Sun Safety Among Agricultural Workers: A Systematic Review of Behaviors and Interventions

Summary: Individuals in outdoor occupations such as agriculture have increased cumulative ultraviolet radiation (UVR) exposure and an elevated risk of skin cancer. Outdoor workers consistently exceed safety thresholds for occupational UVR exposure, experiencing six to eight times more exposure than indoor workers. A 2014 review found that agricultural workers, despite being aware of the risks posed by sun exposure, typically neglect adequate protection and shade. This study aims to provide an update on literature on sun safety behaviors and interventions among farmworkers. In accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, a literature search for studies on sun safety behavior and interventions among agricultural workers was performed in PubMed, SCOPUS, Cochrane Library, Web of Science Primary, Agricola, and EBSCO. MeSH (Medical Subject Headings) terms included: “farmer,” “farmworker,” “outdoor worker,” “sun,” “skin cancer,” “ultraviolet radiation,” “sun safety,” “sun behaviors,” “interventions,” “sunscreen,” and “sun protection.” For the inclusion criteria, a manuscript had to be full-text, published between February 1, 2013 and May 15, 2024, in English, and available full-text or by inter-library loan. The search yielded 166 manuscripts, reduced to 82 after removing duplicates. Following double screening by two research team members (CM, MK), there were 40 full-length manuscripts. Screening the reference lists added 8 more, resulting in 48 full-length manuscripts included in the review. 70.8% (n=34) of the studies were survey-based, and 10.4% (n=5) were intervention-focused. 70.8% (n=34) of the studies were from outside the United States (US), while 9 were based in US states, primarily in states in the Midwest with a humid continental climate. 22 studies reported on the frequency of sun protection behaviors including wearing sunscreen (n=20; mean=24.5%; range=9.1-60.5%), hats (n=18; mean=55.5%; range=18.0-92.9%), sleeved shirts (n=12; mean=52.5%; range=6.8-88.9%), and sunglasses (n=15; mean=32.8%; range=0.0-72.5%), as well as seeking shade (n=9; mean=30.9%; range=6.0-69.3%). Overall, sun protection levels were suboptimal with low rates of sunscreen application. Use of hats was commonly reported as the primary sun protection method. In studies that examined gender, sunscreen use was reported more frequently by women, while hat use was reported more frequently by men. Suggested interventions revolved primarily around hats and protective clothing as the most promising avenues to improve farmers’ sun protection. While educational intervention approaches were shown to improve sun protection awareness, their impact may be limited in addressing deeply ingrained behaviors. There is a significant gap overall in research focusing specifically on designing and assessing high-quality sun safety interventions that lead to sustained behavioral change and an effective sun-protective environment for agricultural workers.