No. 3, July 2004
Sun Protection Policy in
Elementary Schools in Hawaii
Paul Eakin, MD, Jay Maddock, PhD, Angela Techur-Pedro, Raphael Kaliko,
D. Christian Derauf, MD
Suggested citation for this article: Eakin P,
Maddock J, Techur-Pedro A, Kaliko R, Derauf DC. Sun protection policy in
elementary schools in Hawaii. Prev Chronic Dis [serial online]
2004 Jul [date cited]. Available from: URL: http://www.cdc.gov/pcd/issues/2004/
Childhood sun exposure is a major risk factor for skin cancer, the most
common form of cancer in the United States. Schools in locations that
receive high amounts of ultraviolet radiation have been identified as
important sites for reducing excessive sun exposure.
The objective of this study was to determine the prevalence of sun
protection policies, environmental features, and attitudes in public
elementary schools in Hawaii. Surveys were sent to all (n = 177) public
elementary school principals in Hawaii. Non-respondents were called three weeks
after the initial mailing. The survey asked about sun protection policies,
environmental features, and attitudes toward sun protection. The survey was
designed to measure all seven components of Guidelines for School Programs to
Prevent Skin Cancer, issued by the Centers for Disease Control and
Seventy-eight percent of schools responded to the survey. Only one school had
a written school policy. Almost all schools (99.3%) scheduled outdoor
activities during peak sun hours. School uniforms rarely included long pants
(6.5%), long-sleeved shirts (5.1%), or hats (1.5%). Current policies did not
support or restrict sun protection habits. Almost one third of those
surveyed were in favor
of a statewide policy (28.1%), and most believed excessive sun exposure was an
important childhood risk (78.9%), even among non-white students (74.5%).
Results of this study suggest the following: 1) school personnel in Hawaii
are concerned about childhood sun exposure; 2) current school policies fail
to address the issue; 3) most schools are receptive to developing sun
protection policies and programs; and 4) students appear to be at high risk
for sun exposure during school hours.
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In the United States, the incidence of skin cancer is increasing faster
than that of any other type of cancer (1). More than 1 million cases of skin cancer occur
every year in the United States, nearly the same number as all other cancers
combined (2). Basal cell carcinoma and squamous cell carcinoma are the most
prevalent types of skin cancer but are the most curable. These two cancers
accounted for almost 1.3 million new cases in the United States
in 2002 (3). Melanoma, while much less prevalent, has a higher mortality rate,
accounting for 75% of all skin cancer deaths (3). In Hawaii, melanoma
incidence rates are similar to the nation at 20.5 per 100,000 for males
(compared to 19.0 per 100,000 for the United States) and at 10.3 per 100,000
for females (compared to 12.0 per 100,000 for the United States) (4).
Melanoma incidence rates among white males in Hawaii are rising rapidly from
less than 30 per 100,000 between 1975 and 1979 to 62.8 per 100,000 from 1995
to 2000 (4).
Estimates show that the majority of lifetime sun exposure takes place
during youth and that 50% to 80% of lifetime cumulative sun exposure occurs
prior to age 18 (5). In addition, blistering sunburns prior to age 20 have
been associated with an increased risk of developing malignant melanoma (6).
Exposure early in childhood appears to be particularly important, with one
study showing that children aged nine to 10 sustain more sun exposure
than adolescents aged 14 to 15 (5). Another study using ultraviolet
(UV) light-sensitive badges in six schools in England showed that primary
school students had higher levels of exposure than secondary school students
(7). Furthermore, consistent use of sunscreen with a sun protection factor
of 15 throughout childhood and adolescence may reduce the lifetime
incidence of basal and squamous cell carcinomas by 78% (5).
In the United States, Hawaii is the only state located in the tropics.
Additionally, most Hawaii residents have a lifestyle that emphasizes outdoor
activities. Hawaii's tropical location results in more direct UV radiation
from the sun than non-tropical locations; research has shown that as
latitude decreases, measured UVB radiation and melanoma incidence increases
(8). Hawaii has a multiethnic population, but skin cancer occurs in all
ethnic groups, especially in tropical climates (9). Also, due to Hawaii’s
warm climate, schools often are built with sprawling, open layouts to take
advantage of cooling trade winds. Because of this, students are frequently
exposed to direct sunlight when walking between classes or during recess
and physical education class. Several studies have been conducted evaluating
institutional sun protection policy, including observational studies of
children at daycare (10) and a national survey of elementary schools (11).
In Hawaii, skin cancer prevention practices have been studied (12), and
public health interventions in outdoor recreational environments have been
able to show modest improvements in children’s sun protection behaviors
(13-15), but no studies have been published on sun exposure or protection in
schools. In the United States, only 12 states require education about skin
cancer prevention at the elementary school level; Hawaii is not one of these
Sun exposure among children in the United States is common. In a national
study of children aged six months to 11 years, children spent a median of 20
hours per week outdoors, including 10 hours while at school (17). Sunscreen
(61.8%) and shade (26.5%) were the most common methods of sun protection in
this study (17). Parents of children aged five to 10 at pools in Boston
and Hawaii reported similar incidence of sunburn (40%) among their children
during one summer (18). In this sample, sunscreen was the most widely used
form of sun protection, with very few children wearing sunglasses or hats
In April 2002, the Centers for Disease Control and Prevention (CDC)
released Guidelines for School Programs to Prevent Skin Cancer (19).
This document outlines seven recommendations for skin cancer prevention in
- Establish policies to reduce sun exposure.
- Provide environmental supports for sun protection.
- Provide health education on sun safety.
- Involve the family in sun safety.
- Provide professional development for staff for sun protection.
- Support sun safety with health services.
- Evaluate the effectiveness of these efforts.
With these seven guidelines in mind, we developed a survey to create a
baseline measure of how well public schools in Hawaii were meeting these
recommendations. We hypothesized that 1) elementary school children in
Hawaii receive a significant amount of sun exposure during school hours, and
2) school policies rarely attempt to limit sun exposure or teach about the
dangers inherent to sun exposure.
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In September 2002, a list of all public elementary schools (n = 177) in
the state of Hawaii was obtained from the State Department of Education.
Elementary schools were defined as schools that contained the first
through fifth grades. Eight schools (4.5%) also included the seventh and
eighth grades and were included in the sample. Students in sixth grade and
kindergarten were included in approximately half of the schools, depending
on the school complex. Private schools were not included in the study
because of the difficulty in obtaining a sample that adequately represented
charter schools, home schools, and other small schools (with less than 50
students), which are prevalent in Hawaii.
The 26-item survey queried current sun protection policies, amount of
time students spent outside during peak sun hours, the use of sunscreen and
clothing by students and staff, and attitudes about the importance of sun protection. It was
designed to measure all seven components of the CDC guidelines: policy;
environmental change; education; family involvement; professional
development; health services; and evaluation (19). Survey items were based
on previous studies in the United States (11) and Australia (20). Additional
items were generated by the study team. The survey instrument is available
in the Appendix. All procedures were approved by the University of Hawaii's
Institutional Review Board and the Hawaii Department of Education.
The survey was pre-tested with a convenience sample of seven elementary
school administrators to determine readability and face validity of the
instrument. Seven school administrators who had agreed to participate in a
larger study to develop observational methods for sun protection among
elementary school children were mailed a survey and then visited by a
trained research staff member one to two weeks later. The staff member
completed a structured interview with each school administrator following
the written survey and assessed the comprehension of each question. None of
the administrators reported any problems in understanding or completing any
of the questions. Since no data were changed on these forms, the survey
responses were pooled with all other responses.
During October 2002, cover letters explaining the study, survey, and
return postcards were mailed to all remaining public elementary schools (n =
170) in the state of Hawaii. The surveys were returned anonymously; a return
postcard sent by participants under separate cover identified schools that
had completed the survey. Non-respondents were contacted by telephone three
weeks after the initial mailing and encouraged to participate.
Data analysis was conducted using SPSS 11.5. Data were analyzed primarily
by calculating percentages. For questions using a 5-point Likert scale,
respondents who endorsed an item with a 4 or 5 were coded as agreeing with
the statement. Schools were also grouped into either having a high
enrollment (more than 40%) or a low enrollment (less than of 40%) of white
students. Mean differences in the endorsement of items were assessed using
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Overall, 78% (n = 138) of the schools responded to the survey. Most of
the respondents were principals (59%), vice principals (9%), or
administrators (14.9%). Schools reported substantial ethnic diversity of
their student bodies, with an average of 21.2% white, 26.9% Asian, 26.7%
Native Hawaiian, and 10.7% Pacific Islander. Only 15.9% of schools that reported
the ethnic composition of the student body reported 40% or
more white students. The postcard was returned by 110 (62.1%) of the
schools. Return of postcards was similar for Oahu (61.8%) and the neighbor
islands (64.8%), (χ2 = .147, P = .70).
Table 1 presents results of the school survey. Only one school (0.7%)
reported having a written policy to limit student sun exposure. However,
of schools believe that a statewide policy is needed. Of the 14.5% of
schools with uniforms, only 1.5% include hats, 6.5% long pants, 5.1% long
skirts, and 5.1% long sleeves as protective clothing options. Many schools
allow students to wear protective clothing when outside. Hats (86.9%),
sunglasses (72.9%), and sunscreen (98.5%) are allowed by most schools, and
only 6.7% of schools require a doctor’s note to bring sunscreen to school.
Very few schools provide sunscreen on field trips (4.3%).
Almost all (99.3%) of schools schedule outdoor activities between 10
and 2 PM, with 28.3% of schools scheduling at least half of their outdoor
activities during this time. Shade-producing structures are common among
schools (75.4%), but most (81.8%) cover less than 25% of play areas. Less
than one quarter (22.2%) of school personnel reported that they often or
always practice sun protection behaviors when supervising outdoor
Less than half (47.7%) of schools teach sun protection as part of the
health education curriculum. Almost half (48.9%) of schools have some
students expressing concern about excessive sun exposure. Most schools
(85.2%) are interested in interactive training sessions on the dangers of
sun exposure. Only one fifth (20.1%) of schools send information home to
parents about keeping their children sun-safe.
Less than 30% of schools reported that they provide any training in sun
protection practices to physical education (PE) teachers, school
administrators, and teachers. More than half of schools (53.6) reported having school nurses
trained or knowledgeable about sun protection behaviors, but only 12.1% of
schools reported that these nurses always or often instruct students
about practicing sun protection behaviors. Only 6.6% of respondents had seen
the CDC school guidelines, while 87.4% were interested in receiving a copy.
Most respondents (78.9%) believed that excessive sun exposure during
childhood is an important health concern, and 74.4% believed this is also
true for non-white students. However, only 19.8% of schools believed that
they have better than average measures to protect their children from the
No significant differences were seen between schools with a high
proportion of white students (more than 40%) and schools with a low
proportion (less than 40%) with regard to 1) the need for a statewide
policy, instruction on sun protection behaviors, or information sent home to
parents; 2) the perception that the school has adequate measures in place;
and 3) the number of students expressing concern about sun exposure. A
non-significant trend (P = .06) exists with schools with a higher
percentage of white students believing that excessive sun exposure is an
important health concern (Table
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Among public elementary schools in Hawaii, we found an absence of
policies to reduce sun exposure and a lack of knowledge about the CDC
guidelines to prevent skin cancer. We found that few teachers receive
professional development in sun protection practices, and that uniform
policies do not usually require protective clothing. Most current school
policies do not prohibit or encourage sun protection behaviors, and most
administrators stated that they had never thought about the effects of sun
exposure on students during school time. Despite these results,
administrators are largely in favor of stronger policies and believe sun
exposure is an important health issue. Our results suggest the need for
state education departments to develop sun protection policies,
environmental supports, and a sun protection curriculum.
Limitations of our study include the selection bias inherent to survey
studies and the possibility that the person responding to the survey is not
well-informed about school conditions. A further study is currently underway
that will address some of these issues through site visits and
direct observation of students’ sun protection behaviors.
Our results are similar to the study done in 1997 by Buller et al in
which only 3.4% of schools in the United States reported written sun
protection policies, while 76.4% of principals were willing to make
environmental changes (11). The Buller study, however, had several
methodological limitations, including a low response rate (41%) and a high
proportion of schools in cities with low UV intensity (63%). Our findings
are likely to be similar to findings in other states that do not have a
comprehensive statewide or district-wide policy, because administrators appear
to be largely in favor of sun protection measures but have not made them a
priority for their schools.
The results from Hawaii and the United States contrast starkly with
results from Australia. In 1993, the Victoria Anti-Cancer Council developed
a SunSmart school accreditation program to recognize schools for having
comprehensive sun protection policies (20). From 1992 to 1997, sun
protection policies in Victoria increased from 17% of schools to 76%
(20,21). Sun protection practices are also much more rigorous in Victoria,
with 78% of schools recommending broad-brimmed hats, 96% providing sunscreen
or encouraging parents to supply it, and 93% teaching sun protection in
classes (20). The CDC has recommended that school districts conduct periodic
evaluations to assess how well schools are meeting the guidelines (19). To
our knowledge, this study represents the first attempt to evaluate the sun
protection policy and environment of all public elementary schools in a
state. Given the substantial lifetime sun exposure burden encountered during
the elementary school years, sun protection policies have the potential to
significantly alter an individual's risk for later development of skin
cancers as adults. Results from this study and from programs in Australia
are encouraging because most school principals have a positive outlook on
sun protection policies. The development of an accreditation program by a
national or state group could lead to great changes in elementary school sun
protection practices. The Guidelines for School Programs to Prevent Skin
Cancer should also be widely distributed along with model policies to
schools — especially to district- and state-level administrators — to
encourage their adoption.
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This study was funded by a grant from the Hawaii Community Foundation.
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Corresponding Author: Jay Maddock, PhD, Assistant Professor, Department
of Public Health Sciences, University of Hawaii, 1960 East-West Rd D104,
Honolulu, HI 96822.
Telephone: 808-956-5779. E-mail: firstname.lastname@example.org.
Author Affiliations: Paul Eakin, MD, Department of Pediatrics, John A.
Burns School of Medicine University of Hawaii at Manoa; Angela Techur-Pedro,
Department of Public Health Sciences, University of Hawaii at Manoa; Raphael
Kaliko, Department of Public Health Sciences, University of Hawaii at Manoa;
D. Christian Derauf, MD, Department of Pediatrics, John A. Burns School of
Medicine, University of Hawaii at Manoa.
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Existing School Policies and Education on Sun Protection, Public Elementary
Schools, Hawaii, 2002
||% Respondents (n = 138)
|Schools with written policy that limits students' exposure to sunlight during outdoor activities
|Schools that feel statewide policy to limit sun exposure to children during school is
| 5 - Very much
| 3 - Average
| 1 - Not at all
|Schools that allow the use of sunscreen during outdoor activities
|Schools that require doctor's prescription or note for student to use sunscreen lotion
|Schools that allow the use of hats during outdoor activities
|Schools that allow students to wear sunglasses when outdoors
enforce a uniform policy
Uniform options among schools with uniform policies
|Schools have outdoor activities between 10
AM and 2
|Percent of activities that fall between 10
AM and 2
| < 25%
| > 75%
|Percent of play or activity covered by shade
| < 25%
| > 75%
|Schools that provide sunscreen for students during school field trips
provide shade-producing structures
|Schools who claim that students are concerned about excessive sun exposure during outdoor activities
|School personnel who practice
sun protection behaviors while supervising outdoor
|Percent of schools that teach sun protection as part of the health education
|Schools that send home information to parents about sun safety
|Staff/teachers trained or knowledgeable about sun damage and sun protection
| Physical education teachers
| School nurses
|School staff had seen CDC sun
| Don't Know
|School health nurses routinely instruct students on
toward sun exposure
believed that excessive sun exposure during childhood is an important health
believed that excessive sun exposure during childhood is an important health
concern for non-white children
believed they have better than average measures to protect their children
from the sun