Reducing sun-induced skin damage in a high-risk group of North Queensland men

Woolley, Torres (2009) Reducing sun-induced skin damage in a high-risk group of North Queensland men. PhD thesis, James Cook University.

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Recorded rates of epithelial skin cancer (squamous and basal cell carcinomas) are higher in Queensland, Australia, than elsewhere. Men in North Queensland (NQ) are at particularly high risk of epithelial skin cancer: NQ men have more than twice the risk of developing skin cancer than women, and NQ men are three times more likely to develop multiple skin cancer than women. As sun exposure is regarded as the major environmental risk factor for skin cancer, NQ men must have poorer sun protective behaviours compared to women. This thesis seeks to identify the reasons for NQ men's poorer sun protective behaviours, and then trial an appropriate strategy to reduce sun-induced skin damage in a high-risk group of NQ men.


1. Identify what predicts sun-induced skin damage and use of sun protection in high-risk NQ men;

2. Explore and develop understandings of NQ men's knowledge, beliefs, attitudes and behaviours toward skin damage, skin cancer and using sun protection, and compare these to women's; and then

3. Use these understandings to determine and implement the most appropriate intervention to improve sun protective behaviours in a high-risk target group.


The three major aims of this thesis are each aligned with the accepted strategy for improving problem health behaviours. This requires the three aims to be done sequentially, with the information gained in the exploratory stage (first and second aims) used to determine the most appropriate target group and intervention used in the intervention stage (third aim).

For the exploratory stage, this body of work used two quantitative studies to determine the group of NQ men at most risk of developing further skin cancer, and to identify the underlying reasons associated with their high risk of skin cancer. The first study was a self-administered cross-sectional survey mailed out to NQ men with a previous histologically-confirmed BCC or SCC (names and addresses obtained from a previous study's database). The second study was a researcher-administered cross-sectional survey with 24-hour telephone follow-up for incidence of sunburn, of NQ men (79%) and women enjoying recreational boating. Both quantitative studies involved participants identified by the literature as being high risk for developing skin cancer.

These underlying reasons are then explored in-depth via a qualitative study of 64 adult residents of Townsville (42 men, 22 women), involving 13 focus groups and 12 in-depth interviews. Older male adults were recruited for the qualitative study using a separate form mailed out with the survey to NQ men with a previous skin cancer, while younger adults and women were recruited via various media. The study used thematic analysis of the participant's own words and thoughts, with emerging themes checked with further groups, and all negative cases – people with thoughts or experiences different to the majority – explored in-depth.

This component of the thesis provides a greater understanding of the sun-related knowledge, beliefs, attitudes and personal barriers behind the gender differences in the sun exposure and sun protective practices of NQ men and women. This information also led to the author identifying the most appropriate intervention strategy to reduce further skin cancer in the high risk group of NQ men.

In the later intervention stage, it was not possible at the time, to do a prospective, controlled intervention, the strongest study design. Instead, this work uses two cross-sectional studies (including a skin examination) to evaluate a proposed mandatory workplace sun protection policy for its effectiveness in reducing the sun-induced skin damage (suntan level, recent sunburn, actinic keratoses and epithelial skin cancer) of NQ outdoor working men by comparing two sites: a site where employees work under a mandatory sun protection policy, and a second site where employees work under a voluntary sun protection policy. The site with the mandatory workplace sun protection policy requires their employees to wear a long-sleeved shirt and wide-brimmed hat when working in the sun, while the comparison site requires employees to wear a corporate uniform, but this uniform can be short-sleeved and employees can further choose whether or not to wear a hat or sunscreen.

Main results – exploratory stage

The first cross-sectional study of NQ men with previous skin cancer found 55% had experienced sunburn since their last skin cancer excised (sunburn being defined as "at least skin redness after 24 hours"). Using multivariate analysis, important predictors of sunburn were identified as being:

•working outdoors for more than two hours on a typical workday (p=<0.01);

•the beliefs that "skin cancer is not caused by recent sun damage" (p=0.02); "sun protection won't help prevent skin cancer" (p=0.04); and "I look better with a suntan" (p=0.01);

•not wearing a long-sleeved shirt (LSS) and wide-brimmed hat (WBH) together (p=0.04).

When NQ men with previous skin cancer went out in sun for at least 20 minutes, 36% reported wearing a long-sleeved shirt, 64% a wide-brimmed hat, and 60% applying sunscreen. The important predictors of wearing a long-sleeved shirt and wide-brimmed hat together included:

•not having barriers to using sun protection (p=0.01);

•the belief "skin cancer is not easily treatable" (p=0.01);

•the attitudes that "the benefits of suntan don't outweigh risk" (p=0.04); and "I don't enjoy being out in the sun" (p=<0.01);

•having more than six skin lesions previously excised (p=0.04).

In addition, the first survey found outdoor working men (defined as spending more than one hour in the sun on a typical workday) with sun-sensitive skin reported more previous skin lesions (p = 0.04) than other men. Also, while outdoor working men are out in the sun more on work days (p=<0.01) and days off (p=<0.01), their use of a long-sleeved shirt, wide-brimmed hat and sunscreen is no better than other men.

In the second cross-sectional study of men and women who regularly participate in recreational boating, 48% experienced sunburn from their trip, mostly on the face. For sun protection, 33% of respondents wore a long-sleeved shirt, 51% wore a wide-brimmed hat, and 84% applied sunscreen at least once. The main predictor of sunburn was not wearing a wide-brimmed hat on the day (p=<0.01), while the main predictor of people using optimal sun protection – a long-sleeved shirt, wide-brimmed hat and sunscreen together – was that people who did use all three strategies rated the other people's sun protection practices on the boat as at least "good".

In addition, the second survey found boaters who worked outdoors reported more previous skin cancer (p=0.06) than other boaters. Also, boaters who reported having previous skin cancer were no more likely to use personal sun protection or have a lighter tan, and no less likely to experience sunburn from the boat trip, than boaters not having skin cancer.

The qualitative investigation component of the exploratory stage found many differences between NQ men and women. NQ men usually had less accurate knowledge about the causes and prevention of skin cancer than women; most men did not know that skin redness after 24 hours, having a dark suntan and peeling sunburns after 20 years of age can all cause skin cancer. Men reported they often experience skin redness and have a suntan, while women often reported habitually using sun protection and avoiding going out in the sun during the midday hours. In contrast to women, men also admitted experiencing negative influences from peers regarding use of sun protection, particularly in the workplace.

There were also differences in NQ men and women's perceived susceptibility to skin cancer: women and outdoor working men with fair skin thought they were highly susceptible to developing multiple skin cancer, but indoor working men and men with "good genetics" did not. Men also appeared to have few concerns about developing skin cancer; most considered it an acceptable risk as a result of work or their lifestyle, with some men even describing how they wait so they can get the GP to remove several at once, thus saving time and money. While both men and women perceived epithelial skin cancers as easily treatable, women were quite concerned about scarring after removal, while men were not.

Differences were also found in the perceived benefits of using sun protection; women thought that not going out in the sun during the midday hours and using a long-sleeved shirt, wide-brimmed hat and sunscreen will avoid future skin cancer and the visible signs of sun-damaged skin, while men thought that sun protection was not necessary for exposures <1 hour, and that skin cancer develops only after many years of not using sun protection. While both men and women reported issues with using sun protection, these annoyances were not enough to stop women using sun protection, but they often did stop the men, particularly outdoor working men. The few men who did say these annoyances were not strong enough to stop them using sun protection were older and had visibly sun-damaged skin with many sunspots and scarring.

Finally, women had a variety of motivators to improve sun protection: to avoid sunburn which which was painful and left the skin looking "mottled; vanity, especially avoiding premature aging of the skin; setting a good example in front of their children; and from information provided in magazine articles and television messages about skin cancer and sun-induced skin aging, and the "danger" of melanoma and "risks" of sun exposure. In contrast, men didn't read many magazines which had health-related articles, thought the same television messages were too emotive, low on facts and of little practical benefit, and outdoor working men regularly commented that their workplace makes a poor attempt at advertising the dangers of sun exposure or promoting the use of sun protection.

Conclusions – exploratory stage

Both quantitative studies found NQ outdoor working men were more likely to report previous skin lesions or skin cancer than other men. In addition, many NQ men regularly experienced sun damage (including a dark suntan and at least skin redness after 24 hours) because they did not consistently or adequately use recommended sun protective behaviours (long-sleeved shirt, wide-brimmed hat, and sunscreen) during work or recreational activities, even if they have already started developing skin cancer. The qualitative study found NQ men's knowledge about skin cancer was often inadequate or incorrect compared to NQ women, and men's sun behaviours did not improve greatly with age; a likely consequence of few motivators and many barriers to using sun protection; perceiving benefits to having a suntan but not to using sun protection; and believing epithelial skin cancer is not a serious health threat. While many women in the interviews had formed good sun protective habits by their mid- or late-twenties, men by their late-twenties often had a well-established habit of not using sun protection.

The literature shows bad habits are hard to break, as habits are established over a long period and often performed automatically; thus, are highly resistant to change. The literature also shows that trying to improve men's sun protection habits using interventions based on fear-appeals, knowledge-change or attitude-change have resulted in only minor or short-term increases in sun protective practices. The exploratory stage of this work shows that, for the majority of NQ men, there are a wide variety of negative and few positive influences on their likelihood of using sun protection, helping to explain why many NQ men often form poor sun-protective habits early in life. It appears that for many NQ men, only when they develop many skin cancers and sun damage is perhaps irreversible, are they sufficiently motivated to more consistently use recommended sun-protective practices.

Therefore, the author of this work decided that an environmental intervention (also called 'social engineering'; for example, interventions to prevent smoking in restaurants or making it illegal not to wear a seat belt while driving on the road) would likely be the most successful intervention strategy, rather than any attempt to improve behaviour via knowledge-change or attitude-change. For improving the sun-protective practices of the high risk group of NQ men for developing epithelial skin cancer – outdoor workers – the logical social engineering approach is making it mandatory for outdoors workers to use at least some of the recommended sun protection practices of a long-sleeved shirt, wide-brimmed hat, long pants and sunscreen.

Results – intervention stage

Compared to employees working under a voluntary workplace sun protection policy, employees working under a mandatory policy (required to wear a LSS and WBH):

•had lighter suntan levels on right forearm (p = 0.002) and dorsum of hand (p = 0.028);

•had fewer actinic (solar) keratoses on right forearm (p = 0.004); and

•reported fewer recent sunburns (p = 0.004) and fewer previously excised skin cancers (p = 0.019).

Conclusions – intervention stage

As statistical analysis showed, there were no differences between the two groups with regard to age and skin type; therefore, the reduction in numbers of self-reported skin cancer and recent sunburns and in the observed actinic (solar) keratoses and suntan level on the hands and arms of employees under the mandatory sun protection policy is a likely consequence of outdoor workers consistently practicing good sun-protective behaviours over a long period of time.

Therefore, the overall conclusion of this thesis is that the most effective strategy to reduce sun-induced skin damage and future epithelial skin cancer in NQ men is a mandatory sun protection policy for all who work outdoors in the tropics.

Main recommendations of the thesis

•There should be mandatory use of at least a long-sleeved shirt and wide-brimmed hat for all who work outdoors in high sun-exposure occupations in NQ, and workplaces should at least strongly advocate for, or make easily available, sunscreen, long pants and sun-gloves. The strength of the barriers and the lack of motivators for NQ men using sun protection suggest it is no longer sufficient to merely provide sunscreen in the workplace in tropical regions, or give workers in the tropics a choice of using sun protective clothing when outdoors for significant periods of time. Workplaces in tropical regions need to adopt a much more serious commitment to skin cancer prevention, which must include a mandatory workplace sun protection policy for outdoor workers.

•NQ men should be provided with factual (and less emotive) information about epithelial skin cancer, as they are often unaware of their increased risk from having a dark suntan or from experiencing skin redness. These misconceptions could be easily targeted by more specific health promotion messages in the media and from medical professionals. Advice should also include using combinations of sun protective measures, but a focus on sun protective clothing with less reliance on artificial shade structures and sunscreen is preferable. This education would be particularly effective for men if social networks were targeted, using identified peer leaders to model recommended sun protective practices. This education strategy should be assessed as a study in the NQ region to determine its potential to improve the sun-protective practices of men participating in social high-sun exposure recreational activities.

•Because of the small sample size and study design of the "intervention" stage of the thesis, it would be highly desirable to investigate, in a future larger, quasi-experimental or randomised, controlled study, the significant reduction in the sun-induced skin damage found in employees from the mandatory sun protection workplace compared to the voluntary sun protection workplace.

Item ID: 11818
Item Type: Thesis (PhD)
Keywords: skin damage, men, North Queensland, epithelial skin cancers, carcinomas, melanomas, sun protection strategies, attitudes, boating, outdoor work, sun exposure, sun protection policies, occupational health, safety behaviours, skin cancers
Related URLs:
Additional Information:

Publications arising from this thesis are available from the Related URLs field. The publications are: Appendix 9: Woolley, Torres, Buttner, Petra G., and Lowe, John B. (2003) Sunburn in Australian men with a history of non-melanoma skin cancer. American Journal of Health Behavior, 27 (3). pp. 195-207.

Appendix 10: Woolley, Torres S., Buttner, Petra G., and Lowe, John (2004) Predictors of sun protection in northern Australian men with a history of nonmelanoma skin cancer. Preventive Medicine, 39 (2). pp. 300-307.

Appendix 11: Woolley, Torres, Buttner, Petra G., and Lowe, John (2002) Sun-related behaviours of outdoor working men previous non-melanoma skin cancer. Journal of Occupational and Environmental Medicine, 44 (9). pp. 847-854.

Appendix 12: Woolley, Torres, and Raasch, Beverley (2005) Predictors of sunburn in north Queensland recreational boat users. Health Promotion Journal of Australia, 16 (1). pp. 26-31.

Appendix 13: Woolley, Torres, and Buettner, Petra (2009) Similarity of sun protection attitudes and behaviours within North Queensland peer groups. Health Promotion Journal of Australia, 20 (2). pp. 107-111.

Appendix 14: Woolley, Torres, Lowe, John, Raasch, Beverley, Glasby, Margaret, and Buttner, Petra G. (2008) Workplace sun protection policies and employees' sun-related skin damage. American Journal of Health Behavior, 32 (2). pp. 201-208.

Date Deposited: 31 Aug 2010 03:58
FoR Codes: 11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111705 Environmental and Occupational Health and Safety @ 50%
11 MEDICAL AND HEALTH SCIENCES > 1117 Public Health and Health Services > 111706 Epidemiology @ 50%
SEO Codes: 92 HEALTH > 9204 Public Health (excl. Specific Population Health) > 920401 Behaviour and Health @ 33%
92 HEALTH > 9205 Specific Population Health (excl. Indigenous Health) > 920504 Occupational Health @ 33%
92 HEALTH > 9205 Specific Population Health (excl. Indigenous Health) > 920505 Mens Health @ 34%
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