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| Journal of the New Zealand Medical Association,
10-February-2012, Vol 125 No 1349
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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.
MethodsSample—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
 ResultsOf 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
DiscussionIn 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.
ConclusionsA 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: tony.reeder@otago.ac.nz
References:
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