: Technical assistance for sun safety policies may increase sun protection of children.

Studying third-parties and environments: New Zealand sun-safety research

Wearable cameras have been used to study health behaviours, but their utility in assessing third-party behaviours and the built environment is uncertain. This paper reports on the feasibility of using wearable cameras for this purpose in a study of sun-protective behaviours and shade availability during school lunch-breaks. The Kids'Cam study provided 168 children (aged 11-13 years), recruited from 16 randomly selected schools in the Wellington region of New Zealand, with wearable cameras. The devices automatically captured images every 7 s from the child's perspective. Images captured during school lunch-breaks by a random sample of 15 children who took part during terms 4 and 1 (October 2014-April 2015) were selected and assessed for usability. The feasibility of studying third-party sun-protective behaviours and school shade availability was assessed for a subset of 320 images. Of the 3492 eligible lunch-break images, 96.4% were useable; the remainders were excluded due to obstruction, blurriness or unsuitable camera position. Overall, 1278 children and 108 shade structures were observed in the sample images. The use of shade, hats, sleeves, collars and sunglasses could be determined for 97.0%, 77.2%, 74.4%, 47.6% and 54.9% of children, respectively. All shade structures could be classified according to type, and canopy composition could be assessed for 95.4% of structures. Wearable cameras are a feasible tool for assessing sun-safety, particularly shade availability, hat wearing and shade use. This methodology could be used to objectively study other third-party health-related behaviours, and other features of the built environment.

A stepped-wedge implementation and evaluation of the healthy active peaceful playgrounds for youth (HAPPY) intervention

Background

Increasing physical activity in children is a health priority. The Healthy Active Peaceful Playgrounds for Youth (HAPPY) study aimed to examine a multi-component playground intervention designed to increase the proportion of physical activity during recess and lunch of primary school students.

Methods

The 2016 Australian focused HAPPY Study was a 12-month, metropolitan primary school based intervention, which was evaluated using a stepped wedge design. The intervention combined teacher development, environmental modifications, and peer support, with the outcomes of increasing physical activity, and analysing students’ sources of social support to be physically active.

Results

Between baseline and follow-up, the proportion of students involved in vigorous activities during recess and lunch times increased significantly from 15 to 25% (p < 0.001). No differences were recorded in sources of social support.

Conclusions

The HAPPY project demonstrated an increase in the proportion of physical activity intensity during recess and lunch times in primary schools, although further investigation is required to determine what components of the study had the greatest effect.

Trial registration

This study was retrospectively registered with the Australian and New Zealand Clinical Trials Registry ACTRN12616000575437. Date of registration: 4 May 2016.

Protect your skin and let the fun begin: The results of an intervention to improve NSW primary schools' implementation of the SunSmart Program

ISSUE ADDRESSED

The SunSmart Policy Support and Intervention Study (SSPSIS) (ACTRN12614000926639) investigated the feasibility of improving schools' implementation of the SunSmart Program, which is a resource for primary school communities to support their development of a comprehensive sun protection policy.

METHODS

A cluster randomised controlled trial (RCT) was used to evaluate the SSPSIS, which was conducted in NSW SunSmart schools (n = 20). Objective measurements of students' sun-safe hat-wearing behaviours and sunscreen application, and teachers' role-modelling behaviours, were collected for baseline, post-test and follow-up data. Interviews with school community stakeholders, including students (n = 103), parents (n = 31), teachers (n = 11) and executive staff (n = 4), were conducted to inform the intervention design, which was implemented following baseline data collection.

RESULTS

The results of baseline observations and interviews have been published previously. The intervention design aimed to combat negative perceptions of hat-wearing policy and create a trigger for sunscreen application by rewarding students practising these sun protection behaviours with play-based incentives. Although this intervention had no significant effect on the wearing of sun-safe hats among students or teachers, it did have a large effect on the consumption of sunscreen.

CONCLUSIONS

Associating sunscreen and play-based incentives can create an effective trigger for students' sunscreen application behaviours. However, further evidence is needed to investigate how students' and teacher role models' hat-wearing behaviours could be increased. SO WHAT?: While combining a play-based incentive with a trigger for behaviour can promptly increase students' sunscreen application, it was unable to increase students' or teacher role models' hat-wearing behaviours.

Australian primary school communities' understandings of SunSmart: a qualitative study

OBJECTIVES

Skin cancer represents a major health issue for Australia. Childhood sun exposure is an important risk factor and evidence suggests the use of sun protection measures by Australian school children could be improved. This study examines how the SunSmart Program, a school-based skin cancer prevention resource, can be supported to further increase sun protection behaviours to assist in lowering skin cancer incidence.

METHODS

The Health Promoting Schools (HPS) framework was adopted to select key stakeholders from a convenience sample of five school communities. Students, teaching staff and parents participated in semi-structured focus group and individual interviews. A thematic analysis was used to extract key themes from the data.

RESULTS

Although these school communities were aware of sun protection practices and the risks associated with sun exposure, their understandings of the SunSmart Program were limited. Sun protection policy implementation was inconsistent and students were unlikely to engage in sun protection practices beyond the school setting.

CONCLUSION AND IMPLICATIONS

School communities require additional support and engagement to holistically enforce the principles of the SunSmart Program.

Rationale and protocol paper for the Healthy Active Peaceful Playgrounds for Youth (HAPPY) study

Background

A growing body of evidence suggest an association between physical activity levels and students psychological well-being. A number of research studies have evaluated playground interventions that aim to increase physical activity levels, decrease conflict and bullying, and improve students behaviour. The HAPPY Study will evaluate the success of an intervention combining environmental modifications, teacher development, and peer support that can culminate in an easy to implement, low cost and effective model for increasing physical activity, and improving psychological well-being for children.

Methods/Design

Data will be collected at six New South Wales (NSW) primary schools, on physical activity levels, on-task time during classes, and social support for physical activity during a 12 month Cluster Controlled Trial (CT). Three quantitative data collection tools will be used to capture student’s physical activity levels during lunch and recess breaks (the SOPARC tool), student’s on-task behaviour during classes following recess and lunch breaks (the BOSS tool) and where students receive the most encouragement to be physically active from (the Physical Activity Social Support Scale survey). Baseline data will be analysed against follow-up data, collected after an intervention that is rolled out in all schools as part of a stepped wedge CT design.

Discussion

A review of relevant Australian and New Zealand literature suggests that playground interventions can be successful at increasing physical activity levels, increasing social and conflict resolution skills in students, and decreasing incidences of bullying. This study will investigate any correlation between physical activity levels, and student behaviour during classes following breaks.

Trial Registration

Australian and New Zealand Clinical Trials Register ACTRN12616000575437, registered May 2016.