In New Zealand, skin cancer is by far the most common cancer type1 with nearly 500 deaths annually.2 New Zealand also has the highest incidence rate for cutaneous malignant melanoma, the most deadly of the skin cancers.3 The burden on the public health system is considerable.1 Yet, we know the main potentially modifiable cause of skin cancer, and that the risk of developing it can be mitigated by reducing exposure to ultraviolet radiation (UVR).4 Exposure to excessive UVR during childhood is associated with an increased risk of skin cancers later in life.5 Reducing sun exposure and encouraging sun protective behaviour while at school can potentially mitigate lifetime skin cancer risk. Schools can play an important role in educating about risk and protective practices as well as implementing policies which will help to protect students and staff from UVR damage.6

The New Zealand Cancer Society SunSmart Accreditation Programme (SSAP) is available free to schools that enrol and comply with 12 sun protection criteria recommended by the World Health Organization and is based on scientific evidence of effective strategies for skin cancer prevention.7 The US-based Community Preventive Services Task Force has concluded that there is strong evidence of effectiveness of this type of primary school-based intervention.8 The SSAP encourages schools to provide a sun protective environment and implement curriculum and policies designed to encourage students and staff to develop positive sun safety behaviours. There is no public funding for the provision of shade or other sun protective resources in schools. However, the Board of Trustees is required “to provide a safe physical and emotional environment for students; and comply in full with any legislation currently in force or that may be developed to ensure the safety of students and employees”.9

The purpose of this paper is to report the findings from a nationwide survey of primary school principals (from both SunSmart accredited and non-accredited schools) on their schools’ sun protection policies and practices.

Methods

The Ministry of Education’s Website10 was used to identify every school delivering education in English to primary age students. Information available included: school name, website, name of principal, contact details, type of school (eg, full primary), location (eg, rural), gender of students (eg, co-educational) and socioeconomic decile rating (a school with a decile rating of 1 receives more Government funding than a school with a decile 10), as well as the proportion of students in each of the five New Zealand Census major ethnic groups attending the school.

In the first instance, the survey was promoted to principals using the Ministry of Education fortnightly email distribution network. Then, each principal was invited to participate in an electronic survey on their school’s sun protection policies and practices. A personalised invitation letter, including a URL link and password, information sheet and letter of support from the Cancer Society was posted (15 April 2017). Schools for which the survey had not been completed were sent a reminder email (10 May), followed by a reminder telephone call (starting 16 May) and final email reminder (3 June). School principals were encouraged to complete the survey themselves, but were able to nominate another person at the school to do it on their behalf. Data collection was closed off on 31 July 2017. As a token of appreciation for participation, there were six random draws for one-litre containers of sunscreen. Feedback summarising the survey findings was emailed to respondents in November 2017.

Questionnaire

The survey instrument was developed collaboratively with Cancer Society staff. Most of the questions were based on items in previous surveys.11 The survey instrument was piloted, with one school principal and several Cancer Society health promotion staff. The questions included each of the 12 sun protection measures that form part of SSAP. In order to reduce possible response bias, response categories were randomly ordered where this was practical. The questionnaire was delivered electronically online, using Lime survey software.12

Data analysis

Most of the survey instrument consisted of fixed response questions. In some instances, there was an ‘other’ option for respondents who felt that the response categories provided did not adequately capture the situation of their school or their point of view. The responses to open-ended questions were collated into common ‘themes’ and reported numerically. Data collation and statistical analysis was conducted using SPSS.13

Ethics

Ethical approval was obtained from the University of Otago ethics committee (D17/045) and Māori consultation undertaken with the Ngāi Tahu Research Consultation Committee.

Results

Of the 2,013 schools invited, 62% (n=1,243) participated, which represents 322,272 students or 62% of the total primary school population. The schools that responded to the survey represent ‘all schools’ well in terms of school socioeconomic decile rating, type, size and geographic region (Cancer Society Division). Schools that were SunSmart accredited and/or had a higher decile rating were slightly over-represented in the final cohort (42% nationwide compared with 45% of respondent schools). The average time taken to complete the survey was 13 minutes.

The majority of respondents (76%) were senior managers at the school, followed by administrative (16%) or teaching staff (8%). Half of the schools responding (50%) were full primary, 39% were contributing, 6% were composite and the remaining 5% were intermediate schools.

More than 90% of respondents reported that their school had either a sun protection policy (57%) or procedure (37%). Of the remaining schools, most respondents were either unsure whether or not there was a sun protection policy/procedure in place, or reported that sun protection was included in another policy (usually Health and Safety). For virtually all schools the policy/procedure was implemented in Terms 1 and 4. A small proportion of schools also implemented the policy or procedure in Terms 2 and 3 (9% and 8% respectively). Approximately half of these schools were in the upper half of the North Island where ultraviolet index (UVI) levels are above 3 (the level at which sun protection is recommended) for a longer period of time.

For schools with a policy, most informed staff (99%), parents/caregivers (96%) and students (96%) about the sun protection policy or procedure. Over 90% of respondents reported that their school reviewed the sun protection policy/procedure at least triennially.

Respondents were asked which types of hats students were permitted to wear—the most commonly reported were broad-brimmed (78%) or bucket hats (73%). In total, 72% allowed only appropriate sun-protective hats to be worn. Some schools noted that resourcing for specific types of hats could be-challenging for low decile schools. Nearly one-third of schools (28%) allowed non sun-protective caps to be worn. In some schools, particular types of sun protective hat were mandated as part of the school uniform.

With the exception of one school, all schools either enforced (90%) or encouraged (10%) students to wear a hat when outdoors. For those schools that enforced sun-protective hats, the consequences of not wearing a hat were that: children had to play in the shade (88%), wear a school ‘spare-hat’ (40%) or play indoors (14%). Overall, over 74% of respondents reported that most students (at least 70%) wore a sun-protective hat during all outdoor activity.

Two-thirds of respondents (68%) reported that their school had a school uniform, and in most cases this was compulsory. For the purposes of this project, a sun-protective uniform was designated to be one that included a collar and sleeves to, at least, mid upper arm (eg, polo shirt). Overall, in 76% of schools, students were wearing/encouraged to wear clothing that was sun-protective. In terms of clothing worn during sports or outdoor events, nearly two-thirds of schools (61%) reported that they did not have a PE uniform. During athletic sports, nearly two-thirds of schools (63%) encouraged the use of sun protective clothing.

Three quarters (75%) of respondents reported that their school encouraged students to use sunscreen. Most schools (93%) provided students with sunscreen at least some of the time and nearly half of schools encourage parents to provide sunscreen (45%). For schools that provided sunscreen, 82% provided it for school outings, 71% had it available in most classrooms, and 60% had it available at other points around the school. During athletic sports, most schools (86%) had sunscreen available for student use. Contrary to Cancer Society recommendations, over half of schools (59%) were encouraging parents to apply sunscreen to children before they leave home for school.

The majority of schools had sufficient shade for passive activities like eating lunch (60%), but fewer had sufficient shade for active pursuits (eg, playground) (14%). In total, 43% of respondents reported that their school had plans to increase shade in the next 12 months (17%) to five years (26%). About one-fifth of schools (21%) were not planning to increase shade because of funding constraints, and 10% because it was not considered to be a priority area. About one-quarter of schools (22%) said they had no plans to increase shade as they already had a sufficient amount. A few schools noted concerns regarding resourcing the provision of shade and the experience of environmental conditions or weather events and the issue of ongoing maintenance and repair.

Less than one-third of respondents (28%) reported that their school attempted to minimise time spent outdoors between 10am and 4pm. The most common strategies for minimising time in the sun were to eat lunch in shady areas (86%) and to hold assemblies either indoors or before 10am (82%).

The behaviour most encouraged for staff was the use of a sun protective hat, which the majority of schools either required (58%) or recommended (36%). Other sun protection behaviours (such as sun protective clothing or use of sunscreen) tended to be recommended rather than required.

As part of the curriculum for all year groups every year, 41% of respondents reported that staff at their school taught about when sun protection is needed and why. Of the remaining schools, most (31%) taught sun protection once or twice during a child’s primary school education.

Two-thirds of schools (66%) always included sun protection in their Risk Management Systems for Education outside the classroom (EOTC) activities. A further 32% reported that sun protection was considered in these situations, but not formalised. Only 20 (3%) respondents said that sun protection was not considered.

In total, 92% of schools had school swimming. Of these schools, 62% conducted swimming at an outdoor venue (mostly (83%) on site). Only a small proportion of schools with outdoor swimming (19%) displayed SunSmart posters or boards to remind people of the need for SunSmart behaviours.

All the schools held athletic sports, generally in the summer months. For non-competing students, most schools encouraged students to use sun protective hats and shade (86%). While competing, most schools encouraged students to use sun protective hats (89%) and most encouraged sunscreen use (86%). Only one-third of venues had plenty of shade available for students.

Most schools implemented sun protection practices in Term 1 and Term 4 rather than relying on the level of UVR on a particular day. A small percentage of schools were incorrectly using temperature/sunny day (16% each) to determine when sun protection was needed.

Discussion

This nationwide survey of all New Zealand primary school principals shows that there has been a substantial improvement in sun protection in a primary school setting over time.14 Since 2009 a number of key sun protection items have improved, including having a sun protection policy/practice (58% in 2009 compared to 94% in 2017), required use of a sun protective hat (74% compared to 88%), and encouragement of students to wear sun protective clothing (42% compared to 75%).14 Despite this improvement, sun protection remains inadequate in many schools and all vulnerable students throughout New Zealand deserve to receive equitable protection.

Having a school policy in place is critical, as it informs staff, Board of Trustee members and parents entering the school of the importance of the expectations of the school community regarding sun protection. In Australia, schools with a sun protection policy report better sun protective practices than those without.15 Almost all New Zealand schools (94%) reported having a sun protection policy/procedure. This is similar to the 91% reported in Queensland.16 As sun protection procedural guidelines incorporated into health and safety policies are counted as meeting accreditation criteria, they were likewise counted as complying with the policy criterion. In this context, it is worth noting that many schools are now using SchoolDocs, a commercial organisation that provides modifiable documents to schools, to help develop and manage all of their policy documentation. In line with Education Review Office (ERO) requirements, most schools review their documents at least triennially and notify their community of the sun protection policy. In Australia, recently introduced Education Department rules now require a sun protection policy in all public schools.17 However, having a policy does not necessarily mean that the policy is comprehensive.18

Most schools enforced (90%) hat wearing, with the consequences of not having a hat being to ‘play in the shade’ (88%) or wear a school ‘spare’ hat (40%). Nearly three-quarters (72%) of schools allowed only sun protective hats. Unfortunately, the remaining schools allowed caps to be worn, and these do not adequately protect much of the face or neck, which are common areas for skin cancers to develop.19 The ultraviolet protective factor of sun protective hats is double that of caps.20 A number of reasons were provided to explain why schools were not complying with the recommended criteria. First, there was a view that any hat was better than no hat. Second, principals reported that students didn’t like to wear fully sun protective hats and found caps more acceptable. Third, the provision of sun protective hats was financially challenging, particularly for families of students attending low decile schools. A particular concern was that some schools required students in Years 1 to 6 to wear a sun protective hat, but then permitted a cap to be worn in Years 7 and 8. Unfortunately, this was likely to be viewed by students as a ‘badge of honour’ for having reached the senior school and, therefore, become an aspirational goal for junior students. On a positive note, three-quarters of respondents reported that, when they observed students, at least 75% would be wearing a sun protective hat in the playground during any of the break periods or during sports events or outings. However, it is important to remember that these are self-reported results. In Queensland, an observation study of hat use in primary schools found only about half of students were wearing hats of any description.21 Similarly in a small observational study of New Zealand school children, only 21.3% were wearing sun protective hats.22

When used as recommended, and in conjunction with other means of sun protection, sunscreen can be an important tool in reducing exposure of the skin to UVR and the development of skin cancers.23,24 Three-quarters of schools reported that they encouraged students to use broad-spectrum SP30+ sunscreen. Almost all schools (93%) provided students with sunscreen—at least some of time. This was largely for school outings (82%) or in individual classrooms (71%). Unfortunately, and contrary to Cancer Society recommendations, over half of schools (59%) encouraged parents to apply sunscreen to children before they leave home. This can be an opportunity, before the UVI reaches 3, for relatively safe endogenous vitamin D production, particularly if students are walking to school. There is also a risk that students will not reapply sunscreen to protect themselves around the middle of the day when the risk of sun damage is greatest.

Shade, either built or from natural sources such as trees, can provide substantial sun protection benefits and reduce UVR exposure,25 not only for current but also future student cohorts. Environmental shade provision means that an individual may not need to make a choice about whether or not they use personal sun protection strategies. It can, however, be costly and financially challenging for schools to provide. Unfortunately, with the exception of new buildings, the Ministry of Education does not provide any funding for the provision of shade in schools, although it does fall under their remit of providing a safe and healthy environment for students and staff.26 Only 14% of schools had sufficient shade for both passive pursuits and active activities. Almost all schools (94%) required their students either to eat lunch in a shady area (86%) or indoors (20%).

The wearing of sun protective clothing can provide a physical barrier that substantially reduces the amount of UVR reaching the skin. School uniforms, when they meet sun protective guidelines and are worn correctly, provide an excellent opportunity to reduce excessive UVR while at school. The use of uniforms can mean that all students are similarly protected without each family or individual needing to make decisions about sun protective clothing practices. Over two-thirds of schools had a school uniform which was, largely, sun protective. Most commonly this included a collared polo shirt with mid-arm length sleeves or a collared shirt. Without specific testing, it can be difficult to reliably assess the extent to which a school uniform is sun protective, since even small alterations, such as the length of a sleeve, can potentially affect subsequent skin cancer risk, as can the colour and weave of the fabric.27 Based on reports of school uniform sleeve length and collar, at 75% of schools, overall, students were either wearing a sun protective uniform or were encouraged to wear sun protective clothing. In Australia, school uniforms for primary students are usually compulsory.27

Parental role modelling has been demonstrated as an important factor for reducing sunburn in children.28 Likewise, teachers can encourage and reinforce appropriate sun protective behaviours in students. Most schools either required or recommended that staff should role model appropriate sun protective behaviours. One school noted the difficulties of dealing with all-day events and getting parents to also role model appropriate behaviour. For staff, it is possible that health and safety employment requirements could be used to achieve compliance. Teachers can be exposed to high levels of ambient UVR during lunch time breaks and outdoor events.29

Less than one-third of schools were reported as rescheduling events outside the 10am to 4pm period when the UVI mostly exceeds 3 during Terms 1 and 4. This criterion may be impractical on a day-to-day basis, as it incorporates much of the school day and essential classroom activities, such as reading and writing, which are often scheduled for that first hour at school when students tend to be most alert and receptive. However, in the case of events such as swimming sports, it may be possible to schedule outdoor activities to later in the day or in the evening. This may have added benefit because it can allow working parents to attend. Rescheduling of outdoor events outside peak UVR is also not a standard practice in Queensland primary schools where, between 4.9% and 22% of schools included this in their sun protection policy. Similarly in the US, 15% of all schools reschedule activities outside times of peak UVR.30

Nearly two-thirds of schools did not have a PE uniform, so that the clothing worn during PE was not prescribed and sun protection could not be ensured. Protection is particularly important during all day events as students can be exposed to high UV levels for extended periods. Of the 92% of schools that had school swimming, 62% held this at an outdoor pool—a potentially particularly risky environment, given UVR reflection off water, a lack of shade and the wearing of clothing that may not be sun protective. Although some schools were reported to require the wearing of rash tops or provision of shade sails, we did not specifically ask about these. Almost all schools held an athletics sports day, generally in summer months when children can be exposed to high levels of UVR for extended periods, making sun protection critical. Also, sports clothing may provide less protection than ordinary daily clothing. The wearing of a sun protective hat while competing in many sports may be impractical. In high UVR contexts, when it may impractical to use clothing and hats for protection from the sun, the correct application and re-application of adequate amounts of sunscreen, the provision of shade or timing of the event is critical in reducing student exposure to excessive UVR. Nearly two-thirds (66%) of schools always included sun protection in their Risk Management Systems for EOTC activities. The remaining schools reported either that it was considered but not formalised (32%), or not considered at all (3%).

It is important not only that students should be instructed in the need to use sun protection, but also educated about the reasons why it is necessary. In this way they would be protected during the period of their lives while they are at school, and develop knowledge that would serve to help them protect themselves throughout life. It is particularly relevant that students understand about New Zealand’s geographical position and why such high UVI levels can be experienced. There are opportunities to link this into the science curriculum, and some of these opportunities are covered in the curriculum resources developed by the Cancer Society in collaboration with educationalists familiar with the requirements of the New Zealand primary and intermediate school curriculum. Less than half of schools (41%) of schools reported they taught sun protection as part of the curriculum every year, but nearly three-quarters of schools (72%) reported that they taught it at least once during the primary school years. Many schools commented that although sun protection was not taught formally every year, it was covered regularly in assemblies or before outdoor events. Sun protection is only one of other equally important health and safety topics (such as Water Safety and Fire Safety) vying for space in the classroom. It is worth noting that in Australia, SunSmart resources are now available in an interactive format,31 which is likely to be attractive to both staff and students.

There are some potential limitations of this study. First, the findings are based entirely on respondents’ self-reports because we were unable to carry out direct observation in order to verify the selected survey responses about sun protection practices at participating schools. It could be expected that this method may inflate positive results, and other comparisons between self-report and observation tend to support that conclusion,32 so actual levels of protection in schools, overall, may be lower than reported.

Secondly, the response rate of 62%, although relatively high for such a survey, may have produced responses that are not representative of the national population of all schools attended by primary age students. However, the likelihood that this occurred is reduced, as a comparison between responding schools and all schools found no significant differences according to their socioeconomic characteristics recorded in the Ministry of Education database.

Conclusions

A substantial improvement in sun protection in primary school settings was observed since a previous survey, but sun protection remains inadequate in many schools and vulnerable students throughout New Zealand deserve equitable protection. Skin cancer is New Zealand’s most common cancer, but also highly preventable, yet primary prevention in school settings is not resourced from public funds. Appropriate school sun protection policies and practices can potentially reduce students’ exposure to excessive UVR and ultimately reduce skin cancer risk.

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