SUN SAFETY SURVEY OF PRESCHOOLS AND DAY CARE CENTERS.

Abstract: Sun exposure is the primary risk factor for skin cancer. This study assessed sun protection policies and the modeling of preventive behaviors at preschools and day care centers in Washtenaw County, Michigan. Forty-five facilities, enrolling 3,471 children, responded to the survey. Eighty-seven percent of the facilities did not have sun protection policies and 56% did not limit children's time in the sun. These facilities can provide critical primary prevention and education by implementing sun safety programs for children and their parents. Sun-safe practices adopted by parents, schools, and recreation programs can reduce the future incidence rates of skin cancer.

Skin cancer is the most common form of cancer in the United States (American Cancer Society [ACS], 1997) with 1.3 million cases of nonmelanoma diagnosed annually (ACS, 1997; and ACS, 1999). Since 1973, the morbidity rate for melanoma, the most deadly skin cancer, has been increasing by 4% per year. There are 7,700 melanoma deaths predicted for 2000 (ACS, 1999). Excessive and unprotected exposure to the sun's ultraviolet radiation (UVR) is the primary risk factor for skin cancer. However, skin cancer is one of the most preventable types of cancers (ACS, 1999).

The damaging and cumulative effects of UVR (Munnings, 1991; and MacKie, 1992) begin when an infant's or toddler's unprotected skin is exposed to sunlight (National Institutes of Health, 1992). To date, nothing has been discovered to undo the previous UVR damage to the skin. According to the American Cancer Society (1997), protecting the skin from UVR can prevent approximately 80% of skin cancers.

Protection from the sun should begin at birth and continue throughout life. The importance of sun protection should be taught early to children in order to decrease their potential for future melanoma and nonmelanoma skin cancers.

It has been calculated that children receive about 80% of their lifetime exposure to UVR during the first 18 years of life (Armstrong & English, 1996; and Elwood, 1992). One severe sunburn early in life doubles the chances of future malignant melanoma (Crane, Marcus, & Pike, 1993). The risk of skin cancer can be decreased by up to 50% if a sunscreen with a Sun Protection Factor (SPF) of 7.5 is regularly used during the first four years of life (Stern, Weinstein, & Baker, 1986).

For children, primary prevention of skin cancer is critically needed. Parents and caregivers must educate children about and protect them from unnecessary and excessive exposure to UVR (Crane, Marcus, & Pike, 1993; Girgis, Sanson-Fisher, Tripodi, & Golding, 1993). Children learn the sun exposure behaviors of parents and caregivers, copying their practices and attitudes regarding tanning. Furthermore, children are regularly sent outdoors to play between 10:00 a.m. and 3:00 p.m. when the sun's rays are the strongest (ACS, 1999).

Typically, children spend between four and seven hours in day care or at school each day. In that time, between one and three hours can be spent outdoors during mid-morning and mid-afternoon recesses, lunch break, physical education classes, and after-school activities (AMC Cancer Research Center [AMC], 1998). Unfortunately, most of the playgrounds and schoolyards in the United States have minimal or limited shaded areas to reduce the exposure to UVR.

Establishing sun protection routines in childhood can foster positive life-long preventive habits. Children should play in the shade during the midday, wear protective clothing and sunglasses, and apply sunscreen daily to decrease their future skin cancer potential.

PURPOSE

To date, little thought has been paid to the skin cancer prevention in early childhood (Crane, Marcus, & Pike, 1993; Girgis, Sanson-Fisher, Tripodi, & Golding, 1993). Preschools and day care centers occupy a critical position to implement primary prevention programs for their students, provide sun protection education to the parents, and develop or update their policies regarding sun safety. Attention to outdoor play time, available shade, positive role modeling by teachers/aides and parents, sunscreen application, and wearing protective clothing can reduce the future incidence of skin cancer for children at preschool and day care centers. The purpose of this study was two-fold: 1) to assess the sun protection policies at preschool and day care facilities in Washtenaw County, Michigan; and 2) to survey the reported sun protection behaviors modeled by teachers and aides at these facilities.

METHODS

A 39-item questionnaire was developed for use in this study. The instrument included demographic items (enrollment, students' age, gender, and ethnicity), amount of shade, outdoor play times, sunscreen use, water opportunities, behaviors of faculty/ staff, and sun protection methods and policies. To assess content validity, a panel of health education professors, wellness specialists, a dermatologist, and day care/preschool directors reviewed the questionnaire. The instrument was field tested on a convenience sample of day care and preschool directors from an adjacent county to improve format and item clarity. Permission to conduct this study was granted from the University Advisory Committee on Human Research.

The names of directors and the addresses for preschools and day care centers in the county were gathered from local telephone books, Internet websites, and a day care director's telephone list. A packet containing an introductory letter, informed consent, the questionnaire, and return postage-paid envelope was mailed to 100 preschool and day care facilities in July of 1997. Participation in the survey was entirely voluntary and anonymous as stipulated by University Advisory Committee on Human Research. The investigator's name, address, telephone and fax numbers, and e-mail address were provided to allow participants to ask questions regarding the study.

Sun protection policies, procedures and Behaviors were measured by self-report. In order to ensure the validity of the self-reported data, methods recommended by Rouse, Kozel, and Richards (1985) were followed to gather data through anonymous inquiry using brief, easily understood directions to complete the surveys. Because the policies and procedures questions examined the respondents' current situation, recall was not a serious concern. Position bias of the respondents was not thought to be a critical issue, considering the anonymity of the survey and the non-threatening nature of the questions (Howard, 1981). The use of self-reported data provided estimates of the most current sun protection policies and behaviors at these facilities.

The data were analyzed in two phases: descriptive statistics and chi-square analyses were generated for all survey items. All statistical tests were performed using .05 as the level of significance.

RESULTS

A total of 48 facilities voluntarily responded to the mailed questionnaire. Three of the sites did not complete the survey; therefore, 45 facilities participated in this study.

There were 3,471 students between the ages of six weeks and 12 years enrolled at these 45 facilities. Seventy-one percent (2,486) of the students were Caucasian, 13% (435) were African-American, 9% (312) were Asian, 4% (135) Middle-Eastern, and 3% (103) were Hispanic.

Twenty-three of the facilities provided infant care (six weeks to 12 months), 28 of the centers cared for toddlers (ages 12-24 months), 28 facilities furnished care for school-aged children (six-12 years), and all 45 facilities provided care for preschool children (ages two to five years). Since preschools and day care facilities supervise differing age groups of children, respondents cited more than one age group. Therefore, the preceding sum is greater than the total number of facilities in the study.

Eighty-seven percent of the facilities did not have a written sun protection policy and 71% had no policy to keep the children out of the sun between 10:00 a.m. and 3:00 p.m. Twenty-five of the 45 centers (56%) had no policy to limit the children's time in the sun. Informal policies to limit the amount of children's UVR exposure varied from 1090 minutes depending on the age of the child, the temperature, and the UV index.

When asked whether the facility provided sun protection information to the parents at the beginning of each summer, 40% of the respondents indicated "Always," 9% answered "Almost Always," 15% listed "Sometimes," 18% stated "Rarely," and 18% admitted "Never." Facility expectations for the parents included: 1) 53% of the center's required written parental consent before sunscreen application, with 9% requiring a physician's note; 2) two-thirds of the centers expected the parents to provide sunscreen for the children during child care; and 3) 70% depended on the parents to dress the children for sun protection.

Children were allowed to play outdoors between 8:00 a.m. and 6:00 p.m. at these facilities. During the critical 10:00-3:00 UVR time frame, the 10:00-11:00 a.m. time slot was the most popular, with 78% of the facilities reporting outdoor play. The 11:00 a.m. to noon hour was the second most-reported outdoor playtime (49%) during intense sunlight, while 20% of the sites allowed play from 2:00-3:00 p.m., with 7% permitting outdoor play from 1:00-2:00 p.m.

Trees provided shade at 82% of the facilities, and over half of the centers reported having playground equipment, playhouses, or sides of the building that shaded outdoor play areas. Umbrellas and awnings furnished shade at 10% of the locations. The mean response for the amount of outdoor play area shaded for at least one hour at these facilities was 21-40%.

Over half (55%) of the parents were reported to furnish sunscreen for their children during childcare. Sunscreen was provided by 36% of the facilities on a regular basis, while 7% of the centers supplied sunscreen only on special occasions such as field trips or a special day at a water park or lake. Additionally, one facility cited legal reasons for not applying sunscreen.

Teachers applying sunscreen on children's skin prior to each outdoor play experience was reported two-thirds of the time ([chi square]= 68.56, p [is less than] .000). Only 11% of the time, sunscreen was applied 26-30 minutes before UVR exposure (Table 1) to allow full absorption into the skin for maximum protection. At four facilities (9%), sunscreen was not applied at all. Respondents cited children's age as a factor in helping to apply or applying sunscreen to their own skin. It was reported that older children (ages 5+) did help to apply their own sunscreen.

Table 1 Percent of Responses for Sunscreen Application Prior to Outdoor Play.

Amount of Time         Percent

5-10 minutes before      45%
11-15 minutes before     18%
16-20 minutes before     11%
21-25 minutes before      2%
26-30 minutes before     11%
Not applied              13%

Chi square value:

[chi square] (5) = 44.48, p < .001

Bold numbers indicate correct amount of time for sunscreen application prior to sun exposure.

At 36% of the facilities, all teachers and aides taught the children how to apply sunscreen before outdoor play, and 38% of all teachers and aides taught children when to apply sunscreen (Table 2). Yet, over one-fourth (27%) of the time it was reported that teachers and aides did not teach children how to apply sunscreen, with 18% not instructing students when to apply sunscreen (Table 2).

Table 2 Percent of Teachers Instructing Children HOW/WHEN to Apply Sunscreen.

Answer                  "HOW to apply   "WHEN to apply"

They all do.                 36%              38%
Most of them do.             15%               6%
A few do                     11%              22%
No, they do not.             27%              18%
Uncertain if they do.        11%              16%

Chi square values:

Do teachers show children HOW to apply sunscreen? [chi square](4) - 34.44, p < .001

Do teachers show children WHEN to apply sunscreen? [chi square](4) - 11.77, p < .05

The percentages of teachers/aides encouraging the children to perform sun protection behaviors are shown in Table 3. Children were "Almost Always" encouraged by faculty (83% of the time) to wear sunscreen. Respondents indicated that 49% of the time the staff "Almost Always" encouraged students to play in the shade. Wearing sunglasses was "Almost Always" encouraged 8% of the time and wearing long-sleeved shirts was "Almost Always" encouraged at 3% of the facilities. Chi-square values for all methods of sun protection were significant: p [is less than] .01 for use of long-sleeved shirts, p [is less than] .001 for sunglass use and wearing combinations (hat, sunglasses, and sunscreen), and p [is less than] .000 for use of sunscreen, wearing a hat, and playing in the shade.

[TABULAR DATA 3 NOT REPRODUCIBLE IN ASCII]

The most frequently reported combination of sun protection methods was wearing sunscreen and a hat. Neither teachers nor students at any of the facilities surveyed used the maximum sun safety behaviors that included wearing sunscreen, sunglasses, a hat, a long-sleeved shirt with a collar, and slacks.

The percentages of sun protection measures that teachers and aides directly modeled to the children when outdoors are provided in Table 3. Faculty who "Almost Always" wore sunscreen was noted 50% of the time and wearing sunglasses was listed at 53%. Staff at 49% of the facilities "Almost Always" modeled playing in the shade. The modeling of wearing long-sleeved shirts was the least common sun protection method. Chi-square values were significant for use of long-sleeved shirts (p [is less than] .02), wearing combinations (p [is greater than] .01), wearing a hat (p [is less than] .001), and for using sunscreen and playing in the shade (p [is less than] .000).

During the summer months, 40 of the 45 facilities provided outdoor water opportunities (sprinklers, kiddy pools, swimming lessons, access to lakes). The length of outdoor water activities ranged from 15-30 minutes at 36% of facilities to over one hour at 13% of centers. Before outdoor water activities, 82% of the respondents stated that waterproof sunscreen was applied on the children's skin. The number of summer days that children were engaged in outdoor water activities ranged from 6-10 days (14% of facilities) to 41 or more days (16% of centers), with 21-25 days as the modal amount.

Although five respondents stated that their facilities had a written sun protection policy, none sent a copy to the investigator. Two directors sent sun safety tips from their newsletters.

Over half of the respondents indicated they would consider adopting a sun protection policy in the future. Twenty-one directors listed that they would consider participating in a 30-45 minute sun protection program in the future.

DISCUSSION

The response rate of 45% was quite good, considering that this was an unsolicited single mailing, anonymous-response survey. Kraus and Allen noted that mailed surveys "frequently yield a response of less than 20 percent, and second or even third rounds of mailing, telephone-call follow-ups, and similar methods may be needed to ensure a fuller response" (1997, p. 179).

The results of this study indicate that these facilities need to assess their sun protection practices, examine written and informal policies, and outdoor play schedules in order to reduce children's UVR exposure. Available shade should be evaluated and additional sources of shade provided through careful planning, budgeting, and/ or fundraising (AMC, 1998). Feedback from staff, parents, and students should be incorporated into the development of feasible goals for sun protection (AMC, 1998). Newly created sun protection policies should address and/or require the use of protective clothing and sunscreen worn by students and be incorporated into the facility's safety statement and implemented over a two to three year time period (AMC, 1998).

During implementation, facilities should notify parents of newly established sun safety policies. Seminars should be scheduled for parents to learn about UVR protection and ask questions about the policies. Sun protection methods should be clearly explained and educational materials disseminated to parents to reduce children's unintentional UVR exposure.

Parents' knowledge is crucial regarding their children's UVR exposure. Parents may falsely believe that a child's skin needs no more protection than their own (Vail-Smith et al., 1997). The misperception of a suntan as healthy or attractive is also a barrier to sun-safe practices. Conversely, parents who avoid sun exposure have been found to be less likely to protect their children's skin (Vail-Smith et al., 1997). Therefore, education efforts targeted specifically to parents and staff is vital to protect children from unnecessary UVR.

Many individuals falsely believe that sunscreen with a SPF of 15 or higher will provide all-day protection for the skin. The SPF number quantifies the amount of erythema reduction caused by using the sunscreen product (Stern, Weinstein, & Baker, 1986). Reapplication of sunscreen does not increase a person's initial UVR protection time (i.e., providing longer protected time in the sun). A sunscreen with a SPF of 15 allows one to be outdoors for up to 15 times longer before the skin would sunburn. If one sunburns within 10 minutes when the skin is unprotected, 150 minutes of UVR exposure is the maximum UVR exposure time when a SPF 15 product is properly applied. Reasons to reapply sunscreen include sweating, swimming, and/or toweling dry (Cardozo, 1993).

Sunscreen application should occur 30 minutes prior to sun exposure to allow absorption into the skin, and should be liberally applied. One ounce (1/8 cup) is needed to properly cover an adult's skin (Munnings, 1991; and Cardozo, 1993). People frequently apply up to 50% less than what is needed, thereby reducing a SPF of 15 to 7.5 or 8 (Sunscreens: The full spectrum, 1993). Rubbing sunscreens into the skin also decreases the SPF (Roach, 1994).

Parents and caregivers should keep infants out of the sun and keep their skin covered. Sunscreens are not recommended for children younger than six months of age.

These facts should be explained to teachers, staff, and parents so the most vigorous sun protection methods are employed to protect children's skin from irreparable damage. Proper sunscreen application should also be demonstrated and modeled as part of the educational effort for the sun safety of young children.

Respondents commented that applying sunscreen to a large number of students eager for outdoor play and distributing many sets of hats and sunglasses are daunting tasks. The facility's sun protection policies can alleviate these problems. As a part of the before-school/day care routine, parents can apply sunscreen to their children's exposed skin. Facilities should require that parents appropriately dress children for sun safety and send cover-up clothing to school. Placing sunglasses and hats in the students' cubbies can become a part of routine organizational practices to reduce excuses that limit sun safety efforts.

In some states, sunscreens are categorized as an over-the-counter drug that cannot be provided nor applied by teachers or staff. Therefore, parents play a critical role in sunscreen application and appropriate dress for their children's sun protection.

Over 50% of the facility directors indicated a willingness to adopt sun protection policies and participate in sun safety training. That only two facilities shared sun protection tips with the investigator was an indication that this issue had not been addressed or that directors did not know where/ how to begin framing sun protection policies and procedures. Local health educators and health care practitioners should join forces to provide sun protection training for parents, and the faculty/staff of day care centers, preschools, and public schools.

Another challenge for establishing sun protection habits and policies occurs in the northern areas of the United States (American Association of Health Education [AAHE], 1998). When hot weather does not predominate the year-round temperature, residents may he more inclined to be sun seekers and less likely to practice sun-safe behaviors (AAHE, 1998). Since this study occurred in a northern state, the sun-safety behaviors, procedures and policies may not be as commonly practiced and documented as in southern or coastal states.

Although these findings have direct implications for primary prevention programs, the limitations of the study must be acknowledged. First, the data is based on self-report from directors of these facilities. These individuals were in the best position to account for demographics and policies at these sites. Self-reported data provided the current perception of procedures, behaviors, and circumstances at the sites (Howard, 1981). A second limitation is the scope of the study. The results are based on data from one county, so any generalizations made must be cautious. Future research is recommended and should investigate the sun protection policies and procedures of preschool and day care facilities in statewide, regional, and national surveys.

CONCLUSIONS AND RECOMMENDATIONS

The results of this study provide support for the establishment of written sun safety policies at preschools and day care centers. Skin cancer morbidity and mortality rates can be decreased through preventive efforts of parents and caregivers. Both must be educated about skin cancer prevention strategies. Parents must become assertive and insist that sunscreen be applied year-round to children's exposed skin before all outdoor activities. Children should be kept safe from unnecessary UVR exposure, therefore parents must firmly request sun protection measures and seek childcare facilities with written sun protection policies in effect.

Day care centers, preschools, public and private schools that enroll children and adolescents pre-K through grade 12, should develop and adopt written sun protection policies. These policies should be well publicized and strictly followed by the faculty, staff, administration, parents, and students. Schools can be made sun-safe to provide a crucial role in skin cancer prevention by: 1) promoting sun protection behaviors among students, faculty and staff; 2) providing sun-safe environments, schedules, and activities; 3) teaching sun safety as a part of a comprehensive school health curriculum; and 4) building and promoting sun safety community partnerships (AMC, 1998).

Most outdoor playgrounds and physical education areas need more shade for activities during the peak UVR hours. Trees (both deciduous and non-deciduous) provide a natural shade source. Temporary and permanent shade structures such as awnings, umbrellas, porches, pavilions, and canopies can provide shade for playgrounds and drop-off/pick-up areas. Besides providing shade, these areas can stimulate imaginative play and beautify the grounds.

Outdoor activities in the sun should be avoided during peak UVR hours: when one is taller than his/her shadow, play in the shade or indoors (Help from your shadow, 1994). Children should play in the shade, and given indoor alternatives such as going to the library, computer lab, or gymnasium if adequate shade is not available outdoors.

Covering the skin is an important sun protection measure. School policies prohibiting hats may need to be reconsidered (AAHE, 1998). Students, faculty and staff should be encouraged or required to wear hats when outdoors during physical education classes, recess and field trips. Loose fitting, long-sleeved shirts with collars and slacks provide the most protection from UVR and should be a recommended or required part of school attire (AMC, 1998) and warm-ups for athletic uniforms (AAHE, 1998). Wearing UV-coated sunglasses while outdoors should also be promoted to prevent long-term damage to the eyes (AAHE, 1998), such as cataracts.

Educational efforts to inform parents and caregivers can come from a variety of sources. School nurses and health care providers should promote sun safety behaviors. Meteorologists can explain the UV Index values given on radio and TV. The media should frequently present news features about sun safety. Dermatologists can provide sun protection presentations for the schools and the community. Obstetricians, pediatricians, and prenatal instructors should educate parents-to-be about protecting their infants/toddlers from UVR. College professors should include sun safety as a part of the teacher preparation curricula. Students can monitor the UV Index in health, science, and physical education classes. Principals can provide sun safety information and the UV Index during daily school announcements (AMC, 1998). Bulletin boards, art contests, and school sun safety days can promote sun protection behaviors (AMC, 1998). Free or low cost skin cancer screenings should be available in most communities.

The American Cancer Society (ACS) and the American Academy of Dermatology (AAD) produce free or low-cost sun safety brochures, posters, and videos. "Sun Basics" from ACS (brochure #98-300M-2012-CC) provides simple sun protection facts for children, and "Skin Protection Guide for Everyone Under the Sun" (ACS brochure #98-300M-No.2012.04) is a parent's guide to sun protection. The AAD furnishes "Sun Protection for Children" (AAD brochure #PAM33-12/96), and distributed a sun safety teaching guide and family sun guide, "Block the Sun Not the Fun," in Scholastic Magazine in the spring of 1998. Schools searching for a comprehensive sun safety curriculum should consider "Sunny Days, Healthy Ways" from AMC Cancer Research Center. (Grades K-5 are available and grades 6-8 are being developed.) It also contains information to assess and formulate a sun safety policy (AMC, 1998).

The Environmental Protection Agency (EPA) is pilot testing "The SunWise School Program" during the 1999-2000 school year, with national implementation set for 2000-2001. Teachers and school nurses using this K-6 program can select cross-curricular lessons, school-wide sun safety activities, information on policies and shade structures, establishing community partnerships, and monitoring and recording the UV Index. Participating students receive a "Certificate of Sun Wisdom." The SunWise web site address is www.epa.gov/sunwise.

Teachers, caregivers, coaches, school staff, school nurses, and parents should become positive role models who practice and promote sun protection behaviors. Students can become peer educators to provide invaluable lessons to classmates and younger students (AMC, 1998). All members of the community should practice "Slip! Slap! Slop!" whenever outdoors. If the U.S. population would slip on a shirt with a collar, slap on a hat and sunglasses, slop on sunscreen with SPF of 15, and seek the shade, the future incidence and mortality rates of skin cancer would decrease.

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Janice Clark Young, Ed.D., CHES, Assistant Professor, Department of Health, Physical Education and Recreation, Southwest Missouri State University, 901 South National Avenue, Springfield, MO 65804, Phone: [phone], FAX: [phone] or 4200, [e-mail].