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Noncompliance with laws to prevent polysubstance misuse

Noncompliance with laws to prevent polysubstance misuse

The effectiveness of statutes to combat hazardous polysubstance use (for example, alcohol and cannabis together) has rarely been evaluated. A multi-institutional team led by Klein Buendel researchers assessed compliance with a state law prohibiting recreational cannabis sales to apparently intoxicated customers in one of the first states to legalize cannabis sales. The assessment has been published in Alcohol: Clinical and Experimental Research.

In January to June 2024, pseudo-patrons visited 189 recreational cannabis stores twice in two large metropolitan areas and attempted to purchase cannabis while displaying alcohol intoxication behaviors. Observers recorded whether sellers were willing to sell the product along with characteristics of the stores (busyness, cleanliness, and signage) and cannabis sellers (sex, race and ethnicity, and age). Neighborhood characteristics by U.S. census tract were obtained (income, race, and ethnicity; population density). Sex and race and ethnicity of the pseudo-patrons, and extent and type of intoxication cues, were recorded. Descriptive statistics and logistic regression were used to describe the sales rate and predictors of the sales rate.

Assessments were completed at 173 stores. Sellers were willing to sell cannabis to pseudo-intoxicated buyers at 255 of 346 visits (73.7%). Sellers refused buyers at both visits in 6.9% of stores but in 54.3% were willing to sell at both visits. Sellers refused cannabis sales at higher rates in stores with signs saying, “no sales to intoxicated customers” (34.3%), particularly when buyers displayed more obvious signs of intoxication (39.8%).

Low compliance with the state regulation possibly occurred because sellers were unaware of the law, perceived little deterrence by the law, or lacked the skills to recognize and refuse intoxicated customers. Noncompliance with the law on selling cannabis to apparently alcohol-intoxicated customers increases the risks of polysubstance impairment and harm.

This research is supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (AA031591; Dr. W. Gill Woodall and Dr. David Buller, Multiple Principal Investigators). Additional collaborating authors include Dr. Robert Saltz from the Pacific Institute for Research and Evaluation; Dr. James Fell from Fell Consulting; Dr. Gary Cutter from the University of Alabama; and Lila Martinez, Amanda Brice, and Noah Chirico from Klein Buendel.

Development of an Online Cancer Prevention Intervention for Rural Emerging Adults

Development of an Online Cancer Prevention Intervention for Rural Emerging Adults

A multi-state research team from Arizona, Colorado, New Mexico, and Utah has published research on a rural health intervention in the Journal of Medical Internet Research. The study developed and pilot tested a theory-based intervention via the web to reduce six cancer risk factors among rural emerging adults through community-engaged research.

The rapid growth of user-generated web-based health information increases the complexity of cancer information seeking. One promising strategy for promoting high-quality cancer information consumption is through targeted interventions that are intentionally designed to reach individuals in the online spaces they occupy. However, there is a paucity of evidence-based information on the best strategies for designing and implementing web-based health behavior change interventions to improve individuals’ cancer-related knowledge and prevent cancer.

This mixed methods approach describes the development of an online cancer prevention intervention aimed at rural emerging adults aged 18-26 years in the United States and delivered in Facebook private groups. The intervention was guided by behavior change theory and co-created with young adults and Stakeholder Organization Advisory Boards to ensure relevance, accessibility, and appropriateness. The paper reported on three formative surveys, a pilot intervention, protocol development, and the community-engaged process for intervention development.

The authors developed 400 posts for a Facebook feed aimed at reducing six cancer risk behaviors (unhealthy diet, lack of physical activity, tobacco use, alcohol use, sun exposure, and human papillomavirus infection) with iterative input from the emerging adults and stakeholder advisory boards. Formative surveys with rural 297 emerging adults and a pilot study of the intervention with this 26 people from this population were conducted. In the pilot study, the intervention reached a sample of participants across several rural counties, with sustained engagement over a one-month period. Key modifications to the intervention content and design emerged from both advisory boards, the formative surveys, and the pilot intervention, focusing on using perceived reliable sources and direct links to source material.

The authors concluded that this web-based cancer prevention intervention is scalable and delivers engaging, evidence-informed health information to rural emerging adults. They offered key insights into the design and implementation of web-based cancer prevention interventions for emerging adults by describing the resources, timelines, and expertise needed to design and implement the intervention. Considerations for fully engaging young people and community stakeholder partners are presented, and how their involvement resulted in modifications that strengthened the intervention was discussed. Finally, the authors highlighted the importance of theory-based health-behavior messaging, digital messaging skillsets, and platform-tailored dissemination strategies for maximizing web-based intervention acceptability.

The research is supported by a grant from the National Cancer Institute (CA268037; Dr. David Buller and Dr. Andrew Sussman, Multiple Principal Investigators). Dr. Buller is the Director of Research at Klein Buendel. 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. The lead author of the Journal of Medical Internet Research paper is Dr. Echo Warner from the College of Nursing and the Huntsman Cancer Institute at the University of Utah.

Who Gives a Hoot about Heat?

Who Gives a Hoot about Heat?

Extreme heat is the leading cause of weather-related deaths. Prevention includes personal practices and emergency procedures. Behavioral interventions to improve prevention of heat-related illnesses are a priority.

A multi-institutional research team led by Emory University and Klein Buendel has published a systematic review and narrative synthesis of behavioral interventions to improve heat-related illness prevention in community and occupational populations. The research team was assisted by a public health informationist from the Woodruff Health Sciences Center Library at Emory University. The paper has been published in the journal, BMC Public Health.

Utilizing systematic review methodology, a comprehensive search strategy was deployed to identify studies reporting evaluations of behavioral heat-illness prevention interventions. Data sources included prominent bibliographic databases and relevant grey literature searches. Inclusion criteria indicated that studies that enrolled adult participants, assessed heat-related outcomes quantitatively, and were published in English from January 2000 to October 2023 be included. Data on study design, intervention features, and outcomes from the retained studies were extracted. A narrative synthesis was conducted, given the small number of studies and heterogeneous features.

Seventeen articles reporting on results from 13 studies were retained. Samples included outdoor workers, professional athletes, or community members (20,154 participants). Study quality was variable, with only two studies classified as good quality. Outcomes assessed were cognitive variables (such as knowledge, attitudes, and intentions), behaviors (such as water intake and dehydration), and clinical indicators (such as kidney function). Seven studies evaluated a health education intervention, two studies tested warning messages, and two studies focused on provision of personal protection equipment. Interventions improved self-reported heat-illness knowledge and prevention behaviors, and reduced deaths. Kidney function and health were improved in two studies. 

The published literature on behavioral heat-related illness prevention interventions was limited, despite frequent periods of high heat. The published evidence suggested that interventions can improve prevention knowledge and behavior and possibly reduce heat injury. Study designs need substantial improvement by including larger samples and randomized designs with comparison groups to avoid threats to internal and external validity in existing data. Policy efforts should be considered along with health education and provision of personal protection equipment to ensure populations are adequately protected.

This research was supported by a grant (U48DP006377) from the Centers for Disease Control and Prevention to the Emory University Prevention Research Center (Dr. Alex Morshed from Emory University and Dr. David Buller from Klein Buendel, MPIs). Additional authors on this publication include Ms. Radhika Agarwal, Dr. Shenita Peterson, Dr. Cam Escoffery, and Ms. Kayla Anderson from Emory University; and Ms. Irene Adjei, Ms. Mary Buller, and Dr. Barbara Walkosz from Klein Buendel.

B-SMART App for DWI Offenders and Family Reduced Alcohol Use and Ignition Interlock Device Lockouts

B-SMART App for DWI Offenders and Family Reduced Alcohol Use and Ignition Interlock Device Lockouts

Driving while intoxicated (DWI) remains a preventable source of morbidity and mortality in the United States. Ignition interlock devices (IIDs) are used to prevent DWI offenders from driving while intoxicated during a mandated installation period and are effective during that time. Once IIDs are removed, DWI rates are like levels of offenders who had no IID.

Researchers at Klein Buendel and the University of New Mexico have published the results of a study that tested the efficacy of a new smartphone app (B-SMART) for DWI offenders with an IID and concerned family members, with the goal of reducing IID alcohol consumption and lockout events. The full paper with methods, analyses, and results has been published in the Journal of Studies on Alcohol and Drugs.

Four B-SMART app modules were developed: 1) Life with Interlock, 2) Supporting Changes in Drinking, 3) Doing Things Together, and 4) Effective Communication. Participants (pairs of DWI offenders and concerned family members) were randomly assigned to receive the B-SMART app (n=58) or referral to a state IID information page, considered usual and customary care (n=65), and followed for nine months. IID data (failed tests and lockout events) were obtained from IID providers as the primary outcome variables. Offender and CFM reports of alcohol consumption in the last 30 days prior to assessment were secondary measures.

IID data were collected on 62% (n=76) of participants. B-SMART participants had significantly fewer lockout events than usual and customary care participants. B-SMART offenders and their concerned family members reported significantly less likelihood of DWI offender drinking at the 9-month follow-up.

Results suggest the B-SMART app reduced DWI offender alcohol consumption and IID lockout events. These outcomes are important because fewer IID lockout events predict lower 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 paper include Dr. Barbara McCrady and Dr. Vern Westerberg from the University of New Mexico; and Julia Berteletti, Lila Martinez, Marita Brooks, and Noah Chirico from Klein Buendel; and Thomas Starke from Impact DWI. The B-SMART app was developed by the Creative Team at Klein Buendel.

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).

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.
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.