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An Implementation Model for the Cost-effective Scale-up of the Sun Safe Workplaces Program

An Implementation Model for the Cost-effective Scale-up of the Sun Safe Workplaces Program

Dr. David Buller and Dr. Barbara Walkosz from Klein Buendel presented a poster on a new implementation model for the cost-effective scale-up of an occupational sun protection program at the 12th Annual Conference on the Science of Dissemination and Implementation in Health in Washington, DC, December 4-6, 2019. The poster was nominated for Best Poster from the Prevention and Public Health Division.

Scale-up is the effort to increase the impact of successful programs to benefit more people on a lasting basis. Scale-up efforts must increase reach, retain effectiveness, and lower costs to provide greater access to benefits and close the research-to-practice gap between effective programs and real-world application. This project is studying the nationwide scale-up of an occupational sun safety intervention, Sun Safe Workplaces, with state Departments of Transportation (DOTs), a public works sector with thousands of outdoor workers.

Costs of national distribution can be daunting and influence intervention intensity and program effectiveness. Identifying cost-effective scale-up strategies is essential for moving research into practice. The new framework draws upon existing implementation models, including those developed for occupational health and safety, and operationalizes implementation for scale-up within RE-AIM. The RE-AIM framework was adapted for this new framework by incorporating cost as a primary factor.

In a randomized trial, Sun Safe Workplaces (SSW) is assessing implementation rate and costs associated with two methods of scaling-up SSW. The original intervention depended on personal visits with managers, materials promoting sun protection policies and education, in-person sun safety training for employee groups, and on-going follow-up communication with managers supporting sun safety (SSW-IP), a resource-intensive form of intervention. Now SSW-IP is being contrasted to a scale-up strategy that uses web-based and telephone conferencing, responsive training platforms, and electronic resources for virtual contacts and training (SSW-T). Technology-based programs have the potential to deliver standardized, engaging content and increase portability while decreasing cost of delivery to enable reaching more employers when scaled-up to nationwide distribution. Districts within DOTs are randomized to one of the two scale-up methods. The SSW-IP and SSW-T interventions are being delivered in 21 state DOTs with 141 districts.

This research is funded by a grant from the National Cancer Institute (CA134705; Dr. David Buller and Dr. Barbara Walkosz, Multiple Principal Investigators). Additional poster coauthors include Dr. Richard Meenan from the Kaiser Permanente Center for Health Research; and Mary Buller, Rachel Eye, Andrew Grayson, and Savanna Olivas from Klein Buendel.

Economic Evaluation of Adopting Occupational Sun Protection Policies

Economic Evaluation of Adopting Occupational Sun Protection Policies

In a recent publication in the Journal of Occupational and Environmental Medicine, Klein Buendel investigators and their colleagues discuss the economic evaluation of an intervention promoting adoption of occupational sun protection actions by Colorado public-sector employers.

The intervention, Sun Safe Workplaces (SSW), was a two-year randomized field trial promoting employer adoption of sun safety policy and providing training in personal sun protection for outdoor workers. The trial included 98 local Colorado government organizations such as municipalities, counties, and special districts (public organizations providing water, sanitation, parks and recreation, and fire protection). SSW intervention costs were organized into two components: “delivery” costs and “action” costs. Delivery costs were incurred to directly implement and maintain the SSW intervention and included costs of both project staff and the participating worksites. Action costs were incurred by the worksites themselves for implementing the sun protection actions.

The publication presents the results of the economic evaluation of SSW. A full description of the methods, measures, results, and conclusion of the research can also be found in the Journal of Occupational and Environmental Medicine publication.

This study demonstrated the interactions of cost and implementation that explain — and hopefully guide — the adoption of and investment in occupational sun safety. The SSW intervention was also successful in extending the adoption of sun protection actions among intervention worksites at a cost per employee that is comparable to other worksite health interventions.

This analysis was funded by a grant from the National Cancer Institute at the National Institutes of Health (CA134705; Dr. David Buller and Dr. Barbara Walkosz, Multiple Principal Investigators). The paper’s lead author is Dr. Richard Meenan from the Kaiser Permanente Center for Health Research in Oregon. Additional authors include Dr. David Buller, Dr. Barbara Walkosz, Ms. Mary Buller, Ms. Rachel Eye, and Ms. Savanna Olivas from Klein Buendel; and Dr. Allan Wallis from the University of Colorado Denver.

Sun Safety Ink! Expands to the Latino Community

Sun Safety Ink! Expands to the Latino Community

Skin cancer rates continue to rise in the Hispanic population. In the last two decades, their annual melanoma incidence has increased by 20% (5). Even though Hispanics are diagnosed at a disproportionately lower level than non-Hispanic whites (NHWs), they are diagnosed with melanoma at a younger age, with a more advanced stage of the disease, and have lower melanoma-specific survival rates than NHWs (1,3).

Klein Buendel’s randomized controlled trial, Sun Safety Ink!, trains tattoo artists to offer skin cancer prevention advice to their clients. A recent diversity supplement will extend the Sun Safety Ink! study by focusing on how this information can be targeted to Hispanic tattoo artists and their clients, especially young adults. The supplement’s goals are to discover new approaches to address the increasing rates of skin cancer in the Hispanic population and to provide insight into the implementation of skin cancer prevention in an often hard-to-reach population.

Over 30% of the Hispanic population has tattoos (4), a rate that is higher than NHWs (25%). Tattoo studios, because they often recommend sun protection in their aftercare instructions, are a unique context in which to promote full body sun protection to Latinos. Sun Safety Ink! will distribute sun safety information to hard-to-reach Hispanic young adults. The diversification of the study sample will provide information on (1) baseline knowledge on sun protection in the Latino population, (2) barriers to sun protection, and (3) at-risk populations.

The supplement includes both formative research and the implementation of the Sun Safety Ink! program. Specifically, tattoo studios with Hispanic artists and clients in Utah, Colorado, Arizona, and New Mexico will be recruited to participate in the study. The tattoo artists will be provided with a version of the Sun Safety Ink! training modified based on formative research conducted by Cristian Gonzalez, MD. Dr. Gonzalez is a Research Fellow at the University of Colorado Anschutz Medical Campus and an upcoming Medical Resident at the University of Texas Southwestern Medical Center.

Dr. Gonzalez explained that the most important aspect of this project is that “Latinos have this invincibility factor that they think they can’t get skin cancer because they don’t know a lot of family members or friends with skin cancer, so sometimes it really doesn’t come up. If we can increase awareness of skin cancer in the Latino community, and if we can also improve sun protection behavior, I think we would see a reduction in melanoma and non-melanoma skin cancer in the future.”

Sun Safety Ink! is funded by a grant and a supplement from the National Cancer Institute (CA206569; Dr. Barbara Walkosz and Dr. Robert Dellavalle, Multiple Principal Investigators). Collaborators include Dr. Barbara Walkosz, Dr. David Buller, Mary Buller, Rachel Eye, and Savanna Olivas from Klein Buendel; and Dr. Robert Dellavalle from the University of Colorado, Denver.

Dr. Cristian Gonzalez

References

  1. Coups EJ, Stapleton JL, Hudson SV, Medina-Forrester A, Natale-Pereira A, Goydos JS. Sun protection and exposure behaviors among Hispanic adults in the United States: differences according to acculturation and among Hispanic subgroups. BMC Public Health. 2012;12:985.
  2. Hay J, Coups EJ, Ford J, DiBonaventura M. Exposure to mass media health information, skin cancer beliefs, and sun protection behaviors in a United States probability sample. Journal of the American Academy of Dermatology. 2009;61(5):783-792. doi: 10.1016/j.jaad.2009.04.023.PMC2854488
  3. Harvey VM, Oldfield CW, Chen JT, Eschbach K. Melanoma disparities among US Hispanics: use of the social ecological model to contextualize reasons for inequitable outcomes and frame a research agenda. Journal of Skin Cancer. 2016;2016:4635740. doi: 10.1155/2016/4635740
  4. One in five U.S. adults now has a tattoo [press release]. New York, NY: Harris Insights & Analytics, February 23. Available at:  https://theharrispoll.com/new-york-n-y-february-23-2012-there-is-a-lot-of-culture-and-lore-associated-with-tattoos-from-ancient-art-to-modern-expressionism-and-there-are-many-reasons-people-choose-to-get-or-not-get-p/.
  5. Skin cancer rates soar in US Hispanics. Sun & Skin News. November 21, 2013;30(4). https://www.skincancer.org/publications/sun-and-skin-news/winter-2013-30-4/soar.
May is Skin Cancer Awareness Month

May is Skin Cancer Awareness Month

Skin cancer is the most common type of cancer in the United States. Ultraviolet (UV) radiation from the sun is the main cause of skin cancer. UV radiation can also come from tanning booths or sunlamps. The most dangerous kind of skin cancer is called melanoma.

The good news? Skin cancer can almost always be cured when it’s found and treated early – and that includes melanoma.

Here are some helpful resources for information, graphics, and materials to raise awareness about skin cancer and help people take action to prevent or detect it early when it is easier to treat.

American Academy of Dermatology (AAD)

Centers for Disease Control and Prevention (CDC)

Healthfinder.gov- Skin Cancer Prevention

Skin Cancer Foundation

Real Health Photos

Use Real Health Photos® for improving the impact of health messages for Skin Cancer Awareness Month. The stock photography website includes numerous images of diverse people being sun safe with hats, sunglasses, shade, and sunscreen. Real Health Photos images show diversity of gender, race, ethnicity, age, income level, and health condition.

For more images, visit Real Health Photos.

Real Health Photos is a stock photography service owned and operated by KB. It was created and evaluated with a research grant (R44MD003338, Mary Buller, Principal Investigator) from the National Institute of Minority Health and Health Disparities at the National Institutes of Health. Real Health Photos is designed to capture the diversity of health through photography and promote the inclusion of all populations in health promotion materials and media.

Skin Cancer Awareness for Winter Enthusiasts

Skin Cancer Awareness for Winter Enthusiasts

Last month, Klein Buendel (KB) teamed up with the Colorado Skin Cancer Task Force (CSCTF) and Rocky Mountain Sunscreen (RMS) at the Annual Outdoor Retailer and Snow Show to spread skin cancer awareness to outdoor winter enthusiasts.

Per their website, the Outdoor Retailer Snow Show is the largest outdoor snow sports industry gathering in North America. The trade show brings outdoor industry brands, suppliers, retailers, and leaders together for a three-day expo at the Colorado Convention Center. Although the trade show is closed to the public, last year the event attracted over 29,000 attendees with representatives from over 1,000 brands.

The extensive Snow Show provides the opportunity to reach thousands of individuals who work and recreate outdoors. Every year, for over a decade, KB has partnered with the CSCTF and RMS to raise awareness about UV radiation and skin cancer prevention at the event. We stress the importance of practicing sun safety at high elevation during the winter months when UV can reach very high levels.

Specifically, KB increases people’s awareness of their personal risk for skin cancer by taking individual’s UV photographs using a Reveal Imager. The imager by Canfield, has the ability to capture and expose a lifetime of sun damage in a single image of someone’s face that is otherwise invisible to the naked eye. From the image, KB staff point out problem areas that have received damage from the sun and suggested simple sun safety practices for people to better protect themselves from accruing further UV damage.

Other members of the CSTF, including Colorado dermatologists and dermatology interns, were also present to help field questions and to perform free skin examinations on request.

Sun Safety Curriculum for Grades K-5 is Now Free for Schools

Sun Safety Curriculum for Grades K-5 is Now Free for Schools

Sunny Days Healthy Ways, an evidence-based sun safety curriculum that provides sun protection education for grades K-5, is now available free online by its authors at Klein Buendel, Inc. Schools can use the curriculum to fulfill the school-based goals of the Surgeon General’s Call to Action to Prevent Skin Cancer.

“I was inspired to remove any barriers to schools having access to the curriculum by previous Surgeon General Dr. Boris Lushniak’s impassioned presentation at the 4th Annual Conference on UV and Skin Cancer Prevention,” explained Mary Buller, President of Klein Buendel.

Sunny Days Healthy Ways provides an average of 15 lessons per grade, that teachers can tailor to their timeframe and needs. Prepared lesson plans, student activity sheets, storybooks, learning objectives, and common core standards minimize prep time and make teaching students about sun safety easy. Project-based learning and technology connections make it fun.

Skin cancer is the most common cancer in the U.S. and is increasing at an alarming rate. Even though skin cancer occurs mainly in adults, much of the damage was likely done during childhood. Long periods of unprotected sun exposure and severe sunburning as a child can lead to skin cancer and eye damage later in life. Good health habits started in childhood are more likely to last a lifetime.

Sunny Days Healthy Ways was first created and evaluated with research grants from the National Cancer Institute (CA62968 & CA23074) and the Arizona Disease Control Research Commission (9403). To access the free curriculum, visit the Sunny Days Healthy Ways website at https://www.sdhw.info/.

Effect of an Occupational Skin Cancer Prevention Program on Employee Sun Safety Practices

Effect of an Occupational Skin Cancer Prevention Program on Employee Sun Safety Practices

Exposure to the sun’s UV rays is the biggest risk factor for skin cancer. It is also the easiest risk factor to modify through practicing sun-safe behaviors. Outdoor workers are at an elevated risk for skin cancer, especially melanoma, due to the amount of UV exposure they endure over the years. In a recent ePub-ahead-of-print paper in the Journal of Occupational and Environmental Medicine, Klein Buendel’s Dr. Barbara Walkosz, Dr. David Buller, Ms. Mary Buller and their co-authors discuss the outcomes of the follow-up assessment to Sun Safe Workplaces, a workplace sun safety program that promoted sun safety policy adoption and education.

Two years after the Sun Safe Workplaces intervention, a follow-up assessment was conducted to determine the impact of the program on employee sun safety behavior. All participants of the original intervention (n=98) were invited to partake in the two-year assessment and 63 (n=33 for intervention, n=30 for control) participated. The sample included local government organizations throughout Colorado with outdoor workers in at least one of the following service areas: parks and recreation, public works, and public safety. Project staff visited each employer to evaluate the sun protection policies in place, sun protection messages, and personal sun protection equipment available at each organization. An assessment of the sun safety policies was conducted that included three domains (administrative procedures, environmental controls, and personal protection practices) with 15 content categories. Additionally, policy implementation was measured through senior manager and line supervisor reports on whether or not employers communicated or provided training about sun safety to employees and/or provided any of the types of the recommended personal sun protection equipment for employees (sunscreen, wide-brimmed hats, sunglasses, long-sleeved shirts, long pants, or outdoor shade). Lastly, key contact managers were asked to assist study staff with distributing self-administered surveys to front-line supervisors and employees who worked outdoors, which included time spent outdoors at work, frequency of sun protection at work, prevalence of sunburn in the past 12 months on the job, attitudes toward occupational sun safety and self-efficacy for sun safety on the job, attitudes toward workplace health and sun safety policy, and job and demographic information. A total of 1,784 (n=913 for intervention, n=871 for control) outdoor workers completed surveys.

Results showed that compared to control workplaces, employees in the intervention workplaces reported more sun protection practices overall as well as more frequent use of sunscreen on the body, wearing of wide-brimmed hats, and more often had sunscreen, sunglasses, and a hat with them when at work. Employees in the intervention workplaces also reported fewer sunburns than those in the control workplaces. Additionally, sun protection messages and equipment, as well as employee training in sun safety, were more likely to occur in intervention workplaces and such actions increased the frequency of employees having sunscreen, sunglasses, and a hat on the job.  For employees at employers with a best-practice policy, the total composite sun safety score was significantly higher than in the no-policy group and employees also reported more frequent use of sunscreen on the face and other exposed body parts and having sunscreen, sunglasses, and a hat with them while at work compared to those at no-policy employers. However, unlike the intervention group, there was no effect of policy on the prevalence of sunburns among the employees.

The authors concluded that policy adoption is an important step towards improving sun protection and preventing sunburns on the job for outdoor workers but recommend that a robust approach that includes a policy, training for employees, and personal protection equipment that can support sun safety is needed to effectively change employees’ sun protection behaviors.

This research was funded by a grant from the National Cancer Institute at the National Institutes of Health (RO1CA134705; Dr. David Buller and Dr. Barbara Walkosz, Principal Investigators). Coauthors included Ms. Mary Buller, Dr. Alan Wallis from University of Colorado Denver, Dr. Richard Meenan from the Kaiser Permanente Center for Health Research, Dr. Gary Cutter from Pythagoras, Dr. Peter Andersen from San Diego State University, and Dr. Michael Scott from Mikonics.

 

Skin Cancer Awareness and the Great Outdoors

Skin Cancer Awareness and the Great Outdoors

In July, Klein Buendel (KB) teamed up with the Colorado Skin Cancer Task Force (CSCTF) and Rocky Mountain Sunscreen (RMS) for the first time in the summer to raise awareness about UV radiation and skin cancer prevention at the new-to-Denver Outdoor Retailer Summer Market at the Colorado Convention Center.

For nearly a decade, KB and the CSCTF partnered with RMS at the winter SnowSports Industries America Snow Show every January to show outdoor retailers that practicing sun safety is just as important in the winter months as in the summer months. Now we can access hundreds of outdoor retailers in the summer months in Denver, too, with the arrival of the Outdoor Retailer Summer Market.

Skin cancer prevention is particularly relevant for members of the outdoor retailer industry because they work and promote recreation in high UV environments, like mountains, deserts, lakes, and oceans. In addition to providing sun safety and skin cancer awareness information, the booth offered a unique opportunity for attendees to have a UV-damage photograph taken of their face with the Reveal Imager. The Reveal Imager by Canfield has the ability to capture damage caused by the sun’s UV rays that are invisible to the naked eye. Participants reported that seeing this type of photograph of themselves is a helpful visual reminder to practice sun safety all year long to reduce their risk of additional sun damage.

Per their website, “the Outdoor Retailer Summer Market is North America’s largest tradeshow in the outdoor industry drawing attendees from around the world. Summer Market is all about face-to-face—it’s where products are shown, orders are written, new accounts are found, connections are made and brands are launched. This show is about buying, sourcing, strategic meetings, trend, education and networking with decision makers, influencers, stakeholders, key buyers and athletes that influence the outdoor market.”

Over the course of the multi-day event, KB staff took dozens of photographs with the UV camera. Other members of the CSCTF (including Colorado dermatologists and dermatology interns) answered questions, distributed sun safety materials, and performed skin examinations. This event is part of the annual outreach and education efforts of the CSCTF. KB has been an active member of the CSCTF for over 10 years.

Interdisciplinary Perspectives on Sun Safety

Interdisciplinary Perspectives on Sun Safety

Skin cancer is the most common cancer in the United States, with more than 5 million new cases diagnosed per year.1 As part of an effort to reduce incidence and mortality from skin cancer, the National Academy of Sciences hosted 19 experts from a variety of healthcare fields (including dermatology, behavioral medicine, public health, adolescent medicine, clinical health psychology, anthropology, and kinesiology). The experts, including Klein Buendel’s Director of Research, Dr. David Buller, met for two days in December 2016 to identify emerging themes in skin cancer prevention and control.

The report of this interdisciplinary collaboration and its five main culminating themes were published in JAMA Dermatology, a monthly peer-reviewed medical journal published by the American Medical Association.

The Emerging Themes for Skin Cancer Prevention and Control

  1. Expanding the definition of risk in order to better tailor sun safety programs, create guidelines that acknowledge the beneficial effects of ultraviolet radiation (UVR) exposure and develop strategies that involve those from diverse backgrounds (e.g. lower socioeconomic status, those with darker skin).
  2. Intertwining sun protection strategies and messages with other health-related strategies and messages, such as physical activity recommendations, in order to prevent increasing a person’s risk for one disease despite decreasing it for another.
  3. Tailoring sun safety messages using multiple components (e.g. place, weather, personal values, individual risk factors and motivations) to better persuade individual behavior change through novel channels such as smartphones and social media platforms.
  4. Recognizing excessive tanning as an addiction in order to enable proper education for clinicians to give a diagnosis and create more effective treatments, including the possibility for pharmacological treatments.
  5. Scaling up evidence-based interventions to increase the impact and achieve population-level skin cancer prevention through identifying the most appropriate dissemination and implementation methods that are also cost-effective, wide-reaching and lead to behavior change.

Authors, including Dr. Buller, conclude by stating that future expert meetings should focus on sun protection in the pediatric population and that future research to address these themes will need to be interdisciplinary to decrease the burden of skin cancer.

References

  1. American Cancer Society. Cancer Facts & Figures 2018. Available at: https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/annual-cancer-facts-and-figures/2018/cancer-facts-and-figures-2018.pdf. 2018. Accessed June 11, 2018.
Skin Cancer Prevention Messages on Facebook

Skin Cancer Prevention Messages on Facebook

Social media use among American adults has grown over the years – from just 5-in-10 in 2011 to seven-in-ten in 2018 – and reasons for using social media range from connecting with others to accessing news content to sharing information.1 With skin cancer still the most common among all cancers,2 it seems logical to use social media to promote and spread skin cancer prevention awareness. But is it effective?

In a recently published article in the Journal of the American Academy of Dermatology, KB’s Dr. Barbara Walkosz and Rachel Eye, along with other collaborators, aimed to review and classify skin cancer prevention messages from non-profit organizations on Facebook to determine which types garnered high engagement, such as likes, comments, and shares. Messages were identified using the following keywords: “skin cancer prevention,” “melanoma,” “melanoma prevention,” and “sun safety.” From May 2014 to May 2015, Facebook pages of 24 skin cancer groups’ and their 824 Facebook messages were coded for the following content: message format (narrative or didactic), motivation (skin cancer risk or appearance), persuasive appeal (social norm, fear, humor, altruism, celebrity story), behavioral target (sunscreen, hats, shade, avoid sunburn, indoor or outdoor tanning, skin exams), imagery, image content, and hyperlink. Engagement and frequency of message types were also determined.

Authors found that the majority of messages were didactic and focused on skin cancer occurrence and type but note that these approaches are not always effective in producing behavior change. Furthermore, the top three behavioral targets addressed were skin exams, indoor and outdoor tanning, and sunscreen use. Messages that were more didactic, appearance-based, myth-busting, used celebrity endorsements, and targeted self-exams received the most engagement. Messages without images received a higher rate of likes, shares and comments compared with messages that included images.

Limitations of the study include the inability to determine if those following the pages studied are representative of populations at risk for skin cancer and the potential of missed messages based on the keywords used for inclusion criteria. Authors state that collaborations between health institutes and researchers could identify characteristics of messages that are both effective for behavior change and produce high engagement rates in order to have the greatest impact on skin cancer prevention.

References

  1. Social media fact sheet. Pew Research Center Web site. Available at: http://www.pewinternet.org/fact-sheet/social-media/. Published February 5, 2018. Accessed April 24, 2018.
  2. Key statistics for melanoma skin cancer. American Cancer Society Web site. Available at: https://www.cancer.org/cancer/melanoma-skin-cancer/about/key-statistics.html. Updated January 4, 2018. Accessed April 24, 2018.