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Implementation of Sun Safety Policies in Public Elementary Schools

Implementation of Sun Safety Policies in Public Elementary Schools

Klein Buendel Research Program Manager, Julia Berteletti, presented insights from a randomized controlled trial that tested a technical assistance program designed to help principals implement district sun safety policies in elementary schools at the 40th Annual Meeting and Scientific Sessions of the Society of Behavioral Medicine, March 6-9, 2019 in Washington, DC.

The Centers for Disease Control and Prevention (CDC) and U.S. Surgeon General have advised the nation’s schools to adopt and implement sun protection policy to reduce children’s exposure to solar ultraviolet radiation to prevent skin cancer. A total of 118 elementary schools from 40 California public school districts that had adopted a school board-approved policy for sun safety were recruited and the principal and a teacher at each school reported on school sun protection practices at baseline and posttest.

Half of the schools were randomly assigned to receive the 20-month Sun Safe Schools intervention, delivered by trained Sun Safety Coaches who met with principals, described the district policy, helped them select and plan implementation of sun safety practices, and provided support and resources matched to the principal’s readiness to implement practices based on Diffusion of Innovation Theory. Control schools received a minimal information treatment containing basic school sun safety information from the CDC, the National Association of State Boards of Education, and U.S. Surgeon General.

Compared to controls, principals at intervention schools reported implementing more sun safety practices in general, whether present in the district’s written policy or not. Similarly, teachers at intervention schools reported implementing a larger number of sun safety practices in general, including practices in their district’s written policy or not, compared with control schools. Overall, the intervention was effective at increasing sun safety practices in public elementary schools. However, convincing school districts to adopt policies may be only the first step in improving sun safety practices becasue districts need to actively disseminate the new policy to schools and provide assistance and materials to facilitate implementation.

This research was supported by a grant from the Eunice Kennedy Shriver National Institute for Child Health and Human Development (HD074416; Dr. Kim Reynolds, Principal Investigator). Collaborators in addition to Julia Berteletti, include Dr. Kim Reynolds and Kim Massie from Claremont Graduate University in California; Dr. David Buller and Mary Buller from Klein Buendel; Dr. Jeff Ashley from Sun Safety for Kids in, California; and Dr. Richard Meenan from Kaiser Permanente Center for Health Research in Oregon.

Implementation of Occupational Sun Safety at a 2-Year Follow-Up in a Randomized Trial

Implementation of Occupational Sun Safety at a 2-Year Follow-Up in a Randomized Trial

The American Academy of Dermatology acknowledges that outdoor workers receive more UV radiation exposure and are at a higher risk for skin cancer than other workers.1 In a recent article e-published in the American Journal of Health Promotion, KB’s Dr. David Buller, Dr. Barbara Walkosz, and Mary Buller, along with multiple collaborators, evaluated the implementation of sun protection policies two years after the initial intervention, called Sun Safe Workplaces (SSW), in cities, counties, and special districts in Colorado with workers in public works, public safety, and parks and recreation. Authors were also interested in whether or not the organizational characteristics had an effect on the implementation of the sun safety policies.

In the original 24-month long study, 98 government organizations in Colorado were enrolled in 2010 and 2011 and half were randomly selected to receive the SSW intervention, where the primary outcome was adoption of a sun protection policy. Each of the organizations’ written workplace policies were assessed and senior managers completed surveys before and after the intervention. In 2015 and 2016, two years after the intervention was completed, the organizations were contacted for a second follow-up and 63 of the original 98 agreed to participate. Self-administered surveys were given to frontline supervisors and employees who worked outdoors by key contact managers. Project staff visited each organization to conduct semi structured interviews with key managers and complete an audit of the workplace for sun protection messages and items.

Implementation of sun protection policies was measured in three ways: 1) inspection of the workplace for sun protection messages and personal sun protection items, such as shade structures or sunscreen; 2) reports from frontline supervisors on whether the organization communicated with employees about sun safety, had unwritten standard operating procedures on sun safety, or provided personal sun protection equipment for employees, such as wide-brimmed hats, sunscreen, long-sleeved shirts, long pants, etc.; and 3) reports from employees on whether they had received any training on sun safety at the workplace or sun safety communication from the organization or a coworker.

Results showed that two years after the initial intervention, sun protection messages and sun protection items were used more often in organizations that were originally part of the intervention group compared to the control group. Survey responses from frontline supervisors at intervention organizations also showed more communication about sun protection to employees, more standard operating procedures on sun safety and more free/reduced cost sunscreen than those from control organizations. Sun protection training and sun safety communication from coworkers and the employer was higher in intervention organizations when compared to control organizations. Additionally, organizations with a sun protection policy implemented more sun safety actions (communication about sun safety and provided personal sun protection equipment) than organizations without a policy.

The authors conclude that the SSW intervention appeared to increase local government organizations’ sun safety actions over time. Authors state that formal policies on sun protection and training together appear to be an important part of occupational sun protection efforts. A full description of the methods, results, conclusions, and limitations of this study can be found in the publication in the American Journal of Health Promotion.

This research was funded by the National Cancer Institute (CA187191; Dr. David Buller and Dr. Barbara Walkosz, Principal Investigators). Collaborators/coauthors include Mary Buller from Klein Buendel, Dr. Allan Wallis from the University of Colorado Denver, Dr. Peter Andersen from San Diego State University, Dr. Michael Scott from Mikonics, Inc., Dr. Richard Meenan from Kaiser Permanente’s Center for Health Research, and Dr. Gary Cutter from the University of Alabama at Birmingham.

Reference

  1. Outdoor workers and skin cancer. Safety+Health. September 23, 2018. Available at: https://www.safetyandhealthmagazine.com/articles/17480-outdoor-workers-and-skin-cancer. Accessed January 14, 2019.

Cost Analysis of a Sun Safety Program at California Elementary Schools

Cost Analysis of a Sun Safety Program at California Elementary Schools

The Surgeon General’s 2014 Call to Action to Prevent Skin Cancer emphasized the importance of sun safety for schools. However, limited cost data exist to inform implementation decisions regarding school sun safety practices. In response, Dr. Richard Meenan from the Kaiser Permanente Center for Health Research (KPCHR), presented data on the costs of delivering a sun protection policy intervention to public elementary schools in California at the 11th Annual Conference on the Science of Dissemination and Implementation in Health in Washington DC, December 3-5, 2018.

The Sun Safe Schools (SSS) program, a joint research effort of Claremont Graduate University (CGU), KPCHR, and Klein Buendel (KB), provided technical assistance to California public elementary schools interested in implementing sun safety practices consistent with their district board policy for sun safety. The research design included a randomized trial of SSS that assessed its effectiveness in promoting implementation and an economic evaluation of the SSS program.

Fifty-eight intervention schools and 60 controls participated. Principals at intervention schools received regular phone and email contact from trained SSS coaches over 20 months to support implementation of selected sun safety practices. Rolling recruitment and intervention occurred over 47 months (2014-18). Study outcome data are from a posttest survey of school principals. Intervention delivery costs were virtually all labor (SSS coach and principal time). Implemented practices were organized into ten categories (such as student education and outdoor shade) and micro-costed using a project-developed template. Required school labor and non-labor resources for implementation were estimated for each practice. Three elementary school principal consultants reviewed the template for appropriateness.

Intervention delivery costs and costs of implemented practices for intervention schools and control schools were presented and are being submitted for publication. Principals’ beliefs about the importance of sun protection were positively correlated with policy implementation, both in numbers of implemented policies and overall dollars invested. Results indicated that a low-cost program of regular phone and email coaching of school administrators can successfully stimulate implementation of sun safety practices in elementary schools at a reasonable cost. Costs per student were similar to other school health practices. These findings can assist administrators with selecting and implementing appropriate sun safety practices for their schools.

This research was supported by a grant from the Eunice Kennedy Shriver National Institute for Child Health and Human Development (HD074416; Dr. Kim Reynolds, Claremont Graduate University, Principal Investigator). Collaborators in addition to Dr. Reynolds and Dr. Meenan include Kim Massie from Claremont Graduate University in California; Dr. David Buller, Julia Berteletti, and Mary Buller from Klein Buendel; and Dr. Jeff Ashley from Sun Safety for Kids in Los Angeles, California.

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.

 

Uptake of MC1R Testing for Melanoma Risk

Uptake of MC1R Testing for Melanoma Risk

The use of personalized medicine or tailoring medicine based on sequencing and analyzing an individual’s DNA, is drastically changing cancer research and treatment, risk assessment and clinical practices1, and skin cancer is one area being affected by this research.2 Currently, melanoma in U.S. Hispanic populations is on the rise and despite melanoma being more common in Caucasians than Hispanics, a melanoma diagnosis is more likely to be fatal for Hispanics.3

In a study recently published in JAMA Dermatology, several researchers (lead author Dr. Jennifer Hay) including Dr. David Buller from Klein Buendel, examined interest and uptake, as well as demographic and skin cancer risk factor covariates of interest and uptake, of the melanocortin-1 receptor gene (MC1R) saliva test among 499 adult participants recruited from diverse clinics in Albuquerque, New Mexico. Forty-four percent (44%) of participants were non-Hispanic white, 48% were Hispanic, and all were registered clinic patients for longer than six months, were 18-years of age or older, and spoke English or Spanish fluently. A study website log-in was given to participants to give them the option to log on and read three educational modules presenting the rationale and pros and cons of MC1R testing.

Results showed that almost 50% (n=232) of participants logged on to the website and that non-Hispanic whites and those with higher education were more likely to do so. Furthermore, participants with a history of sunburn and with at least one first-degree relative were also more likely to log on to the website. Of those who logged on, almost 90% (n=204) decided to request testing and a little over 80% (n=167) of those who requested testing returned the kit. Non-Hispanic whites and older participants had a higher rate of returning the kit.

Authors cite the large, diverse sample and the behavioral outcomes versus self-reported outcomes as strengths of the study while citing the single location and use of one primary care health system for recruitment as a limitation on generalizability. Lastly, authors conclude by calling for future research in socioeconomic and demographic discrepancies in interest and uptake of genetic testing in order to ensure ease of availability of genetic information seeking in the general population.

References

  1. Orchard C. Genomic medicine in the real world: “hope” and “hype”. Harvard T.H. Chan School of Public Health Web site. Available at: https://www.hsph.harvard.edu/ecpe/genomic-medicine-in-the-real-world-hope-and-hype/. Published June 1, 2015. Accessed June 20, 2018.
  2. Genetics of skin cancer (PDQ) – health professional version: genetic testing. National Cancer Institute Web site. Available at: https://www.cancer.gov/types/skin/hp/skin-genetics-pdq#link/_393_toc. Updated June 14, 2018. Accessed June 20, 2018.
  3. Perez MI. Hispanics get skin cancer, too. Skin Cancer Foundation Web site. Available at: https://www.skincancer.org/prevention/are-you-at-risk/hispanic. Published May 25, 2016. Accessed June 20, 2018.
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.
Effects of the Sun Safe Workplaces Program

Effects of the Sun Safe Workplaces Program

Occupational skin cancer prevention is an international priority. People who work outdoors are routinely exposed to high levels of ultraviolet radiation (UV), the primary risk factor for skin cancer. Dr. Barbara Walkosz from Klein Buendel presented findings from the Sun Safe Workplaces project and a follow-up assessment at the 68th Annual Conference of the International Communication Association in Prague, Czech Republic, May 24-28, 2018.

Sun Safe Workplaces (SSW) was a communication theory-based workplace sun safety program for public organizations that employ people who work outdoors. Examples of outdoor work include road and bridge work, parks and recreation facilitation, sanitation and water works, and public safety. The original SSW project promoted the adoption of workplace sun safety policies in the public organizations and provided training in personal sun protection for outdoor workers in a randomized controlled trial. The follow-up study assessed the impact of SSW on employee sun safety behavior.

Sixty-one of the 98 public employers from the original study participated. Managers and line supervisors reported program implementation. A total of 1,784 outdoor workers (913 from the intervention group and 871 from the control group) completed surveys on personal sun protection practices.

In summary, employees’ sun protection improved statistically significantly in the intervention group receiving the SSW program. SSW’s effect on employee sun protection was mediated by the number of workplace actions to implement elements of sun safety policy including sun protection messages and equipment in the workplace and employee reports of training in sun safety.

This research was funded by a grant from the National Cancer Institute (RO1CA187191; Dr. David Buller, Principal Investigator). In addition to Dr. Walkosz and Dr. Buller from Klein Buendel (KB), collaborators/co-authors included Mary Buller from KB; Dr. Allan Wallis from the University of Colorado Denver; Dr. Richard Meenan from the Kaiser Permanente Center for Health Research; Dr. Michael Scott from Mikonics, Inc.; Dr. Peter Andersen from San Diego State University; and Dr. Gary Cutter from the University of Alabama, Birmingham.

Cost of Occupational Sun Protection Policy Intervention Delivery

Cost of Occupational Sun Protection Policy Intervention Delivery

Dr. Richard Meenan presented cost analysis data from the Sun Safe Workplaces project at the 4th International Conference on UV and Skin Cancer Prevention in Toronto, Canada May 1-4, 2018. His presentation focused on an estimated cost of delivering a sun protection policy intervention to public-sector employers in Colorado. The cost of occupational skin cancer prevention interventions poses challenges for organizations delivering interventions and employers that implement sun protection for outdoor workers.

The Sun Safe Workplaces (SSW) intervention promoted occupational sun protection policies and education to 98 public-sector employers in a randomized controlled trial. Intervention components included in-person meetings and follow-up contact by email and telephone with senior managers, in-person trainings for employees, and printed educational materials sent to the workplace. Using a micro-costing approach, costs to the intervening organization were determined from the project accounting system supplemented by external sources. Costs to employers were estimated from responses to semi-structured interviews in a two-year follow-up with 34 senior managers on implementing sun protection education and other actions to support employee sun safety and were presented at the conference. Employers incurred highest average costs for implementing onsite sun safety training, primarily the estimated value of employee time in attendance.

Costs to employers are likely a barrier to acting on skin cancer prevention. In the SSW trial, employers appeared to incur more costs than the intervening organization. Strategies to control employer costs should be considered when designing occupational skin cancer prevention interventions. Costs will be used to determine: (1) the incremental cost of the SSW intervention (ignoring development and research costs) and (2) the incremental cost of the employers’ skin cancer prevention education and policy adoption actions induced by the SSW intervention.

This research was funded by a grant from the National Cancer Institute (RO1CA187191; Dr. David Buller, Klein Buendel, Principal Investigator). Collaborators include Dr. Barbara Walkosz, Rachel Eye, and Mary Buller from Klein Buendel; Dr. Richard Meenan from the Kaiser Permanente Center for Health Research in Portland, Oregon; and Dr. Allan Wallis from the University of Colorado Denver.

Klein Buendel was one of the North American hosts of the UV 2018 conference. The conference was organized by a joint planning committee of skin cancer prevention experts in Canada and the United States from Ryerson University in Toronto, the Canadian Dermatology Association in Ottawa, and Klein Buendel in Denver.