VOL: 103, ISSUE: 26, PAGE NO: 30-31
Jane Freak, NNEB, SEN, RGN
Macmillan skin cancer CNS, surgical directorate, the RoyalBournemouthHospital, Dorset.
ABSTRACT Freak, J. (2007) Evaluation of a sun awareness programme for school children.www.nursingtimes.net
ABSTRACT Freak, J. (2007) Evaluation of a sun awareness programme for school children.www.nursingtimes.net This article describes a pilot of a sun awareness and education programme delivered in a primary school as part of Sun Awareness Week. It describes the planning, implementation and evaluation of the project, along with recommendations for future initiatives. More than 75,000 new cases of skin cancer are diagnosed in the UK each year. Many cases are not reported, however, so the real number of cases is probably much higher. The number of cases reported has almost tripled since the early 1980s and more than 2,300 people die from skin cancer each year (Cancer Research UK, 2006). There is now good evidence that sunburn before the age of 15 increases the risk of melanoma developing in later life. It is therefore particularly important to target children and young adults with advice about protection against sunburn (Chu, 1997). With this in mind, it was decided to promote a sun awareness programme to a local school. Schoolchildren are important targets for sun awareness education, and it is known that the knowledge, attitudes and behaviour of school teachers with regard to this issue is poor (Freak, 2004). The main aim of this article is to give a brief summary of the rationale and strategies used and provide suggestions for future sun awareness programmes. Sun Awareness Week provides opportunities for skin cancer clinical nurse specialists (CNSs) to promote sun safety messages to the general public. The annual event is promoted by the UK Skin Cancer Working Party which last year began on 15 May. Its key health education messages are:
- Avoid excessive sun exposure throughout your lifetime, but especially during childhood years;
- Enjoy the benefits of fine weather without putting yourself at risk;
- Avoid remaining in direct sunlight during the midday hours;
- When in the sun, wear sun-protective hats with wide brims to protect your ears, face and neck;
- When in the sun, wear sun-protective clothing;
- Wear sunglasses to protect the vulnerable skin around the eyes;
- Before going out in the sun, apply suitable high-protection factor sunscreens (Buchanan, 2006).
I was appointed Macmillan skin cancer clinical nurse specialist at the Royal Bournemouth and Christchurch Hospital NHS Foundation Trust in September 2005. The post was established to develop coordinated skin cancer services and provide information and psychological support for patients (and their families) who have been given a diagnosis of skin cancer. In addition, an important part of the role is to educate and advise on the prevention of skin cancer. Since being in post I have overseen several developments in skin cancer services, including:
- Creating a supportive role for people who have been given a diagnosis of skin cancer;
- Developing skin cancer patient information literature;
- Developing skin cancer education programmes and learning packages;
- Making people aware of skin cancer through awareness campaigns;
- Taking the lead in promoting the Sun Awareness Weekprogramme;
- Taking responsibility for developing the British Association of Specialist Skin Cancer Nurses (and being nominated chairperson of the group).
The south-west of England has a particularly high incidence of skin cancer compared with the rest of England and Wales (Fig 1) and malignant melanoma is the sixth most common cancer in the region (SWCIS, 2006) (Fig 2 and 3). Raising awareness is particularly important in Bournemouth, a seaside town in Dorset where the incidence of skin cancer is above the national average. Sun Awareness WeekIt was decided to develop a campaign strategy for Sun Awareness Week (15-19 May 2006) to promote the importance of sun safety and early detection of skin cancer. Data from Australia (a pioneer of sun care) shows that by changing people’s attitudes to sun tans and the necessity of protecting the skin from sunburn, it is possible to reduce the incidence of skin cancer. The objectives of the campaign are listed below (Box 1). Box1. The objectives of Sun Awareness Week
Primary schoolWorking with schools or school nurses to educate children about sun safety is a significant role played by the skin cancer CNS. Knowledge, attitudes and behaviour with regard to sun exposure are poor among young children (and their carers) and they are therefore an important target group for promoting sun awareness. Accordingly, I approached MudefordInfant School, a local primary schoolof approximately 200 children aged 4-7 years, and asked the headmistress if the school would be interested in assisting me by becoming the pilot for Sun Awareness Week. They were enthusiastic about participating in the programme. The headmistress and I met regularly to hold brainstorming sessions and discuss aims and objectives. The main aim was to develop a programme that could be incorporated into the children’s weekly environmental studies. The programme would engage children in sun safety activities over a period of several weeks with completion aimed for Sun Awareness Week itself. A brief synopsis of this timetable is shown as appendix 1. The headmistress and I thought it important to obtain the consent and cooperation of the children’s parents. This was achieved by the headmistress writing to parents explaining my role as a CNS and my intentions. The letter also requested permission for their child to be involved in the sun safety project and parents were asked to give their consent for their child to be photographed. All the reply slips that were returned indicated consent. All the 200 children at the school were involved in the project. It was agreed that besides educating children it was just as important to educate adults about sun safety, so the headmistress and I devised a series of educational sessions for parents and teachers. Before the start of the educational programme I was invited to attend assembly to meet the children and teachers. I introduced myself and explained my intentions. I then invited the children to talk about how they looked after their skin when they went to the beach or played in the sunshine and describe what they thought sunburn was - all of which progressed into very interesting ‘discussions’. Following the discussions, I read the children a story in which one of the characters experiences painful sunburn. I also invited them to take part in two competitions:
- To come up with a name for their sun awareness project;
- To draw a picture of how they could keep themselves safe when they played outside on a hot, sunny day.
I told them prizes would be given for the best pictures, which then would be displayed in the main entrance of the RoyalBournemouthHospital and in the waiting room of a local GP surgery during Sun Awareness Week. The headmistress and I developed pre- and post-questionnaires that the children would be asked to complete during their environmental lessons. This information would help me to assess the children’s knowledge before the programme, and later to gauge whether it had been succesful. ImplementationJust as everyone knows that smoking is bad for your health, people should also know that getting a suntan causes damage to the skin and sometimes results in the development of a skin cancer. A large body of research shows that knowledge promotes healthy behaviour. Education sessions for parents and teachers were held in the evening over a two-week period. It was my intention to give information on skin self-examination and how to recognise benign lesions, malignant and non-melanoma skin cancers. Parents and teachers were also invited to participate in the development of a training manual for people working with children and school guidelines/policies for using sun protection in school. According to Cancer Research UK (2006), each SunSmart school must have:
- An approved sun protection policy;
- A ‘no hat, play in the shade’ rule;
- Sun protection taught at every level;
- Sufficient shade in the school grounds.
Education should aim to continue increasing awareness of the health effects of exposure to ultraviolet radiation. I emphasised to the headmistress the importance of shady areas in the school playground and the need to cover up with suitable clothes and hats (Freak, 2004). I also informed her about the successful skin cancer prevention strategy used in Australian schools - the ‘no hat, no play’ policy - which has now been successfully implemented in some British schools during the summer months (Buchanan, 2001). It is well known that nurses, midwives and health visitors involved with children, parents and carers are in a prime position to instigate health education on skin cancer prevention in this way (Buchanan, 2001). The headmistress thought the rule was an excellent idea and aimed to enforce it from May 2006. She said they already had a ‘no coat, no play’ policy for the winter and that coming to school with a hat in the summer was equally important. Another point I advised her about was the ‘slip, slap, slop’rule, which encourages people to slip on a shirt, slap on a hat and slop on the sunscreen. ‘Slip, slap slop’ has been very effective in Australia and the headmistress thought it should be incorporated into our education programme. Its inclusion in the education questionnaires was also proposed. EvaluationWe know that health promotion in the early years of life influences the psychological development of the child and ultimately the health of the adult. Mothers and young children therefore represent important target groups for health education on sun protection. The ultimate aim is to modify or change sun-seeking behaviour to sun-avoidance behaviour (Buchanan, 2006). Staff at the school very much appreciated the support and information they received and stressed that they would continue to incorporate sun safety into the curriculum. In May 2006 the ‘no hat, no play’ policy was introduced into the school. It even extends to the teachers, who can be seen wearing their hats when outside in the playground. If a childforgets to bring their hat into school they are not allowed outside to play. The pre-education questionnaire revealed a lack of knowledge and the post-education questionnaire showed a remarkable improvement. Some of the questions were left blank, but this is understandable given that some of the children were as young as four. During Sun Awareness Week, my consultant and I visited the school to say thank-you to the children, teachers and parents for participating in the sun awareness project. Prizes were distributed to the best sun safety drawings. Each child was given a certificate for participating in the project. In addition, the local evening paper came and took photographs. Overall evaluationAlthough evaluation forms were not distributed at the parent/teacher sessions, feedback was encouraging with those who attended saying they found the sessions interesting and that they were more knowledgeable than before. I had been pleasantly surprised by their enthusiasm and active participation. Many questions were asked and a lot of interest shown, and parents and teachers appeared to be pleased that their school had been selected as the ‘pilot school’ and voiced their approval of the ‘no hat, no play’ policy. Sunscreen was discussed at great length. The general consensus was that children should be able to self-apply this when at school. The school may purchase suncream dispensers so that children and teachers can self-apply before outdoor activities. This will help to prevent sunburn, an acute toxic reaction to over-exposure to ultraviolet light (Chu, 1997). Disappointingly, there were no volunteers to assist with the development of a sun safety school protocol/policy for sunscreen, but it is something the headmistress and I aim to develop in the future. I am confident that the sun awareness programme will be more than just a one-off event and that the school will continue to promote sun safety annually to all it pupils in preparation for the summer months. I also hope older pupils will take ‘care in the sun’ messages with them when they move into their new schools. RecommendationsThe headmistress and I decided the way forward was to continue with sun safety education programmes that could be extended to more primary school children within the Dorset area. This would be too big a project for me to do alone due to my other commitments, but sun awareness/sun safety education sessions could be organised for professionals (teachers/classroom assistants, school nurses). This information could then be disseminated to schoolchildren of all ages. The main messages I included when delivering my education programmes were:
- That it is fine to be pale;
- To increase children’s awareness of using clothing and shade when outside;
- The importance of avoiding being in the sun between 11am and 3pm;
- The importance of using sun protection with an adequate SPF (>15) and applying it frequently and correctly (at least 30 minutes before going outside, reapplying it at least two-hourly or more frequently according to the manufacturer’s instructions) and to ensure that the sunscreen is not rubbed in (a thin film should be evident).
We thought these messages could be communicated via:
- Books, picture books, CDs, DVDs, videos, the hospital website;
- Using teaching resources;
- Articles in teaching union magazines;
- Articles in school magazines/newsletters;
- Articles in children’s school magazines;
- Radio/TV programmes;
- Public and school libraries;
- Teaching/education sessions.
Visiting schools in order to deliver sun safety education is definitely a project I would be keen to undertake again. Other initiatives undertaken for Sun Awareness Week 2006 included:
- A sun safety questionnaire distributed to all hospital workers (to be repeated annually over a five-year period and then the results audited to see if the education given has had any effect);
- A skin cancer presentation to healthcare professionals;
- A skin cancer awareness presentation at a local department store;
- A skin cancer presentation to the general public at the Bournemouth Pavilion.
Recommendations for future SAW programmes In order to reduce the incidence of skin cancer it is vital to:
- Continue with annual skin cancer education programmes for healthcare professionals and the general public;
- Ensure that these events are broadcast and publicised well in advance;
- Think about ways that the general public can enjoy the sun’s beneficial effects while at the same time protecting their skin from burning;
- Advocate CRUK’s SunSmart message, which is to:
Stay in the shade between 11am and 3pm; Make sure you never burn; Aim to cover up with a hat, T-shirt and sunglasses; Remember to take extra care of children; Then apply factor 15+ sunscreen; Also to report any mole changes or unusual skin growths promptly.
- Ensure that people know that the best all-round defence is to limit the time spent in the sun and to use a good sun protection (factor 15+). Sun protection should begin in infancy and continue throughout one’s lifetime - and it is never too late to start;
- Stress the importance of protecting children so that the incidence of skin cancer (in the future) can be reduced;
- Give information about the dangers of using sunbeds and tanning salons in terms of premature skin ageing and skin cancer development. In addition, tanning bed operators may not know about a medical condition that might predispose someone to burning or that they might be receiving photosensitising drugs;
- Increase the proportion of people reporting to their GP at an early stage of the disease;
- Lobby for environmental change, for example provision of shade, availability of cheaper (or free) sunscreens (especially for children) and use of protective clothing;
- Aim to develop a series of sun awareness/sun safety education sessions for healthcare professionals working in surgery, oncology, dermatology and outpatient wards and departments within hospitals, and aim to extend these sessions to healthcare professionals in primary care and include pharmacists and their assistants;
- Develop a ‘management of skin cancer resource file/folder’ and distribute to each ward/ department within hospitals.
It helps to get sun safety messages across if people can see what damage they have already done to their skin, through fluorescence spectroscopy imaging. Companies that offer this service could be approached and invited to spend a day(s) at the hospital to demonstrate this equipment. As Bournemouth and Christchurch are popular destinations in the summer months for holidaymakers, it is an ideal opportunity to target holidaymakers with information leaflets and literature made available in the following places:
- Travel agents, estate agents;
- Hotels, guest houses and holiday apartments;
- GP and dental surgeries;
- A&E, outpatients and pharmacy departments in hospitals;
- Airports, train stations, ports, bus and coach stations;
- Radio and television slots;
- Leisure centres;
- Supermarkets/department stores;
- In addition, we should focus on restricting minors’ access to sunbeds (<18 years).
Further informationFurther information on Sun Awareness Week, sun safety educational strategies and the British Association of Specialist Skin Cancer Nurses can be obtained from: Jane Freak,
Macmillan Skin Cancer Nurse Specialist
c/o Mr Perry’s Secretary, Surgical Secretariat
The Royal Bournemouth Hospital
Dorset BH7 7DW Telephone: 01202 704725 Bleep: 01202 303626 bleep 2656 Email: email@example.com ReferencesBuchanan, P. (2006) Basal cell carcinoma: update on management.Nurse Prescriber; 1: 9, e29. Buchanan, P. (2001) Skin cancer. Nursing Standard;15: 45, 45-52. Cancer ResearchUK (2006) Skin Cancer Factsheets Chu, T. (1997) Practical advice on sun protection. Dermatology in PracticeJuly/August (sponsored supplement) S1-S3. Flavell, T. (2004) Raising awareness of skin cancers in central Manchester. Dermatological Nursing; 3: 2: 23. Freak, J. (2004) Promoting knowledge and awareness of skin cancer Nursing Standard;18: 35, 45-53. South West Cancer Intelligence Service (2006) Factsheet No. 2: Malignant Melanoma in the SouthWest ICD-10*: C43. Appendix 1. Action plan Sun Awareness Project 2006MudefordCommunityInfantsSchool Area: Environmental Education
|6 March||Questionnaire to all children||Children to work individually to answer questions (except Reception, worked as a class)||PC122 question booklets||All completed and handed toJane Freak|
CIRCLE TIME ACTIVITIES:
|MirrorsMagnifying glassesSun awareness bookSkin type chartsExplanation of skin types.|
|20 March||1. Discuss if you were outside without a sun hat and sun cream where would be the best places to play.2. Walk around school and look at the places you play out side.3. When you are outside talk about the clouds. Discuss if clouds stop you getting burnt by the sun. Sun rays can still travel through thin clouds, so you always need to be careful.3. In pairs make a poster for other children about how to keep safe in school in the sun.4. Talk about the NO HAT, NO PLAY policy.HOMEWORK:5. Make a poster for the NO HAT NO PLAY policy for the playground.||Large paper and felt tip pens.Variety of sun hats.|
|27 March||1. Look at the variety of things you are allowed to take to the beach. Discuss which six things you would take and why.2. In your work books draw all the things you are going to take to keep you safe in the sun.3. Draw a picture of yourself swimming in the sea.4. Discuss whether on a really hot day if swimming in the sea keep you safe from the sun?5. Write the following comment under the picture of you swimming. The sea cannot protect you from the sun. You can burn just as easily in the water as out.HOMEWORK:6. Design a groovy sun hat to wear at the beach.||Selection of beach articles:Towel,Spade, sun tan lotion, sun glasses,T-shirt, flags,parasol, sandwiches, ball, trunks, sun suits, bikini, swim suit. Sun wipes, sun hats, toy, drink of cols, drink of water., rubber ring.Work books|
|3 April||Easter Hols|
|10 April||Easter Hols|
|17 April||Watch the slide showwww.bootslearningstore.comLearn/write out/decorate the slip slop slap rules|
|24 April||Look at a selection of sun cream at different factors, relate to skin types.How often and when to apply.Talk about family in the sun, what could you remind them to keep them safe.(Make a reminder?)||Selection of sun cream at different factors|
|2 May||Visit on Tuesday 2 May from Jane Freak and Mr. Perry from9-9.30pm, class visits to be arranged. Please be doing sun workClassroom work for the week:Group picture of sun safe activities.Competition (to be done in school)Draw a picture of yourself being safe in the sun.||Introduction of NO HAT NO PLAY policyActivities in classroom for the week.||Paper no bigger than A3|
|8 May||Preparation for exhibition||Non school-based -Jane Freak|
|15 May||Sun Awareness weekExhibition at Royal BournemouthChristchurchHospitalPurewell Surgery||Non school-based -Jane Freak|