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6th International Conference on UV and Skin Cancer Prevention: Posters

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

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).

Indoor Tanning Policies Are Insufficient to Protect Young Adults

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.