The survey was modeled after one conducted with elementary school principals in 1998.² In that survey, principals at only 3% of schools reported that there was a sun protection policy for children and less than one-quarter of elementary schools provided sun protection education in the past three years. A similar dearth of policies was observed in elementary schools in Hawaii, although nearly half of them taught children sun safety.³ The principals expressed strong support for sun protection policies but also needed resources to create and implement them (e.g., information for staff and parents about sun safety; a model policy).

Schools were selected proportional to the number of schools in each city. The proportion of completed interviews in each metropolitan area was similar to the original proportionate sampling procedure (deviations ranged from −0.06 to +0.03).

One respondent was interviewed per school. School principals were initially contacted but they could designate another staff person to answer the survey. Respondents held the jobs of principals, assistant principals, health, physical education, science, and family studies teachers, school nurses, and social workers

Bias caused by non-response was investigated in several ways. Later responding school personnel (based on date of interview), who might be more similar to nonresponding personnel, were in larger schools (r=0.12, p=.008) with lower proportions of white, non-Hispanic students (r=−0.14, p=.002) in regions with higher UVR (r=0.10, p=.034) than earlier responding personnel but did not report any greater perceived importance of sun protection education (p>.05) or presence of a sun protection policy (p>.05). Those who responded after more attempts were made to reach them also were from larger schools (r=0.17, p=.0001) but were more likely to report the presence of a sun protection policy (r=0.10, p=.034) than those reached with fewer attempts.

Table 1 Responses from School Personnel

Some schools had policies that discouraged sun protection. Hats and sunglasses were prohibited at some schools and very few provided sunscreen (Table 1). At one-third of schools, students were outdoors at midday when UVR was most intense; the percentage of schools with children outdoors at midday did not differ by regional UVR intensity (chi-square=0.307, p=.580).

Policy Development Two-fifths of personnel at schools without sun protection policies were willing to create them (Table 1), regardless of regional UVR intensity (chi-square=1.34, p=0.247). They were most supportive of requiring students to wear shirts with sleeves, sunscreen, hats, and sunglasses, but few would re-schedule outdoor activities (Table 1). School personnel desired several resources to help them with policy development, most commonly materials to educate teachers, staff, and parents about the importance of sun safety, a sample policy, and step-by-step instructions on creating a policy (Table 1).

Shade Provision Shade was provided at over half of the schools, mostly by trees and in a very limited area (Table 1). Most personnel were willing to increase the amount of shade, if funds were available. Shade (high=81.7%, low=49.6%; chi-square=42.78, p<.0001) and willingness to increase shade (high=72,8%, low=58.8%; chi-square=8.43, p=.004) were more common in high rather than low UVR intensity regions.

There was strong interest in adding instructional materials on sun protection either through written or computer-based instructional materials. Many personnel also desired materials for parents and were interested the daily UV index from the National Weather Service (Table 1). In their opinion, sun protection education would be most well-received by students in health class (Table 1). Personnel at schools in higher UVR regions (84.5%) expressing more interest in written instructional materials than in lower UVR regions (76.2%; chi-square=4.08, p=.043) (this difference did not exist when the data was weighted by the sampling fractions within each city; chi-square=1.96, p=.161). Nearly all schools had money available to purchase additional instructional materials but only a few personnel at the school level had the authority to decide to purchase new curricular materials.

Many secondary school personnel appear receptive to the idea of develop a sun protection policy so organized efforts to promote sun protection policy may be successful. Efforts should focus on promoting the use of sunscreen and changing the dress code to require hats, protective clothing and sunglasses. Schedule changes may be more difficult because it may not be possible to accommodate the large number of classes and organizations that conduct outdoor activities on school grounds without scheduling during the midday hours.

Any policy change program needs to provide school personnel with tools and resources to develop comprehensive policies, not simply tell them to do so. It also must address existing policies that work against sun safety such as prohibiting hats and sunglasses in order to avoid other health problems such as head lice transmission or due to concerns over the display of gang insignias or colors. State and local governments and school districts may need to modify statutory requirement concerning over-the-counter medicines designed to control liability for undesirable side effects in order to increase the use of sunscreen. Where government regulations do not prohibit these items, health officials must make sure that school personnel do not inadvertently enact policies that restrict them.

Changes to school schedules and in the structural and environmental features (e.g., trees, shade covering) of schools may be a longer-term goal in secondary schools, as it is in primary schools. Structure and environmental modifications also face financial challenges; however, one strategy may be to encourage schools to include shading in the design of new school buildings and renovation and upgrades of existing schools and school grounds. Undoubtedly, school officials will need information on the shading properties of various materials and trees, and on effective and affordable shade structure designs.

Some school personnel appear receptive to the idea of adopting formal instructional materials on sun safety. Unfortunately, evidence-based sun safety instructional materials for secondary schools is in limited supply,^{5, 10} although we reported that the Sunny Days, Healthy Ways curriculum produced positive outcomes in grades 6–8.^{7, 11} Still, school personnel will probably need to be convinced to spend the small resources available to schools on sun protection curriculum. As of 2002, most schools still had funds to purchase supplementary instructional materials but many also faced restrictions on adoption decision from the bureaucracy in their school districts. These limitations may explain why despite the professed interest among elementary school principals, few purchased the Sunny Days, Healthy Ways curriculum when we promoted it to them in a recent trial.¹² Additional efforts undoubtedly will be needed to disseminate evidence-based sun safety education to secondary schools, too.

David B. Buller, Klein Buendel, Inc., Golden, Colorado.

Mary Klein Buller, Klein Buendel, Inc., Golden, Colorado.

Kim D. Reynolds, University of Southern California, Alhambra, California.