Addressing sun safety at work in Canada

CAREX Canada has prioritized solar radiation (radiation from the sun between wavelengths of 100 and 400 nanometres on the electromagnetic spectrum) as a high priority for exposure reduction in Canadian workplaces. This is because approximately 1.5 million Canadians are exposed to sun at work.[1] Sun exposure is a workplace hazard that can cause skin cancer, heat stress, and other serious health effects, all of which are preventable. Outdoor workers have a 2.5 to 3.5 times greater risk of skin cancer than indoor workers.[2] Results from the Burden of Occupational Cancer project show that approximately 4,600 non-melanoma skin cancers (NMSC) are attributed to occupational solar radiation each year, which amounts to 6.3% of non-melanoma skin cancer cases diagnosed annually.[3] These cases amount to $28.9 million of direct and indirect costs, including healthcare, out-of-pocket, and productivity costs, each year.[4]

Sun Safety at Work Canada – Project

To help address this exposure, CAREX Canada partnered on the Sun Safety at Work Canada (SSAWC) project, a sun safety program for outdoor workers that developed processes and resources to enhance sun safety in workplaces. CAREX exposure estimates were used to inform the priority workplaces for SSAWC. The SSAWC project was led by Thomas Tenkate, Associate Professor and Director of the School of Occupational and Public Health at Ryerson University in Toronto, and involved a series of partners from across the country. Funding was provided by the Canadian Partnership Against Cancer through their Coalitions Linking Action and Science for Prevention (CLASP) program.

In the first phase of the SSAWC project, the team recruited 17 workplaces in British Columbia, Nova Scotia, New Brunswick, and Ontario to pilot sun safety interventions. The second phase involved engaging with stakeholders and developing a suite of  resources. The resources include posters, fact sheets, and guides designed for workplaces to enhance their sun safety..The project team established this website – sunsafetyatwork.ca – to house these resources and support workplaces in reducing solar UV exposure for their employees. The SSAWC website also hosts a set of videos (shared below), developed in partnership with WorkSafeBC, which illustrate the dangers of sun exposure and heat stress, and describe what workers and employers can do to prevent it.

Sun Safety at Work Canada – Working Group

Since the SSAWC project wrapped up in 2016, CAREX Canada has taken the lead in continuing its momentum by establishing a working group of members from across Canada. Called the Sun Safety at Work Canada Working Group, this effort brings together research, policy, and practice (including health and safety and medical practice) interests and expertise, and provides a platform for national collaboration and networking. Ultimately, the working group seeks to inspire stronger sun safety policies and regulations in Canada, and improve sun protection for outdoor workers. The approach to achieving this from the CAREX perspective focuses on facilitating the exchange of knowledge, expertise, and tools, as well as providing evidence to support a deeper understanding of occupational sun exposure.

The working group meets at least three times per year, and members discuss approaches to further influence and inform policy to protect outdoor workers, and reduce solar UV exposure. We’ve worked with various working group members to draft a series of grant applications to support and fund our continued efforts.

To learn more about the working group, or to propose a potential collaboration, please get in touch with us at info@carexcanada.ca.

Working group members
  • Nicole Braun, Population Health Promotion Practitioner, Saskatchewan Cancer Agency (SCA)
  • Tracy Burgess, Sun Safety Advisor, Sun Safe Nova Scotia (SSNS)
  • Chantal Courchesne, Chief Executive Officer, Canadian Dermatology Association (CDA)
  • Jennifer Dyck, Prevention Consultant – Support Services, SAFE Work Manitoba
  • Lindsay Forsman-Phillips, Project Manager, CAREX Canada
  • Dr. Peter Green, Chair, Sun Safe Nova Scotia (SSNS)
  • Elizabeth Holmes, Health Policy Analyst, Canadian Cancer Society (CCS)
  • Dr. Linn Holness, Director, Centre for Research Expertise in Occupational Disease (CREOD)
  • Dr. Sunil Kalia, Assistant Professor, University of British Columbia
  • Brenda Marsh, Senior OHS Advisor and RN, Sun Safe Nova Scotia (SSNS) and Occupational Health Nurses Association Nova Scotia (OHNANS)
  • Colin Murray, Senior Manager, WorkSafe BC (WSBC)
  • Alison Palmer, Executive Director, CAREX Canada
  • Dr. Cheryl Peters, Co-Principal Investigator, CAREX Canada
  • Judy Purcell, Cancer Prevention, Sun Safe Nova Scotia (SSNS), Cancer Care Nova Scotia (CCNS)
  • Steve Quantz, Population, Public and Aboriginal Health, Alberta Health Services (AHS)
  • Dr. Peter Strahlendorf, Associate Professor, Ryerson University (School of Occupational and Public Health)
  • Dr. Thomas Tenkate, Associate Professor & Director, Ryerson University (School of Occupational and Public Health)

Sun exposure in outdoor workers in Alberta

Despite the significant health and economic impacts of workplace exposure to solar UVR, there are no occupational exposure measurements available to quantify the hazard for most provinces including Alberta, which has some of the highest ambient UV levels in the country. To begin addressing this gap, CAREX Canada launched a study with funding from Alberta Labour (now the Ministry of Labour and Immigration) and support from working group partners to determine:

  1. What are the typical full-day solar radiation exposure levels for outdoor workers in Alberta, and what personal, work, or environmental factors lead to higher levels?
  2. What sun protection behaviours are being used by outdoor workers at work and leisure in Alberta?
  3. What are the best practices for creating a sun exposure and skin cancer surveillance system for outdoor workers in Alberta?

Recruited workers largely identified as male (75%) and Caucasian (75%). They were young (mean 37 years) and mostly from the cities of Edmonton (44%) or Calgary (44%). Most participants worked in the trades (46%), followed by landscape/maintenance services (29%). Other occupations included were recreation, security, and professional services workers.

The results of our study show that outdoor workers in Alberta may be at considerable risk of solar UVR exposure in the summer months. Almost half of the workers were exposed to levels that exceeded the international occupational exposure limit guideline, and some workers were exposed to levels 13 times the international guideline. Those who worked outside for more hours or on sunny and mixed sunny/cloudy days were more likely to have higher daily doses.

We also found that outdoor workers were more likely to practice sun protection behaviours at work than at leisure. At work, workers were more likely to wear protective clothing, hats, and sunscreen, but at leisure, they were more likely to seek shade. As the number of hours spent outdoors at work and leisure increased, sun protection also increased.

There are few examples worldwide of jurisdictions that have surveillance systems in place to support the exposure and NMSC risk reduction in this vulnerable worker population. Key barriers for designing and implementing an occupational surveillance program in Canada include underreporting/under-participation and a lack of funding and awareness, while key facilitators include communication/collaboration, a simple reporting process, and long-term funding.

Refer to the following subsections for more detailed results and a description of the methods used.

Solar radiation exposure levels

When investigating the typical full-day solar UVR exposure levels experienced among outdoor workers in Alberta and the personal, work, or environmental factors that lead to higher levels, we found that:

  • Daily exposure was highly variable, with some workers being exposed to levels up to 16.6 SED (standard erythemal dose), almost 13 times the international occupational exposure guideline, which is 1.3 SED.
  • On average, workers were exposed to 1.93 SED per day.
  • Workers were exposed to the highest average levels between 11:00 and 12:59 (Figure 1). However, even within the earliest and latest time windows, when ambient solar UVR is lowest, exposure levels could exceed the daily international occupational exposure guideline.
  • Overall, 45% of workers were exposed to levels exceeding the international occupational exposure guideline (Figure 2). This varied by occupation; recreational workers had the largest percent of workers exceeding the guideline, but landscape, maintenance, and service workers had the highest percent of workers in the highest dose category (>4 times the guideline).
  • Workers were more likely to have higher daily doses if they worked more hours or on sunny and mixed sunny/cloudy days.
  • Security and professional service workers had lower doses compared to trade workers.

Figure 1. Average and maximum solar UVR dose by time window

 

Figure 2. Outdoor workers’ personal solar UVR measurements compared to the recommended occupational exposure limit guideline (1.3 SED)

These findings are similar to those in a study of outdoor construction workers in Vancouver,[5] but lower compared to a study of outdoor workers from various occupations across British Columbia, Ontario, and Nova Scotia.[6] Variations may be due to differences between workers included in each study (e.g. occupation, age, education). Sampling took place in the summer of 2019, an unusually rainy summer for Alberta. Additional sampling should be conducted to assess whether levels are higher during more typical summers.

Overall, we found that exposure to solar UVR among outdoor workers in Alberta is high, and often exceeds the international occupational exposure guideline. The study findings can help inform future monitoring studies and exposure reduction initiatives aimed at protecting workers, and can provide a benchmark that can be used to test the effectiveness of exposure reduction interventions.

Sun protection behaviours

When examining which sun protection behaviours outdoor workers use at work and leisure in Alberta, we found that:

  • The most common sun protection behaviours at work included wearing shirts with sleeves (81% often/always), hats (73%), and sunglasses (59%) at work (figure 3).
  • Few workers applied sunscreen (36% often/always) or sought shade (12%) at work.
  • 12% of outdoor workers spent time in the sun to get a tan during leisure.
  • Overall, participants protected themselves better at work than at leisure (figure 3). Specifically, they were:
      • More likely to wear protective clothing, hats, and sunscreen.
      • Equally likely to use sunglasses than at leisure.
      • Less likely to seek shade.
  • As the number of hours spent outdoors at work and leisure increased, sun protection increased.
  • Participants who worked in recreation, landscaping, or professional services, who had light to fair skin and dark brown/black eyes, and who were male had higher sun protection scores at leisure.

Figure 3. Percent of participants always or often using a sun habit, at leisure and at work

These results are similar to the study of construction workers in Vancouver,[5] but the frequency of specific sun protection behaviours is higher compared to a national sun survey conducted in Canada in 2006, in which a maximum of 58% of outdoor workers used a given sun protection behaviour.[7] Interestingly, male workers had higher overall sun protection scores than female workers at leisure, which is contrary to typical findings in which women are more likely to protect themselves from the sun.[8] When each individual sun protection behaviour was examined by sex, higher sunscreen use among female participants was observed.

Overall, the frequency of some sun protective behaviours remains low, particularly for shade and sunscreen use. However, effective solar UVR protection requires that multiple measures be taken. Employers should continue to encourage sun safety among outdoor workers (e.g. through educational programs, sun safety policies, sunscreen dispensers, and shade structures), and should incorporate messaging about the importance of sun protection at leisure.

Sun exposure and skin cancer surveillance systems – best practices

When exploring sun exposure and skin cancer surveillance systems for outdoor workers, we found that:

  • No countries have designed or implemented an occupational surveillance system focused solely on outdoor workers.
  • Numerous surveillance strategies exist, and 5 of these (exposure registry, disease registry, disease screening/medical surveillance, sentinel event surveillance, and disease surveillance via data linkage) were investigated in depth.
  • Key barriers for designing and implementing an occupational surveillance program include underreporting/under-participation and a lack of funding and awareness.
  • Key facilitators include communication/collaboration, a simple reporting process, and long-term funding.
  • 10 considerations that should be made when designing an occupational surveillance program are to:
    1. Have a clear purpose/goal
    2. Have a defined target population
    3. Have stakeholder involvement
    4. Distinguish between exposure and disease monitoring
    5. Assess resources available
    6. Assess available data sources/how to capture data/how to analyze
    7. Ensure that there is a pilot phase
    8. Evaluate the program
    9. Disseminate results
    10. Develop interventions, prevention programs, guide policy, continue to educate
  • 5 recommendations for developing an occupational surveillance system focused on non-melanoma skin cancer (NMSC) are to:
    1. Recognize NMSC due to solar UVR as an occupational disease
    2. Create a notification/collection mechanism for NMSC
    3. Continue/build on/improve primary prevention initiatives
    4. Educate workers and employers on the risks of solar UVR
    5. Introduce a medical screening component

Refer to Tables 1 and 2 in the Supplemental Information for detail related to the literature review, and Tables 3 and 4 for additional detail related to the key informant interviews.

Overall, our study demonstrated that there are few examples worldwide of jurisdictions who have surveillance systems in place to support the exposure and NMSC risk reduction in this vulnerable worker population. Programs have been developed in Canada over the years to help support employers in controlling exposure to solar UVR among their workers, but evaluation of these programs has been limited to date. This speaks very much to our finding from this study that sustained funding, data infrastructure, and clear communication and collaboration are vital to the tackling of occupational skin cancer prevention as well as the undertaking of occupational surveillance more broadly.

Methods

To assess solar UVR exposure levels, we recruited workplaces primarily in Alberta with significant outdoor working populations to participate in UVR exposure sampling.[9] Although our recruitment efforts were focused in Alberta, a small number of participants in British Columbia and Saskatchewan were also included after they learned about the study via word of mouth. Workers that spent more than two hours outdoors per day were invited to participate. These workers wore electronic UVR dosimeters for approximately five working days to account for variability in sun exposure over the week. Measurements were compared to the international exposure guideline (1.3 Standard Erythemal Dose (SED)), and differences in solar UVR exposure across groups were assessed.

To collect information on workers’ sun protection behaviours, the same outdoor workers from the measurement study were asked to complete questionnaires about their demographics, skin cancer risk factors, job information, and sun habits at work and leisure. Sun habits of interest included sunscreen, sleeved shirt, sunglass, and hat use, and shade seeking. The frequency of different sun habits at leisure and work was compared; in addition, a score summarizing the overall level of sun protection was calculated.

Finally, to identify key planning components for structuring an effective occupational surveillance program for outdoor workers, we investigated, via a literature review, whether surveillance for outdoor workers has been conducted previously. We also interviewed key informants between August 2019 and January 2020 to better understand the best practices for the design and implementation of a potential surveillance system for outdoor workers. The informants had either experience designing or implementing occupational surveillance systems and/or expertise in skin cancer prevention/sun safety programs. Canadian and international experts were engaged, along with a diverse group of stakeholders.

References and other resources

Sources

2. Radespiel-Tröger, M., Meyer, M., Pfahlberg, A. et al. Outdoor work and skin cancer incidence: a registry-based study in Bavaria. Int Arch Occup Environ Health (2009) 82: 357.
3. Occupational Cancer Research Centre and CAREX Canada. Burden of Occupational Cancer Study: Solar Radiation fact sheet. (2017)
4. Mofidi A, Tompa E, Spencer J, Kalcevich C, Peters CE, Kim J, Song C, Mortazavi S, Demers PA. “The economic burden of occupational non-melanoma skin cancer due to solar radiation.” J Occup Environ Hyg 2018;15:481–491.
5. Peters CE, Demers PA, Kalia S, Nicol AM, Koehoorn MW. “Levels of Occupational Exposure to Solar Ultraviolet Radiation in Vancouver, Canada.” Ann Occup Hyg 2016;60(7):825-835.
6. Peters CE, Pasko E, Strahlendorf P, Holness DL, Tenkate T. “Solar ultraviolet radiation exposure among outdoor workers in three Canadian provinces.” Ann Work Expo Health 2019;63(6):679-88.
7. Marrett LD, Pichora EC, Costa ML. “Work-time sun behaviours among Canadian outdoor workers: results from the 2006 National Sun Survey.” Can J Public Health 2010;101(4):I19-I22.
8. Nahar VK, Ford MA, Hallam JS, Bass MA, Vice MA. “Sociodemographic and Psychological Correlates of Sun Protection Behaviors among Outdoor Workers: A Review.” J Skin Cancer 2013;2013:453174.
9. Rydz E, Harper A, Leong B, Arrandale VH, Kalia S, Forsman-Phillips L, Holness DL, Tenkate T, Peters CE. “Solar ultraviolet radiation exposure among outdoor workers in Alberta, Canada.” Environ Res 2020:109902.

Collaborators

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