A Graded Work Site Intervention Program to Improve Sun Protection and Skin Cancer Awareness in Outdoor Workers in Israel

Author(s): Esther Azizi, Pazit Flint, Siegal Sadetzki, Arie Solomon, Yehuda Lerman, Gil Harari, Felix Pavlotsky, Avraham Kushelevsky, Ronen Glesinger, Esther Shani, Lior Rosenberg Reviewed work(s): Source: Cancer Causes & Control, Vol. 11, No. 6 (Jul., 2000), pp. 513-521 Published by: Springer Stable URL: http://www.jstor.org/stable/3553781 . Accessed: 01/12/2011 02:48
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Cancer Causes and Control 11: 513-521, 2000. @ 2000 Kluwer Academic Publishers. Printed in the Netherlands.

513

A gradedwork site intervention programto improvesun protection and skin cancerawarenessin outdoorworkersin Israel
EstherAzizi"'*, Pazit Flint2,Siegal Sadetzki3, Arie Solomon4,Yehuda Lerman2, Gil Harari5, Felix Pavlotsky',AvrahamKushelevsky6Jt,Ronen Glesinger7, EstherShani8s' & Lior Rosenberg7,' and 4Goldschleger 3Clinical Institute,The ChaimSheba 'Departments of Dermatology, Epidemiology, Eye Research MedicalCenter,TelHashomer, E-mail:esazl @post.tau.ac.il; 52621,Israel;Ph/Fax:972-3-530-2406; 2Department of and PreventiveMedicine,Sackler School of Medicine,Tel Aviv University; 5Medistat,Kfar Saba; Epidemiology and8Faculty 7Department of Plastic Surgery,SorokaMedicalCenter, 6Department of NuclearEngineering, of Health Israel (*Author Sciences,Ben-Gurion Beersheva, University, for correspondence)
Received11 May 1999;acceptedin revisedform 1 December1999

Key words:occupationalsolar ultravioletradiationexposure,skin cancerprevention,sun protection,sunscreen, workplaceintervention. Abstract A graded worksite interventionprogramto improve sun protection and skin cancer awarenessof Objectives: outdoor workerswas implemented and evaluatedlongitudinally over a period of 20 months. Methods: Outdoormaleworkers(144/213recruits) fromgeographically units of the IsraelNationalWater separated = = were to allocated or minimal Company complete (n 37), partial (n 72) (n = 35) interventiongroups. to the and of local an educational and medicalscreeningpackage Subsequent assignment training safety officers, was providedto the corresponding either or a later. Personal sun protectivegear was once, repeatedly year groups intervention. Outcome measures were evaluated provided upon repeated through self-responsequestionnaires administered prior to the first intervention pulse, and 8 months after the first and second interventions. in sun-protection Results:A 15-61% improvement habitswas noted in the entirestudy population8 months after to no sunscreen initialization, use, 20% sun-exposedskin area and highestmean occupational compared exposure dose of 1.68 MED/day at pre-test.An even greateruse of sunscreenwas evident 1 year later in the completeand The baselinerateof self-examination of the skinin the partialintervention groups, + 80% and + 52%,respectively. same two groups (49%) increasedsignificantly at post-test(+ 71% and + 53%, respectively). Conclusions: This integratedinterventionprogramled to significantlyimprovedsun protectionand skin cancer awareness.Repeatedintervention combinedwith the supply of sun-protective to an even greater gear contributed impact. Introduction Sun exposureis the majorcauseof skin cancer,the most common form of human malignancy[1, 2]. Outdoor workers constitute an important group at risk of developingskin cancer as they are exposed to approximately 10% of the ambientsolar ultravioletradiation
t ProfessorAvrahamKushelevsky died on 12 June 1997without seeingthe fruitsof his effortsin press. Professor Lior Rosenberg and Dr EstherShanisharedthe role of the study. leadingand coordinating

(UVR), six to eight times more than indoorworkers[3]. Cumulativeepidemiological evidencereviewedrecently indicates a statisticallysignificantassociation between basal- and squamous-cellcarcinomaand occupational exposure to sunlight [4]. Malignant melanomas in outdoor workershave been linkedto poor tanningand occurmainlyon sun-exposed sitessuch as the head,face and neck [5-7]. In Israel,we identified a populationof approximately 200,000 (about 50% of all outdoor workers in the skin cancer.The criteria country),at a risk of acquiring includedone or more of the following:occupational sun

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exposure exceeding 12 hours per week, over 15% exposed skin area, and the presenceof phenotypicrisk factorssuchas fairskin,lighteye and haircolor, freckles or moles, propensityto burn,and poor tanning[8]. Nearly all skin cancers are preventableas 90% of them are attributed to sun exposure. Therefore, the strategiescould reducethe applicationof sun-protective incidenceof skin cancer. Furthermore, early detection a using secondarypreventionapproachcould decrease morbidityand increasecure rates. The implementation of focused, routine, broad-scaleinterventionprograms is potentially beneficialboth to the target population and to the health services[9]. Such programsare also applicableto the preventionof ocular lesions such as pterygium,pingueculaand photokerato-conjunctivitis, cataractsthat have been associatedwith sun exposure Worldwideskin cancercontrol programsintroduced and evaluatedso far confronteda variety of methodand unanswered questionsregarding ologicaldifficulties the managementand impact on population bases [1113].The aim of this studywas to evaluatethe effectsof a worksitegradedintensityinterventionprogramfor the primaryand secondarypreventionof skin cancer and sun-relatedocular lesions. The interim results showed that this specifically programled, designedintervention a of 20 over period months,to increasedsun protection and self-examinationfor the early detection of skin cancer. Subjectsand methods Following the institutionalreview board's approvalof the interventionproceduresand control measures,all outdoorworkersfrom four waterunits of Mekorot,the IsraeliNational WaterResourceCompany,wereinvited to participatein the study. The operationsof Mekorot involve drilling; pipe laying; construction and maintenance of water pumping stations, water tanks and reservoirs; and the handling of heavy earthworks machinery.This companywas chosen due to the high number of outdoor workersat risk of acquiringskin cancer,previouslyestimatedas 72% [8].The criteriafor
eligibility included permanent worker status at Mekorot, signed informed consent forms and completed pre-, interim-, and post-test questionnaires. Among the three recruited units located in different areas in the south of Israel, deployed up to 450 km apart, one was allocated to the complete and two to the partial intervention program. The fourth unit in the center of the country, deployed up to 120 km apart, was assigned to the minimal intervention program. The three

[10].

componentsof the programconsistedof the assignment a healtheducational and trainingof local safetyofficers; session and subsequentskin and eye examinationsof the participantsat the workplace;and the supply of gear. sun-protective The safety officers were regular members of the companyassignedby the local employers.They underwent a 1-dayclinicaltrainingsession conductedby the study team. Theirrole was to encouragethe workersto and to coordinatebetweenthe takepreventive measures, the team, employees and their managers. The study health educationsession consistedof a 90-minuteslide delivered by a physicianof the study team. presentation the risk of skin cancerand eye The physicianaddressed lesions associatedwith sun exposure. Preventivemeafor protection sures and behavioralrecommendations The characteristic were also discussed. the sun against of and precancerous lesions were signs symptoms with outlined, special emphasis on the importanceof for earlydetectionand treatself-screening appropriate ment. Educational brochures of the Israel Cancer Association were distributedto all participants,who were encouragedto ask questions. Skin examinations or were conductedby one of five senior dermatologists entire skin area was screened The plastic surgeons. (excludingthe genitalia)for phenotypicrisk factors of skincancer(fairskincolor, freckles,moles),diagnosisof acute and chronic sun-inducedskin damage (sunburn, or skin aging of the skin) and precancerous premature cancer lesions [14]. Photographsof suspicious lesions were taken. A senior ophthalmologistconducted eye for the detectionof acute or chronicsunexaminations ocular lesions [15]. Each participantwas ininduced both formed verballyand in writing of his condition. of a to a specialistfor management Some were referred indicated. The entire educational lesion or follow-up,as and health screening session lasted between 3 and 4 hours. The personal sun-protective gear included widebrimmed hats bearing the Company logo, standard and topical (UVEX 9180, UVEX, Germany), sunglasses sunscreens. The selected sunscreen preparation was resistantlotion, a productof Ultrasol water-and-sweat Dr FischerInc. Ltd, Israel,with a claimedsun protection factor (SPF) of 42, including both ultraviolet B and ultraviolet A filters (active ingredients: octocylene, octyl-methoxicinnamate, octyl-salicylate, and benzophenone-3). The study was conducted over a period of 20 months and consisted of two consecutive intervention pulses administered in June 1995 and in June 1996. To allow a dose-response evaluation, it was administered at graded intensities and frequencies to the corresponding study

Prevention of skin cancer in outdoor workers in Israel

515

groups, as delineated in Figure 1. The double-pulse program was designed for the complete intervention group and the single-pulseprogram for the partial interventiongroup. The health education and medical twice to the comscreeningpackage was administered once with the firstpulse - to intervention plete group; the partial interventiongroup; and once - with the second pulse (as a complementary program)- to the minimal interventiongroup. Safety officers were assigned (three per group) to the complete and partial interventiongroups. Those assigned to the complete intervention group underwent clinical training twice, those prior to the first and second pulse, respectively; assigned to the partial interventiongroup, only once prior to the first pulse. In order to evaluate its added value compared with the other components of the interventionprogram,personalsun-protective gear was providedto workersof the completeintervention group concurrentlywith the second pulse. The entire group was then instructed on the proper use of topical sunscreen. Due to the specialrequestsof the participants in the partial interventiongroup, the local managers provided them with personal sunscreenpackages (Piz in June 1996, BuinCream,SPF 15, Greiter,Switzerland) introducinga protocol deviation. The effectiveness of the programwas measuredby the changein the frequencyof use of sunscreenand size of sun-exposed skin area, reflecting the use of more protective clothing. The reduction in the estimated amount of ambientsolar UVR energythat reachedthe outdoor workers during a working day comprised a third outcome measure, reflectingchange in working

scheduleand use of structuralshadow. The secondary preventionoutcomewas measuredby the changein the rate of self-examination of the skin for early signs of skin cancer. The results were derived from multiplechoice questionnairesthat were administeredto all Thesewerefilledout duringthe consentingparticipants. week priorto the firstintervention pulse, and 8 months to the first and second intervention subsequent pulsesat interim-and post-tests,respectively. The questionnaires included demographicdetails, smoking habits, recreational activities and history of time spent outdoors. Skin reaction to the sun was evaluated by history of previous sunburnepisodes, sunburn susceptibility(always, sometimes,never)and tanningability,as per the method[16]. Fitzpatrickskin phototypeclassification Frequency of sunscreen application at work was estimatedby the averageresponseto a single question using an ordinal scale from 1 (no use) to 7 (use every day). Additional questions addressedsite-specificsunscreenapplication,sun protectionfactorand numberof applications during a working day. The number of sunscreen packagesutilizedby the completeintervention groupwas obtainedby the local inventoryreports.The percentageof sunscreensutilized was determinedrelative to the total volume of sunscreensrequired for appropriate protectionof the exposed skin area (2 mg/ cm2), assumingtwice-dailytopical applicationsof the skin surfacewas products[17].The area of sun-exposed calculatedaccordingto the reportedsite-specific dress habits on a characteristicworking day, using the standard burn index for the correspondingsite. The sum of the site-specific exposed skin areas expressedin

INTERVENTION
1stPulse 2nd Pulse

4
Complete Complete
U

No intervention education &

NHealth

medical screening officers

training

PSafety

Evaluation I

Pre-test

I
0

Interim test

Post-test

gear protection

I
+12

I
+20 months

-1/4

+8

Fig. 1. Flow chartof the gradedintervention programand controlevaluation (adoptedfromref. 11). * Protocoldeviation.

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percentages of body area comprised the total sun exposed skin surface. The mean daily occupational solar UVR exposure dose was estimatedfor each participant accordingto the size of the exposed skin surfaceand the reportedwork schedule on a regular day. UVR index (UVRi) was definedfor this purposeas the mean annualsolar UVR dose reachingthe earth'ssurfaceduringthe corresponding hour of outdoor occupation,expressedin minimal erythema dose units [10]. A correction factor for structuralshadow (SF) was introduced,indicating1 in a non-shadedarea, 0.5 in the shade, and 0.05 indoors. The mean annualsolar UVR dose measuredduringthe hourswas derivedfrom continuousdaily corresponding recordsof solar UVR conductedin spectroradiometric Beersheva(31012'N), from 1991 to 1993 [18, 19]. The meandailyoccupational UVR dose = percentof sun-exposedskin x X(SF x UVRi) h (6 am -->6 pm). The frequencyof self-examination for the early detection of skin cancer was evaluatedby the response to a single question (never, once a year, more often). A separatecluster of outcome variablespertainedto the association between risk knowledge, attitude and behavioral changes. This was obtained from additional questionsas reportedin detail elsewhere[20]. Blood samples(5 ml) were collectedfrom all particwith the pre- interim-and post-test ipants concurrently for the determination of serumlevels of 25-OH-vitamin This metabolite was selected as an objective bioD3. markerreflecting the amountof solar UVR that reached the exposed skin and triggeredepidermalVitamin D3 synthesis[14]. The resultsof these tests, as well as the prevalenceof acute and chronic sun-relatedskin and ocularlesions, are reportedelsewhere[20]. ANOVA and chi-squaretests assessedthe differences in the distribution of the descriptive between parameters in the various The outcome participants study groups. variables(sunscreenuse, sun-exposedskin surfaceand mean daily UVR exposure) among the study groups werecomparedby independent-samples t-tests.Pearson were tests used to chi-square compare the categorical variable of rate of self-skin examination. Intergroup changes betweenpre- to interim-and from interim-to post-testwereconductedusing pairedt-testsfor successive variables, and chi-square tests for equal proportions were used for the categorical variables. Multiple regression analyses were performed to investigate the association between mean daily occupational UVR exposure dose and confounded variables that might affect UVR exposure. All tests were two-tailed, and a p-value of 5% or less was considered statistically significant. The data were analyzed using the SAS software (SAS Institute, Cary, North Carolina).

Results From a targetpopulationof 280 male outdoorworkers, 213 (76.0%)respondedto the pre-testquestionnaire. Of these, 203 (95.0%) and 160 (75.1%) respondedto the interim-and post-test questionnaires, respectively.Eligible for analysis were 144 subjects (68%) who completed the three tests: 37 in the complete, 72 in the partial,and 35 in the minimalintervention groups.The highest overall refusal rate (59%) was noted among the minimalintervention group comparedto the other groups (less than 20%). Lower levels of education
(mean = 10.8 years vs. 12.0 years, p < 0.01), a higher rate of smokers (57.1% vs. 30.0%, p < 0.01) and a

lower rate of previous sunburn episodes (31.5% vs. the non-responders. No 64.6%,p < 0.01) characterized other differenceswere noted in the distributionof a or phenotypicrisk varietyof demographic, occupational factorsbetweenthe two groups.Approximately 50% of the study population consisted of blue-collarmaintenance workers employed in excavation, drilling and welding. The rest were white-collarengineers,electricians and supervisors.The mean age of the study population was 42 years (range 23-63 years), mean education was 12 years (range 8-18 years), 30% were in recreational smokers,and 17%participated regularly activities.The above variables, as well as paternalorigin and religious observance, were similarly distributed among the study groups (Table 1). However, the seniority with regard to outdoor occupation was significantly higher in the complete,comparedto the partial and minimal intervention groups. There were more bachelorsamong the membersof the minimalintervention group.Approximately 30%of the workersreported sunburn susceptibility,and about 60% had suffered sunburn episodes in the past, with no significant intergroupdifferences.Easy or moderate tanning was 90% of the population.The reportedby approximately in of sunscreen use during the study change frequency is outlined in 2A. Pre-intervention meaperiod Figure sure was 1.8 (out of the seven-grade ordinalscale)in all groups, indicatingthat the workers did not use sunscreenat work.A statistically increase(+ 25significant was in all three found at 61%) groups interim-compared to pre-test, with no notable intergroup difference. A further significant increase was documented at posttest among the complete and partial intervention groups (+ 80% and +52%, respectively). Local inventory reports indicated utilization of 30% of the total volume of sunscreens required for appropriate sun protection by the complete intervention group. In the minimal intervention group, the frequency of sunscreen use at posttest was similar to that reported at interim test; however,

Prevention of skin cancer in outdoor workers in Israel

characteristics and riskfactorsby studygroup of demographic distribution Table1. Percentage Variable Intervention group Complete(n = 37) Age (years) < 35 36-45 > 46 Education(years) < 12 12 > 12 Origina Israel Eastern Western Maritalstatus Married Religiousobservance Secular Cigarette smoking Yes Sportactivities Yes Sunburn episodes Yes Sunburn susceptibility Never Sometimes Always 24.4 45.9 29.7 38.2 20.6 41.2 2.7 70.3 27.0 97.3 51.3 35.1 21.6 64.7 13.5 67.6 18.9 Partial(n = 72) 26.4 38.9 34.7 40.9 33.8 25.3 8.3 59.7 31.9 94.6 46.5 31.9 16.7 68.0 21.4 57.1 21.5 Minimal(n = 35) 31.4 40.0 28.6 27.3 48.5 24.2 12.1 66.7 21.2 80.8 52.9 25.7 8.6 57.1 11.4 57.1 31.4 n.s. p-value

517

n.s.

n.s.

< 0.05 n.s. n.s. n.s. n.s. n.s.

Tanning ability Yes

Averagedurationof

91.9
17.7? 10.5

88.9
11.8? 7.4

91.4
14.7? 8.4

n.s.
<0.01

outdoor occupation (years)

a Defined father's - bornin Africa/Asia; - bornin Europe/America. Western by countryof birth;Eastern

it was 53% lower compared to the other groups The mean sun-exposedskin areadecreased duringthe study period, most conspicuously in the complete intervention group (Figure2B). Compared to 20% sun-exposedskin area at pre-test, it was significantly reduced both at interim- (-35%) and at post-test (-25%). A slight, non-significant(-15%) reduction was also noted in the partial intervention group at interim-comparedto a mean sun-exposedskin area of 20% at pre-test,which returnedto the pre-testlevel at post-test. In the minimalinterventiongroup, a significant reduction(-32%) was noted at interim-compared to a mean of 19% sun-exposedskin area at pre-test (p < 0.01). However, it increased by 30% at postcompared to interim-test(p < 0.05), and returnedto almost pre-testlevel. The least sun-exposedskin area at post-test (15%) was noted in the completeintervention group, -25% less than in the partialintervention group

(p < 0.01).

(p < 0.05).

Comparedto a mean daily occupationalsolar UVR exposure dose in the range of 1.56-1.68 MED/day at pre-test,a 17% to 37% drop was evident in all three study groups 8 months later (p < 0.05), with no significantinter-groupvariances (Figure2C). Among the completeandpartialintervention groupsit remained persistentlystable - 33% and 18% lower, respectively, at post- compared to 1.68and 1.56MED/day at pre-test (p < 0.05). In the minimalintervention group,however, it increasedat post-test (1.59 MED/day) and returned close to pre-test level (1.61 MED/day) - almost 40% higherthan the other groups(p = 0.06). The results of the regressionanalysis indicatedthat lower mean daily occupational solar UVR exposure dose at post-test was directly associated with more extensive intervention,higher level of education, and lower seniorityin outdoor occupation(Table 2). The consequences of the intervention programon the rate of self-examinationof the skin at least once a year are demonstratedin Figure3. In the complete

518
7-

E. Azizi et al.
Table 2. Multiple regression model for variables associated with 20 months post-test daily occupational sun exposure dose (n = 144) Variable
5

6 p-Value < 0.05 n.s. < 0.05 <0.01 n.s. n.s. n.s. n.s. 0.19 *(/ = 0.25) **(/ = 0.08) ***(P = 0.04)
.....................................

(I)

3 4n4

--

3. 2 I

07

. ..

. . . ...

.. . . . -,-

---.

Group Age Education Seniority of outdoor occupation Smoke Sunburn episodes Tanning ability Origin R2

* Standardized / = 0.17, ** standardized # = -0.17, *** standardized P = 0.38. 25 15 20

-

100

80--_
S 15--------Complete
.15
2

Partial Interventiongroup

Minimal

60 40 00

joU
B pre. inter, post pre. inter. post pre. inter. post

0 0 pre. inter, post Complete pre. inter. post Partial Intervention group Fig. 3. Interim and post-test effects of the intervention program on rate of self-examination of the skin at least once a year for early detection of skin cancer by study group. pre. inter, post Minimal

0-

--_

__

__

S u
.

21.5 .

post pre. inter Complete

. . ...

pre. inter post Partial

. :

pre. inter post Minimal

0.5 -

pre. inter, post Complete

pre. inter, post Partial Intervention group

pre. inter, post Minimal

Fig. 2. Interim and post-test effects of the intervention program on sun-protection habits by study group. A: Frequency of sunscreen use; B: exposed skin surface (%); C: average daily occupational sunexposure dose.

additional 20% increase was noted at post-test (p < 0.005). In the partial intervention group a 59% increase was noted at interim compared to pre-test rate of 49% and remained stable to post-test. In the minimal intervention group self-examination was 35% lower than that of the other groups both at interim and at post-test (p < 0.05). No differences were noted between blue- and whitecollar personnel in any of the outcome measures mentioned above, either at baseline or in changes from pre-test to post-test (data not shown). Discussion The results of this study demonstrated that an extensive and specifically designed worksite intervention program

intervention group a 42% increase was noted at interim compared to pre-test rate of 49% (p < 0.05). An

Prevention of skin cancer in outdoor workers in Israel

519

for the primary and secondary prevention of suninduced skin cancer in male outdoor workers led to significant improvementin sun protection and skin cancer awareness.The repeateddouble-pulseintervention, combined with the provision of personal sunprotectivegear, led to an even more conspicuousrise in the frequencyof sunscreenuse in the complete intervention group compared to the first intervention. therewas a significant increasein the rate Furthermore, of self-examinationin this group. The significantly skin areaamong higherchangein the mean sun-exposed the completecomparedto the partialintervention group at post-test suggested a dose-dependenteffect. The provision of sunscreen(without additional education) by the local managersto the partialintervention group upon the second pulse was also associated with a significantincreasein the frequencyof sunscreenuse at post- comparedto interim-test.The Company'scommitmentto protectingthe workers,and the provisionof protectivegear, exerteda positiveeffect on compliance. To summarize, 20 months after initiation of the intervention,the overall increasein frequencyof sunscreenuse among the completeand partialintervention groups was 2.5-fold;the mean daily occupationalUVR exposuredose decreased by 33% and 18%,respectively. the rateof self-examination at least once a Furthermore, yearin the sametwo groupsincreased by 71%and 53%, respectively. The significantimprovement in sun protectionof the minimalintervention groupat interimcomparedto pretest may be attributed to the Hawthorn effect that includes the presence of the research team, worker meetings, the questionnaires and blood tests, and discussions about sun protection [11]. However, this had no more than a short-term effect.Nevertheless,the lack of any rise in the rate of self-skinexaminationat least once a yearin this groupindicatesthat professional educationis necessaryfor this purpose.The deterioration of the outcome measuresin the minimalintervention group subsequent to the single health package administered at post- comparedto the interim-test was a paradoxicalfinding.This may be attributedto inherent low compliancethat accountsfor the high refusalratein this group, as well as to the inadequatesupportof the local manager. The long delay in completing the intervention programin this groupverylikelyrestrained positive motivationamong its members. Tryingto tease out what works in programssuch as this is very difficult.There is the program itself, the local safetyofficers,and the effect studyteam'spresence, of the sun-protective gear. The overall success of our intervention program, however,conformsto previousreportsattestingto the

fact that the initiation of sun-protection strategiescan be promotedthrougheducation[21-23].Medicalscreening was complementaryto the informationthat was to developing providedregarding personalvulnerability skin cancer and the means to modifyingthe behavior. The significantdecrease in mean daily occupational solar UVR exposure dose at post-test in our study groups was attributedto a combinationof employeefactorsmodifiedby the extentof and managerial-related the intervention, education level, and seniority of outdoor occupation.These includedthe use of protective clothing, shade and changesin the work schedule. Although it is yet unproven, the provision of sunissued for those workers,as protectivegear specifically well as the attempts to change the workers, sunprotectionhabits at the worksite,are likely to be more successfulthan in recreational settings[21]. The results, in any case, should be interpreted cautiously,first due to the relativelysmall numbersof persons participatingin the study. The possibility of bias cannotbe excludedas respondselectionor referral were evidentlymore ers, comparedto non-responders, educated,smokedless and had a higherrate of previous sunburnepisodes.Recall bias or social desirability may have influencedresponsesto questionnaires. However, these allegedbiases,if they existed,did not differwhen comparinginter-groupresults,as all study groups had similardistribution of majordemographic, occupational and phenotypic risk factors and questionnaireswere distributed simultaneously. The higher seniority in outdoor occupation of the workers in the complete comparedto the partialinterventiongroups may have diminishedthe dose-dependent effectin all the outcome measures,as the formerwereevidentlymore resistantto behavioral changes with respect to sun protection. Inadequate dose incrementsin the interventionprograms, and some inevitableinter-group contamination, may have accountedfor these resultsas well. Despite these limitations,this is the longest and most extensivestudy reportedso far regardingthe intervention and application of control measures for sun protection.Relativeto the limitednumberof comparable worksiteinterventionprogramsconductedon outdoor workersin Australiaand California[21-23], the short- and long-term improvementof sun-protection habits recordedin this study is most encouraging.The higher rate of self-examinationat least once a year among the complete and partial interventiongroups, both at interimand post-testcomparedto pre-test,was also morethan satisfactory. For comparison, in a recent case-control Connecticut population-based study, selfexamination of the skin, although practiced by only 15% of all subjects, was associated with a reduced

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incidence of melanoma or advanced disease among melanomapatients[24]. the resultsof this study, as well as those Nevertheless, of previous reports, are only intermediatesteps in achieving the "gold standard"for successfulprimary and secondary prevention of skin cancer; namely, reduced morbidity and mortality, and this warrants further validation [13]. The estimated changes in the mean occupationalsolar UVR dose in our study for objectivevalidationof the resultsshould be interpreted cautiously,as they reflectthe ambientglobal irradiance rather than anatomical, site-specific,dosimetry. The resultspertaining to changesin serum25-OH D3 levels, as reportedelsewhere,were also inconclusiveand could not validate the former [20]. Early detection of skin cancerrequiresfurtherconfirmation indicatingthe type of pathologicalskin lesions diagnosedand treated. The overall 32% refusal rate in our study indicated that the intervention programdid not reachall segments of the workforce.The lower levels of educationand the higher number of smokers characterizethe non-respondersnot only in our studybut also in othersdealing with health-promotionprograms in general [25], and skin cancerpreventivebehaviorin particular[13]. The effect of a non-compliantlocal manageron the higher refusalratein the minimalintervention groupcannotbe ignored. evaluatedin this controlled Althoughthe intervention trial led to a marked improvementin sun protection, the overall number of unprotected outdoor workers and a longerremainedhigh. For furtherimprovement on vulnerable target lastingeffect of sun protection the group, the extent and frequencyof futureinterventions should be evaluated further. Although the long-term benefits in reducingmorbidity and mortality of skin cancerare likely to be substantial,the cost-effectiveness ratio of simple versus more intensive interventions remainsto be evaluated[9].

We appreciatethe collaborativeeffortsof Mr Yoram Tevel, the Chief Safety Officerof the SouthernWater Units, and of the managingstaff of Mekorot. References
1. American Cancer Society (1996) Cancer Facts and Figures.

CancerSociety. Atlanta,GA: American 2. International Agency for Researchon Cancer,ed. (1992) IARC
Monographs on the Evaluation of Carcinogenic Risks to Humans.

on Cancer,Vol. 55. Lyon:International Agencyfor Research 3. Holman CD, Gibson IM, StephensonM, Armstrong BK (1983) of humanbody sites in relationto occupaUltraviolet irradiation tion and outdoor activity: field studies using personal UVR
dosimeters. Clin Exp Dermatol 8: 869-871.

4. Armstrong of sun exposure BK, KrickerA (1996)Epidemiology and skin cancer.In: Leigh IM, Newton BishopJA, KripkeML, eds. Skin Cancer.New York: Cold SpringHarbor Laboratory Press,pp. 133-153. 5. Beral V, Robinson N (1981) The relationshipof malignant melanoma, basal and squamous cell cancers to indoor and
outdoor work. Br J Cancer 44: 886-891.

6. VageroD, RingbackG, Kiviranta H (1986)Melanoma and other tumorsof the skin amongoffice,outdoor and indoorworkersin
Sweden. Br J Cancer 53: 507-512.

7. Dubin N, Moseson M, Pasternack BS (1989) Sun exposureand malignant melanoma among susceptible individuals. Environ
Health Perspect 81: 139-151.

8. Azizi E, Modan M, Fuchs Z, KushelevskyA (1990) Identification of workersin Israel at increasedrisk for skin cancerdue to occupationalover exposureto the sun. Harefuah118: 508511. 9. Cristofolin M, BianchiR, Boi S, et al. (1993)Analysisof the costratio of the health campaignfor early diagnosisof effectiveness in Trentino,Italy. Cancer 71: 370-374. cutaneousmelanoma 10. World Health Organization(1994) Summaryand conclusions.
In: Environmental Health Criteria; 160. Ultraviolet Radiation.

Geneva:WorldHealthOrganization, pp. 1-7. to modify 11. ElwoodJM, MorrisJM (1996)Evaluation of programs sun exposure. In: Mackie RN, ed. Primary and Secondary
Prevention of Malignant Melanoma. Basel Karger, pp. 111-117.

NB (1997) Approaches 12. Cummings to SR, TrippMK, Herrmann the prevention and controlof skin cancer.Cancer Metastasis Rev 16: 309-327. 13. Koh HK, Geller AC (1998) Public health interventionsfor melanoma.Prevention,early detection,and education.Hematol
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Acknowledgements

14. WorldHealthOrganization (1994)HumanStudies:The Skin. In:

EnvironmentalHealth Criteria; 160 Ultraviolet Radiation. Geneva: This study was supportedby a researchgrant from the WorldHealth pp. 127-173. in Occupational 15. World HealthOrganization, andPrevention for Research Committee (1994) Human Studies:The Eye In: Organization

Safety and Health, Israel Ministry of Labor and Social Affairs. We are grateful for the professional advice of Professor Joseph Ribak, Professor Raphael Karel, Dr Judith Shaham and Dr Stanley Rabinovitch, from the Department of Epidemiology and Preventive Medicine, Sackler Faculty of Medicine, Tel-Aviv University.

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