Ms. Amanda Brice from Klein Buendel presented a Live Research Spotlight at the 46th Annual Sessions and Meeting of the Society of Behavioral Medicine in San Francisco, California, March 26-29, 2025.
*Klein Buendel authors are bolded.
Ms. Amanda Brice
Research Spotlight
Title: Rural Emerging Adults’ Physical Activity Motivation, Intentions, Planning, and Engagement Patterns: A Cross-Sectional Analysis
Presenter: Amanda Brice
Authors: Kayla Nuss, Julia Berteletti, Amanda Brice, Alishia Kinsey, Noah Chirico, and Sierra Held
Emerging adulthood, the period between 18 and 26 years old, is critical for the development of long-term health behaviors, like physical activity engagement. Only 25% of emerging adults meet the recommended 150 minutes per week of moderate to vigorous physical activity (MVPA). In rural communities, where residents have less access to behavioral health resources, healthcare, and community services, fewer than 20% of adults meet physical activity recommendations, but data on rural emerging adults is limited. Further, data are lacking in this population on potent drivers of physical activity, such as motivation, intention, and planning. Therefore, the purpose of this study is to describe physical activity engagement, motivation, intention, and planning in a sample of emerging adults from the rural western United States.
Participants were recruited via a nationwide survey panel. Inclusion criteria were: 18 to 26 years old, able to read and understand English, and live in a rural country as defined by the Rural Urban Commuting Area Codes 4-9 in one of the Western states of Colorado, Utah, New Mexico, or Arizona. We assessed physical activity with the Global Physical Activity Questionnaire (GPAQ), Self-Determination Theory motivation with the Behavioral Regulations in Exercise Questionnaire v.3 (BREQ-3), intention and planning with the Behavioral Intentions Scale, and collected demographic variables.
Means, standard deviations, and percentages were calculated for descriptive and outcome variables. Participants reported minutes of MVPA accumulated through work and recreation, and we calculated total MVPA minutes. Using the Shapiro-Wilk test for normality, we found neither total nor recreational weekly minutes of MVPA were normally distributed. The non-normality was due to a high number of participants reporting zero MVPA minutes. We created binary variables of “Meets Recommendations” (≥ 150 minutes of MVPA per week) vs. “Does Not Meet Recommendations” (≤ 149 minutes of MVPA per week) for both total and recreational MVPA.
The sample included 141 respondents: 115 (81.56%) female and 25 (17.73%) male, aged 22.00±2.63 years. Seventy-five (53.19%) met MVPA recommendations when work was included whereas without, only 32 (22.70%) met recommendations. Participants reported low levels of amotivation, external, introjected, identified, and integrated regulation, and intrinsic motivation. They also reported low levels of intention and planning for physical activity.
More emerging adults met MVPA recommendations when minutes accumulated at work were included. Rural emerging adults have low quality of motivation and low intention and planning for physical activity. Researchers should investigate barriers to physical activity participation in this group as they have high instances of health disparities and low access to health resources.
This research was sponsored by Klein Buendel and led by Dr. Kayla Nuss.
Dr. David Buller from Klein Buendel presented three posters at the 46th Annual Sessions and Meeting of the Society of Behavioral Medicine in San Francisco, California, March 26-29, 2025. Dr. Kayla Nuss and Ms. Julia Berteletti from Klein Buendel were co-authors on a fourth poster.
*Klein Buendel authors are bolded.
Dr. David Buller
Poster 1
Title: Economic Evaluation of Two Scalability Strategies for Nationwide Dissemination of an Occupational Sun Safety Intervention
Presenter:David Buller
Authors: Richard Meenan, David Buller, Julia Berteletti, Kimberly Henry, Mary Buller, Gary Cutter, Irene Adjei, and Noah Chirico
Americans spend many hours in work environments that contribute to health risks through hazardous job exposures. An economic evaluation of two methods for scaling up the Go Sun Smart at Work (GSS@W) evidence-based occupational sun protection program to prevent skin cancer in a nationwide transportation industry was conducted. GSS@W promoted employer adoption of sun protection policies and employee use of personal sun protection.
Cost-effectiveness analysis compared digital and in-person scalability strategies for disseminating the GSS@W program in a prospective two-group randomized trial. Regional districts (n=138) in 21 state Departments of Transportation (DOT) throughout the United States were recruited. District managers were assessed before and after scale-up and employees were posttest only. GSS@W was disseminated to managers at DOT districts either via an in-person scalability strategy with face-to-face on-site meetings and employee training or a digital scalability strategy with virtual meetings and online training. Cost of delivering GSS@W was obtained from project accounting records and manager reports on number and associated costs of implemented sun protection actions. Primary cost analysis was incremental cost-effectiveness ratio (ICER) between digital and in-person strategies, using program delivery cost as numerator and number of implemented sun protection actions as denominator. Secondary analysis summarized cost of implemented sun protection actions as reported by participating districts.
Mean implemented actions per district were 6.23 in digital and 6.53 in in-person strategy groups. Program delivery costs were estimated to be $15,658 for the digital strategy and $74,275 for the in-person strategy. Across all districts, the ICER was $3,305, representing average cost savings from an action not implemented under the digital strategy but implemented under the in-person strategy. Training was the most expensive action implemented by districts under either strategy (88% of implemented action costs).
The digital scalability strategy was cost-effective relative to an in-person strategy, generating substantial cost savings and offsetting a lower mean number of implemented GSS@W program actions. The GSS@W intervention may be readily implemented within employers that manage large annual budgets. Cost analysis was limited by not assessing induced costs to employees and potential feedback effects that could produce contamination.
The research was supported by a Cancer Moonshot Initiative grant from the National Cancer Institute (CA210259; Dr. David Buller, Principal Investigator).
Poster 2
Title: Pilot Test of a Social Media Campaign on Preventing Cancer Risk Factors for Emerging Adults in Rural Communities in the American Mountain West
Presenter:David Buller
Authors: David Buller, Andrew Sussman, Echo Warner, Alishia Kinsey, Barbara Walkosz, Judith Gordon, W. Gill Woodall, Douglas Taren, Deanna Kepka, Kimberly L. Henry, Kayla Nuss, Cindy Blair, Evelinn Borrayo, David Wetter, Meghan Skiba, Julia Berteletti, Annelise Small, Dolores Guest, and John Torres
A social media campaign on preventing six cancer risk factors – being physical inactive, eating an unhealthy diet, using nicotine products, binging alcohol, being sunburned, and being unvaccinated for human papillomavirus (HPV) – was pilot-tested with emerging adults aged 18-26 living in rural counties.
Using an integrated theoretical framework, social media posts were developed to counter the cancer risk factors. Posts covered simplicity, benefits, response efficacy/cost, self-efficacy/perceived control, risk perceptions, norms, social support/relatedness, goals/values compatibility, intrinsic/extrinsic motivation, media literacy, and communication with family/friends. Twenty-six (26) emerging adults aged 18-26 living in rural counties in Arizona, Colorado, New Mexico, and Utah received a 4-week social media feed with 64 posts delivered in a private Facebook group. Emerging adults completed pretest and posttest surveys, and engagement (views, reactions, comments) was recorded.
Participants were 85% female and 35% Hispanic, with a median age of 23. At pretest, emerging adults demonstrated cancer risk factors: 53% engaged in <150 minutes of moderate-to-vigorous physical activity weekly, 85% had low daily intake of fruits and vegetables, 35% used nicotine products, 58% binged alcohol, 65% were sunburned, and 38% were unvaccinated for HPV. The campaign feed received 1,060 views, 346 reactions and 72 comments. Of the six cancer risk factors, posts on physical activity received the most views (216 views) while those on HPV and sun safety, the least (115 views each). Posts on physical activity, nicotine products, and alcohol received the most reactions (>50 reactions each) and physical activity and diet posts received the most comments (>9 comments each).
Social media is a popular source for health information among emerging adults. A multi-risk factor social media campaign has potential to engage emerging adults with theory-based cancer prevention messaging. The campaign will be evaluated in a randomized trial in 2025.
The research is supported by a grant from the National Cancer Institute (CA268037; Dr. David Buller and Dr. Andrew Sussman, Multiple Principal Investigators). Dr. Sussman is from the University of New Mexico Comprehensive Cancer Center. Other collaborating investigators are from the University of Utah, the University of Arizona, the University of Colorado, and Colorado State University.
Poster 3
Title: Association of Indoor Tanning State Laws and Other Contextual Factors with Burns from Indoor Tanning in a National Sample of US Young Adults
Presenter:David Buller
Authors: Carolyn Heckman, David Buller, Anna Mitarotondo, Daniel Gundersen, Marisa Tomaino, and Julia Berteletti
Indoor tanning by minors is a significant risk factor for the development of melanoma. In addition to FDA safety regulations, 46 states restrict minor indoor tanning access by minors to prevent acute (burns from UV exposure) and chronic (skin cancer) harms. This study’s purpose was to identify state policy and other contextual factors associated with burns from indoor tanning to inform state policy efforts.
The authors conducted an online, nationally representative survey of individuals aged 18-29 who indoor tanned in the last three years (N=1000). Respondents reported on indoor tanning as adults (age 18 or older) and as minors (under age 18). Stringency of state laws on indoor tanning use by minors was scored, with no laws regulating minor indoor tanning being a “0” and laws banning all minors under 18 from indoor tanning being a “10.” Generalized linear models were used to estimate the associations of policy stringency for minor use and enforcement, indoor tanning behavior, and other contextual factors with burns after indoor tanning as a minor or adult. All analyses used the sampling weights.
Eighty-eight percent (88%) of participants reported engaging in indoor tanning in multiple facility types in the last three years, including indoor tanning salons, gyms, beauty salons, homes, spas, and apartments. Stringency of indoor tanning laws in participants’ home states were coded as an average of 4 (weak) out of 10. Fifty-seven percent (57%) of participants reported burning one or more times from indoor tanning in the past three years, with 14% from their most recent indoor tanning session. Correlates of burns from indoor tanning when a minor were weaker age restrictions, greater enforcement, more binge drinking, tanning at locales other than an indoor tanning salon, more sessions, shorter sessions, and more sunburns. Correlates of burns from indoor tanning when an adult were being between 22-25 years old, lower perceived indoor tanning facility safety in their state, greater enforcement, more sessions, and more sunburns.
This is the first study to investigate the impact of the stringency and enforcement of age restrictions in state indoor tanning law on burns both for indoor tanning before and after age 18, in a representative national sample. Burns were very common in the context of weak laws in many states, yet harmful burns after indoor tanning during childhood appeared to be lower in states with stronger age restrictions. Enforcing weak laws or inadequate safety regulations/compliance appears to have little impact on indoor tanning or burns in minors or adults. Thus, increasing stringency of state indoor tanning laws for all facility types may ultimately decrease acute harm and subsequent skin cancer rates.
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).
Poster 4
Title: Social Comparison as a Behavior Change Technique in Digital Interventions: Users’ Perceptions of Leaderboards to Promote Physical Activity Motivation and Behavior
Presenters: Raj Harsora and Danielle Arigo from Rowan University
Authors: Raj Harsora, Emmanuel Lapitan, Giada Benasi, Amanda Folk, Laura König, Kayla Nuss, Julia Berteletti, Kyle R. Haggerty, and Danielle Arigo
Physical activity leaderboards are a common feature in digital health tools; they display users ranked physical activity behavior from highest to lowest, leveraging social comparison to boost motivation. However, some users find them motivating while others find them aversive. It is not clear how users interpret information from a leaderboard, or for whom or under what circumstances leaderboards might be effective.
To examine these nuances, we surveyed 1,676 adults in the United States and Europe (52% women). Of those who use physical activity apps, 8% indicated that their app has a leaderboard; 70% of these users did not participate in the leaderboard and expressed dislike of this feature for its emphasis on competition, unnecessary pressure, and potential “failure.” The remaining 30% reported using the leaderboard for 2 to 24 months because it kept them motivated by showing their success, particularly as they compared to others at the “same skill level.” After viewing a leaderboard with their own rank depicted, 63% of all respondents (1,504 adults) perceived themselves as doing well with physical activity. In a separate response, however, 51% perceived themselves as doing poorly. These perceptions differed by rank but also showed meaningful heterogeneity for the same rank. Across ranks, 74% of respondents endorsed motivation to engage in physical activity though 26% did not. Physical activity motivation did not differ by rank and was not associated with perceiving oneself as doing poorly but was positively associated with perceiving oneself as doing well; the latter was strongest for those ranked 3rd of 6.
Finally, physical activity motivation in response to the leaderboard did not differ by gender but was higher among those with stronger (vs. weaker) general tendencies to respond positively and negatively to comparison opportunities; the latter did not differ by rank. Findings show that responses to physical activity leaderboards vary widely and aren’t based solely on rank or individual difference characteristics. Further, some people who believe they dislike leaderboards still find them motivating, and it is unclear how leaderboards affect physical activity behavior in daily life. Additional investigation is warranted to identify for whom and under what circumstances leaderboards are most likely to lead to benefits for physical activity.
This research was funded by an NIH Director’s New Innovator Award to Rowan University (DP2HL173857; Danielle Arigo, Principal Investigator).
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.
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).
THE B-SMART APP: FINDINGS FROM AN IGNITION INTERLOCK STUDY
Driving while intoxicated (DWI) is a preventable source of morbidity and mortality in the United States. The Ignition Interlock Device (IID) requires a driver to blow into a breathalyzer installed in a vehicle to establish sobriety and reduces drunk driving while installed. IIDs have become widespread. Most U.S. states require DWI offenders to install IIDs in their cars. However, once IIDs are removed, DWI recidivism levels return to those similar to offenders who had no IID installed.
Klein Buendel Senior Scientist, Dr. W. Gill Woodall, presented DWI intervention study results at the 47th Annual Research Society on Alcoholism Scientific Meeting on June 22-26 in Minneapolis, Minnesota. The purpose of this study was to develop and test an app (“B-SMART”) for DWI offenders and their Concerned Family Members (CFMs) to extend non-intoxicated driving beyond the IID installation period.
The B-SMART app has four modules: 1) Life with the Interlock – orientation to IIDs, 2) processes to support changes in drinking, 3) effective communication skills, and 4) family activities that don’t involve alcohol. Participants (pairs of DWI Offenders and CFMs N=76) were randomly assigned to receive the B-SMART web app (n=30) or access to an IID New Mexico Department of Transportation information page [Usual and Customary (UC) condition, n=46]. Data on failed IID tests and IID lockout events were obtained from Ignition Interlock providers and were the primary outcome variables.
IID data were collected at the end of the project period on 58% (n=71) of 123 participants, with one IID provider not providing IID data due to corporate policy restrictions. Two summary outcome variables were created: 1) the frequency of any failed test during IID installation period, and 2) IID lockout events, which occur when a driver repeatedly fails the breathalyzer test in a set time period. The mean number of failed IID tests was not significantly different for UC participants (n=45) than versus B-SMART participants (n=26). For lockout events, UC participants had significantly more lockout events than B-SMART participants.
Results indicate the B-SMART app reduced IID Lockout events, which is an important outcome as lower IID events predict reduced DWI recidivism.
This research was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (AA022850; Dr. W. Gill Woodall, Principal Investigator). Collaborators on this conference presentation included Dr. Barbara McCrady and Dr. Vern Westerberg from the University of 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.
A research team from The Penn State University Ross and Carol Nese College of Nursing and Klein Buendel made two presentations related to formative research on the development of Just Care for Dementia at the 36th Annual Scientific Sessions of the Eastern Nursing Research Society April 4-5, 2024 in Boston, MA.
Presentation 1
Title: Dementia Care Training Needs for Corrections Staff and Peer Caregivers
Dr. Susan Loeb, Penn State University
Presenter: Dr. Susan Loeb
The number of people living in prison with Alzheimer’s Disease and Related Dementias (ADRD) is growing. Care inequities for ADRD between prisons and community settings exist and warrant addressing. A standardized, evidence-based, feasible, and acceptable ADRD e-training program is needed to prepare corrections staff and peer caregivers for better managing and caring for people with ADRD in prisons.
The purposes of this study were to (1) identify three priority learning needs of corrections staff and peer caregivers who manage and/or care for people living with ADRD in prisons; (2) identify a logo for the Just Care for Dementia training that was desirable to end-users; and (3) translate best practices from community-based ADRD care into evidence-based, accessible, and relevant ADRD content for prison settings. The end goal was to program prototypes for three highly interactive e-learning modules that fit within the restrictive context of corrections.
Focus group methodology guided potential future users in providing insights to ensure the content, design, and technology plans match the needs and constraints of prisons. Human subjects approvals were secured and participants’ signed informed consent was obtained. Settings were one men’s and one women’s state prison in the northeastern United States. Twelve corrections staff and 11 peer caregivers participated. Focus groups were audio recorded, transcribed, and deidentified.
Thematic analysis was completed independently by two researchers. The three priority content areas identified were fostering a safe and calm environment, addressing behavioral and psychological symptoms of dementia, and enhancing awareness of need. Participants identified two logo preferences. Advisory board consultation informed logo selection. Module content was developed via an iterative process to ensure contextual relevance of training, accessibility within the constraints of prisons, and the e-training matched identified training needs.
In summary, participants confirmed the need for ADRD training and indicated e-learning is a viable approach for addressing a pressing care need in prisons.
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). Collaborators included Dr. Erin Kitt-Lewis and Sherif Olanrewaju from Penn State University; and Amanda Brice and Steve Fullmer from Klein Buendel.
Presentation 2
Title: Small-Scale Usability Testing: E-learning modules for Peer Caregivers
Presenter: Dr. Susan Loeb
Growing numbers of people will grow old and die while incarcerated. Research evidence supports using peer caregivers to assist staff with geriatric and end-of-life care. Peer caregivers training varies widely in content and duration. Evidenced-based, accessible, and contextually relevant materials are needed to effectively prepare peer caregivers.
The purpose of this study was to conduct research and development for Just Care, a six-module e-learning program for peer caregivers and a single module to guide corrections staff in launching the program. Deputy Wardens identified people meeting our inclusion criteria. Nineteen people living in prison and 11 staff participated. Throughout usability testing, participants shared their thoughts aloud, while field notes were taken. Participants completed six open-ended questions, a demographic survey, and the System Usability Scale (SUS).
All users easily navigated through the program with minimal guidance. Many noted Just Care’s utility for future peer caregivers. Some users who were incarcerated had difficulty navigating the post-test assessments. A few staff users noted liking the additional resources available via links to PDFs. One staff user voiced concern about the safety of having incarcerated people help with care. Just Care received Round 1 SUS scores of 87.5 by users living in prison and 74.5 by staff. Following rapid refinement, Just Care received Round 2 mean SUS scores of 85.28 by users living in prison and 83.75 by staff. A SUS score of 68 is an above average score.
Overall, participants found Just Care innovative, useful, engaging, interactive, and relevant to providing geriatric and end-of-life care in prisons. Staff noted that Just Care raised awareness about the growing need for programming on geriatric care in prisons and that a peer caregiver program is a viable solution that is implementable by prison staff.
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). Collaborators included Dr. Erin Kitt-Lewis and Sherif Olanrewaju from Penn State University; and Brandon Herbeck, Peter Fu, and Steve Fullmer from Klein Buendel.
Indoor Tanning Policies Are Insufficient to Protect Young Adults
Ms. Anna Mitarotondo, a Research Program Manager from Rutgers University, gave a Research Spotlight presentation on the Indoor Tanning Policy research project at the 45th Annual Sessions and Meeting of the Society of Behavioral Medicine in Philadelphia, PA, March 13-16, 2024. Dr. Carolyn Heckman from Rutgers and Dr. David Buller from Klein Buendel are the project’s Multiple Principal Investigators.
Ms. Anna Mitarotondo, Rutgers University
Five million Americans are treated for skin cancer annually with the incidence of melanoma tripling in the last 40 years. Even a single session of indoor tanning is a well-established cause of melanoma especially at younger ages. Indoor tanning is also associated with sunburn, another major risk factor. In addition to FDA safety regulations, 46 states restrict minor indoor tanning access. More stringent laws (such as age bans vs. parental consent or no law) have been associated with less youth indoor tanning. However, enforcement and compliance are essential for successful law implementation. This study investigates regulation stringency, behavior, facility compliance, and sunburns.
The research team conducted an online, nationally representative survey of 1000 individuals aged 18-29 who indoor tanned in the last three years. 82% identified as female, and 74% as white, non-Hispanic. A majority (89%) indoor tanned multiple times in the past three years. Participants reported being most likely to tan in indoor tanning salons, gyms, and beauty salons. They also reported indoor tanning in homes, spas, and apartment complexes, with participants indoor tanning in more types of facilities after age 18. Despite FDA recommendations, participants reported that only 16% of facilities prohibited daily or unlimited tanning. Nearly half (48%) of participants were not informed of time limits when indoor tanning. Half (50%) reported that over half of the time, they were able to avoid indoor tanning facility rules. Nearly two-thirds (61%) of participants reported burning from an indoor tanning device in the past three years, with 15% reporting a burn from their most recent session. Of participants who reported indoor tanning as minors, 61% reported burns and 30% reported getting medical attention.
This is the first study to show rates of indoor tanning at facilities other than tanning salons, both before and after age 18, in a representative national sample. Participants reported insufficient facility compliance with, and enforcement of, indoor tanning regulations, which in some cases may have led to severe burns. Analyses are underway to further investigate regulation stringency, enforcement, and compliance by type of facility and state, adjusting for demographic factors and additional key covariates. The goal is to inform future indoor tanning policies at the state and federal level.
This research was supported by a grant to Rutgers from the National Cancer Institute (CA244370; Dr. Carolyn Heckman and Dr. David Buller, Multiple Principal Investigators). Coauthors included and Ms. Maame Araba Assan from Rutgers University, Dr. Jerod Stapleton from the University of Kentucky, and Ms. Julia Berteletti from Klein Buendel.
Physical Activity, Motivation, and Social Media Content
Klein Buendel Scientist, Dr. Kayla Nuss, and her collaborators presented two groundbreaking posters on physical activity and exposure to social media physical activity content at the 45th Annual Sessions and Meeting of the Society of Behavioral Medicine in Philadelphia, PA, March 13-16, 2024. The research delved into three types of physical activity content: fitspiration, body positivity, and body neutrality.
Poster 1
Title: Associations Between Exposure to Fitspiration, Body Positive, and Body Neutral Social Media Content and Physical Activity Engagement: A Cross-Sectional Analysis
Dr. Kayla Nuss
Presenter: Dr. Kayla Nuss
In 2021, nearly 70% of Americans reported using social media, a statistic that has remained fairly constant since 2016. The fitspiration trend, which has become increasingly popular on most social media platforms, encourages users to share fitness inspiration content, including health and fitness tips and motivational posts. However fitspiration exposure has no significant effect on physical activity (PA) intentions or engagement.1
The body positivity movement emerged as a direct response to fitspiration, featuring a range of diverse body sizes and types, including fat and plus-sized influencers engaging in activities. Evidence indicates that exposure to body positive content is associated with greater intentions for physical activity and increased engagement when compared to fitspiration content. A third social media movement, body neutrality, focuses on the functionality and appreciation of the body for not how it looks, but rather what it can do. To our knowledge, no study has explored the association between body neutrality exposure and PA engagement. As such, the purpose of this study is to assess the associations among exposure to fitspiration, body positive, and body neutral social media content and PA behavior.
Two-hundred and thirty-seven (237) participants responded to a survey that included the validated Global Physical Activity Questionnaire (GPAQ) to assess weekly moderate to vigorous PA (MVPA) and sedentary time. In addition, the authors assessed participants’ exposure to social media fitspiration, body positive, and body neutral content. During data cleaning, they categorized exposure to the three content types into “no exposure,” “low exposure,” “moderate exposure”, and “high exposure”. The authors also collected demographic and anthropomorphic data. Using a series of analyses of variance tests, they investigated associations among different levels of exposure to fitspiration, body positive, and body neutral content, and PA engagement.
Biological sex had a significant main effect on weekly minutes of MVPA, and was included it in the models. Exposure to fitspiration had no significant effect, but exposure to both body positive content and body neutrality content did. Post-hoc comparisons revealed that in both contexts, participants who reported high exposure to either body positive or body neutral content had significantly more minutes of weekly MVPA than those who reported no exposure levels and low exposure levels, respectively.
The authors concluded that whereas fitspiration content is intended to inspire physical activity and fitness, there is no association between it and engagement. Interventionists may consider creating programs leveraging body positive or body neutral content to increase PA among social media users.
This research was sponsored by Klein Buendel and led by Dr. Kayla Nuss. Coauthors included Dr. Dani Arrigo from Rowan University and Ms. Julia Berteletti from Klein Buendel.
Poster 2
Title: Interaction Effects of Amotivation for Physical Activity and Fitness Social Media Exposure on Physical Activity Intentions
Presenter: Dr. Kayla Nuss
Nearly half of Americans seek fitness, physical activity (PA), and health advice from social media platforms like Facebook and Instagram. Further, nearly 20% have changed a component of their wellness regimen based on that advice. There are three main categories of physical and activity content on social media, each with its own content themes:
Fitspiration features mostly white, thin, Women, unengaged in PA and has no discernable association with motivation or PA engagement.1
Body positive content features diverse bodies, including fat and plus-sized influencers engaged in PA,and has been associated with greater intentions for PA. Associations with motivation and engagement are unknown.
Body neutrality is centered on the functionality of the body, rather than appearance.
To date, no study has examined its associations with PA motivation, intention, or engagement. The purpose of this study is to examine cross-sectional associations of exposure to fitness social media content with Self-Determination Theory motivational subtypes, and PA intention and engagement.
A total of 237 participants responded to a survey that included the validated Global Physical Activity Questionnaire (GPAQ) to assess weekly moderate to vigorous PA (MVPA). The authors examined intention for PA using the Behavioral Intentions Scale and assessed motivation for PA using the Behavioral Regulations in Exercise Scale. The authors also assessed participants’ exposure to social media fitspiration, body positive, and body neutral content. They categorized exposure to the three content types into “no exposure,” “low exposure,” “moderate exposure”, and “high exposure.” They also collected demographic and anthropomorphic data. Using a series of analyses of variance tests, the authors investigated associations among different levels of exposure to fitspiration, body positive, and body neutral content, and motivation, PA intention, and engagement.
For the reporting of results, the authors first examined interaction effects between exposure to fitness content and each of the motivational subtypes on PA intention and behavior. They identified a significant interaction of amotivation (having no drive for the behavior) and exposure to both fitspiration and body positive content on PA intentions, but not engagement. Specifically, highly amotivated individuals who also reported high exposure to these social media types reported greater intentions for PA than those who reported moderate, low, or no exposure. There was no significant interaction effect between amotivation and body neutral exposure on PA intentions nor engagement.
The authors concluded that interventionists may consider exposing highly amotivated individuals to fitspiration or body positive social media to potentially increase intentions for PA. However, the intention-behavior gap must also be addressed in this population.
This research was sponsored by Klein Buendel and led by Dr. Kayla Nuss. Coauthors included Dr. Dani Arrigo from Rowan University and Ms. Julia Berteletti from Klein Buendel.
References
Nuss K, Coulter R, Liu S. Content of social media fitspiration and its effect on physical activity-related behavior: A systematic review. Psychology of Popular Media. Published online 2023.
