In 2011 Cancer Council ACT (CCACT) was asked by the ACT Health Directorate to take action in secondary schools to help solve the problem of poor adolescent sun protection attitudes and declining sun protection behaviours.
Consistent with an evidence-based approach, CCACT commissioned a research project with the help and support of four secondary school nurses working across eight ACT government secondary schools. The aim of this research was to identify potentially effective and achievable strategies that may support an increase in positive sun protection behaviour amongst ACT secondary schools. The project had an emphasis on year 7 and 8 students, this is because it is believed that younger secondary students are more likely to wear a hat on a sunny day in summer compared to older students, this is due to a “flow on” effect from their primary school years where sun protection policies appear to be better implemented and enforced when compared to secondary schools.
The project was considered a ‘low risk’ project, with little to no chance of any physical or psychological harm to participants. The project was approved by both the ACT Health's Human Research Ethics Committee (ACTHREC) and survey sub-committee with the ACT Education and Training Directorate also reviewing and approving the project proposal.
6 of the 8 school principals that were approached also approved the research project and granted permission to proceed. A total of 6 schools participated in the project.
Australia has amongst the highest incidence and mortality rate of skin cancer in the world. Melanoma is the third most common cancer diagnosis overall for residents of the ACT, and it is the most common cancer diagnosis amongst Australian adolescents.
Unfortunately, simple and practical sun protection behaviour, like wearing a hat and applying sunscreen has declined over recent years amongst Canberra secondary school students (ASSAD 2008). And while there are many barriers to creating behavioural change amongst this group (e.g., peer pressure, body image and risky behaviour), Cancer Council ACT believes secondary school environments can still play an important role by actively making steps to minimise UV exposure amongst students and workers alike.
On a more positive note, the 2008 ASSAD findings have also confirmed the notion that less Canberra teenagers are reporting a preference for a suntan (consistant with national findings). So the good news is that there appears to be a drop in the number students that desire a tan, the bad news is that still too many students are reporting they are getting sunburnt over the summer period, ie they are not protecting themselves from the sun and as a result significantly increasing their long term risk of developing skin cancer, including melanoma.
A total of 534 students, 218 staff members and 417 parents and guardians from six ACT secondary schools completed surveys (an additional 7th school 'tested' the survey tools). The student sample for this project was drawn from Year 7 and 8 students to examine a possible “carry-over” effect from primary school sun protection policies. The hope is to identify how to retain these sun protection habits throughout at least the first few years of high school.
In addition 34 staff members and 31 students participated in school focus groups.
Staff members: The majority of staff members (over 80%) that participated in the project believed that secondary schools should play a stronger role in teaching/encouraging/promoting positive sun protection behaviour amongst this age setting. More specifically, close to 70% of staff surveyed, did not believe enough is being done to encourage good sun protection behaviour amongst year 7 and 8 students. Clearly more can be done when it comes to enforcing policies and giving student reminders etc. When asked whether or not their school had a sun protection policy, 50% of staff members were 'unsure', whilst 37% said yes- of these that answered 'yes' 1/3 had not ever read the policy. Only 38% of the staff members who answered 'yes' to having a policy in place believed it was actually implemented and enforced as written.
Whilst most staff members (43%) said that they were 'encouraged' to role model sun protection behaviours at their school, only 11% said that they were 'required' to do so. Just less than half of staff members (46%) responded that they were neither encouraged nor reminded to do this.
Most staff members (62%) did not think there was adequate shade provided at their school where students and staff members are likely to congregate
Year 7 and 8 students: When asked "how do you feel about protecting yourself from the sun when at school?" over half of the students responded that they "try to take care most of the time", whilst 30% suggested that they take care, if it's easy to do something about. Less than 20% suggested that they do not care about protecting themselves from the sun when at school.
Wearing sensible clothing and seeking out shade were the most common methods of sun protection. Overall, and not surprisingly, wearing a hat, came in low on the list. However, wearing a hat, rose to the third most common form of sun protection when the findings included a school with a 'hats on' policy in already in place (see below more about hats in secondary schools).
Approx only 1/3 of students surveyed believed that they protected themselves enough from the sun when at school.
With regard to being taught about sun protection/skin damage at school-findings were evenly split down the middle. Of the half that said 'yes' the vast majority of these (60%) said that they were taught in PE class. Whilst the majority of students that responded to whether or not they would like to learn more about sun protection depended on whether the education would be in the form of activities and would be engaging.
Interestingly, students were also asked "if you had the job of improving sun protection in your school, what would you do? in an open ended format. The most common things students said they would do is to improve hat wearing at their school, followed by increase shade (either through tree planting or shade structures) and making sunscreen more accessible.
Parents and guardians: Overall the majority of parents (60%) were "unsure" as to whether their child's school has a sun protection policy or not- this was not the case amongst parents of the school with a 'hats on' policy already in place in which close to 95% of parents were aware (yes).
The vast majority of parents (83%) believed that secondary schools should be playing a stronger role in teaching/encouraging/promoting positive sun protection behaviour.
When it came to selecting school initiatives that they would be willing to support, the 3 most common strategies that received the most support from parents were "students have easy access to sunscreen (81%), role modelling by teachers (73%) and strategies to increase shade (65%).
General recommendations moving forward
Overall, staff members, students and their parents communicated their support for sun protection education and strategies in their school. Creating more shade may be the most effective strategy that secondary schools can use to help protect students from excessive sun exposure. Other strategies identified as potentially effective include:
- developing a sun protection policy or plan;
- involving students in engaging educational activities in-class;
- making sunscreen more accessible to staff members and students;
- teachers and peers expected to model positive sun protection behaviours;
- implementing a “hats-on” policy amongst at least year 7 and 8 students, for at least some periods of the day;
- reschedule PE classes to take place during the morning period during Term 1 and 4; and
- implement a tree planting program to increase potential shade for future generations.
Hat wearing in ACT secondary schools- can it work?
Probably, well in some schools anyway, sometimes! When it came to recommending a ‘hats on’ policy for at least year 7 and 8 students- the findings suggest that approximately 50% of the staff surveyed would support/enforce hat wearing for certain parts of the day ie when students are required to participate in PE class. This was the fourth most supported Cancer Council recommended initiative by school staff.
With regard to student feedback, overall hat wearing is currently low on the list of sun protection behaviour amongst secondary schools students (coming in at 6 out of a possible 7). Of those students that said they did wear a 'hat' for some periods of the day- the vast majority were wearing a baseball style cap, which Cancer Council does not recommend for sun protection. However when we included one of the participating schools in the data set (a school that does enforce a ‘hats on’ policy amongst its secondary school students) we found that hat wearing shot to number 3, behind uniform and shade. This suggests that hat wearing can work in at least year 7 and 8 secondary school students.
Another interesting finding is how year 7 and 8 students generally feel about wearing a hat now that they are in middle school or high school. The majority of the students (71%) said that they would not mind wearing a hat for some school periods (47% at recess and lunch time, 24% for PE classes and school carnivals). Interestingly 30% of students said that they do not wear a hat but would do so IF all the students in their year had to, and another 15% of students agreed that they would like to wear a hat sometimes but don’t because nobody else in their year does.
It was comforting to learn, that over 90% of the students that currently attend a school with a ‘hats on’ policy said that they did not mind wearing hat during certain school periods.
Schools should also be aware that according to our findings, only a minority (under 10%) of the year 7 and 8 students surveyed made it clear that they would not wear a hat, even if other students in their year wore one.
These findings suggest that a ‘hats on’ policy may work in some ACT secondary schools amongst at least younger entry year levels (ie yr 7 and 8) due to a ‘carry over’ effect established during the primary school years. ACT secondary schools that are joined to primary school years or have a middle school component should consider implementing and enforcing a ‘hats on’ policy to maintain a positive culture around hat wearing in their school setting that has been established in their primary school setting. This may also reinforce the notion that wearing a hat is not just for younger children and babies, but a life long behaviour.
Schools that do choose to introduce a new ‘hats on’ policy may have to use some imagination. This may include using a staged approach, making hats compulsory only for PE and/or lunch time, or for Term 1 and 4 only, allowing students to wear their own hat from home (not a cap), designing a new school hat with student involvement and testing it out, perhaps consider not including your school crest on the hat or making your school hat reversible. Schools should also 'require' all school staff, including the PE staff to wear a hat (not cap) and to actively promote and support the new policy. Schools will also need to brief students and their parents during Term 4, ready for Term 1, about your school’s new ‘hats on’ policy- this may include working closer with your adjoining primary school so year 6 students are aware of what expectation there is once they enter the senior school regarding hats etc.
In sum, the research results suggest there are potentially effective strategies that ACT secondary schools can use to improve sun protection behaviours amongst students, and that the majority of the school community is likely to support their school in taking action. Specifically, developing and enforcing a sun protection policy, providing shade, making sunscreen more accessible at school, modelling, encouraging or enforcing hats and using engaging educational activities are the strategies that are most likely to bring about behavioural change in students. Staff members, students and parents were similar in their feelings and opinions about sun protection in schools, and each group identified potential barriers as well as ways to overcome them. It is encouraging to know that these secondary school students do care about sun protection: the majority trying to protect their skin most of the time and they appreciate what their teachers and schools do to help protect them.
The future of sun protection in secondary schools is bright, and ACT school communities should feel empowered to improve adolescent sun protection behaviour, reducing their risk of skin cancer later in life.