Society of Behavioral Medicine Position Statement: promote sun-safety policies and practices for youth in educational, childcare, and recreational settings

Abstract

Youth should be allowed and encouraged to engage in sun-safe behaviors in educational, childcare, and recreational settings, including use of sunscreen, wide-brimmed hats, other sun-protective clothing, and shade.

Implications.

Goal: The goal of this position statement is to encourage policies that minimize barriers to and promote sun safety among youth in settings where they spend much of their time.

Practice: Adopt evidence-based practices that educate, allow, and encourage youth to engage in sun-safe behaviors including using sunscreen, wide-brimmed hats and other sun-protective clothing, as well as seeking shade.

Policy: Initiate and support evidence-based policies and funding for sun-safety practice, education, and research in educational, childcare, and recreational settings (e.g., the Reducing Cancer and Excessive UV Exposure in Children Act).

Research: Augment the evidence base by conducting research on implementation and impact of sun-safe policies among youth in educational, childcare, and recreational settings.

THE PROBLEM

Skin cancer is the most common cancer in the USA. Melanoma, the deadliest form of skin cancer, is the second leading cause of cancer in adolescents and young adults aged 15–29 years [1]. The incidence rate of melanoma has been rising in the past four decades [1]. Excessive exposure to ultraviolet (UV) radiation is the major cause of skin cancer. UV exposure refers to sun exposure including both intentional outdoor tanning and incidental (e.g., during exercise) sun exposure as well as indoor tanning (e.g., use of tanning beds). Limiting UV exposure among youth could help prevent the development of these highly preventable cancers later in life [2]. In particular, blistering sunburns occurring in childhood and adolescence increase the lifetime risk for both melanoma and keratinocyte (basal and squamous cell) skin cancers [2]. Thus, it is important that youth engage in effective sun protection behaviors, including regular use of sunscreen with a sun protection factor of at least 30 (Figure 1), wearing wide-brimmed hats, other protective clothing, and sunglasses, as well as seeking shade, especially from 10 am to 4 pm when UV radiation is at its strongest, and avoiding indoor tanning [2]. Such behaviors prevent sunburns and can help reduce the risk of skin cancer [2]. Unfortunately, in any given year, over half of youth in the USA get sunburned, and less than a quarter routinely engage in recommended sun protection behaviors, highlighting the need to prioritize youth sun safety in public health efforts [2].

Fig 1.

Mother protecting her son with sunscreen.

POLICY GAPS

Youth spend a significant portion of their day at school, daycare, and/or camp throughout the year. Much of the time spent playing and learning outside is during peak hours of UV radiation strength. Due to federal, state, and local regulations, youth and their parents currently experience unnecessary barriers to regular use of sun protection such as sunscreen and hats in educational, childcare, and recreational settings. One barrier is that sunscreen is defined as an over-the-counter (OTC) medication that is regulated by the Food and Drug Administration [3]. This OTC designation (rather than cosmetic as in some countries) makes the use of sunscreen in educational, childcare, and recreational settings difficult, as youth may be required to bring a prescription or doctor’s note granting permission for its use. Anecdotally, a second barrier is that hats and other head and/or face protective clothing have been banned from schools due to dress codes and security (e.g., gang) concerns. These restrictions may lead to excessive sun exposure among youth due to lack of adequate protection. Additional barriers are the dearth of policies related to the provision of shade and sun-safety education to youth and their families [4]. Such gaps have been addressed extensively by Buller et al. [5–9]. Other potential barriers to sun safety in educational, childcare, and recreational settings may relate to prevailing myths and misunderstandings (e.g., unprotected UV exposure is required for vitamin D production, base tans prior to sunny vacations reduce the risk of skin damage) among youth, parents, other caregivers, educators, and legislators [10].

POTENTIAL SOLUTIONS

In view of growing concern over increased melanoma rates and high amounts of UV radiation exposure among youth, there is a need for new legislation to address the aforementioned policy gaps to promote sun safety among youth in educational, childcare, and recreational settings. According to the School Health Policies and Practices Study, only about 20% of school districts provided resources for school staff to implement sun-safety policies in 2016 [4]. One initiative launched by the American Society of Dermatologic Surgery Association (ASDSA) to address this policy gap is SUNucate [11]. SUNucate focuses on removing barriers to the use of sun-protective practices and raising awareness of the need for sun safety among youth. The main emphasis of SUNucate has been crafting and influencing legislation that promotes the use of sun protection such as sunscreen and protective clothing in schools and camps. SUNucate created a model bill, the Reducing Cancer and Excessive UV Exposure in Children Act [12], based on legislation first passed in California, Texas, and Oregon, that would ensure access to sunscreen and protective clothing such as hats in schools and camps without the need for a physician’s note. Personnel can be permitted to assist youth in applying sunscreen if necessary. Although it is an optional feature of the model bill, SUNucate also encourages schools and camps to raise awareness via education about skin cancer prevention and sun safety. The ASDSA reports that 23 states have passed SUNucate thus far, with additional states planning to propose bills this year. Position statements from the ASDSA, the American Academy of Dermatology Association, and the American Medical Association have focused primarily on sunscreen in schools and summer camps [13–15]. In addition to school and camp settings mentioned in the SUNucate model bill, daycare facilities are also common settings for young children to be exposed to UV. Along with the sun-safety strategies mentioned in the SUNucate model bill, shade (such as that provided by trees, awnings, or shade sails) [2] can play an important role in protecting youth in childcare and educational settings (e.g., playgrounds, dining areas, field days and/or trips, waiting for busses, summer camps). Some of these policy changes may be more challenging and/or costly than others, but any one of them could help protect youth from sunburns and skin cancer [2]. The ASDSA reports that federal recognition of SUNucate is being considered by Congress, but jurisdiction would remain with individual states. The current position statement does not address indoor tanning (an established melanoma risk factor) among youth. Indoor tanning has been addressed in several prior statements, including one by the Society of Behavioral Medicine (SBM) [16] in favor of a ban for minors. Indoor tanning bans for minors are becoming increasingly common across the USA and globally [17].

Guidelines for policy implementation are beyond the scope of the current statement; however, members of the SBM have been at the forefront of research focused on implementation of sun safety in educational, childcare, and recreational settings (e.g., [5–9, 18]). Australia’s SunSmart program and the U.S. Guide to Community Preventive Services provide evidence and recommendations for adequate resources, infrastructure, message reinforcement, and program duration as part of effective sun-safety campaigns including policy and education in settings such as childcare centers and schools [19]. Australia and the UK have also instituted accreditation programs to reward sun-safe schools for activities related to policy creation, outdoor scheduling, parent, teacher, and student communication, and encouraging the use of protective clothing [20,21]. Estimates based on SunSmart suggest that if such a multicomponent community-wide skin cancer prevention program including mass-media campaigns, setting-specific programs, clinician education, resource development and dissemination, and community-level capacity building was implemented in the USA, 230,000 new melanoma cases and $2.7 billion in initial-year treatment costs could be averted over a 10-year period [22].

RECOMMENDATIONS

• Legislators and policymakers

  • Initiate and support policies (e.g., the Reducing Cancer and Excessive UV Exposure in Children Act) that allow and encourage youth to engage in sun-safe behaviors in educational, childcare, and recreational settings, including the use of sunscreen, wide-brimmed hats, and other sun-protective clothing.

  • Encourage personnel in educational, childcare, and recreational settings to provide evidence-based education to youth about the risks of excessive UV exposure.

  • Support funding for the development or improvement of shaded areas for youth in educational, childcare, and recreational settings.

  • Support funding of research to evaluate the effects of legislative changes on youth’s sun-safety beliefs, practices, and other outcomes (e.g., sunburns).

• Educational, childcare, and recreational settings and personnel

  • Allow and encourage youth to engage in sun-safe behaviors, including use of sunscreen (without the need for a doctor’s note or prescription), wide-brimmed hats, and other sun-protective clothing.

  • As needed, establish setting-specific guidelines [23], procedures, and/or personnel training regarding sun-safety practices (e.g., teacher application of sunscreen on young children) and communication with relevant stakeholders such as parents and health care providers.

  • Provide funding for the development and improvement of shaded areas for youth education and recreation, particularly during times of high UV exposure. Use the Centers for Disease Control and Prevention’s guide “Shade Planning for America’s Schools” as a resource [24].

  • Provide evidence-based education to youth and families about the risks of excessive UV exposure and the importance of sun-safe behaviors.

• Parents

  • Discuss sun safety and act as sun-safety role models for youth.

  • Provide sunscreen, wide-brimmed hats, and other protective clothing to youth.

  • Encourage youth to engage in sun-safe behaviors including using sunscreen, wide-brimmed hats, and other sun-protective clothing, and seeking shade when possible.

  • Advocate for educational, childcare, and recreational settings to allow and encourage youth to engage in sun-safe behaviors.

• Health care providers

  • Provide evidence-based education to parents and their children about the risks of excessive UV exposure among youth and the importance of engaging in sun-safe behaviors. Utilize educational, childcare, and recreational physicals to remind parents and children of the importance of sun-safe behaviors in these settings.

• Researchers

  • Conduct research to examine the dissemination and implementation of policies that promote sun-safety among youth in educational, childcare, and recreational settings.

  • Conduct research to examine the impact of legislative and policy changes on sun-safety knowledge, attitudes, beliefs, behaviors, and other outcomes (e.g., sunburns) among youth in educational, childcare (e.g., before- and after-care), and recreational settings (e.g., camps).

  • Conduct research to augment the evidence base pertaining to effective intervention strategies for improving and sustaining youth and family sun safety.

Position Statement endorsed by: SUNucate (the American Society of Dermatologic Surgery Association), the American Academy of Dermatology Association, National Council on Skin Cancer Prevention, and Melanoma Action Coalition (Fig. 2).

Fig 2.

Position Statement endorsed by: SUNucate (the American Society of Dermatologic Surgery Association), the American Academy of Dermatology Association, National Council on Skin Cancer Prevention, and Melanoma Action Coalition.

Funding

This work was supported by the National Cancer Institute (P30CA072720).

Compliance with Ethical Standards

Conflict of Interest: The authors declare that they have no conflicts of interest.

Human Rights/Welfare of Animals: This article does not involve animal or human participants, and informed consent was therefore not required.