Dr. David Buller, Klein Buendel Director of Research, is part of a multiple institution research team that published a paper on recruitment challenges for Project SHINE. The research team is led by Dr. Yelena Wu from the University of Utah and the Huntsman Cancer Institute. The paper entitled, “Challenges and lessons learned in recruiting participants for school-based disease prevention programs during COVID-19,” was published in Contemporary Clinical Trials.
Schools provide an ideal setting for delivery of disease prevention programs due to the ability to deliver health education and counseling, including health behavior interventions, to large numbers of students. However, the remote and hybrid learning models that arose during the COVID-19 pandemic created obstacles to these efforts. The Contemporary Clinical Trials paper provides insights on collaborating with schools to deliver disease prevention programming during the height of the COVID-19 pandemic, and in subsequent years. The authors illustrate recruitment and engagement strategies by drawing upon their research experiences engaging high schools in a school-based cancer prevention trial focused on sun safety.
Delivery of a cluster-randomized trial of a school-based skin cancer prevention program was initiated in the spring of 2020 at the onset of the COVID-19 pandemic in the United States. The authors present multilevel evaluation data on strategies used to reach schools remotely and share lessons learned that may inform similar approaches moving forward during times of crises.
Although the COVID-19 pandemic interrupted school-based recruitment for this trial, enrollment improved one year later and did not appear to differ between rural and urban schools. Recruitment strategies and trial-related procedures were modified to address new challenges brought about by the pandemic. Despite the COVID-19 crisis altering classrooms, disease prevention programming can continue to be offered within schools, given close community partnerships and new adaptations to the ways in which such programming and research are conducted.
This research is sponsored by the National Cancer Institute (Dr. Yelena Wu from the University of Utah and the Huntsman Cancer Institute, Principal Investigator). Dr. David Buller from Klein Buendel is a Co-Investigator.
Klein Buendel scientists and staff continued to pursue rigorous behavioral science research with multiple national and international collaborators to positively impact the health and safety of people’s lives. Our creative team designed and engineered engaging web-based programs for many of the projects.
In 2024, we started two new large research projects with current collaborators. We co-authored 11 papers published in peer-reviewed journals or published online ahead of print, including one in the American Journal of Public Health. We presented study results at five national or international conferences, including the 6th International Conference on UV and Skin Cancer Prevention in Brisbane, Australia, where we were awarded the Best Poster prize along with our research collaborator, Emory University.
In February, Dr. Gill Woodall gave a presentation at the University of New Mexico Comprehensive Cancer Center entitled, “Randomized Trials of HPV Vaccine Uptake Improvement in New Mexico: Web Apps for Parents and Young Adolescent Girls and Boys.”
In October, Dr. David Buller was an invited presenter on a panel discussion on increasing scale-up research in cancer control, sponsored by the National Cancer Institute. His presentation was entitled “Using Technology to Scale-up and Occupational Sun Protection Program.”
Projects Launched in 2024
“Emotion Regulation Intervention to Prevent Substance Use Among Youth in the Child Welfare System.” An R61 award to Klein Buendel from the National Institute on Drug Abuse (DA059785; Dr. Chris Houck, Principal Investigator, Rhode Island Hospital). The primary Co-Investigator from Klein Buendel is Ms. Julia Berteletti.
“Hybrid Delivery to Increase Access and Sustainability: Evaluating ezParent Implementation.” A Fast Track STTR grant to Klein Buendel from the National Institute (HD116627; Dr. Susan Breitenstein, Principal Investigator, Ohio State University). The primary Co-Investigator from Klein Buendel is Ms. Julia Berteletti.
2024 Publications*
Woodall WG, Buller DB, Saltz R, Martinez L. Professional development to improve responsible beverage service training: formative research results and protocol for a randomized controlled trial. JMIR Res Protoc. 2024 Jan 24:13:e49680. doi: 10.2196/49680.
Breitenstein SM, Berteletti J, Smoske S, Barger C, Tipps K, Helsabeck NP. Administrative dashboard for monitoring use of a web-Based parent training intervention: usability study. JMIR Form Res. 2024 Jan 30:8:e53439. doi: 10.2196/53439.
Buller DB, Sussman AL, Thomson CA, Kepka D, Taren D, Henry KL, Warner EL, Walkosz BJ, Woodall GW, Nuss K, Blair CK, Guest DD, Borrayo EA, Gordon JS, Hatcher J, Wetter DW, Kinsey A, Jones CF, Yung AK, Christini K, Berteletti J, Torres JA, Perez EYB, Small A. #4Corners4Health social media cancer prevention campaign for emerging adults: protocol for a randomized stepped-wedge trial. JMIR Res Protoc. 2024 Feb 22:13:e50392. doi: 10.2196/50392.
Wu YP, Stump TK, Hay JL, Buller DB, Jensen JD, Grossman D, Shen J, Haaland BA, Jones J, Tercyak KP. Protocol for a cluster-randomized trial of a school-based skin cancer preventive intervention for adolescents. Contemp Clin Trials. 2024 May:140:107494. doi: 10.1016/ j.cct.2024.107494.
Hay JL, Wu Y, Schofield E, Kaphingst K, Sussman AL, Guest DD, Hunley K, Li Y, Buller DB, Berwick M. Exploring the role of cancer fatalism and engagement with skin cancer genetic information in diverse primary care patients. Psychooncology. 2024 Apr;33(4):e6331. doi: 10.1002/pon.6331.
Buller DB, Woodall WG, Saltz R, Martinez L, Small A, Chirico N, Cutter GR. Sales to apparently intoxicated customers in three states with different histories of responsible beverage service training. J Stud Alcohol Drugs. 2024 May;85(3):312-321. doi: 10.15288/jsad.23-00258
Kitt-Lewis E, Loeb SJ, Walkosz BJ, Olanreqaju SA, Herbeck B, Fullmer S. Just Care: usability testing of e-learning modules for peer caregivers living in prison. J Offender Rehabil. 2024 Jul;63(6):387-400. Doi: 10.1080/10509674.2024.2370289.
Buller DB, Buller MK, Meenan R, Cutter GR, Berteletti J, Henry KL, Kinsey A, Adjei I, Chirico N. Implementation of an occupational sun safety intervention: comparison of two scalability strategies. J Occup Environ Med. 2024 Oct 10. doi: 10.1097/JOM.0000000000003248. Online ahead of print.
Wu YP, Brunsgaard EK, Siniscalchi N, Stump T, Smith H, Grossman D, Jensen J, Buller DB, Hay JL, Shen J, Haaland BA, Tercyak KP. Challenges and lessons learned in recruiting participants for school-based disease prevention programs during COVID-19. Contemp Clin Trials Commun. 2024 Nov 24:42:101399. doi: 10.1016/j.conctc.2024.101399. eCollection 2024 Dec.
McCrady BS, Woodall WG, Berteletti J, Starling R, Martinez L, Westerberg V, Brooks M, Starke T. Developing a smartphone web app to help DWI offenders and their families. J Subst Use Addict Treat. 2025 Jan:168:209565. doi: 10.1016/j.josat.2024.209565. Online ahead of print.
Buller DB, Berteletti J, Heckman C, Schroth K, Geller AC, Stapleton JL, Adjei I, Mitarotondo A, Guild SR, Gershenwald JE, Dellavalle R, Pagoto S. Bills to Restrict Access to and Harm from Indoor Tanning Facilities in US State Legislatures, 1992–2023. Am J Public Health. Online ahead of print 10.2105/AJPH.2024.307894.
*KB investigators and staff are indicated in bold type
2024 Conference Presentations
Several presentations on research progress, procedures, analyses, and outcomes were given by Klein Buendel scientists, staff, and their collaborators at the following national and international conferences:
45th Annual Meeting of the Society of Behavioral Medicine (March)
36th Annual Scientific Sessions of the Eastern Nursing Research Society (April)
47th Annual Scientific Meeting of the Research Society on Alcohol (June)
6th International Conference on UV and Skin Cancer Prevention (September)
36th International Papillomavirus Conference (November)
Klein Buendel and Emory University won Best Poster at the UV Conference in Australia for “Narrative Synthesis of Skin Cancer Prevention Interventions for Samples with High Proportions of Participants with Skin of Color in a Systematic Review.” The poster was presented by Ms. Irene Adjei from Klein Buendel.
Driving while intoxicated (DWI) results in significant morbidity and mortality. The use of vehicle ignition interlock devices decreases the risk of drinking and driving while installed, but DWI rates increase after the devices are removed. Dr. W. Gill Woodall, Klein Buendel Senior Scientist, and his research collaborators have developed and tested the B-SMART smartphone web app to continue to support offenders and their concerned family members after their ignition interlock devices have been removed. They have published their methods and results of usability testing online in the Journal of Substance Use and Addiction Treatment.
Formative data collection for app development occurred in two phases. Phase 1 included key informant interviews with DWI offenders and concerned family members, development of one app module, and usability testing. Phase 2 included focus groups with DWI offenders and concerned family members, development of three more app modules, and usability testing. The Bangor System Usability Scale was used to rate app usability and satisfaction.
Results of key informant interviews and focus groups indicated that offenders and family members lacked information and were frustrated by the ignition interlock device, experienced financial burden from the DWI and the device, viewed supportive communication and positive shared activities as important, and were positive about the app. The four modules developed were Life with Interlock, Supporting Changes in Drinking, Doing Things Together, and Effective Communication. Each module included an introduction, at least one interactive activity, a video, and text to summarize what was presented. The content of the app modules was written primarily for the concerned family members. Usability testing indicated that the B-SMART modules were easy to use and informative.
The paper published online in the Journal of Substance Use and Addiction Treatment details the research measures, methods, analyses. A diagram describes the flow for the features and design of the app. This careful formative work resulted in an app responsive to the concerns of DWI offenders with ignition interlock devices and their concerned family members.
The authors believe that harnessing the power of the family to help the offender maintain a pattern of driving when not impaired may yield longer, successful outcomes initiated by the ignition interlock device. A future paper will report the efficacy of the B-SMART app after its implementation and testing in a rigorous randomized trial.
This research was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (AA022850; Dr. W. Gill Woodall, Principal Investigator). Collaborators included Dr. Barbara McCrady, Dr. Randall Starling, and Dr. Vern Westerberg from the University of New Mexico; Mr. Thomas Starke from Impact DWI in Sante Fe, New Mexico; and Ms. Julia Berteletti, Ms. Marita Brooks, and Ms. Lila Martinez from Klein Buendel. The B-SMART app was developed by the Creative Team at Klein Buendel.
Two Klein Buendel scientists presented HPV vaccination research at the 36th International Papillomavirus Conference in Edinburgh, Scotland, November 12-15, 2024.
Poster 1
Title: HPV Vaccine Uptake Improvement for Adolescent Boys via a Mobile Web App: TeenVac.org
Human Papillomavirus (HPV) vaccine uptake remains below the U.S. national goal of 80% series completion. Parental concerns and misinformation about the HPV vaccine’s efficacy and safety remain and may be addressed by digital interventions tailored to their concerns.
Based on a previous intervention focused on parents and adolescent daughters, a randomized controlled trial was conducted testing a mobile web app (TeenVac.org) for parents and their adolescent sons (ages 11-14 years), responsive to their concerns and encouraging HPV vaccination. Two hundred nine (209) participants were randomized to receive either the TeenVac app (n=100) or the standard CDC HPV vaccination pamphlet (n=109) online. Adolescent sons’ vaccination records were collected from the New Mexico vaccine registry at the end of the study.
Intent-to-treat and web usage analyses were conducted. Intent-to-treat analyses found that adolescent sons of parents who were randomized to the TeenVac app were significantly more likely to complete the HPV vaccination series than the CDC pamphlet comparison group. Web usage analysis determined that those parents in the TeenVac group who used the web app were significantly more likely to complete the HPV vaccination series than those in the CDC pamphlet group. Modules focused on nature of HPV, the vaccine, and who recommends it were most used, with average durations ranging from 84 to 122 seconds.
The TeenVac app had a meaningful impact on HPV vaccine shot completion, particularly among parents who used the web app. The study trial’s recruitment and implementation were affected by the COVID-19 pandemic, with 86% of parent-adolescent pairs recruited during this period. Despite these challenges, the results provide further evidence that digital interventions can improve vaccine uptake when focused on parents and sons’ vaccine-related concerns.
This research was funded by a grant from the National Cancer Institute (CA210125; Dr. W. Gill Woodall, Principal Investigator). Collaborators were from the University of New Mexico, Indiana University, and Klein Buendel.
Poster 2
Title: Development of Social Media Posts Promoting HPV Vaccination to Emerging Adults in Rural Communities of the united States
Presenter: David Buller, PhD
Authors: David Buller, PhD; Andrew Sussman, PhD; Echo Warner, PhD; Alishia Kinsey; W. Gill Woodall, PhD; Deanna Kepka, PhD; Barbara Walkosz, PhD; Julia Berteletti, MSW; Annelise Small; Dolores Guest, PhD; John Torres
Dr. David Buller
HPV-related cancers are increasing in rural areas of the United States and HPV vaccination rates of emerging adults are low. A social media campaign promoting HPV vaccine uptake, along with five other cancer risk-reduction behaviors, is being developed for emerging adults aged 18-26 living in rural counties in the western United States. Campaign posts were pilot-tested with emerging adults (n=188) in surveys on appropriateness, relevance, and trustworthiness and likelihood of engaging with them (such as read, scroll past, react [such as like, sad, etc.], comment, and click on a shared link). Also, emerging adults (n=26) were enrolled in a 4-week study where they received HPV vaccination posts in a Facebook private group and engagement (such as views, reactions, comments) was recorded.
Initially, 36 posts on HPV vaccination were developed addressing simplicity, benefits, response efficacy/cost, self-efficacy/perceived control, cancer risk perceptions, norms, relatedness, compatibility with goals/values, and intrinsic/extrinsic motivation. Posts debunked common misinformation on HPV vaccines, stressed that unvaccinated emerging adults should get vaccinated, and advised emerging adults on how to discuss HPV vaccination with family and friends. Emerging adults evaluated seven HPV vaccination posts in the surveys and rated them as appropriate, relevant, and trustworthy. Two-thirds of emerging adults said they would read the posts, but also might scroll past them. Over one-third would click on a shared link or leave a reaction, but few would comment. In the 4-week study, seven HPV vaccination posts received 115 views, 26 reactions, and 2 comments (both positive).
Social media is a primary health information source for young adults. Posts promoting HPV vaccination based on health behavior theories can reach and engage emerging adults with HPV vaccine-supportive messaging. The HPV posts will be included in a cancer prevention campaign evaluated in a randomized trial enrolling 1000 emerging adults in 2025.
This research was funded by a grant from the National Cancer Institute (CA268037; Dr. David Buller and Dr. Andrew Sussman, Multiple Principal Investigators). Collaborators were from the University of New Mexico Comprehensive Cancer Center, the University of Utah Huntsman Cancer Institute, and Klein Buendel.
Collaborator Spotlight: Arizona Investigators on the #4Corners 4Health Project
Thirteen scientists from universities and NCI Comprehensive Cancer Centers in Arizona, Colorado, New Mexico, and Utah are collaborating with Dr. David Buller, Klein Buendel’s Director of Research, on the #4Corners4Health study(CA268037). This Collaborator Spotlight features the Investigators from the State of Arizona.
The 4Corners study aims to aid rural emerging adults (ages 18-26 years) in making informed decisions that reduce cancer risk factors and prevent cancer later in life and to help emerging adults evaluate and resist misinformation and marketing that promote cancer risk behaviors. This will be accomplished using a social media campaign designed with community advisors for diverse young adults living in rural counties in the Four Corners states (AZ, CO, NM, and UT). Social media may reach emerging adults more than interventions through other community channels (for example, clinics, schools, and workplaces) and for lower cost in the geographically dispersed, underserved rural communities in the Mountain West.
Dr. Judith Gordon, Co-Investigator, University of Arizona
Judith S. Gordon, Ph.D., is a professor and Associate Dean for Research in the University of Arizona College of Nursing. She is also a professor in the University of Arizona Department of Family and Community Medicine. Dr. Gordon’s areas of expertise include public health tobacco cessation and vaping interventions delivered in dental and medical settings, self-help tobacco and vaping cessation programs, educational tobacco and vaping cessation programs for healthcare practitioners, computer-based tobacco and vaping prevention programs, multi-behavioral interventions to address weight, physical activity, and tobacco, the use of mobile apps for lifestyle change and medication adherence, and the use of guided imagery for tobacco cessation, lifestyle change, exercise motivation, and stress reduction. Dr. Gordon has been a Principal Investigator or Co-Investigator on more than 40 projects funded by the National Institutes of Health, the Department of Defense, and the Robert Wood Johnson Foundation. She has authored and co-authored numerous publications in peer-reviewed journals and has presented widely at national and international scientific conferences. She has served on several proposal review committees, editorial boards, and professional societies.
Dr. Meghan Skiba, Co-Investigator, University of Arizona
Dr. Meghan Skiba, PhD, MS, MPH, RDN, is an Assistant Professor in the College of Nursing Biobehavioral Health Science Division at the University of Arizona. She received her doctorate in Health Behavior Health Promotion from the Mel & Enid Zuckerman College of Public Health. She has additional formal graduate training in epidemiology and nutritional sciences, and completed post-doctoral training at Oregon Health & Science University. Dr. Skiba has extensive training in nutritional sciences, health promotion, behavior measurement, and epidemiology. The focus of her research is to connect cancer survivors and their caregivers to the tools and skills to live their healthiest life. She focuses on healthy aging, women’s health, rural populations, and dyadic health. She takes an integrative approach to research to understand the synergistic effects of nutrition, exercise, energetics, and bioactives and their roles in managing accelerated biological aging in cancer survivorship. She strives to build an innovative research program that incorporates analysis of large datasets, community-based participatory research methods, and sequential interventions to better understand and mitigate and the biological aging cascade in cancer.
Implementation of an Occupational Sun Safety Intervention: Comparison of Two Scalability Strategies
Klein Buendel investigators and their collaborators have published the results of the Go Sun Smart at Work project in the Journal of Occupational and Environmental Medicine. This research compared two methods for scaling up an evidence-based occupational sun protection program nationwide. One hundred thirty-eight (138) regional districts in 21 state Departments of Transportation throughout the United States were randomized to receive the Go Sun Smart at Work program via in-person or digital scalability methods in 2019-2022 in 1:2 ratio. Managers completed pretest and posttest surveys and employees completed posttest surveys. Due to the COVID-19 pandemic, only posttest measures were analyzed (from 255 managers and 1387 employees).
After scale-up, more employees reported training and communication at workplaces in in-person rather than digital strategy. There were no differences in managers’ reports of sun protection training, communication, or actions by scalability method. Overall, occupational sun protection was implemented during program scale-up and employees recalled training/communication more in the in-person than digital strategy. A full description of methods, analyses, and results can be found in the Journal of Occupational and Environmental Medicine publication.
The research was supported by a Cancer Moonshot Initiative grant from the National Cancer Institute (CA210259; Dr. David Buller, Principal Investigator). Collaborators include Dr. Richard Meenan from Kaiser Permanente Center for Health Research, Dr. Gary Cutter from the University of Alabama in Birmingham, Dr. Kimberly Henry from Colorado State University, and Ms. Mary Buller, Ms. Julia Berteletti, Ms. Alishia Kinsey, Ms. Irene Adjei, and Mr. Noah Chirico from Klein Buendel. The authors thank the American Association of State Highway and Transportation Officials (AASHTO) and the senior managers of the participating state Departments of Transportation for supporting this project.
Positive parenting practices help support optimal child social and emotional development. Parent training is considered a gold standard for supporting and strengthening parenting practices and for treating and preventing child behavior problems. A new research grant awarded to Klein Buendel will develop and test a comprehensive implementation package (the ezParent Bundle) to support the hybrid delivery of the ezParent Program.
Klein Buendel Research Investigator, Ms. Julia Berteletti, and the Klein Buendel Creative Team are collaborating with Dr. Susan Breitenstein from Ohio State University (Principal Investigator) on the project. ezParent is the web-based delivery mechanism of the Chicago Parent Program. ezParent integrates empirically supported parenting strategies and includes video vignettes, interactive activities, and in-home practice. The new bundle will include asynchronous web-based facilitator training and the ezParent dashboard, which allows facilitators to track parent program use and offer support.
Young children’s behavioral health is declining with current estimates of up to one-third of preschool children exhibiting behavior problems (such as tantrums, defiance, and aggression). Behavior problems have been more pronounced in minoritized and low-income populations and because of the COVID-19 pandemic. Positive and supportive parenting can buffer the negative effects of early adverse experiences and childhood trauma.
The primary method of delivering parent training involves face-to-face, in-person sessions. Although effective, there are multiple limitations with in-person parent training delivery affecting access and reach (such as time; schedule conflicts; access to childcare, transportation, trained facilitators; and stigma). These barriers result in many referred parents not receiving parent training. Parent completion access issues are more pronounced in underserved communities. An overall goal of this research is to expand parent training access in community organizations dedicated to serving low-income families [such as Head Start and Early Head Start (HS/EHS)].
Many web-based parent training programs are self-administered, yet there is evidence suggesting web-based programs are more effective when paired with human support, known as hybrid delivery. Trained facilitators can foster parent completion of web-based programs and tailoring of strategies. However, parent training programs lack a proven method for systematically integrating facilitator training in an accessible manner. In addition, for hybrid models to be effective, facilitators require methods to monitor and track parent use of the program. Real-time access to training can increase program sustainability and user tracking allows support to be tailored based on parent program use and individual needs.
The ezParent bundle will be evaluated in a cluster randomized trial in 16 HS/EHS sites with personnel facilitators and 516 parents of children aged 2-5 years old. The investigators hypothesize that relative to the control group, parents in the ezParent bundle group will report greater improvements in parenting skills and self-efficacy, parent-child relationship, and reductions in child behavior problems.
This STTR Fast Track grant was awarded to Klein Buendel by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (HD116627; Dr. Susan Breitenstein, Principal Investigator from Ohio State University). Research collaborators include Ms. Julia Berteletti from Klein Buendel, and Dr. Amie Bettencourt and Dr. Deborah Gross from Johns Hopkins University. The ezParent technology will be designed and programmed by the Creative Team at Klein Buendel.
6th International Conference on UV and Skin Cancer Prevention: Posters
Klein Buendel research investigators and staff presented three posters on their skin cancer prevention research at the 6th International Conference on UV and Skin Cancer Prevention in Brisbane, Queensland, Australia, September 10-13, 2024.
Poster 1 – This poster won a BEST POSTER AWARD at the conference.
Title: Narrative Synthesis of Skin Cancer Prevention Interventions for Samples with High Proportions of Participants with Skin of Color in a Systematic Review
Presenter: Irene Adjei, BS
Authors: David Buller, PhD; Alexandra Morshed, PhD; Radhika Agarwal, MPH; Irene Adjei, BS; Shenita Peterson, MPH; Cam Escoffery, PhD; Mary Buller, MA; Barbara Walkosz, PhD; Kayla Anderson, MPH
While melanoma and keratinocyte skin cancers are very prevalent in light-skinned non-Hispanic (NH) White adults in the United States, rates of skin cancer may be increasing in Hispanics, African Americans present with thicker lesions, and both Hispanics and African Americans have higher skin cancer mortality rates than NH Whites. Ethnic minority adults may have lower knowledge and risk perceptions, practice sun protection infrequently and for reasons other than skin cancer, have less access to dermatologists, and receive fewer skin exams than NH Whites. As part of a project adapting an evidence-based occupational program to be more equitable by including lower-risk African American and Hispanic worker populations, investigators conducted a systematic literature review of 25 behavioral skin cancer prevention interventions. Investigators extracted information from 10 studies (2014-2022) that evaluated interventions in samples with 20% Hispanic and/or African American participants. Interventions were delivered in eight clinical and two community settings through verbal (for example, a community health worker), printed, visual (for example, videos/photographs), and e-messages. Adaptations for individuals with skin of color included incorporating culturally relevant images, culturally appropriate language (including Spanish translation), and testimonials, informed by diverse research staff and interested individuals. Seven studies evaluated interventions in randomized controlled trials, two in non-randomized experimental designs, and one in a cohort study, with interventions primarily showing improvements in knowledge, perceived risk, and reported sun protection. To be effective with lower-risk populations, skin cancer prevention interventions should incorporate cultural tailoring of images, language, and testimonials. This research was funded by a grant from the Centers for Disease Control and Prevention (U48DP006377; Alexandra Morshed and David Buller, Multiple Principal Investigators).
Poster 2
Title: Feasibility of Using Location-Based Data through the Strava App to Provide Tailored Sun Protection Advice to Outdoor Exercisers
Presenter: Alishia Kinsey, BS
Authors: Alishia Kinsey, BS; Julia Berteletti, MSW; David Buller, PhD; Chuck Anderson, PhD; Kimberly Henry, PhD
Individuals who engage in more physical activity have a higher prevalence of sunburn, and melanoma is positively associated with physical activity. This study was designed to determine the feasibility of using Strava, a popular exercise tracking app, to promote sun protection tailored to individuals who engage regularly in outdoor physical activity. To provide tailored sun protection advice, investigators connected through the Strava Application Programming Interface (API) to collect retrospective activity data from users who consented and authorized collection of data from the past two years. Despite robust recruitment efforts, only 78 Strava users provided this authorization. From these users, 16,669 outdoor activity events were accessed. Of those activities, 46.1% occurred during high UV (between 10 am and 4 pm) for at least 30 minutes. Using predictive modeling, time outdoors for more than one hour during high UV was predicted by day of week (more likely occurs on weekends) or proximity to a high UV event (less likely occurs the day after a previous high UV event). While Strava users are active and prone to overexposure to the sun, privacy settings in the Strava app, which became more restrictive during the study, and users’ resistance to share their data were substantial barriers to employing the app to deliver tailored advice on sun safety. It may be possible to predict when exercisers would be outside during high UV periods if periodicity of individuals’ exercise bouts are known (information that users might be willing to disclose in a mobile app without sharing location data). This research was funded by a grant from the National Cancer Institute (CA241637; Dr. David Buller and Ms. Julia Berteletti, Multiple Principal Investigators).
Poster 3
Title: Gender Differences in the Sun Safety Practices of Tattoo Studio Clients
Presenter: Mary Buller, MA
Authors: Barbara Walkosz, PhD; Mary Buller, MA; David Buller, PhD; Robert Dellavalle, MPH, MD
Melanoma is the one of the most common cancers among young adults and low rates of sun protection are elevated in this group. Approximately 225 million people worldwide have tattoos and 40% of adults ages 18-29 have at least one tattoo. The Sun Safety Ink! program trained tattoo artists to promote full-body comprehensive sun protection to clients to compliment standard aftercare instructions that recommend sun protection for new tattoos. Thirty-seven tattoo studios participated. At pretest, 861 clients completed an online survey and self-reported sun protection on a 5-point scale as: apply sunscreen SPF 15+ on face (aftershave, face lotion, or make-up); apply sunscreen SPF 30+ exposed skin areas; reapply sunscreen; apply sunscreen lip balm; wear any hat; wear wide-brimmed hat; wear sunglasses; stay mostly in the shade; wear protective clothing; watch skin for sunburn or tanning. Women were significantly more likely to apply sunscreen of SPF 15+ on the face, apply sunscreen of SPF 30+ to exposed skin, reapply sunscreen every two hours, limit time in the sun, and watch their skin for signs of sunburn. Men were significantly more likely to wear any hat and a brimmed hat. Strategies are needed to promote specific sun protection practices for men and women as these reported practices have remained persistent. This research was funded by a grant from the National Cancer Institute (CA206569; Barbara Walkosz and Robert Dellavalle, Multiple Principal Investigators).
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Klein Buendel investigators and staff were collaborators on two additional skin cancer prevention research posters at the UV and Skin Cancer Prevention conference.
Poster 4
Title: Indoor Tanning Facility Regulation Compliance in the United States Remains Suboptimal: A Confederate Study
Presenter: Carolyn Heckman, PhD
Authors: Carolyn Heckman, PhD; Anna Mitarotondo; Melissa Goldstein, MS; Rucha Janodia; Ileana Gonzalez; Julia Berteletti, MSW; David Buller, PhD
In the United States, indoor tanning is regulated by the Food and Drug Administration (FDA) and individual state legislation. Twenty-two states and the District of Columbia ban minors under age 18 from indoor tanning, 22 have varying age restrictions and parental involvement requirements, and six have no age restrictions. This study assesses law compliance of indoor tanning facilities, hypothesized to be insufficient and inconsistent. Trained female staff pseudo-patrons called indoor tanning facilities (such as indoor tanning salons, beauty salons/spas, gyms, apartments) posing as minors one year younger than the state’s permitted age to tan (for example, 17 in a state banning indoor tanning under age 18). Pseudo-patrons asked about unlimited indoor tanning packages (contrary to FDA recommendations), sunburns, and whether they were permitted to indoor tan. One hundred and twelve (112) calls were completed across 15 states. Twenty-one percent of facility staff did not ask pseudo-patrons for their age, and 41% told pseudo-patrons they could indoor tan despite being underage. Forty-one percent (41%) of gyms/apartments did not require pseudo-patrons to be a member/tenant to indoor tan. Eight-one percent (81%) of facilities offered unlimited indoor tanning packages or unlimited access during open hours, and 29% of staff did not admit to pseudo-patrons that they could be sunburned from indoor tanning. Although many state laws restricting indoor tanning have been passed in the United States, and indoor tanning has decreased, facilities continue to be non-compliant with restrictions for minors, putting children at risk of sunburns and skin cancer. Further analyses will evaluate compliance by type of facility, law stringency, and U.S. region. This research was supported by a grant from the National Cancer Institute (CA244370; Carolyn Heckman and David Buller, Multiple Principal Investigators).
Poster 5
Title: Adolescents’ Perceived Threat and Perceived Efficacy in Relation to Skin Cancer: Associations with Tanning, Sunburns, and Sun Protection
Presenter: Tammy Stump, PhD
Authors: Tammy Stump, PhD; Jennifer Hay, PhD; Kenneth Tercyak, PhD; David Buller, PhD; Douglas Grossman PhD, MD; Jacob Jensen, PhD; Jincheng Shen, PhD; Yelena Wu, PhD
According to the Extended Parallel Process Model (EPPM), health promotion programs are optimally successful when they heighten the perceived threat of a medical condition while also enhancing perceived efficacy for offsetting that threat. For skin cancer prevention, the authors developed a school-based intervention based on EPPM constructs. The program was designed to both enhance perceived threat of skin cancer (such as susceptibility, severity) and perceived efficacy for sun protection (such as self-efficacy, response efficacy). In advance of the intervention, 2,199 participants (52% female) at 36 Utah high schools completed a baseline survey, which was analyzed as an initial test of the conceptual model underlying the intervention approach. Within a series of linear regression models, all four EPPM constructs were simultaneously entered as independent variables. Self-reported sun protection, tanning (intentional, outdoor, and unintentional), and sunburns served as dependent variables. In these models, self-efficacy significantly predicted all outcomes. Response efficacy for sun protection was associated with greater weekend sun protection. Susceptibility to skin cancer was significantly associated with all outcomes except indoor tanning. Severity of skin cancer was significantly associated with sun protection use only. In sum, self-efficacy was the strongest predictor of outcomes whereas perceived severity of skin cancer had a small effect, and only on one outcome. Overall, these findings suggest that by targeting EPPM constructs, the intervention is likely to have an effect on adolescents’ tanning, sunburns, and sun protection behaviors. This research is sponsored by the National Cancer Institute (Dr. Yelena Wu from the University of Utah and the Huntsman Cancer Institute, Principal Investigator).
6th International Conference on UV and Skin Cancer Prevention: Presentations
Klein Buendel research investigators and staff gave three oral presentations on their skin cancer prevention research at the 6th International Conference on UV and Skin Cancer Prevention in Brisbane, Queensland, Australia, September 10-13, 2024.
Presentation 1
Title: Comparison of Two Scalability Methods for Nationwide Dissemination of an Occupational Sun Protection Intervention in a Randomized Trial
Presenter: David Buller, PhD
Authors: David Buller, PhD; Julia Berteletti, MSW; Mary Buller, MA; Kimberly Henry, PhD; Richard Meenan, PhD; Gary Cutter, PhD; Alishia Kinsey, BA; Irene Adjei, BS; Noah Chirico, MPH
The promise of sun protection interventions relies on successfully disseminating them to new populations and settings with sufficient fidelity to be effective. Two methods for disseminating our evidence-based occupational sun protection intervention, Go Sun Smart at Work, were evaluated. One hundred thirty-eight (138) regional districts from 21 state Departments of Transportation throughout the United States were randomized to two scalability methods in a randomized pretest-posttest two-group design. The in-person scalability method included in-person visits to the workplaces to meet with managers and deliver training to employees. The digital scalability method utilized low-cost virtual communication with managers and video training for employees. At posttest, 255 managers reported their program implementation actions while 1387 employees reported receipt of sun safety training/communication and protection practices. Nearly all managers reported implementing training, communication, and sun protection actions, but implementation did not differ by scalability method. However, more employees reported sun protection training and communication from in-person than digital scalability method. Employee sun protection practices were unrelated to scalability method. Both scalability strategies motivated managers to implement sun safety training and communication, and more than other sun safety actions, possibly because training/communication fit into existing safety training processes and communication channels and required few resources. In-person training is preferred by many workers and technological barriers may have interfered with digital training delivery. Restrictions placed on the workplaces due to the COVID-19 pandemic interfered with scalability, possibly biasing the result towards the null. This research was funded by a grant from the National Cancer Institute (CA210259; David Buller, Principal Investigator).
Presentation 2
Title: The Development of the GSSW SmartBot: A Virtual Guide for Occupational Sun Safety Implementation
Presenter: Mary Buller, MA
Authors: Mary Buller, MA; Barbara Walkosz, PhD; David Buller, PhD; Julia Berteletti, MSW; Brandon Herbeck, B; Irene Adjei, BS; Robert Martin; Steven Fullmer, BFA
Outdoor workers are exposed to an extreme amount of solar ultraviolet radiation, making them highly vulnerable to skin cancer and heat illness. Increasing disparities in skin cancer survival and heat mortality in Black and Hispanic Americans, who are overrepresented in the outdoor workforce in the United States, highlight the need for inclusive and comprehensive sun safety education. Informed by systematic literature reviews and interviews with employees and managers, Go Sun Smart at Work (GSSW), an evidence-based skin cancer prevention program, was adapted to include enhanced messaging for people of color and to combine skin cancer and heat illness prevention. An online format was used, in response to the COVID-19 pandemic, to make sun safety implementation accessible, flexible, and simple for employers. A custom intelligent system, the SmartBot, guides employers (for example, safety managers) through three program components: policy, training, and implementation. It asks users questions about their organization and uses an enhanced version of the GravityForms survey engine to identify and tailor sun safety resources based on their responses. As users progress through the SmartBot, they collect resources from a library of sun safety content (Resource Hub). Built with the WordPress Content Management System, the Resource Hub includes informational videos, posters, fact sheets, a 45-minute training with quizzes, and sample safety policies. Users can return to their Resource Hub to retrieve resources or quickly search and filter all the resources in the system. The SmartBot’s impact on employee sun protection will be tested with 20 employers in a randomized field trial. This research was supported by a grant from the National Cancer Institute (CA257778; Mary Buller, Principal Investigator).
Presentation 3
Title: Bills to Restrict Access to Indoor Tanning Facilities in U.S. State Legislatures, 1991-2023
Presenter: David Buller, PhD
Authors: David Buller, PhD; Julia Berteletti, MSW; Carolyn Heckman, PhD; Kevin Schroth, JD; Alan Geller, RN; Jerod Stapleton, PhD; Irene Adjei, BS; Anna Mitarotondo, BA; Samantha Guild, JD; Jeffrey Gershenwald, MD; Donna Regen, BA
In the United States, indoor tanning facilities are regulated by state legislation and U.S. Food and Drug Administration. State laws with more stringent age restrictions are associated with less indoor tanning by youth. Legislative bills on indoor tanning introduced in states, the District of Columbia (DC), and Puerto Rico were collected and coded for age restrictions, parental involvement, warnings, operator requirements, and enforcement. Overall, 184 bills were introduced in 49 of 50 states and DC between 1991 and 2023, mostly after 2008. Overall, 56 bills were passed and enacted in 47 states and DC, and 126 bills failed. The first bill banning minors under age 18 from indoor tanning facilities was enacted in 2012, with an under-18 ban currently enacted in 22 states and DC. Age restrictions at other younger ages (14-17.5 years) were enacted in 10 other states. In many states, it took several years and proposed bills before a law was passed, with proposed bills typically becoming more stringent over time and enacted bills being more stringent than failed bills. However, warnings, operator requirements, and enforcement provisions were classified as weak in most bills. Association of political party of both bill sponsor and legislative majority with age restrictions and bill enactment were presented. Bills restricting indoor tanning facilities, including those restricting minors under age 18, have garnered support across the U.S. political spectrum. Findings can inform advocates and legislators on ways to increase stringency of indoor tanning laws that can contribute to decreasing rates of melanoma in young adults. This research was supported by a grant from the National Cancer Institute (CA244370; Carolyn Heckman and David Buller, Multiple Principal Investigators).
Collaborator Spotlight: Utah Investigators on the #4Corners 4Health Project
Thirteen scientists from universities and NCI Comprehensive Cancer Centers in Arizona, Colorado, New Mexico, and Utah are collaborating with Dr. David Buller, Klein Buendel’s Director of Research, on the #4Corners4Health study(CA268037). This Collaborator Spotlight features the Investigators from the State of Utah.
The 4Corners study aims to aid rural emerging adults (ages 18-26 years) in making informed decisions that reduce cancer risk factors and prevent cancer later in life and help emerging adults evaluate and resist misinformation and marketing that promote cancer risk behaviors. This will be accomplished using a social media campaign designed with community advisors for diverse young adults living in rural counties in the Four Corners states (AZ, CO, NM, and UT). Social media may reach emerging adults more than interventions through other community channels (for example, clinics, schools, and workplaces) and for lower cost in the geographically dispersed, underserved rural communities in the Mountain West.
Dr. Deanna Kepka, Co-Investigator, Huntsman Cancer Institute, University of Utah
Deanna Kepka, PhD, MPH, is a Huntsman Cancer Institute research investigator and a tenured Associate Professor in the College of Nursing. Dr. Kepka is dedicated to improving the quality of primary health care services for cancer prevention and control among underserved populations locally and globally. She has specific expertise in HPV vaccination, HPV-related cancer prevention, and health equity research. She is the founder and director of the Mountain West HPV Vaccination Coalition and the Director of Global and International Health in the College of Nursing.
As a Pre-Doctoral Biobehavioral Cancer Prevention and Control Fellow at the University of Washington and Fred Hutchinson Cancer Research Center, Dr. Kepka developed a rural-focused community-based HPV vaccination intervention that included fotonovela educational pamphlets and a radionovela. These educational tools improved knowledge and sparked interest in the HPV vaccine among rural Latino parents. She also received training in epidemiological and behavioral research methods as a National Cancer Institute Cancer Prevention Post-Doctoral Fellow. As a Fellow, she received the Cancer Prevention Fellowship Merit Award. In the years since, Dr. Kepka’s work has been recognized with 20 awards for excellence at the international, national, local levels.
Dr. Echo Warner, Co-Investigator, Huntsman Cancer Institute, University of Utah
Echo Warner, Ph.D., MPH, is an Associate Member of the Huntsman Cancer Institute and an Assistant Professor in the College of Nursing. Her research targets improving cancer health outcomes and reducing cancer health disparities among adolescent and young adult cancer patients, survivors, and care partners. Dr. Warner has experience with diverse patient populations and an extensive range of methods and analytical approaches, especially in mixed-methods study designs and data integration. Her research establishes methods to study social media and online health (mis)information to improve cancer information seeking online.
Dr. David Wetter, Co-Investigator, Huntsman Cancer Institute, University of Utah
David Wetter, Ph.D., M.S., is the distinguished Jon M. and Karen Huntsman Presidential Professor, Director of the Center for Health Outcomes and Population Equity (HOPE), Senior Director for Cancer Health Equity Science, and Associate Director for Practice Engagement and Translation at the Clinical and Translational Sciences Institute at the University of Utah and Huntsman Cancer Institute. His research focuses on promoting health equity in cancer and chronic disease through translational research. Specific research topics include (a) theoretical models of health risk behaviors; (b) the development and evaluation of theoretically-based interventions; and, (c) translational research to implement and disseminate those interventions in real world settings. His work addresses populations that have been historically marginalized, with a major focus on low socioeconomic status, rural/frontier, and diverse groups. Dr. Wetter has conducted an extensive portfolio of grants funded by the National Institutes of Health over 25 years. He has published nearly 300 peer-reviewed manuscripts. His research program has received awards from the Society of Behavioral Medicine, American Society for Preventive Oncology, Society for Health Psychology, and AstraZeneca/Scientific American.
