Journal of Agromedicine, 20:8594, 2015

Copyright Taylor & Francis Group, LLC

ISSN: 1059-924X print/1545-0813 online
DOI: 10.1080/1059924X.2015.1010059

ORIGINAL RESEARCH

Skin Cancer Beliefs, Knowledge, and Prevention Practices:

A Comparison of Farmers and Nonfarmers
in a Midwestern Population
Alexandra Carley and Erik Stratman
Department of Dermatology, Marshfield Clinic, Marshfield, Wisconsin, USA

ABSTRACT. Farmers have substantial sun exposure and increased skin cancer risk but poor sun
protection practices. There are few studies regarding the underlying factors that contribute to inadequate skin cancer prevention practices in the farming population, and minimal data to guide skin cancer
awareness and educational interventions for this population. The purpose of this study was to assess
skin cancer knowledge, sun protection behaviors and barriers, health care information sources, and the
impact of skin cancer screening among midwestern farmers and nonfarmers. Individuals attending a free
skin cancer screening during 2011 Wisconsin Farm Technology Days were surveyed for self-reported
sun protection use, extent of sun exposure, and skin cancer and sun protection beliefs and knowledge.
A total of 476 individuals participated in the study, including 194 farmers. Although farmers identified
sun protection benefits, few reported optimal practices, with only 23% of farmers reporting sunscreen
use always or frequently when out in the sun for 15 minutes or more. Common barriers to sun protection included discomfort with wearing long pants and long shirts, forgetfulness with sunscreen use, and
inconvenience with wearing wide-brimmed hats. Higher knowledge scores in farmers were associated
with better sun protection. Farmers utilized different sources of health care information compared with
nonfarmers, including farm magazines and newspapers, radio, and farm organizations. Providers should
consider the unique characteristics of the farming population to provide skin cancer prevention education that is tailored to the needs of this population, such as reminders for sunscreen use and resources
for sun-protective hats that do not interfere with work. Among individuals without prior history of skin
cancer, 34% of farmers and 22% of nonfarmers (P = .0127) were referred for additional evaluation
due to identification of a concerning lesion at the screening event. Thus, farmers may preferentially
benefit from skin cancer screening events, and this population should be targeted for additional screening events in the future. This study identifies unique characteristics of the farming population that can
assist providers in caring for this population and guide the future development of skin cancer awareness,
prevention, and screening initiatives to benefit farmers.

KEYWORDS. Farmer, health care information, skin cancer, skin cancer screening, sun protection

Address correspondence to: Alexandra Carley, Department of Dermatology (3P2), Marshfield Clinic,
1000 North Oak Avenue, Marshfield, WI 54449, USA (E-mail: cameli.alexandra@marshfieldclinic.org).
85

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SKIN CANCER BELIEFS, KNOWLEDGE, AND PREVENTION PRACTICES

INTRODUCTION
Farmers have high levels of occupational sun
exposure and increased risk of skin cancer.1,2
Although most farmers understand their risk for
skin cancer and believe sun-protective behaviors reduce skin cancer risk,1 most do not routinely use adequate sun protection.1,3,4 Despite
this disparity between knowledge and practice,
there are minimal data regarding the barriers
and distinct challenges encountered by the farming community regarding skin cancer prevention
practices.
Our goal was to identify factors that distinguish the farming population from the nonfarming population, such as unique sun protection
barriers and sources of health care information, to provide future guidance for improved
education and targeted preventative counseling.
We evaluated attitudes, knowledge, and behaviors regarding skin cancer and sun protection
in a midwestern farming population through a
written survey tool at a free skin cancer screening event. We also evaluated rates of actinic
keratoses (AKs) and lesions suspicious for skin
cancer detected during the screening event to
determine if the farming population preferentially benefits from skin cancer screening compared with nonfarmers.

METHODS
This study was approved by the Marshfield
Clinic Research Foundations Institutional
Review Board. The study population was
recruited from individuals attending a free
skin cancer screening sponsored by the
National Farm Medicine Center of Marshfield
at Wisconsin Farm Technology Days, the
largest agricultural show in Wisconsin, held
July 1214, 2011. Volunteer dermatologists,
dermatology residents, and allied health care
providers examined participants for presence
of AKs and lesions suspicious for skin cancer,
such as basal cell carcinoma (BCC), squamous
cell carcinoma (SCC), and melanoma.
All individuals attending the free skin cancer screening were eligible to participate in the

study if they fulfilled the following criteria:

(1) age 18 years, (2) able to read and write
in the English language, and (3) identified themselves as capable of making their own personal
medical decisions. Verbal consent was obtained
from participants, and a written introductory
paragraph was included on the survey form.
Each survey was assigned a unique study identification code to allow for data collection without
use of identifying patient information. The skin
cancer screening examination form for each participant had a corresponding study identification
code to allow for de-identified linking of the
study survey and skin cancer screening results.
All individuals attending the screening event
were offered a free hat, sunscreen samples, and
informational handouts regarding skin cancers,
regardless of their participation in the study.
Study participants received a 13-question,
written survey and completed the survey without the assistance of the investigators. The survey tool was developed from questions utilized
in a previous survey of Wisconsin dairy farmers regarding skin cancer beliefs, sun protection, skin cancer knowledge, and sources of
health care information.1 We obtained permission to utilize the survey tool in this manner for this study. Questions were updated to
include new health care information sources that
developed since the original study, primarily
Internet and electronic sources. Survey items
regarding sunscreen were updated to reflect current American Academy of Dermatology recommendations advising using sunscreen with
a sun protection factor (SPF) of at least 30.5
Study participants reported demographic information, previous skin cancer history, and screening practices. In this study, farmers included
all individuals who identified themselves as
a full-time farmer/farm worker, part-time
farmer/farm worker, or retired farmer/farm
worker. Specific definitions were not included
for these occupations. Participants recalled the
average number of hours they spend outdoors
each day during peak hours. They were also
questioned regarding the frequency of use for
various sun-protective methods when outside for
15 minutes or more utilizing a scale (never,
rarely, sometimes, frequently, always). If they

Carley and Stratman

did not always use the sun protection method,

they were asked to indicate their reason for this,
including it takes too much time, it gets in
the way of my work (inconvenient), it costs
too much, it is too hot to wear, I forget
to wear it, and other (explain). Participants
could select multiple reasons for each sun protection method if they desired. The survey
included questions to assess attitudes regarding
skin cancer and sun protection utilizing a Likert
scale (strongly agree, agree, neutral, disagree,
strongly disagree). Four knowledge questions
regarding skin cancer and sun protection were
included in the survey, and participants selected
True, False or Dont know. Participants
were asked to rank their top five health care
information sources from a list of sources,
including other with space to write information. Health care providers involved in the
screening completed standardized forms indicating diagnosis and follow-up recommendations.
The patient received a copy of this form, and
the original copy was retained for data analysis. Individuals with positive findings on the skin
cancer screen were advised to follow-up with a
health care provider.
In this convenience sample study, frequency
and percent of each survey question regarding
self-reported sun protection practices and precancerous or cancerous skin lesions were calculated and compared according to farming status
(farmers vs. nonfarmers) using Fishers Exact
test. A P value of <.05 was considered statistically significant. To assess correlation between
each sun protection behavior with outcomes of
skin cancer screening, Spearmans correlation
coefficients and corresponding P values were
obtained. All data analyses were performed
using SAS (version 9.2, English; Cary, NC).
The discrepancy between the positive belief
in sun protection practices (defined as subjects
who agreed or strongly agreed that a given sun
protection method reduced the risk of skin cancer) and good sun protection practice (defined
as subjects who reported frequently or always
using the given sun protection method) was
defined as a performance gap and was calculated in the following method for both farmers
and nonfarmers for all sun protection practices
included in this study:

87

Performance gap = (% subjects with positive

belief) (% subjects with
good practice)

RESULTS
Demographics
Of the 516 individuals who presented for
screening, 476 individuals participated in the
survey study, with 194 self-identified as farmers.
Most nonparticipation was related to individuals who declined to volunteer for the study, and
exclusion of individuals who were under the age
of 18. As described in Table 1, the farming group
included older individuals and more men compared with the nonfarming group (60.4 years
compared with 56.6 years, P = .0072, and 73%
male compared with 47% male, P < .0001).
Additionally, the farming population had significantly fewer years of schooling and reported
spending more time outdoors than nonfarmers
(Table 1).

Skin Cancer and Sun Protection Beliefs

and Attitudes
Compared with nonfarmers, a significantly
higher percentage of farmers believed they
were likely to get skin cancer in their lifetime
(P = .0107) and that their risk of skin cancer
was higher than the average person due to their
occupation (P < .0001; Table 2). Overall, both
farmers and nonfarmers believed that sun protection practices reduce the risk of skin cancer.
The majority of farmers (84%) and nonfarmers
(82%) agreed or strongly agreed that wearing
sunscreen with SPF of 30 or greater reduces
the likelihood of skin cancer (Table 3), which
was not statistically significant. Similar high
rates were found regarding belief in protective effects of hats, shirts, and long pants for
reducing skin cancer risk. There were no significant belief differences between farmers and
nonfarmers regarding benefits of sun protection with hats, sunscreen, shirts, or long pants.
Despite strong belief in benefits of sun protection, 46% of farmers and 39% of nonfarmers

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SKIN CANCER BELIEFS, KNOWLEDGE, AND PREVENTION PRACTICES

TABLE 1. Demographics
Characteristic

Farmers
n (%)

Respondents
Total
Demographics
Gender
Male
Female
Age in years, mean (range)
Years of schooling, mean (range)
Hours spent outdoors between 10 AM
and 3 PM May through October,
mean (range)

P value

Nonfarmers

194

Respondents

n (%)

277

192

<.0001

277
141 (73)
51 (27)
60.4 (2085)
13.0 (821)
3.9 (05)

193
191
183

130 (47)
147 (53)
56.6 (2091)
13.7 (222)
2.8 (05)

277
276
255

.0072
.0002
<.0001

Of 516 subjects screened, 476 participated in survey. Results reported for 471 survey participants who responded to
question regarding farming.
Unless otherwise noted.
P values derived from Fishers exact test for categorical variables and from Wilcoxon rank-sum test for continuous variables

TABLE 2. Skin Cancer Beliefs and Knowledge for Farmers and Nonfarmers
Skin cancer belief/knowledge

Skin cancer beliefs (agree/strongly agree)

Likely to get skin cancer
Increased occupational skin cancer risk
Sun protection reduces skin cancer risk
Most people look better with a tan

Farmers

P value

Nonfarmers

Respondents

n (%)

Respondents

n (%)

192
191
190
192

103 (54)
145 (76)
151 (79)
88 (46)

274
270
273
275

113 (41)
71 (26)
227 (83)
108 (39)

Skin cancer knowledge (correct response) (%)

Melanoma is serious
Skin cancer is common
Skin cancer can be deadly
Cloudy day does not protect from harmful
effects of sun

60
56
80
60

65
66
83
75

.0107
<.0001
.3307
.1822
.2846
.0341
.5441
.0006

Results

reported for the survey participants who responded to each respective survey question.
otherwise noted.
P values derived from Fishers exact test for categorical variables and from Wilcoxon rank-sum test for continuous
variables.
Unless

agreed or strongly agreed that most people look

better with a tan (P = .1822).

Relating Farmer Sun Protection Beliefs to

Sun Protection Practices
For all the self-reported sun protection
behaviors, Good practice was defined as frequently or always wearing the sun protection
method when in the sun for 15 minutes.
Good sunscreen practices were significantly

lower among farmers (23%) compared with

nonfarmers (35%; P = .0054; Table 3). Farmers
had significantly higher rates of good sun protection with long pants and long-sleeved shirts
compared with nonfarmers (P < .0001 and
P = .0459, respectively). Overall, long pants
were the most common sun protection method
for farmers. Good sun protection with hats was
uncommon (18%), and there was no significant difference between farmers and nonfarmers
(P = 1.0).

Carley and Stratman

89

TABLE 3. Beliefs, Practices, and Performance Gaps About Sun Protection Methods for Farmers
and Nonfarmers
Sun
protection
method
Hats
Shirts
Long pants
Sunscreen

Positive sun protection beliefs

Good sun protection practice

Performance gap

Farmers,
n (%)

Nonfarmers,
n (%)

P
value

Farmers,
n (%)

Nonfarmers,
n (%)

P
value

Farmers

Nonfarmers

P
value

147 (77)
156 (81)
156 (81)
162 (84)

202 (74)
228 (84)
228 (84)
223 (82)

.5866
.5368
.5368
.6242

34 (18)
36 (19)
127 (68)
43 (23)

48 (18)
33 (12)
99 (36)
96 (35)

1.0000
.0459
<.0001
.0054

59
62
13
61

56
72
47
47

.6344
.0443
<.0001
.0008

Subjects

who agreed or strongly agreed that given sun protection method reduced risk of skin cancer.
who reported frequently or always using given sun protection method.
(% of subjects with positive belief) (% of subjects with good practice).
Percentage calculated based on number of respondents for each question.
All P values derived from Fishers exact test.
Survey question regarding positive sun protection beliefs combined the sun protection methods of shirts and long pants
in the same question item, although the items were assessed separately for sun protection practices.
Subjects

Although farmers had strong positive beliefs

about benefits of sun protection and recognized their occupational risk for skin cancer,
few reported good sun protection practices. The
performance gap for using sunscreen is significantly greater for farmers compared with
nonfarmers (P = .0008) (Table 3). Farmers had a
significantly smaller performance gap for wearing shirts and pants compared with nonfarmers
(P = .0443 and P < .0001, respectively).

Skin Cancer Knowledge Associated With

Farmer Sun Protection Habits
As depicted in Table 2, most study participants correctly identified that skin cancer can
be deadly, including 80% of farmers and 83%
of nonfarmers (P = .5441). Nonfarmers had
significantly better knowledge compared with
farmers regarding sun exposure risk on cloudy
days. Additionally, nonfarmers were more likely
to correctly answer that skin cancer is the most
common cancer.
Better skin cancer knowledge was associated with higher rates of good sun protection practices with sunscreen and long-sleeved
shirts (Table 4). In farmers who answered all
knowledge questions correctly, 43% reported
wearing sunscreen frequently or always, compared with 17% with fair knowledge (23 questions correct) and 12% with poor knowledge

(1 question correct) (P = .0006). In farmers who answered all knowledge questions correctly, 33% reported wearing long-sleeved shirts
frequently or always, compared with 13% who
had fair knowledge and 17% with poor knowledge (P = .0202). This trend continued for hat
use, although the results were not statistically
significant (P = .0735). Good sun protection
with long pants was common and did not correlate with level of skin cancer knowledge in
farmers (P = .3273).

Barriers to Farmer Sun Protection

Farmers identified several barriers to optimal
sun protection (Table 5). The most commonly
cited barriers varied for different sun protection methods. Although long-sleeved shirts and
long pants were commonly identified as too hot
to wear by 73% and 62% of farmers, respectively, the most common barrier to sunscreen use
was forgetfulness (63%). A significantly higher
percentage of farmers reported that wearing a
wide-brimmed hat gets in the way of their
work (45%) compared with nonfarmers (19%;
P < .0001).

Sources of Health Care Information for

Farmers
Both farmers and nonfarmers identified
health care professionals and television as top
sources of health care information (Table 6).

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SKIN CANCER BELIEFS, KNOWLEDGE, AND PREVENTION PRACTICES

TABLE 4. Skin Cancer Knowledge and Sun Protection Practices in Farmers

Knowledge score

Sun protection method

Good
(4 correct)

Hats
Frequently/always
Never/rarely/sometimes
Shirt
Frequently/always
Never/rarely/sometimes
Pants
Frequently/always
Never/rarely/sometimes
Sunscreen
Frequently/always
Never/rarely/sometimes

Fair
(23 correct)

P valuea
Poor
(01 correct)

(%)

(%)

(%)

14
35

(29)
(71)

16
92

(15)
(85)

4
31

(11)
(89)

16
33

(33)
(67)

14
91

(13)
(87)

6
29

(17)
(83)

33
14

(70)
(30)

74
31

(70)
(30)

20
15

(57)
(43)

21
28

(43)
(57)

18
90

(17)
(83)

4
30

(12)
(88)

.0735

.0202

.3273

.0006

aP

value was derived from Fishers exact test.

otherwise noted.
Respondants who reported frequently or always using given sun protection method.
Number of correct responses out of 4 total knowledge questions.
Unless

TABLE 5. Barriers to Optimal Sun Protection for Farmers

Sun protection method

Sun protection barriers

% of farmers identifying barrier

Wide-brimmed hat

Gets in the way of work

Forgetfulness
Too hot
Time
Cost
Other
Too hot to wear
Forgetfulness
Gets in the way of work
Time
Cost
Other
Too hot to wear
Forgetfulness
Gets in the way of work
Time
Cost
Other
Forgetfulness
Time
Gets in the way of work
Cost
Too hot
Other

45
30
12
1
0
19
73
10
6
1
0
12
62
8
3
1
0
28
63
14
7
2
1
18

Long-sleeved shirt

Long pants

Sunscreen with SPF 30

Carley and Stratman

91

TABLE 6. Sources of Health Care Information for Farmers and Nonfarmers

Resource

Farmers
(N = 188)

Health professional
Television
Farm magazines/newspapers
Radio
Internet news sites
Other farmers
Internet Web site of the hospital or clinic where you receive health care
Farm organizations
Other health care specific Internet Web sites
Agriculture extension service
Internet Web site of a hospital or clinic where you do not receive health
care
Veterinarians
Other
Internet blogs
Local feed dealer
Facebook
Local equipment dealer
Twitter
%
P

Nonfarmers
(N = 267)

P value

153
138
94
94
45
44
44
40
39
38
30

81
73
50
50
24
23
23
21
21
20
16

226
182
50
102
94
24
111
23
110
22
85

85
68
19
38
35
9
42
9
41
8
32

.3737
.2522
<.0001
.0127
.0130
<.0001
<.0001
.0002
<.0001
.0004
.0001

24
20
17
16
15
13
13

13
11
9
9
8
7
7

20
32
25
16
19
17
17

7
12
9
6
7
6
6

.0759
.7651
1
.3529
.7217
.8493
.8493

of respondents who identify resource as a health information source.

value was derived from Fishers exact test.

As expected, farmers were significantly more

likely to identify farm magazines/newspapers,
other farmers, radio, and farm organizations and agricultural extension services
for health care information compared with
nonfarmers. Farmers were more likely to
identify veterinarians as a source of health care
information (13%) compared with nonfarmers
(7%), although this difference was not statistically significant (P = .0759). Internet resources
including news sites, hospital Web sites, and
other health care Web sites were used by
farmers as sources of health care information,
but less often than nonfarmers.

Regular Skin Cancer Screening

Farmers with a skin cancer history were significantly more likely to receive regular skin
cancer screening examinations compared with
farmers without a skin cancer history. Whereas
64% of farmers with a skin cancer history
reported receiving regular skin cancer screening
examinations, only 6% of farmers without previous skin cancer reported regular skin cancer

screenings (P < .001). There was no statistically

significant difference in the percentage of farmers with a skin cancer history (13%) compared
with nonfarmers (10%; P = .2393). In individuals with a skin cancer history, there was
no statistically significant difference in regular skin cancer screenings between farmers and
nonfarmers.

Skin Cancer Screening Preferentially

Benefits Farmers
Skin cancer screening data was available for
473 study participants, of whom 193 were farmers. A significantly higher percentage of farmers
received the presumptive diagnosis of AKs compared with nonfarmers (33% vs. 14%; P <
.0001). Both populations had similar rates for
presumptive squamous cell carcinoma (SCC),
basal cell carcinoma (BCC), and melanoma.
In farmers without a prior skin cancer history,
36% with poor skin cancer knowledge had the
presumptive diagnosis of AK, BCC, or SCC on
skin cancer screening, compared with 29% with
fair knowledge and 21% with good knowledge,

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SKIN CANCER BELIEFS, KNOWLEDGE, AND PREVENTION PRACTICES

although these values did not reach statistical

significance (P = .3767). In these farmers, there
was no significant difference in the incidence
of presumptive AK, BCC, or SCC diagnosis
between those reporting poor sunscreen use and
good use (30% vs. 22%, respectively; P = .39)
In individuals without a skin cancer history,
farmers were more likely than nonfarmers to
be referred for further evaluation following the
screening event; 34% of farmers with no prior
skin cancer history were referred, compared
with 22% of nonfarmers without previous skin
cancer (P = .0127). Overall, 38% of farmers
and 23% of nonfarmers were referred for further
evaluation (P = .0023) after the screening event.

DISCUSSION
The study results demonstrate that farmers
represent a unique population at risk for skin
cancer, with significant differences in skin cancer beliefs, knowledge, sun protection practices,
and health care information sources compared
with nonfarmers.
Despite strong knowledge and beliefs in benefits of sun protection, few farmers report optimal sun protection practices, resulting in substantial sun protection performance gaps in the
farming population. Given the increased occupational risk of sun exposure and skin cancer
in farmers, these gaps are particularly concerning. These data may be useful for developing
interventions to improve farmers sun protection behaviors. For instance, since farmers identify forgetfulness as the most common barrier
to optimal sunscreen use, interventions might
include reminder strategies (e.g., sunscreen
reminder stickers for tractors). Previous studies
identified text message reminders as a helpful, low-cost tool for increasing sunscreen use
adherence.6 Similar concepts could be applied
for the increasingly tech-savvy farming population, and such programs could be marketed at skin cancer screening events, health
care provider offices, and media sources utilized by farmers. A previous study of farmers
showed that a modified baseball cap with a sunprotective flap covering the neck is preferred
to traditional wide-brimmed straw hats.7 Since
farmers report wide-brimmed hats interfere with

their work, providing information about alternative sun protective hats could reduce this barrier.
We demonstrated that better knowledge
scores were associated with higher rates of
optimal sunscreen use, although causation
cannot be proven. Overall, skin cancer knowledge was lower in farmers compared with
nonfarmers, indicating that the farming population specifically may benefit from educational
interventions. In a previous study, teenagers
in the Future Farmers of America program in
rural Wisconsin were trained to provide sun
protection education to third-grade students
in their community school, and there was a
significant knowledge gain for students in the
intervention group at follow-up 6 months after
the educational experience.8
A community-based intervention for a farming population in Michigan was associated with
improved skin cancer prevention behaviors.9
Additionally, a study of Georgia farmers showed
self-reported previous skin cancer prevention
counseling from a health care provider was
associated with sunscreen use and skin cancer
knowledge.10 In a study of California farmers,
greater concern about skin conditions was associated with better self-reported sun protection
practices.3 Thus, community-based interventions, educational programs, and patient counseling directed at the farming population should
be considered.
Since farmers identify different sources
of health care information compared with
nonfarmers, educational interventions should be
targeted to sources they most commonly utilize. This study provides evidence that skin
cancer awareness programs should include farm
magazines and other agricultural media sources
and organizations. Online resources are also
commonly used by farmers, as 4 of their top
11 health information resources involve the
Internet.
The impact of skin cancer screening in the
farming population is significant. Farmers were
more likely than nonfarmers to have AKs identified as a presumptive diagnosis during screening. Although the majority of farmers with a
skin cancer history receive regular screening,
only 6% without skin cancer receive routine
examinations. As a result of this screening
event, 34% of farmers without a skin cancer

Carley and Stratman

history were referred for further evaluation. This

demonstrates that skin cancer screening in this
population identifies concerning skin lesions in
individuals who otherwise do not access regular skin examinations. Thus, the farming population represents a subset of individuals that
may receive particular benefit from skin cancer screening initiatives. Marketing of screening
events should target this subset of farmers.
Limitations of this study include demographic differences between farming and nonfarming populations. Farmers had significantly
fewer years of schooling and were older compared with nonfarmers. There were more men
in the farming population compared with the
nonfarmer group. Some discrepancies in knowledge, sun protection practices, and health care
information sources could be affected by these
demographic differences. Populations were selfidentified, and definitions of roles (farmers,
farm workers) could be interpreted differently depending on the particular population.
Previous studies of sunscreen adherence identified substantial discrepancies in patients selfreported adherence rates and objective measures of adherence.6 All the skin cancer prevention behaviors and health care practices were
self-reported, and recall bias could affect this
survey-based study. The measured sun protection behavior may be independent of the intention for sun protection. The intent of wearing long pants and long-sleeved shirts may be
related to occupational needs of farmers, such
as protection from chemical exposure, with skin
cancer prevention being an incidental benefit.
The nonfarming and farming populations in this
study may not represent the average nonfarming
population, because the study population was
recruited from a convenience sample at a screening event at a farm technology fair. The study
involved an upper Midwest population with
minimal racial and ethnic diversity at a single
screening event at one site. Thus, there may be
limitations in generalizing data from this study.

CONCLUSION
This study provides evidence that the farming population is unique compared with the

93

nonfarming population. There are multiple differences in skin cancer knowledge, beliefs,
sun protection practices, and sources of health
care information between these populations.
Interventions to improve skin cancer knowledge,
sun protection practices, and screening should
account for unique features of the farming population to provide optimal benefit.

ACKNOWLEDGMENTS
The authors acknowledge the staff of the
Marshfield Clinic National Farm Medicine
Center for their assistance in the skin cancer
screening event. They also recognize Barbara
Marlenga, RN, PhD, for providing access to
previous research that was utilized to develop
the survey tool for this study. They acknowledge Marie Fleisner of the Marshfield Clinic
Research Foundations Office of Scientific
Writing and Publication for editorial assistance
in the preparation of the manuscript.

FUNDING
Funding for this study was provided by the
Marshfield Clinic physician research funds.

REFERENCES
1. Marlenga B. The health beliefs and skin cancer prevention practices of Wisconsin dairy farmers. Oncol Nurs
Forum. 1995;22:681686.
2. Blair A, Freeman LB. Epidemiologic studies in
agricultural populations: observations and future directions. J Agromedicine. 2009;14:125131.
3. Schenker MB, Orenstein MR, Samuels SJ. Use of
protective equipment among California farmers. Am J Ind
Med. 2002;42:455464.
4. Rosenman KD, Gardiner J, Swanson GM, Mullan
P, Zhu Z. Use of skin-cancer prevention strategies among
farmers and their spouses. Am J Prev Med. 1995;
11:342347.
5. American Academy of Dermatology. How do I
prevent skin cancer? Available at: http://www.aad.org/
skin-care-and-safety/skin-cancer-prevention/be-sun-smart/
be-sun-smart. Accessed April 2014.
6. Armstrong AW, Watson AJ, Makredes M,
Frangos JE, Kimball AB, Kvedar JC. Text-message

94

SKIN CANCER BELIEFS, KNOWLEDGE, AND PREVENTION PRACTICES

reminders to improve sunscreen use: a randomized, controlled trial using electronic monitoring. Arch Dermatol.
2009;145:12304236.
7. Lee B, Marlenga B, Miech D. Farmers Caps and
Hats: Skin Cancer Prevention Project. Marshfield, WI:
National Farm Medicine Center, Marshfield Clinic; 1992.
8. Reding DJ, Fischer V, Gunderson P, Lappe K,
Anderson H, Calvert G. Teens teach skin cancer prevention. J Rural Health. 1996;12:265272.

9. Mullan PB, Gardiner JC, Rosenman K, Zhu

Z, Swanson GM. Skin cancer prevention and detection practices in a Michigan farm population following
an educational intervention. J Rural Health. 1996;12:
311320.
10. Robinson JD, Silk KJ, Parrott RL, Steiner C, Morris
SM, Honeycutt C. Healthcare providers sun-protection
promotion and at-risk clients skin-cancer-prevention outcomes. Prev Med. 2004;38:251257.

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