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Sun Protection Policies and Environmental Features in US Elementary Schools
David B. Buller, PhD;
Alan C. Geller, RN, MPH;
Maura Cantor, MA;
Mary Klein Buller, MA;
Kevin Rosseel, MS;
Drusilla Hufford, MBA;
Lori Benjes, MD;
Robert A. Lew, PhD
Arch Dermatol. 2002;138:771-774.
ABSTRACT
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Objective To assess current sun protection policies and the receptiveness to new
policies at elementary schools in the United States.
Design A cross-sectional telephone survey.
Setting General educational community.
Patients or Other Participants In 1998, a random sample of 1000 public elementary schools in the United
States was selected (proportional to population size) from 27 metropolitan
areas chosen from the 58 US cities regularly reporting the UV index in 1997.
A final sample of principals from 412 elementary schools completed the survey.
Intervention None.
Main Outcome Measures Only 3.4% of schools had a sun protection policy. The most common reasons
for not having a policy included the principal's lack of awareness (n = 113)
or organizational barriers in the school districts (n = 77). Most principals
(84.2%) said that students were outdoors during midday hours. Many principals
(48.3%) were willing to adopt a sun protection policy. Most schools (72.8%)
had shade structures but the majority (67.3%) reportedly covered less than
one fifth of the grounds. Most principals (76.4%) were willing to increase
the amount of shade structures.
Conclusions The low frequency of sun protection policies and shade structures calls
for national efforts to change policies and environments to increase sun protection
at US schools. Research is needed to demonstrate the efficacy of these changes.
INTRODUCTION
NEW STRATEGIES are needed in the United States to combat the increasing
rates of melanoma and other skin cancers caused by exposure to UV radiation
(UVR) in sunlight.1 Severe sunburns occur during
childhood, which may promote melanoma later.2-3
Reducing sun exposure in childhood seems to reduce the development of nevi.4-5 Policies that facilitate environmental
change and personal protection should be an essential part of efforts to improve
childhood sun safety.6 Broad social environment
changes, including adoption of policies at schools, have influenced child
health care behavior, most notably to reduce smoking.7
PARTICIPANTS AND METHODS
In 1998, a survey on sun protection policies was conducted with elementary
school principals in the United States. A sample of 1000 public elementary
schools was randomly selected in 27 metropolitan areas (proportional to population
size) from a list obtained from the National Center for Education Statistics.
The cities were chosen from the 58 US cities regularly reporting the UV index
in 1997 in 9 regions defined by UV intensity. After receiving an introductory
letter, principals were contacted by telephone by professional interviewers
from the AMC Cancer Research Center's Survey Research Center to complete the
survey. Of the 800 eligible schools identified by the interviewers (199 listings
did not have a valid telephone number; 1 of the calls was terminated owing
to inability to speak English), 387 surveys were completed with school principals
(48.4%); 321 (40.1%) refused to be interviewed; and 92 (11.5%) were not reached.
Bias caused by nonresponse seemed small: later responding principals, who
might be more similar to nonresponding principals, were in larger schools
than earlier responding principals (r = 0.12, P<.02), but no other correlations of school characteristics
or sun protection policy measures with date of interview were significant.
The National Center for Education Statistics list was the most comprehensive
sampling frame available, but it did not contain newly opened schools. To
provide newly opened schools with a probability of being selected, participating
principals were asked to identify newly opened schools in their school districts.
Another 80 new schools were identified, and interviews were successfully completed
with 25 principals. Only school size differed between newly opened schools
(mean, 668 students) and schools from the National Center for Education Statistics
list (mean, 507 students; P<.02) (which may account
for the correlation above), suggesting little bias due to this limitation
in the sampling frame.
The final sample was 412 principals from public elementary schools.
The proportion of completed interviews in each metropolitan area was similar
to the original proportionate sampling procedure (deviations ranged from -0.04
to +0.03); the latter was used in a weighted analysis to balance the sample
with respect to metropolitan area population. Since there were few differences
between the weighted and unweighted responses, we report only the unweighted
responses.
The 94-item survey assessed whether (1) schools had a sun protection
policy, (2) what was included in the content of any such policies, (3) whether
such policies prohibited personal sun protection (eg, sunscreen, sunglasses),
and (4) whether principals at schools were willing to develop a sun protection
policy where no such policy existed. The time scheduled for outdoor activities
by children, the presence and extent of outdoor shade, and the willingness
to increase outdoor shade was measured. Time of school session, size of school,
ethnic composition of students, and student's grades were reported by principals.
Finally, principals were asked to cite the reasons why they did not have a
sun protection policy.  2 Tests were used to compare differences
in policies by areas of low and high UV intensity.
RESULTS
There was an average ± SD of 517 ± 253 students per school,
which is only slightly higher than the average size for schools nationally
in 1997 and 1998.6 Schools completing the survey
contained kindergarten (K) to fifth grade (46%), K to sixth grade (38%), or
K to eighth grade (16%). National comparison data showed 42% of schools having
K to fifth grade; 24%, K to sixth grade; 7%, K to eighth grade; 18%, fourth,
fifth, or sixth grade to sixth to eighth grade; and 9%, other grade spans.8 On average, principals estimated that 61% of their
students were non-Hispanic white; 17%, African American; and 15%, white-Hispanic.
Data are identical to national estimates for 1998 and 1999.9
Thirty-seven percent of schools were in cities with high year-round UV intensity,
including the Southeast, Southern California, and the Southwest (UV index
range, 7-9) and 63% were in cities with lower UV intensity (UV index range,
4-6).
Only 3.4% of schools (n = 14) had a policy with rules or recommendations
for students, teachers, staff, or parents designed to improve sun protection,
for instance, scheduling outdoor activities to avoid having children outside
during daily peak UVR (n = 9); requiring children to wear shirts with sleeves
(n = 4), hats with a brim (n = 6), or sunglasses (n = 3); or requiring children
to wear sunscreen during outdoor times (n = 2) (multiple rules were listed
by some schools). There were no differences in the proportion of schools with
a sun protection policy by the average UV intensity in the metropolitan areas
(P = .45). Of the 503 reasons given for not having
such a policy, principals most commonly said that they were unaware of a skin
cancer problem or that it had yet to become an issue in their school (n =
113; unweighted, 22.4%) or organizational barriers to policy creation existed,
including policy decisions being made elsewhere (n = 77; 15.3%); they were
only able to suggest changes but not require them (n = 53; 10.5%); and legal
issues existed regarding policy adoption (n = 38; 7.6%). Sixty-six principals
thought that such a policy was unimportant (13.1%) or that other health care
issues were more important (4.0%). Weather conditions precluding a policy,
sun safety already being taught in school, no time available for policy development,
lack of support by parents, staff, or children, and financial burden comprised
in total less than 10% of replies.
Some existing policies discouraged the use of personal sun protection
by students (Table 1). Less than
5% of schools provided sunscreen for students, more than two thirds prohibited
staff from applying sunscreen to students in general, and nearly half required
a physician's prescription before staff could apply sunscreen to students.
Hats were prohibited at some schools, although less commonly at schools in
areas with higher UV intensity (P<.01). Nearly
two thirds of schools prohibited students from wearing sunglasses.
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Table 1. Existing School Policies That Discourage Use of Personal Sun
Protection by Students
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Almost half of principals at schools without sun protection policies
(48.3%) were willing to create a policy for their school. They were most willing
to require hats with a brim (35.2%), shirts with sleeves (28.1%), and sunscreen
with a sun protection factor of 15 or more (24.6%). They were less willing
to require sunglasses (19.6%) and to schedule outdoor activities at nonpeak
hours of daily UVR (13.6%). Many principals noted that the following educational
tools could be helpful or very helpful in developing policies: printed materials
for teachers and staff explaining sun safety (91.5% [unweighted]), an example
of a school sun protection policy (88.4%), printed messages for parents explaining
why sun protection of their children is important at school (87.0%), and printed
step-by-step instructions on creating such a policy (77.9%). Some desired
a qualified person to present a seminar on sun protection for parents (60.9%),
tools to evaluate the school's current sun protection policy and environment
(53.3%), and consultants to draft a policy or present a seminar on how to
develop one (46.7%).
Most principals (84.2%) reported that students were outdoors between
10:00 AM and 2:00 PM, the daily period of peak UVR (Table 2). Schools in areas of high UVR intensity were more likely
than schools in low intensity areas to have outdoor activities before 10:00
AM (P = .02). Almost three quarters of schools have
structures that provide shade (most commonly planted trees), but two thirds
of principals reported that one fifth or less of the school grounds were shaded.
A quarter of principals reported that shade existed on 40% of their grounds.
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Table 2. Environmental Features Promoting Sun Protection in US Schools
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Three quarters of principals indicated that they were willing to make
structural changes to increase the amount of shade available at school if
funds were available. Three fifths of the schools had made improvements to
their playground or play fields in the past 5 years, but most said that the
funding process was involved and complicated. These responses did not differ
by regional UV intensity (P = .70).
COMMENT
Currently, few schools in the United States have sun protection policies;
consequently, many children and school staff when outside are unprotected
from the sun. Many school principals are willing to develop such policies
but were unaware of skin cancer as a health problem or the role that their
school could play in preventing adverse sun exposure. Less common obstacles
include decision-making powers often beyond the scope of the individual principal.
While there are validity concerns with all self-report measures, the very
low frequency of sun safety policies and shade structures suggest that little
bias is present in these data.
Greater public awareness and concern regarding the dangers of excessive
sun exposure, coupled with educational forums for school principals, administrators,
and teachers, might stimulate schools to implement sun protection policies.
In the short term, efforts need to be directed at changing some school policies.
Requiring a physician's prescription for sunscreen is especially detrimental,
as sunscreen is not dispensed by prescription and it is difficult to specify
the appropriate "dose" to be applied. State and local health departments may
need to change this requirement, or if a prescription is not required by state
policy, health officials should make sure that school officials are aware
that a prescription requirement exceeds state regulations. Changes that permit
hats and sunglasses to be worn while outdoors would be beneficial in reducing
skin and eye exposure to UVR.10-11
However, these changes must be balanced against efforts to control other problems,
including preventing gang insignias and head lice transmission. It may be
more practical to routinely ask parents to apply sunscreen to children before
school and to have them wear protective clothing. However, sunscreen should
not be the primary means of protection because people often do not adequately
apply and reapply it to achieve its maximum protection.12
Longer-term goals such as policy alternatives that change structural
and environmental features (eg, trees, shade covering) and those that reschedule
outdoor activities to times when less sun exposure will occur might help overcome
the reluctance of school administrators to require personal sun protection
of children who are unable to take these actions. Schools should first perform
an audit of existing outdoor shade (amount, usability, reflection) and schedules13 and develop plans to increase shade, especially in
high use areas (eg, lunch areas, walkways, bus stops, assembly areas, playground
equipment), and decrease sun exposure during the midday. School personnel
also will need information on the shading properties of various materials
and trees and on effective and affordable shade structure designs. For instance,
shade structures should (1) be designed to cover more of the sky, not just
block direct sunlight, by decreasing height and increasing width or overhang;
(2) be carefully placed relative to the sun's angle to create maximum usable
shaded area; and (3) include side barriers as well as overhead protection
to block indirect UVR.14-15 Also,
darker colored soils and paints should be used to reduce sun reflection.14 Data on the efficacy of these policy and environmental
changes in reducing sun exposure are currently limited.
Recently, there has been a call for national recommendations on the
prevention of skin cancer.6 These would undoubtedly
help sun protection become an item on school districts' agendas. However,
creating local support for sun protection among parents is essential because
local entities determine whether national recommendations are implemented.
Thus, recommendations to schools and education of school officials and the
public are needed to convince administrators to reallocate resources to increase
shade and change the traditional school day schedule to avoid midday exposure.
It is also necessary to work with parents to increase personal protection
behavior for children. Researchers in Australia, where strong behavioral changes
for sun protection have been implemented, have observed that school-based
programs may be most successful when they are aligned with other community
activities and complemented by structural changes.16
Further studies are needed to identify the vital components for behavior change
in the United States.
AUTHOR INFORMATION
Accepted for publication September 26, 2001.
The survey was sponsored by grant X826339-01-0 from the Environmental
Protection Agency to Boston University. Institutional review board approval
was provided by the Boston University School of Medicine.
Corresponding author and reprints: David B. Buller, PhD, Center for
Health Communication, AMC Cancer Research Center, 1600 Pierce St, Denver,
CO 80214.
From the AMC Cancer Research Center, Denver, Colo (Dr Buller); Boston
University School of Medicine, Department of Dermatology, Boston, Mass (Mr
Geller); Environmental Protection Agency, Washington, DC (Mss Cantor and Hufford
and Mr Rosseel); Partners for Health Systems Inc, Denver (Ms Buller); and
Argose, Inc, Waltham, Mass (Dr Lew). Dr Benjes is in private practice in Wellesley,
Mass.
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