The Important Role of Schools in the Prevention of Skin Cancer

Sun exposure in childhood is an important risk factor for the future development of skin cancer. The risk of developing melanoma is strongly related to a history of sunburns (an indicator of intense UV radiation exposure) during childhood and adolescence.1 However, skin cancer risk can be greatly reduced if children and adolescents are protected from UV radiation, suggesting the importance of protecting young people from the sun beginning at an early age.1 Given the amount of time children spend in school settings, schools can play an important role in protecting children and adolescents from UV exposure and the future development of skin cancer.1,2 Skin cancer prevention can be addressed in schools through policy and environmental changes and educational programs.2 School-based efforts to change children’s knowledge, attitudes, and behaviors regarding sun protection can play a vital role in saving lives, improving quality of life, and reducing avoidable costs from the treatment of skin cancers. Acknowledging the critical role of schools, key strategies outlined in the Surgeon General’s Call to Action to Prevent Skin Cancer2 include increasing the availability of sun protection in educational settings and supporting the inclusion of sun protection in school policies, construction of school facilities, and school curricula. The Guide to Community Preventive Services (The Community Guide)3 specifically recommends interventions to prevent skin cancer in primary and middle schools as well as child care centers, based on strong evidence of their effectiveness in increasing sun-protective behaviors and decreasing UV exposure, sunburn incidence, and formation of new moles. Recommended interventions to promote sunprotective behaviors include educational interventions, supportive behavioral interventions, and environmental and policy changes.3 Educational and behavioral interventions include teaching children about sun safety and the effects of UV radiation. Environmental and policy changes include increasing the availability of sun protection (eg, sunscreen, sun-protective clothing), increasing the availability of shade, and implementing sunprotection policies (eg, clothing guidelines, restrictions on outdoor activities during peak sunlight hours).3 Despite these recommendations and evidence of their effectiveness in preventing skin cancer, findings of the Centers for Disease Control and Prevention4,5 reveal that the use of these policies and practices in schools throughout the United States remains low. The Centers for Disease Control and Prevention’s School Health Policies and Practices Study (SHPPS)6 is a national survey periodically conducted to assess school health policies and practices. The SHPPS collected data on policies and practices related to sun safety at the state and district levels in 2012, and on sun safety–related information at the school level in 2014.6 The SHPPS data from 20124 indicate that most states and school districts do not have policies in place to support skin cancer prevention, and most school districts neither recommend nor require sunsafety strategies for their students. At the state level, only 31% of states developed, revised, or assisted in developing model policies, policy guidance, or other materials; 32% of states distributed or provided such materials to district or school staff; 25% of states (and only 18% of school districts) provided funding for professional development or offered professional development on how to implement schoolwide policies and programs during the 2 years before the study; and 42% of states provided technical assistance to district or school staff during the 12 months before the study.4 Moreover, very few schools required and only 25% to 44% of schools recommended certain sun-safety strategies in schools,4 such as allowing students to apply sunscreen while at school, encouraging students to wear hats or visors when in the sun during the school day, encouraging students to wear protective clothing (eg, long sleeve shirts or long pants) when in the sun during the school day, encouraging students to wear sunglasses when in the sun during the school day, and scheduling outdoor activities to avoid times when the sun is at peak intensity during the school day. According to the 2014 school-level data (Table),5 almost half (48%) of schools allow students time to apply sunscreen at school, and 66% teach about sun safety or skin cancer prevention as part of required instruction. Other sun-safety practices are generally uncommon in US schools, representing missed opportunities for prevention. Previous research has found the most common reasons for not having a policy are lack of awareness of school leadership and organizational barriers at the school distrct.7 Many school principals have indicated their willingness to develop skin cancer prevention policies but were unaware of skin cancer as a health problem or the role they could play in prevention.7 Some schools have practices that may create barriers to sun safety for students. For example, some schools prohibit students from wearing hats or visors (8%) or sunglasses (7%) when in the sun during the school day (Table). In addition, school policies about over-the-counter drugs that prohibit the use of sunscreen or require application by a school nurse may also limit students’ ability to use sun protection.2 Previous research found that nearly half of schools required a physician prescription before staff could apply sunscreen to students.7 It is important to identify and address these barriers to skin cancer prevention in schools, as these policies may create barriers to ensuring adequate sun protection during outdoor school activities. VIEWPOINT