1.A Background

Skin cancer, including melanoma and keratinocyte (non-melanoma), is now a worldwide health concern, and the United Kingdom (UK) is no exception. Since the early 1990s, melanoma skin cancer incidence rates have more than doubled (140%), and keratinocyte skin cancer rates have increased by 169% [1]. In practice, this translates to 46 new cases of malignant melanomas and 430 keratinocyte skin cancer cases in the UK every day (2016–2018) [1].

It is estimated that skin cancer now constitutes 50% of a dermatologist’s workload [2] and with a shortage of dermatologists in rural and remote areas, dermatology services in the UK continue to feel the pressures of this increasing workload [3]. The financial burden of skin cancer is pressing, with hospital episode statistics suggesting that the cost of skin cancer treatment was forecast to increase from between £106–£112 million in 2008 to at least £180 million in 2020 in England alone [4].

However, estimates suggest 86% of melanoma is preventable with modified sun exposure [5, 6]. Most skin cancers are the result of excess ultra-violet (UV) exposure, the majority occurring before adulthood [7] and severe sunburn as a child greatly increases the risk of developing future skin cancer [8]. Clearly, avoiding excess sun exposure is key when it comes to preventing skin cancer. While this sounds straightforward, in the UK, a face-to-face survey highlighted the fact that both knowledge and behaviour about how to reduce the risk of skin cancer risk are limited and needed to improve if skin cancer rates were to decrease. Respondents underestimated the importance of sunburn in the aetiology of skin cancer with only 40% rating it a very important risk factor. Similarly, while only 43% recognised the role of a high factor sunscreen in reducing their risks, even less, (one third) used sun cream to prevent their risks [9]. Additionally, individuals generally perceive their overall susceptibility to skin cancer as low [10] and both positive attitudes to tanning and perceived barriers to adopting sun-safe behaviours (e.g. the hassle of putting on sun cream) are both major obstacles in the battle for prevention [10].

Skin cancer prevention activities have been shown to be beneficial and effective when delivered to children both due to the importance of limiting sunlight exposure during childhood and because this is when individuals are more amenable to adopting new attitudes and behaviours [11]. Children spend almost half their childhood at school with approximately 8 school hours outside per week, often during the hours of the day (11am-3pm) and months of the year (May-July) where UV levels are at their highest in the UK. School-based education programmes are one way to instil lifelong sun-safe habits from an early age, with several education programmes being shown to be effective in children under 18 [12], and in primary schools [13]. While these interventions have been more successful in Australia than in North America and Europe [14], the evidence suggests more research is needed [12, 14]. In a critical review of ‘Skin Cancer Prevention for Children’, most programs improved sun safety knowledge, but changes in attitude and behaviours were smaller and strategies to improve sun safety policies needs further study [14].

In England, in 2019, sun safety education became a compulsory component of the curriculum. Similarly, the World Health Organisation [15]; the Melanoma Taskforce [16] and NICE [17] all recommend sun safety is taught in schools. However, in Wales it is still up to individual schools to implement their own policies and sun safety education is not mandatory. This is despite The National Assembly’s Children and Young People Committee’s 2012 inquiry into sun protection recommending schools had clear plans for sun protection and The Welsh Network of Healthy Schools National Quality award recommending schools have a sun safety policy in place.

While there is a clear case for focusing on skin cancer prevention in schools: a strong policy emphasis on prevention; health expert recommendations; the fact that 86% of melanomas are preventable and encouraging results from other studies on educational approaches to sun safety; there is no current funding from Welsh Government for skin cancer prevention, and little UK research in this area. To address this important gap, we have designed the Sunproofed study, a 2-year mixed-methods scoping study funded by Health and Care Research Wales (HCRW).

1.B Study aim

Understand how primary schools in Wales are responding to growing skin cancer rates and explore the effectiveness of sun safety policies in schools on knowledge and behaviour.

1.C Objectives

The study is divided into 5 work packages (WPs), each with its own objective(s). To:

1. Discover if primary schools in Wales have sun safety policies; policy characteristics; determine factors that may influence their presence and identify areas where schools need support. (WP1)
2. Determine what EHR data is available regarding the incidence of sunburn in primary school aged children and the feasibility of using this data to evaluate the impact of sun safety policies. (WP2)
3. Understand the impact of sun safety policies in schools on sun-safe knowledge and behaviour levels amongst children, parents, teachers, and school management; identify barriers and facilitators to schools implementing sun safety policies. (WP3)
4. Co-produce guidance regarding sun safety policies and best methods for implementation in schools. (WP4)
5. Disseminate guidance and findings widely to ensure impact and uptake. (WP5)

2.A Overview

We will use the Behaviour Change Wheel as a theoretical framework [18]. This framework focuses on 3 essential conditions for behaviour change: capability, opportunity and motivation. It lays out how interventions such as education, training and modelling can change behaviour. We will also use the framework of co-production [19] to produce guidance on the best methods for schools to implement sun safety programmes.

To clarify how these theoretical assumptions, project inputs and processes link with our outcomes, we have created a logic model, [20] (Fig 1) a graphical representation of how we intend Sunproofed to work, an approach suggested by the MRC and supported by all major health promotion agencies [21, 22]. The logic model will be instrumental in ensuring we capture all inputs, outputs and any opportunities for transferability beyond the school setting.

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Fig 1. Sunproofed logic model.

https://doi.org/10.1371/journal.pone.0268141.g001

2.B Public involvement

As schools operate under unique pressures, input from those who understand the complexities of the school environment was paramount in shaping this research. Two teacher representatives provided input from a school’s perspective into the study proposal. Going forward, they will help with the design of data collection tools and participant facing information, ensuring materials are written age appropriately. They will also be instrumental in the co-production of guidance regarding the implementation of sun safety policies, the final report and dissemination.

Feedback from charities, such as Tenovus Cancer Care, who previously worked with schools on sun safety, is that difficulties still exist in engaging schools despite making materials easily available. Our 2 teacher representatives will be instrumental in helping overcome this issue.

We will also recruit 2 parent representatives who will advise us on what’s important to them, including some of the challenges they face when sending their children to school on sunny days. In line with best practice, we will provide honoraria, briefings and other support as needed and report public involvement in our outputs [23–25].

3.1 WP 1: Scoping study and nationwide school survey

3.2 WP 2: Exploration of EHR data

In severe cases of sunburn in children, parents may ring National Health Service (NHS) Direct Wales, or the non-emergency number ’111’, present to their General Practice (GP), a minor injury unit (MIU), the Emergency Department or a Burns Unit. NHS contacts are routinely recorded and coded within electronic health records (EHRs). The Secure Anonymised Information Linkage (SAIL) Databank holds anonymised individual-level population-scale EHR data sources linkable across multiple data sources, enabling longitudinal research [30]. This project has been approved by the SAIL independent Information Governance Review Panel (IGRP), project 1080.

To date, the information in SAIL has not been used to explore the numbers of severe sunburn related incidents in children in Wales. We will aim to identify any links with healthcare contacts for sunburn and area-based information on schools, including their catchment areas (for example, will the data provide further evidence on the effectiveness of any schools’ sun safety policies?). We will explore how far back this data is available, assess data quality retrospectively and, recognising that a lack of admissions may be linked to poor weather, will look at seasonality over the years.

3.3 WP 3: Qualitative case studies

We will identify 5 schools from those indicating that they would like to participate in further research in WP1. The selection of schools will be informed by our logic model and sampling frame. The schools will be selected to ensure that at least some are operating a sun safety policy, one of which will be a Welsh Medium school if possible. The other schools will be chosen from those who do not have active policies or teaching in place. We will ensure that schools represent different percentages of children on free school meals, ethnicity, size, and location (e.g. coastal or inland) within this sample. Permission to conduct the case studies in a school will be given by the Headteacher or a delegate and confirmed in writing or electronically.

Within our 5 schools, we will conduct in-depth case studies with focus groups, telephone interviews and short questionnaire data. To allow schools to communicate in their preferred medium, a Welsh speaking Qualitative Researcher will conduct the case study in the Welsh Medium School. We will work closely with this researcher to ensure data collection activities are as similar as possible to the other 5 schools.

In each school, we will conduct:

• Focus groups with teachers (n = ~8–10 people per group) to gather their sun safety knowledge and behaviour and their opinions on their school’s current practices and policies. We will explore how effective the teachers see the policies in terms of helping them assist children, modify the school environment and what barriers or facilitators to implementation currently exist. Focus groups will be conducted at a convenient time and ideally will be face-to-face. However, as online methods are increasingly acceptable [31] and allow more people to speak [32] we will explore these if necessary.
• Semi-structured interviews with school governors who have specific responsibility for wellbeing if possible (1/school, n = 5). These will explore the feasibility of implementing sun safety policies in schools, including any barriers to action.
• Semi-structured telephone interviews with parents or guardians (~ 20 in total), drawn from all case study schools. The interviews will explore parents’ own knowledge and behaviours as well as their thoughts on sun safety policies in schools. While predicting numbers for qualitative data collection is difficult, we estimate 20 interviews to be sufficient to reach data saturation (e.g. no new themes emerging). We will monitor this by reviewing the codebook, particularly after 5, 10 and 15 interviews, to identify the point at which no new codes are developed.
• Short online questionnaire surveys with children in KS2 classes (years 3–6, n = ~20 classrooms). These surveys will be presented as ‘quizzes’ for the children and will consist of ~10 questions designed to measure sun safety knowledge and behaviour. PPI reps will help develop and pilot these questionnaires to be suitable for the children’s ages and literacy level. Parental consent will be sought in the first instance before gaining permission from the children themselves.
• A focus group with policymakers, healthcare professionals and education experts (n = ~7 in the group). The discussion will focus on how respondents feel about sun safety being taught in schools, the priority they attach to it and any potential barriers to implementing policies in schools.

3.4 WP 4: Co-production of guidance

Hickey describes co-production as a process in which researchers, practitioners, and the public share power [19]. He argues that public participation in research generates useful knowledge leading to better outcomes. We will organise a stakeholder workshop to draw together findings from WP1-3 and co-produce guidance for schools on implementing sun safety policies and all study members and participants (teachers, heads of schools, governors, parents) will be invited to attend. Other key stakeholders, including charities, members of The National Assembly for Wales Children and Young People and the Education Committee will also be invited to attend. We recognise that it may be difficult for some participants (e.g. teachers) to attend and will explore the most effective way to elicit their opinions and make sure their ideas are included.

As bringing children to this event will be difficult, PPI representatives advised that we seek to involve children early on to participate in this co-production. We will explore the option of a smaller stakeholder event for children, perhaps with schools identifying their own child sun safety champions as ambassadors and co-producing documentation of their own that could feed into the larger stakeholder workshop. Children are integral to this process, and we will ensure that their views and voices are included.

3.5 WP 5: Dissemination and impact

We will produce both a study Publication and a Communications Plan. The Publication Plan will indicate key papers to publish, potential co-authors, target journals for submission and proposed dates for submission. It will also outline specific conferences and meetings we will look to present at, such as Public Health Wales’ annual conference, the British Association of Dermatologist’s Annual Meeting and the Cross-Party Group on Skin. The Communication Plan will clearly outline how we will give feedback to the schools and other members of the public, including dissemination of the co-production of guidance. Within this plan, we will also detail methods for engaging with the media and communicating with other key stakeholders such as policymakers and skin cancer experts.