Application of an appearance based intervention to improve sun protection outcomes of outdoor workers in queensland, australia

Keywords Appearance-based intervention, behaviour, facial UV-photograph, intention, intervention, leisure time, organisation, outdoor workers, quantitative, risk perception, skin cancer

Application of an Appearance-Based

Intervention to Improve Sun

Protection Outcomes of Outdoor Workers in Queensland, Australia

Brisbane, Australia May 2012

Keywords

Appearance-based intervention, behaviour, facial UV-photograph, intention,

intervention, leisure time, organisation, outdoor workers, quantitative, risk perception,

skin cancer prevention, sun safety policy, theory, work time

List of Abbreviations

ARPANSA Australian Radiation Protection and Nuclear Safety Agency

H&S Health and Safety

i-Change Integrated Model for Change

ICNIRP International Commission on Non-Ionizing Radiation Protection

NHMRC National Health and Medical Research Council

POWER Protection of Outdoor Workers from Environmental Radiation

SCRAT Skin Cancer Risk Assessment Tool

UV Ultraviolet

Definitions for this Thesis

Policy is defined as having work sun protection measures and risk management in place

for employees to protect from the risks of sun exposure

Current: belonging to the present time

Practice: habitual or customary performance regarding sun protection

Sun protection: protection of the skin and eyes through the use of shade, clothing and/or

sunscreen

Outdoor worker: a person that spends at least half of their time outside

working day) working in an outdoor environment According to Stepanski and Mayer

(1998) outdoor workers typically spend 30 work hours or more per week exposed to

UVR

Change: a transformation or modification; alteration

Intervention group: a group(s) of people that undergo the same study condition which

includes the intervention part of the study The intervention part is meant to be the

effective changing component of the study

Control group: a group(s) of people that undergo the same study condition and do not

undergo the intervention part of the study

Effectiveness: adequate to accomplish a purpose; producing the intended or expected

result

Impact: to have an effect on; influence; alter

Stringent sun protection policy setting: having an organisational policy that protects

employees from the risks of sun exposure that is clear and consciously implemented and

reviewed

Less stringent sun protection policy setting: not having a stringent organisational policy

in place for the protection of employees

Abstract

Outdoor workers are exposed to high levels of ultraviolet radiation (UVR) and may thus

be at greater risk to experience UVR-related health effects such as skin cancer, sun burn,

and cataracts A number of intervention trials (n=14) have aimed to improve outdoor

-related sun protection cognitions and behaviours Only one study

however has reported the use of UV-photography as part of a multi-component

intervention This study was performed in the USA and showed long-term (12 months)

improvements in work-related sun protection behaviours Intervention effects of the

other studies have varied greatly, depending on the population studied, intervention

applied, and measurement of effect Previous studies have not assessed whether:

- Interventions are similarly effective for workers in stringent and less stringent

policy organisations;

- Implemented interventions are effective in the long-term;

- The facial UV-photograph technique is effective in Australian male outdoor

workers without a large additional intervention package, and;

and behaviours

Therefore, the present Protection of Outdoor Workers from Environmental Radiation

[POWER]-study aimed to fill these gaps and had the objectives of: a) assessing outdoor

-related cognitions and behaviours at work and during leisure time in

stringent and less stringent sun protection policy environments; b) assessing the effect of

the two policy settings; and d) assessing the immediate post-intervention effect

Effectiveness was described in terms of changes in sun-related risk perceptions and

intentions (as these factors were shown to be main precursors of behaviour change in

many health promotion theories) and behaviour

The study purposefully selected and recruited two organisations with a large outdoor

worker contingent in Queensland, Australia within a 40 kilometre radius of Brisbane The

two organisations differed in the stringency of implementation and reinforcement of

their organisational sun protection policy Data were collected from 154 male

predominantly Australian born outdoor workers with an average age of 37 years and

predominantly medium to fair skin (83%) Sun-related cognitions and behaviours of

workers were assessed using self-report questionnaires at baseline and six to twelve

months later Variation in follow-up time was due to a time difference in the recruitment

of the two organisations Participants within each organisation were assigned to an

intervention or control group The intervention group participants received a one-off

personalised Skin Cancer Risk Assessment Tool [SCRAT]-letter and a facial

UV-photograph with detailed verbal information This was followed by an immediate

post-intervention questionnaire within three months of the start of the study The control

group only received the baseline and follow-up questionnaire

Data were analysed using a variety of techniques including: descriptive analyses,

parametric and non-parametric tests, and generalised estimating equations A 15%

proportional difference observed was deemed of clinical significance, with the addition

of reported statistical significance (p<0.05) where applicable

Objective 1: Assess and compare the current sun-related risk perceptions, intentions, behaviours, and policy awareness of outdoor workers in stringent and less stringent sun protection policy settings Workers within the two organisations (stringent n=89 and less

stringent n=65) were similar in their knowledge about skin cancer, self efficacy, attitudes,

and social norms regarding sun protection at work and during leisure time Participants

were predominantly in favour of sun protection Results highlighted that compared to

workers in a less stringent policy organisation working for an organisation with stringent

sun protection policies and practices resulted in more desirable sun protection intentions

(less willing to tan p=0.03) ; actual behaviours at work (sufficient use of upper and lower

body protection, headgear, and sunglasses (p<0.001 for all comparisons), and greater

policy awareness (awareness of repercussions if Personal Protective Equipment (PPE)

was not used, p<0.001)) However the effect of the work-related sun protection policy

was found not to extend to leisure time sun protection

Objective 2: Compare changes in sun-related risk perceptions, intentions, and behaviours between the intervention and control group The effect of the intervention was minimal

and mainly resulted in a clinically significant reduction in work-related self-perceived risk

of developing skin cancer in the intervention compared to the control group (16% and

32% for intervention and control group, respectively estimated their risk higher

compared to other outdoor workers: , p=0.11) No other clinical significant effects were

observed at 12 months follow-up

Objective 3: Assess whether the intervention was equally effective in the stringent sun protection policy organisation and the less stringent sun protection policy organisation

The appearance-based intervention resulted in a clinically significant improvement in the

work (workplace*time interaction, p=0.01) In addition to a reduction in their willingness

to tan both at work (will tan at baseline: 17% and 61%, p=0.06, at follow-up: 54% and

33%, p=0.07, stringent and less stringent policy intervention group respectively The

workplace*time interaction was significant p<0.001) and during leisure time (will tan at

baseline: 42% and 78%, p=0.01, at follow-up: 50% and 63%, p=0.43, stringent and less

stringent policy intervention group respectively The workplace*time interaction was

significant p=0.01) over the course of the study compared to the less stringent policy

intervention group However, no changes in actual sun protection behaviours were

found

Objective 4: Examine the effect of the intervention on level of alarm and concern

regarding the health of the skin as well as sun protection behaviours in both

organisations The immediate post-intervention results showed that the stringent policy

organisation participants indicated to be less alarmed (p=0.04) and concerned (p<0.01)

about the health of their skin and less likely to show the facial UV-photograph to others

(family p=0.03) compared to the less stringent policy participants A clinically significantly

larger proportion of participants from the stringent policy organisation reported they

worried more about skin cancer (65%) and skin freckling (43%) compared to those in the

less stringent policy organisation (46%,and 23% respectively , after seeing the

UV-photograph)

In summary the results of this study suggest that the having a stringent work-related sun

protection policy was significantly related to for work-time sun protection practices, but

did not extend to leisure time sun protection This could reflect the insufficient level of

sun protection found in the general Australian population during leisure time

Alternatively, reactance caused by being restricted in personal decisions through

work-time policy could have contributed to lower leisure work-time sun protection Finally, other

factors could have also contributed to the less than optimal leisure time sun protection

behaviours reported, such as unmeasured personal or cultural barriers All these factors

combined may have lead to reduced willingness to take proper preventive action during

leisure time exposure

The intervention did not result in any measurable difference between the intervention

and control groups in sun protection behaviours in this population, potentially due to the

long lag time between the implementation of the intervention and assessment at

12-months follow-up In addition, high levels of sun protection behaviours were found at

baseline (ceiling effect) which left little room for improvement Further, this study did

not assess sunscreen use, which was the predominant behaviour assessed in previous

effective appearance-based interventions trials Additionally, previous trials were mainly

observed immediate post-intervention result could be due to more emphasis being

placed on sun protection and risks related to sun exposure in the stringent policy

organisation Therefore participants from the stringent policy organisation could have

been more aware of harmful effects of UVR and hence, by knowing that they usually

protect adequately, not be as alarmed or concerned as the participants from the less

stringent policy organisation

In conclusion, a facial UV-photograph and SCRAT-letter information alone may not

achieve large changes in sun-related cognitions and behaviour, especially of assessed

6-12 months after the intervention was implemented and in workers who are already quite

well protected Differences found between workers in the present study appear to be

more attributable to organisational policy However, against a background of

organisational policy, this intervention may be a useful addition to sun-related workplace

health and safety programs

The study findings have been interpreted while respecting a number of limitations These

have included non-random allocation of participants due to pre-organised allocation of

participants to study group in one organisation and difficulty in separating participants

from either study group Due to the transient nature of the outdoor worker population,

only 105 of 154 workers available at baseline could be reached for follow-up (attrition

rate=32%) In addition the discrepancy in the time to follow-up assessment between the

two organisations was a limitation of the current study

Given the caveats of this research, the following recommendations were made for future

research:

outside at work as well as in the way sun protection behaviours are measured

and reported

- Future studies should implement and assess the value of the facial

UV-photographs in a wide range of outdoor worker organisations and countries

- More timely and frequent follow-up assessments should be implemented in

intervention studies to determine the intervention effect and to identify the best

timing of booster sessions to optimise results

cognitions and behaviours and improve these if possible

use of sun protection Given the evidence generated by this research, organisations

employing outdoor workers should consider stringent implementation and

reinforcement of a sun protection policy Finally, more research is needed to improve

ways to generate desirable behaviour in this population during leisure time

Table of Contents

Keywords i

List of Abbreviations iii

Definitions for this Thesis v

Abstract vii

List of Figures xix

List of Tables xxi

Statement of Original Authorship xxv

Acknowledgements xxvii

1 Introduction 1

1.1 Problem statement 1

1.2 Overall research aims 2

1.3 Research approach 2

2 Background 5

2.1 Outdoor Workers 5

2.1.1 What defines an outdoor worker? 5

2.1.2 Why are outdoor workers at risk? 6

2.1.3 Requirements of Australian workplaces to limit UVR exposure 8

2.1.4 Occupational sun exposure and sun protection behaviours of outdoor workers and related policy 10

Sun exposure of outdoor workers 11

Sun protection behaviours among outdoor workers 12

Predictors of sun protection for outdoor workers 15

The effect of sun protection policy 16

2.1.5 Sun exposure and sun protection of outdoor workers during leisure time 16

2.1.6 I

cognitions and behaviours 18

2.1.7 Summary 26

2.2 Skin cancer 28

2.2.1 What is skin cancer? 28

2.2.2 Incidence and mortality 30

2.2.3 Skin cancer risk factors 32

Modifiable risk factors 34

Risk factors for specific skin cancer types 34

2.2.4 Sun protection methods to reduce risk of skin cancer 37

2.2.5 Summary 39

2.3 Risk communication 40

2.3.1 How is risk information processed? 40

2.3.2 What is effective risk communication? 42

2.3.3 Risk communication in relation to generating behaviour change 44

2.4 Skin cancer prevention and health promotion 47

2.4.1 Theories of health behaviour 47

Social Cognitive Theory 47

Transtheoretical Model 50

Health Belief Model 52

2.4.2 Theories of health behaviour applied in skin cancer prevention studies

54

2.4.3 History overview of skin cancer prevention campaigns in Australia 57

2.4.4 Skin cancer prevention intervention components 61

2.4.5 Challenges in measuring behavioural changes in skin cancer prevention research 69

2.4.6 Summary 73

2.5 Systematic review: Appearance-based interventions 75

2.6 Overview of the background 94

3 Methods 97

3.1 Research directions and importance 97

3.2 Study overview 98

Aims 99

3.3 Ethics 101

3.4 Design 101

3.5 Participants 102

3.5.1 Selection criteria for industries and participants 102

3.5.2 Recruitment 104

3.5.3 Workplace characteristics and setting 105

3.6 POWER-study 111

3.6.1 Intervention grounding and development 111

3.6.2 Questionnaires 113

3.6.3 Intervention components 122

SCRAT-letter 122

Facial UV-photograph 124

3.6.4 Flow of study procedures and data collection 126

3.6.5 Conducting the intervention 127

3.6.6 Follow-up 128

3.7 Outcomes 130

3.8 Sample size and power 133

3.9 Allocation of participants 136

3.10 Statistical considerations 137

3.10.1 Data cleaning 137

3.10.2 Analytical plan: Treatment of data and assumptions 138

3.10.3 Significance of results 140

3.10.4 Data analyses: Objective one 142

3.10.5 Data analyses: Objective two 144

Regression 150

3.10.6 Data analyses: Objective three 151

Regression 153

3.10.7 Data analyses: Objective four 155

3.10.8 Overview of the data analyses conducted in the POWER-study 157

4 Results 159

4.1 Participant enrolment 159

4.2 Participant characteristics 161

4.3 Objective 1 172

4.3.1 Summary of results objective 1 185

4.4 Objective 2 187

4.4.1 Regression results 187

4.4.2 Summary of results objective 2 194

4.5 Objective 3 195

4.5.1 Regression results 196

4.5.2 Summary of results objective 3 203

4.6 Objective 4 205

4.6.1 Summary of results objective 4 209

5.1 The aims of the POWER-study 211

5.2 POWER-study findings and challenges 213

5.3 Comparing the POWER-study and the Iowa road workers study 214

5.4 Organisational sun protection policy and its impact 219

5.4.1 Other environmental influences and work-related protection 224

5.4.2 Leisure time behaviour 226

5.5 The effect of an appearance-based intervention 229

5.5.1 Intention and behaviour effects 230

5.5.2 Immediate intervention effects 232

5.6 Limitations of the POWER-study 234

5.6.1 Study assessment methods, design and recruitment 234

5.6.2 Limitations in the types of sun protection behaviour assessed 238

5.7 Strengths and recommendations 239

5.7.1 Strengths of the POWER-study and recommendations for research and practice 239

5.7.2 Final reflections 242

5.8 Conclusion 243

REFERENCES 245

Appendix A: Overview of intervention studies aimed at outdoor workers to change skin cancer-related cognitions and behaviour 265

Appendix B: Overview of descriptive studies and interventions focussing on outdoor workers 273

Appendix C: Outdoor worker review protocol 277

Appendix D: Systematic review protocol 281

Appendix E: Ethics approval 285

Appendix F: Newsletter 287

Appendix G: Health and safety officer questions 289

Appendix H: Participant information sheet 291

Appendix I: Consent form 295

Appendix J: Overview of all the Baseline questions and their justification/validation 297

Appendix K: Baseline questionnaire 301

Appendix L: Follow-up questionnaire 313

Appendix M: Immediate post-intervention questionnaire 339

Appendix N: SCRAT-letter 341

Appendix O: SCRAT-score calculation 343

Appendix P: Intervention script 345 Appendix Q: Thank you letter 347 Appendix R: Overview of collapsed variables in the baseline questionnaire 349 Appendix S: Results of objective two with 95% confidence intervals for the proportions within the control and intervention group 351 Appendix T: Results of objective three with 95% confidence intervals for the

proportions within the less stringent and stringent policy organisation intervention groups 355 Appendix U: Association between level of concern, alarm, and SCRAT-letter category

of the intervention group participants with the three risk perception questions at

follow-up 359

List of Figures

Figure 1 Incidence rates for melanoma (a) and all cancers combined (b) per age category

(AIHW, 2010a) 29

Figure 2 Incidence (a) and mortality (b) rates for malignant melanoma for men and women per 100,000 people (Adapted from the AIHW, 2010a) 31

Figure 3 The triadic relationship of the constructs of the SCT (Bandura, 1986) 49

Figure 4 Stages of change in the Transtheoretical Model (Prochaska, 1984) 51

Figure 5 The Health Belief Model (Janz & Becker, 1984) 53

Figure 6 The Cancer Council Australia SunSmart campaign logo (The Cancer Council Victoria, 2011) 58

Figure 7 Study design of the POWER-study 102

Figure 8 Enrolled number of participants in each study condition per organisation 109

Figure 9 Example of a UV-photograph indicating damage to the skin potentially due to UVR exposure 124

Figure 10 Study overview and participant time commitment 126

Figure 11 Model for pathways of the constructs assessed in the POWER-study and their relation to one another 131

Figure 12 Overview of total participant involvement in the POWER-study per organisation 135

Figure 13 Schematic overview of the relation of objective one to the design of the POWER-study 142

Figure 14 Schematic overview of the relation of objective two to the design of the POWER-study 144

Figure 15 Schematic overview of the relation of objective three to the design of the POWER-study 151

Figure 16 Schematic overview of the relation of objective four to the design of the POWER-study 155

Figure 17 Flow diagram of participant involvement 159

List of Tables

Table 1 An overview of assessed and improved sun protection behaviours of outdoor workers in order of variety of types of protection behaviours assessed (the more variety the better) to overall protection score and study efficacy 23 Table 2 Studies using appearance-based (UV-imaging) interventions to change skin cancer-related cognitions and behaviours 79 Table 3 Overview of sun protection behaviours assessed and changed in the facial UV-imaging interventions 88 Table 4 Selection criteria for study organisation participants 104

organisation and the less stringent policy organisation to the Australian Radiation

Protection and Nuclear Safety Agency (ARPANSA) standard 107 Table 6 Overview of study assessment and intervention materials (shaded in grey) 111 Table 7 Overview of assessment instruments 113 Table 8 Overview of the additional variables measured at follow-up and their

measurement properties 117 Table 9 Overview of measured variables and their statistical background at the

intervention time 118 Table 10 Reliability of some constructs in the baseline questionnaire of the POWER-study 121 Table 11 Overview of dates and locations the POWER-study was conducted 130 Table 12 Additional evidence for the importance of the outcome measures of this study 132 Table 13 An overview of the clinically and statistically significant differences between the intervention and control group at baseline 146 Table 14 Outline and properties of the adjusting variables and the eleven outcome measures 147 Table 15 An overview of the significant differences between the stringent and less stringent intervention policy groups at baseline 152 Table 16 Overview of the study objectives with related questions and statistical methods used for analysis 157

Table 17 Descriptive characteristics of the demographic variables of the total participant population, the stringent policy organisation and the less stringent policy organisation 162 Table 18 Phenotype, health, skin, and skin cancer-related factors of the total participant population, the stringent policy organisation and the less stringent policy organisation 164 Table 19 Sun exposure and sun protection-related cognitions of the total participant population, the stringent policy organisation and the less stringent policy organisation 168 Table 20 Baseline results for the current risk perception in a stringent policy versus less stringent policy outdoor worker organisation with 95% confidence 173 Table 21 Baseline results for the current intention in a stringent policy versus less stringent policy outdoor worker organisation with 95% confidence 175 Table 22 Baseline results for the current behaviour in a stringent policy versus less stringent policy outdoor worker organisation 179 Table 23 Baseline results for the current policy awareness in a stringent policy versus less stringent policy outdoor worker organisation 183 Table 24 Risk perceptions, intentions, behaviours, and differences in policy awareness found that were more desirable for work and leisure time-related sun protection in the stringent policy organisation and the less stringent policy organisation 186 Table 25 Odds Ratios (ORs) or mean and standard error (SE) with 95% Confidence Intervals (CIs) and proportions for risk perception, intention, and behaviour of the control group compared to the intervention group at each time point (baseline and follow-up) and over time 190 Table 26 Odds Ratios (ORs) or mean and standard error (SE) with 95% Confidence Intervals (CIs) and proportions for risk perception, intention, and behaviour of the Less stringent policy organisation intervention group compared to the Stringent policy

organisation intervention group at each time point (baseline and follow-up) and over time 199 Table 27 Overview of the immediate effect of the facial UV-photograph and SCRAT-letter information with 95% confidence intervals 205 Table 28 Overview of the effect of the facial UV-photograph and SCRAT-letter

information at follow-up with 95% confidence intervals 207 Table 29 Comparison of the Iowa road workers study and the POWER-study 215

Table 30 Overview of workplace policy on main outcomes in proportion of participants

between the POWER-study and the study by Woolley et al (2008) 222

Statement of Original Authorship

The work contained in this thesis has not been previously submitted to meet

requirements for an award at this or any other higher education institution To the best

of my knowledge and belief, the thesis contains no material previously published or

written by another person except where due reference is made

Signature: _

Acknowledgements

Foremost, I would like to acknowledge my supervisory team, the panel members and

examiners who have spent their time reading this work This project would not have

been possible without the continued support and advice from my supervisory team:

Associate Professor Monika Janda, Professor Michael Kimlin, Doctor Thomas Tenkate and

Doctor Carolyn Lang I would especially like to thank Associate Professor Monika Janda

for her input and belief in my project, especially at those times when I was almost ready

of this thesis I would not have made it without her support Additionally, I would like to

thank Doctor Katrina Giskes for her editorial advice, aiding the grammatical and technical

writing of this Thesis

Importantly, I would to thank my very supportive family: mother, brothers, aunt, cousins

and grandmother Without their encouragement and love of travel I would not have

made the step to come back to Australia to start this PhD My family has always believed

in me and supported me; they listened to me when things were not going that great and

never got sick of it (or at least did not show if they did) They definitely were my

lifesavers, and it has been very hard at times being so far away from them A special

thanks goes to my brother, Guus, who designed the logo for this study! In addition,

thanks to my best friends back home; you were always there to support me and sent me

your encouraging messages During this journey and over the time I have been in

Australia it has been tremendously important for me to know that the people who I love

have never forgotten about me, and were always there!

During my time in Australia I created a fantastic network of friends who I could always

here the best it could be! Special thanks go out to Stephanie Harink, who has been a

This project would not have been possible without the help and co-operation of the

organisations that were studied and their employees I would like to acknowledge the

participated in this study), Mr Brett Harrison, who was instrumental in involving Energex

in this project Thank you also to all the Energex employees who participated Gratitude

Finally, a special thanks to all the office members of E-205 and A-113, in particular

Loretta McKinnon You have been supportive of a fellow student in need You have

helped me implement my project and data collection and were willing to proof read my

work You helped me through those long hours in the evening and, most importantly, we

have become friends

Thank you to everyone who believed in me!!

1 Introduction

1.1 Problem statement

Currently, skin cancer is the most common cancer in Australia and is estimated to cost the

Australian health system 300 million dollars annually (Australian Institute of Health and

Welfare (AIHW), 2005a) Skin cancer can potentially be disfiguring and deadly (AIHW,

2010a) The high prevalence of skin cancer in Australia is due to a number of factors: high

levels of ambient ultraviolet radiation (UVR), an outdoor-focused lifestyle, a fair-skinned

population and less-than-optimal sun protection behaviours

A number of skin cancer prevention interventions have been developed and implemented in

Australia in the past 31 years (Montague, Borland, & Sinclair, 2001) These interventions

have been directed towards the general population and targeted a range of population

sub-groups such as children, adolescents, adults, males, females and outdoor workers Their

effectiveness has been varied, and this is thought to be largely due to the unique

characteristics of these groups, the vast differences in intervention formats, and their

different sun exposure and sun protection-related cognitions as well as skin cancer

prevention behaviours (Arthey & Clarke, 1995)

Outdoor workers are predominantly male, and interventions specifically targeting outdoor

workers only emerged in the 1990s (Andersen et al., 2008; Azizi et al., 2000; Dobbinson,

Borland, & Anderson, 1999; Girgis, Sanson-Fisher, & Watson, 1994; Hanrahan, Hersey,

Watson, & Callaghan, 1995; Mayer et al., 2007; Stock et al., 2009, see Table in Appendix A)

Implementation of a sun protection policy within organisations employing outdoor workers

has shown to improve their sun protection cognitions and behaviours (Dobbinson & Knight,

More recently, an appearance-based intervention that uses imaging of underlying skin

damage has been trialled This technique has

for skin cancer prevention behaviours and the behaviour as well (Mahler, Kulik, Butler,

Gerrard, & Gibbons, 2008; Mahler, Kulik, Gerrard, & Gibbons, 2010; Siegel, 2009) However,

to date most appearance-based interventions have studied female college students in the

USA So far only one study has applied this intervention to outdoor workers (Stock, et al.,

2009) and no known Australian study has used this intervention technique

1.2 Overall research aims

The aim of this thesis was to assess the work- and leisure-time sun exposure and sun

protection-related cognitions and behaviours among outdoor workers employed in

organisations with stringent or less stringent sun protection policies in Queensland,

Australia Furthermore, the research also examined the effectiveness of an

behaviours

1.3 Research approach

Chapter 2 summarises the characteristics of the outdoor worker population and provides an

overview of skin cancer prevention interventions that have been designed and implemented

specifically for this group to date Furthermore, Chapter 2 provides a summary of the

effectiveness of a range of skin cancer prevention interventions, including those that have

used appearance-based (facial UV-photograph) strategies

Chapter 3 describes the methods employed in the appearance-based intervention study that

was undertaken in this Thesis research (the Protection of Outdoor Workers from

Environmental Radiation [POWER]-study) Chapter 4 provides a comprehensive description

of study results Finally, Chapter 5 summarises these findings with respect to those reported

previously in the literature and acknowledges the strengths and limitations of the research

undertaken This Chapter concludes with the implications of the findings for future research

as well as for the professional public health field and the conclusions drawn from this study

2 Background

2.1 Outdoor Workers

2.1.1 What defines an outdoor worker?

spend time outside to perform work-related tasks (e.g construction, road work,

transportation, electricity, mail delivery, and D

Woolley and colleagues studied road and construction workers in North Australia and

classified a person as an outdoor worker if they spent at least thirty minutes per day outside

for work (Woolley, Lowe, Raasch, Glasby, & Buettner, 2008), while McCool and colleagues in

New Zealand defined outdoor workers as those spending four hours outside for work

(McCool, et al., 2009) Six or more hours outside per day was required to qualify as outdoor

worker by Girgis and colleagues who studied workers from an electricity supply organisation

in Australia (Girgis, et al., 1994)

Outdoor occupations tend to be male dominated (Andersen et al., 2008; Azizi et al., 2000;

Dobbinson, Borland, & Anderson, 1999; Girgis, Sanson-Fisher, & Watson, 1994; Hanrahan,

Hersey, Watson, & Callaghan, 1995; Mayer et al., 2007; Stock et al., 2009), although some

are gender balanced (e.g lifeguards) or may be female dominated (e.g day camp staff)

(Geller et al., 2001; Glanz, Maddock, Lew, & Murakami-Akatsuka, 2001) Outdoor

occupations can vary widely in the potential intensity of UVR that workers are exposed to

1

Due to inconsistency in classification of outdoor workers by the amount of time spent outside in the

(Andersen, et al., 2008; Mayer, et al., 2007; Stock, et al., 2009) This is due to environmental

factors including the amount of time spent outside per day, time of the day, geographical

location, and also the protection used

2.1.2 Why are outdoor workers at risk?

Up to one-third of the working population is exposed to UVR during work time on a regular

basis; this is 1.2 million workers in over 300 outdoor occupations across Australia (Cancer

Council Australia, 2007; Hitchcock, Murray, Patterson, & Rockwell, 1997) It has been

estimated that up to 34,200 persons develop occupation-related skin cancers in Australia

annually (Fritschi & Driscoll, 2006) Squamous cell carcinoma (SCC), a form of non-melanoma

skin cancer (NMSC), shows a strong direct relationship with occupational sun exposure

(Rosso et al., 1996)

Outdoor workers are at risk of developing skin cancer if they receive a high level of

occupational UVR exposure combined with other factors predisposing of skin cancer such as

lifestyle, phenotype and gender (Andersen, et al., 2008; Dixon et al., 2008; Gies, Roy,

Toomey, Maclennan, & Watson, 1995; Lewis, Mayer, & Slymen, 2006) Many outdoor

workers in Queensland, Australia are exposed to very high levels of environmental solar UVR

regularly (Gies, et al., 1995; Herlihy, Gies, Roy, & Jones, 1994) It has been reported that

Australian outdoor workers are exposed to 10-70% of environmental UVR, depending on the

amount of work time they spend outdoors (Larko & Diffey, 1983) This contrasts with indoor

workers who are found to be exposed to only 6% of the environmental UVR in summer

(Larko & Diffey, 1983) A Northern European study performed by Diffey (1987) showed that

outdoor workers have a four-fold higher risk of developing skin cancer compared to indoor

workers Male outdoor workers in Germany were found to have a relative risk of basal cell

carcinoma (BCC) of 2.9 and relative risk of SCC of 2.5 compared to those working indoors

(Radespiel-Tröger et al., 2009) Furthermore, Kütting and Drexler (2010) reviewed several

studies from the USA, Japan and Europe and detected a significant association between skin

cancer and outdoor occupation Taken together, these findings suggest that Australian

outdoor workers may be at even higher risk of developing NMSCs compared to overseas

workers due to the higher overall level of environmental UVR in Australia

Annual cumulative UVR exposure has been associated with developing NMSC (Elsner et al.,

2007; Vishvakarman & Wong, 2003) Cumulative UVR exposure is determined not only by

occupational but also recreational exposures In addition to their occupational UVR

exposure, outdoor workers are more likely to be active, nature-oriented people who also

spend time outdoors during their leisure time and may self-select into outdoor jobs (Lichte

et al., 2010; Marlenga, 1995), increasing their cumulative UVR exposure (Lewis, et al., 2006)

Furthermore, a considerable proportion of outdoor workers have skin types that are at high

risk for damage (Andersen, et al., 2008) Outdoor workers with sun-sensitive skin types

reported more skin lesions being removed compared to those with less sensitive skin types

(Woolley, Buettner, & Lowe, 2002), highlighting their greater skin cancer risk

There are marked gender differences in skin cancer distribution and body site, and this may

be due (in part) to different occupational UVR exposures and sun protection behaviours The

incidence of SCC has been found to be 75% higher for men than women, probably due to the

time and intensity of the UVR received and/or sun protection behaviours practiced (AIHW,

2008; Green et al., 1996; Lewis, et al., 2006; Mayer, et al., 2007; Woolley, et al., 2008)

Studies have shown that men working outdoors are exposed to more ambient UVR and use

less Personal Protective Equipment (PPE) to reduce UVR exposure such as hats, shirts, and

trousers compared to women (Dixon, et al., 2008; Godar, Wengraitis, Shreffler, & Sliney,

2001)

On the other hand, Green and colleagues (1996) found no association between skin cancer

and outdoor occupation in the Australian Nambour Study They concluded that outdoor

workers tend to be a self-selected group with fewer of the phenotypic characteristics

associated with increased skin cancer risk (such as fair complexion) This was based on their

findings that people with olive skin colour and a low susceptibility to sunburn were

significantly more likely to report lifetime outdoor work than those with lighter skin colour

(Green, et al., 1996), indicating an occupational selection mechanism whereby people who

are less likely to develop skin cancer are more likely to select for occupations with more UVR

exposure than those with more susceptible complexions Although this selection mechanism

may operate, the weight of the evidence to date suggests that outdoor workers have higher

UVR exposures, leading to increased risk of developing skin cancer

2.1.3 Requirements of Australian workplaces to limit UVR exposure

As outdoor workers are at risk of developing skin cancer, guidelines for occupational UVR

exposures were published by the National Health and Medical Research Council (NHMRC) in

1989 and were based on guidelines by the International Commission on Non-Ionizing

Radiation Protection (ICNIRP) In these guidelines, occupational exposure was defined as

exposure gained while performing work-related activities i.e exposure of outdoor workers

to solar radiation as well as to artificial sources of UVR (Gies & Wright, 2003) In Australia,

the occupational exposure limit is set at a maximum personal dose of 30 J m-2 of UVR for an

eight hour working day (ICNIRP, 1996), with levels above this regarded as overexposure

The Australian Government also developed the Radiation Protection Standard for

Occupational Exposure to Ultraviolet Radiation (taking into account UVR exposures from all

sources, i.e natural and artificial), based on international guidelines for UVR exposure from

1989 This standard was revised in December 2006 This document contains an overview of

duties and responsibilities of (outdoor) workers and their employers The standard provides

guidance on how employers can meet their duty-of-care obligations for sun protection under

the workplace health and safety legislation This standard states that employers must

develop a plan to control the UVR exposure of their workers and do all that is necessary to

implement this plan e.g provide appropriate PPE Employees must follow the protection

practices outlined in the plan and are obligated to wear PPE when it is provided by their

employer Further, employers are obliged to develop a risk management process and engage

in control prioritisation (Australian Government, 2006)

However, an Australian study found that almost 37% of workplaces did not reinforce

sun-safe practices (Woolley, et al., 2002) In addition, a study conducted by Geller and colleagues

(2001) did not show any change in sun protection behaviours among employees in

organisations that had implemented a sun protection policy Despite some evidence that

mandatory sun protection at work may reduce sun damage and increase the uptake of sun

protection practices (McCool, et al., 2009; Woolley, et al., 2008), more studies are required

that focus on implementing sun protection policies in organisations that employ outdoor

workers

Employers who fail to eliminate or minimise the risk of UVR exposure for skin cancer do so at

their own risk At least two legal cases have been settled in favour of workers with

occupation-related skin cancer in Australia (Cancer Council Australia, 2007) However, courts

have found that employees also have a legal responsibility to implement sun protection

Claims made by employees against an Australian organisation with a stringent sun

(providing employees with sunscreen, hats, and other PPE) were cited as grounds for this

decision An additional reason given for rejecting the claim was that the claimants had

incurred significant exposure in their leisure time (Mr B Harrison, personal communication,

March 11, 2011)

2.1.4 Occupational sun exposure and sun protection behaviours of outdoor

workers and related policy

Several descriptive studies have focused on outdoor workers and assessed their sun

exposure and sun protection behaviours An overview of some of these studies is provided in

Appendix B The reported studies were selected via searches in databases such as Pubmed,

Medline, Psychinfo, web of science, and ScienDirect in addition to journals specific for this

field of research such as the Journal of Occupational Health These studies were selected as

they were outdoor worker focussed with the study aim to acquire information on sun

exposure/sun protection behaviour or predictors thereof in this population across the globe

The reported studies develop an understanding of the variety and diversity regarding study

techniques, outdoor worker population definition, and outcomes The following sections

summarise their findings