All public and private elementary and middle schools in the United States are eligible to participate in the SunWise School Program. Schools are recruited by distributing information via conferences of various teacher and nurse organizations, meetings of skin cancer interest groups, newsletters, publications, the Internet, and referrals from partner organizations, such as the American Cancer Society and the SHADE Foundation (Arizona). Single classrooms, multiple classrooms, schools, or entire school districts were are eligible. All school faculty, including school nurses and classroom teachers, are recruited and eligible to participate.
The cross-curricular, standards-based classroom lessons were contained in an activity guide and later expanded in the SunWise Tool Kit. An expert panel of educators, curriculum specialists, and skin cancer researchers reviewed the lessons. Educational standards were established by governing bodies for each content area (e.g. – science standards were developed by the National Science Teachers Association, math standards by the National Council of Teachers of Mathematics) in order to have a consistent baseline of knowledge that students must have to progress from one grade tothe next. Lessons focus on three key areas: 1) the effects of UV radiation, 2) risk factors for overexposure, and 3) sun-protection habits. Each lesson consists of a variety of developmentally-appropriate activities meeting prescribed educational standards that combines education about sun protection and the environment with other aspects of student's regular learning in sciences, social studies, health, and mathematics. The expectation is that at least one or two hours will be spent on the activities.
There are at least 30 activities for faculty to choose from, ranging from lessons on ozone depletion to one on the testing of different sunscreens using a UV-sensitive Frisbee (included in Kit) (Figure ).
Other activities are supplemented by the SunWise website, which offers schools the opportunity to check for the UV Index, report, chart, and compare UV measurements, and play educational games. Educators can similarly test the effectiveness of UV-blocking sunglasses.
To further encourage active participation in the program, SunWise launched an awards program in spring 2003 (Figure ). The program was designed to officially recognize elementary and middle school educators and administrators who have shown an exemplary commitment to sun safety education.
Pretests and posttests in schools receiving SunWise program
The effect of classroom lessons on students' knowledge, attitudes, practices, and intended practice was evaluated using identical, self-administered pretest surveys distributed in September-March (autumn-spring) and posttests distributed immediately after teaching the SunWise educational program (generally May-June) (spring-summer).
The evaluation of the SunWise School Program was approved by the Boston Medical Center Institutional Review Board, which did not request parental consent or child assent since there were no personal identifiers on the survey form and the purpose of the evaluation was to track SunWise teaching. Surveys were collected and individually analyzed each year from 1999–2002 and no students or teachers were surveyed more than once. The number of schools from which the sample was drawn as of April of each of the school years was 25 in 1999, 130 in 2000, and 300 in 2001, and 3450 in 2002. From this roster of 3905 schools, using an alphabetical listing of all of the schools, we randomly chose 1 out of every 25 schools to participate in the survey process.
All schools agreeing to participate in the SunWise School Program must register at the SunWise website http://www.epa.gov/sunwise
. Teachers or nurses enrolling in the program include the address and state, as well as the grade level and the number of students in the school.
Testing in schools receiving SunWise (experimental) and not receiving SunWise (controls)
In the year 2000, all 9 elementary schools in Framingham, MA served as controls (n = 1,285 students) and provided no education during spring months. School nurses conducted pretests (November) and posttests with 4th and 5th grade children in June. Student responses in the control schools were compared with the nationwide profile of children in similar grades receiving SunWise education in the spring of 2000.
Surveys conducted by school nurses in two separate academic years
Compared with responses from the earlier academic year, we sought to determine whether SunWise teaching would lead to maintenance of new knowledge and healthy attitudes, and if there would be any resultant changes in sun protection practices or sunburning rates. Therefore, since school nurses were more likely than classroom teachers to follow the same children in successive school years, in 11 schools, the nurses conducted 3 surveys-the pretest, the routine follow-up in the spring and a second follow-up survey in the following fall as the children had progressed to the next grade.
Separate teacher surveys were mailed to an additional 600 schools and 320 teachers responded (53%). Teachers were asked to: rate their overall satisfaction with the program; describe infrastructure enhancements such as new school wide policies; report on change in their own personal sun protection behaviors; and note their receptiveness to: new curriculum on the safety of tanning beds.
Measures and Scales
The student survey was derived from other instruments, reviewed and edited by educational and child development experts, pilot tested by 10 children ages 6–7 for readability and length, and time tested to ensure completion within 5–7 minutes. The instrument included questions on demographics (age, sex, hair color); knowledge (appropriate SPF for outdoor play, highest UV Index number corresponding with need for sun protection, need for hats and shirts outside), attitudes (tanning as good or healthy, whether suntan is good for the skin); practices (sunscreen use and parts of the body covered with sunscreen, and use of hats, long-sleeved shirts, and sunglasses), and intended practices (sunscreen use and playing in shade for the upcoming summer). A single question asked children to report the number of sunburns experienced the previous summer. Students were asked, "when I'm outside in the sun during the summer, I wear sunscreen, hats, long-sleeved shirt, and sunglasses," and given the choices of all of the time, sometimes, and never.
For purposes of this analysis, the use of sunscreen, hat, and sunglasses was considered routine, if practiced all of the time, and use of long-sleeved shirts as routine, if practiced always or sometimes. Scales differed since earlier studies indicated that long-sleeve shirt use was far less commonly practiced than sunscreen [6
]. Intended practices as a key outcome measure was chosen since much of the teaching occurred in the early spring and there was little opportunity for children to immediately change their sun protection practices.
Since the surveys were anonymous, it was not possible to link individual students' answers from both surveys. Therefore, the measure of the effect of the program is the difference between the pretest and the posttest in the percentage of students providing specific responses rather than the change in individual students' responses. Ninety-five per cent confidence intervals of the difference between pretest and posttest and p-values using the chi-square test for 2 × 2 contingency tables were calculated. In order to control for slight differences in the age distribution of students at pretest and posttest, we age-standardized all proportions using the overall student age distribution as the standard. Since there were only very minor differences between the crude and age-adjusted results, we chose to present the crude results only.
The effects of the intervention were evaluated by adjusting for baseline difference (pre-experimental versus precontrol schools). Z-tests on Peffect for statistical significance were performed.