Abstract
Importance
Exposure to the sun’s UV radiation is a leading cause of skin cancer. Positive attitudes and beliefs about sun safety behavior, which would make sun protective behavior more likely, could be promoted and supported by school policies and practices.
Objective
To identify school characteristics associated with having adopted practices that promote sun safety.
Design, Setting, and Participants
School-level data from the February 3 to July 23, 2014, School Health Policies and Practices Study’s Healthy and Safe School Environment questionnaire were analyzed. The School Health Policies and Practices Study uses a 2-stage sampling design to select a nationally representative sample of schools. All public, state-administered, Catholic, and non-Catholic private schools with any of the grades from kindergarten through 12 were eligible for inclusion. All analyses were conducted using weighted data.
Main Outcomes and Measures
Prevalence of sun safety practices.
Results
In a nationally representative sample of 828 US schools, representatives of 577 schools (69.7%) responded. Overall, sun safety practices were not common among schools. The most frequent practice was having teachers allow time for students to apply sunscreen at school (47.6%; 95% CI, 42.4%-52.9%). Few schools made sunscreen available for students to use (13.3%; 95% CI, 10.2%-17.0%), almost always or always scheduled outdoor activities to avoid times when the sun was at peak intensity (15.0%; 95% CI, 11.4%-19.6%), or asked parents to ensure that students applied sunscreen before school (16.4%; 95% CI, 12.9%-20.6%). High schools were less likely than elementary schools and middle schools to adopt several practices: for instance, 37.5% of high schools (95% CI, 29.7%-46.0%), 51.6% of middle schools (95% CI, 43.3%-59.7%), and 49.5% of elementary schools (95% CI, 42.0%-57.0%) had teachers allow time for students to apply sunscreen at school, and 11.8% of high schools (95% CI, 7.7%-17.5%), 18.2% of middle schools (95% CI, 13.3%-24.4%), and 14.7% of elementary schools (95% CI, 9.6%-21.8%) almost always or always scheduled outdoor activities to avoid times when the sun was at peak intensity. Other school characteristics were either not significantly associated with the adoption of any of the sun safety school practices studied (eg, metropolitan status) or were inconsistently associated with such policies and practices (eg, region, percentage of students eligible for free or reduced-price lunch, and school enrollment).
Conclusions and Relevance
School practices that could protect children and adolescents from sun exposure and that could change norms about sun safety are not common. Interventions aimed at increasing the adoption of sun safety practices among schools are needed regardless of the level, location, size, and poverty concentration of the school. Such practices would cost little to implement and would support other messages targeted toward children, adolescents, adults, and parents, with an aim to reduce skin cancer morbidity and mortality.
This cross-sectional survey study used data from the School Health Policies and Practices Study to identify school characteristics associated with having adopted practices that promote sun safety.
Key Points
Question
What school characteristics are associated with having adopted school practices that promote sun safety?
Findings
Nationally representative, cross-sectional survey data from the 2014 School Health Policies and Practices Study show that, overall, sun safety practices were uncommon among schools and that high schools were less likely than elementary and middle schools to adopt several practices. Other school characteristics were either not significantly associated with the adoption of any of the sun safety school practices studied (eg, metropolitan status) or were inconsistently associated with such policies and practices (eg, region, percentage of students eligible for free or reduced-price lunch, and school enrollment).
Meaning
Increasing the adoption of sun safety practices among schools is needed regardless of the level, location, size, and poverty concentration of the school.
Introduction
Exposure to the sun’s UV radiation is a leading cause of skin cancer. Different patterns of exposure to UV radiation from the sun increase the risk for different types of skin cancer. In particular, data suggest that intermittent, recreational exposure (vs chronic exposure, as with outdoor workers) more often leads to sunburn. In addition, the risk of melanoma increases with the number of sunburns experienced. In the United States, sunburn prevalence is high, particularly among the non-Hispanic white population, which is most at risk for melanoma. In 2015, more than half (55.8%) of high school students overall and 72.5% of white non-Hispanic high school students had experienced 1 or more sunburns during the past 12 months.
Limiting exposure to UV radiation from the sun (as well as from artificial sources) is recommended to reduce the risk of skin cancer. Recommended sun safety strategies vary somewhat across government and nongovernment institutions but generally include using broad-spectrum sunscreen, avoiding outdoor activities during midday, seeking shade, and using protective clothing (eg, long-sleeved shirts and long pants), hats (particularly wide-brimmed hats that shade the face, ears, and neck), and sunglasses. Despite these recommendations, most adolescents—and adults who are role models for children and adolescents—fail to engage in behaviors that protect them from the sun.
It is not known how many schools keep students inside during the school day (eg, do not have outdoor recess or physical education classes or do not allow students outside during lunch) and may, therefore, deem sun safety practices during the school day to be unnecessary. A study conducted during 1992-1994 suggests that children and adolescents spend about 10% of their day outdoors. However, for elementary schools, a 1998 study suggests that schools schedule outdoor activities most often between 10 am and 2 pm, while another study showed that, at all school levels, after-school care programs, physical activity clubs, and intramural and intermural sports that are held outside (eg, walking or running, flag football, soccer, baseball or softball, football, and track and field) are common. Furthermore, the desire for many adolescents to tan suggests a lack of awareness of sun protection or a lack of desire to protect their skin from the sun.
Positive attitudes and beliefs about sun safety behavior, which would make such behavior more likely, could be promoted and supported by school policies and practices According to the Centers for Disease Control and Prevention’s (CDC’s) Guidelines for School Programs to Prevent Skin Cancer, “School staff can play a major role in protecting children and adolescents from UV exposure and the future development of skin cancer by instituting policies, environmental changes, and educational programs that can reduce skin cancer risks among young persons.”(p1) Such policies and practices can include, for example, teaching students about sun safety, involving family members so that caregivers adopt sun protection behaviors and influence students’ behaviors, providing shade, scheduling activities during hours that UV radiation is lower, and allowing students to wear sun-protective clothing and use sunscreen at school without a prescription. The goal of this coordinated approach is to ensure that the importance of sun safety is communicated, skills for being safer in the sun are taught, and the school environment supports sun safety. Perhaps such a comprehensive approach would also encourage families and students to adopt sun safety practices outside of the school setting by changing social norms.
Although a small proportion of school districts and schools have adopted policies to address sun safety, most have not, even though it is common for students to be outside during the midday hours or after school when the sun is still at peak intensity. Thus, the purpose of this study was to analyze data from a nationally representative sample of schools in the United States to identify school characteristics associated with having adopted practices that promote sun safety. More specifically, this study examined whether school activities were scheduled to avoid the sun’s peak intensity, whether use of sunscreen was promoted in a variety of ways, whether use of protective clothing and sunglasses was encouraged, and whether these policies and practices varied by school level, region, metropolitan status, school enrollment, and poverty concentration as measured by the percentage of students eligible for free or reduced-price lunch. The findings can be used to inform public health outreach aimed at improving school policies and practices about sun safety.
Methods
We analyzed school-level data from the 2014 School Health Policies and Practices Study’s (SHPPS’s) Healthy and Safe School Environment questionnaire. The SHPPS is a national survey conducted periodically by the CDC to assess school health policies and practices at the state, district, school, and classroom levels, as well as the characteristics of school health identified in the Whole School, Whole Community, Whole Child model. The 2014 SHPPS was conducted from February 3 through July 23, 2014, and was reviewed by the Institutional Review Boards at both the CDC and ICF International (contractor who conducted fieldwork for SHPPS 2014) and determined to be exempt. Participant consent was assumed with completion of the interview.
Sample and Survey Administration
A detailed description of the 2014 SHPPS methods has been published previously. Briefly, a 2-stage sampling design was used to select a nationally representative sample of schools. All public, state-administered, Catholic, and non-Catholic private schools with any of the grades from kindergarten through 12 were eligible for inclusion. Alternative schools, schools that provided services to a population of students who were also provided services at another eligible school, schools run by the Department of Defense or Bureau of Indian Education, and schools with fewer than 30 students were excluded, leaving 828 schools in the sample. The Healthy and Safe School Environment questionnaire was composed of 3 modules that grouped related items so schools could identify a respondent who was responsible for or most knowledgeable about the items covered in that module. For the module containing questions about sun safety, the school response rate was 70% (n = 577). Of the responding schools, 190 were high schools, 187 were middle schools, and 200 were elementary schools. Approximately 90% of the data were collected via computer-assisted, in-person interviews; the remaining 10% of respondents used paper questionnaires.
Study Measures
The 2014 SHPPS asked the following questions about practices that promote sun safety: (1) “During the past 12 months, how often were outdoor activities during the school day scheduled to avoid times when the sun was at peak intensity?” (2) “Are parents asked to ensure students apply sunscreen before school?” (3) “Do teachers allow time for students to apply sunscreen at school?” (4) “Do teachers remind students to apply sunscreen before going outside at school?” (5) “Does [the school] make sunscreen available for students to use?” (6) “Does [the school] encourage students to wear protective clothing, such as long sleeve shirts or long pants, when in the sun during the school day?” (7) “Does [the school] encourage students to wear hats or visors when in the sun during the school day?” and (8) “Does [the school] encourage students to wear sunglasses when in the sun during the school day?” (Response options for question 1 were never, rarely, sometimes, almost always or always, and response options for questions 2-8 were yes and no.)
The 2014 SHPPS data were linked with extant data from the Market Data Retrieval database (now MCH Strategic Data). The Market Data Retrieval database is updated annually and contains information about individual schools. To examine whether school location, school size, and concentrated poverty might be associated with sun safety policies and practices, the following Market Data Retrieval variables were included in this analysis: region (West, Midwest, Northeast, and South), metropolitan status (city, suburb, town, or rural), number of students enrolled in the school (range, 30-3948; mean, 479.4 [95% CI, 442.3-516.5]), and the percentage of students eligible for free or reduced-price lunch (range, 0%-100%; mean, 50.4% [95% CI, 46.5%-54.2%]).
Statistical Analysis
Data were weighted to produce national estimates and to adjust for nonresponse. Analyses were conducted using SUDAAN statistical software (Research Triangle Institute) to account for weighted data and the complex sampling design. We used χ2 tests to identify significant associations between categorical school characteristics and sun safety practices. When χ2 findings were significant, 2-tailed t tests were used to identify significant pairwise differences in school characteristics. Univariate logistic regression analyses were used for the 2 continuous independent variables, school enrollment and percentage of students eligible for free or reduced-price lunch. P < .05 was considered statistically significant. All analyses were conducted using weighted data.
Results
Overall, sun safety practices were not common among schools (Table 1). The most frequent practice was for teachers to allow time for students to apply sunscreen at school (47.6%; 95% CI, 42.4%-52.9%). Few schools made sunscreen available for students to use (13.3%; 95% CI, 10.2%-17.0%), almost always or always scheduled outdoor activities to avoid times when the sun was at peak intensity (15.0%; 95% CI, 11.4%-19.6%), or asked parents to ensure students applied sunscreen before school (16.4%; 95% CI, 12.9%-20.6%).
Table 1. Sun Safety Practices Among US Schools, School Health Policies and Practices Study, 2014a.
| Practice | Schools, % (95% CI) |
|---|---|
| Outdoor activities almost always or always scheduled to avoid times when the sun was at peak intensityb | 15.0 (11.4-19.6) |
| Parents asked to ensure students applied sunscreen before school | 16.4 (12.9-20.6) |
| Teachers allowed time for students to apply sunscreen at school | 47.6 (42.4-52.9) |
| Teachers reminded students to apply sunscreen before going outside at school | 28.2 (24.0-32.9) |
| Sunscreen made available for students to use | 13.3 (10.2-17.0) |
| Students encouraged to wear protective clothing (eg, long-sleeved shirts or long pants) when in the sun during the school day | 30.4 (25.8-35.4) |
| Students encouraged to wear hats or visors when in the sun during the school day | 33.1 (28.4-38.2) |
| Students encouraged to wear sunglasses when in the sun during the school day | 20.7 (16.7-25.4) |
Unweighted N = 577. Percentages and 95% CIs were calculated using weighted data.
During the 12 months before the study.
High schools were less likely than both middle schools and elementary schools to ask parents to ensure students apply sunscreen before school (4.2%; 95% CI, 2.0%-8.7% vs 16.9%; 95% CI, 11.6%-23.9% and 20.9%; 95% CI, 15.3%-28.0%), to have teachers allow time for students to apply sunscreen at school (37.5%; 95% CI, 29.7%-46.0% vs 51.6%; 95% CI, 43.3%-59.7% and 49.5%; 95% CI, 42.0%-57.0%), and to encourage students to wear hats or visors when in the sun during the school day (22.4%; 95% CI, 16.8%-29.3% vs 37.3%; 95% CI, 30.1%-45.1% and 35.0%; 95% CI, 28.3%-42.4%) (Table 2 and Table 3). High schools were also less likely than elementary schools to encourage students to wear protective clothing when in the sun during the school day (22.2%; 95% CI, 16.7%-28.8% vs 33.4%; 95% CI, 26.8%-40.8%).
Table 2. Presence of Sun Safety Practices by School Characteristics, School Health Policies and Practices Study, 2014a.
| Characteristic | Schools, % (95% CI) | |||
|---|---|---|---|---|
| Outdoor Activities Almost Always or Always Scheduled to Avoid Times When the Sun Was at Peak Intensityb | Teachers Allowed Time for Students to Apply Sunscreen at School | Teachers Reminded Students to Apply Sunscreen Before Going Outside at School | Sunscreen Made Available for Students to Use | |
| School level | ||||
| Elementary | 14.7 (9.6-21.8) | 49.5 (42.0-57.0) | 27.2 (21.2-34.2) | 11.9 (8.0-17.4) |
| Middle | 18.2 (13.3-24.4) | 51.6 (43.3-59.7) | 30.3 (23.6-38.0) | 12.9 (8.7-18.8) |
| High | 11.8 (7.7-17.5) | 37.5 (29.7-46.0) | 28.2 (21.4-36.1) | 17.2 (11.6-24.7) |
| χ2 P value; significant pairwise comparisonsc | .17 | .03; High < middle, elementary |
.79 | .42 |
| Region | ||||
| Northeast | 6.4 (3.0-13.0) | 49.7 (37.2-62.2) | 37.0 (26.1-49.5) | 16.1 (9.8-25.5) |
| Midwest | 8.4 (4.5-15.0) | 43.3 (33.4-53.7) | 24.7 (17.1-34.1) | 11.0 (6.6-17.7) |
| South | 26.6 (19.3-35.4) | 44.7 (35.6-54.2) | 24.0 (17.8-31.5) | 10.1 (5.8-16.9) |
| West | 14.0 (7.1-25.6) | 54.0 (43.6-64.1) | 30.5 (22.4-40.0) | 17.4 (10.6-27.2) |
| χ2 P value; significant pairwise comparisons | .002; South > Northeast, Midwest, West | .46 | .24 | .35 |
| Metropolitan status | ||||
| City | 15.9 (9.4-25.7) | 43.8 (34.8-53.2) | 26.9 (19.8-35.5) | 14.5 (9.1-22.3) |
| Suburb | 16.1 (9.6-25.8) | 53.6 (43.3-63.5) | 33.0 (25.2-41.8) | 13.0 (8.2-20.1) |
| Town | 10.8 (4.2-25.1) | 38.7 (24.3-55.3) | 18.1 (10.6-29.4) | 14.3 (6.6-28.2) |
| Rural | 14.6 (9.2-22.4) | 49.5 (40.4-58.7) | 28.9 (20.8-38.6) | 11.6 (6.7-19.3) |
| χ2 P value | .86 | .36 | .17 | .93 |
| School enrollment, No. | ||||
| 30-279 (Smallest tertile) | 10.8 (6.6-17.2) | 52.6 (43.5-61.6) | 30.4 (22.6-39.4) | 14.9 (9.5-22.7) |
| 280-517 (Middle tertile) | 13.0 (7.9-20.6) | 46.2 (37.5-55.2) | 26.3 (19.5-34.4) | 10.1 (6.1-16.3) |
| 518-3948 (Largest tertile) | 21.3 (14.5-30.1) | 43.9 (35.2-53.1) | 27.2 (20.9-34.4) | 14.5 (9.8-20.8) |
| Logistic regression P value (β)d | .01 (β = .001) | .04 (β = −.000) | .25 (β = −.000) | .98 (β = −.000) |
| Percent eligible for free or reduced-price lunch | ||||
| 0%-32% | 16.2 (10.2-24.8) | 52.0 (41.7-62.1) | 35.8 (26.9-45.8) | 17.6 (10.7-27.6) |
| 33%-65% | 14.1 (8.3-22.9) | 49.2 (40.2-58.4) | 29.8 (22.0-39.0) | 12.7 (8.0-19.7) |
| 66%-100% | 23.2 (15.3-33.4) | 37.6 (27.7-48.8) | 20.2 (12.8-30.4) | 7.2 (3.5-14.2) |
| Logistic regression P value (β) | .16 (β = .008) | .01 (β = −.012) | .01 (β = −.013) | .03 (β = −.017) |
Unweighted N = 577. Percentages and 95% CIs were calculated using weighted data.
During the 12 months before the study.
P = χ2 P value. When χ2 P value was <.05, t tests were used to identify significant pairwise difference (< or > indicates significant pairwise difference [P < .05]).
Logistic regression with independent variable as continuous. A negative β indicates a negative relationship. Categorical descriptive data are presented for context only.
Table 3. Encouragement of Sun Safety Practices by School Characteristics, School Health Policies and Practices Study, 2014a.
| Characteristic | Schools, % (95% CI) | |||
|---|---|---|---|---|
| Parents Asked to Ensure Students Apply Sunscreen Before School | Students Encouraged to Wear Protective Clothingb When in the Sun During the School Day | Students Encouraged to Wear Hats or Visors When in the Sun During the School Day | Students Encouraged to Wear Sunglasses When in the Sun During the School Day | |
| School level | ||||
| Elementary | 20.9 (15.3-28.0) | 33.4 (26.8-40.8) | 35.0 (28.3-42.4) | 22.7 (16.7-30.1) |
| Middle | 16.9 (11.6-23.9) | 30.8 (23.9-38.6) | 37.3 (30.1-45.1) | 17.5 (12.7-23.6) |
| High | 4.2 (2.0-8.7) | 22.2 (16.7-28.8) | 22.4 (16.8-29.3) | 19.8 (14.8-26.0) |
| χ2 P value; significant pairwise comparisonsc | <.001; High < middle, elementary |
.04; High < elementary |
.003; High < middle, elementary |
.41 |
| Region | ||||
| Northeast | 23.4 (13.9-36.6) | 34.0 (23.5-46.4) | 35.0 (25.6-45.7) | 24.1 (16.3-34.1) |
| Midwest | 14.2 (8.5-22.8) | 19.3 (12.7-28.1) | 21.0 (13.8-30.6) | 14.6 (8.0-25.2) |
| South | 15.8 (10.5-23.0) | 28.0 (21.6-35.3) | 32.4 (25.5-40.1) | 19.4 (13.8-26.6) |
| West | 14.2 (8.5-22.8) | 41.9 (31.5-53.1) | 44.7 (33.3-56.6) | 25.8 (16.8-37.5) |
| χ2 P value; significant pairwise comparisons | .56 | .01; Midwest < Northeast, West; South < West |
.02; Midwest < Northeast, South, West |
.31 |
| Metropolitan status | ||||
| City | 14.4 (8.8-22.7) | 30.6 (23.5-38.6) | 34.8 (26.1-44.6) | 20.5 (13.5-29.8) |
| Suburb | 23.1 (15.7-32.8) | 30.3 (21.7-40.6) | 34.0 (25.1-44.3) | 18.6 (12.3-27.2) |
| Town | 8.7 (4.0-17.6) | 23.2 (12.5-38.9) | 19.6 (10.8-33.0) | 18.1 (8.3-35.0) |
| Rural | 14.8 (9.5-22.3) | 33.4 (24.5-43.6) | 35.8 (27.7-44.9) | 24.3 (17.2-33.3) |
| χ2 P value | .09 | .69 | .14 | .74 |
| School enrollment, No. | ||||
| 30-279 (Smallest tertile) | 19.3 (13.1-27.4) | 27.1 (19.8-36.0) | 32.1 (24.1-41.2) | 20.7 (14.5-28.6) |
| 280-517 (Middle tertile) | 13.8 (8.9-21.0) | 28.7 (21.8-36.8) | 28.9 (21.7-37.3) | 21.3 (14.9-29.4) |
| 518-3948 (Largest tertile) | 15.8 (10.7-22.7) | 34.9 (27.2-43.6) | 38.1 (30.0-46.8) | 19.9 (13.8-27.7) |
| Logistic regression P value (β)d | .12 (β = −.000) | .35 (β = .000) | .52 (β = .000) | .74 (β = −.000) |
| Percent eligible for free or reduced-price lunch | ||||
| 0%-32% | 23.5 (15.9-33.4) | 35.2 (25.5-46.2) | 39.9 (30.1-50.5) | 20.2 (13.5-29.1) |
| 33%-65% | 14.5 (8.4-23.9) | 28.5 (21.4-36.8) | 33.2 (25.7-41.5) | 25.2 (18.0-34.1) |
| 66%-100% | 12.6 (6.8-22.0) | 32.3 (22.8-43.5) | 29.6 (20.8-40.2) | 19.6 (2.7-29.1) |
| Logistic regression P value (β) | .01 (β = −.016) | .65 (β = −.002) | .08 (β = −.008) | .63 (β = −.002) |
Unweighted N = 577. Percentages and 95% CIs were calculated using weighted data.
Such as long-sleeved shirts or long pants.
P = χ2 P value. When χ2 P value was <.05, t tests were used to identify significant pairwise difference (< or > indicates significant pairwise difference [P < .05]).
Logistic regression with independent variable as continuous. A negative β indicates a negative relationship. Categorical descriptive data are presented for context only.
Several sun safety practices varied by region. Schools in the South (26.6%; 95% CI, 19.3%-35.4%) were more likely than schools in the Northeast (6.4%; 95% CI, 3.0%-13.0%), Midwest (8.4%; 95% CI, 4.5%-15.0%), and West (14.0%; 95% CI, 7.1%-25.6%) to almost always or always schedule outdoor activities to avoid times when the sun was at peak intensity (Table 2). In contrast, schools in the West (41.9%; 95% CI, 31.5%-53.1%) were more likely than schools in the South (28.0%; 95% CI, 21.6%-35.3%) and Midwest (19.3%; 95% CI, 12.7%-28.1%) to encourage students to wear protective clothing when in the sun during the school day (Table 3). Also, schools in the Northeast (34.0%; 95% CI, 23.5%-46.4%) were more likely than schools in the Midwest (19.3%; 95% CI, 12.7%-28.1%) to encourage students to wear protective clothing when in the sun during the school day. Schools in the West (44.7%; 95% CI, 33.3%-56.6%), Northeast (35.0%; 95% CI, 25.6%-45.7%), and South (32.4%; 95% CI, 25.5%-40.1%) were more likely than schools in the Midwest (21.0%; 95% CI, 13.8%-30.6%) to encourage students to wear hats or visors when in the sun during the school day.
None of the sun safety policies or practices was statistically significantly associated with metropolitan status. School enrollment was positively associated with almost always or always scheduling outdoor activities to avoid times when the sun was at peak intensity. As school enrollment increased, the likelihood of scheduling outdoor activities to avoid times when the sun was at peak intensity also increased (smallest tertile [30-279 students], 10.8%; 95% CI, 6.6%-17.2%; middle tertile [280-517], 13.0%; 95% CI, 7.9%-20.6%; and largest tertile [518-3948], 21.3%; 95% CI, 14.5%-30.1%) (Table 2). In contrast, school enrollment was negatively associated with teachers allowing time for students to apply sunscreen at school: larger schools were less likely than smaller schools to have teachers allow time for students to apply sunscreen at school (smallest tertile, 52.6%; 95% CI, 43.5%-61.6%; middle tertile, 46.2%; 95% CI, 37.5%-55.2%; and largest tertile, 43.9%; 95% CI, 35.2%-53.1%).
The percentage of students eligible for free or reduced-price lunch was negatively associated with parents being asked to ensure students apply sunscreen at school (0%-32% eligible, 23.5%; 95% CI, 15.9%-33.4%; 33%-65% eligible, 14.5%; 95% CI, 8.4%-23.9%; and 66%-100% eligible, 12.6%; 95% CI, 6.8%-22.0%), teachers allowing time for students to apply sunscreen at school (0%-32% eligible, 52.0%; 95% CI, 41.7%-62.1%; 33%-65% eligible, 49.2%; 95% CI, 40.2%-58.4%; and 66%-100% eligible, 37.6%; 95% CI, 27.7%-48.8%), teachers reminding students to apply sunscreen before going outside at school (0%-32% eligible, 35.8%; 95% CI, 26.9%-45.8%; 33%-65% eligible, 29.8%; 95% CI, 22.0%-39.0%; and 66%-100% eligible, 20.2%; 95% CI, 12.8%-30.4%), and making sunscreen available for students to use (0%-32% eligible, 17.6%; 95% CI, 10.7%-27.6%; 33%-65% eligible, 12.7%; 95% CI, 8.0%-19.7%; and 66%-100% eligible, 7.2%; 95% CI, 3.5%-14.2%%) (Tables 2 and 3).
Discussion
Our study found that, in 2014, most schools lacked practices that could protect children and adolescents from exposure to UV radiation while at school. These findings emerged in spite of both strong evidence that sun exposure can lead to skin cancer–associated morbidity and mortality and multiple calls for improvements in school programs (including policies) to prevent skin cancer. A few state legislatures have promulgated laws permitting the use of protective clothing or sunscreen without a prescription at school (eg, California, New York, Oregon, and Texas), but a review of the published literature suggests that little progress has been made since 2002 in the prevalence of school-level policies and practices.
It might not be surprising that high schools were less likely than both elementary schools and middle schools to ask parents to ensure that students apply sunscreen before school, to have teachers allow time for students to apply sunscreen at school, and to encourage students to wear hats or visors when in the sun during the school day and that high schools were less likely than elementary schools to encourage students to wear protective clothing when in the sun during the school day; however, sun safety practices are equally important for high school–aged youth. Adolescents and young adults are unlikely to engage in sun protection behaviors, perhaps because they are more often concerned about their appearance and intentionally spend time in the sun to get a tan. Indeed, recent data suggest that 7% of high school students used an indoor tanning device and 56% had a sunburn 1 or more times during the past 12 months. Children of all ages could benefit from reminders and supportive school policies and practices that encourage students to protect themselves from sun exposure. To that end, as respected members of the medical community, dermatologists could garner support for improved school policies and practices aimed at reducing sun exposure and its associated morbidity and mortality. Such advocacy would complement the US Preventive Services Task Force’s recommendation related to primary care physicians’ behavioral counseling about sun safety.
The CDC’s Guidelines for School Programs to Prevent Skin Cancer propose 7 guidelines that schools can use to reduce sun exposure and risk of skin cancer. These guidelines were written in the context of a coordinated school health program in which messages about specific health topics are integrated into all aspects of school health such as health education, school environment, physical education, health services, family involvement, and staff wellness and development. The SHPPS was not designed to evaluate the extent to which schools are implementing the guidelines, but its results offer glimpses at some elements within the guidelines. For example, in 63.4% of elementary schools, 59.4% of middle schools, and 77.1% of high schools, teachers taught about sun safety or skin cancer prevention as part of required instruction. Thus, it appears that many schools are teaching about sun safety, but this analysis suggests that far fewer schools have practices that support such instruction even though the practices examined here (with the exception of making sunscreen available) require minimal time and money to implement. Such practices would reinforce messages that students receive during classroom instruction and promote positive norms about sun protection practices.
The amount of UV radiation that reaches a specific area depends on factors such as latitude, day of the year, ozone, elevation above sea level, and cloud cover. The UV Index—the predicted strength of the UV radiation from the sun—takes these factors into account. A summary of the mean monthly UV Index across the continental United States shows that when schools are in session (typically September through May, but in some schools also August and June), the Midwest and Northeast have the lowest mean UV Index, while the southernmost states have the highest monthly mean UV Index. Our study showed that schools in the South were the most likely to always or almost always schedule outdoor activities to avoid times when the sun is at peak intensity, but the prevalence of other practices was not consistently higher in the South than in other regions, and overall, the prevalence of such practices was low. Furthermore, it is possible that schools’ scheduling of outdoor activities was about avoiding high temperatures rather than avoiding exposure to UV radiation. Further study could identify the barriers to practices that encourage sun safety behaviors.
Reynolds et al found that, in a study of school district sun safety policies in California and Colorado, district size was positively associated with the adoption of such policies. The SHPPS data suggest that larger schools were most likely to schedule activities to avoid times when the sun was at peak intensity but were also less likely for teachers to allow time for students to apply sunscreen at school. No other practices were associated with school size.
Several policies and practices were negatively associated with the percentage of students who were eligible for free or reduced-price lunch. Although these schools may have fewer resources overall, many of the practices that aim to protect students from sun exposure are of little to no cost, such as reminding students about wearing protective clothing or allowing time for sunscreen application. Providing sunscreen is a more costly endeavor and perhaps most important in lower-income schools, in which purchasing sunscreen would be a difficult expense for disenfranchised families.
Limitations
The results of this study should be considered in the context of several limitations. First, SHPPS data are cross-sectional. Causal associations between school characteristics and sun safety practices cannot be determined. Second, although SHPPS procedures were designed to have the most knowledgeable respondent complete a questionnaire or module, it is possible there was some under- or overreporting resulting from poor knowledge or social desirability on the part of the respondent. Finally, the SHPPS 2014 did not include questions about the presence of natural shade or manmade shade structures in outdoor areas.
Conclusions
Although skin cancer is the most common form of cancer in the United States, school practices that could protect children and adolescents from exposure to UV radiation from the sun while at school, and that could change norms about sun safety practices, are not common. The findings of our study show that high schools were less likely to adopt several sun safety practices even though high school students may be at particular risk for sun exposure because of their desire for a tan. Other school characteristics were either not significantly associated with the adoption of any of the sun safety school practices studied (ie, metropolitan status) or were inconsistently associated with such policies and practices (ie, region, percentage of students eligible for free or reduced-price lunch, and school enrollment). Interventions driven by the public health and medical community educating school leadership and policymakers about the importance of sun safety are needed regardless of level, location, size, and poverty concentration of the school. These efforts could be instrumental in increasing the adoption of sun safety practices among schools. Many such practices would cost little to implement and would support other messages targeted toward children, adolescents, adults, and parents, with an aim to reduce skin cancer morbidity and mortality.
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