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

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

Skin Cancer Statistics and Issues Prevention Policy


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

References

  1. Whiteman DC, Whiteman CA, Green AC. Childhood sun exposure as a risk factor for melanoma: a systematic review of epidemiologic studies. Cancer Causes Control 2001 Jan;12(1):69-82 Available from: http://www.ncbi.nlm.nih.gov/pubmed/11227927.
  2. Godar DE. UV doses worldwide. Photochem Photobiol 2005 Jul;81(4):736-49 Available from: http://www.ncbi.nlm.nih.gov/pubmed/15819599.
  3. Kimlin MG, Guo Y. Assessing the impacts of lifetime sun exposure on skin damage and skin aging using a non-invasive method. Sci Total Environ 2012 May 15;425:35-41 Available from: http://www.ncbi.nlm.nih.gov/pubmed/22459885.
  4. Green AC, Wallingford SC, McBride P. Childhood exposure to ultraviolet radiation and harmful skin effects: epidemiological evidence. Prog Biophys Mol Biol 2011 Dec;107(3):349-55 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21907230.
  5. Seidenari S, Giusti G, Bertoni L, Magnoni C, Pellacani G. Thickness and echogenicity of the skin in children as assessed by 20-MHz ultrasound. Dermatology 2000;201(3):218-22 Available from: http://www.ncbi.nlm.nih.gov/pubmed/11096192.
  6. Armstrong BK. How sun exposure causes skin cancer: An epidemiological perspective In: Hill D, Elwood JM, English D. Prevention of Skin Cancer. Dordrecht, The Netherlands: Kluwer Academic Publishers; 2004. p. 89-116.
  7. Khlat M, Vail A, Parkin M, Green A. Mortality from melanoma in migrants to Australia: variation by age at arrival and duration of stay. Am J Epidemiol 1992 May 15;135(10):1103-13 Available from: http://www.ncbi.nlm.nih.gov/pubmed/1632422.
  8. Autier P, Boyle P. Artificial ultraviolet sources and skin cancers: rationale for restricting access to sunbed use before 18 years of age. Nat Clin Pract Oncol 2008 Apr;5(4):178-9 Available from: http://www.ncbi.nlm.nih.gov/pubmed/18268545.
  9. Baade PD, Green AC, Smithers BM, Aitken JF. Trends in melanoma incidence among children: possible influence of sun-protection programs. Expert Rev Anticancer Ther 2011 May;11(5):661-4 Available from: http://www.ncbi.nlm.nih.gov/pubmed/21554037.
  10. Kricker A, Weber M, Sitas F, Banks E, Rahman B, Goumas C, et al. Early Life UV and Risk of Basal and Squamous Cell Carcinoma in New South Wales, Australia. Photochem Photobiol 2017 Nov;93(6):1483-1491 Available from: http://www.ncbi.nlm.nih.gov/pubmed/28710897.
  11. Australian Institute of Health and Welfare. Cancer data in Australia. [homepage on the internet] Canberra, Australia: AIHW; 2022 Jul 1 [cited 2022 Jul 27]. Available from: https://www.aihw.gov.au/reports/cancer/cancer-data-in-australia/contents/summary.
  12. Australian Institute of Health and Welfare. Cancer in adolescents and young adults in Australia. Canberra Australia: Australian Institute of Health and Welfare; 2018 Apr 18 [cited 2020 Apr 14]. Report No.: cat. no. CAN 110. Available from: https://www.aihw.gov.au/reports/cancer/cancer-adolescents-young-adults.
  13. Iannacone MR, Youlden DR, Baade PD, Aitken JF, Green AC. Melanoma incidence trends and survival in adolescents and young adults in Queensland, Australia. Int J Cancer 2014 May 8 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24806428.
  14. Cancer Council Australia. SunSmart schools and early childhood programs. Sydney, Australia; 2012 Available from: https://www.cancer.org.au/preventing-cancer/sun-protection/sunsmart-schools/.
  15. Cancer Council Australia. Turning the tide of skin cancer. [homepage on the internet] Sydney, Australia; [cited 2020 Aug 4]. Available from: https://www.cancer.org.au/about-us/how-we-help/prevention/stories/turning-the-tide-of-skin-cancer.
  16. Hunkin H, Morris JN. A decade of sun protection in Australian early-childhood services: analysis of cross-sectional and repeated-measures data. Health Educ Res 2020 Apr 1;35(2):99-109 Available from: http://www.ncbi.nlm.nih.gov/pubmed/32101611.
  17. Wright CY, Reeder AI, Bodeker GE, Gray A, Cox B. Solar UVR exposure, concurrent activities and sun-protective practices among primary schoolchildren. Photochem Photobiol 2007 May;83(3):749-58 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17576384.
  18. Hunkin H, Pollock K, Scupham R. The National SunSmart Schools Program: Impact on sun protection policies and practices in Australian primary schools. Health Promot J Austr 2020 Apr;31(2):251-257 Available from: http://www.ncbi.nlm.nih.gov/pubmed/31466123.
  19. Winslade M, Wright B, Dudley D, Cotton W, Brown A. Australian primary school communities' understandings of SunSmart: a qualitative study. Aust N Z J Public Health 2017 Oct;41(5):483-489 Available from: http://www.ncbi.nlm.nih.gov/pubmed/28664586.
  20. Turner D, Harrison SL, Buettner P, Nowak M. School sun-protection policies--does being SunSmart make a difference? Health Educ Res 2014 Mar 20 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24650947.
  21. Dudley DA, Cotton WG, Winslade MJ, Wright BJ, Jackson KS, Brown AM, et al. An objective and cross-sectional examination of sun-safe behaviours in New South Wales primary schools. BMC Public Health 2017 Jan 5;17(1):21 Available from: http://www.ncbi.nlm.nih.gov/pubmed/28056902.
  22. Turner D, Harrison SL, Buettner P, Nowak M. Does being a 'SunSmart School' influence hat-wearing compliance? An ecological study of hat-wearing rates at Australian primary schools in a region of high sun exposure. Prev Med 2014 Mar;60:107-14 Available from: http://www.ncbi.nlm.nih.gov/pubmed/24382297.
  23. Livingston PM, White VM, Ugoni AM, Borland R. Knowledge, attitudes and self-care practices related to sun protection among secondary students in Australia. Health Educ Res 2001 Jun;16(3):269-78 Available from: http://www.ncbi.nlm.nih.gov/pubmed/11497111.
  24. Dobbinson SJ, White V, Wakefield MA, Jamsen KM, White V, Livingston PM, et al. Adolescents' use of purpose built shade in secondary schools: cluster randomised controlled trial. BMJ 2009 Feb 17;338:b95 Available from: http://www.ncbi.nlm.nih.gov/pubmed/19223344.
  25. Livingston PM, White V, Hayman J, Dobbinson S. Australian adolescents' sun protection behavior: who are we kidding? Prev Med 2007 Jun;44(6):508-12 Available from: http://www.ncbi.nlm.nih.gov/pubmed/17400286.
  26. Nicholson AK, Hill J, Walker H, Heward S, Dobbinson S. Teacher perceptions of sun protection practices in the secondary school setting: Barriers, enablers and recommendations for future. Health Promot J Austr 2020 Apr;31(2):258-267 Available from: http://www.ncbi.nlm.nih.gov/pubmed/31269302.
Skin Cancer Statistics and Issues
Skin Cancer Statistics and Issues
Skin cancer introduction
Skin cancer types
Skin cancer incidence and mortality
Detection and screening
Risk factors/epidemiology
UV radiation
Sun protection
Trends in sun protection behaviours
Tanning
Sunburn
Solariums
Vitamin D
Climate change
Settings: Children and adolescents, Early childhood education and care, and schools
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