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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.

MobileMen Project Protocol

MobileMen Project Protocol

African American men are at higher risk for serious health conditions such as cardiovascular disease, diabetes, and stroke compared to non-Hispanic White men. Physical activity is a modifiable health behavior that has been shown to decrease chronic disease risk. Still, engagement in physical activity is alarmingly low in African American men. While interventions to improve physical activity engagement are effective in several populations, very few have been tailored to the unique needs of African American men. Even fewer have leveraged mobile health apps, despite African American men’s interest in and willingness to use such technologies for health improvement.

Now a multi-disciplinary research team from Klein Buendel, Pennington Biomedical Research Center, and three universities is conducting a comparative effectiveness trial that aims to evaluate MobileMen, a physical activity promotion app tailored to the needs and preferences of African American men. The team has published the plans and methods for the trial in JMIR Research Protocols.

The trial compares the MobileMen app to a commercially available physical activity promotion app with similar features but without culturally tailored components. Specifically, the study is recruiting a sample of 100 “low active” (less than 7500 steps per day) African American men aged 30 years or older from Baton Rouge, Louisiana and its surrounding communities. All participants are given a Fitbit Charge 6 wearable activity tracker to assess daily physical and steps. Participants are randomly assigned to either the MobileMen intervention app or a comparator app. The intervention period is six months, during which participants will interact with their assigned mobile app.

MobileMen includes features such as digital badges earned for physical activity, tangible prizes like exercise equipment, challenges among participants, goal setting, nutrition, physical activity, and behavior change educational information in text, audio, and video formats.

Participants complete assessments at baseline and at six months after random assignment. Assessments include objective measurements of daily steps and minutes of moderate to vigorous physical activity, quality of life, dietary measures, self-efficacy for fruit and vegetable consumption and physical activity, and autonomous motivation for physical activity. Detailed descriptions of measures and methods can be found in the JMIR Research Protocols paper.

Mobile apps are a widely accessible means to disseminate culturally tailored physical activity promotion interventions to various populations, including African American men. MobileMen has the potential to impact physical engagement in African American men, to help improve the overall health and chronic disease risk in this underrepresented population.

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 Callie Hebert, 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; Dr. Derek Griffith from the University of Pennsylvania; and Dr. Kayla Nuss, Amanda Brice, and Dr. David Buller from Klein Buendel. The MobileMen app was programmed by the Klein Buendel Creative Team.

Cost Analysis of an Occupational Sun Safety Intervention

Cost Analysis of an Occupational Sun Safety Intervention

Klein Buendel investigators and their collaborators have e-published the results of the cost analysis of distributing the Go Sun Smart at Work program via two different methods in the Journal of Occupational and Environmental Medicine (JOEM).

This randomized trial compared two methods (digital and in-person) for scaling up an evidence-based occupational sun protection program nationwide. The program was designed to help workplaces implement skin cancer prevention policy and training for employees who work outdoors. One hundred thirty-eight (138) regional districts in 21 state Departments of Transportation throughout the United States were randomized to receive the Go Sun Smart at Work program via in-person or digital scalability methods in 2019-2022. Results of the effectiveness of the trial were published in JOEM in January 2025.

For the economic analysis reported in this companion publication, the cost of delivering the Go Sun Smart at Work program was obtained from project accounting records and manager reports. The study followed the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guideline for economic evaluation (1). The primary outcome of the economic analysis was an incremental cost-effectiveness ratio (ICER) from the perspective of the disseminating organization, although induced costs to the employer were also recorded and reported. The ICER numerator is the incremental difference between digital and in-person strategies in average program cost (C) per regional district. The denominator is the incremental difference between digital and in-person strategies in the mean number of implemented workplace sun protection actions (per regional district) (E [for effect]):

                                    ICER = (Cdigital – Cin-person) / (Edigital – Ein-person)

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 a sun safety action not implemented under the digital strategy but implemented under the in-person strategy. In summary, 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 program actions. Full descriptions of the research methods, results, and limitations are included in the JOEM publication.

The research was supported by a Cancer Moonshot Initiative grant from the National Cancer Institute (CA210259; Dr. David Buller, Principal Investigator). Co-authors include Dr. Richard Meenan from Kaiser Permanente Center for Health Research; Dr. Gary Cutter from the University of Alabama in Birmingham; Dr. Kimberly Henry from Colorado State University; Dr. Sherry Pagoto from the University of Connecticut; and Mary Buller, Julia Berteletti, Irene Adjei, and Noah Chirico from Klein Buendel. The authors thank the American Association of State Highway and Transportation Officials (AASHTO) and the senior managers of the participating state Departments of Transportation for supporting this research project.

References

  1. Husereau D, Drummond M, Augustovski F, et al. Consolidated health economic evaluation reporting standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluations. Value Health. 202;25:3-9.

Content Analysis of Posts Featuring Popular Instagram Fitness and Exercise Trends

Content Analysis of Posts Featuring Popular Instagram Fitness and Exercise Trends

Four main health and wellness trends have emerged on social media over the past several years: thinspiration, fitspiration, body positivity, and body neutrality. Thinspiration is intended to inspire consumers to obtain a very thin body and is often considered to be promoting disordered eating behavior. Fitspiration intends to inspire consumers to participate in exercise and aspire to a “fit” body. Body positivity promotes acceptance and appreciation of all body types and body neutrality prioritizes the function of the body, rather than its appearance. The content of body neutrality posts has gone largely unexamined, and no study has comparatively examined the content of fitspiration, body positivity, and body neutrality – until now.

Dr. Kayla Nuss, Klein Buendel Scientist, and her co-authors have published new data on the content of Instagram posts pertaining to exercise in the journal, Psychology of Popular Media. The paper is entitled, “What’s in a Hashtag? A Comparative Content Analysis of Fitspiration, Body Positivity, and Body Neutrality Posts on Instagram.”

The research team conducted a comparative analysis of 200 Instagram posts from three categories: fitspiration, body positivity, and body neutrality. There were 605 total posts. All content types featured mostly White women, although fitspiration featured slightly more racial diversity. Most people featured in fitspiration and body positivity posts were thin whereas the majority of those in body neutrality posts were of average body size. Commercialization was the most prominent message in all three content types and weight loss was featured often in both fitspiration and body positivity posts.

Based on these results, the authors conclude that body positivity has seemingly drifted away from its original intention and body neutrality now seems aligned with the origins of body positivity. Full descriptions of the study design, methods, results, and limitations are provided in the Psychology of Popular Media publication. In the paper, the authors offer recommendations for researchers to develop social media health behavior interventions using elements of these popular content types.

This research was sponsored by Klein Buendel and led by Dr. Kayla Nuss. Her collaborators included Julia Berteletti, Dr. Barbara Walkosz, Irene Adjei, Annelise Small, Liliana Salcido Beltran, and Noah Chirico from Klein Buendel; Anne Poirier from Shaping Perspectives in South Carolina; and Dr. Danielle Arigo from Rowan University in New Jersey.

STAC-T Usability Testing Results

STAC-T Usability Testing Results

A research team from Boise State University and Klein Buendel have published a paper in JMIR Human Factors entitled, “Usability Testing of a Bystander Bullying Intervention App (STAC-T) for Rural Middle Schools: A Mixed-Methods Study.” The paper reports on the conduct and outcomes of the usability testing of a bystander bullying intervention app for rural middle school students.

Students who are targets of bullying are at high risk for negative mental health outcomes including depression, anxiety, and suicidal ideation. Implementing school-based bullying prevention programs reduces bullying. Bullying prevention programs are particularly important in rural schools, as bullying is more prevalent in rural schools compared to urban schools. Comprehensive, school-wide bullying prevention programs, however, require resources that create significant barriers to implementation for rural schools. Because technology-based programs can reduce some of these implementation barriers, the development of a technology-based program to address bullying increases access to bullying prevention for students in rural settings.

This study assessed the usability and acceptability of the STAC-T app and differences in usability between school personnel and students. Qualitative feedback related to usability, program features, and feasibility was also obtained and analyzed. A sample of 21 participants (10 school personnel and 11 students) recruited from two middle schools in rural, low-income communities in two states completed usability testing followed by a qualitative interview. We used descriptive statistics and independent sample t-tests to assess usability and program satisfaction. We used consensual qualitative research (CQR) as a framework to extract themes related to usefulness, relevance, needs, barriers, and feedback for intervention development.

Usability testing indicated the app was easy to use, acceptable, and feasible. Both school personnel and students rated the app well above the standard cutoff score for above-average usability (68.0) and both school personnel and students gave the app high user-friendliness ratings (0-7 scale, with 7 high user-friendliness). Overall ratings also suggested school personnel and students were satisfied with the program. Among school personnel, 100% said they would recommend the program to others and 10%, 50%, and 40% rated the program as 3, 4, and 5 stars, respectively. Among students, 90.9% said they would recommend the program to others and 27.3% and 72.7% rated the program as 4 stars and 5 stars, respectively. There were no statistically significant differences in ratings between school personnel and students.

Qualitative data revealed that both school personnel and students found the STAC-T app useful, relevant, and appropriate, while providing feedback related to the importance of narration of the text and the need for teacher and parent trainings to accompany the student program. Data also showed school personnel and students would find a tracker useful, in which students could report the different types of bullying they witnessed and strategies they used to intervene. Data from school personnel also indicated the program was perceived as practical and very likely to be adopted by schools, with time, cost, and accessibility being noted as potential barriers for schools in rural communities. The results demonstrate high usability and acceptability of the STAC-T app and provide support for implementing a full-scale randomized controlled trial to test the efficacy of STAC-T.

This research is funded by an STTR Phase II grant to Klein Buendel from the National Institute on Minority Health and Health Disparities at the National Institutes of Health (MD014943; Dr. Aida Midgett, Principal Investigator, Boise State University). Co-authors include Dr. Diana Doumas, Dr. Claudia Peralta, and Dr. Blaine Reilly from Boise State University; Dr. Matthew Peck from the University of Arkansas; and Ms. Mary Buller from Klein Buendel. The STAC-T modules were graphically designed and programmed by Klein Buendel’s Creative Team.

Design of a high-resistance inspiratory muscle strength training app

Design of a high-resistance inspiratory muscle strength training app

Dr. Kayla Nuss, Klein Buendel Scientist, and a collaborative research team from Klein Buendel and the University of Colorado Boulder have published a paper on the feasibility and design of a novel smartphone app to deliver blood pressure-lowering high-resistance inspiratory muscle strength training in the journal mHealth.

High-resistance inspiratory muscle strength training (IMST) is a time-efficient form of respiratory exercise shown to lower blood pressure in midlife and older adults (aged ≥50 years) in randomized controlled trials delivered in clinical research settings. The purpose of this study was to design a feasible and acceptable smartphone application (app) for independently delivering IMST for lowering blood pressure.

Two rounds of iterative focus groups comprised of midlife and older women and men with above-normal systolic blood pressure (self-reported ≥120 mmHg) were performed to gain feedback on interest in an IMST smartphone app and design features. Focus group results were analyzed using a Consensual Qualitative Research (CQR) coding and data analysis protocol. Clickable wireframes were developed based on focus group findings. The wireframes were then beta tested for usability and additional feedback from target users was obtained.

Among midlife and older adults, there was considerable interest in app-delivered IMST as a
lifestyle intervention for lowering blood pressure. Potential facilitators and barriers of use for a potential app also were uncovered. Furthermore, the app wireframes were found to be highly usable, indicating that the app is ready for full-scale programming. Detailed research methods, analyses, and results of this research are reported in the mHealth paper. In conclusion, the authors report that they have designed a feasible and acceptable smartphone app for independently delivering blood pressure-lowering IMST in midlife and older adults.

The research is supported by an STTR grant to Klein Buendel from the National Heart, Lung, and Blood Institute (HL167375; Dr. Douglas Seals, Principal Investigator, from the University of Colorado Boulder). The authors are Dr. Kayla Nuss, Amanda Brice, and Steven Fullmer from Klein Buendel; and Elizabeth Jones, CeAnn Udovich, Dr. Kaitlin Freeberg, Narissa McCarty, Dr. Douglas Seals, and Dr. Daniel Craighead from the Department of Integrative Physiology at University of Colorado Boulder.

Analysis of Indoor Tanning Legislation in the United States

Analysis of Indoor Tanning Legislation in the United States

Dr. David Buller, Klein Buendel Director of Research, and a national team of scientists, physicians, and attorneys, have published an article in the American Journal of Public Health that describes the progression, content, and stringency of state legislation regulating indoor tanning in the United States.

Skin cancer is a highly prevalent, potentially deadly, and expensive disease. Indoor tanning is a well-established cause of melanoma and keratinocyte (non-melanoma) carcinomas. In the most recent estimates, nearly 6% of adolescents and 5% of adults indoor tan. Most individuals begin indoor tanning as adolescents or young adults. Stringent state indoor tanning laws that include age bans for minors instead of just parental consent are associated with less indoor tanning.

For this study, trained research assistants used legal mapping methods to collect and code legislative bills on indoor tanning introduced in U.S. states, the District of Columbia, and Puerto Rico. The research aimed to (1) describe the progression of state indoor tanning legislation (enacted or failed); (2) detail the content and stringency of bills with special attention to whether bills banned indoor tanning by minors (individuals aged younger than 18 years (under-18 ban); and (3) explore the potential impact of political party affiliation of state government leadership when bills were proposed.

Between 1992 and 2023, 184 bills were introduced in 49 of 50 states and the District of Columbia (56 laws were enacted, and 126 bills failed). An under-18 ban was enacted in 22 states and the District of Columbia. Analyses calculated composite scores on the stringency of age restrictions and of warnings, operator requirements, and enforcement. The research team evaluated associations of the political party of the legislative sponsor and legislature majority. Specific methods, coding protocols, statistical analyses, results, conclusions, limitations, and public health implications are detailed in the American Journal of Public Health paper.

In many states, it took several years and proposed bills before a law on indoor tanning was enacted. Enacted bills were more stringent than failed bills. Party affiliation of the bill sponsor and legislature majority combined to affect bill passage and age restrictions. Increasing support for stringent regulations on indoor tanning is evident and may motivate other states or the federal government to prohibit minors from using indoor tanning facilities in an effort to improve health and prevent death.

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). Paper authors include Dr. Carolyn Heckman, Ms. Anna Mitarotondo, and Mr. Kevin Schroth from Rutgers University; Mr. Alan Geller from Harvard University; Dr. Jerod Stapleton from the University of Kentucky; Ms. Samantha Guild from the AIM at Melanoma Foundation in Texas; Dr. Jeffrey Gershenwald from the MD Andersen Cancer Center at the University of Texas; Dr. Robert Dellavalle from the University of Minnesota; Dr. Sherry Pagoto from the University of Connecticut; and Dr. David Buller, Ms. Julia Berteletti and Ms. Irene Adjei from Klein Buendel.

Recruitment Challenges for Project SHINE

Recruitment Challenges for Project SHINE

Dr. David Buller, Klein Buendel Director of Research, is part of a multiple institution research team that published a paper on recruitment challenges for Project SHINE. The research team is led by Dr. Yelena Wu from the University of Utah and the Huntsman Cancer Institute. The paper entitled, “Challenges and lessons learned in recruiting participants for school-based disease prevention programs during COVID-19,” was published in Contemporary Clinical Trials.

Schools provide an ideal setting for delivery of disease prevention programs due to the ability to deliver health education and counseling, including health behavior interventions, to large numbers of students. However, the remote and hybrid learning models that arose during the COVID-19 pandemic created obstacles to these efforts. The Contemporary Clinical Trials paper provides insights on collaborating with schools to deliver disease prevention programming during the height of the COVID-19 pandemic, and in subsequent years. The authors illustrate recruitment and engagement strategies by drawing upon their research experiences engaging high schools in a school-based cancer prevention trial focused on sun safety.

Delivery of a cluster-randomized trial of a school-based skin cancer prevention program was initiated in the spring of 2020 at the onset of the COVID-19 pandemic in the United States. The authors present multilevel evaluation data on strategies used to reach schools remotely and share lessons learned that may inform similar approaches moving forward during times of crises.

Although the COVID-19 pandemic interrupted school-based recruitment for this trial, enrollment improved one year later and did not appear to differ between rural and urban schools. Recruitment strategies and trial-related procedures were modified to address new challenges brought about by the pandemic. Despite the COVID-19 crisis altering classrooms, disease prevention programming can continue to be offered within schools, given close community partnerships and new adaptations to the ways in which such programming and research are conducted.

This research is sponsored by the National Cancer Institute (Dr. Yelena Wu from the University of Utah and the Huntsman Cancer Institute, Principal Investigator). Dr. David Buller from Klein Buendel is a Co-Investigator.

Smartphone Web App for DWI Offenders and Families

Smartphone Web App for DWI Offenders and Families

Driving while intoxicated (DWI) results in significant morbidity and mortality. The use of vehicle ignition interlock devices decreases the risk of drinking and driving while installed, but DWI rates increase after the devices are removed. Dr. W. Gill Woodall, Klein Buendel Senior Scientist, and his research collaborators have developed and tested the B-SMART smartphone web app to continue to support offenders and their concerned family members after their ignition interlock devices have been removed. They have published their methods and results of usability testing online in the Journal of Substance Use and Addiction Treatment.

Formative data collection for app development occurred in two phases. Phase 1 included key informant interviews with DWI offenders and concerned family members, development of one app module, and usability testing. Phase 2 included focus groups with DWI offenders and concerned family members, development of three more app modules, and usability testing. The Bangor System Usability Scale was used to rate app usability and satisfaction.

Results of key informant interviews and focus groups indicated that offenders and family members lacked information and were frustrated by the ignition interlock device, experienced financial burden from the DWI and the device, viewed supportive communication and positive shared activities as important, and were positive about the app. The four modules developed were Life with Interlock, Supporting Changes in Drinking, Doing Things Together, and Effective Communication. Each module included an introduction, at least one interactive activity, a video, and text to summarize what was presented. The content of the app modules was written primarily for the concerned family members. Usability testing indicated that the B-SMART modules were easy to use and informative.

The paper published online in the Journal of Substance Use and Addiction Treatment details the research measures, methods, analyses. A diagram describes the flow for the features and design of the app. This careful formative work resulted in an app responsive to the concerns of DWI offenders with ignition interlock devices and their concerned family members.

The authors believe that harnessing the power of the family to help the offender maintain a pattern of driving when not impaired may yield longer, successful outcomes initiated by the ignition interlock device. A future paper will report the efficacy of the B-SMART app after its implementation and testing in a rigorous randomized trial.

This research was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (AA022850; Dr. W. Gill Woodall, Principal Investigator). Collaborators included Dr. Barbara McCrady, Dr. Randall Starling, and Dr. Vern Westerberg from the University of New Mexico; Mr. Thomas Starke from Impact DWI in Sante Fe, New Mexico; and Ms. Julia Berteletti, Ms. Marita Brooks, and Ms. Lila Martinez from Klein Buendel. The B-SMART app was developed by the Creative Team at Klein Buendel.

Implementation of an Occupational Sun Safety Intervention: Comparison of Two Scalability Strategies

Implementation of an Occupational Sun Safety Intervention: Comparison of Two Scalability Strategies

Klein Buendel investigators and their collaborators have published the results of the Go Sun Smart at Work project in the Journal of Occupational and Environmental Medicine. This research compared two methods for scaling up an evidence-based occupational sun protection program nationwide. One hundred thirty-eight (138) regional districts in 21 state Departments of Transportation throughout the United States were randomized to receive the Go Sun Smart at Work program via in-person or digital scalability methods in 2019-2022 in 1:2 ratio. Managers completed pretest and posttest surveys and employees completed posttest surveys. Due to the COVID-19 pandemic, only posttest measures were analyzed (from 255 managers and 1387 employees).

After scale-up, more employees reported training and communication at workplaces in in-person rather than digital strategy. There were no differences in managers’ reports of sun protection training, communication, or actions by scalability method. Overall, occupational sun protection was implemented during program scale-up and employees recalled training/communication more in the in-person than digital strategy. A full description of methods, analyses, and results can be found in the Journal of Occupational and Environmental Medicine publication.

The research was supported by a Cancer Moonshot Initiative grant from the National Cancer Institute (CA210259; Dr. David Buller, Principal Investigator). Collaborators include Dr. Richard Meenan from Kaiser Permanente Center for Health Research, Dr. Gary Cutter from the University of Alabama in Birmingham, Dr. Kimberly Henry from Colorado State University, and Ms. Mary Buller, Ms. Julia Berteletti, Ms. Alishia Kinsey, Ms. Irene Adjei, and Mr. Noah Chirico from Klein Buendel. The authors thank the American Association of State Highway and Transportation Officials (AASHTO) and the senior managers of the participating state Departments of Transportation for supporting this project.