Sun Exposure Prevention Practices Within U.S. Naval Aviation
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MILITARY MEDICINE, 187, 1/2:167, 2022
Sun Exposure Prevention Practices Within U.S. Naval Aviation
Willis H. Lyford, MD, LT, MC, USN; Angela Crotty, MD, LT, MC, USN;
Nicholas Fred Logemann, DO, CDR, MC, USN
ABSTRACT
Introduction:
Occupational exposure to ultraviolet radiation is a critical concern for those serving in the U.S. Military. Work and
mission requirements predispose members to significant sun exposure, while sun-protective behavior often comes second
to mission accomplishment. Prior research implicated institutional practices and constraints as preventing the routine
use of sun protection modalities, but no large-scale studies have assessed service members’ perceptions regarding sun
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protection modalities available to them in their work environment or their daily sun protection practices.
Methods:
The study employed a cross-sectional survey distributed to active duty (AD) U.S. Navy service members assigned to 1
of 19 aircraft squadrons based in Southern California and deployed on missions across the Pacific theater of operations.
The intent was to evaluate rates of sunburn, sun-protective practices, and perceptions regarding sun exposure and pre-
vention practices in their workplace. The study and survey tool received approval from the Naval Medical Center San
Diego Institutional Review Board. Statistical analysis of survey answers was performed to assess for trends in response
rates overall and response rates within sociodemographic groups. Pearson’s chi-squared tests were utilized to assess for
significance where appropriate. P-values 15.
29.1% of survey respondents reported working in direct sunlight always/almost always. This was lower than the
rates reported in a previously surveyed U.S. Air Force population of aviation maintainers. Low rates of respondents
reported frequent reminders to use sun protection (18.9%), and fewer reported the routine or frequent use of sunscreen
while at work (12.3%). A higher percentage reported regular use of sunscreen during outdoor leisure activities (36.5%),
suggesting a barrier to use in the workplace.
Conclusions:
U.S. Military personnel report higher rates of sunburn and lower rates of routine use of sun protection practices compared
to a previously surveyed civilian population. The overall rates of sun protection use while in the work setting are low
both overall and compared to reports of routine use during outdoor leisure activities. Reported rates of reminders to
use sunscreen are low, suggesting that increased education regarding the risk of excessive sun exposure and tools for
effective sun protection are still needed.
INTRODUCTION predispose them to significant sun exposure and make sun-
Throughout the USA, the incidence of skin cancer and its protective behaviors secondary to mission accomplishment.
related mortality have been increasing at a precipitous rate, Nowhere is this more true than in the U.S. Military popula-
including a tripling of rates among individuals of light com- tion, whose work environments, mission requirements, and
plexion.1 Currently, skin cancer is diagnosed in one in five extracurricular activities of choice often result in extended
Americans and accounts for nearly 10,000 deaths annu- periods of time spent outdoors and in climates where sun
ally.2,3 The general consensus is that this rate will continue exposure is prolonged and severe.4,12 The retiree population
to rise, especially in populations whose work requirements of U.S. Military veterans is a reflection of these practices
in the past: a 2010 retrospective review of a tumor registry
Department of Dermatology, Naval Medical Center San Diego, San
performed by the DoD and the National Cancer Institute
Diego, CA 92134, USA
found that populations of individuals over 45 years with a
doi:https://doi.org/10.1093/milmed/usab099 history of military service had a significantly increased risk
Published by Oxford University Press on behalf of the Association of Mil-
for melanoma-type skin cancer compared with their coun-
itary Surgeons of the United States 2021. This work is written by (a) US
Government employee(s) and is in the public domain in the US. terparts who had not previously served.5,6,9,10 Similarly, a
MILITARY MEDICINE, Vol. 187, January/February 2022 167A Cross-sectional Survey of Practice and Behaviors
2014 study compared an active duty (AD) population with practices in our current AD population may be a harbinger of
a diagnosis of melanoma to a control population compris- further increased rates of diagnosis in the future.
ing general U.S. population and found that the melanoma
incidence rate was 62% greater in active military personnel.7 METHODS
More recent data suggest that this trend may continue. A This cross-sectional survey (see Supplemental Appendix 1)
recent survey from a DVA hospital in Nashville, TN, querying was derived from previously validated survey tools. The ques-
veterans of Operation Iraqi Freedom and Operation Endur- tions ascertaining demographics and assessing sun protection
ing Freedom about their sun protection use was discouraging. practices and sunburn history were derived from the National
Only 13% of respondents reported routine sunscreen use, Health Interview Survey Cancer Control Supplement.14,15,19
despite the fact that 52% of those surveyed reported work- Questions regarding workplace sun protection practices were
ing >6 hours per day in bright sun. Similarly, troubling is the derived from the ADSEPPS survey, a tool previously uti-
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fact that only 23% of the surveyed veteran pool felt that they lized to survey a population of AD USAF regarding sun
had been made very aware of their increased risk for skin can- protection practices and behaviors.11 The composite survey
cer and had received any training on sun-protective behavior.8 tool consists of three parts and assesses population demo-
A study in U.S. Air Force (USAF) AD aircraft maintainers graphics, military service, sun exposure, sun burn history,
reported that, although ~65% of respondents reported work- and workplace sun protection availability and utilization.
ing in direct sunlight “all” or “most” of the time, about 64% The study and survey tool received approval from the Insti-
reported “never” or “almost never” using sunscreen during tutional Review Board of the Naval Medical Center San
work. Worryingly, 61% reported they were “never” or “almost Diego.
never” reminded to use sun-protective measures at work.11 A single primary care facility serving U.S. Navy personnel
It is well-known that skin cancer prevention begins with was the recruitment site. Surveys were offered to all eligi-
individual sun-protective measures. Ultraviolet light exposure ble members presenting for routine care appointments from
is the simplest and most direct modifiable risk factor for reduc- February to May 2019. Inclusion criteria were that the respon-
tion of risk for developing skin cancer.13 As a result, reducing dent should be AD, >18 years old, and assigned to any of the
rates of non-melanoma and melanoma skin cancer relies on 19 aircraft squadrons tenanted on site. There were no spe-
primary prevention. Yet the U.S. Military lacks current data cific exclusion criteria. The survey was completely voluntary
on the prevalence of sun-protective practice usage, and the for members presenting for care and was designed to take
data we do have suggest that failure to promote sun-protectiveA Cross-sectional Survey of Practice and Behaviors
All descriptive statistics were performed using STATA were consistent in terms of demographics within the U.S.
v13.1 (StataCorp. Stata Statistical Software: Release 13. Navy and representative of the U.S. Military as a whole.16
College Station, TX). Categories for age, rank, and tendency Rank distribution was also similar to the military as a
to sunburn (used as surrogate for ethnicity and skin type and whole, with 35.3% of those surveyed being considered “junior
derived from the NHIS CCC) were generated to allow for enlisted” (ranks E1-E4), 43.0% being considered junior non-
sociodemographic analysis of responses using Pearson’s chi- commissioned officers (NCO, ranks E5-E6), and 21.5% being
squared tests to assess for significance where appropriate. considered senior NCO and officers (E7-O5). None of those
P-values 31 years reporting rou-
31+ 279 (31.4) tine or frequent use of sunscreen and sun-protective clothing,
Gender – respectively. In general, junior enlisted respondents reported
Male 625 (70.4) less frequent use of any sun protection method when com-
Female 263 (29.6) pared with senior enlisted and officer respondents. However,
Rank – results were only significant for responses regarding the use
E1-E4 314 (35.3) of sunscreen as a sun protection tool. In this case, only 25.6%
E5-E6 382 (43.0) of the junior enlisted surveyed reported routine or frequent
E7-O5 192 (21.5)
use of sunscreen compared to 34.3% and 59.7% of E5-E6 and
Years active duty (total) –
senior enlisted/officer respondents, respectively.
0-3 288 (35.3)
3-8 310 (34.9) A total of 54.9% of survey respondents reported a sunburn
>8 284 (31.9) within the past year, with no significant difference in the rates
Not indicated 6 (0.7) of sunburn reported between genders (55.0% of females sur-
Sunburn risk category/surrogate skin – veyed vs 55.6% of males surveyed). Similarly, age and years
typea of AD did not show a significant association with reporting
Severe blistering sunburn 16 (1.8) a sunburn within the past year. There was a significant rela-
Moderate sunburn with peeling 162 (18.2)
Burn mildly with some to no 249 (28.0)
tionship between rank and reported skin type—or tendency
darkening/tanning to burn—and having experienced sunburn in the past year:
Turn darker without sunburn 297 (33.4) increasing rank was directly associated with increased report-
Nothing would happen 97 (10.9) ing of sunburn, while lighter skin type was associated with
I do not go out in the sun 4 (0.4) increased report of sunburn (Supplemental Table S1).
I do not know 44 (5.0)
Not indicated 19 (2.1)
Sun Exposure and Sun Protection Practices
a Sunburn risk category is derived from NHIS Cancer Control Supplment Employed
survey questionnaire; question reads, “If you were to spend 1 hour in the
sun without any sunscreen or other sun protection, what would be the effect The largest percentage of the population surveyed reported
on your skin?”. that in their current role they work in direct sunlight
MILITARY MEDICINE, Vol. 187, January/February 2022 169A Cross-sectional Survey of Practice and Behaviors
TABLE II. Survey Responses and Rates TABLE II. (Continued)
How much sun exposure do you think is recommended per day for the
When you go outside on a warm sunny day ≥1 hour, how often do you:
average person?
Stay in the shade? n (%)
30 minutes 476 (53.5)
Sometimes 513 (57.6)
NA 22 (2.5)
Rarely or never 126 (14.0)
Don’t know/NA 13 (1.3) True or false: It is recommended to spend time in the sun to get enough
Vitamin D:
Wear sun-protective clothing?
True 718 (80.8)
Always/almost always 306 (34.5)
False 145 (16.4)
Sometimes 293 (33.0)
NA 25 (2.8)
Almost never/never 283 (31.9)
Don’t know/NA 6 (0.6) It is recommended for everyone to regularly use sun-blocking measures:
True 829 (93.4)
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Wear sunscreen?
False 34 (3.8)
Always/Almost Always 324 (36.5)
NA 25 (2.8)
Sometimes 236 (26.6)
Almost never/never 322 (36.3)
Don’t know/NA 6 (0.6)
“sometimes” (37.4%, n = 332), with the lowest percentage
Always’or ‘Almost Always’ to ≥1 of the 555 (62.2)
reporting working in direct sunlight “always” or “most of the
above:
time” (29.1% n = 259). Survey respondents reported roughly
If you use sunscreen, what is the SPF?
1-14 84 (9.4)
equal rates of working in direct sunlight “always/most of
15-50 675 (75.9) the time” and “sometimes” during their cumulative careers
NA 129 (14.5) in the military (41.2%, n = 366, 42.3%, n = 376). Female
I have been sunburned in the past year: respondents showed a statistically significant trend toward
Yes 489 (55.1) decreased time working in direct sunlight. Similarly, increas-
No 393 (44.2) ing age, increasing rank, and increased tendency to sunburn
NA 6 (0.7)
were significantly correlated with decreased rates of working
When I was sunburned in the past year, I used one or any of the above frequently in direct sunlight (Supplemental Table S1). There
sun-protective measures:
Always/almost always 273 (30.7)
was no significant association between either the frequency
Sometimes 208 (23.3) of working in direct sun in their current role (P = .21) or the
Almost never/never 202 (22.8) frequency of working in direct sunlight in their cumulative
NA/I have not been sunburned 206 (23.2) military service (P = .39) and reporting a sunburn in the past
How often do you use sunscreen when you are away from work doing year. A majority of those surveyed overall reported “rarely” or
an activity outdoors? “never” being reminded to use sun protection when working in
Always/almost always 324 (36.5)
sunlight (57.6%, n = 512). While there were some statistically
Sometimes 258 (29.0)
Almost never/never 291 (32.7) significant trends in response rates across sociodemographic
NA 16 (1.8) factors, in general all demographics surveyed reported being
In your current job: reminded to use sun protection modalities infrequently. Fre-
How often do you work in direct sunlight? quency of sunscreen use while working in direct sunlight
Always/almost always 259 (29.1) was also infrequent, with 67.3% of respondents reporting
Sometimes 332 (37.4) they “rarely” or “never” used sunscreen while at work in
Almost never/never 282 (31.9)
NA 15 (1.4)
direct sunlight compared to 12.3% reporting using sunscreen
“always/most of the time” while working in direct sunlight at
How often are you reminded to use sun protection methods?
Always/almost always 168 (18.9) work. A larger percentage of those surveyed reported using
Sometimes 192 (21.6) sunscreen “always/most of the time” when away from work
Almost never/never 512 (57.7) (36.5%, n = 324).
NA 16 (1.8)
How often do you use sunscreen? Knowledge of Sun Protection Recommendations
Always/almost always 109 (12.3)
Sometimes 162 (18.2)
54.5% of respondents believed that >30 minutes of sun expo-
Almost never/never 598 (67.3) sure was recommended daily. 93.4% (n = 829) agreed that it
NA 20 (2.2) is recommended that all persons regularly use sun-blocking
During your total US Military Service: methods of protection (Table II).
How often have you worked in direct sunlight?
Always/almost always 366 (41.2) DISCUSSION
Sometimes 376 (42.3) To our knowledge, this is the first survey assessing sun pro-
Almost never/never 133 (15.0)
tection knowledge and practices being employed by AD indi-
NA 14 (1.5)
viduals within the U.S. Navy, and the largest survey study
(continued) assessing AD personnel’s impressions of the effectiveness and
170 MILITARY MEDICINE, Vol. 187, January/February 2022A Cross-sectional Survey of Practice and Behaviors
consistency of sun protection practices employed by aviation commonly employed tactic for sunburn prevention among
operational commands day to day. The survey we utilized female SMs was the use of sunscreen, whereas for male SMs
was comprised of questions derived from the Centers for sun-protective clothing was most commonly utilized. Almost
Disease Control and Prevention’s NHIS as well as from a uniformly, military SMs were found to utilize sun protec-
previous survey tool assessing sun exposure knowledge and tion measures less frequently than their civilian counterparts.
practices among members of the USAF. The results demon- Although SMs’ use of sunscreen is varied, it is reassuring to
strate disparity both with civilian counterparts and with ser- see that the vast majority of those utilizing sunscreen as a
vice members (SMs) from another military branch. A number sun protection method are using agents that are sun protection
of contrasts bear discussion. factor 15 or greater.
Of note, the rate of sunburn reported by SMs in the With regard to workplace practices employed for sun pro-
past year was markedly higher than the rate reported within tection, our results demonstrate several interesting observa-
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a representative U.S. civilian population.17,18 Our surveyed tions as well as key contrasts with the results obtained by
population reported a rate of sunburn of 54.9%. By compar- other surveyed populations of AD, reservists, and veterans
ison, a civilian population surveyed by the NHIS reported a of recent combat operations.8,11 A much smaller percentage
rate of 35.3%. Interestingly, response rates by sociodemo- of our surveyed members (29.1%) reported working in direct
graphic subcategories of age, gender, and total years of AD sunlight “always” or “most of the time.” Similarly, a much
service were not significant with regard to rates of sunburn larger percentage reported rarely or never working in direct
reported within the past year. The greater U.S. population sunlight. This is a stark contrast to a 2015 survey of veterans
surveyed with the NHIS reported similar rates for females of Operation Iraqi Freedom and/or Operation Enduring Free-
and males reporting sunburns, but there was a trend toward dom, 73.6% of whom reported working primarily outdoors,
decreasing sunburn rates as age increased. This was not sim- with the majority reporting >6 hours of work in direct sunlight
ilarly observed in our study, where reported rates of sunburn daily.8
remained relatively stable with increasing age, and did not Although our surveyed population did report higher rates
show any significant trend. Conversely, rank did show a of working in direct sunlight during their total time in ser-
trend demonstrating significance: those of higher rank (senior vice (41.2%), numbers reported were still markedly below
enlisted and officers) were more likely to report a sunburn the rates previously reported in surveyed USAF members.
within the past year (Supplemental Table S1). This is likely Of note, neither there was correlation between members’ fre-
a reflection of the demographics of the senior enlisted and quency of working in the sun at their current job and having
officer corps, which has a higher percentage of individuals of had a sunburn in the past year (P = .21), nor was there correla-
Caucasian race or ethnicity.16 Our cross-demographic analy- tion between history of working in the sun in the military and
sis showed a significant correlation between increasing rank they having experienced sunburn in the past year (P = 0.39).
and increasing tendency to sunburn if exposed to ≥1 hour of Concerningly, only 18.9% of SMs in our population reported
direct sun, which was used as a surrogate for skin type. As frequent or regular reminders regarding use of sun protec-
expected, darker skin type/tendency to tan instead of burn was tion when working in the sun. Although reminders to use
inversely correlated with report of sunburn in the past year. sunscreen while working in direct sunlight were significantly
The overall reported rate of sunburn within our a cohort of AD and positively correlated with rates of working in direct sun-
military members is well above the goals set by a U.S. intera- light (P = .00), the numbers themselves were still suboptimal;
gency workgroup tasked with cancer prevention and outlined 50.0% of those who reported “always” working in direct sun-
in the Healthy People 2020 goals. These goals were developed light reported rarely or never being reminded to use sunscreen,
by a joint task force composed of members from the Institute while 58.2% of those reporting “almost always” working in
of Medicine, the National Academy of Sciences Goals and direct sun reported infrequent or no reminders. Our data also
the U.S. Department of Health and Human Services and are suggest that while younger age and lower rank correlated with
intended to target reduction of preventable cancer deaths in increased frequency of working in direct sunlight in their cur-
the USA. This suggests that while the greater U.S. population rent job (P = .0), it was older individuals and those of higher
is on track to meet this goal, our AD U.S. population may not ranks who more frequently reported use of sunscreen at their
be similarly situated to meet this objective. jobs, with 75.0% and 75.4% of those aged 18-24 and ranks
This population of AD members also shows disparity E1-E4 reporting “almost never” or “never” using sunscreen
in rates of the utilization of sun protection methods com- in their job versus 59.3% and 59.9%, respectively, for those
monly recommended and employed. Overall, 62.2% reported >30 years old and E6 or higher in rank. This would suggest
using some commonly accepted form of sun protection fre- a benefit to specifically counseling younger and more junior
quently or consistently. This rate is once again below the rate enlisted SMs on the importance of sun protection from the
reported in a civilian population surveyed (70.8%) and is well start of their military careers, as this is the AD population that
below the Healthy People 2020 target rate of 73.7%. Meth- is likely seeing the highest levels of exposure and, worryingly,
ods of sun protection employed by SMs also demonstrated doing the least to protect themselves during this exposure.
a contrast with the surveyed civilian population; the most Clearly, this is an area for improvement, and routine and
MILITARY MEDICINE, Vol. 187, January/February 2022 171A Cross-sectional Survey of Practice and Behaviors
targeted reminders to the most frequently exposed SMs should burden to the veterans administration and to our health-
be employed. care system as a whole. Though means exist to effectively
Another area of concern is the marked disparity between diagnose and treat skin cancer, the most effective tool to
sunscreen use while at work and sunscreen use during leisure combat the burgeoning epidemic of skin cancer cases is via
activities. Only 12.3% of those surveyed reported using sun- increased utilization of effective prevention practices and
screen while at work and sun-exposed versus 36.5% who education regarding high-risk behaviors and effective pre-
reported sunscreen use during leisure activities with heavy vention tools. Our results highlight several important trends
sun exposure. This gap suggests a subset of AD members in sun protection behaviors and sun protection practices
who are not using or are under-utilizing sunscreen while in within the U.S. Navy both in a high-risk work environ-
the work environment, despite exhibiting a preference for and ment and at home and highlight several interesting con-
routinely practicing sunscreen use while not in their work trasts with other service branches and the civilian U.S.
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environment. There could be a number of factors that con- population.
tribute to this non-use; the work by Powers et al. has suggested
issues with sun protection availability in the workplace. Our ACKNOWLEDGMENTS
survey results would also suggest that a lack of reminders The authors would like to acknowledge Dr. Howard Greene, PhD, and
to utilize sun protection practices may play a role, since a Dr. Ronald Riffenburgh, PhD, for their assistance with the study’s statisti-
strong majority (57.7%) reported they were rarely or never cal design as well as statistical analysis and interpretation and Mrs. Susan
Driscoll-Bannister for her assistance in developing and implementing the
reminded to use sun protection when working in direct sun-
study protocol.
light. Regardless, the underlying causes merit further investi-
gation. Interestingly, a comparatively larger percentage of our
SUPPLEMENTARY MATERIAL
cohort reported frequent or regular use of sunscreen during
Supplementary material is available at Military Medicine online.
leisure activity (36.5%, n = 324) versus the population previ-
ously surveyed from the USAF (23.4%). “Sometimes” use of
FUNDING
sunscreen was less common in our population (29.0%).
Study was entirely self-funded.
As with the USAF survey population, the majority of our
respondents appeared to be unaware that the overwhelming
CONFLICT OF INTEREST STATEMENT
majority of U.S. residents derive adequate levels of vitamin
The view expressed in this article reflect the results of research conducted
D via dietary intake, regardless of sun exposure. In both sur- by the authors and do not necessarily reflect the official policy or position of
vey populations, there was an erroneous impression that it was the Department of the Navy, Department of Defense nor the United States
recommended to receive >30 minutes of sun exposure daily. Government.
This may highlight an area for education for dermatologists We are military service members or federal/contract employees of the
and primary care providers across services. Reassuringly, a United States Government. This work was prepared as part of our official
strong majority of our respondents understood that sun protec- duties. Title 17 U.S.C. 105 provides that copyright protection under this title is
tion methods are recommended for all populations regardless not available for any work of the United States Government.’ Title 17 U.S.C.
of the skin type. 101 defines a U.S. Government work as work prepared by a milita1y service
Limitations to this study include the regional nature of member or employee of the U.S. Government as part of that person’s official
duties.
the study and limitation to a single center. Although limi-
tation to a single branch of service could be considered a
weakness, one of the express purposes of the study was to REFERENCES
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