Abstract
Introduction
School policy can encourage sun safe habits, such as wearing hats and applying sunscreen. However, sun safety policies (SSP) have not been formally assessed for Texas independent school districts (ISDs), particularly in counties with the highest melanoma incidence relative risk (RR). This study aims to assess the presence, strength, and intent of SSPs across Texas ISDs located in counties with the highest and lowest melanoma incidence. We also identify factors correlated with stronger SSP.
Methods
Eleven components of SSPs from 102 ISDs were evaluated in this cross-sectional study by examining school district websites, official documents, social media, media appearances, statements by school officials, and the Texas Education Agency’s online database. Coders were trained to score each policy’s content, presence, and strength.
Results
Policies for sunscreen use and hats existed in 94% (n = 96) and 92% (n = 94) of ISDs, respectively. In counties with the highest melanoma incidence RR, 30% (n = 15) and 44% (n = 22) of ISDs allocated resources for sun safety and outdoor shade, compared to 2% (n = 1) and 3% (n = 2) in low-risk counties. No ISDs had SSPs on UV protective clothing, accountability, or modeling sun safety behaviors. SSP strength was positively correlated with percentage of school nurses (ρ = 0.564, P < 0.001), community median household income (ρ = 0.431, P < 0.001), percentage of female students (ρ = 0.461, P < 0.001), and tax rate (ρ = 0.366, P = 0.0002). Negative correlations were found with percentage of central staff administration (ρ = −0.523, P < 0.001) and graduation rates (ρ = −0.335, P < 0.001).
Conclusion
Our findings underscore the need for interventions to strengthen SSPs across Texas.
Plain Language Summary
Schools can play an important role in protecting students from the sun by allowing sunscreen use, permitting hats, and providing shade. However, Texas schools have not been formally evaluated for sun safety policies, especially in areas with the highest melanoma rates. In this study, we reviewed sun safety policies from 102 school districts in Texas, focusing on counties with the highest and lowest melanoma risk. We examined school websites, official documents, and other sources to assess the strength of these policies. We found that nearly all districts allowed sunscreen and hats, but very few provided resources for sun safety or outdoor shade. No schools had policies on UV-protective clothing, ensuring sun safety accountability, or modeling good sun protection behaviors. Stronger sun safety policies were correlated to factors like a higher percentage of school nurses, higher household income, and more female students. Weaker policies were associated with more central staff administrators and higher graduation rates. Our results highlight the need for better sun safety policies in Texas schools.
Introduction
Melanoma is projected to become the second most common cancer in the US by 2040. 1 Although melanoma has multifactorial etiology, ultraviolet (UV) exposure is a primary driver. UV rays alter cellular structure and function, leading to potential cancer-causing mutations in DNA. 2 When compared to children with fewer sunburns and lower sun exposure, children with more sunburns and greater cumulative sun exposure in childhood develop more melanocytic nevi3-5 and have a higher risk of developing melanoma later in life.6,7 Given that children spend a significant portion of their day at school—often engaging in outdoor activities such as recess and sports—schools represent an ideal setting for sun protection interventions. This evidence highlights the need for policies that encourage sun safe practices for children.
School districts can influence student behaviors and habits, including sun safe practices, through policy. 8 In 2002, the US Centers for Disease Control and Prevention (CDC) issued programmatic guidelines for national schools to institute sun-safe practices. 9 However, few US schools have sun protection policies 10 : a 2011 study found that only 31% of school districts in southern California and Colorado had policies addressing sun safety, including UV-protective clothing, hats, sunscreen, and sun-safety education. 11
Efforts to reduce melanoma risk at a population level must include both secondary prevention (early diagnosis) and primary prevention (sun safe practices) efforts.12-14 One ongoing effort is American Society for Dermatologic Surgery Association’s (ASDSA) SUNucate campaign that aims to reduce the risk of skin cancer and excessive UV exposure in children through model legislation for state assemblies. 15 To date, approximately 30 states have passed SUNucate or similar legislation, including Texas in 2015 known as SB 265. 16
While school sun safety policies have been explored in California, Hawaii, and Colorado11,13 school policies have not been explored in Texas, a state with high levels of UV exposure and a climate that permits outdoor activities and UV exposure year-round. We identified Texas counties with the lowest and highest population-adjusted melanoma incidence rates then documented sun safe policies and community/district characteristics for each county-associated school district. By analyzing policies and correlative components, we hope to better understand community and school-district factors associated with strong sun safety policies.
Methodology
Overview
In this cross-sectional study, our methodology begins with identifying the counties with the lowest and highest population-adjusted melanoma incidence in Texas using Texas Cancer Registry data. We then identified the independent school districts (ISDs) within those counties to evaluate their individual sun safety policies and population characteristics. In some U.S. states, such as Texas, an ISD refers to a public school district that operates independently of municipal or county governments. ISDs typically are composed of elementary, middle, and high schools. ISDs were created to provide local control over education, and each ISD has their own elected school board, taxing authority, and administrative structure. Once ISDs of the lowest and highest melanoma incidence counties in Texas were identified and sun safety policies evaluated, results were correlated with ISD population characteristics, such as per-pupil spending and percentage of school nurses. The reporting of this study conforms to STROBE guidelines. 17
Identifying the Counties with Lowest and Highest Melanoma Incidence Relative Risk
Melanoma incidence data from 2000 to 2018 were obtained from the Texas Cancer Registry (TCR) and aggregated by county and year. 18 We included all TCR data, including those from a pilot program conducted from 2010-2013 to increase melanoma case ascertainment. The melanoma incidence relative risk (RR) for each of the 254 Texas counties was estimated using a Bayesian inseparable spatiotemporal modeling framework that accounts for both spatial and temporal dependencies and adjusted based on population. 19 Counties with RR greater than 1 were identified as higher-than-expected number of melanoma cases, suggesting areas of elevated melanoma burden. The counties were rank-ordered from highest to lowest melanoma RR. Two groups were then identified for further investigation: the ten counties with the lowest RR (0.50 - 0.68), and the ten counties with the highest RR (1.46 - 1.73). These two groups included a total of 52 ISDs in the ten lowest-risk counties and 46 ISDs in the ten highest-risk counties. To ensure a balanced comparison of ISD policies between both cohorts, an eleventh county was added to the highest-risk group, resulting in final cohorts of 52 ISDs from the lowest-risk counties and 50 ISDs from the highest-risk counties. Once ISDs were identified, the school district characteristics—such as percentage of school nurses, female and male students, students graduating, central administration staff, race, free and reduced lunch—were pulled from either the National Center for Education Statistics, 20 the Texas Education Agency (TEA), 21 or the school district website.
Policy Identification, Selection, Coding and Grading
Sun safety policies of each identified ISD were identified, selected, coded and graded, a stepwise methodology adapted from studies conducted by Reynolds et al and Berteletti et al.11,13 Policies were identified through a review of school districts’ websites, official social media channels, media appearances, and statements by school officials. Data from social media, including Facebook, X, and Instagram, was collected via a general Google search and direct searches within these platforms using the ISD name. Media appearances and official statements were sourced from news reports and publicly available communications. The TEA’s online database that oversees public education in the state was also queried. 21
Policies were selected if they addressed sun exposure or the enactment of preventive actions such as permission to wear hats when playing outside. All selected policy documents for each ISD were downloaded. Selected school policies were then coded into eleven components 11 : sunscreen use, UV protective clothing, hats, education of students, education of teachers, outdoor shade, scheduling, parent outreach, resource allocation, accountability, and modeling.
Each of the eleven coded sun safety policy components were graded based on presence of policy (0 = policy is not addressed, 1 = policy is addressed) and the strength of policy wording (0 = not allowed or not specified, 1 = allowed or recommended, 2 = required). Policy intent (0 = indirect sun protection; 1 = direct sun protection) was only assessed for policies on UV protective clothing, hats, and outdoor shade because the enactment of policies in these categories could have a different purpose from sun protection but indirectly improve sun safety. For example, if a stated policy includes the phrasing “student may wear clothing to protect against UV exposure”, then this was graded as 1 for direct sun protection. This was assessed based on whether sun safety was explicitly mentioned as the rationale behind the policy.
Reviewers were trained in using the policy component coding and grading system. Two reviewers (NA, BB) coded and graded the ISD sun safety policies. If there was discrepancy between reviewer scores, a third reviewer (SZ) assessed the online sources and adjudicated the difference. This ensured inter-rater reliability throughout the study and reduced the risk of inadvertent policy exclusion.
Data Analysis
Descriptive statistics (counts, percentages, and averages) were computed for every policy component and overall policy score (comprising codes for policy presence, strength, and intent). Spearman Rank correlations were calculated, and then stepwise regression with forward selection was used to test the relationship between policy scores and school district characteristics. School district characteristics included the total number of enrolled students, student demographics, number of English as a Second Language (ESL) students, total full time equivalent staff, and teachers, teacher demographics, total operating revenue per pupil, total actual expenditures, number of school nurses, household income of parents and teacher turnover rate. For all statistical tests, a two-tailed alpha threshold of P < .05 indicated statistical significance. All statistical analyses were conducted in R version 4.3.2, utilizing the dplyr and purrr packages for data manipulation and analysis. 22
Results
Fifty-two and fifty ISDs were identified within the counties of lowest and highest melanoma incidence RR from 2000-2018, respectively (Figure 1). ISDs with the lowest melanoma incidence RR were located along the Texas-Louisiana border (n = 9) and one county was in rural West Texas. ISDs with the highest melanoma incidence RR were all located within or adjacent to major metropolitan areas of Texas, such as San Antonio, Houston, Fort Worth, Austin, and Amarillo. Texas Counties With the Highest and Lowest Overall Melanoma Relative Risk (RR) of Melanoma From 2000 to 2018
Sun Protection Policy Scores and Means of Counties With the Lowest and Highest Risk of Melanoma From 2000-2018
Univariate Spearman’s Rank Correlations Between School District Characteristics and Total Sun-Protection Policy Strength Score (N = 102 School Districts)
*Sum of strength across policy components regardless of intent.
***: Highly significant (P < 0.001).
**: Moderately significant (0.001 ≤ P < 0.01).
*: Marginally significant (0.01 ≤ P < 0.05).
“ “: Not significant (P ≥ 0.05)
The stepwise regression analysis revealed that the final model significantly predicts policy strength (R2 = 0.527). The analysis revealed a strong positive correlation between median household income (P < 0.001) and the number of nurses (P < 0.001) with policy strength in school districts, indicating that districts with more nurses and higher median incomes have stronger sun-protection policies. We also explored how ISD community type correlated with sun-protection policy strength. Community types were classified based on the National Center for Education Statistics (NCES) locale codes. 23 In this system, large urban centers are defined as those with high population density and extensive infrastructure. Rural areas are sparsely populated, non-metropolitan areas and other central cities have small population clusters, and independent towns are those not part of a larger metropolitan area. These classifications reflect differences in socioeconomic resources, population density, and infrastructure. When using the NCES community types, ISDs in rural, other central city, non-metropolitan, and independent town community types were associated with lower policy strength, and ISDs in large urban centers (eg, Houston, Austin, Fort Worth) had stronger policies (b = 4.535, P < 0.001).
The number of nurses is positively associated with policy strength (b = 0.051, P < 0.001), while the percentage of ESL-enrolled students has a non-significant effect (b = −0.0009, P = 0.144). The model is statistically significant overall (F = 14.95, P < 0.001).
Discussion
Our study found that ISDs in counties with the highest melanoma incidence RR had a greater sun safety policy presence, strength, and intent compared to those in counties with the lowest risk. ISDs in high-melanoma incidence RR counties demonstrated stronger sun safety policies relating to student and teacher education, outdoor shade structures, scheduling adjustments, parent outreach, and resource allocation. Despite the variation in melanoma incidence RR between counties, no ISDs in either group had explicit policies addressing UV-protective clothing, accountability, or role modeling. This contrasts with a 2017 study on California public schools, which found that nearly 190 districts had policies encouraging role modeling and allowing personal protective behaviors, including UV-protective clothing. 13 The absence of similar policies in Texas districts highlights a missed opportunity to address sun safety across the state. Recommended dress codes for Texas ISDs that include UV-protective clothing may consist of long-sleeve shirts made of UPF-rated fabrics (eg, blended textiles), dresses with long sleeves, long pants or capris, wide-brimmed hats, UV-blocking sunglasses, or sun jackets. 24 Several factors may contribute to the development of these sun safety practices in counties with the highest melanoma incidence RR, including a statistically significant correlation with increased school nurses, median household income, and racial and ethnic diversity.
Policy Correlations
The number of states in the US with sun safety laws has increased substantially since 2013. 25 Our study found that 94% of reviewed Texas ISDs had a policy addressing sun safety, particularly allowing sunscreen application on school property. This may be explained by the passing of SB 265 in 2015 by the Texas legislature that stated “a student may possess and use a topical sunscreen while on school property” and “waive any immunity from liability of a school district”. 14 This is greater than a 2012 study on California and Colorado where only 51.9% and 7.8% of school districts, respectively, had implemented sun safety policies regarding sunscreen use. 11
In our study, the percentage of school nurses was the strongest factor correlated with the strength of sun safety policies within ISDs. This suggests that having more school nurses can play a key role in advocacy for and implementation of sun safety measures, highlighting the role healthcare professionals in influencing district-level health policies. ISDs that have greater funding and those in well-resourced counties can allow for increased hiring of school nurses, which may further contribute to their ability to play a role in advocacy. 26 School nurses are often more aware of student and parent health concerns and can effectively advocate for policy development. 27 Their role includes supporting schools in developing health education programs, promoting preventive care, and ensuring schools comply with health guidelines. 28 By serving as liaisons between students, staff, and the external medical community, school nurses play a key part in shaping policy pertaining to student health.29,30
In contrast, the number of central staff administrators was significantly negatively correlated with policy strength. This may be due to top-heavy leadership structures where decision-making processes can become slower and complex, hindering the implementation of certain sun safety policies and prioritizing district-wide policies that do not address specific local student health ; diverting resources away from direct education or health-related interventions in favor of other district priorities such as salaries; and being removed from the day to day challenges schools face in implementing health policies, which leads to policies that are less responsive to external pressures such as activism and new legislation. 31
A positive correlation was also found between total sun safety policies and median household income and property tax rate. In counties with higher median household income, homes tend to have greater property values, which can lead to higher property tax revenues. Higher-income areas generate more property tax revenues since property taxes are assessed as a percentage of property value. While the actual tax rate may vary based on local governance to meet budget needs, wealthier communities generate more tax revenue. This increased tax revenue is a primary revenue source for schools. 32 Greater revenue allows for more resource allocations, such as bonds, and newer facilities, like outdoor shade structures. In our study, ISDs in counties with the highest melanoma incidence RR—centered around urban centers and with greater household income—had more resource allocations and shade structures compared to ISD in counties with the lowest melanoma incidence RR, often centered in rural areas with lower median household income and tax rate.
A previous study in 2012 showed that policy scores were highest in districts with fewer Caucasian students in California. 11 Consistent with this study, the strength of sun safety policy in our study was negatively correlated with the percentage of students who are Caucasian. Past literature has suggested multiethnic districts are more responsive to external pressure from legislation, activism, and increased awareness of national health recommendations, including sun safety practices.33,34 Additionally, urban districts, which often have a more diverse student population, may have more resources or policy infrastructure to implement stronger sun safety measures. These findings highlight the potential influence of demographic composition on policy adoption.
Given the rising incidence of skin cancer, educational and other policy initiatives are critical to ensure that students, teachers, and parents are aware of effective sun protection strategies. However, previous success in California, where collaboration with a state school board association led to 60% of schools adopting a standardized sun safety policy, suggests that similar strategies could be effective in Texas. 13 This points to the need for coordinated policy enhancement, such as that modeled by ASDSA’s SUNucate model legislation, to improve sun safety and mitigate health risks statewide. Currently, Texas’s SB 265 falls short of certain measures, notably the lack of provision for sun-safe education and sun-protective clothing such as hats and UV-protective apparel. 16
Limitations
Our study had several limitations, including restricted informational access, lack of policy implementation data, limited generalizability, and challenges related to establishing causality. First, we chose to extract sun safety policies via online public records rather than contacting individual ISDs, due to a lack of response, response biases, and concerns for social desirability reported in previous studies.10,11 With a reliance on records made available online, it is possible our data extraction may have included incomplete or outdated policies. Similarly, our study did not include an analysis of individual policy implementation at each ISD, thus our identified policies may not be indicative of actualized sun safety behaviors or risk.
Second, some factors related to sun safety are difficult to evaluate, including accountability, modeling, and recess schedules. Accountability and modeling are crucial aspects of effective teaching and are particularly important in teaching sun safety behaviors, such as sunscreen application. Accountability may have been addressed in other parts of school policy, such as nursing protocols, that were outside the scope of our sun safety policy evaluation. With zero policies identified relating to teacher accountability and modeling, pursuing analysis of these important teaching elements poses similar challenges as investigating policy implementation at individual schools and ISDs. Additionally, scheduling was also difficult to measure as not all ISDs publish each school’s recess period, which could provide indirect sun safety.
Last, our study has limitations in its generalizability and the causality of sun safety policies on melanoma incidence. We analyzed 102 of approximately 1200 school districts in Texas, thus results may not be reflective of the other counties. 21 However, we selected these districts because they represented counties with the highest and lowest melanoma incidence RR, providing a meaningful and distinct comparison for our analysis and insight into the current state of policy strength in at-risk areas. While our study identifies correlations between policy strength and melanoma RR, we did not investigate or establish causation. Investigating the impact of sun safety policies on melanoma RR poses many challenges related to confounding factors and time to realization of primary prevention, especially as such policies were not substantially introduced until 2015.14,24 However, future studies could investigate how specific components of sun safety policies (eg, UV protective clothing, outdoor shade, educational programs) are associated with sun safety behavior and melanoma rates. This would help in identifying which elements are most effective and where improvements are needed.
Conclusion
School district policies on sun safety are increasing, particularly for sunscreen use at school. Our data reveal variability in sun safety policies across school districts, with high melanoma-risk counties having more policies addressing factors like education, outdoor scheduling, and resource allocation--correlated with increased school nurses, median household income, and tax rate. Given that these counties have increased resources and health provider advocacy, it is reasonable to expect stronger sun safety policies. Nonetheless, even in these districts, safety gaps persist, such as a lack of policies on UV protective clothing and adult modeling of sun-safe behaviors. Public health policies should promote consistent and direct sun safety across all districts, regardless of risk, with standardized education, support for protective clothing, and equitable resource distribution. Particularly, given the complete absence of intent in all population types other than urban, there is much opportunity for education in these areas. Furthermore, rural districts, which tend to have weaker policies, would benefit from targeted support, such as increased nurse staffing and funding.
Overall, this study informs of the current sun safety policy environment in Texas, identifies variability in policy presence, strength, and intent between high and low-risk counties, and highlights county characteristics most correlated with these differences. Importantly, while our study focused on policy content, future efforts must also consider how policies are implemented and enforced within schools, as accountability plays a role in ensuring sun safe behaviors. These findings can inform future primary prevention efforts directed at improving sun safety policies, education, and resources in Texas. Future research is needed to investigate policy implementation and their effect on melanoma incidence.
Footnotes
Ethical Considerations
There are no human participants in this article and informed consent is not required.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by an educational grant award from the National Institutes of Health and National Cancer Institute (R25CA056452) and Cancer Prevention Research Institute of Texas, RP230036, MPI Bauer and Nelson.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.