Journal of the New Zealand Medical Association, 10-February-2012, Vol 125 No 1349
Anthony I Reeder, Janet A Jopson, Andrew Gray
Skin cancer is a concern in New Zealand (NZ) where cutaneous malignant melanoma incidence is among the world’s highest: 43.0 and 37.4 per 100,000 (age standardised to World Health Organization [WHO] world population) for men and women, respectively, and 371 deaths in 2008.1 For each person dying from skin cancer an estimated average 15.5 potential years of life is lost, and skin cancers place a substantial burden on direct health system costs, estimated at $NZ57.1 M per annum, with total annual economic costs estimated at $NZ123 M.2
Yet most skin cancers are potentially preventable, as excessive solar ultraviolet radiation (UVR) exposure plays a key role in development,3 causing as much as 65% of melanoma worldwide (95% in high exposure contexts like Australia) and 99% of basal cell and squamous cell carcinomas.4 NZ UVR levels are ~40% higher than those at similar northern hemisphere latitudes in summer,5 and experienced by a largely European population more susceptible to negative effects than groups indigenous to areas of comparably high UVR.
Excessive childhood solar UVR exposure increases the risk of skin cancers.6,7 Since ‘sun exposure in the first 10 years of life determines to a substantial degree the lifetime potential for skin cancer’, there is ‘a very strong case on epidemiological grounds for giving priority to the control of early life sun exposure.’4 School settings are an identified priority,8 since students can spend extended periods outdoors during school hours in organised and discretionary activities.
A recent review concluded there was ‘sufficient’ evidence that education and policy approaches can be effective for increasing sun protective behaviours in primary school settings.9 An economic evaluation of the US ‘SunWise’ programme, a school-based programme similar to the SSAP, concluded that for every dollar invested, between $2 and $4 in medical care costs and productivity losses were saved.10
The WHO recommends as ‘best practice’ a comprehensive approach to school sun protection policy and practices, classroom teaching, and the education of parents and caregivers, with an award system to acknowledge effort,11 similar to the Australian SSAP.12 The NZ SSAP is modelled on the Australian programme, with administration and resource distribution coordinated through a comprehensive website, and support from Cancer Society of New Zealand (CSNZ) health promotion staff.
Schools must meet 12 criteria for accreditation: policy, information, hats, ‘play in the shade’, sunscreen, clothing, role modelling, curriculum, planning, rescheduling, shade provision and review. The present paper reports the 2009 distributions for each of these components among randomly selected NZ primary schools.
Sample—Two 10% samples of state or state integrated schools (representing 99% of primary-age children) were randomly selected, within geographical regions corresponding to CSNZ Divisions and Centres, from the Ministry of Education national schools database. The first included 200 from 1,999 then eligible schools (March 2005), with additional schools randomly selected to reach a minimum of 16 within each CSNZ centre, producing 242 participants. Subsequent re-organisation grouped CSNZ centres into six Divisions, listed from North to South in Table 1.
Replacements for non-responding schools were randomly selected within regions.13 In 2009, 189 of these 242 schools agreed to participate again, supplemented with an additional, similarly selected sample (199 of 1,973 eligible schools) to strengthen analyses (Figure 1). This sampling process allowed the proportion of schools which reported following any particular guideline to be estimated using 95% confidence intervals (CI’s) ± 25% within centres and ± 5.1% overall when looking at all 388 schools. Three institution types were represented: Full Primary (Years 1–8; age ~5 to 13 years), Contributing (Years 1–6; age 5–11 years) and Composite/Area (Years 1–13; age 5–18 years) schools.
Instrument—The survey instrument to assess sun protection policy, practice, curriculum and environment was adapted from Australian precedent14 in consultation with CSNZ staff developing SSAP application forms. Minimum criteria and requirement(s) are directly related to these forms (Table 2). The CSNZ proposed no weighting for programme components and, since non-subjective weighting was considered difficult to achieve and justify, each criterion was treated as of equal weight. The CSNZ proposed that, although all criteria needed to be met in order to achieve accreditation, no arbitrary level of compliance was required to register—the goals being to facilitate participation, reduce barriers and monitor progress.
Procedures—The survey was mailed (2 September 2009) to school principals, with a Freepost, pre-addressed envelope enclosed and a request to return completed questionnaires and related policy documents. Scheduled follow-ups were by email (23 September) and post (23 October—which included an extra questionnaire in case the original was misplaced.
Further email and telephone reminders followed and, where possible, the principal was contacted directly and urged to complete the survey in order to facilitate a representative summary of the situation in primary schools.
All participants were asked to respond to questions in relation to primary students (Y1–6) and practices in Terms 1 and 4, when solar UVR can reach ‘very high’ to ‘extreme’ levels15 and sun protection is recommended. Ethical approval was obtained at the Departmental level (20 August 2009), following University of Otago procedures.
Analysis—Responses to specific survey questions determined the attainment of each criterion and were analysed with Stata v11.1 statistical software. Most measures used fixed response options, but some included an ‘other’ option, allowing alternatives to be recorded, collated and coded as discrete responses. Sampling and post-stratification weights, using the number of schools per region in 2009, were used to estimate percentages giving particular responses and achieving each criterion, compensating for oversampling within some regions and differential response rates between regions.
Figure 1. Sample selection and response to the 2009 survey of NZ schools with students of primary school age
Of the 242 schools in the baseline survey, 78% participated at follow-up. In 2009, 199 of the 324 (61%) additional randomly selected schools participated.
Overall, the 388 participating schools were comparable with schools nationally in socioeconomic decile distribution (level 1 being the 10% of schools with the highest proportions of students enrolled from low socioeconomic communities) and institution type (Table 1).
Participating schools were representative of the national distribution of primary school size. Because of the ‘boosting’ to a minimum number in the smaller centres, the geographical distribution of participating schools was somewhat different to the national distribution, with higher representation from divisions which contained smaller centres in the original sampling.
Adjustments were made to correct the effect of this oversampling. Overall, the responses of the participating schools are likely to provide a representative and comprehensive picture of sun protection practices in NZ primary schools.
Table 1. Characteristics of all eligible New Zealand schools with primary school age children, and those schools participating in the 2009 survey
* Roll size was not available for one school in the national database so percentages are based on 387 schools.
The percentages of schools attaining each of the 12 SSAP criteria are presented in Table 2. Details of responses to specific survey questions are reported for each criterion.
Policy—The written sun protection policies provided included 10% with a section in their Health and Safety Policy. Additionally, 9% had a policy ‘under development’.
Information—Schools were asked to indicate, from a list, which things parents/caregivers were informed about, during enrolment, regarding sun protection at school—multiple responses were allowed. Information was most commonly provided about the requirement for children to wear hats when outside (92%), the need for parents ‘to supply their children with sunscreen to take to school’ (49%), encouragement ‘to wear clothing that protects the skin from the sun’ (46%), and for adults ‘to practice sun protection behaviours when involved with the school’ (45%). Two percent indicated that no sun protection information was given. Respondents were also asked to indicate from a list which method(s) their school used to convey messages about sun protection (Table 3).
Table 3. Methods of conveying sun protection messages at school
Hats—Hat wearing was ‘enforced’ in 87% of schools and ‘encouraged’ in the remainder. With respect to the types of hats worn by students, multiple responses were permitted. In 64% of schools, students wore either ‘broad-brimmed hats (at least 7.5 cm brim)’, legionnaire hats, or bucket hats (at least 6 cm brim and deep crown).
The remaining 23% of schools may have chosen one of those protective options, but additionally chose an option unacceptable for accreditation: ‘any hat’, ‘bucket hats (less than 6 cm brim)’, or a free response, such as ‘caps’. When enforcement was re-examined in relation to hat type, a more realistic picture emerged. Overall, 60% reported enforcing the wearing of broad-brimmed, legionnaire, or big bucket hats.
Play in the shade—The most common consequence for not wearing a hat when outside was that students ‘must play in the shade’ (81%). Other consequences selected from a list of four options included that ‘they must play indoors’ (13%) or ‘they must wear a hat from school spare hats’ (30%). Write-in responses included punitive measures (such as ‘time out’, exclusion from physical education (PE) class or sitting in shade with no play allowed), encouragement to wear a hat ‘next time’, or measures ‘differing in different conditions’.
In 6% of schools there was ‘no restriction or consequence’. Although not penalised a second time for the type of hats worn, respondents were required to indicate that hat wearing was enforced, not simply encouraged.
Sunscreen—Schools reported that: ‘students are actively encouraged to use sunscreen’ (87%); ‘parents are encouraged to provide sunscreen’ (49%); sunscreen is available ‘in all classrooms’ (61%); and available ‘at various points around the school’ (38%).
Sunscreen was not supplied in 7% of schools, including 5% which neither supplied nor encouraged parents to provide sunscreen. SPF30+ was the most common type of sunscreen available at school (88%), with an additional 9% having at least SPF 15.
Clothing—Opportunities to choose sun protective clothing were explored through three questions about uniform or dress codes. Overall, 48% of schools had a uniform and most of these (98%) had a polo type shirt for summer use, whereas 30% had an option that included elbow length sleeves or longer. However, in 46% of these schools, male students were required to ‘wear shorts that fall above the knee’ and in 43% female students were required to ‘wear shorts or skirts that fall above the knee’, indicating that uniforms did not necessarily include sun protective options.
For non-uniform schools, we assumed there would be no restriction on wearing protective clothing, but for both uniform and non-uniform schools we were interested to know about protective expectations. There were substantial differences in some clothing expectations between uniform and non-uniform schools (Table 4).
Table 4. Percentages of uniformed and non-uniformed schools meeting various clothing expectations or dress code options in 2009*
* Calculations based on 367 schools with complete data for clothing questions.
Role modelling—In most schools (92%) staff were ‘encouraged to wear a sun protective hat during school outdoor activities and breaks in Terms 1 and 4.’
Curriculum—An accreditation question specifically asked if an ‘extended’ session on sun protection was taught as part of either the Science or Health/PE curriculum ‘at all levels throughout the school every year’, in order to distinguish schools which simply gave reminders about protection (covered by the ‘information’ criterion). Overall, 46% attained this criterion through the Health / PE curriculum, and an additional 7% through the Science curriculum.
Planning—Although there were no specific questions (in the survey or SSAP application form) about planning outdoor events, several questions addressed related issues. To meet this criterion, respondents needed to indicate at least one way in which sun protection was considered.
Rescheduling—Although there was potential overlap between the ‘planning’ and ‘rescheduling’ criteria, the latter focused on practices by means of which time spent outside between 11am and 4pm was minimised (Table 5).
Table 5. Percentages of schools reporting rescheduling practices to minimise time spent outside, 11am–4pm, Terms 1 and 4
* For accreditation, these two categories were combined (as on SSAP application form), so schools needed to indicate an additional practice in order to meet the rescheduling criterion. In 5% of schools, lunch was eaten neither indoors nor in shade.
Environmental shade—When indicating the ‘situation at your school with respect to shade’, 13% of respondents selected the most protective option: ‘substantial shade available for both passive and active activities.’ Most respondents indicated that there was ‘sufficient existing shade for most students to sit under for passive activity’ (52%), including areas for eating lunch and outdoor classroom activities. An additional 31% indicated that there was ‘some useful shade, but insufficient for most activities’, whereas 4% agreed that there was ‘inadequate shade for students to use for any activity.’
Among those without ‘substantial shade’, 21% had ‘definite plans to increase shade in the next 12 months’ and 26% in 1–3 years. However, 23% reported that ‘providing shade is not currently a priority area’ and 38% indicated that increasing shade ‘poses funding concerns.’ Formal shade assessment is not required for accreditation and for 67% of all schools there was ‘no documented assessment of shade provision.’ Few schools carried out a ‘formal shade inventory or shade audit’ (5%), although in 23% there had been a ‘less formal, but written, assessment of shade provision.’
Review—In response to the question: ‘Do your Board of Trustees and Principal review the sun protection policy or guidelines at least every 3 years?’, 82% responded affirmatively with an additional 12% indicating that was the intention, but the policy or guidelines were less than 3 years old.
Table 6. Percentages of schools achieving total accreditation scores 12–1; weighted to correct for oversampling in some areas
In 2009, most NZ primary schools only partially addressed sun protection, with 4% meeting all 12 criteria for accreditation. An additional 15% met 11 criteria and could potentially achieve accreditation with relatively limited changes. However, 52% of Australian schools surveyed in 2005 had attained SunSmart status.16
Furthermore, whereas 58% of NZ schools reported having a written school sun protection policy, 80% of Australian schools had such a policy in 2005. Nevertheless, Australian and NZ levels are both substantially higher than those generally reported for the US,17–19 other than California and Colorado, where elementary school policies are controlled at district level.20 Higher level administrative procedures may exert a positive influence, so stronger support for sun protection through the National Administrative Guidelines (NAGs) for health and safety in NZ schools may provide more sun safe environments more quickly.
The NZ SSAP criteria least likely to be met relate to clothing (42%), shade and the curriculum (54% each). With respect to clothing, there is a need to ensure that attractive, suitably protective and affordable products are readily available and, if not, to work with suppliers to achieve that. The provision of adequate shade can be costly and requires professional guidance to achieve optimal placement at the required time. Although a substantial NZ manual is available,21 relatively few professionals seem to be engaged and there are limited training opportunities for architects and planners. Considerable improvement would probably be achieved if shade was required to be considered in all school building plans.
With respect to the curriculum, some suitable and attractive components are available,22 but these deserve greater promotion to all levels of the education sector. Development of further suitable curricular materials should also be a priority.
The ‘role modelling’ criterion may be too lax, and could be strengthened as part of occupational UVR hazard management.23 Rescheduling of outdoor excursions and sports days (Table 5) could receive greater attention, and the high UVR period immediately after school hours (3–4pm), which falls outside of school jurisdiction, deserves greater attention as a time when harmful UVR exposure may occur.
The SSAP currently only applies to primary and intermediate level students, with a lack of continuity through the secondary level. Earlier research found that few secondary schools had a written sun protection policy, there was little evidence of related curriculum content and students often lacked knowledge and protective attitudes.24
Study limitations—The present study was based on reports from school staff, which may overestimate positive practices. However, as an adjunct to this study, on-site visits were conducted at 22 primary schools,25 and there was broad agreement between observation and practices reported as survey data. Measures in the survey instrument were based on Australian precedent and not specifically tested for validity or reliability in NZ, but were similar to the SSAP application form. Statistical predictors of accreditation scores, changes over time, and regional differences will be addressed elsewhere.
A review of interventions for the primary prevention of skin cancer in children and adolescents concluded that:
The SSAP takes such an approach, but requires consolidation. Although progress has been made towards making NZ primary schools safer for students with regard to sun protection, there remains considerable room for improvement. Schools struggled most in the areas of curriculum delivery, clothing protection and provision of adequate shade. There is a need to further assist developments in these areas.
Incomplete implementation of the SSAP potentially leaves a substantial number of NZ primary school children at risk of harmful UVR exposure at school and less than fully informed about the rationale and need for sun protection in other contexts.
Competing interests: None declared.
Author information: Anthony I Reeder, Associate Professor and Director, Cancer Society Social & Behavioural Research Unit; Janet A Jopson, Assistant Research Fellow, Cancer Society Social & Behavioural Research Unit; Andrew Gray, Biostatistician; Department of Preventive & Social Medicine, Dunedin School of Medicine, University of Otago, Dunedin
Acknowledgements: Special thanks are due to Mary Duignan, Dr Judith Galtry, Jane Armstrong, Louise Sandford and the Cancer Society SunSmart Schools Operational Group. Nathalie Huston’s assistance was invaluable for coding and mailing. We acknowledge the school staff who took time to complete the survey. The Health Promotion programme of the Cancer Society of New Zealand Inc is acknowledged for funding this project, in addition to the core support provided to Assoc Prof Reeder and the Cancer Society of New Zealand Social & Behavioural Research Unit.
Correspondence: Tony Reeder, Cancer Society Social & Behavioural Research Unit, Department of Preventive & Social Medicine, Dunedin School of Medicine, PO Box 913, Dunedin 9054, New Zealand. Fax: +64 (0)3 4797298; email: firstname.lastname@example.org
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