Feasibility of a Bullying Bystander Intervention (STAC) Parent Module for Rural Schools.

The purpose of this study was to assess the feasibility of parent training designed as a companion module to a bullying bystander intervention (STAC) for middle school students in rural communities. Parents (N = 23) invited from three rural middle schools viewed a parent training and completed measures to assess limited efficacy through immediate program outcomes (e.g., knowledge, confidence, self-efficacy, attitudes, behavioral intentions) and program feasibility, as well as participated in focus groups to provide feedback about program acceptability, demand, practicality, and online delivery adaptation. Parents reported increases in knowledge and confidence in supporting their adolescents to intervene in bullying situations, confidence and comfort in managing bullying, bullying self-efficacy, communication self-efficacy, responsibility to actively engage in bullying prevention, and anti-bullying attitudes from pre-training to post-training. Parents also reported behavioral intentions to use strategies they learned to support their adolescents to intervene in bullying situations. Further, parents' responses suggested high levels of program acceptability, as well as interest in an interactive, self-paced online parent training. Themes from focus groups (n = 12) revealed a need for bullying prevention training for both students and parents in rural communities and found the training to be useful, easy to understand, and relevant and appropriate for their community. Parents identified barriers including cost, time, program flexibility, and the importance of parent buy-in. Parents also provided feedback specific to an online training, including a preference for a smartphone application and design elements to increase engagement. Implications for program development for rural communities are discussed.

Posttraining Outcomes, Acceptability, and Technology-Based Delivery of the STAC Bystander Bullying Intervention Teacher Module: Mixed Methods Study.

BACKGROUND: Bullying is a significant problem for youth associated with wide-ranging negative consequences. Providing students who witness bullying with intervention strategies to act as defenders can reduce bullying and negative associated outcomes for both targets and bystanders. Educating teachers about bullying and training them to support students to intervene as defenders may increase the efficacy of bystander programs as teachers' attitudes and responses to bullying relate to bystander behavior. This is particularly important in middle school, when bullying peaks and rates of reporting bullying to teachers begin to decline. Reducing implementation barriers, including limited time and resources, must also be considered, particularly for schools in low-income and rural areas. Technology-based programs can increase access and scalability but require participant buy-in for adoption. OBJECTIVE: We used a mixed methods design to inform the development of the STAC teacher module, a companion training to a brief bullying bystander intervention. STAC stands for the four bystander intervention strategies: Stealing the Show, Turning it Over, Accompanying Others, and Coaching Compassion. Objectives included examining the effectiveness of the STAC teacher module and informing the translation of the training into a technology-based format that can be used as a companion to the technology-based STAC. METHODS: A sample of 17 teachers recruited from 1 middle school in a rural, low-income community completed pre- and posttraining surveys assessing immediate outcomes (ie, knowledge, confidence, comfort, and self-efficacy), intention to use program strategies, and program acceptability and relevance, followed by a qualitative focus group obtaining feedback regarding program appropriateness, feasibility, content, perception of need, and desire for web-based training. Descriptive statistics, 2-tailed independent-sample t tests, and thematic analyses were used to analyze the data. RESULTS: Assessment of pre- and posttraining surveys indicated that teachers reported an increase in knowledge and confidence to support defenders, confidence and comfort in managing bullying, and bullying self-efficacy. Furthermore, most participants reported that they were likely or very likely to use STAC strategies to support students who intervene in bullying. Quantitative and qualitative data revealed that participants found the training easy to use, useful, relevant, and appropriate. Qualitative data provided feedback on ways of improving the program, including revising role-plays and guidance on understanding student behavior. Participants shared positive perceptions regarding program feasibility and need for bullying-specific prevention, the most significant barriers being cost and parent buy-in, suggesting the importance of including parents in the prevention process. Finally, participants shared the strengths of a web-based program, including ease of implementation and time efficiency, while indicating the importance of participant engagement and administration buy-in. CONCLUSIONS: This study demonstrates the effectiveness of the STAC teacher module in increasing knowledge and bullying self-efficacy and provides support for developing the module, including key information regarding considerations for web-based translation.

Parent reports of sun safety communication and behaviour for students in a randomised trial on a school policy implementation intervention.

OBJECTIVE: Schools are an important setting for skin cancer prevention. An intervention for implementation of school sun safety policy, Sun Safety Schools (SSS), was evaluated. METHODS: Primary schools (n=118) in California school districts that had already adopted a sun safety policy were enrolled in a study with a randomised controlled design. Half of the schools were randomised to SSS intervention (N=58). Parents completed an online post-test. RESULTS: More parents in intervention schools received information about sun safety (mean=26.3%, sd=3.1%, p=0.017) and children more frequently wore sun-protective clothing when not at school (mean=2.93, sd=0.03, p=0.033) than in control schools (mean=18.0%, sd=2.5%; mean=2.83, sd=0.03, respectively). In schools where principals reported implementing sun safety practices, parents reported that children spent less time outdoors at midday (mean=14.78 hours, sd=0.25, p=0.033) and fewer were sunburned (mean=12.7%, sd=1.1%, p=0.009) than in non-implementing schools (M=16.3 hours, sd=0.67; mean=21.2%, sd=3.8%, respectively). Parents who received sun safety information (mean=3.08, sd=0.04, p=0.008) reported more child sun protection than parents not receiving information (mean=2.96, sd=0.02). CONCLUSIONS: A school district sun protection policy and support for implementation increased dissemination of sun safety information to parents and student sun safety. Implications for public health: Technical assistance for sun safety policies may increase sun protection of children.

Randomized controlled trial evaluating an intervention supporting implementation of sun safety policies in California public elementary schools.

Solar ultraviolet radiation (UV) exposure is the primary risk factor for skin cancer and children receive about one-quarter of lifetime UV exposure before age 18. Thus, skin cancer prevention is essential for children. The objective of this study was to test an intervention to facilitate implementation of district sun safety policies. Elementary schools (N = 118) from 40 California public school districts with a school board-approved policy for sun safety were recruited along with one principal and teacher from each school. Elementary schools were randomly assigned to receive the 20-month Sun Safe Schools intervention (N = 58) or to a minimal informational control condition (N = 60). Principals were 47.8 and teachers 44.3 years of age and were predominately female (principals 72.7%; teachers 86.7%) and White (principals 72.0%; teachers 68.2%). The 20-month Sun Safe Schools intervention was delivered to principals and included a coaching session, telephone and email contacts, provision of resources for practice implementation, and a small grant program. The principal (N = 118) and a teacher (N = 113) at each school reported on school sun protection practices 20-months post-baseline. The schools were diverse in student characteristics (M = 64.1% free/reduced price meals; M = 54.5% Hispanic). Intervention principals reported implementing more sun safety practices overall (control M = 2.7, intervention M = 4.2, p < .005) and more practices not present in the district's policy (control M = 0.4, intervention M = 0.9, p = .005). Principals and teachers combined replicated these findings and also reported implementing more practices present in the district policy (control M = 0.9, intervention M = 1.3, p = .005). In sum, the intervention increased sun safety practices in public elementary schools. Trial Registration. This study is registered in ClinicalTrials.gov, www.clinicaltrials.gov, with the identification number of NCT03243929.

School-Level Factors Associated with Sun Protection Practices in California Elementary Schools.

BACKGROUND: This study examined implementation of district sun safety policy in schools and tested correlates of implementation in California public school districts. METHODS: Principals (N = 118) and teachers (N = 113) in California public elementary schools (N = 118) were recruited and completed a survey on sun protection policies and practices. The sample contained schools whose districts subscribed to the California School Boards Association and adopted Board Policy 5141.7 for sun safety. Principals and teachers reported on implementation of 10 school practices related to BP 5141.7 indicating which practices were implemented in the school. RESULTS: Years in public education (Exponentiated Score (ES) = 0.51, p < .001), years worked in the current district (ES = 0.49, p < .001), perception that parents should take action to protect children from the sun (ES = 0.43, p < .01), and personal skin phenotype (Low Risk ES = 0.55; High Risk ES = 0.09, p < .05) were associated with number of practices implemented in the school using multiple Poisson regression. CONCLUSIONS: Policy implementation is more likely among schools with experienced faculty, when parents are seen as important partners in student skin cancer prevention, and when school principals and teachers have a lower personal risk phenotype.

Economic Evaluation of a Sun Protection Promotion Program in California Elementary Schools.

BACKGROUND: An economic evaluation of Sun Safe Schools intervention designed to aid California elementary schools with implementing sun safety practices consistent with local board-approved policy. DESIGN: Program cost analysis: intervention delivery and practice implementation. SETTING: California elementary schools (58 interventions and 60 controls). Principals at 52 intervention and 53 control schools provided complete implementation data. PARTICIPANTS: Principals completing pre-/postintervention surveys assessing practice implementation. INTERVENTION: Phone-based 45-minute session with a project coach on practice implementation, follow-up e-mails/phone contacts, $500 mini-grant. Schools chose from a list of 10 practices for implementation: ultraviolet monitoring, clothing, hats, and/or sunscreen recommendations, outdoor shade, class education, staff training and/or modeling, parent outreach, and resource allocation. The duration of intervention was 20 months. Rolling recruitment/intervention: February 2014 to December 2017. MEASURES: Intervention delivery and practice implementation costs. Correlations of school demographics and administrator beliefs with costs. ANALYSIS: Intervention delivery activities micro-costed. Implemented practices assessed using costing template. RESULTS: Intervention schools: 234 implemented practices, control schools: 157. Twenty-month delivery costs: $29 310; $16 653 (per school: $320) for project staff, mostly mini-grants and coaching time. Administrator costs: $12 657 (per school: $243). Per-student delivery costs: $1.01. Costs of implemented practices: $641 843 for intervention schools (per-school mean: $12 343, median: $6 969); $496 365 for controls (per-school mean: $9365, median: $3123). Delivery costs correlated with implemented practices (0.37, P < .01) and total practice costs (0.37, P < .05). Implemented practices correlated with principal beliefs about the importance of skin cancer prevention to student health (0.46, P < .001) and parents (0.45, P < .001). CONCLUSION: Coaching of elementary school personnel can stimulate sun safety practice implementation at a reasonable cost. Findings can assist schools in implementing appropriate sun safety practices.

Economic Evaluation of an Intervention Promoting Adoption of Occupational Sun Protection Policies.

OBJECTIVE: Economic evaluation of an intervention promoting adoption of occupational sun protection actions by Colorado public sector employers. METHODS: Randomized controlled trial with 2-year follow-up conducted during 2010 to 2013. Thirty-three intervention and 30 attention-control worksites in final economic sample. Twenty-four-month intervention of personal contacts, training, and materials. Intervention delivery micro-costed. Costs of implemented actions from employer self-report. RESULTS: Twenty-four-month intervention costs: $121,789, 51.8% incurred by project staff (per-worksite mean=$1,732). Worksite costs: $58,631 (mean = $1,777). Per-employee costs: $118 project staff, $56 worksites. Materials cost: $5990 (mean = $181). Intervention worksites implemented 72 nontraining sun protection actions post-Sun Safe Workplaces (SSW) (mean = 2.18). Control worksites implemented 39 actions (mean = 1.30). Total costs to intervention worksites of implementing the 72 post-SSW actions: $90,645 (mean = $2,747). Control worksite costs: $66,467 (mean = $2,216). Per-employee implementation costs are comparable to other worksite health interventions. CONCLUSION: SSW expanded adoption of sun protection actions at a reasonable per-employee cost.

Randomized Trial Evaluating Targeted Photographic Health Communication Messages in Three Stigmatized Populations: Physically-Disabled, Senior, and Overweight/Obese Individuals.

The homophily principle that perceived similarities among people produce positive reactions is a cross-cultural, global phenomenon. The prediction that photographs depicting models similar to the target population improve health communication was tested. Three nationally-representative samples (n = 1,796) of adults who are disabled, seniors, or considered overweight/obese were selected from GfK's Knowledge Panel®. Participants read a message promoting physical activity and improved diets and responded to assessments of behavioral intentions, outcome and self-efficacy expectations, and identification. Photographs from a stock photograph service versus photographs created for the research project to match the three populations, Real Health Photos (RHP), were included in the message. Structural equation modeling confirmed that RHP which matched the population increased behavioral intentions mediated by identification (p < 0.05) in the physically-disabled and overweight/obese samples. Messages with only half of the matched RHP images had these same positive indirect effects (p < 0.05). Matched visual images in health messages improved effectiveness by capitalizing on the homophily and identification processes. Health educators should leverage these hardwired, evolutionary, biological phenomena that extend to health status as well as race and ethnicity. For optimal effects, not all persons shown need to be homophilous to the target audience, reducing logistical difficulties in showing diverse persons of various types.

The Conversations About Cancer (CAC) Project-Phase II: National findings from viewing When Cancer Calls and implications for Entertainment-Education (E-E).

OBJECTIVE: We address cancer communication by creating and assessing the impacts of a theatrical production, When Cancer Calls…(WCC…), anchored in conversations from the first natural history of a patient and family members talking through cancer on the telephone. METHODS: A national study was conducted using a multi-site and randomized controlled trial. An 80-minute video was produced to assess viewing impacts across cancer patients, survivors, and family members. Comparisons were made with a control video on cancer nutrition and diet. Pretest-posttest sample size was 1006, and 669 participants completed a 30-day follow-up impacts assessment. RESULTS: All five family and communication indices increased significantly for WCC…. When compared to the placebo, average pretest-posttest change scores were higher for self-efficacy (775%), family fabric (665%), outside support (189%), and family communication (97%). One month following viewings, WCC…participants reported 30% more conversations about cancer among patients and family members about cancer. CONCLUSION: A new genre of Entertainment-Education (E-E) was created that triggers positive reactions from audience members. Managing delicate and often complex communication about the trials, tribulations, hopes, and triumphs of cancer journeys is fundamentally important for everyday living. PRACTICE IMPLICATIONS: Unique opportunities exist to make WCC… available to national and global audiences, create tailored curricula, and integrate these viewings into educational programs for patients, family members, and care-provider teams across diverse health, corporate, and governmental systems.

Perceived availability of culturally and demographically diverse photographs for health education materials, Colorado, 2010.

An online survey was conducted with health educators in Colorado to ascertain their needs and ability to access relevant stock art photographs for their print and electronic educational media. Health educators were dissatisfied with the cultural and demographic diversity of photographs available from their own sources or from commercial stock art websites. There was a perceived need for more photographs that would better represent their target populations. The health educators believed, furthermore, that representative visual images can help improve their message effectiveness.

The Conversations About Cancer (CAC) project: assessing feasibility and audience impacts from viewing The Cancer Play.

Basic communication research has identified a major social problem: communicating about cancer from diagnosis through death of a loved one. Over the past decade, an award-winning investigation into how family members talk through cancer on the telephone, based on a corpus of 61 phone calls over a period of 13 months, has been transformed into a theatrical production entitled The Cancer Play. All dialogue in the play is drawn from naturally occurring (transcribed) interactions between family members as they navigate their way through the trials, tribulations, hopes, and triumphs of a cancer journey. This dramatic performance explicitly acknowledges the power of the arts as an exceptional learning tool for extending empirical research, exploring ordinary family life, and exposing the often taken-for-granted conceptions of health and illness. In this study, a Phase I STTR project funded by the National Cancer Institute (NCI), we assess the feasibility of educating and impacting cancer patients, family members, and medical professionals who viewed the play as a live performance and through DVD screenings. Pre- and postperformance questionnaires were administered to solicit audience feedback. Pre-post change scores demonstrate overwhelming and positive impacts for changing opinions about the perceived importance, and attributed significance, of family communication in the midst of cancer. Paired-sample t-tests were conducted on five factor-analyzed indices/indicators-two indices of opinions about cancer and family communication, two indices measuring the importance of key communication activities, and the self-efficacy indicator-and all factors improved significantly (<.001). Informal talkback sessions were also held following the viewings, and selected audience members participated in focus groups. Talkback and focus-group sessions generated equally strong, support responses. Implications of the Phase I study are being applied in Phase II, a currently funded effort to disseminate the play nationally and to more rigorously test its impact on diverse audiences. Future directions for advancing research, education, and training across diverse academic and health care professions are discussed.

School sun-protection policies: measure development and assessments in 2 regions of the United States.

BACKGROUND: In 2002, the US Centers for Disease Control and Prevention recommended that schools adopt policies that reduce exposure of children to ultraviolet radiation to prevent skin cancer. We report here the development of a school sun-safety policy measure and baseline descriptive statistics from the assessment of written policies collected in 2005-2007 from public school districts that enrolled in a randomized trial evaluating a policy promotion program. METHODS: Written policies were collected from 103 of 112 school districts in Colorado and Southern California prior to randomization. We developed methods for selecting policy headings/sections topics likely to contain sun-safety policies for students and for assessing the presence, strength, and intent of policies. Trained coders assessed the content of each policy document. RESULTS: Overall, 31% of districts had a policy addressing sun safety, most commonly, protective clothing, hats, sunscreen, and education at baseline. More California districts (51.9%) had these policies than Colorado districts (7.8%, p < .001). Policy scores were highest in districts with fewer Caucasian students (b = -0.02, p = .022) in Colorado (b = -0.02, p = .007) but not California (b = 0.01, p = .299). CONCLUSION: The protocol for assessing sun-safety policy in board-approved written policy documents had several advantages over surveys of school officials. Sun-protection policies were uncommon and limited in scope in 2005-2007. California has been more active at legislating school policy than Colorado. School district policies remain a largely untapped method for promoting the sun protection of children.

Motivating public school districts to adopt sun protection policies: a randomized controlled trial.

BACKGROUND: In 2002, CDC recommended that the nation's schools establish policies that reduce sun exposure to decrease students' risk of skin cancer. PURPOSE: A program to convince public school districts to adopt such a policy was evaluated. DESIGN: RCT. SETTING/PARTICIPANTS: Public school districts in Colorado (n=56) and Southern California (n=56). INTERVENTION: Policy information, tools, and technical assistance were provided through printed materials, a website, meetings with administrators, and presentations to school boards. An RCT enrolled public school districts from 2005 to 2010. Policy adoption was promoted over 2 years at districts randomized to the intervention. MAIN OUTCOME MEASURES: School board-approved policies were obtained from 106 districts and coded at baseline and 2-year follow-up. Analyses were conducted in 2010. RESULTS: There was no difference in the percentage of districts adopting a policy (24% in intervention; 12% in control; p=0.142); however, intervention districts (adjusted M=3.10 of 21 total score) adopted stronger sun safety policies than control districts (adjusted M=1.79; p=0.035). Policy categories improved on sun safety education for students (intervention adjusted M=0.76; control adjusted M=0.43, p=0.048); provision of outdoor shade (intervention adjusted M=0.79; control adjusted M=0.28, p=0.029); and outreach to parents (intervention adjusted M=0.59; control adjusted M=0.20, p=0.027). CONCLUSIONS: Multifaceted promotion can increase adoption of stronger policies for reducing sun exposure of students by public school districts. Future research should explore how policies are implemented by schools.

Randomized trial evaluating computer-based sun safety education for children in elementary school.

BACKGROUND: Interactive multimedia programs derived from the Sunny Days, Healthy Ways (SDHW) sun safety curriculum were evaluated with children aged 5-13. METHODS: A randomized pretest to posttest 3-group study was conducted with 871 students in 12 primary schools in the western United States comparing computer programs alone, teacher-led presentation, or both combined. RESULTS: Computer programs with teacher-led presentation improved knowledge over either treatment individually (P = .001). The combination improved self-reported sun protection in lower but not higher grades over teacher-led presentation (P = .005). CONCLUSIONS: Computer-based sun safety instruction used with teacher instruction in primary schools may improve sun safety, especially with younger children.