7. Occupational Skin Cancer – Prevention of Skin Cancer

Karina Weinert

The German Occupational Health and Safety Act (ArbSchG) [628] sets out the employer's basic obligations regarding the implementation of occupational health and safety measures to improve the safety and health of employees at work. In doing so, an order of priority must be observed for the measures to be taken.

Proportional preventive measures, i.e., organisational and technical protective measures, are to take precedence over behavioural preventive measures, i.e., personal measures. This is referred to as the hierarchy of the TOP principle:

1. Technical
2. Organisational
3. Personal protective measures ([629])

They are to be recorded in the risk assessment and include the following evidence-based recommendations.

Ruppert et al. [630] conducted a randomized study on skin cancer prevention measures with German vocational school students employed at outdoor workplaces. Six participating vocational schools with a total of 245 participants were randomly assigned into three groups (two intervention groups and one control group). The first intervention group received a 30-minute lecture focusing on workplace sun protection, while the second intervention group was shown a three-minute video produced by the Federal Office for Radiation Protection with comprehensive information on UV radiation and sun protection. The control group received no intervention.

The first intervention group showed a positive association with taking breaks from work in the shade (p<0.05). Furthermore, the first intervention group was more likely to seek shade during breaks than the second intervention group as well as the control group (Phi: 0.24). The analysis also confirmed that the provision of shaded workstations increased the willingness to work in the shade by a factor of four in the long term (OR: 4.63, 95% CI: 1.00; 21.51).

Kearney et al. [632] conducted a systematic review on sun protection among farmers and farm workers. A total of 22 studies were included in the review. Two of these included studies conducted interventions aimed at switching to appropriate headwear, for example through a combination of information and action or encouragement. As a result, 25% of the participants in the intervention group in study one switched from a baseball cap to a wide brimmed hat (Burwell et al. 2004. In study two, more participants also wore wide brimmed hats and protective clothing after the intervention than before (p=0.01) (Christensen et al. 2007). Another study intervened by providing a six-month information program on sun protection as well as (early) detection and provided head coverings. The intervention group showed increased sun protection behaviour after the program (p<0.01) (Malak et al. 2011). Another study implemented a community sun protection promoting program. After completing the program, the intervention group had increased sun protection behaviours and a higher number of physician visits for screening and treatment than before the program began (Mullan et al. 1996).

A randomized controlled trial by Mayer et al. [633] aimed at promoting sun protection among United States Postal Service (USPS) letter carriers included 70 postal stations with a total of 2,662 participants. Analyses included 1,183 participants in the intervention group and 1,318 participants in the control group. Participants averaged 43 years of age (SD=8.6), worked an average of 3.9 hours a day outside (SD=1.9), and 77% had skin type III or IV. Over the course of the study, participants were given questionnaires on sun protection behaviours. Furthermore, they were observed and the skin colour of the participants was measured. Follow-ups were conducted after three months, after one year, and after two years. The intervention was based on an ecological behavioural model and a social learning theory as part of the SUNWISE project. At the relationship level, sun protection hats and sunscreen with SPF 30 were provided, as well as visual cues for sun protection implementation using posters, water bottles, key chains, mouse pads, and magnets. At the behavioural level, there were a total of six educational sessions, each lasting five to ten minutes over the two years, with tailored messages about sun protection measures and exposure behaviours. In the intervention group, 27.3% always used a sun protection hat at the beginning of the study. After three months this was 42.7%, after one year 41.1%, and after two years 40.0%. In the control group, 21.0% always used a sunscreen hat at baseline, 21.4% after three months, 24.0% after one year, and 22.3% after two years. Sunscreen was always used before the start of the study within the intervention group by 26.9% and within the control group by 23.5%. After three months, the odds ratio for regular sunscreen use was 2.8-fold higher in the intervention group (95% CI: 2.2-3.5). In the intervention group 39.4% now always used sunscreen and in the control group this was 23.1%. After one year, 41.6% always used sunscreen in the intervention group and 28.1% in the control group. At the last follow-up after two years, 39.2% (OR=2.9; 95% CI: 2.3-3.6) from the intervention group always used sunscreen and 26.3% from the control group.

As part of a randomized controlled trial in a 2x2 factorial design, Stock et al. [634] studied a total of 148 male Iowa Department of Transportation (DOT) highway workers in an age range of 24 to 64 years. Participants had been working in outdoor occupations for an average of 27 years. During this time, 90% spent five to six hours in the sun per workday, and 60% spent as much as seven to ten hours. Eighty-one percent of respondents never to occasionally used sunscreen at baseline, and 83% never to occasionally wore long-sleeved shirts. Older participants with a history of skin cancer and participants with lighter skin reported higher levels of sun protection behaviours. Interventions were based on the Health Belief Model as well as the Prototype Model of Health Behaviour. Participants were randomly assigned to one of four total intervention groups or the control group. Participants in two of the intervention groups received a UV photo of the face at baseline, and all intervention groups received a 12-minute educational video about skin cancer or ageing due to UV radiation or sun exposure, respectively. The videos included photos of skin wrinkles, age spots, skin cancer, and skin protection information related to sunscreen use, explanation of SPF, recommendation to use a Sun Protection Factor of at least 15, and common sunscreen use mistakes. The control group did not receive any video or UV photo. Follow-up occurred immediately after the intervention, at two months, and at one year. At the post-intervention time point, the knowledge of the intervention groups was better than that of the control group. There was also a significant difference in sun protection behaviour between the intervention groups and the control group at this time point (Fs>7.55, ps<0.01, ds>0.81). There was no significant difference within the intervention groups (Fs<0.63, ps>0.4). Furthermore, a positive attitude towards sun protection was found among the intervention groups (F (1,146) =11.49, p=0.001, d=0.86, Ms=3.6 vs. 3.1). Two months after the interventions, more frequent use of sunscreen by the intervention groups was found (F (1,144) =6.04, p<0.02, d=0.68, Ms=0.78 vs. 1.02). At the last follow-up one year after the intervention was given, the control group had the lowest sun protection behaviour. The intervention groups that had received a UV photo had significantly higher sun protection behaviour after one year compared to the time before the intervention (ps<0.02). Only between the control group and the first intervention group, which did not receive a UV photo and a skin aging video, was no significant difference found. An intervention with a UV photo and/or information on skin cancer was found to be most effective for street workers.

Andersen et al. [631] and Buller et al. [387] examined the long-term effects of the so-called Go Sun Smart (GSS) campaign in a randomized controlled trial beginning in the winter of 2001. In this campaign, embassies in ski resorts in the western USA and Canada recommended sun protection measures for outdoor and indoor workers and guests, for example through posters, newsletters, and a website. The randomized subsample included 3,801 employees of 26 ski resorts after excluding ineligible individuals. At the first follow-up in spring 2002, 2,119 participants still took part and at the second follow-up in autumn 2002, this number was 1,463. The participants were on average 34 years old, 96% light-skinned, and 59% of the participants worked outdoors. The control group was composed of ski area employees without intervention. At first follow-up, a dichotomous scale showed 14% fewer sunburns compared to baseline in winter 2001, and 8% fewer in the control group (OR=1.63, p<0.05). The number of sunburns was lower in the intervention group than in the control group (difference: 0.25%, p<0.05). There were differences in sun protection behaviour at the second follow-up. Participants in the intervention group were now more likely to wear sunglasses (OR=1.26, p<0.01), more likely to use sunscreen (OR=1.43, p<0.01), and more likely to avoid the sun while working (OR= 1.17, p=0.08). Overall, the intervention group had a higher sun protection behaviour score than the control group (IG: 2.57, CG: 2.63, p=0.04). There were no significant effects for sun protection at the follow-ups. Overall, the results were dependent on the ski resort and its level of implementation of Go Sun Smart (GSS) measures. Through the study, employees were found to suffer more sunburns and take fewer sun protection measures at ski areas that implemented fewer GSS materials. The GSS program reduced excessive UV exposure of employees at ski resorts in the short term. Medium-term effects of the GSS program on skin cancer prevention at ski resorts are at least as large as the short-term effects, especially with respect to sun protection behaviours. The effects are greater in summer than in winter.

The study by Ruppert et al. [630] dealt, as already described in detail above, with the effectiveness of occupational prevention measures on the subject of skin cancer among vocational school students employed at outdoor locations in Germany. In addition to the results already described, a significant correlation between the use of sunscreen products and gender (female) as well as age (>22 years) was also found three months after the baseline survey. Participants' attitudes towards sunscreen were rated as good at this time.

Houdmont et al. [635] addressed sun protection among construction workers in the UK as part of a controlled study. A total of 1,279 participants were included in the study. Follow-up was carried out on 120 participants. A total of 70 outdoor workers were in the intervention group and 50 in the control group. The intervention was delivered during working hours using a 12-minute DVD entitled "Sun Safety in Construction: A Workplace Health Guidance Film." The control group was not shown the DVD. A questionnaire was completed by the participants at the beginning of the study and at the follow-up after approximately one year. Using the questionnaire, participants were asked about ten sun protection measures and an assessment of personal use was made using one of five statements, based on the stages of the Transtheoretical Model (TTM) (stages: lack of intention, intention formation, preparation, action, maintenance, completion).

In terms of sun protection knowledge, there were no significant results for the five items. For sun protection behaviours, however, there was an increase in the Transtheoretical Model for nine measures for the intervention group compared to two for the control group. The nine sun protection measures that improved within the intervention group included using a cover when working in the sun (33% change, p<0.001), checking moles regularly (27% change, p<0.001), job rotation to minimize time working in the sun (24% change, p< 0.001), wearing sunglasses (22% change, p<0.001), minimizing working in direct midday sun (21% change, p<0.01), using sunscreen (17% change, p<0.05), wearing long-sleeved, loose-fitting clothing (14% change, p<0.01), checking the UV index daily (10% change, p<0.05), and wearing a helmet with neck protection (9% change, p<0.05).

As explained in more detail above, Kearney et al. [632] conducted a systematic review of a total of 22 studies on the topic of sun protection among farmers and farm workers. Two of these included studies conducted interventions aimed at switching to appropriate headgear, for example, through a combination of information and action or encouragement. Twenty-five percent of participants in the intervention group from study one switched from a baseball cap to a wide brimmed hat as a result (Burwell et al. 2004). In study two, more participants also wore wide brim hats as well as protective clothing after the intervention occurred than before (p=0.01) (Christensen et al. 2007). Another study intervened by providing a six-month information program on sun protection as well as (early) detection and provided head coverings. The intervention group showed increased sun protection behaviour after the programme (p<0.01) (Malak et al. 2011).

As discussed above, the study by Houdmont et al. [635] included an intervention in the form of a short DVD on sun protection in construction, which was played during working hours. As a result, more workers in the intervention group used a cover-up when working in the sun (33% change, p<0.001). Furthermore, more participants in the intervention wore sunglasses (22% change, p<0.001) as well as long-sleeved, loose-fitting clothing (14% change, p<0.001) and a helmet with neck protection (9% change, p<0.05).

Buller et al. [387] and Andersen et al. [631] investigated the long-term effects of the so-called Go Sun Smart (GSS) campaign in selected ski resorts in the winter of 2001. Endpoints on sun protection behaviour included the frequency of use of protective clothing, hats, and sunglasses and goggles. At the second follow-up in autumn 2002, the intervention group wore sunglasses more frequently (OR=1.26, p<0.01) and generally had a higher total score for sun protection behaviour (2.57) compared to the control group (2.63) (p=0.04).

In the study by Mayer et al. [633], interventions took place as part of the SUNWISE project. At the ratio level, sun protection hats were provided, among other things. In the intervention group, 27.3% always used a sun protection hat at the beginning of the study. After three months this figure was 42.7%, after one year, 41.1%, and after two years, 40.0%. In the control group, 21.0% always used a sun protection hat at baseline, 21.4% after 3 months, 24.0% after one year, and 22.3% after two years.

In the study by Mayer et al. [633], nterventions were also carried out within the framework of the SUNWISE project. At the ratio level, sun cream with Sun Protection Factor 30 was provided, among other things. The endpoint here was the amount of sunscreen used with a community pump bottle on display. Before the start of the study, sunscreen was always used within the intervention group by 26.9% and within the control group by 23.5%. After three months, the odds ratio for regular sunscreen use was 2.8-fold higher in the intervention group (95%CI: 2.2-3.5). In the intervention group 39.4% now always used sunscreen and in the control group 23.1%. After one year, 41.6% always used sunscreen in the intervention group and 28.1% in the control group. At the last follow-up after two years, 39.2% (OR=2.9; 95% CI: 2.3-3.6) from the intervention group always used sunscreen and 26.3% from the control group.

Stock et al. [634] studied a total of 148 male Iowa Department of Transportation (DOT) road workers as discussed in detail above. Eighty-one percent of participants never to occasionally used sunscreen at baseline. Videos shown during the intervention included information on skin protection as it relates to sunscreen use, sun protection factor explanation, recommendation to use a Sun Protection Factor of at least 15, and common sunscreen use mistakes. At the post-intervention time point, there was a significant difference in sun protection behaviour between the intervention groups and the control group (Fs>7.55, ps<0.01, ds>0.81). Furthermore, a positive attitude towards sun protection was found among the intervention groups (F (1,146) =11.49, p=0.001, d=0.86, Ms=3.6 vs. 3.1). Two months after the interventions, more frequent use of sunscreen by the intervention groups was found (F (1,144) =6.04, p<0.02, d=0.68, Ms=0.78 vs. 1.02). At the last follow-up one year after the intervention had taken place, the control group had the lowest sun protection behaviour.

Buller et al. [387] and Andersen et al. [631] investigated the long-term effects of the Go Sun Smart (GSS) campaign in selected ski resorts in winter 2001. Endpoints on sun protection behaviour included the frequency of sun cream and lip balm use. At the second follow-up in autumn 2002, the intervention group used sunscreen more frequently (OR=1.43, p<0.01) compared to the control group.

Ruppert et al. [630] investigated the effectiveness of occupational skin cancer prevention measures among vocational students employed at outdoor workplaces in Germany, as discussed in detail above. Among other things, a significant correlation between the use of sunscreen products and gender (female) and age (>22 years) was found three months after the baseline survey and after the intervention. Participants' attitudes toward sunscreen were rated as good at this time.

The study by Houdmont et al (2016) included an intervention in the form of a short DVD on sun protection in construction which was played during working hours. As a result, more participants in the intervention group used sunscreen compared to the control group (17% change, p<0.05).

Kearney et al. [632] conducted a systematic review of sun protection among farmers and farm workers. The educational interventions within the 22 different studies produced significant improvements in knowledge, attitudes, and behaviour. Face-to-face contacts were the most effective.

The interventions implemented in a study by Mayer et al. [633] turned out to be successful in increasing sun protection behaviour in view of the results already discussed in detail above. The ease of implementation in institutions also turned out to be positive. These interventions were, at the relationship level, the provision of sun protection hats and sunscreen with Sun Protection Factor 30 with the support of visual cues to implement sun protection measures, for example in the form of posters, water bottles, key rings, mouse pads, or magnets. At the behavioural level, six educational sessions, each lasting five to ten minutes, were conducted over a two-year period with tailored messages about sun protection measures and exposure behaviours.

Stock et al. [634] concluded, based on previous research described above, that a video on skin aging did not make a significant difference to long-term sun protection behaviour. An intervention with a UV photo and/or information on skin cancer was found to be most effective for street workers.

Andersen et al. [631] and Buller et al. [387] examined the long-term effects of the Go Sun Smart (GSS) campaign in a randomized controlled trial beginning in the winter of 2001. In this campaign, embassies at ski resorts in the western United States and Canada recommended sun protection measures for outdoor and indoor workers and guests, such as posters, newsletters, and a website. The GSS program reduced excessive UV exposure and sunburns among employees at the affected ski resorts in the short term. Medium-term effects of the GSS programme on skin cancer prevention are at least as large as the short-term effects, especially with regard to sun protection behaviour. The effects are greater in summer than in winter. (Further studies, for example in other working areas, over longer periods of time, in countries with greater UV exposure, are necessary for generalization).

Based on previous studies, which have already been discussed in detail above, Ruppert et al. [630] concluded that prevention measures and health education on skin cancer protection for outdoor workers should be started at an early age. Information and training on UV radiation and protection should be provided from the first year of training. A lecture intervention is more effective than a video. In addition, the prevention of the relationship is an important factor. Employers should provide sun protection measures.

Preventive occupational medicine is intended to contribute to maintaining employability and to the further development of occupational health protection. It serves to determine whether there is an increased risk to health when performing a certain activity and to detect work-related health disorders at an early stage. In this respect, it is an instrument of secondary prevention (early detection – also of risk factors; early intervention, i.e. targeted advice). An essential element of preventive occupational medicine is individual counselling. If there is an appropriate indication, an offer of examination is made, which the employee can accept or reject.

Only doctors with the specialist title of occupational medicine or the additional title of occupational medicine may be commissioned to carry out preventive occupational medicine. As a rule, the company doctor should carry out the preventive medical check-up.

The basic requirements for preventive occupational medicine are regulated in the ArbMedVV and the AMR. A distinction is made between the initiation of mandatory and available preventive medical care:

§ 4 ArbMedVV – Mandatory preventive care

The employer must arrange obligatory preventive care for employees in accordance with the annex. Mandatory preventive care must be arranged before the start of the activity and at regular intervals thereafter. The employer may only allow an activity to be carried out if the employee has taken part in compulsory preventive care.

§ 5 ArbMedVV – Preventive care on offer

The employer must offer the employees preventive care on offer in accordance with the Annex. Preventive care must be offered before the employee starts work and at regular intervals thereafter. Refusal of an offer does not release the employer from the obligation to continue to offer preventive care on a regular basis.

The second amendment to the ArbMedVV, which came into force on 18 July 2019, only provides for offering preventive care for outdoor activities. The employer must offer occupational health care to employees who are exposed to intensive exposure to natural UV radiation of regularly one hour or more per day. In addition, he must keep exposure to hazardous sunlight as low as possible.

AMR 13.3 "Outdoor Activities with Intensive Exposure to Natural UV Radiation of Regularly One Hour or More Per Day," which was published in the Joint Ministerial Gazette (GMBI) on 24 September 2019, specifies outdoor activities with intensive exposure to natural UV radiation based on the following criteria:

For activities in Germany, the following conditions must be met:

(1) For outdoor activities

• "In the period from April to September
• between 10 a.m. and 3 p.m. Central European Time (CET) (corresponds to 11 a.m. to 4 p.m. Central European Summer Time (CEST))
• for a total duration of at least one hour per working day
• on at least 50 working days.

(2) In the case of activities in the shade (e.g. by means of enclosure or other shading measures) which are carried out there permanently and uninterruptedly, a supply precaution is only to be offered from a duration of at least two hours in total due to the lower intensity of the UV radiation. The other criteria set out in paragraph 1 shall remain unaffected.

(3) In the case of outdoor activities on snow-covered surfaces above 1000 metres above sea level, the period referred to in paragraph 1 shall be extended to the duration of one calendar year. This shall not affect the other criteria referred to in paragraph 1 (GMBl No. 36, 24 September 2019, p. 697)."

For activities outside Germany in the equatorial region between 30th degrees north latitude and 35th degrees south latitude, the following requirements for the offer of preventive care on the part of employers shall apply:

(1) For outdoor activities

• all year round
• between 10 a.m. and 3 p.m. local time
• for a total duration of at least one hour per working day
• on at least eight working days.

(2) In the case of activities in the shade (e.g. by means of enclosure or other shading measures) which are carried out there permanently and uninterruptedly, preventive care shall only be offered from a duration of at least two hours in total due to the lower intensity of UV radiation. The other criteria mentioned in paragraph 1 shall remain unaffected.

(3) For activities outside Germany in the entire area of the northern hemisphere greater than 30th degree northern latitude as well as in the entire area of the southern hemisphere greater than 35th degree southern latitude, the criteria specified in section 4.2 shall apply accordingly, whereby the local time shall be decisive instead of the CET and the months of October to March shall be taken into account for the southern hemisphere (GMBl No. 36, 24 September 2019, p. 697). The employer's offer of offer provision must be made on a regular basis and also in the event of the employee(s) rejecting an earlier offer. The maximum time limits, which are regulated in AMR No. 2.1 "time limits for the initiation/offer of occupational health care" (Bundesanstalt für Arbeitsschutz und Arbeitsmedizin, 2016), are therefore as follows for outdoor activities:

1. The first precaution must be initiated or offered within three months before the start of the activity.
2. The second precaution must be arranged or offered no later than twelve months after the start of the activity. 
3. Each subsequent screening must be initiated or offered no later than 36 months after the previous screening.

Shorter periods are possible if they are considered necessary from an occupational health point of view and can be specified in the risk assessment. The indication of when renewed occupational medical screening is indicated from a medical point of view is part of the precautionary certificate within the meaning of § 6 Paragraph 3 Number 3 ArbMedVV (see AMR 6.3), which is issued to the employer and the employee. In the first years of employment, the focus is on education and the identification of individual risk factors. Early skin cancer detection becomes more important with increasing duration of exposure.

In order to facilitate the organisation of preventive care and individual information and advice on all work-related health hazards, all preventive care occasions should be bundled in one appointment with the company doctor.