The worldwide incidence of skin cancer has increased year on year by between 3% and 8% since 1960.1 In line with this trend, the incidence of skin cancer in Spain has tripled between 1978 and 2007.2 Excessive exposure to ultraviolet radiation, whether from the sun or artificial sources, is the main avoidable cause of skin cancer,3 and childhood is a critical period of risk: one or more episodes of sunburn during childhood doubles the risk of melanoma later in life.4

Education in healthy habits in terms of sun protection is the best strategy for preventing skin cancer.5 Educational programs such as SunSmart School in Australia,6 SunWise in the United States,7 or SolSano in Spain8 have raised awareness and improved behaviors in sun protection in school children, and also reduced sunburn in the target population. These programs have also been shown to be the most cost-efficient. The SunWise program, run by the United States Environmental Protection Agency, is estimated to provide a return of 2–4 dollars in savings in medical care costs and productivity losses for every dollar invested.7

The World Health Organization encourages governments to develop policies for sun protection (focused on the school curriculum, shade, time of day spent with outdoor activities, school uniform, use of headwear, sunglasses, and sunscreen) when children participate in outdoor activities and the ultraviolet index (UVI) is greater than or equal to 3. Likewise, it recommends creating accreditation systems with public recognition for those schools with suitable measures as a means to encourage them to promote the use of sun protection measures.9 Certification of sun protection was initiated in schools in countries such as Australia, New Zealand, United States, and Germany with good uptake and excellent outcomes in nurseries and primary schools.10–12

In the present article, we describe the process of creating the Soludable (a play on the Spanish words sol [sun] and saludable [healthy]) accreditation program, as a model for certifying sun protection developed in Andalusia. This project is one of the initiatives of the sun protection campaign “Enjoy the sun while saving your skin,”13 whose objective is to promote policies and healthy sun protection practices in schools with involvement of the entire educational community.

The Delphi consensus method used to draft the text of the consensus program with a panel of experts.14 Before starting on the text, the context was drafted and the scope and timing of the project determined, seeking input from persons responsible in the Health Promotion Service (Health Department), Service of Planning and Educational Programs (Education Department), and the Patient Safety Monitoring System of the Andalusian Agency for Health Quality (Health Department), and Andalusian regional government. A multidisciplinary panel of experts was then selected and the members committed to collaborating with the project. This panel comprised 17 healthcare professionals with experience in primary skin cancer prevention and development of educational interventions about sun protection measures; 4 education professionals with experience as teacher consultants and implementation of sun protection education programs; and 1 volunteer from the Asociación Española Contra el Cáncer (Spanish Cancer Association).

In a first phase, a coordinating group performed a literature search to collect the best recommendations and experience in Spanish and international school sun protection programs. The SunSmart School sun protection policies15,16 were selected to form the basis for a preliminary proposal for recommendations for the accreditation program, in view of the quality of the documentation and the results obtained after more than 20 years of experience in the sector. Work on the consensus took place between January and June of 2015, in sequential phases alternating between face-to-face meetings and online exchanges (using the 2-round Delphi technique).

In the first face-to-face meeting, the proposal and project objectives were presented to the experts in order to assess whether all the recommendations that should be considered were indeed appropriately formulated (clear and concise language), whether all key players were involved, and whether the recommendations could be measured and assessed. The recommendations should define objective facts or actions that enable distinction between schools that actively promote sun protection and those that do not. Alongside the recommendations, their goals should be explicitly described. For this purpose, 4 working groups were formed with a coordinator and spokesperson. Each group worked on a series of recommendations to be subsequently presented to the other groups in a plenary session. Two coordinators took note of all the observations and drafted a final report with the conclusions.

In a secondary face-to-face meeting, an expert panel defined the assessment criteria for each of the selected recommendations. Following the same approach as in the previous meeting, 4 groups were formed with a coordinator and spokesperson. Each group worked on a set of recommendations, for which at least one objective and measurable assessment criterion was to be designated. Subsequently, all panel members discussed the assessment criteria in their entirety and the degree of difficulty of the recommendations; finally, a name was proposed for the accreditation program.

For the online phase, a survey was set up using Surveymonkey in order to assign priority to the recommendations, establish degrees, and select the name of the future accreditation system. The recommendations were scored according to importance and feasibility with a 5-point Likert scale (not at all important or feasible, very little, occasionally, usually, and always). In addition, the degree of difficulty of each recommendation was assessed, with basic recommendations considered as level I and advanced ones as level II. Finally, the survey was used to choose a name for the accreditation program from among those proposed in the second face-to-face meeting. The panelists had 10 days to complete the survey.

Table 1 shows the 25 recommendations formulated initially by the coordinating group, grouped into 7 domains: 1) organizational leadership (7 recommendations); 2) effective communication (2 recommendations); 3) structural elements (3 recommendations); 4) training of professionals (3 recommendations); 5) school curriculum (2 recommendations); 6) behavioral models (2 recommendations); and 7) protection habits (6 recommendations).

Table 2 shows the 14 recommendations selected and reformulated by the expert panel after the first face-to-face meeting, along with the aims and criteria defined in the second face-to-face meeting, and grouped in 7 domains: 1) organizational leadership (5 recommendations); 2) effective communication (2 recommendations); 3) structural elements (2 recommendations); 4) training of professionals (1 recommendation); 5) school curriculum (1 recommendation); 6) behavioral models (2 recommendations); and 7) protection habits (1 recommendation).

Table 3 shows the results of the first Delphi round, in which 19 of the 22 panel members participated. All recommendations reached the established level of agreement, with median scores for assessing the importance and feasibility greater than or equal to 3, and greater than or equal to 7 for the combined median of both components. In addition, in 4 of the recommendations, the median combined score was the maximum possible (median 10 points: 1.1, 1.2, 2.1, and 2.2).

Table 4 shows the results of the second Delphi round, in which 17 of the 22 panel members participated. All recommendations reached the established level of agreement, with a percentage of coincidence greater than 50%. Of the 14 recommendations, 7 were classed as basic or level I (1.1, 1.2, 1.5, 2.1, 2.2, 5.1, 6.1) and the remaining 7 as advanced or level II (1.3, 1.4, 3.1, 3.2, 4.1, 6.2, 7.1).

Finally, of the 5 proposals for the name of the accreditation program, the one with the most support was Soludable (as mentioned above, a play on the Spanish words sol [sun] and saludable [healthy]).

The Soludable accreditation program is the first acknowledgement of school sun protection to be developed in our country. This is a certification model that identifies those schools that actively encourage policies and practices of sun protection and involve the entire educational community.

The project was undertaken by a multidisciplinary group of experts including healthcare and educational professionals of national renown in coordination with the Health Promotion Service (Health Department), Service of Planning and Educational Programs (Education Department), and the Patient Safety Monitoring System of the Andalusian Agency for Health Quality.

In addition, the project was endorsed by the Academia Española de Dermatología y Venereología (Spanish Academy Dermatology and Venereology).

The structure of the model adopts the line of quality accreditation systems developed by the Andalusian Agency for Health Quality.17 The recommendations included in the model are based on the policies of the Australian SunSmart School,15,16 and are consistent with the educational plans and programs of healthy living habits of the Education Department of the Andalusian regional government18 and also with the European health promotion guidelines, focused on creating environments that facilitate healthier lifestyles “Healthy cities in the twenty-first century” and “Health-promoting schools.”19,20

The model for SunSmart School certification was implemented in Australia in 1993,21 and has been greatly extended in the last 10 years. More than 90% of the Australian primary schools are registered with the SunSmart School program,22,23 and these schools have shown better sun protection practices among students.24,25 New Zealand adopted the SunSmart School program in 2005 and a notable improvement in sun protection policies and practices have been observed between 2005 and 2009 in primary schools.26,27 Furthermore, the introduction of education in matters of sun protection in schools is not only associated with better practices within the school itself, but it also seems to improve sun protection habits outside the school environment.28,29

In a range a studies conducted in primary school and secondary school populations in Andalusia, high rates of sunburn have been reported (between 54% and 74%).30–32 In this same risk population, an improvement has also been demonstrated in sun protection awareness and behavior in teenagers after an Internet-based educational intervention.33 The introduction of this accreditation system, whose intention is to encourage good sun protection behavior among school children, will alleviate cancer risk in the coming years, as schools start to adhere to the strategy of the Soludable accreditation system.

Setting up these measures may be difficult, as it requires commitment from education professionals, head teachers, and government organizations should structural changes be necessary. To assist the schools in obtaining accreditation, we have drawn up a manual for certification and an easily navigated online self-assessment tool in the Andalusian Agency for Health Quality for each of the domains. This would enable schools to identify their position within the accreditation system, determine what they want to achieve, and plan their actions accordingly, with consensus and shared goals. This would be complemented with the progressive nature of the accreditation system. This process is understood to be dynamic, continuous, and evolving, and would reflect the potential for improving quality.

Currently, we do not have information on the sun protection measures that are used in Spanish schools. We therefore need new studies to determine the current prevalence of sun protection practices and policies in schools. The presentation of this accreditation system in schools would enable assessment of the number of schools interested in requesting the certification model, as well as the impact this has on the school itself; it would also enable assessment of the main barriers and opportunities for implementation, and evaluation of the changes made after implementation.

In conclusion, we have presented a school certification model that enables identification of schools that actively encourage sun protection by introducing a set of measures or good practices that are objective and evaluable. This is the first school accreditation system for sun protection to be developed in Spain. It can be expected that, in the coming years, adherence of schools, whether primary or secondary, to this strategy will contribute to reducing the incidence of sunburn in school children, although long-term studies are needed to determine the uptake and health and economic impact of this initiative without precedent in Spain.

The Health Department of the Andalusian Regional Government, call for research projects in the area of public health, PS-O295-16.

The authors declare that they have no conflicts of interest.