A novel skin cancer prevention strategy: Preservice teachers' perceptions of a sun safety intervention and experiences in schools

Abstract Issue addressed Teachers play a vital role in developing children's sun protection routines however upskilling preservice teachers (PSTs) while at university has not yet been trialled as a targeted skin cancer prevention strategy. Hence, this study investigated PSTs perceptions and experiences of sun safety following a brief pilot intervention and placement in primary schools in Western Australia. Methods This study used a triangulation mixed methods design. Participants (n = 161) completed a post intervention survey which was analysed quantitatively. A random sub‐sample was invited to participate in focus groups (three groups, n = 21) and one‐on‐one interviews (n = 4). This data was transcribed and uploaded in NVIVO software for thematic analysis. Results Participants felt the intervention increased their awareness of the dangers of overexposure to ultraviolet radiation (UVR) with many feeling more knowledgeable, skilled and confident to teach sun safety in school settings. Most reported clear sun safety messages in their placement schools. However, only 34.4% reported they had been briefed on the school's sun safety procedures. There was consensus among PSTs that sun protection in primary schools needs to be improved to maximise the protection of children from harmful UVR overexposure. Participants supported a need for consistent sun protection messaging across primary schools with greater emphasis on education rather than compliance management to sun protection. Conclusion Enhancing existing teacher education programs to include more rigorous curriculum content and pedagogical approaches to sun protection education is a novel skin cancer prevention strategy and could feasibly support PSTs self‐efficacy to effectively deliver sun safety curriculum in Australian schools.

ences of school-based sun safety. Enriching existing teacher education programs to include more rigorous curriculum content and pedagogical approaches to sun protection education could be a potential strategy to support PSTs self-efficacy to deliver sun safety in schools. Therefore, this study addresses this gap in the literature and aims to explore PSTs perceptions of a sun safety education intervention and explore their attitudes towards tanning, sun protection and experiences of sun safety approaches in primary schools while on placement. Findings from this study provide important information to inform university-based interventions for PSTs.

| Participants and procedures
Approval to conduct this research was granted by the relevant University Human Research Ethics Committee (HREC22500). All participants provided informed consent to participate in the study. The sample was drawn from a larger study by Scott et al 17  shop (intervention) delivered by the research team and after they completed their normal school-based placements as required for their degree, they completed a short survey. A sub-sample of participants were randomly selected from this group and invited to participate in semistructured face-to-face focus groups or interviews (see Table 1). Those unable to attend face-to-face were offered to participate via telephone interview. Consistent protocols were followed during interviews and focus groups to ensure reliability.

| Intervention
The preservice teacher sun safety (PSTSS) intervention was an exploratory pilot to inform a large study and comprised of a face-to-face interactive workshop conducted by members of the research team in March 2019. The social cognitive theory (SCT) 18 and the social ecological model (SEM) 19 where used to inform the design of the intervention. The SCT provided a framework for exploring interactions between sun behaviours, attitudes and environmental influence and self-efficacy. The SEM was used to explore determinants that influence the adoption of UV protective behaviours across individual, organisation and community levels. The intervention focused on sun safety education, sun protection strategies for primary-aged children, school sun protection policies and availability of resources for teachers including the UVI and Cancer Council's SunSmart smartphone application which provides daily UVR levels and times of day where sun protection is required. 20 The intervention details are described in Table 2.

| Survey
Participants completed a brief survey 6 wk postintervention. Six weeks was selected as this allowed sufficient time for completion of respective placements in schools. Participants were emailed a QR code and link to the online survey. Questions related to: participants' attitudes towards sun protection and their in-school experiences of sun safety while on placement (three questions, 5-point Likert scale anchored at strongly disagree and strongly agree); and PSTs sun safe behaviours while on placement (two questions; 5-point Likert scale anchored at never and everyday) (see Table 3).

| Focus groups and interviews
The theoretical domains framework 21 was used to inform the design focus group questions exploring areas including perceived knowledge, skills, social role/identity, beliefs about capabilities, intentions, and social and environmental influences on behaviours and perceptions. Questions focused on participants' personal tanning and sun behaviours as wells as their attitudes towards, and experiences with, school-based sun safety while on placement. On completion of the survey, a random sample of survey participants were invited by phone to participate in focus groups.
To ensure consistency, the same researchers (J.S. and R.J.) conducted both the interviews and the focus groups. Researchers were not known to the study participants. Focus group included between five and nine participants and lasted approximately 40 min and interviews approximately 20 min. Each focus group/interview was audio recorded, with permission, and later independently transcribed verbatim by a research assistant outside the research team. After three focus group interviews and four interviews, J.S. and R.J. agreed that data saturation had been achieved, 22 therefore, no further invitations were extended.

| Analysis
This study used a triangulation mixed methods design to guide analysis of data. 23

| Sample
Of the 161 participants, 10 did not provide responses to survey questions focusing on their experiences in schools and were excluded from the analysis. The demographics of study participants (n = 151) are provided in Table 1. Participants were aged between 18 and 54 years (mean = 23.3, SD = 6.64) and the majority were female (80.1%), Australian-born (77.5%), spoke English at home (96.0%) and attended both primary and secondary school in Australia (86.8%). The focus group and interview participants shared similar demographic characteristics to the larger sample.

| Survey
Data indicated that most PSTs wore a hat when outdoors on placement every day (55.0%) or often (27.2%) (

| Opinions towards tanning
Many participants in the focus groups and interviews reported that they attempt to tan, particularly in the summer months.
"I always tan [and] barely ever use sunscreen… I put it on, but [don't remember] to reapply"(FG1).
This was not universal however with others reporting they never attempt to tan.  Most of the participants who reported tanning were aware of the potential risks associated with this although others did not perceive they personally were at risk.
"It always tends to be the 'it-won't-happen-to-me' kind of thing. Like, yeah, I get a tan, but I'm not at risk, or anything like that" (FG1).
Many participants justified attempting to get a tan by reporting that they feel healthier with a tan.
Skin sensitivity to sunburn was reported as a deterrent for attempting to tan with some reporting that their skin would burn rather than tan when exposed to the sun.

| Barriers for using sun protection
Use of sun protection was commonly context or temporally based.
For example, many PSTs reported that they wore sunscreen while at the beach, at school on placement, or only during the summer months, but not in other settings or seasons. Lack of time and inconvenience were the most commonly reported barriers for sun protection use.
Some participants reported that they only would use sunscreen or hats when they were out in the sun for longer than 30 min.
"Everyone's sort of busy, and sometimes you just think I'm only going to be out in the sun for a couple of minutes, so I'm not going to bother putting sunscreen on, when I just think I'm going to sit outside for a bit" (FG2).
The PSTs also reported impracticality and discomfort with sun protection measures as barriers for use. For example, some participants reported a barrier to wearing sun protective clothing was that they did not like wearing heavy clothing in warmer weather.

| Facilitators for sun protection
The act of developing a sun protection routine was a commonly reported factor in facilitating the regular use of sun protection measures. Some reported that the pain and discomfort from previous significant sunburns was a deterrent for going out in the sun unprotected and a motivator for using sun protection in the future.
Many reported using sunglasses, hats and clothing more often than sunscreen as it was easier to use, easier to remember and had fewer or lower ongoing financial costs. There was high agreement among PSTs that when they were in a school setting they were more likely to

| Attitudes towards school approaches
Focus group participants reported that almost all of the schools in which they completed placement had some form of sun protection recommendation in place. However, most reported they never saw the written policies and were unaware of the policy content. Many observed that compliance to hat wearing was the most common method of sun protec-  To improve teacher and school approaches to sun protection, PSTs recommended including more UVR education for both pre-and inservice teachers. They suggested this could be implemented through professional learning opportunities at university and in schools complimented by increased access to free online teaching resources.

| Perceived knowledge, skills and confidence
The majority of participants reported that being involved in the intervention improved their knowledge and awareness of UVR and the recommended sun protective measures for themselves and their future students. Most participants felt the intervention made them more knowledgeable and skilled to teach sun safety when they enter schools in the future.
"the information that was given to us [in the intervention], just blew our minds, because there were things that we didn't think of…well, weren't aware of" (FG3).
"I'm more confident in the knowledge of the facts" (FG1).

| Attitudes towards sun safety education
There was unanimous agreement among participants that the intervention increased their awareness of the importance of sun education for PSTs, in-service teachers and children.

| Intentions to change and future sun safety goals
Some participants reported that although the intervention did not change their current sun protective behaviours, they intend to improve them in the future, particularly when they move into paid teaching-related employment.
"…when I'm a teacher and I've got all those kids every day…I'll need to wear my hat, wear my sunscreen and eventually I feel like it will just become an everyday sort of thing, more of a habit" (FG1).
As well as goals specific to the school context, participants also indicated they had personal goals to increase sun protective behaviours to reduce future risks of skin cancer and improve health. These goals related to a range of behaviours including: more frequent hat and sunscreen use; change to using broad-brimmed hats; long sleeved clothing; daily moisturisers that contain sunscreen; using an app that provide UVR levels and checking the UVI more frequently. Some participants reported that they had good intentions to improve their sun protection practices but ongoing motivation and maintenance was questioned.  26 The program promotes sun protection policies and practices in Australian schools from foundation years to year 12 and aims to minimise harmful UV exposure in school settings. 27 Recent research indicates that early childcare centres that are members of the SunSmart program enact significantly more sun protection practices compared non-members. 28 However, school leaders remain responsible for the extent to which the sun protection programs are implemented in their schools, with varying levels of mandatory policy requirements between jurisdictions from governing bodies such as departments of education and independent educational institutions. In addition, research indicates that the enactment of existing SunSmart primary school policies could be vastly improved. 29 For skin cancer prevention programs to be effective, schools need to implement sun protection policies, environmental changes and comprehensive educational programs. 30 Environmental and policy changes can include school guidelines on use of sun protective clothing, hats, sunscreen and shade or restrictions on outdoor activities during peak UVR times. Educational programs should also include comprehensive UVR/UVI curriculum and education for both teachers and students. The level of in-service teachers understanding of UVR and the UVI remains unknown and should be the focus for future research.
In this study many PSTs reported that in their personal lives, they attempted to get a tan in the summer months even while knowing that this increased their risk of developing skin cancer in later life.
Consistent with previous findings, skin sensitivity to sunburn was a deterrent for attempting to tan. 17,31 PSTs reported many barriers for utilising sun protection measures outside school settings including: discomfort, impracticality, appearance and embarrassment. This may reflect the relatively young age of our sample (three-quarters were aged ≤24), as comparatively, Australian adolescents have also been reported to positively view sun exposure and negative view sun protection measures with most selecting sunglasses, hats and clothing based on fashion rather than effectiveness of protection. 32 Interestingly, PSTs reported no issue with wearing wide-brimmed hats, long sleeves and sunscreen in school settings and all agreed that it was important that teachers model effective sun protection behaviours to their students. Teachers modelling sun safe behaviours has been shown to positively affect students' sun protection behaviours. 33 Many reported that this was the primary reason for wearing sun protection while in primary schools, rather than being conscious of reducing their own skin cancer risks. Demographic data indicated that the majority of participants in this study were ≤24 years of age and attended school in Australia. Given that the SunSmart School program started in WA in 1998, 27 it is therefore likely that most would have attended primary schools when these programs were being implemented. We can speculate this may be an influencing factor as to why most PSTs felt motivated to be a role model and comply with school policy in primary school settings. While many reported that there was a clear sun safety message in their placement school, only one third indicated that they were briefed on the sun safety policy on entering the school. Findings indicate a need for schools to comprehensively inform the school community (including visiting staff and PSTs) of existing sun safety policies.
Many study participants reported they saw little-to-no UVR or UVI education during their placement. The UVI has been reported to be a valuable tool in determining when protection of the skin from UVR is recommended. 6 However, Australian research suggests that population understanding and utilisation of the UVI remains minimal. 15 20 and some reported they used this as a tool to guide sun protective behaviours. Smartphone application technology which provides simple and easy to read UVI levels alongside sun protective recommendations may be a potential strategy to improve PSTs sun behaviours. 35 A recent study found that consulting the UVI regularly assisted young people to make decisions about sun protection behaviours. 7 Further research focusing on the use of the SunSmart application in primary school settings is warranted.
PSTs speculated that practicing teachers faced many barriers when attempting to protect themselves and their students from the sun with many recommending a strength-based approach (ACARA 36 ) to increase children's sun safety skills rather than focusing on sun protection compliance management. PSTs felt educating students to independently use the UVI to inform sun protection practices was a more feasible longer-term strategy to prevent UVR overexposure in children; but were conscious that teachers need to have the skills and resources to effectively teach their students. Enriching initial teacher education programs in combination with increasing education departments' level of support to enhance schools and teacher's ability to implement holistic health promotion strategies that combine policy, environmental and curriculum approaches to sun safety could be a potential strategy to increase individual's ability to protect themselves from the sun and may minimise many of the reported barriers teachers face.
Participants reported that they found the PSTSS intervention increased their knowledge and awareness of the UVI and risks associated with skin cancer. Consistent with previous findings by Scott et al 37 participants reported they felt more knowledgeable, skilled and confident to teach sun safety and that the intervention was helpful in increasing their awareness of the UVI as a useful tool to protect themselves from the sun. However, a number also indicated that the brief intervention highlighted gaps in their skills to teach this content in school settings which reduced their confidence levels. While the PSTSS intervention shows promise as a feasible strategy to raise knowledge and awareness of the UVI among PSTs, these findings may indicate that a longer-term multifaceted approach to school sun safety may be required to develop pre-and in-service teachers skills as such approaches have been shown to be more effective that brief one-off interventions. 38 There was unanimous agreement among the PSTs that all tertiary teacher education programs should include comprehensive UVR education so that they can develop the knowledge and skills to properly protect themselves and their future students in school settings. Many PSTs also reported that as a result of attending the PSTSS intervention, they either had changed or intended to change their sun protective behaviours. These findings suggest that some PSTs may in a contemplation, preparation or action phase of behaviour change 39 which could mean the university setting is an important setting for skin cancer prevention interventions for PSTs.
To the authors' knowledge, this was the first study to explore PSTs perceptions and experiences of sun safety in primary schools when on placement during their initial teacher education degree. A strength of this study was that it used both quantitative and qualitative methodology so as to provide a deeper understanding of participants' personal attitudes behaviours and motivations, as well as their perceptions and experiences of sun safety in primary schools.
While this study had noted strengths, there are some limitations.
First, this was a exploratory pilot study with a relatively homogeneous sample from one tertiary institution, which may limit the generalisability of findings. Future research studies with samples from a range of different universities with diverse samples is recommended. Second, as this study was exploratory pilot to inform a future larger study, there was no control group. Third, the focus group questions were not pilot tested. Fourth, the focus groups interviews were conducted by members of the research team, who also conducted the intervention, which potentially could have resulted in some participant bias.

| CONCLUSION
There was consensus among PSTs that sun protection in Australian primary schools needs to be improved to maximise the protection of children from harmful UVR overexposure. Participant recommendations included more consistent approaches to sun protection across Australian primary schools with a greater focus on UVR and UVI education, rather than compliance management. Furthermore, innovating and enriching existing teacher education curriculum and programs to include more rigorous content and pedagogical approaches to sun protection, UVR and the UVI education is novel and could support PSTs self-efficacy to deliver sun safety to students. Based on initial responses to this intervention, such an approach in teacher education programs is likely to be well-received by PSTs. However, to be effectively implemented such approaches will need to be supported by universities, school policies and be endorsed by governing bodies, school administrators and school com-