Settings: Children and adolescents, Early childhood education and care, and schools

Childhood and adolescence are critical periods during which exposure to UV radiation is more likely to contribute to skin cancer in later life,^[1][2][3][4] representing 33% of the lifetime melanoma risk up to 60 years of age.^[4] It has been estimated that 50% of total UV exposure up to age 60 occurs before age 20;^[4] the dermis is thinner in children, with skin thickness gradually increasing from birth to adulthood. Skin thickness of the face, limbs, and trunk of children aged two-13 years is significantly thinner compared with young adults, 25-40 years.^[5] A Queensland study found UV exposure during the first 18 years of a person's life was the most critical risk factor for skin cancer, and also caused skin damage and premature ageing.^[3] Studies of child and adult migrants from low UV environments to high UV environments also add to the evidence that childhood and adolescence are critical periods during which exposure to UV radiation is more likely to contribute to skin cancer in later life.^[1][6][7][8]

Like many cancers, skin cancer has a long latency period,^[9] and overexposure during childhood and adolescence increases risk of developing skin cancer at a later age.^[4] Up to the age of 20, exposure has been shown to result infrequently in melanoma, and much more rarely, in non-melanocytic skin cancer.^[4][10] Mild premature skin ageing, freckling and the development of melanocytic naevi are the more immediate results of overexposure to UV radiation in the first two decades of life.^[4] Although early onset melanoma is comparatively rare (with mean diagnosis age 64 years^[11]), in 2018 melanoma was the most common cancer in people aged 15-29 years, with 358 cases accounting for 15% of all cancers diagnosed in this age group.^[11] However, age-standardised incidence rates for melanoma fell from 96 new cases per 1 million young Australians aged 15-24 in 1985–1989 to 44 new cases per 1 million in 2010–2014.^[12]

In 2018, most melanomas below the age of 20 occurred in the 15-19 year old age group (82%).^[11] Research from Queensland suggests a decline in the incidence of thin invasive melanoma since the mid- to late 1990s among young people who have been exposed to primary prevention and early detection programs since birth.^[13]

In the period 2010-2014, five-year relative survival was high (96%) for young Australians aged 15-24 with melanoma.^[12] Between 1981–1985 and 2011–2015, the age-standardised mortality rate for melanoma in young Australians decreased by 81%, the biggest decline of all cancer types. During 2011-2015, melanoma of the skin was the tenth cause of cancer death among young Australians (14 deaths).^[12]

The National SunSmart Schools Program was launched in 1994 and adopted nationally by 2008. It was followed by the National SunSmart Early Childhood Program, which launched in 1996 and was established in all Australian states and territories by 2009. The programs aim to minimise UV radiation exposure and ultimately reduce lifetime risk of skin cancer in schools and early childhood settings^[14] by asking schools and child care services to apply to be a SunSmart member. This membership ensures that effective sun protection policy and practice are in place when UV levels are 3 and above, and minimum criteria are met. Such criteria include wearing of sun protective hats, sun protection education, uniform/dress code requirements, the provision and encouragement of shade and sunscreen use, teacher/educator role modelling, community involvement, and a written sun protection policy.

In 2020, the programs were collectively estimated to reach well over two million children in Australia.^[15]

Early childhood services

According to 2019 data collated from state and territory SunSmart programs, an average of two-thirds of early childhood education and care (ECEC) services across Australia voluntarily participate in the National SunSmart Early Childhood Program. This program complements the requirements of the Education and Care Services National Law, the Education and Care Services National Regulations and the National Quality Standard (NQS). The eligibility of out of school hours care services varies according to jurisdiction.

A 2020 national study assessed the sun protection policies and practices of early childhood education and care services across Australia over the decade from 2008 to 2018.^[16]

In 2018:

• Most ECEC services (97%) had a written sun protection policy, similar to the 95% of services surveyed in 2008
• The percentage of services requiring children at their service to wear sunscreen increased significantly from 91% in 2008 to 98%.
• Nearly all services require hat wearing for children (>99%) and staff (99%)
• A significantly higher percentage of services required children to wear a Cancer Council approved hat (broad-brimmed, legionnaires or bucket hat) than 2008 (94% vs. 74%)
• 89% of services required children to wear sun protective clothing - a significant increase from 2008 (68%)
• 80% of services reported there was enough shade for all children to play outside, an increase from 75% in 2008.

Primary schools

Children spend long periods of time at primary school during peak UV periods. Research on children’s UV radiation exposure in New Zealand primary schools has shown that exposure is generally higher on weekdays than during the weekend. Physical education, athletics and lunch breaks are associated with high UV radiation exposure. This confirms the importance of sun protection in the primary school setting.^[17]

According to the latest 2019 data collated from the individual state and territory SunSmart programs, an average of around two-thirds of primary schools across Australia voluntarily participate in the National SunSmart Schools Program. Participation rates vary across the country due to support of educational organisations, individual Cancer Council resourcing, capacity, and number of years involved in the program.

In a study evaluating sun protection policies in primary schools and the effect of the National SunSmart Schools Program,^[18] it was found that sun protection policies and practices remained relatively stable between 2005 and 2016, Membership in the program was associated with a significantly greater likelihood of several policies and practices being employed, compared to non-participating schools.

The study showed:

• Schools recommending gold-standard “SunSmart” hats (ie, broad‐brim, bucket and legionnaire style) significantly increased from 80% in 2005 to levels around 90% in 2011 and 2016
• Sunscreen use was encouraged in a number of ways, with sunscreen available in most or all classrooms for 57% of schools in 2016, a significant increase from 2005 levels
• Shade provision for outdoor activities showed some variability across years, with 2016 levels significantly higher than 2005, but significantly lower than 2011. The majority (86%) of schools reported providing shade for passive activities in 2016, while 39% had shade for both active and passive activities
• The incorporation of sun protection into the curriculum appeared to be a reduced focus in 2011 and 2016, with a significant decrease in the proportion of schools which featured this material in class teaching, student assemblies and whole‐school activities

In 2016, SunSmart schools were significantly more likely than non-SunSmart schools to:

• Include SunSmart hats in the school uniform
• Actively encourage the use of sunscreen
• Hold assemblies and swimming carnivals outside peak UV periods.

While sun protective behaviours are evident in many Australian primary schools, a New South Wales study found that students are unlikely to engage in sun protection practiced beyond the school setting.^[19]

A study of the comprehensiveness of sun-protection policies in North Queensland primary schools found that although 96.6% of schools had a written sun protection policy, less than one in four schools addressed shade use or providing shade at events, while policies addressing hats (93.8%) and clothing (98.2%) were the most common. Only 5.4% of Queensland primary schools met all SunSmart criteria in their written policy (encompassing sun protection including adequate shade provision, role modelling, rescheduling, promoting sun safety and education, policy use for planning outdoor events and periodic review of policies).^[20]

Levels of observed sun protection practices may differ to levels of self-reported behaviour. Among a sample of SunSmart primary schools in NSW, 60% of students were observed wearing a SunSmart hat at school, a proportion well below the percentages being reported in national surveys as a whole. The level of hat-wearing also varied considerably across schools, and sunscreen consumption by school students during the school day was negligible.^[21]

A Queensland study has shown that although the proportion of students and adult role-models wearing hats was not significantly higher in SunSmart status schools overall, a greater proportion of students at SunSmart schools wore highly protective hats (broad-brimmed/bucket/legionnaires) in October–March compared to non-SunSmart schools.^[22]

Secondary schools

Results of a survey of Australian secondary students in 1996 showed that they were likely to "accept structural changes that move desired activities out of the sun".^[23] Consistent with this, a study of randomly selected Melbourne secondary schools showed that adolescents used—rather than avoided—shade in the form of newly-installed shade-sails. This is evidence that built shade can help reduce exposure to UV radiation in secondary school settings.^[24]

Routine use of hats, sunscreen and covering clothing was low among adolescents taking part in the Australian Secondary School Alcohol and Drug Questionnaires in 2002 (the most recent year for which national data is available).^[25] Only 54% of boys and 31% of girls routinely wore a hat. The prevalence of adolescents ‘usually’ or ‘always’ wearing covering clothing was also low (25% and 13%). Routine sunscreen use was more common: 36% among boys and 50% among girls.

A Cancer Council Victoria study identified that regulatory support and/or strong leadership is required to enable effective sun protection in secondary schools. While the study identified potential strategies to improve sun protection, it is acknowledged that it is often perceived to be a low priority relative to other health and well-being demands in this setting.^[26]

Sun protection compliance among adolescents on summer weekends

See here for trends in sun protections behaviours among Australian adolescents on summer weekends.

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Last modified: 12 August 2022