Mandatory Training Increases Drink Refusals to Intoxicated Patrons in California

Mandatory Training Increases Drink Refusals to Intoxicated Patrons in California

Klein Buendel scientists and staff are collaborators on a study that evaluated mandatory responsible beverage service training in California and its association with higher refusals of service to apparently intoxicated patrons in drinking establishments. The study, led by Dr. Robert Saltz at the Pacific Institute for Research and Evaluation, has been published in the Journal of Studies on Alcohol and Drugs.

The California Responsible Beverage Service (RBS) Training Act mandated training for all alcohol servers by 2023, giving this multi-institutional research team a rare opportunity to see how a statewide initiative might influence server behavior.

In 2022, 300 licensed on-premises establishments were sampled in nine counties in and around the San Francisco Bay Area. From July 2022 to January 2023, pseudo-patron and observer teams visited each establishment, and pseudo-patrons attempted to buy alcohol while displaying obvious signs of intoxication. The outcome of each purchase attempt and characteristics of establishments, servers, and pseudo-patrons, and month, day, and time, were recorded. In 2024, the same premises were visited as a follow up.

At baseline, 19.6% of the outlets refused service to the pseudo-patron. At follow up, the refusal rate increased significantly to 39.2% in a regression model controlling for establishment, server, and pseudo-patron characteristics. A typology of establishments (such as sports bar, casual restaurant, fine dining restaurant) did not show any association with refusal rate except that fine dining places refused more often than other types of establishments. Observers’ ratings of how obvious the pseudo-patron’s apparent intoxication was strongly associated with refusals.

The researchers conclude that there was substantial improvement in alcohol over-service refusals two years after the California mandatory RBS training law went into effect.

This research was funded by a grant to PIRE from the National Institute on Alcohol Abuse and Alcoholism (AA028772; Dr. Robert Saltz, Principal Investigator).  Co-authors include Dr. Mallie Paschall and Dr. Sharon O’Hara from PIRE; and Dr. W. Gill Woodall, Dr. David Buller, and Ms. Lila Martinez from Klein Buendel.  

Feasibility of the STAC-T Bullying Bystander App

Feasibility of the STAC-T Bullying Bystander App

Bullying is a significant public health issue, with approximately 25% of middle school students reporting being a target of bullying in the past year. STAC is an evidence-based bullying bystander intervention for middle school students. A multi-institutional research team developed a technology-based version of STAC (STAC-T) and evaluated the acceptability and relevance of the program, as well as how acceptability and relevance are related to the use of specific skills (STAC strategies) students learn in the program. Significance, methods, data, and results have been published in the scientific journal, JMIR Formative Research.

STAC-T, which included a 40-minute training and a 15-minute booster session, was completed by 249 middle school students recruited from six middle schools in rural, low-income communities in the United States. Students completed a post-training survey assessing program acceptability and relevance, whether they witnessed bullying post-training, and the use of the STAC strategies to intervene in bullying situations. Descriptive statistics were used to assess acceptability, relevance, and the use of STAC strategies. Linear regression analysis was used to assess the relationship of program acceptability and relevance to STAC strategy use.

Most students reported the program was acceptable (82.1 to 90.0%) and relevant (78.6 to 83.0%) for students at their school; 88.8% (111) of the 50.2% (125) of students who witnessed bullying post-training also reported the use of at least one STAC strategy to intervene when witnessing bullying. Program relevance was a significant predictor of post-training use of STAC strategies. In contrast, program acceptability was not a significant predictor of post-training STAC strategy use.

This study provides support for the acceptability and relevance of STAC-T, as well as the effectiveness in promoting the use of the STAC strategies to intervene in bullying situations. Further, program relevance was related to STAC strategy use, highlighting the importance of assessing program relevance for specific student populations.  

The multi-institutional team was led by Dr. Aida Midgett from Boise State University. Collaborators included Dr. Diana Doumas, Taylor Perron, and Jennalyn Shelton from Boise State University; Dr. Robin Hausheer from the University of Vermont; Dr. Amanda Winburn from the University of Mississippi; and Brandon Herbeck and Mary Buller from Klein Buendel. The research was supported by a grant to Klein Buendel from the National Institute on Minority Health and Health Disparities (R42MD014943; Dr. Aida Midgett, Principal Investigator).

Just Care Simulated Usability Testing

Just Care Simulated Usability Testing

Growing numbers of people will grow old and die while incarcerated. A team from The Penn State University Ross and Carol Nese College of Nursing and Klein Buendel participated in a panel presentation at the Gerontology Society of America Annual Scientific Meeting on November 12-15 in Boston, MA, to discuss their research on caring for the aged and dying in prison.

The panelist, Dr. Erin Kitt-Lewis from Penn State, presented a pragmatic approach to the usability testing of Just Care. Just Care is a 7-module digital program to train people living in prison to assist staff by providing care to their peers who are older or dying. The web-based program educates prison staff on the needs of chronically ill, aging, and dying people who are incarcerated and provides implementation tools for providing care. Research evidence supports using peer caregivers to assist staff with geriatric and end-of-life care.

The Just Care team learned that gaining access to conduct research with external technology is limited at some correctional facilities as many are reassessing their technology capacity and policies, especially with limited staff. As a result, a pragmatic approach to conducting the research was necessary. In collaboration with the prison administration at one state prison system that had instituted restricted access to technology, an innovative approach — simulated usability testing — to test the program using focus groups was developed.

A total of six focus groups, two with staff and four with people living in prison, were held at one men’s and one women’s prison in a mid-Atlantic State; nine staff and 28 peer caregivers participated. The modified approach involved two on-site researchers conducting the focus groups while projecting the Just Care e-learning on a large screen and interacting with participants. Simultaneously, two off-site researchers connected via videoconference to screen share Just Care and take handwritten field notes. Participants were asked to comment on the content, feasibility, clarity, and ease of use of the program. 

Analysis of the qualitative data collected from the simulated usability testing resulted in three themes: barriers, facilitators, and future directions for the program. Each of these were described by the panelist in some detail.

This research was funded by an STTR grant to Klein Buendel from the National Institute on Aging (AG057239; Dr. Susan Loeb from Penn State and Dr. Barbara Walkosz from Klein Buendel, Multiple Principal Investigators). Additional collaborators include Dr. Erin Kitt-Lewis, Dr. Kalei Crimi, and Nawal Alsearhi from the Ross and Carol Nese College of Nursing at Penn State University; and Amanda Brice and Steve Fullmer from Klein Buendel.

Helps and hindrances to passing state indoor tanning laws

Helps and hindrances to passing state indoor tanning laws

Indoor tanning causes skin cancers, including potentially deadly melanoma. Indoor tanning often starts during youth, a critical time for deleterious skin damage. About half of U.S. states have enacted laws banning indoor tanning for minors under the age of 18. A multi-institutional team of researchers including Dr. David Buller and Julia Berteletti from Klein Buendel has published a paper in Translational Behavioral Medicine that reports qualitative findings from interviews with key informants involved in indoor tanning legislative efforts to identify/describe factors influencing law enactment, based on the Multiple Streams Framework (1).

Guided by expert advisors and using snowball-sampling, 64 key informants from 16 states with most recently enacted indoor tanning laws regulating minor access and states without restrictions were contacted. In virtual interviews, key informants shared their unique “story” of indoor tanning bill efforts, enactment, implementation, impact, and potential future directions, which were transcribed and qualitatively coded by trained staff.

Although key informant roles (legislators, advocates, clinicians, and melanoma survivors) and legislative processes vary by state, similar facilitators and barriers to indoor tanning bill passage were identified: personal stories, advocacy, opposition, preparation, legislator education, economic/ enforcement issues, bill stringency, political values/partisanship, and legislative process. Other factors influencing bill enaction included failed U.S. Food and Drug Administration attempts toward federally banning minor indoor tanning and competing priorities.

Despite evidence of laws’ impact on minors’ indoor tanning, policy enaction is challenging and slow. Understanding key facilitators and barriers may help advocates to advance legislation efforts. Advocating for stringent laws necessitates consideration of potential downstream effects. For example, even with policy enactment, key informants believed enforcement and compliance were likely insufficient and variable, with minors continuing to indoor tan, putting them at risk for potentially deadly skin cancer.

This research was supported by a grant to Rutgers University from the National Cancer Institute (CA244370; Dr. Carolyn Heckman and Dr. David Buller, Multiple Principal Investigators). Authors include Dr. Carolyn Heckman, Ms. Anna Mitarotondo, Mr. Kevin Schroth, and Dr. Shawna Hudson from Rutgers University; Dr. Jerod Stapleton from the University of Kentucky; Dr. Robert Dellavalle from the University of Minnesota; Dr. Sophie Balk from the Albert Einstein College of Medicine; and Dr. David Buller and Ms. Julia Berteletti from Klein Buendel.

References

  1. Kingdon JW. Agendas, Alternatives, and Public Policies. Longman, 2003.
Collaborator Spotlight:
Ms. Anne Poirier

Collaborator Spotlight:
Ms. Anne Poirier

Meet Klein Buendel’s newest research collaborator, Ms. Anne Poirier. She is the originator of the concept of body neutrality, which helps people step away from dieting and redefine their relationships with eating, their bodies, and themselves.

Ms. Poirier is the owner of a body neutrality coaching company and the author of books about self-care and compassion. She graduated from Plymouth State University with a bachelors’ degree in exercise science. She is also a graduate of the Eating Disorder Institute at Plymouth State University and the Life Coach Institute. She is an intuitive eating counselor, a self-talk trainer, and an NSCA-CSCS strength and conditioning specialist. She also serves on the National Eating Disorders Association Lived Experience Task Force.

Ms. Poirier is a nationally recognized body image expert and the author of The Body Joyful and Not a Fat Annie. She is a pioneer and leading voice for the body neutrality movement and has been featured and cited in major media outlets around the word including Shape, Women’s Health, New York Times, Washington Post, Newsy, Livestrong, ABC, and NPR. She is a long-time eating disorder survivor and certified self-talk trainer. She has been a guest on more than 50 podcasts. In 2015, she founded the company Shaping Perspectives…A Woman’s Way to Joy. The cornerstone of the company is the Body Joyful Solution, a coaching program based on the principles of body neutrality.

As her mission is to reduce bullying, body shaming, weight stigma, and eating disorders for the next generation, Ms. Poirier is collaborating with Klein Buendel Scientist, Dr. Kayla Nuss, on NoWeigh!, a novel approach to weight management. The NoWeigh approach emphasizes gratitude for the body’s function, a neutral attitude about the body’s appearance, and engagement in movement that is enjoyable, rather than weight loss. The NoWeigh! Project is funded by an SBIR grant from the National Institute of Diabetes, Digestive and Kidney Diseases (DK142209; Dr. Kayla Nuss, Principal Investigator).

TeenVac to Improve HPV Vaccine Uptake in Adolescent Boys

TeenVac to Improve HPV Vaccine Uptake in Adolescent Boys

Human papillomavirus (HPV) vaccine uptake remains below the Healthy People 2030 goal of 80% series completion in the United States. Parental concerns about the efficacy and safety of the vaccine remain and may be addressed by digital interventions tailored to their concerns.

Dr. W. Gill Woodall, Klein Buendel Senior Scientist, led a large study supported by the National Cancer Institute to increase HPV vaccination among adolescent boys . The results of the study have been published in the Journal of Adolescent Health. Specifically, the paper reports on the purpose, methods, and effectiveness of TeenVac, a mobile app to encourage HPV vaccination in families with adolescent boys.

A randomized trial was conducted between May 2019 and December 2020, testing the mobile web app (teenvac.org) that encouraged HPV vaccination for parents and sons aged 11–14 years old. Parents and 209 adolescent sons were randomized to receive either the TeenVac app or the Centers for Disease Control and Prevention (CDC) HPV vaccination pamphlet online. Participants had access to the TeenVac app or the CDC pamphlet for the 9-month study duration. Adolescent sons’ vaccination records were collected from the state 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 randomized to the TeenVac app were significantly more likely to complete the HPV vaccination series than those randomized to the CDC pamphlet group. Web usage analysis confirmed that the TeenVac group parents who used the web app were significantly more likely to have sons complete the HPV vaccination series than those in the CDC pamphlet group.

The TeenVac app meaningfully impacted HPV vaccine series completion, particularly among parents who used the web app. The results provide further evidence that digital interventions can improve vaccine uptake when focused on parents’ and sons’ vaccine-related concerns.

This research was supported by a grant from the National Cancer Institute (CA210125; Dr. W. Gill Woodall, Principal Investigator). Dr. Woodall’s coauthors include Dr. Gregory Zimet from Indiana University; Dr. Alberta Kong, Dr. Lance Chilton, and Dr. Tamar Ginossar from the University of New Mexico; Jennyfer Reither from Denver Health Hospital; and Dr. David Buller, Lila Martinez, Marita Brooks, and Noah Chirico from Klein Buendel.

Young Adult Melanoma Survivors and Family Member Skin Exams

Young Adult Melanoma Survivors and Family Member Skin Exams

Dr. David Buller, Director of Research at Klein Buendel, is a coauthor on a paper entitled, “Engagement in and correlates of total cutaneous exams and skin self-exams among young melanoma survivors and their family,” in the Journal of Behavioral Medicine.

Young adult melanoma survivors and their close family (first-degree relatives) are at increased risk for developing a melanoma. However, little is known about engagement in and correlates of their clinical skin examination and skin self-examination behaviors. Five hundred and seventy-four (574) young adult melanoma survivors and their first-degree relatives completed an online survey assessing engagement in clinical skin exam and skin self-exam. The survey also included measures of background factors, cognitive and psychosocial factors, clinical skin exam and skin self-exam planning, and family influences.

About 90% of young adults had a clinical skin exam and 90% performed skin self-examination in the last year. Engagement in clinical skin exams among first-degree relatives was lower. Being female, having a physician recommendation, having fewer barriers, and more planning were associated with clinical skin exams. Family influences were not associated with clinical skin exam. For skin self-exams, a physician recommendation and greater self-efficacy were associated with engagement. More comprehensive skin self-examination was associated with a physician recommendation, lower education, greater self-efficacy, and more planning. Stronger family normative influences were associated with more comprehensive skin self-exams among males.

Findings suggest that first-degree relatives may benefit from interventions to improve clinical skin exams and skin self-exams. These results also show that physician recommendation may be a key intervention target to stimulate clinical skin exams and skin self-exams. Examinations are vital for the early detection and effective treatment of melanoma. Details on the significance, methods, analyses, and results of the research may be found in the Journal of Behavioral Medicine manuscript.

This research was supported by a grant from the National Cancer Institute to the Rutgers Cancer Institute of New Jersey at Rutgers University (CA221854; Dr. Sharon Manne, Principal Investigator). Coauthors include Dr. Carolyn Heckman, Dr. Adam Berger, Sara Frederick, Alexandria Kulik, and Morgan Pesanelli from Rutgers University; Dr. Deborah Kashy from Michigan State University; Dr. Sherry Pagoto from the University of Connecticut; Dr. Susan Peterson from the University of Texas; Joseph Gallo from Hackensack Meridian Jersey Shore Medical Center; and Dr. David Buller from Klein Buendel.

MobileMen and mHealth

MobileMen and mHealth

Ms. Amanda Brice, Klein Buendel Project Coordinator, is the lead author on a research paper published in the journal mHealth. The paper reports on the development of MobileMen, a mobile app to promote physical activity in African American men.

African American men experience higher rates of chronic diseases including diabetes, cardiovascular disease, and obesity compared to other race and gender groups. This population also has high levels of inactivity, one of the major risk facts for chronic disease. Due to the promise shown by mobile apps in providing tailored and easily accessible health interventions, the authors set out to design an app to help African American men initiate and maintain their physical activity.

The research team conducted focus groups with 24 African American men to gain insight on the features and design aspects to include in the app prototype. They then used an iterative design process to conduct multiple rounds of beta and usability testing to create a prototype that was easy to use, visually pleasing, and culturally tailored. A satisfaction and helpfulness questionnaire and the System Usability Scale (SUS) were used as quantitative measures in addition to qualitative data provided by participants. Tasks were given to participants to test for ability to navigate and use the app features.

The average satisfaction and helpfulness ratings from participants were 3.9/5 and 3.7/5 for beta testing and 4.3/5 and 4.1/5 for usability testing, which met the pre-determined criteria of ≥3.5. Only one of the satisfaction questions, which was about cultural tailoring for African American men, was below the pre-determined criteria (2.7). By round two of usability testing, most tasks were able to be completed by all participants, and the mean SUS score was 90.36 out of 100 which exceeded a priori feasibility criterion of a mean rating of 68.0. The feedback on the finalized features was positive, and participants expressed that they would use the app if it were on the market.

Based on both the qualitative and quantitative data obtained from multiple iterative design rounds, the MobileMen app was easy to use and contained culturally tailored features. It was well received by the target population and deemed ready to be tested on a larger scale for effectiveness. Full descriptions of the methods, analyses, and findings can be found in the mHealth paper.

This research is funded by an STTR Fast Track grant to Klein Buendel from the National Institute on Minority Health and Health Disparities (MD014947). The Principal Investigator is Dr. Robert Newton from the Pennington Biomedical Research Center. Authors on this paper include Amanda Brice, Steve Fullmer, Charles Barger, Joel Serbinski, Michael Gallik, Dr. David Buller, and Dr. Kayla Nuss from Klein Buendel; Phillip Nauta, and Dr. Robert Newton from the Pennington Biomedical Research Center; Dr. April Stull from Baylor University; Dr. Damon Swift from the University of Virginia; and Dr. Derek Griffith from the University of Pennsylvania. The MobileMen app was designed and programmed by the Klein Buendel Creative Team.

No Weigh!

No Weigh!

Klein Buendel Scientist, Dr. Kayla Nuss, has launched a new research project, funded by the National Institute of Diabetes, Digestive and Kidney Diseases. It will test a novel approach to physical activity promotion. The proposed intervention, NoWeigh!, is a mobile app based on a framework called body neutrality. Body neutrality emphasizes gratitude for the body’s function, a neutral attitude about the body’s appearance, and engagement in movement that is enjoyable, rather than weight loss.

Obesity rates are on the rise in the United States. Weight loss has been the primary recommendation for managing comorbidities with obesity, such as elevated blood lipids and glucose, despite ample evidence that weight loss attempts generally lead to weight regain and weight cycling, which are associated with negative mental health outcomes like anxiety and depression. Experts have called for non-weight loss obesity management, by emphasizing health behaviors such as physical activity. An effective method to deliver physical activity interventions is via mobile apps, of which women are the most frequent users. However, most physical activity apps emphasize weight loss.

The goal of the new Phase I SBIR project is to demonstrate the technical merit and feasibility of developing a smartphone mobile app (NoWeigh!) to support physical activity engagement using the tenants of body neutrality and Self-Determination Theory as frameworks. Mobile health (mHealth) approaches using smartphones offer several advantages for dissemination and implementation of health interventions including that they are portable, typically “on,” readily available, affordable, and offer advanced functionality. In addition, ownership of smartphones among adults is high, enabling potentially vast reach and apps have been shown to improve uptake of, and adherence to, healthy lifestyle strategies.

Project Specific Aims

Aim 1: Perform iterative focus groups in adult women (aged ≥18 years) from diverse backgrounds to collect potential-user information to identify barriers, needs and preferences for a body-neutrality physical activity app design.

Aim 2: Design the conceptual model and develop planned components of the NoWeigh! app which will include storyboards and clickable wireframes.

Aim 3: Conduct beta and usability testing on the clickable wireframes prototype of the NoWeigh! app to show feasibility, acceptability and potential for engagement, and finalize the app design.

Successful completion of Phase I SBIR research will provide evidence to support a larger Phase II project to program and test the full-scale NoWeigh! app in a randomized comparative effectiveness trial. The goal is to produce a commercially ready mobile app for physical activity promotion that does not center on weight loss, a cost-effective lifestyle intervention for decreasing disease risk and reducing healthcare costs. This mHealth approach is an ideal medium for physical activity promotion because the reach, portability, and advanced functionality of mHealth devices allows for effective use by a broad range of adult women.

This grant was awarded to Klein Buendel by the National Institute of Diabetes, Digestive and Kidney Diseases (DK142209; Dr. Kayla Nuss, Principal Investigator). Dr. Nuss’ research collaborator on this project is Anne Poirier. She is the owner of a body neutrality coaching company and the author of the book, The Body Joyful, a guide to a life based on self-care and compassion. The NoWeigh! app will be designed and programmed by the Creative Team at Klein Buendel.

Analysis of Municipal Shade Policies

Analysis of Municipal Shade Policies

Shade is an essential environmental feature to prevent heat illnesses and skin cancer. A research team led by Klein Buendel has published a description of municipal shade policies in Frontiers in Public Health. Written policies related to shade from municipalities in four southwest and four northeast U.S. states were collected and analyzed.

Municipal codes, planning documents, and manuals/guidelines from 48 municipalities in eight U.S. states were coded for content related to shade by research assistants. A standardized protocol was used to assign numeric codes to each document to assess type of document, type of shade, location, resource allocation, accountability, and design standards. Results were summarized using descriptive statistics.

Three-quarters of municipalities (75.0%) had a policy document that addressed shade, including municipal codes (54.2%), planning documents (29.2%), and manuals/guidelines (12.5%). Protecting from heat (31.3%) was mentioned in policies more than protecting from ultraviolet radiation (8.3%), as was natural shade (56.3%) rather than constructed shade (25.0%). Policies prescribed several design standards, most frequently shade material, proportion of area covered, and attractiveness. Half (50.0%) of municipalities mentioned accountability for shade in the policy, but only a third (35.4%) addressed resource allocation. Regional differences were seen in policy document type, shade type, locations, design standards, and resource allocation.

Many municipalities had policies that mentioned shade, but only a minority of policies indicated that the purpose of the policy was protection from heat or ultraviolet radiation. In northeast municipalities, which can have local home rule traditions, policies on shade appeared almost entirely in municipal codes. Southwest municipalities often included policies in planning documents that may have less legal force than municipal codes.

This research was funded by Klein Buendel and a grant from the National Cancer Institute to the Rutgers Cancer Institute at Rutgers University (CA072720; Dr. Steven Libutti, Principal Investigator). Authors include Phoebe Grutter from Science Park High School, Dr. Margaret Morrissey-Basler from Providence College, Dr. Ian Buller from DLH, Dr. Carolyn Heckman from Rutgers University, and Alishia Kinsey, Taylor Sullivan, and Dr. David Buller from Klein Buendel.