Klein Buendel investigators and their collaborators have e-published the results of the cost analysis of implementing the Go Sun Smart at Work program via two different methods in the Journal of Occupational and Environmental Medicine (JOEM).
This randomized controlled trial compared two methods (digital and in-person) for scaling up an evidence-based occupational sun protection program nationwide. The program was designed to help workplaces implement skin cancer prevention training and policy for employees who work outdoors. 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. Results of the effectiveness of the trial were published in JOEM in January 2025.
For the economic analysis reported in this companion publication, the cost of delivering the Go Sun Smart at Work program was obtained from project accounting records and manager reports. The study followed the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) reporting guideline for economic evaluation (1). The primary outcome of the economic analysis was an incremental cost-effectiveness ratio (ICER) from the perspective of the disseminating organization, although induced costs to the employer were also recorded and reported. The ICER numerator is the incremental difference between digital and in-person strategies in average program cost (C) per regional district. The denominator is the incremental difference between digital and in-person strategies in the mean number of implemented workplace sun protection actions (per regional district) (E [for effect]):
Program delivery costs were estimated to be $15,658 for the digital strategy and $74,275 for the in-person strategy. Across all districts, the ICER was $3,305, representing average cost savings from a sun safety action not implemented under the digital strategy but implemented under the in-person strategy. Full descriptions of the research methods, results, and limitations are included in the JOEM publication. In summary, the digital scalability strategy was cost-effective relative to an in-person strategy, generating substantial cost savings and offsetting a lower mean number of implemented program actions.
The research was supported by a Cancer Moonshot Initiative grant from the National Cancer Institute (CA210259; Dr. David Buller, Principal Investigator). Co-authors 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; Dr. Sherry Pagoto from the University of Connecticut; and Mary Buller, Julia Berteletti, Irene Adjei, and 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 research project.
References
Husereau D, Drummond M, Augustovski F, et al. Consolidated health economic evaluation reporting standards 2022 (CHEERS 2022) statement: updated reporting guidance for health economic evaluations. Value Health. 202;25:3-9.
Dr. David Buller from Klein Buendel presented three posters at the 46th Annual Sessions and Meeting of the Society of Behavioral Medicine in San Francisco, California, March 26-29, 2025. Dr. Kayla Nuss and Ms. Julia Berteletti from Klein Buendel were co-authors on a fourth poster.
*Klein Buendel authors are bolded.
Dr. David Buller
Poster 1
Title: Economic Evaluation of Two Scalability Strategies for Nationwide Dissemination of an Occupational Sun Safety Intervention
Presenter:David Buller
Authors: Richard Meenan, David Buller, Julia Berteletti, Kimberly Henry, Mary Buller, Gary Cutter, Irene Adjei, and Noah Chirico
Americans spend many hours in work environments that contribute to health risks through hazardous job exposures. An economic evaluation of two methods for scaling up the Go Sun Smart at Work (GSS@W) evidence-based occupational sun protection program to prevent skin cancer in a nationwide transportation industry was conducted. GSS@W promoted employer adoption of sun protection policies and employee use of personal sun protection.
Cost-effectiveness analysis compared digital and in-person scalability strategies for disseminating the GSS@W program in a prospective two-group randomized trial. Regional districts (n=138) in 21 state Departments of Transportation (DOT) throughout the United States were recruited. District managers were assessed before and after scale-up and employees were posttest only. GSS@W was disseminated to managers at DOT districts either via an in-person scalability strategy with face-to-face on-site meetings and employee training or a digital scalability strategy with virtual meetings and online training. Cost of delivering GSS@W was obtained from project accounting records and manager reports on number and associated costs of implemented sun protection actions. Primary cost analysis was incremental cost-effectiveness ratio (ICER) between digital and in-person strategies, using program delivery cost as numerator and number of implemented sun protection actions as denominator. Secondary analysis summarized cost of implemented sun protection actions as reported by participating districts.
Mean implemented actions per district were 6.23 in digital and 6.53 in in-person strategy groups. Program delivery costs were estimated to be $15,658 for the digital strategy and $74,275 for the in-person strategy. Across all districts, the ICER was $3,305, representing average cost savings from an action not implemented under the digital strategy but implemented under the in-person strategy. Training was the most expensive action implemented by districts under either strategy (88% of implemented action costs).
The digital scalability strategy was cost-effective relative to an in-person strategy, generating substantial cost savings and offsetting a lower mean number of implemented GSS@W program actions. The GSS@W intervention may be readily implemented within employers that manage large annual budgets. Cost analysis was limited by not assessing induced costs to employees and potential feedback effects that could produce contamination.
The research was supported by a Cancer Moonshot Initiative grant from the National Cancer Institute (CA210259; Dr. David Buller, Principal Investigator).
Poster 2
Title: Pilot Test of a Social Media Campaign on Preventing Cancer Risk Factors for Emerging Adults in Rural Communities in the American Mountain West
Presenter:David Buller
Authors: David Buller, Andrew Sussman, Echo Warner, Alishia Kinsey, Barbara Walkosz, Judith Gordon, W. Gill Woodall, Douglas Taren, Deanna Kepka, Kimberly L. Henry, Kayla Nuss, Cindy Blair, Evelinn Borrayo, David Wetter, Meghan Skiba, Julia Berteletti, Annelise Small, Dolores Guest, and John Torres
A social media campaign on preventing six cancer risk factors – being physical inactive, eating an unhealthy diet, using nicotine products, binging alcohol, being sunburned, and being unvaccinated for human papillomavirus (HPV) – was pilot-tested with emerging adults aged 18-26 living in rural counties.
Using an integrated theoretical framework, social media posts were developed to counter the cancer risk factors. Posts covered simplicity, benefits, response efficacy/cost, self-efficacy/perceived control, risk perceptions, norms, social support/relatedness, goals/values compatibility, intrinsic/extrinsic motivation, media literacy, and communication with family/friends. Twenty-six (26) emerging adults aged 18-26 living in rural counties in Arizona, Colorado, New Mexico, and Utah received a 4-week social media feed with 64 posts delivered in a private Facebook group. Emerging adults completed pretest and posttest surveys, and engagement (views, reactions, comments) was recorded.
Participants were 85% female and 35% Hispanic, with a median age of 23. At pretest, emerging adults demonstrated cancer risk factors: 53% engaged in <150 minutes of moderate-to-vigorous physical activity weekly, 85% had low daily intake of fruits and vegetables, 35% used nicotine products, 58% binged alcohol, 65% were sunburned, and 38% were unvaccinated for HPV. The campaign feed received 1,060 views, 346 reactions and 72 comments. Of the six cancer risk factors, posts on physical activity received the most views (216 views) while those on HPV and sun safety, the least (115 views each). Posts on physical activity, nicotine products, and alcohol received the most reactions (>50 reactions each) and physical activity and diet posts received the most comments (>9 comments each).
Social media is a popular source for health information among emerging adults. A multi-risk factor social media campaign has potential to engage emerging adults with theory-based cancer prevention messaging. The campaign will be evaluated in a randomized trial in 2025.
The research is supported by a grant from the National Cancer Institute (CA268037; Dr. David Buller and Dr. Andrew Sussman, Multiple Principal Investigators). Dr. Sussman is from the University of New Mexico Comprehensive Cancer Center. Other collaborating investigators are from the University of Utah, the University of Arizona, the University of Colorado, and Colorado State University.
Poster 3
Title: Association of Indoor Tanning State Laws and Other Contextual Factors with Burns from Indoor Tanning in a National Sample of US Young Adults
Presenter:David Buller
Authors: Carolyn Heckman, David Buller, Anna Mitarotondo, Daniel Gundersen, Marisa Tomaino, and Julia Berteletti
Indoor tanning by minors is a significant risk factor for the development of melanoma. In addition to FDA safety regulations, 46 states restrict minor indoor tanning access by minors to prevent acute (burns from UV exposure) and chronic (skin cancer) harms. This study’s purpose was to identify state policy and other contextual factors associated with burns from indoor tanning to inform state policy efforts.
The authors conducted an online, nationally representative survey of individuals aged 18-29 who indoor tanned in the last three years (N=1000). Respondents reported on indoor tanning as adults (age 18 or older) and as minors (under age 18). Stringency of state laws on indoor tanning use by minors was scored, with no laws regulating minor indoor tanning being a “0” and laws banning all minors under 18 from indoor tanning being a “10.” Generalized linear models were used to estimate the associations of policy stringency for minor use and enforcement, indoor tanning behavior, and other contextual factors with burns after indoor tanning as a minor or adult. All analyses used the sampling weights.
Eighty-eight percent (88%) of participants reported engaging in indoor tanning in multiple facility types in the last three years, including indoor tanning salons, gyms, beauty salons, homes, spas, and apartments. Stringency of indoor tanning laws in participants’ home states were coded as an average of 4 (weak) out of 10. Fifty-seven percent (57%) of participants reported burning one or more times from indoor tanning in the past three years, with 14% from their most recent indoor tanning session. Correlates of burns from indoor tanning when a minor were weaker age restrictions, greater enforcement, more binge drinking, tanning at locales other than an indoor tanning salon, more sessions, shorter sessions, and more sunburns. Correlates of burns from indoor tanning when an adult were being between 22-25 years old, lower perceived indoor tanning facility safety in their state, greater enforcement, more sessions, and more sunburns.
This is the first study to investigate the impact of the stringency and enforcement of age restrictions in state indoor tanning law on burns both for indoor tanning before and after age 18, in a representative national sample. Burns were very common in the context of weak laws in many states, yet harmful burns after indoor tanning during childhood appeared to be lower in states with stronger age restrictions. Enforcing weak laws or inadequate safety regulations/compliance appears to have little impact on indoor tanning or burns in minors or adults. Thus, increasing stringency of state indoor tanning laws for all facility types may ultimately decrease acute harm and subsequent skin cancer rates.
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).
Poster 4
Title: Social Comparison as a Behavior Change Technique in Digital Interventions: Users’ Perceptions of Leaderboards to Promote Physical Activity Motivation and Behavior
Presenters: Raj Harsora and Danielle Arigo from Rowan University
Authors: Raj Harsora, Emmanuel Lapitan, Giada Benasi, Amanda Folk, Laura König, Kayla Nuss, Julia Berteletti, Kyle R. Haggerty, and Danielle Arigo
Physical activity leaderboards are a common feature in digital health tools; they display users ranked physical activity behavior from highest to lowest, leveraging social comparison to boost motivation. However, some users find them motivating while others find them aversive. It is not clear how users interpret information from a leaderboard, or for whom or under what circumstances leaderboards might be effective.
To examine these nuances, we surveyed 1,676 adults in the United States and Europe (52% women). Of those who use physical activity apps, 8% indicated that their app has a leaderboard; 70% of these users did not participate in the leaderboard and expressed dislike of this feature for its emphasis on competition, unnecessary pressure, and potential “failure.” The remaining 30% reported using the leaderboard for 2 to 24 months because it kept them motivated by showing their success, particularly as they compared to others at the “same skill level.” After viewing a leaderboard with their own rank depicted, 63% of all respondents (1,504 adults) perceived themselves as doing well with physical activity. In a separate response, however, 51% perceived themselves as doing poorly. These perceptions differed by rank but also showed meaningful heterogeneity for the same rank. Across ranks, 74% of respondents endorsed motivation to engage in physical activity though 26% did not. Physical activity motivation did not differ by rank and was not associated with perceiving oneself as doing poorly but was positively associated with perceiving oneself as doing well; the latter was strongest for those ranked 3rd of 6.
Finally, physical activity motivation in response to the leaderboard did not differ by gender but was higher among those with stronger (vs. weaker) general tendencies to respond positively and negatively to comparison opportunities; the latter did not differ by rank. Findings show that responses to physical activity leaderboards vary widely and aren’t based solely on rank or individual difference characteristics. Further, some people who believe they dislike leaderboards still find them motivating, and it is unclear how leaderboards affect physical activity behavior in daily life. Additional investigation is warranted to identify for whom and under what circumstances leaderboards are most likely to lead to benefits for physical activity.
This research was funded by an NIH Director’s New Innovator Award to Rowan University (DP2HL173857; Danielle Arigo, Principal Investigator).
Implementation of an Occupational Sun Safety Intervention: Comparison of Two Scalability Strategies
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: 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).
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.
