Sun Safety Among U.S. Postal Service Letter Carriers ("Project SUNWISE")

In 2006, approximately 62,000 people in the United States were diagnosed with melanoma, and more than 1 million were diagnosed with nonmelanoma skin cancers. Exposure to solar ultraviolet radiation (UVR) is a key risk factor for these diseases. Reducing exposure to UVR is associated with a decreased risk of skin cancer. Outdoor workers may receive 6 to 8 times the dose of UVR that indoor workers receive, and they have a higher risk for squamous cell cancer and possibly other forms of skin cancer. U.S. Postal Service (USPS) letter carriers are one such high-risk group, working outdoors an average of 5 hours per day according to one descriptive study. Despite their increased risk for skin cancer due to regular exposure to UVR, only 14% reported that they always wore sunscreen, and only 33% reported that they always wore a hat.

Sun Safety Among US Postal Service Letter Carriers ("Project SUNWISE") is a skin cancer prevention intervention promoting the regular occupational use of wide-brimmed hats and sunscreen by USPS letter carriers.

Health educators visit participating postal stations and distribute free 12-ounce refillable bottles of sunscreen, hats, and coupons for discounts on replacement hats to the letter carriers. The health educators install large pump bottles of sunscreen in locker rooms at the intervention stations, which they refill regularly. They also distribute materials to promote use of solar protective strategies.

In addition, the health educators deliver an introductory presentation at the beginning of the intervention followed by five 5- to 10-minute on-site educational presentations over a 2-year period. The introductory presentation includes information on the amount of UVR letter carriers are exposed to and UVR as a skin cancer risk factor. A case study is given of a former carrier who had a precancerous growth removed. Protection strategies and specific information about the hats and sunscreen are given. Subsequent presentations offer the following themes: (1) importance of sun safety, even in winter; (2) sun safety for the eyes; (3) sharing sun safety tips with loved ones; (4) relevance of sun safety to letter carriers of all races/ethnicities; and (5) recap and encouragement to continue practicing sun safety behaviors. The presentations are given using large flip charts with colorful illustrations tailored to letter carriers.

The Implementation Guide is a resource for implementing this program. It provides important information about the staffing and functions necessary for administering this program in the user's setting. Additionally, the steps needed to carry out the research-tested program, relevant program materials, and information for evaluating the program are included. The Implementation Guide can be viewed and downloaded in the Products page.

This program is an example of education and policy approaches in outdoor occpation settings (Sun Safety) which has an insufficient evidence finding from the Community Preventive Services Task Force, as found in the Guide to Community Preventive Services. Insufficient evidence means the available studies do not provide sufficient evidence to determine if the intervention is or is not effective. This does not mean that the intervention does not work. It means that additional research is needed to determine whether the intervention is effective. To expand understanding of this intervention category consider communicating with members from NCI’s Research to Reality (R2R) community of practice who may be able to help you with your research efforts. Following is a link to start an online discussion with the R2R community of practice, after completing registration on the R2R site: https://researchtoreality.cancer.gov/discussions.

Administering the program involves periodic visits by health educators to postal stations over a 2-year period to distribute hats, install sunscreen dispensers and refill them monthly, distribute materials encouraging use of sun protective behaviors, and deliver six 5- to 10-minute educational presentations.

The primary audience for the program is USPS letter carriers.

The program is designed to be administered at postal stations.

The program toolkit includes the following materials:

- Postal scripts for sun safety presentations (6 sessions)
- Wide-brimmed hats (to be provided by the implementer)
- Sunscreen (to be provided by the implementer)

Although not required, research staff also distributed water bottles, mouse pads, key chains, and magnetic clips imprinted with sun safety messages. Additionally, an "ask the skin doctor" poster was placed in the break room and was updated monthly with sun safety questions asked by members of the target audience and answers provided by a dermatologist.

Costs associated with the program's implementation are not provided.

Sun Safety Among US Postal Service Letter Carriers ("Project SUNWISE") was evaluated using a randomized controlled trial of a sun safety intervention, with randomization at the USPS station level. Seventy postal stations participated, representing three geographic regions in Southern California: San Diego County, Riverside County (nondesert) and San Bernardino County, and Riverside County (desert). The local postmaster and the USPS district manager ensured the participation of these stations.

Approval for all study-related procedures and materials was obtained from USPS officials (regional) and from the National Association of Letter Carriers (local, regional, and national).  To meet the required number of stations, all but two stations in San Diego County were included, and the remaining stations were those located closest to San Diego County. Employees at the remaining two San Diego stations provided input on all intervention strategies during their development. Stations were stratified by region and were randomly assigned to either intervention or control group (delayed intervention). Within each station, the researchers attempted to recruit all letter carriers to participate voluntarily in the evaluation cohort. Small incentives (valued at less than $10 each) were used to promote participation in each evaluation.

Data were collected at baseline and 3 months, 1 year, and 2 years later. At the baseline evaluation, letter carriers were unaware of their station's study group, and data collectors were blinded to group assignment. Until the completion of the 2-year evaluation, control stations received evaluation procedures only. After that, they received all components of the intervention during a 1-year period.

The final sample included 1,183 intervention participants and 1,318 control participants. They had a mean age of 43 years (SD=8.6) and had worked for the USPS for an average of 12.4 years (SD=7.9). The majority were men (69.9%), were married (69.3%), and had completed at least some college (71.7%). The sample was 51.3% non-Latino White, 19.3% Latino, 12.4% Asian, 8.3% African American, 4.3% Pacific Islander, 0.6% American Indian, and 3.7% other race/ethnicity.

The primary outcomes were self-reported occupational use of (1) sunscreen with an SPF of 15 or higher and (2) wide-brimmed hats (>2.5 inches wide). These behaviors were measured at the stations via a paper-and-pencil questionnaire, which asked how often respondents had used each item while carrying mail during their past 5 workdays.

Effects on Use of Wide-Brimmed Hats While Delivering Mail

• The percentage of postal carriers reporting the use of wide-brimmed hats during their past 5 workdays increased significantly (p<.05) from baseline to 3-month follow-up for the intervention group (from 27.3% to 42.7%), but not for the control group (from 21.0% to 21.4%). This effect persisted at the 1-year follow-up (41.4% for intervention vs. 24.0% for control, p<.05) and 2-year follow-up (40.0% for intervention vs. 22.3% for control, p<.05).

Effects on Use of Sunscreen While Delivering Mail

• The percentage of postal carriers reporting the use of sunscreen during their past 5 workdays increased significantly (p<.05) from baseline to 3-month follow-up for the intervention group (from 26.9% to 39.4%), but not for the control group (from 23.5% to 23.1%). This effect persisted at the 1-year follow-up (41.6% for intervention vs. 28.1% for control, p<.05) and 2-year follow-up (39.2% for intervention vs. 26.3% for control, p<.05). 

Mayer,J.A.; Slymen,D.J.; Clapp,E.J.; Pichon,L.C.; Eckhardt,L.; Eichenfield,L.F.; Elder,J.P.; Sallis,J.F.; Weinstock,M.A.; Achter,A.; Balderrama,C.; Galindo,G.R.; Oh,S.S.; (2007). Promoting sun safety among US Postal Service letter carriers: impact of a 2-year intervention. American Journal of Public Health, 97 (3), 559-565.

Mayer, J. A., Slymen, D., Clapp, E. J., Pichon, L. C., Elder, J. P., Sallis, J. F., Eichenfield, L. F., & Weinstock, M. A. (2009). Long-term maintenance of a successful occupational sun safety intervention. Archives of Dermatology, 145 (1), 88-89.

Lewis, E., Mayer, J. A., & Slymen, D. (2006). Postal workers' occupational and leisure-time sun safety behaviors (United States). Cancer Causes and Control, 17 , 181-186.

Pichon, L. C., Mayer, L. A., Slymen, D. J., Elder, J. P, Lewis, E. C., & Galindo, G. R. (2005). Ethnoracial differences among outdoor workers in key sun-safety behaviors. American Journal of Preventive Medicine, 28 (5), 374-378.

Oh, S. S., Mayer, J. A., Lewis, E. C., Slymen, D. J., Sallis, J. F., Elder, J. P., Eckhardt, L., Achter, A., Weinstock, M., Eichenfield, L., Pichon, L. C., & Galindo, G. R. (2004). Validating outdoor workers' self-report of sun protection. Preventive Medicine, 39 , 798-803.