Expanding occupational sun safety to an outdoor recreation industry: a translational study of the Go Sun Smart program

Systematic Review of Interventions to Increase Awareness of Ultraviolet Radiation-Induced Harm and Protective Behaviors in Post-Secondary School Adults

College and university students are a group known for excessive sun exposure and indoor tanning. Health education campaigns for avoidance of ultraviolet (UV) radiation have been relatively unsuccessful in this population. This systematic review examines interventions aimed at post-secondary school young adults on college and university campuses for skin cancer awareness, photoprotection, and change in UV-exposure-related behavior. Fifty-nine studies were identified for inclusion according to predetermined criteria. Study heterogeneity was high; methods of intervention were individual or group-based, and were mostly visually delivered and/or passive learning. Most interventions occurred at a single time point. Intervention success was assessed by evaluating subject behavior, intention, attitudes, knowledge, and emotion. Multicomponent interventions, generally consisting of UV photography and a passively delivered educational component, may be more effective than a single component alone. Overall, study quality was poor. Sample size of the majority of studies was <150 subjects. Most studies used self-report of behavior and had a short follow-up time. Generalizability of findings may be impacted as women, particularly white/Caucasian women, were overrepresented in the studies identified by this systematic review. For this specific target population, themes arising from the review include the importance of self-relevance and message framing. Self-affirmation was identified as a potential challenge in designing interventions for this target group, which can lead to defensiveness and a negative reaction to the health message. The findings of this systematic review may inform future research in this field, as well as guide planning of effective interventions in this target population.

Sun protection habits and behaviors of a group of outdoor workers and students from the agricultural and construction sectors in north-Italy

Background:

Despite the relevant frequency of ultraviolet induced adverse health effects in workers, solar ultraviolet radiation (UVR) exposure is an occupational risk not adequately minimized in Italy.

Objective:

To assess the characteristics and prevalence of sun exposure habits and behaviors in a group of students and outdoor workers (OW) from the agricultural and construction sectors of a north-Italian region.

Methods:

Based on a previously developed standardized questionnaire, we collected full information on individual sun exposure habits at work and during leisure activities.

Results:

In 2018, 380 high school students and OW from the agricultural and construction sectors participated in a sun-safety campaign. More than a third (39.0%) of OW reported never using sunglasses, 52.8% never applied sunscreens at work, and a quarter never wear a UV protective hat. Considering leisure-time, students reported more frequent sunburns compared to OW: 25.0% vs. 13.8%; half (51.6%) of students and a third (36.4%) of OW reported never wearing a UV protective hat. A third (30.1%) of students and 37.2% of OW never or only seldom applied sunscreens on holidays.

Discussion:

The majority of OW in our study reported poor protective solar exposure habits. Young students of the construction and agricultural sectors indicated even worse sun-protective behaviors, both during apprenticeship and leisure activities. Our study highlights the low health literacy related to solar UVR in OW and apprentices. Further educational initiatives are required in Italy to improve the adoption of protective behaviors during outdoor activities.

Primary prevention of keratinocyte carcinoma among outdoor workers, the general population and medical professionals: a systematic review updated for 2019

Worldwide 2-3 million cases of keratinocyte carcinoma (KC) are diagnosed annually. Sun-related knowledge is essential for adequate protection against solar ultraviolet radiation (UVR), the main risk factor for KC. The goal was (i) to provide an updated overview of primary prevention against KC including skin cancer-related knowledge, attitudes and sun protection behaviour (SPB) of outdoor workers, the general population and medical professionals as well as (ii) to evaluate the effectiveness and acceptability of sun protection programmes. We conducted a systematic review of articles indexed for MEDLINE on PubMed using selected MeSH terms and keywords related to the studied topic as well as an extensive hand search of publications between 1 January 2012 and 31 December 2018. We identified 51 relevant cross-sectional studies and 22 interventional studies. Sun-related knowledge and attitude showed substantial differences with some alarming results, including people who had not even heard about skin cancer before. Reported SPB varied enormously between the included studies, with none of the studies providing an overall sufficient SPB in their examined sun protection measures. However, sun protection programmes using new technologies seem to have great potential to increase sun-related knowledge and SPB. In countries worldwide, particularly in those where KC is not yet a public health issue, UVR protection should be promoted by healthcare institutions and authorities, politicians, cancer foundations and dermatologists to increase awareness as well as SPB and to decrease the worldwide burden of KC.

Skin cancer interventions across the cancer control continuum: Review of technology, environment, and theory

The National Cancer Institute's Skin Cancer Intervention across the Cancer Control Continuum model was developed to summarize research and identify gaps concerning skin cancer interventions. We conducted a mapping review to characterize whether behavioral interventions addressing skin cancer prevention and control from 2000 to 2015 included (1) technology, (2) environmental manipulations (policy and/or built environment), and (3) a theoretical basis. We included 86 studies with a randomized controlled or quasi-experimental design that targeted behavioral intervention in skin cancer for children and/or adults; seven of these were dissemination or implementation studies. Of the interventions described in the remaining 79 articles, 57 promoted only prevention behaviors (e.g., ultraviolet radiation protection), five promoted only detection (e.g., skin examinations), 10 promoted both prevention and detection, and seven focused on survivorship. Of the 79 non-dissemination studies, two-thirds used some type of technology (n=52; 65.8%). Technology specific to skin cancer was infrequently used: UVR photography was used in 15.2% of studies (n=12), reflectance spectroscopy was used in 12.7% (n=10), and dermatoscopes (n=1) and dosimeters (n=2) were each used in less than 3%. Ten studies (12.7%) targeted the built environment. Fifty-two (65.8%) of the studies included theory-based interventions. The most common theories were Social Cognitive Theory (n=20; 25.3%), Health Belief Model (n=17; 21.5%), and the Theory of Planned Behavior/Reasoned Action (n=12; 15.2%). Results suggest that skin cancer specific technology and environmental manipulations are underutilized in skin cancer behavioral interventions. We discuss implications of these results for researchers developing skin cancer behavioral interventions.

A Randomized Trial of an Advanced Sun Safety Intervention for Vacationers at 41 North American Resorts

Taking vacations in sunny locations is associated with the development of skin cancer. This study tested a multi-component sun protection intervention based on diffusion of innovations theory and transportation theory designed to increase vacationers' comprehensive sun protection, i.e., use of clothing, hats, and shade, and use, pre-application, and reapplication of sunscreen. The trial enrolled 41 warm weather resorts in North America in a pair-matched group randomized pretest-posttest design and assessed samples of adult vacationers at resort outdoor recreation venues regarding sun protection at pretest (n = 3,531) and posttest (n = 3,226). While results showed no overall effect of the intervention on comprehensive sun protection across venues, the intervention produced statistically significant improvements in sun protection at waterside venues (pools and beaches). The intervention's overall effects may have been impeded by a lack of uniformly robust implementation, low interest in skin cancer prevention by guests, or shortcomings of the theories used to create prevention messages. The intervention may have worked best with guests in the highest-risk recreation venue, i.e., waterside recreation where they exposed the most skin. Alternative approaches that alter resort organizations, such as through changes in policy, environmental features, or occupational efforts might be more effective than targeting vacationers with behavior-change messages.

Effect of an intervention on observed sun protection by vacationers in a randomized controlled trial at North American resorts

During vacations, many individuals receive high-risk sun exposure that is associated with skin cancer. Vacationers in outdoor recreation venues (pretest n=4347; posttest n=3986) at warm-weather destination resorts in North America (n=41) were enrolled in a pair-matched, group-randomized pretest-posttest controlled quasi-experimental design in 2012-14. Print, audiovisual, and online messages based on Transportation Theory and Diffusion of Innovation Theory and promoting advanced sun protection (e.g., use of clothing, hats, shade and pre-application/reapplication of sunscreen and reliable cues to high UV) were delivered through resort channels. Vacationers' sun protection practices observed by trained research staff (i.e., body coverage and shade use analyzed individually and in combined scores) did not differ by experimental condition (p>0.05) or intervention implementation (p>0.05). However, recreation venue moderated intervention impact. The intervention improved sun protection at waterside recreation venues (z-score composite: intervention pre=-22.74, post=-15.77; control pre=-27.24, post=-23.24) but not non-waterside venues (z-score composite: intervention pre=20.43, post=20.53; control pre=22.94, post=18.03, p<0.01). An additional analysis showed that resorts with greater program implementation showed more improvements in sun protection by vacationers at waterside (z=score composite: high implementation pre=-25.45, post=-14.05; low implementation pre=-24.70, post=-21.40) compared to non-waterside (z-score composite: high implementation pre=14.51, post=19.98; low implementation pre=24.03, post=18.98, p<0.01) recreation venues. The intervention appeared effective with the vacationers in recreation venues with the highest-risk for sun exposure, waterside venues. However, it was not effective throughout all the resort venues, possibly because of the sun-seeking desires of vacationers, information overload at the resorts, and constraints on clothing styles and sun protection by recreation activity.

Adoption of sun safe workplace practices by local governments

CONTEXT

Outdoor workers are especially susceptible to skin cancer--the most common, but also one of the most preventable, forms of cancer. Colorado, the location of the study, has the second highest rate of skin cancer deaths in the nation.

OBJECTIVE

Local government managers in Colorado-in municipalities, counties, and special districts-were surveyed to ascertain the extent to which they engage in formal (written) and informal practices to protect their outdoor workers against excessive exposure to sun.

DESIGN

The survey consisted of 51 questions assessing awareness of formal or informal practices for sun protection of outdoor workers. An index of practices--the study's dependent variable--was created that was composed or practices such as providing employees free or reduced-cost sunscreen, wide-brimmed hats, sunglasses, long-sleeved work shirts, long work pants, and temporary or permanent outdoor shade shelters. Proscriptive policies, such as restricting the use of broad brimmed hats, were subtracted from the index. Surveys were completed by 825 administrators representing 98 jurisdictions. Responses from administrators in the same jurisdiction were averaged.

RESULTS

More than 40% of responding jurisdictions indicated that they engaged in informal sun safety practices. Tests conducted to determine what variables might account for the adoption of these sun protection practices found that the degree to which a community could be regarded as cosmopolite and as having an individualistic political culture were significant predictors. Type of government was also significant. Although, higher community income was a significant predictor, neither local government budget nor size was significant.

CONCLUSIONS

The adoption of sun safe practices bears low costs with potentially high returns. Findings from this study suggest that awareness campaigns might most effectively target cosmopolite communities, but that the greatest impact might be achieved by targeting localite communities. Government size and budget do not appear to be constraints in the adoption of sun safe practices.

Melanoma Epidemiology and Prevention

The epidemiology of melanoma is complex, and individual risk depends on sun exposure, host factors, and genetic factors, and in their interactions as well. Sun exposure can be classified as intermittent, chronic, or cumulative (overall) exposure, and each appears to have a different effect on type of melanoma. Other environmental factors, such as chemical exposures-either through occupation, atmosphere, or food-may increase risk for melanoma, and this area warrants further study. Host factors that are well known to be important are the numbers and types of nevi and the skin phenotype. Genetic factors are classified as high-penetrant genes, moderate-risk genes, or low-risk genetic polymorphisms. Subtypes of tumors, such as BRAF-mutated tumors, have different risk factors as well as different therapies. Prevention of melanoma has been attempted using various strategies in specific subpopulations, but to date optimal interventions to reduce incidence have not emerged.

Rationale, design, samples, and baseline sun protection in a randomized trial on a skin cancer prevention intervention in resort environments

INTRODUCTION

Exposure to solar ultraviolet radiation during recreation is a risk factor for skin cancer. A trial evaluated an intervention to promote advanced sun protection (sunscreen pre-application/reapplication; protective hats and clothing; use of shade) during vacations.

MATERIALS AND METHODS

Adult visitors to hotels/resorts with outdoor recreation (i.e., vacationers) participated in a group-randomized pretest-posttest controlled quasi-experimental design in 2012-14. Hotels/resorts were pair-matched and randomly assigned to the intervention or untreated control group. Sun. protection (e.g., clothing, hats, shade and sunscreen) was measured in cross-sectional samples by observation and a face-to-face intercept survey during two-day visits.

RESULTS

Initially, 41 hotel/resorts (11%) participated but 4 dropped out before posttest. Hotel/resorts were diverse (employees=30 to 900; latitude=24° 78' N to 50° 52' N; elevation=2ft. to 9726ft. above sea level), and had a variety of outdoor venues (beaches/pools, court/lawn games, golf courses, common areas, and chairlifts). At pretest, 4347 vacationers were observed and 3531 surveyed. More females were surveyed (61%) than observed (50%). Vacationers were mostly 35-60years old, highly educated (college education=68%) and non-Hispanic white (93%), with high-risk skin types (22%). Vacationers reported covering 60% of their skin with clothing. Also, 40% of vacationers used shade; 60% applied sunscreen; and 42% had been sunburned.

CONCLUSIONS

The trial faced challenges recruiting resorts but result showed that the large, multi-state sample of vacationers were at high risk for solar UV exposure.

Sustained use of an occupational sun safety program in a recreation industry: follow-up to a randomized trial on dissemination strategies

The sustainability of evidence-based programs is needed to obtain long-term benefits. To assess sustainability of Go Sun Smart (GSS), an occupational skin cancer prevention program disseminated to the North American ski industry. Fifty-three of the 68 ski areas from the original dissemination trial participated in 2012 and 2013, 5 to 7 years after program distribution by enhanced or basic dissemination strategies. Sustained use was measured by: (1) on-site observation of sun protection communication and (2) an online survey with senior managers. In the sustainability assessment, sun safety communication had declined, and dissemination strategy did not affect continued use. Managers held weaker attitudes about skin cancer importance and program fit, but more managers provided free/reduced-cost sunscreen than in the dissemination trial. Manager turnover was a key factor in program discontinuance. Sustainability remains a challenge. Additional research is needed to determine the best strategies for sustainability.

Mediation analysis of decisional balance, sun avoidance and sunscreen use in the precontemplation and preparation stages for sun protection

OBJECTIVE

Mediation analyses of sun protection were conducted testing structural equation models using longitudinal data with three waves. An effect was said to be mediated if the standardised path between processes of change, decisional balance and sun protection outcomes was significant.

DESIGN

Longitudinal models of sun protection using data from individuals in the precontemplation (N = 964) and preparation (N = 463) stages who participated of an expert system intervention.

MAIN OUTCOME MEASURES

Nine processes of change for sun protection, decisional balance constructs of sun protection (pros and cons), sun avoidance behaviour and sunscreen use.

RESULTS

With the exception of two processes in the preparation stage, processes of change predicted the pros (r = .126-.614), and the pros predicted the outcomes (r = .181-.272). Three models with the cons as mediator in the preparation stage, and none in the precontemplation stage, showed a mediated relationship between processes and outcomes.

CONCLUSION

In general, mediation analyses found both the process of change-to-pros and pros-to-behaviour paths significant for both precontemplation and preparation stages, and for both sun avoidance and sunscreen use outcomes. Findings provide support for the importance of assessing the role of underlying risk cognitions in improving sun protection adherence.

Interventions to decrease skin cancer risk in outdoor workers: update to a 2007 systematic review

Background

Outdoor workers are at high risk of harmful ultraviolet radiation exposure and are identified as an at risk group for the development of skin cancer. This systematic evidence based review provides an update to a previous review published in 2007 about interventions for the prevention of skin cancer in outdoor workers.

Results

This review includes interventions published between 2007-2012 and presents findings about sun protection behaviours and/or objective measures of skin cancer risk. Six papers met inclusion criteria and were included in the review. Large studies with extended follow-up times demonstrated the efficacy of educational and multi-component interventions to increase sun protection, with some higher use of personal protective equipment such as sunscreen. However, there is less evidence for the effectiveness of policy or specific intervention components.

Conclusions

Further research aimed at improving overall attitudes towards sun protection in outdoor workers is needed to provide an overarching framework.