Title: Sunproofed: A mixed methods evaluation of sun safety policies in primary schools in Wales
Funder: Health and Care Research Wales (Welsh Government)

Abstract: Background: Skin cancer, which includes both melanoma and keratinocyte (non-melanoma) cancer, is estimated to be as common as all other cancers combined. In Wales, the burden of skin cancer is substantial; skin cancer rates have risen by 63% since 2005 and the disease now comprises 50% of a dermatologist’s workload. This has a significant impact on already overstretched dermatology services . Most skin cancers are a result of excess exposure to ultraviolet radiation, the majority occurring before adulthood. In fact, severe sunburn as a child is the best predictor of developing future skin cancer. However, estimates suggest that 86% of melanoma is preventable with modified sun exposure. Welsh Government policy is to encourage prevention activities to keep people healthier for longer and educating children about sun safety in schools is one way to help prevent skin cancer. Health organisations such as the World Health Organisation and National Institute for Health and Care Excellence (NICE) recommend that sun safety is taught in schools and in Australia this has had a positive impact on skin cancer incidence rates. In England teaching sun safety in primary schools is now compulsory. However, in Wales it is not compulsory for primary schools to have sun safety policies in place and we do not yet know the impact of this. Aims: To understand how the primary school sector in Wales can respond to growing rates of skin cancer and to evaluate the effectiveness of sun safety policies in schools on knowledge and behaviour. Plan: Mixed methods evaluation, comprising 5 work packages (WP) using survey and routine electronic health record (EHR) data supplemented by qualitative case studies. Each WP has its own objective(s): WP1: To discover if primary schools in Wales currently have sun safety policies in place, the factors which may influence whether a policy exists, and to identify characteristics of these policies WP2: To explore EHR data: What is currently available regarding incidence of sunburn in primary school aged children and what is the feasibility of using this to evaluate the impact of sun safety policies in Welsh primary schools? WP3: To evaluate sun safety policies in schools and assess levels of sun safe knowledge (including knowledge of vitamin D) and behaviour amongst children, parents, teachers and school management; to explore opinions on polices and identify barriers or facilitators to schools implementing sun safety policies. WP4: To co-produce guidance regarding sun safety policies and best methods for implementation in schools. WP5: To disseminate guidance and findings widely to ensure impact and uptake from Welsh schools. Summary of benefits: Rates of skin cancer are increasing in Wales which has a detrimental impact on NHS resources. With strong evidence suggesting that reducing sun exposure in children can help prevent skin cancer in later life, an urgent shift from treatment to prevention is needed and education in school is one way to facilitate this. This research has the potential to benefit children and their parents and to inform the development of future practice. A clear assessment of the current situation in Wales with respect to sun safety polices in schools and co-producing evidenced-based guidance on best methods for implementation will enable Wales to move towards prevention. This will in turn reduce the number of skin cancer cases in the future and keep people healthier for longer.

Lay abstract: Why this project: Skin cancer is the most common cancer in the world. In Wales, skin cancer rates have risen by 63% since 2005 and dermatologists now spend 50% of their time treating skin cancer. This means they cannot spend as much time on other conditions and people with other skin diseases are suffering. Skin cancers are divided into melanoma and keratinocyte (non-melanoma). For melanoma, 86% of cases can be prevented through less exposure to the sun’s ultra-violet radiation (UVR). Studies show that children who are badly sunburned are more likely to develop melanoma skin cancer when they are older. With the Welsh Government recommending that people do more to prevent future health problems, preventing skin cancer is now more important than ever. Children spend almost half their time at school playing and learning outdoors, and one way to prevent skin cancer is to teach children at school how to protect themselves from UVR. A sun safety policy is a programme or procedure that schools use that sets out how they will teach and protect children from the sun while at school. A policy may include how the school will provide shade or if teachers can help with sunscreen. What we will do: We want to understand how primary schools are responding to the growing problem of skin cancer (for example do they have a policy in place and what does it look like). We want to explore what is currently being taught in schools about sun safety and if this has any influence on knowledge and behaviours of children, teachers, staff and school managers. One of the outcomes of this study will be for participants to work together to write an action plan for schools. This will help them to start using sun safe policies. How we will do this: Firstly, we will send out a questionnaire to all primary schools in Wales to discover if they have a sun safe policy in place. We will look at data on contacts with healthcare providers to understand the numbers of sunburn accidents. We will visit 7 schools -some with and some without a sun safety policy. During our visit, we will speak to children, parents, school staff and governors to find out what they know about sun safety. We will also invite them to help write a document that will guide schools on the best way to implement a sun safety policy. We will also ask people who have expertise in education and in skin cancer to help with this. Who is involved: It is very important that we have the involvement of schools including staff, parents and children. We have two teachers, (one of whom speaks Welsh and is also a parent governor) on our study team and they will give advice on how best to work with schools and how to design study paperwork suitable for children. We also have recruited two parents who will advise on what is important to them when considering sun safety. We have also met with the Headteacher of one school, who gave valuable input into the design of this study. Who we will tell and how they will benefit: Children should be free to enjoy the sun safely without the worry of developing future skin cancer. With this study we will better understand what schools in Wales are doing to help children protect themselves and how this can be improved. We will tell schools our findings and give them a copy of the guidance we produce. We will present findings at meetings for people with responsibility for education and health policies and will write up results for publication in academic journals.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: CANCER AND NEOPLASMS