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The SunWise Policy Intervention for School-Based Sun Protection: A Pilot Study

Karen M. Emmons, PhD, is a professor in the Department of Society, Human Development and Health, Harvard School of Public Health, and Dana-Farber Cancer Institute, Boston

Alan C. Geller, MPH, RN

Alan C. Geller, MPH, RN, is a research associate professor at Boston University School of Medicine

Vish Viswanath, PhD

Vish Viswanath, PhD, is an associate professor in the Department of Society, Human Development and Health, Harvard School of Public Health, and Dana-Farber Cancer Institute, Boston

Linda Rutsch, MBA, MPH

Linda Rutsch, MBA, MPH, is Director, SunWise Program, Environmental Protection Agency, Washington, D.C

Jodie Zwirn, MPH

Jodie Zwirn, MPH, is Research Coordinator, Center for Community-Based Research, Dana-Farber Cancer Institute, Boston

Sue Gorham

Sue Gorham is Executive Director, SHADE Foundation of America, Scottsdale, AZ

Elaine Puleo, PhD

Elaine Puleo, PhD, is an associate professor in the Department of Public Health—Biostatistics and Epidemiology Concentration, University of Massachusetts, Amherst

	Abstract

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Skin cancer is highly preventable, but clearly there is a critical need to focus on better ways to disseminate information about known skin cancer prevention. The U.S. Environmental Protection Agency’s (EPA) SunWise Program is one channel for reaching children, teachers, and school nurses. In a pilot study designed to increase adoption of school-based sun protection policies, 28 schools were randomly assigned to one of three groups: Control, which included the EPA’s original SunWise curriculum toolkit; SunWise Policy, which included a revised toolkit emphasizing policy; and SunWise Policy plus Technical Assistance, which included the policy toolkit and 3 technical assistance phone calls. The enhanced SunWise Policy plus Technical Assistance intervention led to more new sun protection policies. Use of study interventions for improving sun protection practices such as policy toolkits or brief counseling can be easily interwoven into school hours by school nurses and other health educators.

Key Words: skin cancer prevention • schools • policy

Sun exposure in childhood is a significant risk factor for development of skin cancer later in life (Arthey & Clarke, 1995; Marks, 1988; Oliveria, Saraiya, Geller, Heneghan, & Jorgensen, 2006). Skin cancer is highly preventable, but clearly there is a critical need to focus on better ways to disseminate information about known skin cancer prevention practices and integrate them into daily practice through channels that can reach parents, care-givers, and children. During school hours, U.S. children receive many hours of unprotected sun exposure each year (Buller et al., 2002). Implementing policy changes, such as providing sun-screen, shade structures, and rescheduling of outdoor sun activities during peak sun exposure times, could complement curricula efforts designed to increase knowledge about the importance of sun protection and to change tan-promoting attitudes. Importantly, policy changes may be an effective vehicle for improving sun protection behaviors. There is substantial evidence from tobacco control documenting the impact of policies on smoking behavior (Farkas, Gilpin, White, & Pierce, 2000; Gilpin, White, Farkas, & Pierce, 1999). Although there have been a number of surveys designed to document the prevalence of school sun protection policies, initiatives to increase policy implementation remains a largely unexplored area in school-based sun protection efforts. (Buller et al., 2002; Eakin, Maddock, Techur-Pedro, Kaliko, & Derauf, 2004; Kirsner et al., 2005).

There has been a significant amount of work on skin cancer prevention conducted in schools with a primary focus on development of curricula to teach sun protection skills (Buller & Borland, 1998). Although these interventions have been developed with the goal of improving knowledge and changing both attitudes and behavior, the primary impact has been on increased knowledge (Geller et al., 2008; Hatmaker, 2003; Saraiya et al., 2004). The Environmental Protection Agency’s (EPA) SunWise School Program, the major sun protection and education program in U.S. public and private schools, provides a natural vehicle for adopting and disseminating new policy guidelines to U.S. schools. The EPA has a very effective, albeit limited, infrastructure for conducting trainings that could facilitate the development of a sustainable approach to policy implementation nationwide. However, although the SunWise materials mention policy, there has been relatively little emphasis on this in the standard curriculum or training program.

In the absence of trials to increase the number of new sun protection policies at U.S. schools, the researchers sought to determine the optimal method for improving inclusion of new sun protection policies. We compared the standard SunWise curricula training of nurses/health educators (control) with two other conditions: a newly revised version of the toolkit with additional emphasis on policy development (SW Policy) and the policy toolkit coupled with the assistance of three technical assistance telephone calls from a health educator (SW Policy/TA). The intervention was targeted to school nurses/health educators who provide schoolwide education to elementary school students and are therefore a key resource for implementing new health promotion activities. Educational activities designed to increase new sun protection policies and environmental support for sun protection stemmed from seven broad guidelines established by the Centers for Disease Control and Prevention’s (CDC) Guidelines for School Programs to Prevent Skin Cancer including those for policy, environmental change, education, families, professional development, health services, and evaluation (Glanz, Saraiya, & Wechsler, 2002).

	METHOD

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The EPA provided listings of all Massachusetts elementary school nurses or health educators who had participated in a SunWise training program during May–June 2005. Between November and December 2005, introductory letters were sent to these participants (n = 52), followed by invitation telephone calls. Eight of these educators were district or public health nurses not affiliated with a particular school, and seven were no longer at the school. Of the 37 eligible individuals, 9 refused to participate, and 28 consented to participate in the study (76% response rate). The 28 schools were randomized into three groups by school size and income levels. Four of the towns and cities had at least two participating schools. Enrollment at the participating schools ranged from 164 to 919 students, with a mean of 398. Eighty-eight percent of the students in these school districts were Caucasian. To minimize contamination, all schools within a town were assigned to the same study condition. This procedure led to a slight imbalance in the distribution of schools across conditions. Each of the three conditions had at least one town with multiple schools. The Institutional Review Board at the Dana-Farber Cancer Institute approved the study.

Measures
The school nurses/health educators at the 28 consenting schools were asked to fill out a brief pretest survey in January 2006 inquiring about their school’s current sun protection curriculum, sun protection policies, and practices. Specific questions centered around eight policy/environmental support domains: (a) whether the school implemented the SunWise curriculum since the May 2005 training programs, (b) if SunWise teaching is required, (c) if outdoor activities are limited between 10:00 a.m. and 4:00 p.m., (d) if hats, sunglasses, and/or sunscreen are allowed when children are outdoors, (e) if sunscreen is available and used for outdoor activities, (f) if sun protection information is included in written communication to parents, (g) if the school has any structures that provide shade for students and staff to use during outdoor time, and (h) if there are shade trees on the school playground. On receiving the completed surveys, the schools were then randomized into the three different study conditions. Posttest surveys were completed in May–June, 2006 before the end of the school year. Response rate for the posttest was 96%.

Intervention
The control schools (n = 8) received SunWise curricula materials distributed at the initial training session plus new brochures designed and distributed by the SHADE Foundation highlighting general information about sunscreen and how children can be safe in the sun (http://www.shadefoundation.org/prevention.php).

Policy schools (n = 11) received the SunWise curricula training, the SHADE Foundation brochures, and the newly revised version of the SunWise toolkit with additional emphasis on policy development (http://www.epa.gov/sunwise/). The toolkit included an evaluation tool to assess the school’s current sun protection practices and shade availability, a chart to assist educators to integrate the SunWise lessons into a regular classroom curriculum, and a checklist that provides a menu of sun protection policy options. Written templates included sun protection language used in a sample letter to parents requesting them to provide sun protection for school and field trips, sample press releases, sample language for newsletters, donation letters, and sample school policies. An additional section describing why adopting SunWise policies is important was reinforced by a teen melanoma survivor providing her personal story. The mailing of these materials was timed to reach school nurse/educators at the same time that telephone calls were being made to SW Policy/TA schools.

SW Policy/TA schools (n = 9) received the SunWise curricula training, the SHADE Foundation brochures, the revised policy version of the toolkit, and 3 technical assistance telephone calls, ranging in duration from 15 to 45 min, from a health educator at monthly intervals between January and April 2006. The calls were designed to assist participants in developing goals for implementing school policies and determining best methods for overcoming barriers for policy implementation. During the first phone call, the study health educator used the SunWise kit’s evaluation checklist to assess each school’s current sun protection practices and worked with the school nurse/health educator to choose the most feasible options from the policy "menu." A time-line, action plan, and a list of contacts were drawn up on the first call and referred to in subsequent sessions. Schools in the SW Policy/TA group were sent follow-up letters after each telephone call summarizing the individual goals, next steps, and timelines for the practices they chose to develop. All nine SW Policy/TA schools participated in all technical assistance calls as planned.

Statistical Analysis
Basic univariate and bivariate percentage of attainment by intervention group were calculated for each policy of interest. Comparisons of baseline and follow-up values were calculated based on the change in percentage. Because of the small sample size, statistical comparisons would not have been valid, and therefore are not presented. The analyses represent a descriptive presentation of the impact of the pilot intervention.

	RESULTS

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Twenty-eight elementary schools participated in the pilot study; combined, these schools serve more than 10,000 Massachusetts children. At baseline, across all schools, adherence to sun protection policies was mixed. Only 4 schools (14%) scheduled outdoor activities during nonpeak sun exposure times, and only 5 (18%) of the schools had sunscreen available for use during outdoor activities. Nine schools (32%) had a structure to provide shade or shelter during students’ time outdoors. Although 23 schools (82%) allowed sun protection gear when outdoors, none required it; 21 of the schools (75%) made some mention of sun protection information in written communication with parents (Table 1).

Across the 3 conditions, of the eight chosen policies, implementation of SunWise curriculum was most successful. Prior to the intervention, only 5 schools had implemented SunWise curriculum, and only one of these schools required SunWise teaching. Postintervention surveys indicated that 11 additional schools implemented SunWise curriculum; 6 of these were SW Policy/TA schools, and in 4 of these, SunWise teaching was now required. Although the small sample size limits the conclusions that can be drawn about differences between conditions, it is worth noting that the SW Policy/TA schools had more than 20% improvement in six of the eight policy areas, compared to similar levels of improvement in only one of the control schools, and none of the SW Policy schools.

	DISCUSSION

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Although the importance of sun protection policies has been noted, there has been relatively little intervention research in the United States to increase adoption of these school-based policies. In this pilot study, the enhanced SW Policy/TA intervention, which provided a new policy toolkit and three brief telephone calls, appeared to lead to more new sun protection policies than the control and SW Policy toolkit–only conditions. The findings of this study are consistent with work in Australia that demonstrated increased uptake of "no hat no play" policies in schools receiving policy-based interventions and a subsequent positive effect on children’s hat wearing on the playground (Giles-Corti et al., 2004). Of note, the Australian work demonstrated that mailed dissemination of policy guidelines was ineffective and that a more intensive strategy that includes support for policy development is needed.

"The findings of this study are consistent with work in Australia that demonstrated increased uptake of ‘no hat no play’ policies in schools receiving policy-based interventions and a subsequent positive effect on children’s hat wearing on the playground."

Earlier studies have documented suboptimal adoption of schoolwide sun protection policies. In 1998, in a random sample of 412 U.S. public elementary schools, only 3.4% of schools had a sun protection policy despite the fact that most principals (84%) said that students were outdoors during midday hours. The most common reasons for not having a policy included the principals’ lack of awareness or organizational barriers in the school districts (Buller et al., 2002). Surveys of secondary school principals conducted 4 years later found slight improvements. Ten percent of schools had policies, and 93% were providing some type of classroom education (Buller, Buller, & Reynolds, 2006). Recent analysis from the CDC’s School Health Policies and Programs Study, a nationally representative sample of schools in all 50 states, provided little evidence of further improvement, with only 2% of districts requiring scheduling to avoid peak sun exposure and 4% of districts requiring use of sunscreen before outdoor play (Jones, Fisher, Greene, Hertz, & Pritzl, 2007). Regional surveys have confirmed the very low level of implementation of school sun protection policies.

In Hawaii, 99% of schools scheduled outdoor activities during peak sun hours. School uniforms rarely included long pants (6.5%), long-sleeved shirts (5.1%), or hats (1.5%). However, almost one third (28.1%) of those surveyed were in favor of a statewide policy (Eakin et al., 2004). The Miami-Dade County school district enacted countywide hot climate recommendations regarding hat use and parent application of SPF 15 sunscreen. A survey of school officials conducted 7 years after implementation found that 78% knew about the county school system’s guidelines for avoiding excessive heat exposure. Although one of the two recommendations was to parents, only 21% shared these guidelines with parents. None of the schools surveyed required sunscreen, hats, or protective clothing (Kirsner et al., 2005).

Policies in U.S. schools differ from those in Queensland, Australia, where 94% of teachers teach and practice sun protection, 84% of schools have compulsory hat wearing, 83% require lunch inside, 81% provide adequate shade, 75% of primary schools are accredited as SunSmart schools, and 56% of parents supplied sunscreen. It took schools in Australia many years to enact strong policies, including the development of the "no hat no play" school rules, and they did so coupled with large-scale media campaigns directed to improving caregiver protection of their children. The Australian studies have noted the importance of identifying champions who will drive policy development (Giles-Corti et al., 2004).

In the present study, limiting sun exposure during peak hours appeared to cause the most resistance to policy changes. This is not very surprising given that the intervention took place during a 4-month period, and changing of school activity scheduling likely requires a much more lengthy process. It is also unclear whether there is a willingness to even undertake such a process. Future policy interventions should include outreach to school nurses/health educators and their organizations as well as to school and district administrators. Multilevel approaches to institute new school policies, led by parents, principals, and school health faculty at the level of the local schools and district office, can inspire comprehensive guidelines from state-based departments of public health and education (Geller et al., 2008).

Limitations
In this study, all data were self-reported; however, future studies can easily corroborate school nurse/ health educator reports of the adoption of new curriculum, provision of sunscreen, or construction of new shade structures. Second, this study was designed as a pilot to determine if trends were sufficient to warrant larger-scale studies. Thus, statistical analyses to determine between-group significance was not possible. Additional studies with larger samples are needed to determine if the interventions lead to significantly greater policy implementation and if the findings are generalizable to other schools and geographic regions. There are also some strengths that should be noted. The intervention is built on the EPA’s widely implemented SunWise program, which has an effective vehicle for dissemination. The study was conducted in schools that represent a range of community socioeconomic levels. Finally, use of study interventions such as policy toolkits or brief counseling were easily interwoven into school hours.

Implications for School Nursing Practice
To date, more than 21,000 educators, including about 3,000 school nurses, have registered for the SunWise program, representing almost 17,000 schools throughout the United States. The EPA’s successful incorporation of SunWise teaching in U.S. schools provides a potential building block for policy implementation. School nurses can use SunWise materials to teach in the classroom and advocate for sun protection policies on the schoolyard. Furthermore, a national database of all nurses, health educators, and teachers who have registered for and been trained in SunWise curriculum provides a special resource and infrastructure for conducting large-scale studies. The EPA’s infrastructure for training is limited but effective. Maintaining and expanding resources for this effort could have significant payoffs in terms of a national policy effort targeting schools. The results of this pilot study provide preliminary evidence of the need for a larger randomized trial to test the efficacy of a policy toolkit for U.S. school faculty, school nurses, health educators, and administrators as a stand-alone product or in tandem with brief technical assistance.

"School nurses can use SunWise materials to teach in the classroom and advocate for sun protection policies on the schoolyard."

Conclusion
New interventions are needed to increase adoption of sun protection policies in schools where children can receive sunburns during recess and afterschool activities. Multilevel approaches to institute new school policies led by parents, principals, school nurses, and health educators will create the groundswell and provide the impetus for state education and health officials to develop new policies. Materials and interventions, such as policy toolkits or brief counseling, must be easy to implement and flexibly interwoven into school hours. In this pilot study, the enhanced SW Policy/TA intervention was widely accepted by school nurses and educators and appeared to lead to more new sun protection policies than the control and SW Policy toolkit–only conditions. Further research in more schools with direction is vital in combating the epidemic of skin cancer that begins with adverse exposures in young school-age children.

	Footnotes

 
Authors’ Note: This study was funded by a generous donation from Curt and Shonda Schilling, support from the SHADE Foundation of America, and a grant from the National Cancer Institute (1K05 CA124415-01A1).

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The Journal of School Nursing, Vol. 24, No. 4, 215-221 (2008)
DOI: 10.1177/1059840508319627


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