There are slightly over one million workers in the landscape service industry in the US. These workers have potential for high levels of solar ultraviolet radiation exposure, increasing their risk of skin cancer. A cross-sectional sample of 109 landscapers completed a self-administered questionnaire based on Health Belief Model (HBM). The participants correctly answered 67.1% of the knowledge questions, 69.7% believed they were more likely than the average person to get skin cancer, and 87.2% perceived skin cancer as a severe disease. Participants believed that the use of wide-brimmed hats, long sleeved shirts/long pants, and sunscreen was beneficial but reported low usage of these and other sun protective strategies. The primary barriers to using sun protection were “I forget to wear it” and “it is too hot to wear.” Of the HBM variables, perceived benefits outweighing perceived barrier (
In the US, there are millions of workers in the outdoor occupations who have the potential for overexposure to solar ultraviolet radiation (UVR), placing them at higher risk of developing skin cancer [
A review article showed that a number of research studies were conducted on outdoor workers to assess quantitative data of sun exposure and sun protection behaviors, with the majority of studies carried out on farmers and recreation workers [
For this study, the Health Belief Model (HBM) was used as a theoretical framework to explain and assess why landscapers may or may not take action to practice sun protection behaviors. The HBM is one of the most extensively used theories that was developed in the early 1950s by Hochbaum, Kegels, and Rosenstock [
The present study focused specifically on landscape service workers of North Mississippi. The primary purpose of this study was to determine and explain landscapers’ health beliefs with regard to skin cancer, level of skin cancer knowledge, cues to sun protective actions, self-efficacy to engage in sun protection practices, and current sun protection behaviors. Moreover, this study examined the utility of HBM constructs in explaining landscapers’ engagement in sun protection behaviors.
By assessing the level of skin cancer knowledge, perceptions of skin cancer, and frequency of sun protection measures use among landscapers of North Mississippi, public health professionals will gain valuable insights regarding development, implementation, and evaluation of interventions to prevent skin cancer in this population. In addition, the information related to barriers to sun protection will provide a deeper understanding of how to modify or design sun protection intervention strategies that will well match the specific needs of landscapers which will ultimately help in changing their sun protection behaviors and reduce the risk and rates of skin cancer among this high risk target groups.
This cross-sectional study was conducted between May and October 2012. After Institutional Review Board approval, the landscape service companies in North Mississippi were identified through internet search and personal contacts. A phone call was made to the landscaping service companies to obtain consent, and companies were given choices to participate either through on-site administration of the survey or self-addressed prepaid postage survey. The lead investigator hand-delivered the information letter and questionnaire in a confidential envelope to participants during breaks. The survey took approximately ten minutes to complete. Moreover, the information letter and questionnaires with a self-addressed prepaid postage envelope were sent to the companies that decided to participate with this approach. The participants voluntarily completed the questionnaires and sent them back to the lead investigator in the enclosed self-addressed prepaid postage envelope.
The modified version of “Skin Cancer Survey” was used for this study [
To determine sun protection behaviors, participants were asked to indicate on a five-point Likert-type scale (never, rarely, sometimes, frequently, and always) how frequently they use sun protection measures when out in the sun for 15 minutes or more. Moreover, after every sun protection behavior question, participants were asked to select barriers if they do not always perform the sun protection behaviors. All responses to barriers were measured using Nominal scale (checked = yes; not checked = no). Additionally, respondents were given an option if they wish to specify any other barriers for not always practicing sun protection behavior.
The knowledge of participants regarding skin cancer was assessed via the use of 10 items and was evaluated based on correct response. All the items required Nominal level responses (true, false, and I do not know). Responses false and I do not know were considered incorrect.
The participants’ perceived susceptibility to skin cancer was measured by two items on five-point Likert-type scale anchored with strongly disagree, disagree, neutral, agree, and strongly agree. Two items assessed participants’ perceived severity of skin cancer. The response metric was on five-point Likert-type scale ranging from strongly disagree to strongly agree. The scores from perceived susceptibility and perceived severity were multiplied to obtain the perceived threat score.
Perceived benefits of sun protection were measured by using six Likert-type items with five-point responses ranging from strongly disagree to strongly agree. One item was used to measure perceived barrier to sun protection with responses on a 5-point Likert-type scale ranging from strongly disagree to strongly agree. A variable perceived benefits outweighing perceived barrier was created by average of perceived benefits score minus perceived barrier score.
Cues to action were measured by asking participants about their sources of sun protection information. Nominal responses were required on a three-point scale (yes, no, and I do not know). For all nine items response I do not know was considered no.
The self-efficacy was assessed with eight items. Participants were asked about their confidence to engage in sun protection behaviors when out in the sun for 15 minutes or more. Responses to items on the self-efficacy were given on a scale ranged from cannot do at all (0) to certainly can do (10).
All data were analyzed using computerized SPSS version 21. Descriptive statistics were computed to characterize all the variables. Additionally, a Pearson correlation was performed to assess the associations between HBM constructs and sun protection behaviors. Alpha level of .05 was set a priori.
A total of 23 landscaping companies consisting of 140 employees were identified in North Mississippi. Only one company chose to have an investigator to administer the survey on site, which yielded six completed questionnaires. The remaining 134 questionnaires were mailed to 22 companies. Finally, data from 109 fully completed questionnaires were used for the analyses.
In this study, landscapers received substantial (
The skin cancer history rate (5.5%) reported by landscapers of this study is reasonably similar to the rate noted in the previous study (7%) [
An interesting finding to emerge from the data comparisons was that family history of skin cancer in this study was higher than the rates revealed by Wisconsin dairy farmers (25.7% versus 15%) [
With regard to sunburns, results revealed that more than half (58%) of the landscapers experienced at least one or more episodes of sunburns within the year preceding the survey; this shows that sun exposure level was high enough to induce sunburn. This study did not identify the sunburned body sites. Nevertheless, another plausible explanation for high prevalence of sunburn is that the landscapers did not protect themselves as much as they could to reduce sun exposure.
Landscapers indicated more routine (i.e., frequently/always) use of sunglasses (78%), in comparison with wearing sunscreen and sun protective clothing. A similar pattern was reported by Sydney construction site workers, Australia [
The current sun protection behavior data were also compared with Marlenga’s (1995) study conducted on Wisconsin dairy farmers [
Frequencies and percentages of sun protection behaviors.
Practice | Never |
Rarely |
Sometimes |
Frequently |
Always |
---|---|---|---|---|---|
Wear wide-brimmed hat | 26 (23.9%) | 31 (28.4%) | 36 (33%) | 11 (10.1%) | 5 (4.6%) |
Wear long sleeved shirt | 40 (36.7%) | 26 (23.9%) | 28 (25.7%) | 6 (5.5%) | 9 (8.3%) |
Wear long pants | 9 (8.3%) | 8 (7.3%) | 29 (26.6%) | 19 (17.4%) | 44 (40.5%) |
Wear work gloves | 26 (23.9%) | 29 (26.6%) | 36 (33%) | 13 (11.9%) | 4 (3.7%) |
Wear sunglasses | 5 (4.6%) | 6 (5.5%) | 13 (11.9%) | 27 (24.8%) | 58 (53.2%) |
Wear sunscreen | 39 (35.8%) | 17 (15.6%) | 22 (20.2%) | 25 (22.9%) | 6 (5.5%) |
Overall, landscapers indicated mean score of 67.1% correct on the knowledge questions regarding skin cancer (see Table
Likewise, results of the responses to perceived severity questions were mixed. Most landscapers (87.2%) agreed with the statement that “skin cancer is a serious disease,” whereas, only 13.8% agreed with the statement that “if they get skin cancer, they will not be able to continue work as a landscaper.” This may be explained by inconsistency in answers to knowledge questions. On the one hand, 73.4% of landscapers correctly identified that “skin cancer can cause death.” On the other hand, 43.1% thought “melanoma was the least serious form of skin cancer.” More broadly, additional studies are required to ascertain these speculations. In the workplace, an educational program that covers not only the seriousness of skin cancer but also the effects that skin cancer would have on one’s ability to work is necessary. Our data reveal that people have not been well educated on the overall aspects of skin cancer. In fact, knowing where outdoor workers get their health knowledge (television, magazine articles, etc.) is helpful in preparing an educational program.
Furthermore, the correlation analysis revealed no significant relationship between perceived threat and sun protection behaviors among this sample of landscapers (
Nearly three-quarters (73.4%) of landscapers correctly reported that “most skin cancers can be prevented.” This may have led the majority of the landscapers to believe that the use of wide-brimmed hat (60.5%), long sleeved shirt (69.7%), long pants (69.7%), and sunscreen (69.7%) are beneficial. In addition to this, 76.1% reported that “if they protect themselves from the sun daily, they will be less likely to get skin cancer.” Nevertheless, it was also found that 52.3% of the participants agreed or strongly agreed that tanned individuals look more attractive than individuals with no tan. Perhaps this landscapers’ perceived attractiveness of tanned look is one of the barriers to the use of sun protection methods. It was documented that for many, the belief about physical attractiveness for tan skin contributes to unprotected exposure to sun for extended time periods [
The fact that is the most commonly expressed barrier to wearing sun protective clothing was “it is too hot to wear” consistent with the previous studies [
Frequencies and percentages of barriers to continuous practicing of sun protection behavior.
Barrier | Wide-brimmed hat |
Long sleeved shirt |
Long pants |
Work gloves |
Sunglasses |
Sunscreen |
---|---|---|---|---|---|---|
Takes too much time | 2 (1.8%) | 1 (0.9%) | 0 (0%) | 4 (3.7%) | 0 (0%) | 23 (21.1%) |
Inconvenient | 46 (42.2%) | 12 (11%) | 6 (5.5%) | 50 (45.9%) | 12 (11%) | 4 (3.7%) |
Costs too much | 1 (0.9%) | 1 (0.9%) | 0 (0%) | 1 (0.9%) | 0 (0%) | 7 (6.4%) |
Too hot to wear | 28 (25.7%) | 86 (78.9%) | 60 (55%) | 40 (36.7%) | 3 (2.8%) | 9 (8.3%) |
Forget to wear | 50 (45.9%) | 11 (10.1%) | 11 (10.1%) | 52 (47.7%) | 35 (32.1%) | 70 (64.2%) |
Frequencies and percentages of correct responses to knowledge of skin cancer (descending order).
Statements | Correct responses |
---|---|
Sun exposure causes most skin cancers | 87 (79.8%) |
Most skin cancers can be prevented | 80 (73.4%) |
Skin cancer can cause death | 80 (73.4%) |
When skin cancer is detected early, the cure rate is very high | 78 (71.6%) |
The sun’s rays are the strongest at midday | 77 (70.6%) |
A person with fair skin color needs the most protection from the sun | 74 (67.9%) |
Sunburn causes lasting damage to the skin | 74 (67.9%) |
Experts suggest using sunscreen with a sun protection factor (SPF) of 15 or higher | 73 (67%) |
Skin cancer is the most common form of cancer | 55 (50.5%) |
Melanoma is the least serious form of skin cancer | 47 (43.1%) |
Moreover, results from the current study showed significant correlation between perceived benefits minus perceived barriers and sun protection behaviors (
In the present study, the most frequently identified source of sun protection information was friends or family (78%). Parrott and Lemieux (2003) reported that skin cancer prevention and detection information given by families contributes to likelihood of farmers’ sunscreen use [
The majority of the landscapers in the present study also listed television (72.5%), magazine articles or advertisements (60.6%), and health information pamphlets (52.3%) as their common sources of information to protect from sun. Studies demonstrated that utilization of media channels to design an intervention can be an effective approach to increase the sun protection behaviors and reduce the risk of skin cancer among outdoor workers [
Of all participants, 42.2% chose “cannot do at all (0)” in regard to the statement “limit sun exposure between 10 a.m. and 4 p.m.” About one-quarter reported “moderately certain can do (5)” regarding their confidence to wear wide-brimmed hat (25.7%) and work gloves (22%). Around one-fifth (19.3%) indicated confidence (10) to wear a long sleeved shirt. A total of 23% were confident to wear a sunscreen with a sun protection factor (SPF). The majority (42.2%) were confident (10) in their ability to wear long pants. Over half (54.1%) were confident (10) about wearing sunglasses.
We found a significant relationship between self-efficacy and sun protection behaviors (
There were several limitations to this study that should be acknowledged. First, although this study had a respectable response rate (83.6%) and data were collected from multiple geographical locations of Northern Mississippi, the sample was relatively small in size. Consequently, findings may not be generalizable to all landscapers of North Mississippi or other parts of the US. Second, most of the landscapers who participated were White (77.1%) and males (94.5%), limiting generalizability of the results to females and other racial/ethnic populations. Third, because this study used a convenience sampling, the possibility of self-selection bias cannot be ruled out.
The self-reported data of this study is subject to recall and social desirability biases. Another limitation of this study lies in the fact that internal consistency of the self-efficacy to engage in sun protection behavior was
We did not provide information or definitions about different forms of skin cancer. It is possible that landscapers misclassified personal or familial history of skin cancer with conditions such as seborrheic keratosis (SKs) or actinic keratosis (AKs) or moles removed that are not skin cancers.
Furthermore, no attempt was made to control the influence of potential confounding variables. Therefore, caution must be applied when interpreting the results of relationships between HBM variables and practice of sun protection behavior. Also, the cross-sectional design of this study presents additional limitation that restricts causal relationships.
The HBM proposes that individual’s likelihood to engage in protective behavior is based on perceived threat. This HBM proposition is not supported in the present study. However, the results indicate that the difference of perceived benefits outweighing perceived barriers to sun protection is associated with sun protection behaviors. Furthermore, self-efficacy to engage in sun protection is associated with sun protection behaviors. The factors that account for absence of the relationship between perceived skin cancer threat and sun protection behaviors could be lack of skin cancer knowledge and low rate of personal skin cancer history. To better represent all landscapers in North Mississippi, a randomized study that incorporates a larger sample of landscapers is recommended. Certainly, a prospective design should be considered for future studies in order to provide more definitive evidence of directionality or causality between HBM variables and sun protection behaviors. In order to supplement information on barriers to sun protection practice, it is suggested that public health professionals should collaborate with local and state health and safety legislators to obtain information and to have an understanding of current policies and responsibilities of landscapers. Further research regarding the use of policy and provision of sun protection measures is warranted for this population.
We would like to thank Dr. Philip R. Loria Jr M.D. for his input regarding content validity on the survey instrument.