Sun awareness in school teachers

C.FLEMING, C.NICOLSON,* F.TOAL* AND R.MACKIEDepartment of Dermatology, University of Glasgow, Western Infirmary, Glasgow G11 6NT, U.K.*Department of Health Promotion, Greater Glasgow Health Board, Glasgow, U.K.

Accepted for publication 18 February 1998

Summary School children are important targets for sun awareness education, but the knowledge, attitudes andbehaviour of school teachers with respect to sun awareness are poorly understood. A questionnaire-based survey of 76 school teachers was undertaken. Twenty-four per cent of teachers indicatedprevious experience in teaching sun awareness, but 93% of teachers had no classroom resources forteaching sun awareness. Sun awareness was perceived by respondents as unimportant relative toother health education issues. There was considerable scope for improvement in attitudes andbehaviour of teachers with respect to sun awareness. Teachers need more information aboutenvironmental factors which affect strength of sunlight, individual risk factors for sunburn andsunscreen strength. Intervention strategies involving school teachers need simple messages,emphasizing the importance of shade, clothing and hats in sun avoidance.

An important risk factor for cutaneous malignantmelanoma is excessive sun exposure in childhood.1 Inthe U.K., protection of children from the damagingeffects of sunlight is often inadequate,2 and adolescentsinfrequently use sun protective measures in strongsunlight.3 Schools and school teachers are thereforeimportant targets for sun awareness education.

In view of the lack of data concerning sun awarenessin teachers, we have undertaken a questionnaire-basedsurvey to establish the personal and professional attitudesto sun awareness in local teachers. The informationgained from this study is critical for development offuture sun awareness interventions in schools.

Materials and methods

A self-completed questionnaire was designed and pre-tested, and minor modifications in layout were made.Questions of attitude and behaviour were developed intwo focus groups of nine individuals of mixed sex,varying age (17–24, 22–32 years) and social class(A, including four school teachers, and B, C1 and C2),using questions from previous studies as source mate-rial.4 Behavioural questions assessed intention to useeach of four methods of sun protection, at home andabroad.

The questionnaire was sent to 100 school teachers in45 primary and five secondary comprehensive schools.The predominance of primary schools was due to theneed to assess teachers with access to children of a

relatively young age. The questionnaire consisted offour sections. The first sought basic descriptive informa-tion. Skin colour of respondents was not requested, asthere was concern that this may be misconstrued byrespondents. The second section assessed resources,experience and perceptions of the importance of sunawareness issues in teaching. The third section evalu-ated attitudes and behaviour of teachers with respect tosun awareness (Table 1) and the fourth assessed know-ledge of sunlight and sunburn (Table 2). The informationwas processed on the Statistical Package for Social Sciences.

In section 3 of the questionnaire respondents wereasked to indicate agreement with statements by answer-ing ‘strongly agree’, ‘agree’, ‘neither agree nor dis-agree’, ‘disagree’ or ‘strongly disagree’. Scores werecalculated on the basis of ‘strongly correct’ answer(score 9), ‘correct’ answer (8), ‘neither agree nor dis-agree’ (5), ‘incorrect’ answer (2) and ‘strongly incor-rect’ answer (1). The scoring system is necessarilyarbitrary, and is weighted so that ‘good’ intentionsscore highly and ‘poor’ intentions do not. Strong inten-tions are given greater recognition, although in thescoring system this effect is marginal, as we are notcertain of the difference between an intention and astrongly expressed intention, in regard to sun exposure.The open question at the start of section 4 was scoredout of 4, with 1 for ‘hat’, ‘clothes’ or similar, 1 for‘sunscreen’ or similar, 1 for ‘shade’ or similar, and 1 for‘avoid midday sun’ or similar.

The mean scores for questions 1–16 of section 3 were

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compared with the mean scores of 15 dermatologists(who were assumed to practise well-informed attitudesand behaviour) who answered these questions (Table 3).The hypothetical minimum score, indicating ‘very poor’attitudes and behaviour of the group is 1 and thehypothetical maximum score, indicating ‘very good’attitudes and behaviour, is 9. The questions in section4 were tested with 15 dermatologists and all questionswere answered correctly, with no ‘don’t know’s.

ResultsSection 1: basic information

Seventy-six questionnaires were returned (76%). Allreturned questionnaires were answered fully. Eightyper cent of teachers worked in primary and 20% insecondary schools. Eighty-two per cent were womenand 18% were men. Forty-three per cent were parentsor carers of children under the age of 16 years.

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Table 1. Section 3 of the questionnaire: attitudes and behaviour. Respondents were asked to reply ‘strongly agree’, ‘agree’, ‘neither agree nordisagree’, ‘disagree’ or ‘strongly disagree’ to statements 1–16

In Britain on a sunny summer day:1 I try to avoid the midday sun2 I wear factor 8 or stronger suncream when outdoors3 I try to sit in the shade, rather than in direct sunlight4 I wear a hat when outdoors

If abroad:5 I would wear a hat when I was outdoors in the sun6 I would wear factor 8 or stronger suncream when I was out in the sun7 I like to get the deepest possible tan8 I would try to avoid the midday sun9 I would try to sit in the shade, rather than in direct sunlight

In general:10 I don’t mind burning if it helps me get a good tan11 Suntanning causes skin to look old and leathery12 One of my main reasons for going on holiday in the summer is to get a tan13 I feel unattractive when I don’t have a suntan14 When I have the chance I like to spend as much time in the sun as I can15 Tanned skins look more healthy than untanned skins16 Overall there is a low risk that I will develop skin cancer during my lifetime17 How many times in the past 12 months have you had painful and red skin, due to too much sun?

Table 2. Section 4 of the questionnaire: knowledge of sunlight and sunburn. Question one was an open question. Respondents were asked to reply‘agree’, ‘don’t know’ or ‘disagree’ to statements 2–14

1 If you had a child aged between 5 and 10 years in a park in Glasgow during the afternoon of a hot sunny day, what four things would youdo to protect the child’s skin from the sun?

2 The sun’s rays are strongest in the mid-afternoon3 The strength of the sun’s rays is increased on cloudy days4 The strength of the sun’s rays is increased at the top of mountains5 Sunlight increases vitamin A production in the skin6 In general, the amount of sunlight that is safe for you depends on how easily your skin burns7 In general, the amount of sunlight that is safe for you depends on your skin colour8 Sun damage rarely occurs in the U.K. because there is so little sunlight9 Both UVA and UVB cause skin damage

10 Factor 8 sunscreen is eight times more protective than no sunscreen11 Factor 8 sunscreen is the weakest sunscreen recommended for children12 Children who burn easily in the sun have a reduced risk for developing skin cancer13 The sun’s rays are strongest at midday14 Children who are exposed to excessive sunlight have a reduced risk for developing skin cancer

Section 2: perceived importance of sun awareness

Respondents were asked to select the health issues mostlikely to be discussed in the classroom, from a list of sixpossibilities. Issues most frequently discussed were roadsafety (for 56% of teachers this was first choice), druguse (20% first choice) and healthy eating (15% firstchoice). The least frequently discussed issues weresexual health (50% of teachers had this as last choice)and sun awareness (44% last choice). The next questionrequested respondents’ opinions of the most importanthealth issues to discuss in the classroom. Fifty-one percent chose road safety and 28% chose drug abuse. Thesubjects considered least important were sexual health(48% had this as last choice) and sun awareness (33%last choice). Teachers were asked to rate the importanceof sun awareness on a scale from 0 to 10. The meanscore was 6·2, and 31 (41%) teachers scored 5 or less.Nine (12%) respondents scored 10.

Teaching sun awareness

Two questions assessed previous experience of teachingsun awareness. In the first, 24% indicated previousexperience in teaching sun awareness. When thesame question was rephrased, 39% of teachers indicatedthat they had not spent any time teaching sun aware-ness, 54% had mentioned sun awareness during teach-ing of other subjects, 5% had taught a single lesson onthe issue and one teacher had taught a programme oflessons on sun awareness. Ninety-three per cent ofteachers had no classroom resources for teaching sunawareness. Preferred resources for future teaching were

workbooks (61%), leaflets (19%) and computer software(5%); 15% had no preference.

The aspects of sun awareness which teachers feltshould be covered in teaching were sun protection,positive health effects of the sun and environmentalissues (98%, 90% and 53%, respectively, of teachersselected these topics from a list of suggestions). Respon-dents obtained most information about sun awarenessfrom newspapers, magazines and television (67%, 65%and 83%, respectively, of teachers selected these topicsfrom a list of suggestions).

Section 3: attitudes and behaviour of teachers

The scores of answers to section 3 of the questionnaireare given in Table 3.

Section 4: knowledge of sunlight and sunburn

The average score on question 1 was 3·45 (maximumpossible score 4, range 2–4, median 3, dermatologists’average score 3·9). Of the 37 who failed to score fullmarks, 25 (68%) omitted to mention shade. The ques-tion was well answered, suggesting a good understand-ing of practical measures required to protect childrenfrom excessive sunlight. This result is probably an over-estimate of true knowledge, as respondents were primedwith the correct answers in the preceding section. Thescores of answers to questions 2–14 are given in Table 4.

Discussion

There are limited resources available for sun awareness

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Question Teachers’ mean score ‘Well-informed’ mean score

6. Suncream abroad 8·50 9·010. Don’t mind burning 8·40 8·6

8. Midday sun abroad 8·09 8·511. Old and leathery 7·82 9·0

5. Hat abroad 7·79 8·09. Shade abroad 7·29 8·51. Midday sun in Britain 7·16 7·5

13. Unattractive 7·00 7·93. Shade in Britain 6·70 8·87. Deepest tan 6·50 9·0

12. Reason for holiday 6·46 8·02. Suncream in Britain 6·42 8·54. Hat in Britain 5·78 5·3

14. As much time in sun 4·95 7·816. Low risk of skin cancer 4·54 7·315. Tanned skin healthy 4·30 5·8

Table 3. Mean scores of answers to questions1–16 in section 3 of the questionnaire, indescending order of teachers’ scores

interventions and it is desirable to target high-riskgroups in primary prevention strategies. Children whoare exposed to excessive ultraviolet radiation form animportant risk group for cutaneous malignant melan-oma.1 School teachers are the main providers of formalhealth education for children and have an importantrole in sun awareness education. The effectiveness ofteachers in primary prevention of skin cancer is deter-mined by their knowledge, beliefs, training andresources. Although sun awareness in children andparents has been examined,4–12 there are no previousstudies of the attitudes, behaviour or knowledge ofschool teachers with respect to sun awareness, and sowe have undertaken a questionnaire-based, descriptivestudy to obtain this information.

The study suggests that teachers are poorly equippedto teach sun awareness. Most respondents had noexperience of teaching the subject, and few resourcesto enable them. Most teachers obtained informationabout sun awareness through non-specialized media.This is partly a resource problem which may be tackledby the development and dissemination of cheap, user-friendly teaching aids. When working with schools,dermatologists and other health educationalists needto be aware of the need for such resources, as well as thepossible shortage of fixed resources such as structures toprovide shade.13

The ability of teachers to raise sun awareness dependson more than material resources. Teachers need toperceive sun awareness as a relevant topic. The surveysuggests that sun awareness is perceived as relativelyunimportant. The aim of sun awareness promotersmust be to increase the perceived relevance of sun

awareness without deflecting attention from otherhealth issues. This could be measured in future studiesby repetition of the two questions from the study ques-tionnaire which asked respondents to rank the impor-tance of health issues from a given list, and to rate theimportance of teaching sun awareness on a numericalscale. A desirable outcome would be similar answers tothe former question, but increased scoring on the latterquestion. There is a limit to the amount of time devotedto health issues in schools, but it may be possible tointroduce subjects such as sun awareness into differentareas of the school curriculum. We are presently follow-ing this strategy with a sun awareness CD-ROM,14

which is intended for use in computing classes as wellas health education.

The respondents demonstrated reasonable overallknowledge of sunlight and sunburn, but incompletecomprehension of the variables which affect strengthof sunlight, individual risk factors for sunburn andsunscreen strength. These issues need to be taken intoaccount when planning future sun awareness initiativeswith teachers.

The study suggests that many teachers express ‘desir-able’ attitudes and behavioural intentions, but thatthere is considerable scope for improvement. In parti-cular, respondents had low scores in questions relatingto hats and shade, depth of tan and suntanning atti-tudes, indicating that teachers hold suntans and sun-tanning in high esteem. The respondents, as a group,underestimated the risk of developing skin cancer. Simi-lar views have been demonstrated in individuals,regardless of their depth of suntan.15 In addition, 16%of individuals recorded sunburn on at least one occasionin the previous year. Although self-reported behaviourdoes not always correlate with true behaviour,16 theseobservations emphasize the gap between desirable andactual attitudes and behaviour.

The first research into attitudes to sunbathing wasreported in 1987,17 and there have been few detailedstudies examining perceptions of suntanning and per-ceived risks of sunbathing.18 Focus groups are a quali-tative research method, where group dynamics permitin-depth exploration of attitudes difficult to measure byquantitative analysis. Focus groups are a useful tool forinvestigating the beliefs underlying intentions of beha-viour,19,20 and so questions of attitude and behaviour inthis study were developed from focus group sessions.One result of this was to divide questions of intention touse sun protection into the categories ‘at home’ and‘abroad’, and there is evidence that this distinction maybe widely perceived in the U.K.8

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Table 4. Scores of answers to questions 2–14 in section 4 of thequestionnaire, in descending order of teachers’ scores

Question Correct (%) Don’t know (%)

13. Midday 92 512. Burn easily 86 13

8. Sun damage rare in U.K. 83 1514. Excessive sunlight 82 1510. Eight times more protective 70 24

9. UVA and UVB 60 324. Top of mountains 59 307. Skin colour 55 153. Cloudy days 54 386. How easily your skin burns 50 152. Mid-afternoon 32 8

11. Weakest sunscreen 21 415. Vitamin A 18 61

Qualitative methods of investigation may be valuablein sun awareness studies,20 but there has been littlepublished work in this area to date. Sensible sunbehaviour messages are complex compared withissues such as road safety and smoking. Teachers needclear learning objectives and children require simplemessages for successful adoption of safe sun behaviour.This underlines the need for future interventions tocontain straightforward messages, similar to the ‘Shiftto the Shade’ campaign of 1996.

Acknowledgments

We would like to thank Dr David Burden, Department ofDermatology, Western Infirmary, Glasgow for his com-ments on the manuscript and Dr T.Aitchison, Depart-ment of Statistics, University of Glasgow, for statisticaladvice.

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