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Family Determinants of Sun-Safe Behaviors in Hispanic Children

Family Determinants of Sun-Safe Behaviors in Hispanic Children

Melanoma is common, particularly among Non-Hispanic Whites (NHW). However, Hispanics are diagnosed at more advanced stages compared to NHW prompting the need for more research into Hispanic sun protection practices.  

Sarah Davila, Klein Buendel collaborator and student from Claremont Graduate University, recently presented findings on family determinants of child sun protection from the Sun Safe Schools project at the virtual 2020 American Public Health Association conference. Family determinants of child sun protection have seldom been tested among Hispanics. The team hypothesized that parent sun protection behavior, perceived risk for skin cancer, skin-phenotype, and purchase of sun protection products, along with child skin-phenotype and interaction of child skin-phenotype with child ethnicity would associate with child sun protection behavior and child sunburn. To test this, parents of elementary school-aged children completed self-report surveys and a multilevel analysis was conducted with Hispanic and NHW parents nested within schools and nested within districts.  

Parent sun protection behavior, number of sun-safe items purchased, and child skin-phenotype were all positively associated with child sun protection behavior, while parent perceived risk was negatively associated. The interaction of child skin-phenotype with child ethnicity was significant, indicating no difference at Type 1 skin-phenotype, but greater protective behavior for Hispanics relative to NHW for subsequent skin-phenotypes. Parent perceived risk and child skin-phenotype were also positively associated with child sunburn. Overall, the results suggest a need for parent modeling and environmental controls to increase sun protection behavior in Hispanic children.  

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 included 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 Julia Berteletti, Mary Buller, and Lucia Liu from Klein Buendel. 

Tattoo Aftercare Instructions and Sun Protection

Tattoo Aftercare Instructions and Sun Protection

Skin cancer rates continue to rise in the United States, so health researchers continue to explore novel ways to reach people with potentially life-saving information. In a recent commentary published in the Journal of Clinical and Aesthetic Dermatology, Klein Buendel Senior Scientist, Dr. Barbara Walkosz, and co-authors discuss how tattoo studios and their aftercare instructions provide a unique opportunity to reach younger adults with skin cancer prevention recommendations.

Sun protection for new tattoos, to some degree, is provided to most clients as part of the tattoo aftercare process. However, most aftercare instructions focus on the protection of the client’s tattooed skin, not comprehensive full-body sun protection. Most artists are not prepared to impart thorough sun safety recommendations, “such as applying sunscreen prior to sun exposure with a sun protection factor (SPF) of 30 or higher, reapplying sunscreen when outdoors for more than two hours, using clothing that physically blocks ultraviolet rays, wearing wide-brimmed hats that shade the head, or seeking shade when available.”

However, research suggests that tattoo artists are interested in learning about sun safety measures and open to sharing the information with their clients. In the commentary, the authors pinpoint the unique opportunity tattoo studios provide to reach younger adults with public health information, including through studio websites and social media pages. The commentary also shares results from in-depth interviews with tattoo artists and describes how tattoo aftercare instructions vary from state to state.

This research team was funded by a grant and supplement from the National Cancer Institute (CA206569; Dr. Barbara Walkosz and Dr. Robert Dellavalle, Multiple Principal Investigators). Authors include Dr. Cristian Gonzalez from the Department of Dermatology at 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.  

Scaling-up an Evidence-based Workplace Sun Safety Program

Scaling-up an Evidence-based Workplace Sun Safety Program

Authors of a recent online publication in Contemporary Clinical Trails recommend that “successful methods for scaling-up evidence-based programs are needed to prevent skin cancer among adults who work outdoors in the sun.” The paper describes the design and baseline descriptive data from a workplace intervention being conducted by Klein Buendel and several research collaborators. The on-going randomized trial compares two methods of scaling-up the Sun Safe Workplaces intervention with 21 state Departments of Transportation and their employees who work outdoors. 

A total of 138 regional districts from the Departments of Transportation were randomly assigned to either an in-person program where project staff meet personally with managers, conduct trainings for employees, and provide printed materials, or a digital program where project staff conduct these same activities virtually, using conferencing technology, online training, and electronic materials.

Delivery of Sun Safe Workplaces in both groups is tailored to managers’ readiness to adopt occupational sun safety. Posttesting will assess manager’s support for and use of Sun Safe Workplaces and employees’ sun safety. An economic evaluation will explore whether the method that uses digital technology that may result in lower implementation of Sun Safe Workplaces, is more cost-effective relative to the in-person method.

The 21 state Departments of Transportation vary in size from 997 to 18,415 employees. At baseline, managers reported being generally supportive of occupational sun safety. A minority reported that the Departments had a written sun safety policy, half reported sun safety training for employees, and two-thirds reported messaging and communication about sun protection for employees. The research will help determine whether digital methods can facilitate a cost-effective scale-up of Sun Safe Workplaces for outdoor workers in industries across the country.  

This research project (CA210259) is funded as part of the National Cancer Institute’s Cancer Moonshot Initiative, which aims to accelerate cancer research in order to make more therapies available to patients, while also improving the ability to prevent cancer and detect it at an early stage. This project, Sun Safe Workplaces-Technology, is being led by KB’s Director of Research, Dr. David Buller, as Principal Investigator. Co-authors on the Contemporary Clinical Trails publication include Dr. Richard Meenan from Kaiser Permanente’s Center for Health Research, Dr. Gary Cutter from Pythagoras, Inc., Dr. Sherry Pagoto from the University of Connecticut, and Ms. Mary Buller, Ms. Julia Berteletti, Ms. Rachel Eye, and Dr. Barbara Walkosz from Klein Buendel.

Sun Safe Partners Online

Sun Safe Partners Online

Findings from a pilot randomized controlled trial evaluating the feasibility and preliminary impact of an online couple-focused intervention to improve sun protection behavior were published recently in the Journal of Medical Internet Research. The research team was led by Dr. Sharon Manne from the Rutgers Cancer Institute of New Jersey. Collaborators from Michigan State University, the University of Connecticut, Memorial Sloan Kettering Cancer Center, and Klein Buendel rounded out the research team.

At the time of the study, Sun Safe Partners Online was a web-based intervention with four individual-focused modules and four couple-focused modules. A total of 75 couples who reported suboptimal levels of sun protection were randomly assigned to receive either Sun Safe Partners Online or a generic sun safety education intervention. Participants were recruited through Facebook advertising, resulting in rapid enrollment and higher acceptance than was evident in a previous trial testing telephone and print intervention. Feasibility was assessed by enrollment, engagement, survey completion, module completion, and module satisfaction. Participants also completed pre/post surveys assessing sun protection, sun exposure on weekends, sunburn incidence, and attitudes toward sun protection. A full description of the methods, analyses, and effects of the study can be found in the publication.

Sun Safe Partners Online was found to be an innovative strategy for engaging adults in sun safety. The authors conclude that “a couple-focused intervention may hold promise as a way to improve sun protection behaviors beyond interventions focused solely on individuals by leveraging the concern, collaboration, and support among intimate partners and addressing relationship-based barriers to sun protection.”

This pilot research was supported by Rutgers Cancer Institute of New Jersey Institutional funds.

Using Machine Learning Techniques to Predict Sunburn Risk in Outdoor Exercisers

Using Machine Learning Techniques to Predict Sunburn Risk in Outdoor Exercisers

In response to recreational UV exposure being associated with skin cancer (1), Julia Berteletti, MSW, and David Buller, PhD, of Klein Buendel have launched a new research project to harness technology to increase individual’s sun safety during outdoor physical activity. The title of the new project is “Using Retrospective and Real-Time Physical Activity Tracking to Predict Risk of Sunburn in Outdoor Exercisers on Strava.”

The Strava Sun Project is based on evidence that individuals who engage in more physical activity have a higher prevalence of sunburn (2, 3-6), a proximal biomarker of melanoma risk, and melanoma is positively associated with physical activity (7). For some athletes, forgetting to apply sunscreen (8,9) or not liking its feel while engaged in physical activity can be barriers to sun protection (8,10). An expert meeting hosted by the National Cancer Institute identified sun safety during physical activity as a priority research area (11) and the U.S. Surgeon General prioritized strategies for coordinating messages on sun safety and physical activity in the Call to Action to Prevent Skin Cancer (12).

Online and mobile technologies for tracking physical activity have exploded over the past decade. Many Americans wear activity trackers or GPS-enabled devices, such as  Fitbit and Garmin, and upload their physical activity data to websites/mobile apps. Strava, an activity tracking app and social networking site for athletes of all abilities, is one of the most popular. Millions share their own activities and follow and comment on physical activity by other users in their network. The goal of this project is to increase skin cancer prevention among a high-risk population, adults who engage in outdoor physical activity by establishing feasibility of interfacing sun protection advice with the Strava website/mobile app.

Specifically, the research will create an algorithm that predicts when individuals are likely to be engaged in physical activity outdoors, and delivers sun safety advice tailored to time, location, and personal risk (for example, skin sun sensitivity). The Strava Sun program will obtain user data and deliver ecologically-valid sun safety advice by utilizing Strava’s open-source Applications Programming Interface (API) and location-based advice algorithms developed by Klein Buendel for the sun safety mobile app, sunZapp (13). Machine learning techniques will be employed to develop an algorithm using Strava activities to predict high-risk behavior, such as outdoor physical activity when UV levels are high and sun safety is advised.

Overall, a sun protection interface for the Strava platform will allow for the identification of a large population of Americans at high risk for skin cancer who routinely engage in physical activity, often outdoors with high-risk sun exposure, and reach them with sun safety advice they may not seek on their own to motivate them to practice sun safety during outdoor activities.

This project is funded by a grant from the National Cancer Institute at the National Institutes of Health (CA241637; Dr. David Buller and Ms. Julia Berteletti, Multiple Principal Investigators). Co-Investigators include Dr. Kim Henry and Dr. Chuck Anderson from Colorado State University. Other collaborators include Dr. Sherry Pagoto from the University of Connecticut and Mr. Scott Camichael, a recent software engineer at Strava. Developers at Klein Buendel will produce the API database and program.

References

  1. Moehrle M. Outdoor sports and skin cancer. Clin Dermatol. 2008;26(1):12-15.
  2. Holman DM, Ding H, Guy GP, Jr., Watson M, Hartman AM, Perna FM. Prevalence of Sun Protection Use and Sunburn and Association of Demographic and Behaviorial Characteristics With Sunburn Among US Adults. JAMA Dermatol. 2018;154(5):561-568.
  3. Holman DM, Berkowitz Z, Guy GP, Jr., Hartman AM, Perna FM. The association between demographic and behavioral characteristics and sunburn among U.S. adults – National Health Interview Survey, 2010. Prev Med. 2014;63:6-12.
  4. Hall HI, Saraiya M, Thompson T, Hartman A, Glanz K, Rimer B. Correlates of sunburn experiences among U.S. adults: results of the 2000 National Health Interview Survey. Public Health Rep. 2003;118(6):540-549.
  5. Coups EJ, Manne SL, Heckman CJ. Multiple skin cancer risk behaviors in the U.S. population. Am J Prev Med. 2008;34(2):87-93. doi: 10.1016/j.amepre.2007.09.032
  6. Lawler S, Sugiyama T, Owen N. Sun exposure concern, sun protection behaviors and physical activity among Australian adults. Cancer Causes Control. 2007;18(9):1009-1014.
  7. Moore SC, Lee IM, Weiderpass E, et al. Association of Leisure-Time Physical Activity With Risk of 26 Types of Cancer in 1.44 Million Adults. JAMA Intern Med. 2016;176(6):816-825.
  8. Petty KN, Knee CR, Joseph AK. Sunscreen use among recreational cyclists: how intentions predict reported behavior. J Health Psychol. 2012;18(3):439-447.
  9. Wysong A, Gladstone H, Kim D, Lingala B, Copeland J, Tang JY. Sunscreen use in NCAA collegiate athletes: Identifying targets for intervention and barriers to use. Prev Med. 2012;55(5):493-496.
  10. Berndt NC, O’Riordan DL, Winkler E, McDermott L, Spathonis K, Owen N. Social cognitive correlates of young adult sport competitors’ sunscreen use. Health Educ Behav. 2011;38(1):6-14.
  11. Geller AC, Jablonski NG, Pagoto SL, et al. Interdisciplinary perspectives on sun safety. JAMA Dermatol. 2018;154(1):88-92. PMC5839662.
  12. U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent Skin Cancer. Washington, D.C.: U.S. Department of Health and Human Services, Office of the Surgeon General;2014.
  13. Heron KE, Smyth JM. Ecological momentary interventions: incorporating mobile technology into psychosocial and health behaviour treatments. Br J Health Psychol. 2010;15(Pt 1):1-39.

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.

Economic Analysis of a School-based Sun Protection Program

Economic Analysis of a School-based Sun Protection Program

The U.S. Surgeon General and the Centers for Disease Control and Prevention have called on the nation’s schools to help prevent skin cancer by implementing sun safety practices and policies. The Sun Safe Schools program was designed by Klein Buendel researchers and collaborators in response to those calls to action. The program was implemented and evaluated with 118 public elementary schools in California school districts with formal sun safety policy. Administrators of schools randomized to the Sun Safe Schools intervention group received phone and email support for implementing school sun safety practices by trained coaches over 20 months.

A significant part of the program evaluation — an economic analysis — has been e-published ahead of print in the American Journal of Health Promotion. The lead author is Dr. Richard Meenan, a Senior Investigator and Health Economist from the Kaiser Permanente Center for Health Research in Portland, Oregon.

The publication reports the methods, analyses, results, conclusions, and limitations of the economic analysis. Sun Safe Schools program delivery costs were micro-costed and self-reported school practices were organized into ten categories that were assigned labor and non-labor costs. Across 53 intervention schools, per-student delivery costs averaged $0.69, of which $0.44 represented school administrator time. Program delivery costs, the costs of implementing sun safety practices (such as student education, parent outreach, and shade construction), and predictors of costs are detailed in the publication.

The authors conclude that a program of phone and email coaching of elementary school administrators in school districts with formal sun safety policies can stimulate implementation of sun safety practices at a reasonable cost. The results can assist school administrators with the implementation of sun safety practices.

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). Other 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.

Parents’ Reports of School Communication on Sun Safety

Parents’ Reports of School Communication on Sun Safety

The U.S. Surgeon General and the Centers for Disease Control and Prevention have called on the nation’s schools to help prevent skin cancer by implementing sun safety practices and policies. The Sun Safe Schools program was designed by Klein Buendel researchers and collaborators in response to those calls to action. The program was implemented and evaluated with 118 public elementary schools in California.

Dr. David Buller, Klein Buendel Director of Research, presented data on the impact of the Sun Safe Schools intervention on parents’ reports of sun safety communication from schools and children’s sun protection behavior at the 12th Annual Conference on the Science of Dissemination and Implementation in Health in Washington, DC, December 4-6, 2019.

Schools randomized to the Sun Safe Schools intervention group (N=58) received support for implementing school sun safety practices by trained coaches over 20 months. Based on Diffusion of Innovations Theory, support and resources for implementation were tailored to school principals’ readiness to implement. Parents completed an online posttest survey through invitations sent by principals or while attending parent-oriented school events. Parents were surveyed to test the hypothesis that parents would report more communication about sun safety at schools receiving the intervention than at control schools.

The Sun Safe Schools program appeared to increase communication on sun safety and the use of student sun protection. Parents in intervention schools were more likely to report receiving information about sun safety from the school and that their children wore sun-protective clothing than in control schools. The improvement in sun safety appeared to result from policy implementation. In schools where principals reported implementing sun safety practices at posttest, parents reported that children spent less time outdoors and had fewer sunburns than at non-implementing schools. Further, parents who received information about sun safety from the school reported more sun protection for their child than parents not receiving the information.

In summary, a school district-level policy, combined with active technical support for schools within the district, appears to be effective at increasing implementation of school sun safety practices to help protect children from solar ultraviolet radiation, the primary risk factor for the development of skin cancer.

The Sun Safe Schools program is a joint 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, Multiple Principal Investigators). Other collaborators included 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 Chapman University; and Julia Berteletti and Mary Buller from Klein Buendel.