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Sun Safety: Knowledge and Behavior among Egyptian Farmers—a Multicomponent Intervention Study

Sun Safety: Knowledge and Behavior among Egyptian Farmers—a Multicomponent Intervention Study The purpose of study was to screen for health hazards related to sun exposure and to examine the effectiveness of a sun safety multicomponent intervention designed specifically for the Egyptian farmers. A multicomponent interventional study was conducted among 128 farmers from three villages in Zagazig district, Sharkia Governorate, Egypt, from January to July 2022. It passed through three phases: phase 1: assessment of participants’ risk of skin cancer and vision screening; phase 2: filling a semi-structured questionnaire assessing sun exposure hazards and sun safety knowledge, behavior, and barriers; and phase 3: conducting multicomponent intervention composed of education session, providing sun safety supplies and reminders then evaluate the effect of this intervention after one month. Most of participants had moderate risk for skin cancer (69.0%), history of photokeratitis (77.3%), cataract (15.6%), and bad/very bad self-reported overall eyesight (43.0%). After intervention, there was a statistically significant improvement in the participants’ awareness regarding sun exposure-related hazards, all knowledge items about sun safety measures (p < 0.01) and some sun safety behaviors (p < 0.05) including wearing protective clothing, minimization of direct sunlight exposure, taking breaks, plentiful water intake, regular self-checking of skin, wearing wide brimmed hats, and job rotation. Furthermore, there was a statistically significant improvement in all sun protection barriers (p < 0.01) except sunscreen and sunglasses related barriers (p ˃ 0.05). The multicomponent intervention composed of education session, providing sun safety supplies and reminders was effective in increasing awareness of farmers with sun exposure hazards and improving their knowledge and behavior towards sun safety measures. Keywords Sun safety · Knowledge · Behavior · Barriers · Farmer · Vision screening · Brief skin cancer risk assessment tool · Skin cancer screening Introduction to UVR leads to worldwide loss of 1.5 million days from people’s lives each year when disability-adjusted life year Solar ultraviolet radiation (UVR) has been described as a rates (DALY) was calculated [3]. Despite all previously precancerous factor that has a vital role in the causation of mentioned health hazards, the hazard of regular exposure to skin cancer. Excessive UV exposure can lead also to other UVR has completely undiscovered until now [4]. negative skin consequences, such as actinic keratosis and Outdoor workers are exposed to solar UVR nearly eight premature skin aging [1]. There is also a cause-effect rela- times more than indoor workers. So, they are at increased tionship between UVR exposure, and many eye problems risk for the development of solar UVR-related health haz- such as photokeratitis, pinguecula, pterygium, cataract, ards. Occupational exposure to UVR among several outdoor and possibly ocular neoplasm [2]. Furthermore, exposure occupations (e.g., construction and agricultural sector) was estimated in numerous UV dosimetry studies to be greater than the safe limits determined by the International Com- * Dalia A. El-Shafei mission on Non-Ionizing Radiation Protection (ICNIRP) [2]. d_elshaf3y_mony@hotmail.com So, our study would pay attention towards farmers because Department of Community, Environmental and Occupational they spend most of their working hours outdoors, putting Medicine, Faculty of Medicine, Zagazig University, Zagazig, them at increased risk of health problems related to sunlight Egypt exposure. Furthermore, although they are not exposed only Department of Family Medicine, Faculty of Medicine, to sunlight risks but also to a diversity of environmental risk Zagazig University, Zagazig, Egypt Vol.:(0123456789) 1 3 Journal of Cancer Education factors such as chemicals, mechanical devices, and various technique from all villages of Zagazig district. The 2nd stage biological risks, their occupation has less safety protocols included the selection of farmers. The researchers started at than other occupations [5]. the center of the selected village and randomly selected a Our study would also pay attention to promote sun safety direction. They started at the nearest farmland then through behaviors because occupational exposure to solar UV radi- farmland-to-farmland survey; they interviewed the farmers ation is a modifiable risk factor with high possibility for consecutively until they reached the target sample size. The change in workplaces. This is consistent with the recent sample size was divided equally over the three villages (46 reviews and recent Community Preventive Services Task farmers in each). Force recommendation which reported strong evidence for Inclusion criteria included all farmers over 18 years of the effectiveness of targeted interventions in promoting out - age who consented to participate in the study. Exclusion cri- door workers’ sun safety habits. These interventions were teria included farmers with previous diagnosis of skin can- multicomponent; i.e., they were not only limited to edu- cer, received phototherapy for treatment of dermatological cation sessions aimed to increase the workers’ awareness condition, suffering from an intellectual disability or mental of sun exposure-related health hazards and how to avoid impairment of any kind. them but also included various strategies such as providing The pilot study was conducted on 10% of the sample wide brimmed hats and sunscreen, distributing reminders (13 farmers) during January 2022 to test the applicability of sun safety, training of safety officers, developing policy of the study and to test the response to different items of and safety regulations, and applying role modeling through the questionnaires. The reliability for all questionnaires was peer leader [1]. acceptable with Cronbach’s alpha coefficients ranged from Sun safety programs directed to manual outdoor work- 0.72 to 0.94. According to the result of the pilot study, some ers especially in agriculture and construction sectors have modifications were done on questionnaires. All farmers of achieved successful improvements in knowledge, attitudes, the pilot were excluded from the results of the study. and practice. Nevertheless, according to our knowledge, there is a lack in sun safety intervention research studies Study Procedures and Data Collection Tools targeting the Egyptian agriculture workers. So, increasing the research on sun safety, especially in sunny countries like Our study was conducted in three phases: Egypt, is essentially an urgent need. Therefore, the aim of this study was to screen for health hazards related to solar Phase 1: Included assessment of participants’ risk of skin UVR exposure and to examine the effectiveness of a sun cancer and vision screening through the following: safety multicomponent intervention designed specifically for the Egyptian farmers. a) Brief skin cancer risk assessment tool (BRAT): It is a valid and reliable tool adapted from Glanz et al. (2015) [7] addressing the key risk factors for skin Materials and Methods cancers. It was an interviewer administered. Its score was based on asking about mole count (none, 0; A multicomponent interventional study was conducted 1–2, 5; 3–5, 10; 6–10, 20; > 10, 30), freckles count among farmers living in three villages of Zagazig district, (none, 0; few, 2; many, 4), childhood residence (all Sharkia Governorate, Egypt, from January to July 2022. participants were from tropics, 10), sunburn history (none, 0; 1–2, 1; 3–5, 2; 6–10, 3; > 10, 4), skin color Study Population (dark brown/black, 0; med brown, 2; light brown, 4; olive,16; fair, 18; very fair, 20), natural hair color Determination of Sample Size and Sampling Technique (black, 0; dark brown, 1; light brown, 2; blonde, 3; red, 4), ease of sun burning (no, 0; yes, 3), and tan- The sample size was estimated to be 116 subjects using the ning (dark, 0; medium, 1; light, 2; none, 3). Scores paired t statistic online calculator depending on effect size on the BRAT ranged from 0 to 78. Participants scor- 50%, standard deviation of the change in the outcome 1.9 ing 26 or below were placed in the low-risk cat- according to result of previous study [6], a confidence inter - egory; scores of 27–35 were considered moderate- val of 95%, and the power of test 80%, taking into considera- risk; and scores of 36 and higher were classified as tion 20% dropouts, so the calculated sample size was 139 high-risk. subjects, of which 128 of them completed the educational b) Vision screening: Screening for eye problems intervention. linked to sun exposure was done through the fol- A two-stage cluster sample was used. In the 1st stage, lowing approach: firstly, asking about symptoms of three villages were selected by simple random sampling photokeratitis (pain or redness in the eyes, swelling, 1 3 Journal of Cancer Education light sensitivity, blurry vision, gritty sensation in Section III: Assessing sun safety practice of the stud- the eyes, twitching of the eyelids, temporary loss of ied farmers through measuring 11 behaviors (using vision and seeing halos that may last from 6 to 24 h, shade, protective clothes, sunglasses, sunscreen, but they usually disappear within 48 h). Secondly, plentiful water intake, checking the UV index for the spot diagnosis for pinguecula, pterygium, and cata- day, regular self-checking of skin, limiting time in sun ract. Finally, screening for visual impairment due between 10 am and 4 pm, wearing a hat, and job rota- to sun exposure induced cataract or macular degen- tion). Frequency of use for each sun protection behav- eration by a self-reported visual function question- ior was rated using a 5-point Likert scale ranging from naire adapted from Quandt et al. (2016) [5]. It was 1 = rarely to 5 = always. an interviewer-administered asking the farmers to Section IV: Assessing barriers to sun protection rate their eyesight using both eyes as very good, behaviors represented in seven items include lack of good, moderate, bad, or very bad and how much dif- knowledge about sun protection measures, lack of con- ficulty they had in four activities needing far or near cern about sun exposure, feeling too hot when wearing vision: (1) recognizing a friend across the street, (2) sun protection clothing, inconvenience of sun self-pro- watching television, (3) reading print, and (4) doing tection all the time, expensive sun protection measures, work or hobbies that require near vision. The five sunscreen-related barriers (use of sunscreen is too fem- responses to each activity were none, mild, moder- inine, I do not like the smell of sunscreen, sunscreen ate, severe, and extreme/cannot do. is greasy, sunscreen attracts dirt, and I cannot reapply sunscreen), and sunglasses related barriers (glasses fall Phase 2: After giving the participants feedback about off the face while farming, I feel it affect my vision). their risk of skin cancer and the results of vision screen- Participants reported their agreement with each state- ing, they were informed about the need for an educa- ment on a dichotomous yes/no scale with addition of tional intervention for sun safety. In this phase, a semi- a third response “not applicable.” The frequency of structured pre-test questionnaire guided by relevant agreement is compared before and after intervention. literature and previous studies [6, 8] was distributed among farmers. After explaining the purpose of the Phase 3: A multicomponent health education program study, the pre-test questionnaire was filled through a was conducted after assessing the gap in the studied farm- face-to-face interview with farmers and took 10–15 min ers’ knowledge and behavior towards sun safety from to be completed. All participants were asked questions analysis of the pre-test questionnaire. The educational covering the following sections: message was tailored to satisfy the needs of the studied farmers and to remove barriers to sun protection behav- Section I: Sociodemographic and occupational iors. The objectives of the program were to: characteristics of the studied farmers include age, gender, marital status, level of education, family his- – Increase the farmers’ perceived risks of sun exposure tory of skin cancer, duration of work, the average on skin and eye. number of hours spent working outside per day, and – Promote the farmers sun safety practices including training received on the risks of sun exposure in last using shade when working in the sun, wearing long- 12 months. sleeved loose-fitting tops and trousers with an ultra- Section II: Assessing sun exposure hazards and sun violet protection factor (UPF) rating of ≥ 30, wearing safety knowledge of studied farmers by 21 items wraparound-style sunglasses that block out 99% to divided into six items assessing awareness of sun 100% of UVR, using sunscreen with a sun protec- exposure-induced skin damage (skin burn, tanning, tion factor [SPF] ≥ 30 in correct way, wearing a wide skin aging, hyperpigmentation, skin cancer, no side brimmed hat with neck protection instead of the effects), other six items assessing awareness of sun beloved baseball hats, plentiful water intake, check- exposure-induced eye damage (aging, corneal sunburn, ing the UV index for the day through the weather app cataracts, pinguecula and pterygia, macular degenera- on their smart phone, regular self-checking of skin tion, no side effects), and nine items assessing knowl- for moles or unusual changes and seeking medical edge about sun safety measures “sunscreen (2 items), advice immediately, minimization of direct sunlight sunglasses (1 item), time of sun exposure (2 items), exposure in middle of day between “10 AM to 4 PM” wearing a hat (1 item), clothing (1 item), tanning (2 through doing much of work before 10 AM or after items).” Participants indicated their agreement with 4 PM, taking breaks, and job rotation. each statement on a 5-point Likert scale ranging from – Eliminate barriers to sun protection behaviors 1 = strongly disagree to 5 = strongly agree. through (1) providing samples of sunglasses, sun- 1 3 Journal of Cancer Education screens, and wide brimmed hats; (2) marketing to Table 1 Socio-demographic and occupational characteristics of the studied farmers cheap and at the same time effective types of sun - screen and sunglasses; (3) demonstrating how to fix Characteristics (N = 128) % No sunglasses to avoid its fall off the face during farm- ing; (4) Advising to have glasses designed for both Age groups sight correction and sun protection at the same time;   < 40 years 79 61.7 (5) Providing list of clothes choices suitable for sun   ≥ 40 years 49 38.3 protection; and (6) offering various options to mini-    Mean ± SD 28.1 ± 8.9 mize direct sunlight exposure in middle of day.    Range 19–68 Gender According to Egyptian General Authority of Meteorology   Male 72 56.3 (2022) [9], the months with the highest UV index in Egypt   Female 56 43.7 are June and July (UV index 12), while the month with the Marital status lowest UV index is December (UV index 3). So, the time of   Un-married* 41 32.0 the intervention was chosen to be in April and May between   Married 87 68.0 9 AM and 6 PM (working hours). Participants were divided Level of education into three groups. Each group included the farmers living in   Illiterate 45 35.2 the same village. Each participant was asked to attend one   Basic education 66 51.6 training session of 1-h period. The session was held dur-   University/technical diploma 17 13.3 ing the time preferred by the participants. Different training Family member had skin cancer methods were used for illustration as the PowerPoint presen-   Yes 5 3.9 tation, photos, and video files. At the end, participants were   No 123 96.1 given flyers containing all needed information to ensure Duration of work (years) remembering the message. One month after the implemen-   < 10 yrs 43 33.6 tation of the training program, the participants were asked to   ≥ 10 yrs 85 66.4 complete the same questionnaire that was used in the pre-test    Mean ± SD 21.9 ± 8.3 to detect the effect of the training program.    Range 3–42 Hours worked outdoors on a typical day Statistical Analysis   Mean ± SD 9.4 ± 3.5   Range 6–12 The collected data were statistically analyzed using SPSS Sun safety training received in last 12 months program (Statistical Package for Social Science) version   Yes 15 (11.7) 16.0. Qualitative data were represented as frequencies and   No 113 (88.3) percentages and were compared using McNemar’s test. *Un-married including single, divorced, and widower Quantitative data were represented as mean ± SD and were compared using Paired t-test. The test results were consid- ered significant when p value < 0.05. Excel 2019 was used The assessment of participants’ risk of skin cancer to draw the graphs. through brief skin cancer risk assessment tool (BRAT) revealed that most of participants (69.0%) had moderate risk Results for skin cancer (Graph 1). As regarding vision screening, Table  2 illustrates that One hundred and twenty-eight farmers were included in the most participants (77.3%) had a history of photokeratitis. About one quarter of them (24.2%) had pinguecula on spot study. More than half of them were males (56.3%) and less than 40 years old (61.7%) with a mean age of 28.1 ± 8.9 diagnosis. The overall self-reported eyesight was bad/very bad among near half of participants (43.0%). Moderate dif- with basic education (51.6%). Most of them were married (68.0%). Only 5 of them (3.9%) had positive history of fam- ficulty was the most prevalent in all evaluated activities “recognizing a friend across the street (46.1%), watching ily member skin cancer. As regards occupational history, more than half of participants (66.4%) had worked in farm- television (48.4%), reading fine print (46.1%), doing work or hobbies requiring up close vision (48.4%).” ing for more than 10 years with a mean of 21.9 ± 8.3 with an average number of hours worked outdoor on a typical day of Results of this study showed that there was a significant improvement in the participants’ awareness (pre-/post- 9.4 ± 3.5. Only 11.7% of them received sun safety training in last 12 months (Table 1). intervention) regarding sun exposure-induced skin and eye 1 3 Journal of Cancer Education As regards assessing sun safety practice through sun pro- Risk for skin cancer tection behavior index (pre/ post Intervention), it was sig- nificantly improved after intervention (p < 0.05) especially 11.7% in the items of clothing type, minimization of direct sunlight, 19.5% taking breaks, plentiful water intake, regular self-checking of skin, wearing wide brimmed hats with neck protection, and job rotation (Table 4). Graph 2 illustrates that there was a statistically significant improvement in the participants’ agreement with the sun 68.8% protection barriers among the studied farmers (pre-/post- intervention), especially in the items of lack of knowledge or concern, and expensive sun protection measures (p < 0.01). Low Moderate High Discussion According to the results of screening phase of this study, Graph 1 Risk of skin cancer among studied farmers most of farmers (69.0%) had moderate risk for skin cancer according to BRAT. This is consistent with many studies Table 2 Results of vision screening among studied farmers which concluded that due to the major role of sun expo- sure in skin cancer especially early and long-term exposure, Items (N = 128) % outdoor workers—primarily farmers—are at significantly No higher risk of developing skin cancer [10, 11]. The results History of photokeratitis 99 77.3 of screening also revealed many eye problems among the Spot diagnosis studied farmers either acute problems like photosensitivity   Pinguecula 31 24.2 in the most of them or chronic problems like pinguecula,   Pterygium 13 10.2 pterygium and cataract in fair number of them. Furthermore,   Cataract 20 15.6 there was moderate difficulty in self-reported overall eye- Overall self-reported eyesight sight, near vision, and far vision which may be due to sun   Very good/good 32 25.0 exposure-related cataract or macular degeneration. This is   Moderate 41 32.0 consistent with many studies which described the effects of   Bad/very bad 55 43.0 solar UVR on the eye [12, 13]. Difficulty recognizing a friend across the street Regarding the change in knowledge and behavior of   None/mild 39 30.5 the studied farmers towards sun safety after intervention,   Moderate 59 46.1 although the study showed significant improvement in all   Severe/extreme or cannot do 30 23.4 knowledge items, it only showed significant improvement in Difficult watching television some sun safety behaviors such as using protective clothes,   None/mild 50 39.1 taking breaks, plentiful water intake, regular self-checking   Moderate 62 48.4 of skin, wearing wide brimmed hats with neck protection,   Severe/extreme or cannot do 16 12.5 and job rotation. This is consistent with the narrative review Difficulty reading fine print which concluded that face-to-face educational interventions,   None/mild 51 39.8 such as those demonstrated in Utah, Turkey, and Michigan,   Moderate 59 46.1 proved to be highly effective in changing knowledge, attitude,   Severe/extreme or cannot do 18 14.1 and behavior of farmers towards sun safety measures [10]. Difficulty doing work or hobbies requiring up close vision The sun safety behaviors that did not show improvement   None/mild 34 26.6 after intervention included using a shade when working in   Moderate 62 48.4 the sun, wearing sunglasses, using sunscreen, and check-   Severe/extreme or cannot do 32 25.0 ing the UV index for the day. This could be explained by the self-reported barriers that the study tried to eliminate but resulted in insignificant improvement. These barriers damages (p < 0.01). As regards the knowledge about sun included: Firstly, the barrier against using a shade when safety measures, it was significantly improved (p < 0.01) working in the sun was “this behavior is not working for after intervention in all items (Table 3). farmers.” Secondly, the barrier against wearing sunglasses 1 3 Journal of Cancer Education Table 3 Awareness of Items Pre-intervention Post-intervention p value sun exposure hazards and knowledge about sun safety Sun exposure-induced skin damage 44.92 ± 7.42 93.63 ± 15.01 0.000* measures among studied Sun exposure-induced eye damage 36.88 ± 9.34 84.46 ± 13.39 0.000* farmers Sun safety measures   - Sunscreen 48.27 ± 7.38 91.55 ± 15.24 0.000*   - Sunglasses 38.98 ± 8.14 87.42 ± 14.31 0.000*   - Time of sun exposure 49.67 ± 9.32 92.15 ± 13.10 0.000*   - Wearing a hat 43.68 ± 9.02 91.46 ± 14.69 0.000*   - Clothing 40.39 ± 7.19 89.51 ± 13.87 0.000*   - Tanning 42.77 ± 8.75 90.72 ± 11.36 0.000* Highly statistically significant (p < 0.01) Table 4 Sun safety practice Items Pre-intervention Post-intervention p value through sun protection behavior index among studied farmers Using a shade/cover when working in the sun 36.35 ± 11.23 38.71 ± 12.08 0.067 Clothing type 32.27 ± 9.64 51.32 ± 11.37 0.005* Minimization of direct sunlight 38.25 ± 11.59 57.44 ± 13.03 0.014* Taking breaks 38.67 ± 11.23 45.07 ± 11.84 0.049* Wearing sunglasses 22.72 ± 10.84 27.42 ± 13.89 0.071 Using sunscreen in correct way 22.65 ± 9.13 29.19 ± 9.33 0.061 Plentiful water intake 45.75 ± 13.44 61.83 ± 13.58 0.009* Check the UV index for the day 17.09 ± 8.87 21.21 ± 9.33 0.089 Regular self-checking of skin 35.50 ± 11.82 53.78 ± 11.32 0.011* Wearing wide brimmed hats with neck protection 59.54 ± 9.42 75.54 ± 10.35 0.012* Job rotation 41.87 ± 10.09 46.43 ± 8.69 0.023* Statistically significant (p < 0.05) Graph 2 Evaluation of sun Sun protection barriers protection barriers among the studied farmers 93.8% 92.2% 88.3% 89.1% 78.1% 74.2% 75.8% 75.8% 68.0% 63.3% 60.2% 18.8% 11.7% 5.5% Lack of Lack of Expensive Sun Feeling too hot Inconvenince of SunscreenSunglasses knowledge** concern** protection when wearing sun self- measures** sun protection protection* clothing* Pre-intervention Post-intervention * Statistically significant (p < 0.05). ** Highly statistically significant (p < 0.01) 1 3 Journal of Cancer Education was “this behavior is expensive and impractical because of Limitations of the study include the following: first, repeated fall of sunglasses from the face during farming and it was one group pretest–posttest study with no control sunglasses cannot replace eyeglasses if vision is impaired.” group, a study design that might identify ineffective pro- Thirdly, the barrier against using sunscreen was “this behav- gram, but could not confirm the cause-effect relationships ior is expensive, the use of sunscreen is too feminine, its between program and outcome; second, lack of long-term smell is not liked, its nature is greasy, it attracts dirt, and the follow-up that may be needed to assure the maintenance user needs to reapply it to work correctly.” Finally, the bar- of preventive behaviors; third, inability to generalize the rier against checking the UV index for the day was “most of results because of small sample size which necessitates the studied farmers were illiterate or of basic education so, further studies; and finally, in a self-reported study, par - they could not use the weather app on their smart phone.” ticipants may over-report sun safety practices leading to Many studies conducted in Australia, Brazil, and the USA inflated results. Despite its limitations, this study consti- reported that the majority of farmers recognized wearing a tutes an important first step in research focused on the wide brimmed hat as their primary method of sun protec- development of knowledge and understanding concerning tion, while dependence on other sun protection practices, sun safety issues in the Egyptian agriculture sector. including wearing sunglasses or using sunscreen, was much lower [14–16]. The self-reported barriers to the sun protection behav- iors that showed a statistically significant improvement Conclusion and Recommendations among the studied farmers after intervention included lack of knowledge about sun protection practices, lack of concern Based on the results, the multicomponent intervention about sun exposure, feeling too hot when wearing sun pro- composed of education session, providing sun safety sup- tection clothing, and inconvenience of sun self-protection all plies and reminders, was effective in increasing awareness the time. The study succeeded to eliminate all these barriers of farmers with sun exposure hazards and improving their through tailoring specific messages for farmers providing knowledge and behavior towards sun safety measures. So, them with practical solutions. These barriers reflect that the it is recommended that more aggressive educational inter- Egyptian agriculture sector is neglected and miss the oppor- ventions in the form of agricultural events, healthcare part- tunities of the educational interventions that raise the aware- nerships, and promotional sun safety campaigns should ness with occupational health hazards. So, attention should target farmers as a reminder to protect themselves against be directed towards designing educational interventions spe- the hazards of sun exposure. These interventions should cifically for farmers. Further, tailoring the message content also assure providing farmers with sun safety supplies to of these interventions may have greater impact on farmers motivate them to adhere to the sun protective behaviors. than generic or non-tailored messages as such messages are Acknowledgements The authors would like to thank all participants seen as more personally relevant, and consequently may be of this study for their great cooperation. more probable to motivate its recipients to make healthful behavior changes [7]. Author Contribution All authors were responsible for the study and Finally, this study showed that although the studied farm- contributed to its conception and design. Material preparation was per- formed by [Dalia A. El-Shafei]. Data management was performed by ers became aware of the risks posed by excessive sun expo- [Randa M. Said]. The first draft of the manuscript was written by all sure, they typically did not perform routinely all the sun authors. All authors read and approved the final manuscript. protective behaviors especially that needed financial support such as using sunglasses and sunscreen. This reflects the Funding Open access funding provided by The Science, Technology & importance of organizational role in the protection of farm- Innovation Funding Authority (STDF) in cooperation with The Egyp- tian Knowledge Bank (EKB). ers from the sun through providing the safety supplies [1]. The relation between the perceived risk posed by excessive Data Availability The study tools; including used survey questions and sun exposure and positive sun protection behaviors among informational materials are available from the corresponding author farmers is controversial where some studies concluded that upon request. a higher perception of risk has been found to be strongly associated with more positive sun protection behaviors [17], Declarations while other studies concluded that although farmers were aware of the dangers posed by excessive sun exposure, they Ethics Approval The Institutional Review Board (IRB) of the Faculty of Medicine, Zagazig University, approved the study protocol (reference typically did not wear adequate protection when working no: #9618). Ethical considerations and confidentiality were respected. outdoors [10]. 1 3 Journal of Cancer Education Consent to Participate An informed consent was granted from all par- 6. 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Boyas JF, Nahar VK, Brodell RT (2016) Skin protection behav- org/ joe/ 2007a ugust/ rb5. php. Accessed 20 July 2022 iors among young male Latino day laborers: an exploratory study using a social cognitive approach. Dermatol Res Pract Publisher's Note Springer Nature remains neutral with regard to 2016:1479637. https:// doi. org/ 10. 1155/ 2016/ 14796 37 jurisdictional claims in published maps and institutional affiliations. 5. Quandt SA, Schulz MR, Chen H, Arcury TA (2016) Visual acuity and self-reported visual function among migrant farmworkers. Optomet Vis Sci 93(10):1189–1195. https://doi. or g/10. 1097/ OPX. 00000 00000 000948 1 3 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Cancer Education Springer Journals

Sun Safety: Knowledge and Behavior among Egyptian Farmers—a Multicomponent Intervention Study

Journal of Cancer Education , Volume OnlineFirst – Oct 25, 2022

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0885-8195
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10.1007/s13187-022-02230-3
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Abstract

The purpose of study was to screen for health hazards related to sun exposure and to examine the effectiveness of a sun safety multicomponent intervention designed specifically for the Egyptian farmers. A multicomponent interventional study was conducted among 128 farmers from three villages in Zagazig district, Sharkia Governorate, Egypt, from January to July 2022. It passed through three phases: phase 1: assessment of participants’ risk of skin cancer and vision screening; phase 2: filling a semi-structured questionnaire assessing sun exposure hazards and sun safety knowledge, behavior, and barriers; and phase 3: conducting multicomponent intervention composed of education session, providing sun safety supplies and reminders then evaluate the effect of this intervention after one month. Most of participants had moderate risk for skin cancer (69.0%), history of photokeratitis (77.3%), cataract (15.6%), and bad/very bad self-reported overall eyesight (43.0%). After intervention, there was a statistically significant improvement in the participants’ awareness regarding sun exposure-related hazards, all knowledge items about sun safety measures (p < 0.01) and some sun safety behaviors (p < 0.05) including wearing protective clothing, minimization of direct sunlight exposure, taking breaks, plentiful water intake, regular self-checking of skin, wearing wide brimmed hats, and job rotation. Furthermore, there was a statistically significant improvement in all sun protection barriers (p < 0.01) except sunscreen and sunglasses related barriers (p ˃ 0.05). The multicomponent intervention composed of education session, providing sun safety supplies and reminders was effective in increasing awareness of farmers with sun exposure hazards and improving their knowledge and behavior towards sun safety measures. Keywords Sun safety · Knowledge · Behavior · Barriers · Farmer · Vision screening · Brief skin cancer risk assessment tool · Skin cancer screening Introduction to UVR leads to worldwide loss of 1.5 million days from people’s lives each year when disability-adjusted life year Solar ultraviolet radiation (UVR) has been described as a rates (DALY) was calculated [3]. Despite all previously precancerous factor that has a vital role in the causation of mentioned health hazards, the hazard of regular exposure to skin cancer. Excessive UV exposure can lead also to other UVR has completely undiscovered until now [4]. negative skin consequences, such as actinic keratosis and Outdoor workers are exposed to solar UVR nearly eight premature skin aging [1]. There is also a cause-effect rela- times more than indoor workers. So, they are at increased tionship between UVR exposure, and many eye problems risk for the development of solar UVR-related health haz- such as photokeratitis, pinguecula, pterygium, cataract, ards. Occupational exposure to UVR among several outdoor and possibly ocular neoplasm [2]. Furthermore, exposure occupations (e.g., construction and agricultural sector) was estimated in numerous UV dosimetry studies to be greater than the safe limits determined by the International Com- * Dalia A. El-Shafei mission on Non-Ionizing Radiation Protection (ICNIRP) [2]. d_elshaf3y_mony@hotmail.com So, our study would pay attention towards farmers because Department of Community, Environmental and Occupational they spend most of their working hours outdoors, putting Medicine, Faculty of Medicine, Zagazig University, Zagazig, them at increased risk of health problems related to sunlight Egypt exposure. Furthermore, although they are not exposed only Department of Family Medicine, Faculty of Medicine, to sunlight risks but also to a diversity of environmental risk Zagazig University, Zagazig, Egypt Vol.:(0123456789) 1 3 Journal of Cancer Education factors such as chemicals, mechanical devices, and various technique from all villages of Zagazig district. The 2nd stage biological risks, their occupation has less safety protocols included the selection of farmers. The researchers started at than other occupations [5]. the center of the selected village and randomly selected a Our study would also pay attention to promote sun safety direction. They started at the nearest farmland then through behaviors because occupational exposure to solar UV radi- farmland-to-farmland survey; they interviewed the farmers ation is a modifiable risk factor with high possibility for consecutively until they reached the target sample size. The change in workplaces. This is consistent with the recent sample size was divided equally over the three villages (46 reviews and recent Community Preventive Services Task farmers in each). Force recommendation which reported strong evidence for Inclusion criteria included all farmers over 18 years of the effectiveness of targeted interventions in promoting out - age who consented to participate in the study. Exclusion cri- door workers’ sun safety habits. These interventions were teria included farmers with previous diagnosis of skin can- multicomponent; i.e., they were not only limited to edu- cer, received phototherapy for treatment of dermatological cation sessions aimed to increase the workers’ awareness condition, suffering from an intellectual disability or mental of sun exposure-related health hazards and how to avoid impairment of any kind. them but also included various strategies such as providing The pilot study was conducted on 10% of the sample wide brimmed hats and sunscreen, distributing reminders (13 farmers) during January 2022 to test the applicability of sun safety, training of safety officers, developing policy of the study and to test the response to different items of and safety regulations, and applying role modeling through the questionnaires. The reliability for all questionnaires was peer leader [1]. acceptable with Cronbach’s alpha coefficients ranged from Sun safety programs directed to manual outdoor work- 0.72 to 0.94. According to the result of the pilot study, some ers especially in agriculture and construction sectors have modifications were done on questionnaires. All farmers of achieved successful improvements in knowledge, attitudes, the pilot were excluded from the results of the study. and practice. Nevertheless, according to our knowledge, there is a lack in sun safety intervention research studies Study Procedures and Data Collection Tools targeting the Egyptian agriculture workers. So, increasing the research on sun safety, especially in sunny countries like Our study was conducted in three phases: Egypt, is essentially an urgent need. Therefore, the aim of this study was to screen for health hazards related to solar Phase 1: Included assessment of participants’ risk of skin UVR exposure and to examine the effectiveness of a sun cancer and vision screening through the following: safety multicomponent intervention designed specifically for the Egyptian farmers. a) Brief skin cancer risk assessment tool (BRAT): It is a valid and reliable tool adapted from Glanz et al. (2015) [7] addressing the key risk factors for skin Materials and Methods cancers. It was an interviewer administered. Its score was based on asking about mole count (none, 0; A multicomponent interventional study was conducted 1–2, 5; 3–5, 10; 6–10, 20; > 10, 30), freckles count among farmers living in three villages of Zagazig district, (none, 0; few, 2; many, 4), childhood residence (all Sharkia Governorate, Egypt, from January to July 2022. participants were from tropics, 10), sunburn history (none, 0; 1–2, 1; 3–5, 2; 6–10, 3; > 10, 4), skin color Study Population (dark brown/black, 0; med brown, 2; light brown, 4; olive,16; fair, 18; very fair, 20), natural hair color Determination of Sample Size and Sampling Technique (black, 0; dark brown, 1; light brown, 2; blonde, 3; red, 4), ease of sun burning (no, 0; yes, 3), and tan- The sample size was estimated to be 116 subjects using the ning (dark, 0; medium, 1; light, 2; none, 3). Scores paired t statistic online calculator depending on effect size on the BRAT ranged from 0 to 78. Participants scor- 50%, standard deviation of the change in the outcome 1.9 ing 26 or below were placed in the low-risk cat- according to result of previous study [6], a confidence inter - egory; scores of 27–35 were considered moderate- val of 95%, and the power of test 80%, taking into considera- risk; and scores of 36 and higher were classified as tion 20% dropouts, so the calculated sample size was 139 high-risk. subjects, of which 128 of them completed the educational b) Vision screening: Screening for eye problems intervention. linked to sun exposure was done through the fol- A two-stage cluster sample was used. In the 1st stage, lowing approach: firstly, asking about symptoms of three villages were selected by simple random sampling photokeratitis (pain or redness in the eyes, swelling, 1 3 Journal of Cancer Education light sensitivity, blurry vision, gritty sensation in Section III: Assessing sun safety practice of the stud- the eyes, twitching of the eyelids, temporary loss of ied farmers through measuring 11 behaviors (using vision and seeing halos that may last from 6 to 24 h, shade, protective clothes, sunglasses, sunscreen, but they usually disappear within 48 h). Secondly, plentiful water intake, checking the UV index for the spot diagnosis for pinguecula, pterygium, and cata- day, regular self-checking of skin, limiting time in sun ract. Finally, screening for visual impairment due between 10 am and 4 pm, wearing a hat, and job rota- to sun exposure induced cataract or macular degen- tion). Frequency of use for each sun protection behav- eration by a self-reported visual function question- ior was rated using a 5-point Likert scale ranging from naire adapted from Quandt et al. (2016) [5]. It was 1 = rarely to 5 = always. an interviewer-administered asking the farmers to Section IV: Assessing barriers to sun protection rate their eyesight using both eyes as very good, behaviors represented in seven items include lack of good, moderate, bad, or very bad and how much dif- knowledge about sun protection measures, lack of con- ficulty they had in four activities needing far or near cern about sun exposure, feeling too hot when wearing vision: (1) recognizing a friend across the street, (2) sun protection clothing, inconvenience of sun self-pro- watching television, (3) reading print, and (4) doing tection all the time, expensive sun protection measures, work or hobbies that require near vision. The five sunscreen-related barriers (use of sunscreen is too fem- responses to each activity were none, mild, moder- inine, I do not like the smell of sunscreen, sunscreen ate, severe, and extreme/cannot do. is greasy, sunscreen attracts dirt, and I cannot reapply sunscreen), and sunglasses related barriers (glasses fall Phase 2: After giving the participants feedback about off the face while farming, I feel it affect my vision). their risk of skin cancer and the results of vision screen- Participants reported their agreement with each state- ing, they were informed about the need for an educa- ment on a dichotomous yes/no scale with addition of tional intervention for sun safety. In this phase, a semi- a third response “not applicable.” The frequency of structured pre-test questionnaire guided by relevant agreement is compared before and after intervention. literature and previous studies [6, 8] was distributed among farmers. After explaining the purpose of the Phase 3: A multicomponent health education program study, the pre-test questionnaire was filled through a was conducted after assessing the gap in the studied farm- face-to-face interview with farmers and took 10–15 min ers’ knowledge and behavior towards sun safety from to be completed. All participants were asked questions analysis of the pre-test questionnaire. The educational covering the following sections: message was tailored to satisfy the needs of the studied farmers and to remove barriers to sun protection behav- Section I: Sociodemographic and occupational iors. The objectives of the program were to: characteristics of the studied farmers include age, gender, marital status, level of education, family his- – Increase the farmers’ perceived risks of sun exposure tory of skin cancer, duration of work, the average on skin and eye. number of hours spent working outside per day, and – Promote the farmers sun safety practices including training received on the risks of sun exposure in last using shade when working in the sun, wearing long- 12 months. sleeved loose-fitting tops and trousers with an ultra- Section II: Assessing sun exposure hazards and sun violet protection factor (UPF) rating of ≥ 30, wearing safety knowledge of studied farmers by 21 items wraparound-style sunglasses that block out 99% to divided into six items assessing awareness of sun 100% of UVR, using sunscreen with a sun protec- exposure-induced skin damage (skin burn, tanning, tion factor [SPF] ≥ 30 in correct way, wearing a wide skin aging, hyperpigmentation, skin cancer, no side brimmed hat with neck protection instead of the effects), other six items assessing awareness of sun beloved baseball hats, plentiful water intake, check- exposure-induced eye damage (aging, corneal sunburn, ing the UV index for the day through the weather app cataracts, pinguecula and pterygia, macular degenera- on their smart phone, regular self-checking of skin tion, no side effects), and nine items assessing knowl- for moles or unusual changes and seeking medical edge about sun safety measures “sunscreen (2 items), advice immediately, minimization of direct sunlight sunglasses (1 item), time of sun exposure (2 items), exposure in middle of day between “10 AM to 4 PM” wearing a hat (1 item), clothing (1 item), tanning (2 through doing much of work before 10 AM or after items).” Participants indicated their agreement with 4 PM, taking breaks, and job rotation. each statement on a 5-point Likert scale ranging from – Eliminate barriers to sun protection behaviors 1 = strongly disagree to 5 = strongly agree. through (1) providing samples of sunglasses, sun- 1 3 Journal of Cancer Education screens, and wide brimmed hats; (2) marketing to Table 1 Socio-demographic and occupational characteristics of the studied farmers cheap and at the same time effective types of sun - screen and sunglasses; (3) demonstrating how to fix Characteristics (N = 128) % No sunglasses to avoid its fall off the face during farm- ing; (4) Advising to have glasses designed for both Age groups sight correction and sun protection at the same time;   < 40 years 79 61.7 (5) Providing list of clothes choices suitable for sun   ≥ 40 years 49 38.3 protection; and (6) offering various options to mini-    Mean ± SD 28.1 ± 8.9 mize direct sunlight exposure in middle of day.    Range 19–68 Gender According to Egyptian General Authority of Meteorology   Male 72 56.3 (2022) [9], the months with the highest UV index in Egypt   Female 56 43.7 are June and July (UV index 12), while the month with the Marital status lowest UV index is December (UV index 3). So, the time of   Un-married* 41 32.0 the intervention was chosen to be in April and May between   Married 87 68.0 9 AM and 6 PM (working hours). Participants were divided Level of education into three groups. Each group included the farmers living in   Illiterate 45 35.2 the same village. Each participant was asked to attend one   Basic education 66 51.6 training session of 1-h period. The session was held dur-   University/technical diploma 17 13.3 ing the time preferred by the participants. Different training Family member had skin cancer methods were used for illustration as the PowerPoint presen-   Yes 5 3.9 tation, photos, and video files. At the end, participants were   No 123 96.1 given flyers containing all needed information to ensure Duration of work (years) remembering the message. One month after the implemen-   < 10 yrs 43 33.6 tation of the training program, the participants were asked to   ≥ 10 yrs 85 66.4 complete the same questionnaire that was used in the pre-test    Mean ± SD 21.9 ± 8.3 to detect the effect of the training program.    Range 3–42 Hours worked outdoors on a typical day Statistical Analysis   Mean ± SD 9.4 ± 3.5   Range 6–12 The collected data were statistically analyzed using SPSS Sun safety training received in last 12 months program (Statistical Package for Social Science) version   Yes 15 (11.7) 16.0. Qualitative data were represented as frequencies and   No 113 (88.3) percentages and were compared using McNemar’s test. *Un-married including single, divorced, and widower Quantitative data were represented as mean ± SD and were compared using Paired t-test. The test results were consid- ered significant when p value < 0.05. Excel 2019 was used The assessment of participants’ risk of skin cancer to draw the graphs. through brief skin cancer risk assessment tool (BRAT) revealed that most of participants (69.0%) had moderate risk Results for skin cancer (Graph 1). As regarding vision screening, Table  2 illustrates that One hundred and twenty-eight farmers were included in the most participants (77.3%) had a history of photokeratitis. About one quarter of them (24.2%) had pinguecula on spot study. More than half of them were males (56.3%) and less than 40 years old (61.7%) with a mean age of 28.1 ± 8.9 diagnosis. The overall self-reported eyesight was bad/very bad among near half of participants (43.0%). Moderate dif- with basic education (51.6%). Most of them were married (68.0%). Only 5 of them (3.9%) had positive history of fam- ficulty was the most prevalent in all evaluated activities “recognizing a friend across the street (46.1%), watching ily member skin cancer. As regards occupational history, more than half of participants (66.4%) had worked in farm- television (48.4%), reading fine print (46.1%), doing work or hobbies requiring up close vision (48.4%).” ing for more than 10 years with a mean of 21.9 ± 8.3 with an average number of hours worked outdoor on a typical day of Results of this study showed that there was a significant improvement in the participants’ awareness (pre-/post- 9.4 ± 3.5. Only 11.7% of them received sun safety training in last 12 months (Table 1). intervention) regarding sun exposure-induced skin and eye 1 3 Journal of Cancer Education As regards assessing sun safety practice through sun pro- Risk for skin cancer tection behavior index (pre/ post Intervention), it was sig- nificantly improved after intervention (p < 0.05) especially 11.7% in the items of clothing type, minimization of direct sunlight, 19.5% taking breaks, plentiful water intake, regular self-checking of skin, wearing wide brimmed hats with neck protection, and job rotation (Table 4). Graph 2 illustrates that there was a statistically significant improvement in the participants’ agreement with the sun 68.8% protection barriers among the studied farmers (pre-/post- intervention), especially in the items of lack of knowledge or concern, and expensive sun protection measures (p < 0.01). Low Moderate High Discussion According to the results of screening phase of this study, Graph 1 Risk of skin cancer among studied farmers most of farmers (69.0%) had moderate risk for skin cancer according to BRAT. This is consistent with many studies Table 2 Results of vision screening among studied farmers which concluded that due to the major role of sun expo- sure in skin cancer especially early and long-term exposure, Items (N = 128) % outdoor workers—primarily farmers—are at significantly No higher risk of developing skin cancer [10, 11]. The results History of photokeratitis 99 77.3 of screening also revealed many eye problems among the Spot diagnosis studied farmers either acute problems like photosensitivity   Pinguecula 31 24.2 in the most of them or chronic problems like pinguecula,   Pterygium 13 10.2 pterygium and cataract in fair number of them. Furthermore,   Cataract 20 15.6 there was moderate difficulty in self-reported overall eye- Overall self-reported eyesight sight, near vision, and far vision which may be due to sun   Very good/good 32 25.0 exposure-related cataract or macular degeneration. This is   Moderate 41 32.0 consistent with many studies which described the effects of   Bad/very bad 55 43.0 solar UVR on the eye [12, 13]. Difficulty recognizing a friend across the street Regarding the change in knowledge and behavior of   None/mild 39 30.5 the studied farmers towards sun safety after intervention,   Moderate 59 46.1 although the study showed significant improvement in all   Severe/extreme or cannot do 30 23.4 knowledge items, it only showed significant improvement in Difficult watching television some sun safety behaviors such as using protective clothes,   None/mild 50 39.1 taking breaks, plentiful water intake, regular self-checking   Moderate 62 48.4 of skin, wearing wide brimmed hats with neck protection,   Severe/extreme or cannot do 16 12.5 and job rotation. This is consistent with the narrative review Difficulty reading fine print which concluded that face-to-face educational interventions,   None/mild 51 39.8 such as those demonstrated in Utah, Turkey, and Michigan,   Moderate 59 46.1 proved to be highly effective in changing knowledge, attitude,   Severe/extreme or cannot do 18 14.1 and behavior of farmers towards sun safety measures [10]. Difficulty doing work or hobbies requiring up close vision The sun safety behaviors that did not show improvement   None/mild 34 26.6 after intervention included using a shade when working in   Moderate 62 48.4 the sun, wearing sunglasses, using sunscreen, and check-   Severe/extreme or cannot do 32 25.0 ing the UV index for the day. This could be explained by the self-reported barriers that the study tried to eliminate but resulted in insignificant improvement. These barriers damages (p < 0.01). As regards the knowledge about sun included: Firstly, the barrier against using a shade when safety measures, it was significantly improved (p < 0.01) working in the sun was “this behavior is not working for after intervention in all items (Table 3). farmers.” Secondly, the barrier against wearing sunglasses 1 3 Journal of Cancer Education Table 3 Awareness of Items Pre-intervention Post-intervention p value sun exposure hazards and knowledge about sun safety Sun exposure-induced skin damage 44.92 ± 7.42 93.63 ± 15.01 0.000* measures among studied Sun exposure-induced eye damage 36.88 ± 9.34 84.46 ± 13.39 0.000* farmers Sun safety measures   - Sunscreen 48.27 ± 7.38 91.55 ± 15.24 0.000*   - Sunglasses 38.98 ± 8.14 87.42 ± 14.31 0.000*   - Time of sun exposure 49.67 ± 9.32 92.15 ± 13.10 0.000*   - Wearing a hat 43.68 ± 9.02 91.46 ± 14.69 0.000*   - Clothing 40.39 ± 7.19 89.51 ± 13.87 0.000*   - Tanning 42.77 ± 8.75 90.72 ± 11.36 0.000* Highly statistically significant (p < 0.01) Table 4 Sun safety practice Items Pre-intervention Post-intervention p value through sun protection behavior index among studied farmers Using a shade/cover when working in the sun 36.35 ± 11.23 38.71 ± 12.08 0.067 Clothing type 32.27 ± 9.64 51.32 ± 11.37 0.005* Minimization of direct sunlight 38.25 ± 11.59 57.44 ± 13.03 0.014* Taking breaks 38.67 ± 11.23 45.07 ± 11.84 0.049* Wearing sunglasses 22.72 ± 10.84 27.42 ± 13.89 0.071 Using sunscreen in correct way 22.65 ± 9.13 29.19 ± 9.33 0.061 Plentiful water intake 45.75 ± 13.44 61.83 ± 13.58 0.009* Check the UV index for the day 17.09 ± 8.87 21.21 ± 9.33 0.089 Regular self-checking of skin 35.50 ± 11.82 53.78 ± 11.32 0.011* Wearing wide brimmed hats with neck protection 59.54 ± 9.42 75.54 ± 10.35 0.012* Job rotation 41.87 ± 10.09 46.43 ± 8.69 0.023* Statistically significant (p < 0.05) Graph 2 Evaluation of sun Sun protection barriers protection barriers among the studied farmers 93.8% 92.2% 88.3% 89.1% 78.1% 74.2% 75.8% 75.8% 68.0% 63.3% 60.2% 18.8% 11.7% 5.5% Lack of Lack of Expensive Sun Feeling too hot Inconvenince of SunscreenSunglasses knowledge** concern** protection when wearing sun self- measures** sun protection protection* clothing* Pre-intervention Post-intervention * Statistically significant (p < 0.05). ** Highly statistically significant (p < 0.01) 1 3 Journal of Cancer Education was “this behavior is expensive and impractical because of Limitations of the study include the following: first, repeated fall of sunglasses from the face during farming and it was one group pretest–posttest study with no control sunglasses cannot replace eyeglasses if vision is impaired.” group, a study design that might identify ineffective pro- Thirdly, the barrier against using sunscreen was “this behav- gram, but could not confirm the cause-effect relationships ior is expensive, the use of sunscreen is too feminine, its between program and outcome; second, lack of long-term smell is not liked, its nature is greasy, it attracts dirt, and the follow-up that may be needed to assure the maintenance user needs to reapply it to work correctly.” Finally, the bar- of preventive behaviors; third, inability to generalize the rier against checking the UV index for the day was “most of results because of small sample size which necessitates the studied farmers were illiterate or of basic education so, further studies; and finally, in a self-reported study, par - they could not use the weather app on their smart phone.” ticipants may over-report sun safety practices leading to Many studies conducted in Australia, Brazil, and the USA inflated results. Despite its limitations, this study consti- reported that the majority of farmers recognized wearing a tutes an important first step in research focused on the wide brimmed hat as their primary method of sun protec- development of knowledge and understanding concerning tion, while dependence on other sun protection practices, sun safety issues in the Egyptian agriculture sector. including wearing sunglasses or using sunscreen, was much lower [14–16]. The self-reported barriers to the sun protection behav- iors that showed a statistically significant improvement Conclusion and Recommendations among the studied farmers after intervention included lack of knowledge about sun protection practices, lack of concern Based on the results, the multicomponent intervention about sun exposure, feeling too hot when wearing sun pro- composed of education session, providing sun safety sup- tection clothing, and inconvenience of sun self-protection all plies and reminders, was effective in increasing awareness the time. The study succeeded to eliminate all these barriers of farmers with sun exposure hazards and improving their through tailoring specific messages for farmers providing knowledge and behavior towards sun safety measures. So, them with practical solutions. These barriers reflect that the it is recommended that more aggressive educational inter- Egyptian agriculture sector is neglected and miss the oppor- ventions in the form of agricultural events, healthcare part- tunities of the educational interventions that raise the aware- nerships, and promotional sun safety campaigns should ness with occupational health hazards. So, attention should target farmers as a reminder to protect themselves against be directed towards designing educational interventions spe- the hazards of sun exposure. These interventions should cifically for farmers. Further, tailoring the message content also assure providing farmers with sun safety supplies to of these interventions may have greater impact on farmers motivate them to adhere to the sun protective behaviors. than generic or non-tailored messages as such messages are Acknowledgements The authors would like to thank all participants seen as more personally relevant, and consequently may be of this study for their great cooperation. more probable to motivate its recipients to make healthful behavior changes [7]. Author Contribution All authors were responsible for the study and Finally, this study showed that although the studied farm- contributed to its conception and design. Material preparation was per- formed by [Dalia A. El-Shafei]. Data management was performed by ers became aware of the risks posed by excessive sun expo- [Randa M. Said]. The first draft of the manuscript was written by all sure, they typically did not perform routinely all the sun authors. All authors read and approved the final manuscript. protective behaviors especially that needed financial support such as using sunglasses and sunscreen. This reflects the Funding Open access funding provided by The Science, Technology & importance of organizational role in the protection of farm- Innovation Funding Authority (STDF) in cooperation with The Egyp- tian Knowledge Bank (EKB). ers from the sun through providing the safety supplies [1]. The relation between the perceived risk posed by excessive Data Availability The study tools; including used survey questions and sun exposure and positive sun protection behaviors among informational materials are available from the corresponding author farmers is controversial where some studies concluded that upon request. a higher perception of risk has been found to be strongly associated with more positive sun protection behaviors [17], Declarations while other studies concluded that although farmers were aware of the dangers posed by excessive sun exposure, they Ethics Approval The Institutional Review Board (IRB) of the Faculty of Medicine, Zagazig University, approved the study protocol (reference typically did not wear adequate protection when working no: #9618). Ethical considerations and confidentiality were respected. outdoors [10]. 1 3 Journal of Cancer Education Consent to Participate An informed consent was granted from all par- 6. 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Journal

Journal of Cancer EducationSpringer Journals

Published: Oct 25, 2022

Keywords: Sun safety; Knowledge; Behavior; Barriers; Farmer; Vision screening; Brief skin cancer risk assessment tool; Skin cancer screening

References