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.
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).
A research team led by Dr. Yelena Wu from the University of Utah and the Huntsman Cancer Institute, and including Dr. David Buller from Klein Buendel, has published a detailed protocol for the project entitled, “Sun-safe Habits Intervention and Education” in Contemporary Clinical Trials. Project SHINE examines the efficacy of a personalized intervention targeting sun protection and tanning of high school students.
Adolescents infrequently use sun protection and engage in intentional tanning more frequently compared to other age groups, leading to increased ultraviolet radiation (UVR) exposure that heightens skin cancer risk across the lifespan. High schools are therefore an ideal setting for offering skin cancer prevention interventions. Yet, there are limited UVR protection interventions for high school students, especially those that are personalized, tested using randomized designs, and include long-term outcome assessment to determine the durability of intervention effects.
The SHINE cluster-randomized trial will test a novel, personalized intervention that targets high school adolescents’ sun protection and tanning behaviors, and tracks their outcomes for up to one year following intervention. Enrolled high schools will be randomized to receive either the personalized SHINE intervention, which includes facial UVR photographs and sun protection action planning, or standard education using publicly available materials. Students in both conditions will receive information about skin cancer, sun protection, and skin self-examination. Outcome variables will include students’ sun protection and tanning behaviors and sunburn occurrence. Potential moderators (such as race/ethnicity) and mediators (such as self-efficacy) will also be assessed and tested.
The investigators believe Project SHINE will lead to new scientific understanding of the theoretical mechanisms underlying outcomes and moderators of the intervention effects, which will inform future intervention tailoring to meet the needs of vulnerable subgroups.
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, Director of Research at Klein Buendel, is a Co-Investigator.
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.
#4Corners4Health: Protocol for a Randomized Stepped-Wedge Trial
Dr. David Buller from Klein Buendel and Dr. Andrew Sussman from the University of New Mexico are leading a large multiple state research team on the design, implementation, and evaluation of #4Corners4Health. The research study aims to decrease cancer risk factors among emerging adults (ages 18-26) living in rural counties in the Four Corners states of Arizona, Colorado, New Mexico, and Utah using a targeted social media campaign. The team has published a full description of their study procedures in JMIR Research Protocols.
Many emerging adults are prone to making unhealthy choices, which increase their risk of premature cancer morbidity and mortality. In the era of social media, rigorous research on interventions to promote health behaviors for cancer risk reduction among emerging adults delivered over social media is limited. Cancer prevention information and recommendations may reach emerging adults more effectively over social media than in settings such as health care, schools, and workplaces, particularly for emerging adults residing in rural areas.
Specifically, the research team will recruit a sample of 1000 emerging adults aged 18 to 26 years residing in rural counties in the Four Corners states from the Qualtrics’ research panel and enroll them in a randomized stepped-wedge, quasi-experimental design. The inclusion criteria include English proficiency and regular social media engagement. A social media intervention will promote guideline-related goals for increased physical activity, healthy eating, and HPV vaccination and reduced nicotine product use, alcohol intake, and solar UV radiation exposure. Posts will cover digital and media literacy skills, responses to misinformation, communication with family and friends, and referral to community resources. The intervention will be delivered over 12 months in Facebook private groups and will be guided by advisory groups of community stakeholders and emerging adults and focus groups with emerging adults. The emerging adults will complete assessments at baseline and five additional data after randomization. Assessments will measure six cancer risk behaviors, theoretical mediators, and participants’ engagement with the social media campaign.
The trial is being led by a steering committee. Team members are working in three subcommittees to optimize community engagement, the social media intervention, and the measures to be used. The Stakeholder Organization Advisory Board and Emerging Adult Advisory Board were formed and provided initial input on the priority of cancer risk factors to target, social media use by emerging adults, and community resources available. A framework for the social media intervention with topics, format, and theoretical mediators has been created, along with protocols for social media management.
In summary, the researchers believe that social media can be used as a platform to counter misinformation and improve reliable health information to promote health behaviors that reduce cancer risks among emerging adults. Because of the popularity of web-based information sources among emerging adults, an innovative, multiple risk factor intervention using a social media campaign has the potential to reduce their cancer risk behaviors.
This research is supported by a 5-year R01 grant from the National Cancer Institute (CA268037) to Klein Buendel. Dr. David Buller from Klein Buendel and Dr. Andrew Sussman from the University of New Mexico are the project’s Multiple Principal Investigators. The JMIR publication has 24 collaborating authors from multiple institutions.
Three occupational sun safety projects were presented by collaborating researchers from Klein Buendel and Emory University at the 16th Annual Conference on the Science of Dissemination and Implementation in Health held December 10-13, 2023, in Washington, DC. Each presentation complemented the conference theme of “Raising Expectations for Dissemination & Implementation Science: Challenges and Opportunities,” by approaching occupational skin cancer prevention in a unique and challenging way.
Poster 1
Title: Differences in Program Implementation and Sun Protection of an Occupational Sun Safety Intervention: Comparison of Two Dissemination Strategies
Presenter: Dr. David Buller, Klein Buendel
Dr. David Buller
Balancing effectiveness and cost is essential when scaling up evidence-based interventions. In this study, two methods for disseminating an evidence-based occupational sun protection intervention that differed in cost and personal contact were compared. Solar ultraviolet radiation is a carcinogen associated with skin cancer.
Sun Safe Workplaces (SSW), a policy and education intervention, was effective in a randomized trial in Colorado (1,2). Two methods for disseminating SSW were compared in a randomized pretest-posttest two-group trial design. State departments of transportation (DOTs; n=21) participated and the 136 districts within these DOTs were randomly assigned to receive SSW either by an in-person coaching method or a virtual coaching method. In each district, managers were pretested prior to randomization (n=1,484) and posttested (n=289) after 29-40 months (timing and attrition were affected by the COVID pandemic) on implementation of SSW training and communication and personal sun protection practices. Employees (n=1,388) also were posttested on training and communication implementation and personal sun protection practices.
There was no difference in managers’ reported implementation of sun protection actions at the workplace between dissemination methods. But more employees reported receiving sun protection training in in-person (60%) than virtual (46%) dissemination method and being more favorable toward this training (in-person M=3.70, virtual M=3.60.) Managers at workplaces receiving SSW via in-person dissemination experienced fewer sunburns in the past year while working outdoors than with virtual program delivery (M=0.69 v. M=1.58 sunburns; estimate=-0.875, p<0.011), especially at workplaces receiving it before the pandemic compared to later in the pandemic (in-person=0.43, virtual=0.79).
Effectiveness of evidence-based programs when scaled-up may be affected by the method of dissemination. Here, in-person coaching may have increased implementation of SSW training. It also may have aided coaches in convincing managers that there was a need for occupational sun safety and motivated them to avoid sunburn themselves and work to make employees see the value in training. The virtual delivery method may not have affected employees’ personal protection because they had limited contact with the coaches. Pandemic restrictions may have reduced intervention success.
This research was supported by a grant (CA210259; Dr. David Buller, PI) from the National Cancer Institute at the National Institutes of Health. Coauthors on this poster presentation included Ms. Julia Berteletti and Ms. Mary Buller from Klein Buendel; Dr. Kimberly Henry from Colorado State University; Dr. Richard Meenan from Kaiser Permanente, and Dr. Gary Cutter from the University of Alabama.
References
Buller, D. B., Walkosz, B. J., Buller, M. K., Wallis, A., Andersen, P. A., Scott, M. D., Eye, R., Liu, X., & Cutter, G. R. (2018). Results of a randomized trial on an intervention promoting adoption of occupational sun protection policies. American Journal of Health Promotion, 32, 1042-1053.
Walkosz, B. J., Buller, D. B., Buller, M. K., Wallis, A., Meenan, R., Cutter, G., Andersen, P. A., & Scott, M. D. (2018). Sun safe workplaces: Effect of an occupational skin cancer prevention program on employee sun safety practices. Journal of Occupational and Environmental Medicine, 60, 900-997.
Presentation 1
Title: Adaptation of an Evidence-based Occupational Sun Safety Program for Underserved Outdoor Workers in Southwest Georgia
Presenter: Dr. Alex Morshed, Emory University
Dr. David Buller, Ms. Mary Buller, Dr. Alex Morshed, Dr. Cam Escoffery
African American and Hispanic workers face unique skin cancer risks from UV exposure and are underrepresented in occupational sun safety research. This presentation reported on adaptation of an existing evidence-based sun safety program—Go Sun Smart at Work—to predominantly African American and Hispanic outdoor workers in local government employers in Southwest Georgia. The adaptation is renamed Go Sun Smart Georgia.
The systematic adaptation process was informed by Dr. Cam Escoffery’s Key Adaptation Steps (1), Implementation Research Logic Model (IRLM) (2), and the Framework for Reporting Adaptations and Modifications (3). The original intervention promotes workplace policy and education to improve sun protection and was effective in a randomized trial in Colorado (4,5). The team mapped the program and delivery using IRLM and developed an adaptation tracking tool based on Rabin et al. (6) to catalogue and make decisions about potential adaptations. The team integrated multiple sources of information to identify compatible and feasible adaptations: consultation with program experts and community partners, qualitative data collection with outdoor workers and managers at two local government employers (Jul-Sep 2023), and synthesis of literature.
The intervention includes training of peer coaches; written audit of employer sun safety policies, practices; employee training; and resource website (for example: training, sample policies, print materials, videos). In a pilot study with two local government employers, 11 employees identified by senior managers completed virtual 30-minute instruction to be peer coaches. Peer coaches delivered the sun safety training at staff meetings (21-39 employees per session). Several promising adaptations were identified, including modification of educational materials to better represent the worker population, addressing misconceptions, and use of external peer coaches at the workplace. Interviews with managers and focus groups with employees are in process.
Adaptation of existing, effective interventions to better address population characteristics and needs can increase feasibility and scalability with employers throughout Georgia, which furthers dissemination and reach of existing evidence base for improving occupational sun safety and preventing cancer.
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). Coauthors on this oral presentation included Ms. Mary Buller, Dr. Barbara Walkosz, Ms. Irene Adjei, Mr. Brandon Herbeck, and Dr. David Buller from Klein Buendel; and Ms. Kayla Anderson, Dr. Cam Escoffery, and Radhika Agarwal from Emory University.
Title: “Technology for Workplace Implementation of Solar Radiation Safety in Response to Climate Change”
Presenter: Ms. Mary Buller, Klein Buendel
Ms. Mary Buller
The sun’s energy is both life-saving and life-threatening. Americans who work outdoors are exposed to rising temperatures and extreme levels of ultraviolet radiation from the sun. These exposures, without preventive measures, can cause heat illness, skin cancer, and death. It is estimated that solar radiation contributed to over 350,000 deaths from excessive heat in 2019 and over 120,000 deaths from skin cancer in 2020. The U.S. government recently launched an interagency effort to combat extreme heat, including for persons who work outdoors, and the Surgeon General has identified occupational sun safety as part of a national priority for skin cancer prevention.
Workplace interviews, a review of literature and existing programs, and expert consultants helped increase dissemination potential by expanding an intervention for occupational skin cancer prevention to include heat illness prevention. Content consultants included safety training professionals, behavioral scientists, and dermatologists. The program, Go Sun Smart at Work, also includes messaging for outdoor workers of all skin types and risk profiles for both heat illness and skin cancer to be delivered online through workplace learning management systems to improve its dissemination. It will be evaluated in 2024 in a randomized controlled trial enrolling 20 worksites, their managers, and outdoor employees.
A virtual learning environment (VLE) has been programmed to disseminate and guide the implementation of comprehensive sun exposure reduction to workplaces. The VLE is a web-based program with a content database, a media platform for trackable employee training (compliant with eLearning standards), and an innovative, automated decision support tool. The tool is a chat bot-like program that customizes advice on adopting workplace policy and implementing prevention procedures to management’s readiness to innovate on sun safety based on Diffusion of Innovations Theory.
Solar radiation prevention is urgently needed to help outdoor workers adapt to a warming world. Employers have been adopting virtual training rapidly to improve accessibility, resource and learning efficiency, engagement and information retention, and fidelity and trackability. Improvements in dissemination, training, and practice, as facilitated by this VLE, can save employers time and money, improve employee health behaviors, and reduce solar-related adverse events at work.
This research was supported by a grant (CA257778; Ms. Mary Buller, PI) from the National Cancer Institute. Coauthors on this poster presentation included Dr. Barbara Walkosz, Ms. Julia Berteletti, Mr. Brandon Herbeck, Ms. Irene Adjei, and Dr. David Buller from Klein Buendel.
Three Klein Buendel Principal Investigators gave presentations on their recent or active research projects at the 14th European Society for Prevention Research Conference held October 4-6, 2023 in Sarajevo, Bosnia and Herzegovina. The presenters were Dr. David Buller, Director of Research, Dr. Barbara Walkosz, Senior Scientist, and Ms. Mary Buller, President. Each presentation complemented the conference theme of “Optimizing Prevention Infrastructures.” The prevention interventions were implemented in workplaces to reach their target populations directly and impactfully.
Presentation 1
Dr. David Buller
“Formative Research on Professional Development Training to Maintain Responsible Beverage Service Practices”
Improved interventions are needed to reduce the negative consequences of alcohol intoxication. Responsible beverage service (RBS) training has been effective at reducing service to intoxicated customers in some cases. Its efficacy might be improved with an intervention that supports RBS techniques in the years between government-required RBS retraining. We conducted formative research to develop an ongoing professional development component for an online RBS training.
Formative research explored feasibility, acceptability, and content for an ongoing professional development intervention for alcohol servers. Semi-structured interviews were performed with owners/managers of licensed establishments (n=10) and focus groups (n=19) and survey (n=24) with alcohol servers in New Mexico and Washington. A prototype of a professional development component was produced, covering advanced RBS skills, support from experienced servers, professionalism, and basic management training, for delivery through social media. It was evaluated in a usability survey with alcohol servers (n=20) in California, New Mexico, and Washington.
While owners, managers, and alcohol servers were favorable toward RBS in their establishments, they endorsed the need for ongoing support for RBS for servers. Among topics of high interest were sharing tips, methods, and stories from experienced servers, balancing pressure to sell, navigating adult-use marijuana laws, dealing with children, recognizing intoxication, and managing difficult customers. The prototype was comprised of 50 social media posts, including text, infographics, videos, and interactive activity. Servers rated it as highly usable and appropriate for themselves and the establishment. Most servers (70%) were interested in receiving the ongoing information and activities.
Owners, managers, and servers believed that an ongoing professional development component on RBS would benefit servers and licensed establishments. Servers were interested in using such program. The professional development component has the potential to improve an existing RBS intervention.
Collaborators on this presentation included Dr. David Buller and Dr. W. Gill Woodall from Klein Buendel, and Dr. Robert Saltz from the Prevention Research Center at the Pacific Institute for Research and Evaluation in California. This research was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (AA029364; W. G. Woodall and D. Buller, MPIs).
Presentation 2
Dr. Barbara Walkosz
“Sun Safety Ink!: Sun Safety Practices of Tattoo Studio Clients”
Melanoma is the second most common cancer among young adults in the United States. Sunburn prevalence and low rates of sun protection are elevated in this group. Thus, efforts are needed to promote skin cancer prevention. An estimated 225 million people worldwide have tattoos with 40% of adults ages 18-29 with at least one tattoo, and at least 30% of American have tattooed skin. Sun Safety Ink! is a skin cancer prevention program targeted to clients of tattoo studios The goal of Sun Safety Ink! is to promote full-body comprehensive sun protection to clients of tattoo studios to compliment standard aftercare instructions that recommend sun protection for new tattoos.
Thirty-seven tattoo studios were enrolled in the Sun Safety Ink! program. At pretest, clients were recruited by tattoo artists to complete an online survey that assessed current self-reported sun protection (sunscreen, lip balm, hats, protective clothing, sunglasses, and shade), number of sunburns, and sunbed tanning frequency in the last year. Respondents were also asked to locate the position of tattoos on their body, using a drawing tool.
A total of 861 clients completed the online survey. Respondent demographics: age, average 31 yrs.; 67% female, 30% male; 60% white, 27% more than one race, 2% African American, 1% Asian and Native American, 13% Hispanic/Latino. The most prominent tattoo locations included: front left arm, 66%, front right arm, 58%, front upper torso, 52%, and back upper torso, 48%. Sun safety practices, that is, full body sun protection, (on a 5-point scale of “always” to “never”) were reported as: apply sunscreen SPF 15+ on face (aftershave, face lotion, or make-up), 3.31; apply sunscreen SPF 30+ on all exposed skin areas, 3.22; reapply sunscreen, 3.08; apply a lip balm, 3.28; wear any hat, 2.91; wear wide-brimmed hat, 2.21; wear sunglasses, 3.89; stay mostly in the shade, 3.38; and wear protective clothing, 2.91. Respondents also reported the number of sunburns as 1.53 and number of times indoor tanning as 1.11 in the last 12 months.
The pretest results indicate that full-body sun safety practices of tattooed adult can benefit from improvement, particularly wearing of hats and sun protective clothing. Further, knowledge of tattoo locations can direct sun safety recommendations to include protecting not only tattoos on arms and torsos but also non-tattooed skin on those areas of the body. Tattoo studies may be a viable location to delivering effective sun safety interventions to hard-to-reach tattooed, young adults.
Collaborators on this presentation included Dr. Barbara Walkosz, Ms. Mary Buller, and Dr. David Buller from Klein Buendel, and Dr. Robert Dellavalle from the University of Colorado School of Medicine and the Department of Veteran Affairs. This research was supported by a grant (CA206569; B. Walkosz, PI) from the National Cancer Institute.
Presentation 3
Ms. Mary Buller
“Protection from Solar Radiation in the Era of Climate Change: Preventing Heat Illness and Skin Cancer for Outdoor Workers”
The sun’s energy is both a necessity and a threat to humans. Extreme heat linked to climate change and unprotected exposure to ultraviolet radiation (UV) make people who work outdoors vulnerable to life-threatening heat illness and skin cancer. It is estimated that infrared radiation (heat) and UV contributed to over 120,000 deaths from skin cancer in 2020 and over 350,000 deaths from excessive heat in 2019. Efforts to protect workers from heat or UV can work in tandem to help outdoor workers adapt to the warming world.
Workplace interviews, a review of literature, and expert consultants helped expand an existing intervention for U.S. occupational skin cancer prevention to include heat illness prevention, and to be delivered online. Content consultants include safety training professionals, behavioral scientists, and dermatologists. The program, Go Sun Smart at Work (GSSW), will be evaluated in 2024 in a randomized controlled trial enrolling 20 U.S. employers.
GSSW is an innovative virtual learning environment and resource hub promoting comprehensive solar radiation policy, training, and personal protection for outdoor workers. It includes (1) a manager resource hub that guides decision-makers through implementation strategies using a structured conversation agent; (2) an employee sun safety training video that is compliant with eLearning standards and compatible with learning management systems for monitoring; and (3) a trove of resources and downloadable materials addressing heat illness and skin cancer prevention. The structured conversational agent adjusts workplace implementation strategies for management’s readiness to innovate on sun safety based on Diffusion of Innovations Theory.
GSSW will help outdoor workers protect themselves from the serious threats of climate change by providing employers with a convenient, comprehensive solar radiation safety policy and training program. It will support the shift to online training to improve accessibility, fidelity, adherence, and tracking, while saving resources.
Collaborators on this presentation included Ms. Mary Buller, Dr. Barbara Walkosz, Ms. Julia Berteletti, Mr. Brandon Herbeck, Ms. Irene Adjei, and Dr. David Buller from Klein Buendel. This research was supported by a grant (CA257778; M. Buller, PI) from the National Cancer Institute.
Approximately five million cases of skin cancer are diagnosed among Americans at a cost nearing $9 billion annually. Indoor tanning (IT) is a risk factor for skin cancer. Restricting IT facilities, especially access by minors, has been the subject of state laws. More stringent restrictions on youth access (for example, bans by age vs. parental consent laws) appear to be associated with reduced IT by youth.
Julia Berteletti and David Buller at SBM
A team led by Dr. Carolyn Heckman from Rutgers University and Dr. David Buller from Klein presented a poster characterizing the IT policy landscape of U.S. states at the 44th Annual Sessions and Meeting of the Society of Behavioral Medicine in Phoenix, Arizona on April 26-29, 2023. The poster was entitled “Comparison of the stringency of indoor tanning bills regarding minors that passed and failed in state legislatures over the last 30 years.”
The research team coded 107 state IT law documents and compared passed laws to failed bills (proposed but not voted on or proposed but voted down), using a validated coding tool that assessed the presence of age bans, parental consent/accompaniment, warnings, operator requirements, and enforcement. Component codes were scaled on 10-point stringency measures (0=no regulation, 10=very strong regulation). Component and total summed scores were calculated, with higher scores indicating more stringent IT restrictions.
Between 1991 and 2022, 46 states and the District of Columbia passed a law on IT, with 23 banning access to IT facilities by minors under age 18. By contrast, 60 bills on IT failed to pass in 31 states since 2008. However, stringency of laws is weak, overall, which may explain why recent research found low compliance of IT facilities with regulations and continued IT among minors. Failed bills without minor bans were less stringent than similar passed laws, on nearly all components. Failure may have presented advocates opportunities to improve stringency of subsequent bills and time to garner more support for IT restrictions. In fact, less stringent bills may have failed because they had less support from outside constituencies (for example, medical societies and public health advocates) and among legislators. To gain insight into this public health legislation process, we are interviewing key informants from states with recent policy activity.
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). Co-authors included Ms. Julia Berteletti from Klein Buendel and Ms. Anna Mitarotondo from Rutgers University.
Adapting a Sun Safety Program for Low-Risk Outdoor Workers
Ultraviolet radiation (UV) from the sun is an occupational hazard that causes skin cancer. Outdoor workers are disproportionately Hispanic and African American (AA). Though risk for skin cancer is greater for non-Hispanic Whites, Hispanics and AAs are more likely to die from skin cancer as a result of delays in detection. Interviews (n=32) and an online survey (n=81) were conducted with a predominantly male, Hispanic, and AA sample of outdoor workers to inform the systematic adaptation of an existing evidence-based workplace sun safety program. The goal was to learn how to target messaging to underrepresented outdoor workers with darker skin types.
The interview sample was largely male (87%), Hispanic (78%), and AA (25%). Interviews were qualitatively reviewed to identify common themes. Most employees reported not getting sunburned while at work. Some reported skin darkening as a negative consequence. Sun protection is not a topic usually discussed with others but skin cancer is a concern. They reported engaging in sun protection, but not frequently wearing sunscreen. They were positive about receiving sun safety training at work and suggested it be combined with heat stroke prevention, which is a common training topic. The survey sample also was largely male (74%), Hispanic (25%), and AA (58%). Respondents reported an average of 2.66 sunburns in the past year, 85% occurring at work. They learned about sun protection most often from parents (46%), followed by employers (37%) and healthcare providers (37%). Only half (49%) reported being very confident they can practice sun safety. Limiting time outside during high UV (46%) and wearing sunscreen (35%) were the least used forms of sun protection reported. Participants in the interviews and survey listed avoiding sunburn, preventing skin darkening, and preventing heat stroke as benefits of sun safety training.
Overall, employees with darker skin types knew about UV protection and often put the knowledge into practice on the job. Motivation based on perceived risk for skin cancer and self-efficacy could be improved, especially with regard to sunscreen. Other appearance and health concerns, such as preventing heat illnesses in this period of climate-driven extreme heat events, may be highlighted to motivate sun protection among outdoor workers with darker skin types. Employers are an important source of sun safety information for these employees, since many do not talk about it with other people in their lives.
This formative research is supported by the National Cancer Institute of the National Institutes of Health under award number CA257778 (Mary Buller, Klein Buendel President, Principal Investigator). Collaborators from Klein Buendel include Dr. Barbara Walkosz, Ms. Julia Berteletti, and Ms. Irene Adjei.
