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Sun Safety Communication and Behavior for Students in a School Policy Intervention

Sun Safety Communication and Behavior for Students in a School Policy Intervention

In a recent publication in the Australian and New Zealand Journal of Public Health, Klein Buendel researchers and collaborators evaluated the Sun Safe Schools policy implementation intervention program in California school districts.

The United States has a high occurrence of skin cancer which has created a call to action for many organizations. The Sun Safe Schools program was created to help prevent skin cancer and to protect the nation’s youth by encouraging healthy sun safety habits for young students. In schools specifically, “children receive substantial solar ultraviolet radiation (UV) exposure, including while at school (1), and are frequently sunburned (2).”

In the study, primary schools who had existing sun safety policies were randomized into intervention and control groups and a posttest was distributed to parents. With parents in the intervention schools receiving more information about sun safety, their students on average were more likely to wear sun-protective clothing outside of school more frequently than the students of parents in the control schools. Parents in the intervention group also reported less sunburns and less time outdoors among children whose schools had implemented sun safety practices. A full description of the methods, analyses, results, conclusions, and limitations can be found in the publication.

Overall, support and implementation for a sun protection policy in school districts increased the amount of sun safety information to parents and increased the effectiveness of sun safety behaviors for children. However, experienced faculty and engaging parents are both important factors in the prevention of student skin cancer.

This research was funded by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health (HD074416; Dr. Kim Reynolds and Dr. David Buller, Multiple Principal Investigators). Other authors include Dr. Richard Meenan from the Kaiser Permanente Center for Health Research in Portland, Oregon; Dr. Jeff Ashley from Sun Safety for Kids in Los Angeles, California; Kim Massie previously from Claremont Graduate University; and Mary Buller and Julia Berteletti from Klein Buendel.

References

1. Buller DB, Borland R. Skin cancer prevention for children: a critical review. Health Educ Behav. 1999;26(3):317-43.

2. Buller DB, Cokkinides V, Hall HI, Hartman AM, Saraiya M, Miller E, et al. Prevalence of sunburn, sun protection, and indoor tanning behaviors among Americans: systematic review from national surveys. J Am Acad Dermatol. 2011;65(5 Suppl 1):114-23.

Supporting Implementation of Sun Safety Policies in Schools

Supporting Implementation of Sun Safety Policies in Schools

Many schools in California are working to increase sun protection practices by students, parents, teachers, and staff in an effort to reduce over-exposure to ultraviolet radiation and prevent skin cancer in the long term. A paper published recently in Preventive Medicine presents the results of a large randomized trial assessing an intervention designed to close a sun safety policy-practice gap in California elementary schools. The trial tested the hypothesis that schools with sun safety policies randomly assigned to receive the Sun Safe Schools intervention would implement more sun safety practices than schools in a minimal information control group.

Research collaborators from Claremont Graduate University, Klein Buendel, the Kaiser Permanente Center for Health Research, and Sun Safety for Kids, Inc. implemented the Sun Safe Schools program in 118 elementary schools from 40 California public school districts. Each school district had a school board-approved policy for sun safety (Board Policy 5141.7). The 20-month intervention was delivered to principals and included a coaching session, telephone and email contacts, resources for implementing sun protection practices, and a small grant program (for example, to purchase sunscreen for students).

The Sun Safe Schools intervention was effective at narrowing the sun safety policy-practice gap in participating California elementary schools. The program increased the total number of sun safety practices implemented by intervention schools compared to control schools. Also, more intervention schools’ sun safety practices reflected elements of district policy and sometimes went beyond the elements included in district policy. Detailed descriptions of the sample, measures, methods, analyses, outcomes, strengths, and limitations of the randomized controlled trial can be found in the Preventive Medicine publication.

The research was funded by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health (HD074416; Dr. Kim Reynolds, Claremont Graduate University, and Dr. David Buller, Multiple Principal Investigators). Coauthors, in addition to Dr. Reynolds and Dr. Buller, include Kim Massie formerly from CGU; Dr. Jeff Ashley from Sun Safety for Kids in Los Angeles, California; Dr. Richard Meenan from the Kaiser Permanente Center for Health Research in Portland, Oregon; and Julia Berteletti and Mary Buller from Klein Buendel.

Factors Impacting Sun Protection in California Schools

Factors Impacting Sun Protection in California Schools

Findings from a school-based sun safety study, Sun Safe Schools, were published recently in the Journal of School Health. The research team from Klein Buendel, Claremont Graduate University, the Kaiser Permanente Center for Health Research, and Sun Safety for Kids examined the correlates of sun safety policy implementation in California public school districts.

In 2002, California was the first state to enact legislation governing sun protection for students. It is California Education Code Section 35183.5. In 2005, the Sun Safe Schools research team collaborated with California Schools Board Association to develop a comprehensive Sample Board Policy for sun safety (BP 5141.7) based on California law and recommendations from the U.S. Centers for Disease Control and Prevention. The study included California public school districts that had already adopted the board-approved sun safety policy.

For the study, principals and teachers completed an online survey about sun protection policies and practices. Respondents reported on the implementation of ten school practices related to BP 5141.7 and indicated which practices, if any, were implemented in their school. Years in public education, years worked in the current district, perception that parents should take action to protect children from the sun, and respondents’ personal skin types were associated with the number of practices implemented in the school.

A full description of the methods, analyses, results, conclusions, and limitations can be found in the publication. In summary, the authors concluded that policy implementation is more likely among schools with experienced faculty, when parents are seen as important partners in student skin cancer prevention, and when school principals and teachers have a personal skin type at lower risk for melanoma.

The Sun Safe Schools program was a collaborative research effort of Claremont Graduate University (CGU), the Kaiser Permanente Center for Health Research, and Klein Buendel. The research was funded by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health (HD074416; Dr. Kim Reynolds, CGU, and Dr. David Buller, Klein Buendel, Multiple Principal Investigators). Collaborators included Dr. Richard Meenan from the Kaiser Permanente Center for Health Research; Dr. Jeff Ashley from Sun Safety for Kids in Los Angeles, California; Kim Massie previously from CGU; and Julia Berteletti, Xia (Lucia) Liu, and Mary Buller from Klein Buendel.

Hispanic Tattoo Artists as Skin Cancer Prevention Influencers

Hispanic Tattoo Artists as Skin Cancer Prevention Influencers

Skin cancer is increasing in the Hispanic population and there is a public health need for campaigns to target this often-underrepresented population. In a recent publication in The Journal of Drugs in Dermatology (JDD), authors from the University of Colorado School of Medicine and Klein Buendel examine how Hispanic tattoo artists can serve as skin cancer prevention advocates for the Hispanic population. JDD also released a podcast with the authors about the study earlier this month.

Multiple in-depth interviews were conducted with Hispanic tattoo artists at various tattoo studios in Salt Lake City, Utah. The interviews provided insight into the artist’s skin cancer knowledge, their current sun safety recommendations to clients, and their willingness to incorporate skin cancer prevention into their future work routines.

Data analysis indicated that a most of the artists had a large percentage of Hispanic clients and repeat customers. All artists also had some level of skin cancer knowledge, though not extensive enough to provide basic sun protection tips in their regular tattoo aftercare instructions to clients (such as what specific Sun Protection Factor to use, when to reapply sunscreen, and the use of cover up clothing). Despite this, all artists were enthusiastic about providing sun safety messages on their social media pages and would be willing to partake in some level of skin cancer prevention training and education in the future.

With lengthy tattoo sessions and repeat clientele, Hispanic tattoo artists could serve as beneficial influencers in the early detection of skin cancers in the Hispanic population. Researchers concluded that by providing comprehensive full-body sun protection information to their clients through tattoo aftercare instructions, alerting clients to suspicious moles, and using social media messages, Hispanic tattoo artists could have a big impact on their clients’ skin health. The study’s complete analysis and discussion can be found in the publication.

This project was funded by a grant and a supplement from the National Cancer Institute (CA206569; Dr. Barbara Walkosz and Dr. Robert Dellavalle, Multiple Principal Investigators). Authors include Dr. Cristian Gonzalez, and Dr. Adrian Pona from the University of Colorado School of Medicine; Dr. Barbara Walkosz from Klein Buendel; and Dr. Robert Dellavalle from the University of Colorado School of Medicine and the U.S. Department of Veterans Affairs Rocky Mountain Regional VA Medical Center Dermatology Service.

Project SHINE for Adolescent Tanning Prevention

Project SHINE for Adolescent Tanning Prevention

Dr. David Buller, Klein Buendel Director of Research, is a Co-Investigator on a new research project funded by the National Cancer Institute and being led by Dr. Yelena Wu, Principal Investigator, from the University of Utah. Project SHINE (Sun-safe Habits Intervention and Education) is a multi-modal intervention that targets adolescents’ views on the personal relevance of skin cancer and their ability to prevent the disease in order to increase their sun protection use and decrease their intentional tanning.

Project SHINE incorporates action plans, sun damage photographs, and education to teachers and parents in order to build on adolescents’ interest in novelty and need for highly personalized interventions. It also promotes environmental supports for adolescent skin cancer prevention. SHINE is novel in its application of the Extended Parallel Process Model, used in smoking and drug abuse interventions, to pediatric skin cancer prevention. The five-year study will be conducted with 30 high schools and over 10,000 students in 9th or 10th grade health classes. To support the rigor of this research, the project will objectively measure ultraviolet radiation (UVR) exposure among 10% of the sample who will wear a UVR monitoring device for 3-day periods after self-reported assessments.  

Dr. Buller is part of a well-established team that includes experts in skin cancer prevention, adolescent health behavior change, dermatology, school programs, and randomized trials. He will provide input on the design and implementation of the study, help develop parent/teacher education materials, and participate in results interpretation and manuscript preparation.

Skin cancer is a significant public health priority. It is the most commonly diagnosed form of cancer, afflicting more than 5 million people in the United States each year. Treatment costs total more than $8 billion each year. Skin cancer is highly preventable if individuals limit UVR exposure by using sun protection strategies, such as sunscreen, hats, protective clothing, and by avoiding tanning. Use of prevention strategies is critical during childhood and adolescence, when skin cells are particularly vulnerable to UVR damage leading to skin cancer. Due to their poor use of sun protection and likelihood to intentionally tan, adolescents, more than any other pediatric group, urgently need efficacious skin cancer preventive interventions. Schools offer the ideal setting to deliver skin cancer preventive interventions to large numbers of adolescents.

An Implementation Model for the Cost-effective Scale-up of the Sun Safe Workplaces Program

An Implementation Model for the Cost-effective Scale-up of the Sun Safe Workplaces Program

Dr. David Buller and Dr. Barbara Walkosz from Klein Buendel presented a poster on a new implementation model for the cost-effective scale-up of an occupational sun protection program at the 12th Annual Conference on the Science of Dissemination and Implementation in Health in Washington, DC, December 4-6, 2019. The poster was nominated for Best Poster from the Prevention and Public Health Division.

Scale-up is the effort to increase the impact of successful programs to benefit more people on a lasting basis. Scale-up efforts must increase reach, retain effectiveness, and lower costs to provide greater access to benefits and close the research-to-practice gap between effective programs and real-world application. This project is studying the nationwide scale-up of an occupational sun safety intervention, Sun Safe Workplaces, with state Departments of Transportation (DOTs), a public works sector with thousands of outdoor workers.

Costs of national distribution can be daunting and influence intervention intensity and program effectiveness. Identifying cost-effective scale-up strategies is essential for moving research into practice. The new framework draws upon existing implementation models, including those developed for occupational health and safety, and operationalizes implementation for scale-up within RE-AIM. The RE-AIM framework was adapted for this new framework by incorporating cost as a primary factor.

In a randomized trial, Sun Safe Workplaces (SSW) is assessing implementation rate and costs associated with two methods of scaling-up SSW. The original intervention depended on personal visits with managers, materials promoting sun protection policies and education, in-person sun safety training for employee groups, and on-going follow-up communication with managers supporting sun safety (SSW-IP), a resource-intensive form of intervention. Now SSW-IP is being contrasted to a scale-up strategy that uses web-based and telephone conferencing, responsive training platforms, and electronic resources for virtual contacts and training (SSW-T). Technology-based programs have the potential to deliver standardized, engaging content and increase portability while decreasing cost of delivery to enable reaching more employers when scaled-up to nationwide distribution. Districts within DOTs are randomized to one of the two scale-up methods. The SSW-IP and SSW-T interventions are being delivered in 21 state DOTs with 141 districts.

This research is funded by a grant from the National Cancer Institute (CA134705; Dr. David Buller and Dr. Barbara Walkosz, Multiple Principal Investigators). Additional poster coauthors include Dr. Richard Meenan from the Kaiser Permanente Center for Health Research; and Mary Buller, Rachel Eye, Andrew Grayson, and Savanna Olivas from Klein Buendel.

Economic Evaluation of Adopting Occupational Sun Protection Policies

Economic Evaluation of Adopting Occupational Sun Protection Policies

In a recent publication in the Journal of Occupational and Environmental Medicine, Klein Buendel investigators and their colleagues discuss the economic evaluation of an intervention promoting adoption of occupational sun protection actions by Colorado public-sector employers.

The intervention, Sun Safe Workplaces (SSW), was a two-year randomized field trial promoting employer adoption of sun safety policy and providing training in personal sun protection for outdoor workers. The trial included 98 local Colorado government organizations such as municipalities, counties, and special districts (public organizations providing water, sanitation, parks and recreation, and fire protection). SSW intervention costs were organized into two components: “delivery” costs and “action” costs. Delivery costs were incurred to directly implement and maintain the SSW intervention and included costs of both project staff and the participating worksites. Action costs were incurred by the worksites themselves for implementing the sun protection actions.

The publication presents the results of the economic evaluation of SSW. A full description of the methods, measures, results, and conclusion of the research can also be found in the Journal of Occupational and Environmental Medicine publication.

This study demonstrated the interactions of cost and implementation that explain — and hopefully guide — the adoption of and investment in occupational sun safety. The SSW intervention was also successful in extending the adoption of sun protection actions among intervention worksites at a cost per employee that is comparable to other worksite health interventions.

This analysis was funded by a grant from the National Cancer Institute at the National Institutes of Health (CA134705; Dr. David Buller and Dr. Barbara Walkosz, Multiple Principal Investigators). The paper’s lead author is Dr. Richard Meenan from the Kaiser Permanente Center for Health Research in Oregon. Additional authors include Dr. David Buller, Dr. Barbara Walkosz, Ms. Mary Buller, Ms. Rachel Eye, and Ms. Savanna Olivas from Klein Buendel; and Dr. Allan Wallis from the University of Colorado Denver.

Sun Safety Ink! Expands to the Latino Community

Sun Safety Ink! Expands to the Latino Community

Skin cancer rates continue to rise in the Hispanic population. In the last two decades, their annual melanoma incidence has increased by 20% (5). Even though Hispanics are diagnosed at a disproportionately lower level than non-Hispanic whites (NHWs), they are diagnosed with melanoma at a younger age, with a more advanced stage of the disease, and have lower melanoma-specific survival rates than NHWs (1,3).

Klein Buendel’s randomized controlled trial, Sun Safety Ink!, trains tattoo artists to offer skin cancer prevention advice to their clients. A recent diversity supplement will extend the Sun Safety Ink! study by focusing on how this information can be targeted to Hispanic tattoo artists and their clients, especially young adults. The supplement’s goals are to discover new approaches to address the increasing rates of skin cancer in the Hispanic population and to provide insight into the implementation of skin cancer prevention in an often hard-to-reach population.

Over 30% of the Hispanic population has tattoos (4), a rate that is higher than NHWs (25%). Tattoo studios, because they often recommend sun protection in their aftercare instructions, are a unique context in which to promote full body sun protection to Latinos. Sun Safety Ink! will distribute sun safety information to hard-to-reach Hispanic young adults. The diversification of the study sample will provide information on (1) baseline knowledge on sun protection in the Latino population, (2) barriers to sun protection, and (3) at-risk populations.

The supplement includes both formative research and the implementation of the Sun Safety Ink! program. Specifically, tattoo studios with Hispanic artists and clients in Utah, Colorado, Arizona, and New Mexico will be recruited to participate in the study. The tattoo artists will be provided with a version of the Sun Safety Ink! training modified based on formative research conducted by Cristian Gonzalez, MD. Dr. Gonzalez is a Research Fellow at the University of Colorado Anschutz Medical Campus and an upcoming Medical Resident at the University of Texas Southwestern Medical Center.

Dr. Gonzalez explained that the most important aspect of this project is that “Latinos have this invincibility factor that they think they can’t get skin cancer because they don’t know a lot of family members or friends with skin cancer, so sometimes it really doesn’t come up. If we can increase awareness of skin cancer in the Latino community, and if we can also improve sun protection behavior, I think we would see a reduction in melanoma and non-melanoma skin cancer in the future.”

Sun Safety Ink! is funded by a grant and a supplement from the National Cancer Institute (CA206569; Dr. Barbara Walkosz and Dr. Robert Dellavalle, Multiple Principal Investigators). Collaborators include Dr. Barbara Walkosz, Dr. David Buller, Mary Buller, Rachel Eye, and Savanna Olivas from Klein Buendel; and Dr. Robert Dellavalle from the University of Colorado, Denver.

Dr. Cristian Gonzalez

References

  1. Coups EJ, Stapleton JL, Hudson SV, Medina-Forrester A, Natale-Pereira A, Goydos JS. Sun protection and exposure behaviors among Hispanic adults in the United States: differences according to acculturation and among Hispanic subgroups. BMC Public Health. 2012;12:985.
  2. Hay J, Coups EJ, Ford J, DiBonaventura M. Exposure to mass media health information, skin cancer beliefs, and sun protection behaviors in a United States probability sample. Journal of the American Academy of Dermatology. 2009;61(5):783-792. doi: 10.1016/j.jaad.2009.04.023.PMC2854488
  3. Harvey VM, Oldfield CW, Chen JT, Eschbach K. Melanoma disparities among US Hispanics: use of the social ecological model to contextualize reasons for inequitable outcomes and frame a research agenda. Journal of Skin Cancer. 2016;2016:4635740. doi: 10.1155/2016/4635740
  4. One in five U.S. adults now has a tattoo [press release]. New York, NY: Harris Insights & Analytics, February 23. Available at:  https://theharrispoll.com/new-york-n-y-february-23-2012-there-is-a-lot-of-culture-and-lore-associated-with-tattoos-from-ancient-art-to-modern-expressionism-and-there-are-many-reasons-people-choose-to-get-or-not-get-p/.
  5. Skin cancer rates soar in US Hispanics. Sun & Skin News. November 21, 2013;30(4). https://www.skincancer.org/publications/sun-and-skin-news/winter-2013-30-4/soar.
May is Skin Cancer Awareness Month

May is Skin Cancer Awareness Month

Skin cancer is the most common type of cancer in the United States. Ultraviolet (UV) radiation from the sun is the main cause of skin cancer. UV radiation can also come from tanning booths or sunlamps. The most dangerous kind of skin cancer is called melanoma.

The good news? Skin cancer can almost always be cured when it’s found and treated early – and that includes melanoma.

Here are some helpful resources for information, graphics, and materials to raise awareness about skin cancer and help people take action to prevent or detect it early when it is easier to treat.

American Academy of Dermatology (AAD)

Centers for Disease Control and Prevention (CDC)

Healthfinder.gov- Skin Cancer Prevention

Skin Cancer Foundation

Real Health Photos

Use Real Health Photos® for improving the impact of health messages for Skin Cancer Awareness Month. The stock photography website includes numerous images of diverse people being sun safe with hats, sunglasses, shade, and sunscreen. Real Health Photos images show diversity of gender, race, ethnicity, age, income level, and health condition.

For more images, visit Real Health Photos.

Real Health Photos is a stock photography service owned and operated by KB. It was created and evaluated with a research grant (R44MD003338, Mary Buller, Principal Investigator) from the National Institute of Minority Health and Health Disparities at the National Institutes of Health. Real Health Photos is designed to capture the diversity of health through photography and promote the inclusion of all populations in health promotion materials and media.

Skin Cancer Awareness for Winter Enthusiasts

Skin Cancer Awareness for Winter Enthusiasts

Last month, Klein Buendel (KB) teamed up with the Colorado Skin Cancer Task Force (CSCTF) and Rocky Mountain Sunscreen (RMS) at the Annual Outdoor Retailer and Snow Show to spread skin cancer awareness to outdoor winter enthusiasts.

Per their website, the Outdoor Retailer Snow Show is the largest outdoor snow sports industry gathering in North America. The trade show brings outdoor industry brands, suppliers, retailers, and leaders together for a three-day expo at the Colorado Convention Center. Although the trade show is closed to the public, last year the event attracted over 29,000 attendees with representatives from over 1,000 brands.

The extensive Snow Show provides the opportunity to reach thousands of individuals who work and recreate outdoors. Every year, for over a decade, KB has partnered with the CSCTF and RMS to raise awareness about UV radiation and skin cancer prevention at the event. We stress the importance of practicing sun safety at high elevation during the winter months when UV can reach very high levels.

Specifically, KB increases people’s awareness of their personal risk for skin cancer by taking individual’s UV photographs using a Reveal Imager. The imager by Canfield, has the ability to capture and expose a lifetime of sun damage in a single image of someone’s face that is otherwise invisible to the naked eye. From the image, KB staff point out problem areas that have received damage from the sun and suggested simple sun safety practices for people to better protect themselves from accruing further UV damage.

Other members of the CSTF, including Colorado dermatologists and dermatology interns, were also present to help field questions and to perform free skin examinations on request.