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Skin Cancer: Interventions in Outdoor Occupational Settings


What the CPSTF Found

About The Systematic Review

The Task Force finding is based on evidence from a Community Guide systematic review published in 2004 (Saraiya et al., 7 studies with behavioral outcomes; search period January 1966 – June 2000) combined with more recent evidence (8 studies, search period June 2000 – April 2013). The systematic review was conducted on behalf of the Task Force by a team of specialists in systematic review methods, and in research, practice, and policy related to preventing skin cancer. This finding updates and replaces the 2002 Task Force finding on Education and Policy Approaches in Outdoor Occupational Settings [PDF - 287 kB].


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Summary of Results

Updated Evidence (search period June 2000 - April 2013)

Included studies (8 studies, 11 study arms) evaluated intervention effects on various measures of sun protection behaviors and on physiological consequences of UV radiation exposure among outdoor workers. Results were generally favorable across outcomes.

  • Sunscreen use
    • Median increase of 8.0 percentage points (range: 7.0 to 10.1 percentage points; 3 studies)
    • Other measures of sunscreen use also showed favorable results (1 study)
  • Hat use
    • Median increase of 8.8 percentage points (range: 4.8 to 11.0 percentage points; 4 studies)
    • Other measures of hat use also showed favorable results (1 study)
  • Clothing use
    • Increases of 23.4 and 52.0 percentage points (2 studies)
    • Other measures of clothing use also showed favorable results (1 study)
  • Combined sun-protective behaviors
    • Several measures of combined sun-protection behaviors showed favorable results (4 studies, 7 study arms)
  • Sunburn incidence
    • Median decrease of 5.2 percentage points in the number of sunburn episodes (range: ‑7.0 to ‑3.0 percentage points; 3 studies)
    • Other measures of decrease in sunburns showed favorable results (1 study)
  • Included studies also showed favorable effects of the intervention on the incidence of solar keratosis (1 study) and skin cancer (1 study).

Unfavorable or mixed results were found for the following outcomes.

  • Shade seeking behavior among outdoor workers (1 study)
  • UV radiation exposure measured as a change in skin pigmentation (2 studies)

Previous Review (search period January 1966-June 2000)

Results from 7 studies of behavioral outcomes found favorable results for sunscreen use (2 studies), hat use (1 study), protective clothing use (2 studies), shade use (1 study), sun exposure (1 study), composite sun protective behaviors (1 study), and number of sunburns (1 study).

Summary of Economic Evidence

An economic review of this intervention was not conducted.


Based on the settings and populations from included studies, results are applicable to the following:

  • Workers of all ages
  • People who are white (applicability to other groups is unclear)
  • Full-time and seasonal workers
  • Recreational and non-recreational outdoor settings

Evidence Gaps

Each Community Preventive Services Task Force (Task Force) review identifies critical evidence gaps—areas where information is lacking. Evidence gaps can exist whether or not a recommendation is made. In cases when the Task Force finds insufficient evidence to determine whether an intervention strategy works, evidence gaps encourage researchers and program evaluators to conduct more effectiveness studies. When the Task Force recommends an intervention, evidence gaps highlight missing information that would help users determine if the intervention could meet their particular needs. For example, evidence may be needed to determine where the intervention will work, with which populations, how much it will cost to implement, whether it will provide adequate return on investment, or how users should structure or deliver the intervention to ensure effectiveness. Finally, evidence may be missing for outcomes different from those on which the Task Force recommendation is based.

Identified Evidence Gaps

Large, multi-arm studies, in diverse occupational settings are needed to assess comparative effectiveness by specific intervention components in specific context and settings.

  • Limited evidence is available on the following:
    • Interventions with worksite policy components
    • Interventions targeting non-White outdoor workers
    • Interventions that target outdoor workers in non-recreational occupational settings
    • Interventions to evaluate health outcomes (e.g., new cases of skin cancers)
    • Studies with longer follow-up times would provide useful information about the sustainability of intervention effects and also account for seasonal variations.

Study Characteristics

  • Most studies were randomized control trials conducted in the United States.
  • Most studies combined educational and environmental interventions.
  • 50% of the studies were conducted in recreational settings.
  • One study was implemented as part of a mandatory worksite policy.
  • All studies assessed sun protective behaviors; half assessed sunburns, and one study also assessed solar keratosis and number of skin cancers.