Association of Occupational Sun Safety Policy and Actions in State Transportation Sector in the United States

Abstract

Background

Occupational sun protection is recommended by government health authorities. Sun safety policies and predictors of managers’ reports of sun safety actions were assessed.

Methods

Written policies from 21 state departments of transportation (DOTs) enrolled in a randomized trial testing methods for scaling-up an occupational sun safety intervention were coded for sun safety content at baseline. Managers (n=1,113) supervising outdoor workers reported on sun safety actions in a baseline survey.

Results

Twenty state DOTs (95.2%) have a policy with at least one sun protection component. Sun safety training was increased at workplaces with written sun safety policy (p<0.001) and unwritten standard procedures on sun protection (p<0.001). Reported sun safety actions were highest where there was a written sun safety policy (p<0.001) and unwritten standard procedures on sun protection (p<0.001).

Conclusions

Policies are essential for implementation of employee sun safety. There is room for improvement in existing policies in state DOTs.

Trial Registration ID Number: Clinicaltrials.gov, NCT03278340

Introduction

In the United States, government health authorities recommend the implementation of interventions aimed at protecting outdoor workers from solar ultraviolet radiation (UV) exposure to prevent skin cancer.^1,2 Skin cancer is among the most common cancers worldwide³ and, in the United States, the American Cancer Society estimates that over 3 million cases of keratinocyte skin carcinomas (i.e., basal and squamous cell carcinomas) and over 100,000 cases of malignant melanoma will be diagnosed in 2020.⁴

Outdoor workers are a priority population for skin cancer prevention because they are exposed to large cumulative doses of UV over many years,⁵ which increases their risk for developing keratinocyte skin cancers and possibly melanoma.^6,7 Deaths from melanoma produced an estimated US$66.9 billion in productivity losses from 1990 to 2008.⁸ Sun protection should be promoted because many outdoor workers fail to practice sun safety.^5,9 Occupational sun safety aligns with efforts to address heat stress, other workplace hazards, and more broadly climate change.^10,11 Studies by the authors and others confirmed that interventions can increase workers’ sun protection.^11–15

Over a series of trials, the authors developed an evidence-based, comprehensive approach to occupational sun safety. Based on diffusion of innovations theory¹⁶ and social ecological models,¹⁷ this approach convinced employers to adopt policies for routine sun safety, increased implementation of environmental controls and administrative procedures for sun protection especially when managers were aware of policies, and increased employees’ sun safety practices.^15,18–20 In a Canadian study, implementation of occupational sun safety was influenced by workplace context (e.g., organizational structure, organizational safety culture, and readiness to change), knowledge exchange in the intervention (e.g., use of knowledge brokers, engagement of workers, and type of resources provided), and external context (e.g., regulations regarding solar UV and heat protection in the workplace, regional climate, and average UV Index forecasts [a proxy for UV exposure]).¹¹ A recent analysis in Germany showed that outdoor workers with no support for sun safety were less likely to practice it.²¹

Currently, the authors are conducting a randomized trial to test methods of scaling-up nationwide their comprehensive approach to occupational sun safety. In this paper, the authors report on the coding of sun safety content in existing workplace policies and predictors of managers’ reports of sun safety actions at baseline in that trial in a sample of 21 state departments of transportation (DOTs) in the United States. It was hypothesized that presence and strength of sun safety policy would be associated with greater implementation of sun safety actions at the workplace.

Methods

Experimental Procedure and Recruitment

A randomized trial was initiated to examine scale-up methods for the Sun Safe Workplaces intervention.²² The intervention promoted adoption of sun safety policy and education for outdoor workers. Originally, it was delivered through in-person meetings with senior managers, on-site training sessions for employees, follow-up communication with managers by email and telephone, and online sun safety resources for managers and employees.¹⁸ In this randomized trial, the original in-person method for delivering Sun Safe Workplaces is being compared to a digital method where meetings are conducted virtually and employee training is provided online.²² Working with the American Association of State Highway and Transportation Officials, all 50 state DOTs were approached to participate in the trial. Eligibility criteria for DOTs were being located in the United States, providing written safety policies at pretest, and having managers in each participating regional district complete a pretest. Once agreement to participate was secured, a key contact manager at the state office, usually a senior safety or wellness manager, provided information on the organization and a list of managers from each participating regional district within the DOT for pretesting. Eligibility criteria for managers in the manager’s survey included a) being in a management or front-line supervisory position in a regional district within the DOT; b) supervising outdoor workers; c) consenting to participate, and d) completing the pretest. Managers held positions of Safety Officers/Leads, Safety Coordinators, Maintenance Administrators/Supervisors, Resident/Construction Engineers, Maintenance/ District Superintendents, Operations/Infrastructure Managers, and Project/Section Supervisors. Prior to randomization to experimental condition, invitations for the survey were sent by email followed by five weekly reminders, after which persistent non-responders received a printed survey by U.S. mail, with a return-addressed stamped envelope. All procedures were approved by the Western Institutional Review Board.

Sun Safety Policy Coding Procedures

Human resources and safety documents from each state DOT were provided by the key contact manager and excerpted and coded by research assistants blind to experimental condition. The coding protocol was developed in a previous trial and measured presence, strength, intent, and responsibility for sun safety.¹⁸ Coders assessed 15 policy components: engineering controls (physical environment of the workplace), administrative controls (workplace procedures), and employee personal protection (workers’ sun safety). Each category received a point (0, 1) for presence (total score=15) and a 4-level strength score (−1=not allowed, 0=not mentioned, 1=allow/ recommend, 2=require; total score=30). Because policies on engineering controls (scheduling/shade) and some sun safety practices (hats/protective clothing/protective eyewear) could exist for reasons other than sun safety (e.g., to prevent injury), these components were also coded for whether sun protection was explicitly cited (0,1; total intent score=5). A 3-level responsibility score was also assigned to each of the 15 categories for who provides protection equipment (0=not specified, 1=employee, 2=employer; total score=10). Training ensured inter-coder reliability exceeded 0.70 for all components on content and for all but four components on strength (see Table 1 and Table 2). Composite ordinal scores were created indicating proportion of employers who had any policy (at least one component), along with extent (number of components) and strength (summed across policy components) of the policy.

Table 1:

Content of Written Sun Protection Policies in State Departments of Transportation (n=21)

	Content (%, n)
Policy Categories	Addressed (1)	Addressed with Direct Sun Safety Intent	Addressed with Direct Intent and Fulfills Directive1	Cohen’s Kappa2
Provision of outdoor shade	42.9% (n=9)	9.5% (n=2)		0.90
Scheduling of outdoor work	38.1% (n=8)	9.5% (n=2)	9.5% (n=2)	0.90
Risk assessment of sun exposure and protection	4.8% (n=1)	4.8% (n=1)		0.98
Training of employees	4.8% (n=1)	4.8% (n=1)	0.0% (n=0)	0.90
Training of managers/supervisors	0.0% (n=0)	0.0% (n=0)	0.0% (n=0)	0.90
Policy review and monitoring	0.0% (n=0)	0.0% (n=0)		0.98
Resource allocation	90.5% (n=19)	90.5% (n=19)		0.89
Contractors & subcontractors to comply with policy	4.8% (n=1)	4.8% (n=1)		1.00
Communication with clients/patrons	0.0% (n=0)	0.0% (n=0)		0.90
Posting of UV Index	0.0% (n=0)	0.0% (n=0)		1.00
Sunscreen use (including sunscreen lip balm)	57.1% (n=12)	57.1% (n=12)	33.4% (n=7)	1.00
Hat	95.2% (n=20)	23.8% (n=5)	19.0% (n=4)	1.00
Clothing	95.2% (n=20)	38.1% (n=8)	38.1% (n=8)	1.00
Protective eyewear	90.5% (n=19)	33.4% (n=7)	33.4% (n=7)	0.90
Regular skin cancer screening (self-exam or clinical exam)	23.8% (n=5)	23.8% (n=5)	4.8% (n=1)	0.92

¹The directives were: scheduling=limit outdoor work at midday; training=supervisor-led; sunscreen=sun protection factors (SPF)=30 or higher; hat=wide-brim; clothing=long sleeve shirts and long pants; and eyewear=UV protection.

²Cohen’s Kappa coefficients were calculated for agreement between coders.

Table 2:

Strength of Written Sun Protection Policies in State Departments of Transportation (n=21)

	Strength Content Addressed (%, n)			Strength Content Addressed with Direct Intent (%, n)
Policy Categories	Not Mentioned /Specified	Allowed/ Recommended	Required	Allowed/ Recommended	Required	Cohen’s Kappa1
Provision of outdoor shade	57.1% (n=12)	38.1% (n=8)	4.8% (n=1)	4.8% (n=1)	4.8% (n=1)	0.83
Scheduling of outdoor work	61.9% (n=13)	38.1% (n=8)	0.0% (n=0)	9.5% (n=2)	0.0% (n=0)	0.90
Risk assessment of sun exposure and protection	95.2% (n=20)	4.8% (n=1)	0.0% (n=0)	4.8% (n=1)	0.0% (n=0)	0.92
Training of employees	95.2% (n=20)	4.8% (n=1)	0.0% (n=0)	4.8% (n=1)	0.0% (n=0)	0.94
Training of managers/supervisors	100.0% (n=21)	0.0% (n=0)	0.0% (n=0)	0.0% (n=0)	0.0% (n=0)	0.90
Policy review and monitoring	100.0% (n=21)	0.0% (n=0)	0.0% (n=0)	0.0% (n=0)	0.0% (n=0)	0.88
Resource allocation	9.5% (n=2)	9.5% (n=2)	81.0% (n=17)	9.5% (n=2)	81.0% (n=17)	0.47
Contractors & subcontractors to comply with policy	95.2% (n=20)	0.0% (n=0)	4.8% (n=1)	0.0% (n=0)	4.8% (n=1)	1.00
Communication with clients/patrons	100.0% (n=21)	0.0% (n=0)	0.0% (n=0)	0.0% (n=0)	0.0% (n=0)	0.90
Posting of UV Index	100.0% (n=21)	0.0% (n=0)	0.0% (n=0)	0.0% (n=0)	0.0% (n=0)	1.00
Sunscreen use (including sunscreen lip balm)	42.9% (n=9)	47.6% (n=10)	9.5% (n=2)	47.6% (n=10)	9.5% (n=2)	0.83
Hat	4.8% (n=1)	9.5% (n=2)	85.7% (n=18)	4.8% (n=1)	19.0% (n=4)	0.63
Clothing	4.8% (n=1)	23.8% (n=5)	71.4% (n=15)	9.5% (n=2)	28.6% (n=6)	0.67
Protective eyewear	9.5% (n=2)	9.5% (n=2)	81.0% (n=17)	0.0% (n=0)	33.4% (n=7)	0.69
Regular skin cancer screening (self-exam or clinical exam)	76.2% (n=16)	23.8% (n=5)	0.0% (n=0)	23.8% (n=5)	0.0% (n=0)	0.94

¹Cohen’s Kappa coefficients were calculated for agreement between coders.

Managers’ Survey Measures

Unwritten Procedure for Sun Safety.

Managers reported whether there was an unwritten operating, administrative, or training procedure, or any other unwritten rules, intended to improve the sun protection of employees that are not part of a written policy (yes v. no or don’t know).

Sun Safety Implementation Measures.

Implementation of sun safety actions for employees at the DOT was also reported by managers in the survey. Using measures modified from the authors’ past trial on school sun safety policy,^23,24 managers reported if employees or managers and supervisors at the workplace were trained in sun safety (2-items; yes, no, or don’t know). Next, they indicated whether any of the following nine additional sun protection actions had occurred in the workplace:

1. Employer monitors UV Index and work schedule is adjusted for harm associated with UV level.

2. Employees wear UV-protective clothing or uniforms (shirts with sleeves; long pants), hats, and/or eyewear when outdoors.

3. Employees wear sunscreen with sun protection factor (SPF) 30 or greater when outdoors.

4. Messages are communicated to employees about protecting your skin and eyes from the sun while outdoors at work.

5. Employer provides sun protection resources, such as sunscreen, UV-protective clothing/ uniforms, hats, and/or eyewear to employees. “Provides” means the employer gives employees these items or gives employees money to purchase them for use at work.

6. Temporary or permanent shade structures are provided in the work environment.

7. Employer requests that staff employed by contractors/subcontractors comply with the sun safety policy while working in the employer’s work environments.

8. Employers encourages employees to regularly check their skin for signs of skin cancer either by themselves or by a physician.

9. Employer conducts a risk assessment of sun exposure and sun protection for employees in the work environment

Other Measures.

Managers also responded to questions assessing their attitudes toward skin cancer prevention (e.g., perceived susceptibility) and occupational sun protection (e.g., responsibility of employees and organization, innovation characteristics, and compliance with policy), time spent working outdoors (i.e., if work mostly outdoor, mostly indoors, or outdoors and indoors equally and number of hours spent working outdoors in a typical week in the summer and winter), job and demographic characteristics (i.e., years working for state DOT; direct supervision of day-to-day activities of employees who work outdoors; frequency of being involved in decisions about workplace policy, procedures, and training related to safety and health of employees, opinion leadership,²⁵ cosmopolite-ness (i.e., readership of professional publications or attendance at professional conferences in past 5 years),²⁶ skin type,²⁷ skin cancer history, age, education, Hispanic ethnicity, race, and gender). We included opinion leadership and cosmopolite-ness because they are important in organizational innovation¹⁶ and cosmopolite-ness was associated with occupational sun safety policy previously.²⁸

Statistical Analysis

For the content analysis on the state DOTs’ formal written sun protection policies, PROC FREQ in SAS 9.3 was used to calculate the Cohen’s kappa to estimate inter-rater reliability, with a kappa of 0.70 set as satisfactory agreement. Descriptive statistics of these coded policies were then calculated. Effects of workplace sun protection policies, managers’ sun safety practices, and manager characteristics on presence of workplace training and actions for employee sun safety were identified using stepwise model selection. The potential predictors were selected at the 0.15 level. PROC GLIMMIX in SAS 9.3 was used to fit a multilevel logistic model on the binomial outcome of sun safety training (yes vs. no or don’t know) and to fit a multilevel Poisson model on the number of workplace sun protection actions. Alpha criterion levels were set at 0.05 (two-tailed).

Results

Characteristics of Sample

Departments of transportation in 21 U.S. states participated in the trial (range=997 to 18,415 employees) located in all four Census regions (4 Northeast, 6 Midwest, 7 South, and 4 West). The DOTs had 138 regional districts from which managers were pretested (range=1 to 27 districts per state).

Completed surveys were obtained from 1,113 managers (49.2% of 2,262 managers invited). On average, managers were long-term employees (mean [M]=19.77 years, sd=9.33) and middle-aged (M=48.88 years, sd=8.46). Most were involved in decisions about workplace safety and health (16.2% rarely/never, 33.3% some of the time, 50.5% most/all of the time). Nearly all managers were male (91.5%) and white (91.1%; 5.6% Hispanic), but they had diverse educational attainment (21.9% high school graduate or less, 34.7% education beyond high school, 43.4% 4-year college degree or more). Two-thirds of managers worked outdoors at least part-time (33.5% mostly indoors, 41.6% outdoors and indoors equally, 24.9% mostly outdoors), averaging 17.18 hours (sd=12.15) in the summer and 13.41 hours (sd=11.52) in the winter per week. Nearly a quarter had skin types at high-risk for skin cancer (4.9% always burns and unable to tan, 19.5% usually burns but can tan if work at it, 44.9% sometimes mildly burns and then tans easily, 30.7% rarely burns and tans easily) and several had been previously diagnosed with skin cancer (10.2%).

Sun Protection Policies

Twenty state DOTs (95.2%) had a policy with at least one component of sun protection (Table 1). Nearly all states had policies on personal protection using hats, clothing, and protective eyewear but only half had a policy on sunscreen. About a quarter of policies addressed secondary prevention through regular skin cancer screenings. Environmental controls (i.e., shade and scheduling of work when UV was lower) were present in about 40% of policies. Very few policies addressed administrative procedures of risk assessment, training, policy review, communication with clients/patrons, compliance of contractors and subcontractors, and posting of the UV Index, but nearly all policies mentioned allocating of resources to sun protection.

However, fewer of the states had policy components that explicitly were intended to provide protection from the sun, except for sunscreen which was always described as a sun protection practice (Table 1). For instance, only one-third of states had a “sun-protective” policy on wearing clothing and eyewear and only 9.5% specified sun protection as the purpose of providing outdoor shade or scheduling outdoor work. Even fewer states had best-practice policies that specified an SPF for the sunscreen, specified wide-brimmed hats, long-sleeved shirts, and long pants, and UV protection on eyewear, and scheduled work outside of midday hours, all practices that would maximize sun safety (Table 1).

Personal protection practices including hats, clothing, and protective eyewear were generally required by the policies (Table 2), although the policies explicitly specifying sun safety were more likely to allow or recommend the protection behavior than require it. By contrast, very few other personal protection practices and almost none of the environmental controls or administrative procedures were required, with most being encouraged or recommended including when specifically intended for sun protection (Table 2).

Unwritten Procedures on Sun Protection

A plurality of managers (40.2%) reported that the state DOT had unwritten standard operating, administrative, or training procedures, or unwritten rules, intended to improve employee sun protection. Presence of a written sun protection policy was not related to reports of unwritten procedures: 38.7% of managers at workplaces with policies and 29.5% of managers at workplaces without policies reported unwritten procedures, F=0.41, p=0.532. Only regular readership of printed or online professional publication predicted managers’ reports of unwritten standard operating, administrative, or training procedures to improve employee sun safety. Those who read such publications were more likely to report an unwritten procedure (44.1%) than those not reading them (30.4%; F=18.15, p<0.001).

Relationship of Policy to Workplace Sun Protection Actions

The association of sun protection policies, managers’ sun safety practices, and manager characteristics were examined as predictors of workplace actions to promote sun safety (Table 3). Training of employees, managers, and supervisors on sun safety was positively predicted by the presence of a formal written sun safety policy, presence of an unwritten standard operating, administrative, or training procedure on sun protection, and greater opinion leadership by the manager on employee safety and health. Likewise, the number of other sun protection actions implemented at the workplace was positively predicted by the presence of a formal written sun safety policy, presence of an unwritten standard operating, administrative, or training procedure on sun protection, greater sun protection practices by managers, more involvement of managers in workplace safety and health policy, procedures, and training decisions, managers’ minority race/ethnicity status, working outdoors at least half the time, and not being previously diagnosed with a skin cancer.

Table 3:

Results of regression analyses on predictors of training and other actions promoting workplace sun safety.

Predictor	Training of Employees, Managers, and Supervisors1	F	p	Number of Workplace Sun Protection Actions2	F	p
Formal written policy on sun protection
No	39.9%	119.00	<0.001	1.92 (0.19)	71.65	<0.001
Yes	84.5%			2.81 (0.29)
Unwritten standard operating procedures on sun safety
No	51.8%	52.48	<0.001	1.96 (0.20)	61.67	<0.001
Yes	77.1%			2.74 (0.28)
I am frequently asked to give my opinion concerning safety and health of employees by other people. (agreement scale; range=1 to 5)	Odds ratio point estimate: 1.20 95% CI: [1.04, 1.37]	6.58	0.010
Composite Manager Sun Protection Practices (mean frequency; range=1 to 5)				1.20	31.60	<0.001
Involvement in decision making on workplace policy, procedures and training related to safety and health of employees (frequency rating; range=1 to 5)				1.06	7.76	0.005
Manager’s ethnicity and race				2.18 (0.21) 2.46 (0.27)	4.01	0.046
Non-Hispanic White				2.18 (0.21)	4.01	0.046
All other				2.46 (0.27)
Manager works
Mostly outdoors or outdoors and indoors equally				2.45 (0.24) 2.20 (0.23)	5.24	0.022
Mostly indoors				2.20 (0.23)
Manager’s skin cancer history
No				2.49 (0.23)	3.97	0.047
Yes				2.16 (0.25)

¹Logistic regression (training=not trained v. trained)

²Poisson regression (summed number of sun safety actions, range=0 to 9)

Discussion

Sun safety aligns with workplace initiatives to prevent injury, improve well-being, address heat stress and climate change, and respond to workplace hazards. Workplace hazards can may elevate the risk of cancer (e.g., asbestos and tar) and along with UV radiation can increase the risk of skin cancer (e.g., arsenic, coal tar, mineral oils, insecticides, and herbicides).^10,11,29,30 Many state DOTs had policies that encouraged or recommended that outdoor workers protect themselves from the sun while on the job. These jobs included engineering, construction and/or maintenance of roadways, bridges, tunnels, and ferries, highway safety features (e.g., signs, guardrails, and fencing), and surrounding lands (e.g., vegetation, irrigation, flood, and waste control). However, less than half of these policies explicitly had sun protection as their purpose. Many were intended to protect against other hazards and injuries. Examples were policies on hard hats to prevent head injury, eyewear to prevent injury to vision, and clothing to protect from burns, cuts, chemical exposures, and hypothermia. A plurality also had policies on improving work environments by providing shade or adjusting schedules to avoid time working outdoors during midday periods of high UV, but once again, these policies were intended to protect against other hazards such as heat-related illnesses. Fortunately, almost all policies included some statements on resource allocation to support protective behaviors.

Many of the policies on hats, protective clothing, and eyewear required use of this personal protective equipment. These three practices are among the best ways to protect the skin from the sun because, unlike sunscreen, they do not wear or wash off and do not require re-application for maximum protection. Also, unlike shade, they are always with the workers if they wear them throughout the day. Still, most individuals have some skin exposed to the sun even when wearing hats, clothing, and eyewear that should be protected with sunscreen with SPF 30 or greater, which was only present in half of the policies and was mostly encouraged or recommended, not required. Many state DOTs provide hats, clothing, and eyewear or provide funds for employees to purchase them. Sunscreen may be considerably more expensive to provide because it must be replenished, whereas hats, clothing, and eyewear may be worn for many days before needing replacement.

About two-fifths of state DOTs had policies to provide shade and adjust outdoor work schedules but very few were intended to reduce UV exposure. These policy elements can be challenging to implement. Shade is a more expensive action for sun safety³¹ than providing clothing but it can be available for long periods of time. However, shade may be difficult to provide to many transportation workers as they travel long distances around their regions servicing roads and other infrastructure, using heavy equipment. Vehicles can provide shade and shade may be available from natural (e.g., trees) and manmade objects (i.e., bridges). Adjusting work schedules can be hazardous if it places workers outdoors during times when they are not visible to motorists such as at dawn or dusk.

Policies on administrative procedures, especially training of employees, managers, and supervisors in sun safety, were lacking in most existing policies. Training may be necessary to convince managers and supervisors to engender collective commitment and efficacy by management needed for implementation of policies³² and management support that motivates employee sun protective actions.²¹ Also, studies have shown that workplace education can improve workers’ sun protection.^11–15 Employees should be educated in the need for sun protection (i.e., personal risk for skin cancer and presence of UV, the environmental carcinogen) and ways they can effectively protect their skin on the job (i.e., increasing response and self-efficacy for sun safety) to make the policy result in increased sun protection by employees.

Policies referencing sun protection practices did not always address the optimal form of these behaviors. For instance, less than half of the policies on sunscreen specified an SPF level. Likewise, few policies specified wide-brimmed hats and UV-protection in eyewear. Policies on adjusting work schedules rarely mentioned limiting time during midday hours. Thus, there is considerable room for improvement in several policy components related to sun protection in the state DOT policies. As many DOTs have policies on these behaviors, just not for sun protection, it may be easier to convince managers to expand the safety scope to include sun safety than to convince them to adopt an entirely new safety policy.

In addition to written policies, two in five managers reported that there were unwritten standard procedures or rules on employee sun protection. In lieu of a policy, unwritten procedure may develop when managers become aware of the need for sun safety, say through outside information sources (i.e., professional publications). According to diffusion of innovations theory,¹⁶ these managers are cosmopolite and more likely to adopt innovations. Cosmopolite-ness was likewise associated with formal workplace sun protection policies in the authors’ earlier trial on the Sun Safe Workplaces intervention.²⁸ It is also possible that unwritten procedures developed to operationalize formal written policies in the day-to-day work activities.

The value of the sun safety policy for increasing skin cancer prevention on the safety agenda of the state DOTs was evident in the strong association between policies and implementation of training and other actions to support sun safety at these workplaces. Even the presence of informal operating, administrative, and training procedures increased implementation of sun safety training and actions. This underscores the value of making changes at the organizational level when striving to improve occupational sun safety. The organization and its management control many aspects of the workplace by implementing procedures and allocating resources that can facilitate as well as impede sun safety by employees. Having a formal written policy rather than unwritten procedure is preferable because formal policies should be more permanent and thus influence organizational actions over the long-term, even in the face of personnel turnover. Finally, formal written policies may permit managers to allocate resources including in times when budgets are lean, by indicating that sun safety is an integral part of the workplace safety procedures.

Managers’ own sun safety practices and their performance of work outdoors were associated with reports of greater workplace actions to promote employee sun protection. Likewise, managers who were more involved in decisions about employee safety and health and were treated as opinion leaders on these subjects reported more actions. This might be an indication that in some state DOTs, policies are weak and sun safety actions depends on the personal interest of local managers or their role in the workplace safety culture. One would expect that stronger policies might reduce the influence of managers’ own sun safety or their job responsibilities, which is what we saw after the Sun Safe Workplaces intervention increased the strength of policies in an earlier trial.¹⁹

Finally, it may be unexpected that managers who were non-Hispanic white or had a history of skin cancer reported less sun safety actions at the workplace than managers from ethnic groups less susceptible to skin damage or who have not developed skin cancer. Non-Hispanic white managers and managers who have been diagnosed with skin cancer may realize that their skin is susceptible to being damaged by UV and feel that more could be done by employers to protect employees.

The results reported in this paper are subject to several limitations. While all 50 states DOTs received invitations to participate, managers at the 21 DOTs that agreed to enroll may have had higher interest in skin cancer prevention or were already taking more actions on skin cancer prevention than managers at the DOTs that did not participate. The generalizability of the findings may be limited to public works employers and the transportation sector. The policies were coded objectively but reports of sun protection training and actions were self-reported by managers and thus open to social desirability biases and memory errors. However, self-reports were more feasible to administer than observational measures across the large geographic areas covered by the 21 DOTs. There also may be non-response biases because half of managers invited to complete the survey did not participate.

Policies appear to be essential elements of occupational sun safety in state DOTs. Fortunately, many state DOTs have policies requiring employees to practice personal sun protection but there is considerable room to improve the content and strength of these policies.