The incidence of non-melanoma skin cancer is increasing [1, 2] with the rates of melanoma increasing 3.1% annually since 1992 among non-Hispanic Whites . While less common among Hispanics and Blacks, the rates of skin cancer are also increasing for Hispanics  and survival rates for Blacks are lower . The risk factors predisposing a person to skin cancer include skin type, increased sun exposure, propensity to sunburns, sun burning and blistering throughout life, number of moles, and genetic susceptibility [3, 6, 7]. Outdoor workers are exposed to high ultra violet (UV) levels [7–9] increasing their risk of myeloid leukemia, malignant melanoma, and lip cancer . Nonetheless, the rates of receiving skin examination and the use of sun protection are lower among outdoor workers compared to indoor workers [11, 12], and only less than half of outdoor workers appropriately used sunscreen .
Previous studies have acknowledged several barriers to using sunscreen. A common belief is that those with tanned or olive skin are not at risk for skin cancer, thus protective measures need not be taken . Positive attitudes towards tans are associated with decreased use of sunscreen, thus preventing outdoor workers from taking sun protection seriously . Putting on sunscreen [16, 17], is viewed as a hassle, and long sleeves are uncomfortable in the heat [15, 18]. Men, which constitute majority of outdoor workers, may feel that it is not masculine to protect themselves from the sun , especially when around other males, while women feel that a tan makes them look slender and sexy . In general, the perceived importance of sun protection is low among outdoor workers .
Operating Engineers, one group of outdoor workers, are responsible for the operation and maintenance of heavy earthmoving equipment used in the construction of buildings, bridges, roads, and other facilities . Our prliminary data show that Operating Engineers are at greater risk of skin cancer since they spend an average of 4–5 hours in the sun, over 80% reported getting sunburned at least once per summer, and over half burned more than once a summer . However, about three-quarters of the sample never or only sometimes used sun block and 23% showed interest in sun protection guidance .
The data support the need for sun protection interventions among this Operating Engineers. Therefore, this funded Blue Cross Blue Shield of Michigan RCT will determine the efficacy of four sun protection interventions—education only, education and mailed sunscreen, education and text message reminders, and education, mailed sunscreen, and text message reminders—among Michigan Operating Engineers. The specific aim is to determine differences in changes in sunscreen use and sun burning among Operating Engineers randomized to four sun protection interventions: a) education only; b) education and mailed sunscreen; c) education and text message reminders; and d) education, mailed sunscreen, and text message reminders.
The Health Belief Model  was used to guide the development of the trial for Operating Engineers. The model proposes that behavior is influenced by four constructs including Perceived susceptibility (individual’s assessment of their risk of getting sunburned and subsequent skin cancer), Perceived severity (individual’s assessment of the seriousness of sun burning and subsequent skin cancer), Perceived benefits (individual’s assessment of the positive consequences of using sun protection), and Perceived barriers (individual’s assessment of the influences that facilitate or discourage adoption of sun protection behavior). The Health Belief Model also asserts that there are mediating factors including self-efficacy (confidence) , cues to action, socio-psychological variables, health motivation, and demographic variables. Among the four interventions, the educational component is designed to increase perceived susceptibility to and severity of sun burning and enforce the benefits of sunscreen use. Mailed sunscreen is designed to reduce barriers and will be served as a cue to action. Text messages are designed to emphasize perceived benefits and will be served as cues to action.