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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).

UV Measured under Built Shade in Public Parks

UV Measured under Built Shade in Public Parks

Reducing exposure to ultraviolet radiation (UV) is crucial for preventing UV-induced diseases of the skin and eyes. Shade may offer significant protection from UV.

A research team from Klein Buendel and Cancer Council Victoria and LaTrobe University in Australia have published a paper on UV measurements under shade structure built in public parks in International Journal of Environmental Research and Public Health. The paper expands empirical research to quantify the UV protection offered from built shade to guide disease prevention practices and confidence in investment in shade.

Specifically, the research team quantified UV levels under built shade relative to unshaded passive recreation areas (PRAs) over summer months in parks in two cities (Denver, Colorado, USA and Melbourne, Victoria, Australia). In a randomized controlled trial, 1,144 UV measurements were recorded at the center and periphery of PRAs in a total sample of 144 public parks as part of pretest and posttest measures of use of the PRAs by park visitors. UV measurements were recorded for three recruitment waves per city during 2010 to 2014. Following pretest, 36 of the PRAs received built shade structures.

Regression analyses modelled pre-post change in UV (Standard Erythemal Dose (SED) per 30 min) at PRAs; and environmental predictors. Mean UV at the center of built shade PRAs decreased from pretest to posttest, adjusting for the covariates of ambient SED, solar elevation, and cloud cover. Clouds decreased and solar elevation increased UV levels under shade. No significant differences in UV by design of the shade structure occurred. A substantial reduction in UV exposure can be achieved using built shade with shade cloth designs, offering considerable protection for shade users. Supplementary sun protection  is recommended for extended periods of shade use during clear sky days. This could include things like brimmed hats, long sleeves, sunglasses, and sunscreen.

This research was supported by a grant from the National Cancer Institute (CA140367; Dr. David Buller, PI). Collaborators on this publication also include Dr. Suzanne Dobbinson and Dr. James Chamberlain from Cancer Council Victoria; Jody Simmons from LaTrobe University; and Mary Buller from Klein Buendel.

Collaborator Spotlight:
Dr. Yelena Wu

Collaborator Spotlight:
Dr. Yelena Wu

Yelena Wu, PhD, is an Associate Professor in the Department of Dermatology at the University of Utah and a Research Investigator at the Huntsman Cancer Institute. She received a BA in Psychology from the University of California, Berkeley, and an MA and PhD in Clinical Child Psychology from the University of Kansas. She is also a licensed pediatric and clinical child psychologist.

Dr. Wu’s research and clinical practice center on promoting better health outcomes for children, adolescents, and young adults who have a history of cancer or who are at risk for developing cancer. A specific area of research interest is the prevention of skin cancer by improving adherence to preventive behavior recommendations among children and adolescents at increased risk for developing skin cancer.

Dr. Wu is currently the Principal Investigator on a 5-year project funded by National Cancer Institute (CA244674) to test a school-based program designed to increase adolescents’ use of sun protection and decrease participation in intentional tanning. Dr. David Buller, director of Research at Klein Buendel, collaborates as a Co-Investigator on the project.

In addition to her research, Dr. Wu provides consultations and therapeutic services to medical teams, patients, and caregivers to facilitate communication and aid in the management of cancer through the Family Cancer Assessment Clinic at the Huntsman Cancer Institute.

Family Attitudes and Communication about Sun Protection

Family Attitudes and Communication about Sun Protection

Young melanoma survivors and their families are at increased risk for developing melanoma, yet do not often practice sun protection for skin cancer prevention. Currently, little is known about the role of family interaction in sun protection.

Klein Buendel Senior Scientist, Dr. David Buller, was one of several authors on a recent paper on family attitudes and communication about sun protection among young melanoma skin cancer survivors and their family members e-published in the Journal of Health Communication. The research team was led by Dr. Sharon Manne from the Department of Medicine, Behavioral Sciences Section at the Rutgers Cancer Institute of New Jersey.

The research team set out to “examine correspondence between survivors and family sun protection, individual attitudes, and family attitudes and communication about risk-reducing behaviors, and evaluate the mediating role of family attitudes and communication in the association between individual sun protection attitudes and behavior.” Participants completed questionnaires about their individual attitudes, family attitudes and communication, and sun protection behaviors.  

Analyses showed that families had varying levels of shared attitudes and behaviors. Family discussion was associated with higher sun protection for both men and women. Other findings differed for men vs. women and cancer survivors vs. family members. Full descriptions of the measures, methods, results, and conclusions can be found in the publication. Overall, the authors believe that family-focused interventions may prove effective because families’ attitudes and practices correspond with each other.

This research was supported by a grant from the National Institutes of Health (Dr. Sharon Manne, Principal Investigator). Other authors on the publication include Dr. Deborah Kashy from Michigan State University; Dr. Sherry Pagoto from the University of Connecticut; Dr. Susan Peterson from the University of Texas MD Anderson Cancer Center; Dr. Carolyn Heckman, Joseph Gallo, Dr. Adam Berger, Alexandria Kulik, Sara Frederick, and Morgan Pesanelli from the Rutgers Cancer Institute of New Jersey; and Dr. David Buller from Klein Buendel.

Workplace Sun Safety Training Goes All-Virtual

Workplace Sun Safety Training Goes All-Virtual

People who work outdoors are exposed to high levels of solar ultraviolet radiation (UV) over a lifetime that can substantially increase their risk for developing skin cancer. Workplaces can be an effective channel for UV safety policy and training for employees in order to reduce their UV over-exposure and risk for skin cancer.

Klein Buendel researchers and their collaborators have been developing, evaluating, and refining comprehensive approaches to occupational sun protection for two decades. Now, the experienced research team is launching a new project funded by the National Cancer Institute to develop and evaluate a mechanism for distributing an established sun protection program virtually to diverse workplaces in the United States. The virtual environment will be comprised of a database, content management (interactive toolbox), and media platform (trackable training) to tailor the sun safety program to management’s readiness to innovate on sun safety based on Diffusion of Innovations Theory. In addition, the virtual platform will better integrate sun safety training by improving appropriateness for Hispanic and African American workers and conforming with the latest learning management systems technologies.

The Fast-Track SBIR project (CA257778) will complete a 9-month Phase I feasibility study and a 2-year Phase II effectiveness trial through employers across the country. The primary hypothesis of the study is that compared to employers in a minimal information control group, employers assigned to receive SSW Works will have employees that practice more sun protection at posttest. The research will be led by Mary Klein Buller, Principal Investigator. Co-Investigators include Dr. Barbara Walkosz, Julia Berteletti, and Dr. David Buller from Klein Buendel. The virtual platform will be engineered by Klein Buendel’s Creative Team.

The outdoor workforce in the United States is large and, in many places, at very high risk for skin cancer. Improving sun safety will help reduce health care costs and save lives. Thus, the research will have high impact and potential for commercial adoption, two objectives of SBIR projects.

Sun Safe Partners Online

Sun Safe Partners Online

Findings from a pilot randomized controlled trial evaluating the feasibility and preliminary impact of an online couple-focused intervention to improve sun protection behavior were published recently in the Journal of Medical Internet Research. The research team was led by Dr. Sharon Manne from the Rutgers Cancer Institute of New Jersey. Collaborators from Michigan State University, the University of Connecticut, Memorial Sloan Kettering Cancer Center, and Klein Buendel rounded out the research team.

At the time of the study, Sun Safe Partners Online was a web-based intervention with four individual-focused modules and four couple-focused modules. A total of 75 couples who reported suboptimal levels of sun protection were randomly assigned to receive either Sun Safe Partners Online or a generic sun safety education intervention. Participants were recruited through Facebook advertising, resulting in rapid enrollment and higher acceptance than was evident in a previous trial testing telephone and print intervention. Feasibility was assessed by enrollment, engagement, survey completion, module completion, and module satisfaction. Participants also completed pre/post surveys assessing sun protection, sun exposure on weekends, sunburn incidence, and attitudes toward sun protection. A full description of the methods, analyses, and effects of the study can be found in the publication.

Sun Safe Partners Online was found to be an innovative strategy for engaging adults in sun safety. The authors conclude that “a couple-focused intervention may hold promise as a way to improve sun protection behaviors beyond interventions focused solely on individuals by leveraging the concern, collaboration, and support among intimate partners and addressing relationship-based barriers to sun protection.”

This pilot research was supported by Rutgers Cancer Institute of New Jersey Institutional funds.

Using Machine Learning Techniques to Predict Sunburn Risk in Outdoor Exercisers

Using Machine Learning Techniques to Predict Sunburn Risk in Outdoor Exercisers

In response to recreational UV exposure being associated with skin cancer (1), Julia Berteletti, MSW, and David Buller, PhD, of Klein Buendel have launched a new research project to harness technology to increase individual’s sun safety during outdoor physical activity. The title of the new project is “Using Retrospective and Real-Time Physical Activity Tracking to Predict Risk of Sunburn in Outdoor Exercisers on Strava.”

The Strava Sun Project is based on evidence that individuals who engage in more physical activity have a higher prevalence of sunburn (2, 3-6), a proximal biomarker of melanoma risk, and melanoma is positively associated with physical activity (7). For some athletes, forgetting to apply sunscreen (8,9) or not liking its feel while engaged in physical activity can be barriers to sun protection (8,10). An expert meeting hosted by the National Cancer Institute identified sun safety during physical activity as a priority research area (11) and the U.S. Surgeon General prioritized strategies for coordinating messages on sun safety and physical activity in the Call to Action to Prevent Skin Cancer (12).

Online and mobile technologies for tracking physical activity have exploded over the past decade. Many Americans wear activity trackers or GPS-enabled devices, such as  Fitbit and Garmin, and upload their physical activity data to websites/mobile apps. Strava, an activity tracking app and social networking site for athletes of all abilities, is one of the most popular. Millions share their own activities and follow and comment on physical activity by other users in their network. The goal of this project is to increase skin cancer prevention among a high-risk population, adults who engage in outdoor physical activity by establishing feasibility of interfacing sun protection advice with the Strava website/mobile app.

Specifically, the research will create an algorithm that predicts when individuals are likely to be engaged in physical activity outdoors, and delivers sun safety advice tailored to time, location, and personal risk (for example, skin sun sensitivity). The Strava Sun program will obtain user data and deliver ecologically-valid sun safety advice by utilizing Strava’s open-source Applications Programming Interface (API) and location-based advice algorithms developed by Klein Buendel for the sun safety mobile app, sunZapp (13). Machine learning techniques will be employed to develop an algorithm using Strava activities to predict high-risk behavior, such as outdoor physical activity when UV levels are high and sun safety is advised.

Overall, a sun protection interface for the Strava platform will allow for the identification of a large population of Americans at high risk for skin cancer who routinely engage in physical activity, often outdoors with high-risk sun exposure, and reach them with sun safety advice they may not seek on their own to motivate them to practice sun safety during outdoor activities.

This project is funded by a grant from the National Cancer Institute at the National Institutes of Health (CA241637; Dr. David Buller and Ms. Julia Berteletti, Multiple Principal Investigators). Co-Investigators include Dr. Kim Henry and Dr. Chuck Anderson from Colorado State University. Other collaborators include Dr. Sherry Pagoto from the University of Connecticut and Mr. Scott Camichael, a recent software engineer at Strava. Developers at Klein Buendel will produce the API database and program.

References

  1. Moehrle M. Outdoor sports and skin cancer. Clin Dermatol. 2008;26(1):12-15.
  2. Holman DM, Ding H, Guy GP, Jr., Watson M, Hartman AM, Perna FM. Prevalence of Sun Protection Use and Sunburn and Association of Demographic and Behaviorial Characteristics With Sunburn Among US Adults. JAMA Dermatol. 2018;154(5):561-568.
  3. Holman DM, Berkowitz Z, Guy GP, Jr., Hartman AM, Perna FM. The association between demographic and behavioral characteristics and sunburn among U.S. adults – National Health Interview Survey, 2010. Prev Med. 2014;63:6-12.
  4. Hall HI, Saraiya M, Thompson T, Hartman A, Glanz K, Rimer B. Correlates of sunburn experiences among U.S. adults: results of the 2000 National Health Interview Survey. Public Health Rep. 2003;118(6):540-549.
  5. Coups EJ, Manne SL, Heckman CJ. Multiple skin cancer risk behaviors in the U.S. population. Am J Prev Med. 2008;34(2):87-93. doi: 10.1016/j.amepre.2007.09.032
  6. Lawler S, Sugiyama T, Owen N. Sun exposure concern, sun protection behaviors and physical activity among Australian adults. Cancer Causes Control. 2007;18(9):1009-1014.
  7. Moore SC, Lee IM, Weiderpass E, et al. Association of Leisure-Time Physical Activity With Risk of 26 Types of Cancer in 1.44 Million Adults. JAMA Intern Med. 2016;176(6):816-825.
  8. Petty KN, Knee CR, Joseph AK. Sunscreen use among recreational cyclists: how intentions predict reported behavior. J Health Psychol. 2012;18(3):439-447.
  9. Wysong A, Gladstone H, Kim D, Lingala B, Copeland J, Tang JY. Sunscreen use in NCAA collegiate athletes: Identifying targets for intervention and barriers to use. Prev Med. 2012;55(5):493-496.
  10. Berndt NC, O’Riordan DL, Winkler E, McDermott L, Spathonis K, Owen N. Social cognitive correlates of young adult sport competitors’ sunscreen use. Health Educ Behav. 2011;38(1):6-14.
  11. Geller AC, Jablonski NG, Pagoto SL, et al. Interdisciplinary perspectives on sun safety. JAMA Dermatol. 2018;154(1):88-92. PMC5839662.
  12. U.S. Department of Health and Human Services. The Surgeon General’s Call to Action to Prevent Skin Cancer. Washington, D.C.: U.S. Department of Health and Human Services, Office of the Surgeon General;2014.
  13. Heron KE, Smyth JM. Ecological momentary interventions: incorporating mobile technology into psychosocial and health behaviour treatments. Br J Health Psychol. 2010;15(Pt 1):1-39.

Parents’ Reports of School Communication on Sun Safety

Parents’ Reports of School Communication on Sun Safety

The U.S. Surgeon General and the Centers for Disease Control and Prevention have called on the nation’s schools to help prevent skin cancer by implementing sun safety practices and policies. The Sun Safe Schools program was designed by Klein Buendel researchers and collaborators in response to those calls to action. The program was implemented and evaluated with 118 public elementary schools in California.

Dr. David Buller, Klein Buendel Director of Research, presented data on the impact of the Sun Safe Schools intervention on parents’ reports of sun safety communication from schools and children’s sun protection behavior at the 12th Annual Conference on the Science of Dissemination and Implementation in Health in Washington, DC, December 4-6, 2019.

Schools randomized to the Sun Safe Schools intervention group (N=58) received support for implementing school sun safety practices by trained coaches over 20 months. Based on Diffusion of Innovations Theory, support and resources for implementation were tailored to school principals’ readiness to implement. Parents completed an online posttest survey through invitations sent by principals or while attending parent-oriented school events. Parents were surveyed to test the hypothesis that parents would report more communication about sun safety at schools receiving the intervention than at control schools.

The Sun Safe Schools program appeared to increase communication on sun safety and the use of student sun protection. Parents in intervention schools were more likely to report receiving information about sun safety from the school and that their children wore sun-protective clothing than in control schools. The improvement in sun safety appeared to result from policy implementation. In schools where principals reported implementing sun safety practices at posttest, parents reported that children spent less time outdoors and had fewer sunburns than at non-implementing schools. Further, parents who received information about sun safety from the school reported more sun protection for their child than parents not receiving the information.

In summary, a school district-level policy, combined with active technical support for schools within the district, appears to be effective at increasing implementation of school sun safety practices to help protect children from solar ultraviolet radiation, the primary risk factor for the development of skin cancer.

The Sun Safe Schools program is a joint research effort of Claremont Graduate University (CGU), the Kaiser Permanente Center for Health Research, and Klein Buendel. The research was funded by a grant from the Eunice Kennedy Shriver National Institute of Child Health and Human Development at the National Institutes of Health (HD074416; Dr. Kim Reynolds, CGU, and Dr. David Buller, Multiple Principal Investigators). Other collaborators included Dr. Richard Meenan from the Kaiser Permanente Center for Health Research in Portland, Oregon; Dr. Jeff Ashley from Sun Safety for Kids in Los Angeles, California; Kim Massie previously from Chapman University; and Julia Berteletti and Mary Buller from Klein Buendel.

The Importance of Managers’ Awareness of Sun Protection Policy

The Importance of Managers’ Awareness of Sun Protection Policy

Improving occupational sun protection is a priority in the United States, as The Surgeon General’s Call to Action to Prevent Skin Cancer highlights. Klein Buendel and its collaborators responded to the call by launching a randomized trial to evaluate the effectiveness of a workplace sun protection program for outdoor workers. The program, Sun Safe Workplaces, was implemented with 98 public employers in Colorado, a state with high ultraviolet radiation due to its high elevation and sunny climate. The intervention promoted the adoption or strengthening of sun safety policy and the implementation of employee sun protection training. A two-year follow-up study also was completed with 68 of the 98 public sector employers.

In a recent publication in the American Journal of Industrial Medicine, Dr. Barbara Walkosz, Klein Buendel Senior Scientist, and her coauthors reported results related to the hypothesis that senior managers’ awareness of sun protection policy in the workplace would predict increased sun safety practices by employers and employees who work outdoors.

A full description of the methods (questionnaires and on-site observations), results, conclusions, and limitations of the research can be found in the American Journal of Industrial Medicine publication. In general, more sun safety messages, manager-employee communication, sun safety practices, and sun protection equipment (sunscreen, hats, etc. ) were evident when senior managers were more aware of their organization’s sun protection policy.

Overall, the authors found that occupational sun protection programs can be more effective on the “front line” (with people who work outdoors) when the “back office” (senior management) is aware of and can, therefore, support and encourage their organization’s sun safety policies and practices.

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, Principal Investigators). Dr. Walkosz’s coauthors on this paper included Dr. David Buller, Ms. Mary Buller, and Ms. Xia (Lucia) Liu from Klein Buendel, and Dr. Allan Wallis from the University of Colorado Denver.

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.