Walkosz BJ, Buller DB, Andersen PA, Wallis A, Buller MK, Scott MD. Factors Associated With Occupational Sun-Protection Policies in Local Government Organizations in Colorado. JAMA Dermatol. 2015;151(9):991-997. doi:10.1001/jamadermatol.2015.0575
Skin cancer prevention remains a national priority. Reducing chronic UV radiation exposure for outdoor workers through sun-safety practices is an important step to help reduce the incidence of skin cancer.
To determine the presence of occupational sun-safety policies at local government organizations in a single state.
Design, Setting, and Participants
Of 571 potentially eligible local government organizations of Colorado cities, counties, and special tax districts, we enrolled 98 in a randomized pretest-posttest controlled experiment starting August 15, 2010, that evaluated an intervention to promote the adoption of sun-safety policies. We used a policy-coding protocol to evaluate personal sun-protection practices, environmental and administrative controls, and policy directives for sun safety starting February 10, 2011. We report the baseline assessment of the occupational sun-protection policies of these organizations.
Main Outcomes and Measures
The presence of an occupational sun-safety policy.
Overall, 85 local government organizations (87%) had policies that required personal sun-protection practices, including the use of eyewear, hats, and protective clothing. However, of the 98 responding organizations, only 8 hat policies (8%), 10 eyewear policies (10%), and 7 clothing policies (7%) mentioned sun protection as the intent of the policy. Only cosmopoliteness, operationalized as proximity to an urban area, was associated with the presence of a sun-safety policy (odds ratio, 0.99 [95% CI, 0.98-1.00]; P = .02).
Conclusions and Relevance
Outdoor workers are at increased risk for skin cancer because of long-term exposure to solar UV radiation. Although organizational policies have the potential to increase sun protection in occupational settings, occupational sun-safety policies were uncommon among local governments. Opportunities exist for dermatologists and other physicians to influence occupational sun-safety practices and policies, which are consistent with other safety procedures and could easily be integrated into existing workplace practices.
Occupational sun exposure has recently attracted attention in efforts to prevent skin cancer1,2 owing to its considerable association with the disease3 and the fact that UV radiation (UVR) is now recognized as a carcinogen by the National Institute of Environmental Health Sciences.4 Outdoor workers are exposed to large amounts of UVR, often during the course of many years, and are at increased risk for skin cancer and ocular damage.3,5 Although melanoma may be associated less with outdoor work than nonmelanoma skin cancers,6 some risk for melanoma has been observed for outdoor work.7 Workplaces are ideal locations for promoting sun safety because many outdoor workers get substantial sun exposure and fail to use sun-safety practices.1,2,8,9 Occupational programs for sun protection often use a bottom-up approach by focusing on educating outdoor workers to adopt personal sun-protection practices voluntarily. Such an approach has been shown to improve workplace sun safety significantly.1,10- 12
Top-down policy development and implementation geared to broad action at all organizational levels have also resulted in improved health outcomes,12,13 including workplace health policies.12,14,15 For sun protection, the adoption of comprehensive policies, including a focus on environmental controls (ie, providing shade in work areas and adjusting work schedules), administrative procedures (ie, conducting risk assessments, providing routine employee and supervisor training, reviewing and monitoring policy, allocating resources, and requiring contractor compliance), and personal sun protection by employees (ie, encouraging or requiring sunscreen, protective clothing, hats, and eyewear and screening for skin cancer) should be considered.16,17 Such policies can set organizational and individual agendas for sun safety, integrate sun-protection programs into an organization’s operations, and brand these programs as part of an organization’s culture.
In this study, we analyzed organizational workplace policies obtained from local governments to answer the following research question: In local government organizations with substantial outdoor workforces, what occupational sun-protection policies are present (question 1)? We also queried whether local government organizations in urban areas and in communities with higher socioeconomic status would be more likely to have occupational sun-safety policies (question 2).
We enrolled local government organizations in a randomized pretest-posttest controlled experiment starting August 15, 2010, that evaluated an intervention to promote the adoption of sun-safety policies. At present, we report only baseline data that were obtained by coding the content of written policy documents pertaining to sun protection for employees. All potentially eligible Colorado cities, counties, and special tax districts (n = 571) with at least 3000 residents were stratified by region (Denver metroplex, other Front Range [communities in the urban corridor with the exclusion of the Denver metroplex], eastern Colorado, and southern and western Colorado) and randomly ordered using a computer program. To be eligible, local government organizations had to have employees who worked outdoors in 1 or more of the following sectors: public works, public safety, and parks and recreation. Examples of jobs in each sector include road and bridge crews and water and sanitation workers (public works); police officers and firefighters (public safety); and lifeguards, landscapers, and park maintenance workers (parks and recreation). Project staff then attempted to contact the senior manager at each organization using the randomly ordered list until a statistically valid participation quota was met. Of the 571 organizations contacted, 180 were ineligible and 91 never responded. Of the remaining 300, 135 organizations agreed to participate, 113 refused, and 52 had not decided to participate before enrollment was closed. The differences between the organizations that agreed to participate and those that refused are reported in Table 1. For example, more cities agreed to participate than refused (51 of 98 [52%] vs 43 of 113 [38%], respectively), whereas more counties and special taxing districts refused to participate than enrolled (19 of 113 [17%] vs 10 of 98 [10%] and 51 of 113 [45%] vs 37 of 98 [38%], respectively).
Once recruited, local government organizations were required to provide copies of documents containing formal written policies pertaining to employee safety and to have at least 5 senior managers complete a baseline survey to be enrolled in the trial, after which they were randomized to the control or intervention condition. Organizations in both conditions received materials containing information about the importance of sun-safety and sun-protection measures, skin cancer facts specific to Colorado, prevention tips, and best practice policies for occupational sun protection. Organizations in the intervention condition received additional resources, including personal contact from project health educators, additional policy development information and tools, and a training program on personal sun protection. Exclusion criteria included participating in a previous project in which training on occupational sun protection was provided by the research team. All study protocols and measures were approved by the Western Institutional Review Board. The data reported in this manuscript did not involve human subjects; therefore, informed consent was waived.
Study investigators (B.J.W. and D.B.B.) trained research assistants to review written policy documents and assign codes to sun-protection content. Research assistants practiced coding on policies obtained from organizations not enrolled in the project and had to achieve intercoder reliabilities of greater than 0.70 before coding policies from the participating local government organizations. The research assistants then coded the study policies independently. To monitor intercoder reliability, a set of the same policies (n = 10) was coded at the outset, midway, and at the end of the coding period. If coder drift was detected, additional training was conducted.
The policy-coding review occurred from February through October 2011. The policy-coding protocol was based on procedures initially created for assessing sun-protection content in the policies of public school districts.20 The protocol contained 15 primary content categories in the following 3 domains: (1) environmental controls (ie, provision of shade, schedule of outdoor work), (2) administrative procedures (ie, risk assessment, training of employees and managers or supervisors, reviewing and monitoring policy, resource allocation, communication with clients or patrons, compliance by contractors and subcontractors, and posting of the UV Index), and (3) personal protection practices (ie, use of UV-protective clothing [including long-sleeved shirts and long pants or skirts], hats, protective eyewear, and sunscreen [including sunscreen lip balm] and regular screening for skin cancer [self-examination or clinical examination]). Each policy element was coded for the presence of the policy content (0, not addressed; 1, addressed), strength of the policy (range, −1, not allowed, to 2, required), intent of the policy (0, indirectly addresses sun safety; 1, directly addresses sun safety), responsibility for policy action (0, not specified; 1, employee; and 2, employer), and the date of adoption and/or revision. Presence (possible total score, 15) and strength (possible total score, 30) scores were recorded for all content categories. The score for intent of the policy (possible total score, 5) was recorded for environmental controls and personal protection equipment. The responsibility for policy action score (possible total score, 10) was recorded for personal sun-protection practices. Directives that included additional details on policies (ie, specification of the size of a hat brim or the sun-protection factor of recommended sunscreen) were also coded.
The presence of policy components was summarized using counts and percentages. Measures of cosmopoliteness21- 23 (distance from urban area and region), community socioeconomic status (mean household income of the weighted county population18 and the percentage of bachelor’s degrees from the 2010 US Census),19 and organizational characteristics (type of government organization, size [number of employees], and percentage of female managers as reported) were tested for associations with the presence of a sun-safety policy using logistic regression with stepwise model selection. We used commercially available software (SAS PROC LOGISTIC; SAS Institute Inc) to conduct a simple logistic regression model to investigate the effect of urbanization on the presence of a sun-safety policy. We used receiver operator characteristic curve analysis24 to detect the cut point for distance to the nearest population center. A 2-tailed α criterion of .05 was used for all models.
Initially, 137 local government organizations agreed to participate, and 98 provided the required policy documents and baseline surveys to be enrolled. Thirty-nine organizations failed to provide the documents necessary for enrollment and did not provide reasons for noncompliance (Table 1). The data on sun-protection policies reported in this study come from those 98 local government organizations.
Most local government organizations (n = 80) provided a single document containing policies pertaining to the safety of employees on the job. However, 12 local government organizations provided 2 different documents and 6 provided 3 to 6 documents (18% provided >1 document). The types of documents provided included safety and risk management manuals, employee handbooks, standard operating procedures, personnel manuals, safety binders, administrative and training policies, safety compliance guidelines, and city policies and procedure manuals.
Overall, 85 of 98 local government organizations (87%) had policies that addressed at least 1 sun-safety content area (mean [SD] content score of a possible 15, 2.64 [1.53]). Of the 98 organizations, 8 (8%) addressed 1 content area; 11 (11%), 2 content areas; 49 (50%), 3 areas; and 17 (17%), 4 or more areas. Few local government organizations had policies on environmental controls and administrative procedures to improve sun protection (12%). Most policies addressed the employees’ use of personal protection practices (Table 2). Although most employers provided safety equipment for their employees, few supplied sun-protection equipment. For example, 16 employers included sunscreen use in their policies but only 3 provided it to their employees (mean [SD] responsibility score of a possible 10, 3.71 [2.42]), and 13 employers did not specify responsibility. Table 3 details the safety items provided by the employer and the responsibility accorded to the parallel sun-safety items. Most policies allowed or recommended that employees take these safety precautions (mean [SD] strength score of a possible 30, 5.51 [2.00]).
Most of the existing policies pertaining to personal sun-protection practices (72 [85%) did not specifically state that the intent was to protect employees from excessive sun exposure (mean [SD] intent score of a possible 5, 0.32 [0.88]). Specifically, only 8 hat policies (8%) (6 allowed and 2 required hats), 7 clothing policies (7%) (4 allowed and 3 required protective clothing), and 10 eyewear policies (10%) (4 allowed and 6 required protective eyewear) mentioned sun protection. If policies are limited to just those personal sun-protection practices that were intended for sun safety, only 20% of local government organizations (20%) had sun-protection policies covering at least 1 of the content areas coded (mean [SD] content score, 2.75 [2.07]).
Directives assessed details of the policy regarding the degree to which it addressed sun protection of employees. For scheduling, only 1 policy directed that work schedules be adjusted to avoid being outdoors during midday hours when UVR is at its highest level. The single policy that addressed training employees did not specify who conducted the training (self-directed or led by a supervisor). Five of the 16 policies directing employees to use sunscreen included content stating that the sunscreen should have a sun protection factor of 15 or greater. By contrast, many of the policies on protective clothing (n = 47) directed the employee to wear long sleeves or pants, but only 4 of the 79 policies on hats indicated that the hat should have a broad brim (7 indicated it should have any brim). For eyewear, 19 of 75 organizations included language that lenses should shield eyes from the sun or from UVR exposure. None of the 2 policies on routine screening for skin cancer specified who should perform the screening (self-examination or examination by a health care practitioner) or the interval between screenings.
In the logistic regression, only proximity to the urbanized areas (a measure of cosmopoliteness) was statistically significantly associated with the presence of occupational sun-protection policies in the local government organizations (P = .02; Table 4). The signal detection analysis (receiver operating characteristic curve) revealed that a distance of 27 km from an urbanized area best distinguished local government organizations with and without a sun-safety policy; 13 of 33 (39%) local government organizations within 27 km had a policy, whereas 7 of 65 (11%) local government organizations 27 km or farther from an urbanized area had a policy. The remaining community socioeconomic status and organizational factors were not significantly associated with the presence of these policies (Table 4).
Skin cancer is the most common cancer in the United States and is one of the few cancers with rising rates.25 Sun protection of outdoor workers was generally an uncommon aspect of workplace safety policies at local government organizations in Colorado in 2010 through 2011. Even when sun safety was mentioned in workplace safety policies, few protective actions were recommended. However, sun safety has gained some ground as a policy issue because more than one-fifth of local government organizations had a policy that mentioned some type of sun-protection procedure or practice.
The most common sun-safety policy pertained to personal protection practices. Environmental controls and administrative procedures were far less commonly specified, perhaps because they required local government organizations to alter their workflow or allocate scarce resources after the 2008 economic crisis that depleted public budgets (such policies were usually the responsibility of the organization rather than employee). This result is unfortunate because environmental and administrative policies by government organizations should support or enable employees to practice personal sun protection more easily or more effectively (ie, regular training of supervisors might lead them to remind employees to wear sunscreen, hats, and protective eyewear). Environmental controls also are essential to enable employees to work in the shade or to avoid being outdoors during midday when UVR exposure is strongest; these practices would be difficult or impossible for many employees to perform on their own. However, such policies must also be balanced with concerns that the provision of shade structures or modification of work hours may also be prohibited by safety and practical scheduling issues.
The responsibility for personal sun protection may fall to employees, especially for items such as sunscreen, wide-brimmed hats, long-sleeved shirts and pants that balance heat and sun protection in the summer, and UV-protective eyewear. For most of the sun-safety items, responsibility for the item was not specified. For example, 13 of 16 policies did not specify responsibility for sunscreen provision, suggesting that the burden may fall to the employee. Some workers may prioritize the purchase of these items, and younger workers may not see the need for sun protection. By providing such items, local government organizations can overcome financial concerns and personal preferences regarding sun protection and make a stronger statement about the priority for reducing UVR exposure on the job.
The only variable that was associated with the presence of a policy in 2010 through 2011 was cosmopoliteness, operationalized as distance from the urbanized areas in the state (Table 4). Urban communities are generally more cosmopolite than rural communities26 and are more likely to have access to information centers that facilitate exchanges of information21; consequently, urban administrators in public organizations may have more external connections and more heterogeneous interpersonal networks.21 Early adopters often use more cosmopolite channels and networks than do later adopters of innovations.22 Thus, the administrators in the local government organizations close to the urbanized areas may have been more knowledgeable of the risks to outdoor workers posed by unprotected exposure to solar UVR than administrators at more distant organizations and therefore took more policy action to reduce occupational sun exposure. Of interest, 6 of the rural communities that had sun-safety policies (86%) were resort communities in Colorado, and these communities may also be characterized as cosmopolite because they may have more external connections than traditional rural cities and towns. Cosmopoliteness has been associated with innovation by local government (ie, local clean air ordinances and e-government),23 and our study now confirms that this relationship applies to organizational health and safety policies and practices. We found the same pattern when analyzing administrators’ responses in baseline surveys in the current study. Administrators in local government organizations closer to urbanized areas reported taking more steps to support sun protection of outdoor workers.27
Occupational sun safety remains an overlooked policy issue for many organizations. In addition to skin cancer prevention, sun-safety practices are currently aligned with the following 2 emerging occupational health and safety concerns: heat stress and climate change.28 Workers who labor in hot environments may be at risk for heat stress, resulting in sickness and death,29 and direct sun exposure is a risk factor for heat stress. Sun-safety practices, such as wearing loose, lightweight protective clothing and seeking shade, can complement prevention of heat stress. Likewise, higher ambient temperature and greater UVR exposure in work environments have been identified among the workplace hazards related to global climate change. Elevated temperatures produced by climate change may cause individuals to wear less clothing, and climate change may slow recovery of the earth’s protective ozone layer.30 Both changes could elevate workers’ exposure to UVR, resulting in cortical cataracts,31 skin cancer,32 and immune system dysfunction.33
A limitation of the present study is that the results may not represent the general status of sun-safety policies in the workplace. Owing to local governmental structures and the geographic location of Colorado (at a high altitude), the results may not generalize to other states that may have different local governmental configurations and perceive that they have lower levels of UVR exposure. Another limitation of the study is that only public organizations were enrolled, which limited knowledge about the policies of private companies that employ outdoor workers.
Without intervention by change agents, such as local government organizations or professional associations, the natural evolution of this new workplace policy on sun protection of outdoor workers is likely to be limited to recommendations for employees to practice personal protection rather than organizational actions that require resource allocation. Opportunities also exist for dermatologists to act as change agents to promote workplace sun-safety practices and policies. Possible actions might include (1) advocating workplace sun-safety policies to local government entities, especially in rural areas; (2) reaching out to local governments to provide skin examinations at the worksite and/or promote attendance at worksite health fairs; (3) advising employee safety and health committees on the need to consider skin cancer along with other health and safety issues; and (4) having physicians or dermatologists ask patients if they work outdoors and provide them with recommendations for sun-safety practices while at work.
Many local government organizations had policies that directed employees to behave in ways that were sun protective, yet they did not formally state that the policy was intended to reduce solar UVR exposure. For sun-safety initiatives, convincing local government organizations to modify existing policies to add sun protection (ie, adding UV-protective coating on required safety glasses or wide brims on required hard hats) might be of more benefit than persuading them to adopt an entirely new policy on sun safety. This possibility further suggests that sun safety is compatible with many other safety measures in the workplace. Managers might be open to taking steps to mitigate sun exposure because they are already taking similar actions to reduce employees’ exposure to other environmental hazards. Interventions on occupational sun protection may find success if they focus on incorporating sun safety into existing safety policies on other common environmental hazards.
Outdoor workers are at increased risk for skin cancer because of long-term UVR exposure. The policies of local government organizations may increase sun protection in occupational settings. Unfortunately, occupational sun-safety policies remain uncommon among these organizations. Opportunities exist for dermatologists and physicians to have an effect on occupational practices and policies concerning sun safety, which are consistent with other safety procedures and could easily be integrated into existing workplace practices.
Accepted for Publication: February 22, 2015.
Corresponding Author: Barbara J. Walkosz, PhD, Klein Buendel, Inc, 1667 Cole Blvd, Ste 225, Golden, CO 80401 (email@example.com).
Published Online: May 20, 2015. doi:10.1001/jamadermatol.2015.0575.
Author Contributions: Drs Walkosz and D. B. Buller had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: All authors.
Acquisition, analysis, or interpretation of data: Walkosz, D. B. Buller, Andersen, M. K. Buller, Scott.
Drafting of the manuscript: Walkosz, D. B. Buller, Scott.
Critical revision of the manuscript for important intellectual content: Walkosz, D. B. Buller, Andersen, Wallis, M. K. Buller.
Statistical analysis: D. B. Buller.
Obtained funding: Walkosz, D. B. Buller, Andersen, M. K. Buller, Scott.
Administrative, technical, or material support: D. B. Buller, Wallis, M. K. Buller.
Study supervision: D. B. Buller, Andersen.
Conflict of Interest Disclosures: Ms Buller is the owner of Klein Buendel Inc and is Dr Buller’s spouse. Dr Buller and Ms Buller receive a salary from Klein Buendel Inc. No other disclosures were reported.
Funding/Support: This study was supported by grant CA134705 from the National Cancer Institute.
Role of the Funder/Sponsor: The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Additional Contributions: Xia Liu, MS, Klein Buendel, Inc, conducted the data analysis for the study. No financial compensation was received.