Bilingual Web App to Improve HPV Vaccine Uptake

Bilingual Web App to Improve HPV Vaccine Uptake

Dr. W. Gill Woodall, Klein Buendel Senior Scientist, presented findings from the Vacteens/Vacuna Adolescente Project at the virtual 33rd International Papillomavirus Conference & Basic Science, Clinical and Public Health Workshops (IPVC), July 20-24, 2020.

The uptake of HPV vaccine in the United States remains substantially below the Healthy People 2020 goal of 80% series completion, particularly for young adolescents, when immunogenic response to the vaccine is strongest. Physician and clinic-based interventions have shown some limited positive effect on vaccine uptake. However, parental barriers to HPV vaccination may be addressed by digital interventions, such as smartphone applications, that are tailored to their concerns. Potential parental barriers include confusion, uncertainty, and misinformation about HPV vaccine schedule, safety, and effectiveness.

A research project was conducted to test whether digital information delivered to parents in a community setting may be an effective way to help reach HPV vaccine uptake goals in the United States. Diffusion of Innovations Theory principles were used to guide the development of the Vacteens/Vacuna Adolescente mobile app in English and Spanish. The app was designed  to encourage HPV vaccination in New Mexico, an ethnically-diverse state with insufficient vaccine uptake. Parents and adolescents were recruited from pediatric clinics in New Mexico to a randomized trial evaluating the mobile web app, which focused on daughters (ages 11-14). Parents were randomized to receive either the Vacteens/VacunaAdolescente mobile web app or the usual and customary online HPV vaccination pamphlet from the U.S. Centers for Disease Control and Prevention. Adolescent vaccine records were collected for daughters at a 9-month assessment point. Vaccine uptake results from the trial found that parents who received the Vacteens/VacunaAdolescente web app were significantly more likely to have their daughters vaccinated.

This research was funded by grants from PCORI and the National Cancer Institute (CA210125; Dr. W. Gill Woodall, Principal Investigator). Dr. Woodall’s collaborators include Dr. Alberta Kong and Dr. Lance Chilton from the University of New Mexico, Dr. Greg Zimet from Indiana University, and Jeannyfer Reither, Dr. David Buller, and Dr. Valerie Myers from Klein Buendel.

HPV VACCINATION RATES IN A TRIAL TESTING A SOCIAL MEDIA CAMPAIGN WITH MOTHERS OF TEENAGE DAUGHTERS

HPV VACCINATION RATES IN A TRIAL TESTING A SOCIAL MEDIA CAMPAIGN WITH MOTHERS OF TEENAGE DAUGHTERS

Dr. David Buller, Director of Research from Klein Buendel, presented findings from the Health Chat Project at the virtual 33rd International Papillomavirus Conference & Basic Science, Clinical and Public Health Workshops (IPVC), July 20-24, 2020.

Parental decisions on HPV vaccine uptake in the United States are influenced by information and misinformation about the vaccine in social media. Mothers’ reports on vaccination of their adolescent daughters were examined in an evaluation of a social media adolescent health campaign.

For this intervention, 881 mothers from 34 states were recruited into a randomized controlled trial evaluating a social media adolescent health campaign. Eligibility criteria included having a daughter aged 14-17, in state without a complete ban on indoor tanning by minors, using a Facebook account one or more times a week, completing the baseline survey, and joining the Facebook group. The campaign included didactic and narrative posts some of which promoted HPV vaccination, such as the need for vaccine, percent of adolescents vaccinated, and how HPV vaccines are decreasing infection rates. It was delivered through two Facebook private groups differing on inclusion of indoor tanning or prescription drug mis-use posts .

At baseline, nearly two-thirds of mothers reported that their daughters had been vaccinated for HPV. HPV vaccine uptake increased during the 12-month social media campaign. At the 12-month posttest, nearly 8% more mothers reported that daughters had been vaccinated for HPV. The increase appeared to be largest in completion of the multi-dose series. Uptake increased among older and more educated mothers and those with a family history of skin cancer. Mothers’ reports of HPV vaccine uptake were corroborated by daughters. Effective strategies are needed in social media to promote HPV vaccines and counter misinformation about and resistance to them.

This research is funded by a grant from the National Cancer Institute (CA192652; Dr. David Buller, Klein Buendel, and Dr. Sherry Pagoto, University of Connecticut, Multiple Principal Investigators). Collaborators include Jessica Oleski from the University of Connecticut, Dr. Katie Baker and Dr. Joel Hillhouse from East Tennessee State University, Dr. Kim Henry from Colorado State University, and Dr. Barbara Walkosz and Julia Berteletti from Klein Buendel.

Collaborator Spotlight:
Barbara McCrady, PhD

Collaborator Spotlight:
Barbara McCrady, PhD

Barbara McCrady, PhD, is a Distinguished Professor of Psychology at the University of New Mexico, a licensed psychologist, a specialist in the treatment of alcohol abuse, and a long-time research collaborator with Dr. W. Gill Woodall, Senior Scientist at Klein Buendel.

The research project that Dr. McCrady and Dr. Woodall are currently working on together is entitled “Smartphone Help for DWI Offenders and their Families: A B-SMART App.” B-SMART is a smartphone app intervention designed to extend the drunken driving cessation initially provided by an interlock ignition device. It involves participation of a concerned family member of DWI (driving while intoxicated) offenders by providing coping skills, communication skills, and strategies to help avoid a subsequent DWI. This study is unique because it involves a family member in supporting the DWI offender to not drink and drive, and the use of smartphone technology to make family support immediate, accessible, and diffusible. Dr. McCrady developed the content for the intervention based on empirically validated couples therapy techniques for those with alcohol use disorders.

In her research, Dr. McCrady has focused on conjoint therapy, approaches that involve the social network, cognitive behavioral therapy, mutual help groups, and therapies for women. In her words: “As a clinical scientist, the overall goal of my work is to conduct research to test innovative treatments and treatment delivery systems for persons affected substance use disorders, and to better understand the mechanisms by which these treatments work. An ultimate goal is to improve clinical practice through the use of empirically supported assessment and treatment approaches.”

Dr. McCrady has published more than 250 refereed papers, books, book chapters, and commentaries. She has also published four treatment manuals and client workbooks with Elizabeth Epstein (a member of the B-SMART Project Expert Advisory Board) on empirically supported treatments for couple’s therapy and cognitive behavioral therapy for alcohol use disorders. She has a second edition of a textbook entitled, Addictions: A Comprehensive Guidebook, published by Oxford University Press.

She is the past Director of the Center on Alcoholism, Substance Abuse, and Addictions (CASAA) at the University of New Mexico, and is currently the Chair of the Diversity Committee for the Research Society on Alcoholism and the Vice President for the Research Advisory Committee of the Research Society on Alcoholism.

Investigation of Indoor Tanning Policy Enactment

Investigation of Indoor Tanning Policy Enactment

Klein Buendel is collaborating with Dr. Carolyn Heckman and her team from Rutgers University on a new research project to study the process of translating indoor tanning policy efforts into stringent legislation and compliance, and the effects of the legislation on reduced indoor tanning by minors in the United States.

Indoor tanning is a well-established cause of skin cancer (1-8,10). Most tanners begin indoor tanning as teens or young adults (22). In order to reduce indoor tanning and protect this at-risk population, indoor tanning is currently being regulated in two ways. First, some states restrict access by minors or require parental consent or accompaniment (11). Second, the Food and Drug Administration (FDA) attempts to minimize harm from indoor tanning devices with precautions like protective eyewear and session duration limits (12).  Recent evidence suggests that more stringent indoor tanning laws such as age bans (vs. parent consent laws or no law) are associated with less youth indoor tanning (15,16). Unfortunately, enforcement and compliance with laws are variable and inadequate (9,17-21). Although underutilized (13), legislation such as age restrictions and taxation has been quite successful in decreasing engagement in other risky behaviors such as smoking (14).

The goals of this five-year research project are to (1) clarify the indoor tanning legislation adoption process, (2) employ a pseudo-patron assessment, national survey, and archival data to investigate legislation implementation, and (3) integrate data from the first two aims and external data to assess economic effects relevant to policy sustainability of indoor tanning stringency, enforcement, and compliance.

Health-related policy adoption and promotion is an effective, yet underutilized, strategy for health promotion. To protect the public from melanoma and non-melanoma skin cancer, government bodies have begun to enact legislation to restrict minor access to indoor tanning and minimize harm from indoor tanning devices. In order to contribute to the currently limited evidence base for future policy decision making and sustainability and to accelerate reductions in indoor tanning and sunburn, this project will address policy characteristics associated with regulation compliance, cost-benefits of these policies, and barriers and facilitators of policy adoption.

This research project is funded by the National Cancer Institute (CA244370; Dr. Carolyn Heckman, Rutgers University, and Dr. David Buller, Klein Buendel, Multiple Principal Investigators). Collaborators include Dr. Rich Meenan from the Kaiser Permanente Center for Health Research; Dr. Jared Stapleton from the University of Kentucky; Dr. Shawna Hudson, Dr. Cristine Delnevo, and Dr. Kevin Schroth from Rutgers University; and Julia Berteletti from Klein Buendel.

References

  1. Lergenmuller S, Ghiasvand R, Robsahm TE, et al. Association of Lifetime Indoor Tanning and Subsequent Risk of Cutaneous Squamous Cell Carcinoma. JAMA dermatology. 2019:1-9.
  2. O’Sullivan DE, Brenner DR, Villeneuve PJ, et al. Estimates of the current and future burden of melanoma attributable to ultraviolet radiation in Canada. Preventive medicine. 2019;122:81-90.
  3. Gandini S, Dore JF, Autier P, Greinert R, Boniol M. Epidemiological evidence of carcinogenicity of sunbed use and of efficacy of preventive measures. Journal of the European Academy of Dermatology and Venereology : JEADV. 2019;33 Suppl 2:57-62.
  4. Suppa M, Gandini S. Sunbeds and melanoma risk: time to close the debate. Current opinion in oncology. 2019;31(2):65-71.
  5. O’Sullivan DE, Brenner DR, Demers PA, Villeneuve PJ, Friedenreich CM, King WD. Indoor tanning and skin cancer in Canada: A meta-analysis and attributable burden estimation. Cancer epidemiology. 2019;59:1-7.
  6. Boniol M, Autier P, Boyle P, Gandini S. Cutaneous melanoma attributable to sunbed use: systematic review and meta-analysis. BMJ : British Medical Journal. 2012;345:e4757.
  7. Colantonio S, Bracken MB, Beecker J. The association of indoor tanning and melanoma in adults: Systematic review and meta-analysis. Journal of the American Academy of Dermatology. 2014;70(5):847-857.e818.
  8. El Ghissassi F, Baan R, Straif K, et al. A review of human carcinogens–part D: radiation. The Lancet Oncology. 2009;10(8):751-752.
  9. Reimann J, McWhirter JE, Papadopoulos A, Dewey C. A systematic review of compliance with indoor tanning legislation. BMC public health. 2018;18(1):1096.
  10. Burgard B, Schoepe J, Holzschuh I, et al. Solarium use and risk for malignant melanoma: meta-analysis and evidence-based medicine systematic review. Anticancer research. 2018;38(2):1187-1199.
  11. National Council of State Legislatures. Indoor Tanning Restrictions for Minors: A State by State Comparison. http://www.ncsl.org/research/health/indoor-tanning-restrictions.aspx. Published 2018. Updated 11/2/2018. Accessed.
  12. Food and Drug Administration. Sunlamp products and ultraviolet lamps intended for use in sunlamp products. In. Vol 8. Silver Spring, MD: Food and Drug Administration; 2018.
  13. Abrams DB, Graham AL, Levy DT, Mabry PL, Orleans CT. Boosting population quits through evidence-based cessation treatment and policy. American journal of preventive medicine. 2010;38(3 Suppl):S351-363. PMCID: PMC4515751.
  14. Brownson RC, Haire-Joshu D, Luke DA. SHAPING THE CONTEXT OF HEALTH: A Review of Environmental and Policy Approaches in the Prevention of Chronic Diseases. Annual Review of Public Health. 2006;27(1):341-370.
  15. Guy GP, Berkowitz Z, Jones SE, Holman DM, Garnett E, Watson M. Trends in indoor tanning among US high school students, 2009-2013. JAMA dermatology. 2015;151(4):448-450.
  16. Qin J, Holman DM, Jones SE, Berkowitz Z, Guy Jr GP. State Indoor Tanning Laws and Prevalence of Indoor Tanning Among US High School Students, 2009–2015. American journal of public health. 2018;108(7):951-956.
  17. Driscoll DW, Darcy J. Indoor Tanning Legislation: Shaping Policy and Nursing Practice. Pediatric nursing. 2015;41(2).
  18. Gosis B, Sampson BP, Seidenberg AB, Balk SJ, Gottlieb M, Geller AC. Comprehensive evaluation of indoor tanning regulations: a 50-state analysis, 2012. Journal of Investigative Dermatology. 2014;134(3):620-627.
  19. Mayer JA, Hoerster KD, Pichon LC, Rubio DA, Woodruff SI, Forster JL. Peer Reviewed: Enforcement of State Indoor Tanning Laws in the United States. Preventing chronic disease. 2008;5(4).
  20. Williams MS, Buhalog B, Blumenthal L, Stratman EJ. Tanning salon compliance rates in states with legislation to protect youth access to UV tanning. JAMA dermatology. 2018;154(1):67-72.
  21. Woodruff SI, Pichon LC, Hoerster KD, Forster JL, Gilmer T, Mayer JA. Measuring the stringency of states’ indoor tanning regulations: instrument development and outcomes. Journal of the American Academy of Dermatology. 2007;56(5):774-780.
  22. Tripp MK, Watson M, Balk SJ, Swetter SM, Gershenwald JE. State of the science on prevention and screening to reduce melanoma incidence and mortality: the time is now. CA: a cancer journal for clinicians. 2016;66(6):460-480.

Effects of an Online Responsible Vendor Training for Recreational Marijuana Stores

Effects of an Online Responsible Vendor Training for Recreational Marijuana Stores

The Train To Tend® responsible marijuana vendor (RMV) training research team recently published results from online RMV training on responsible sales for recreational marijuana store personnel as an abstract for the Annals of Behavioral Medicine. The Train To Tend research team is led by Dr. David Buller from Klein Buendel who would have presented the findings at the 41st Annual Meeting and Scientific Sessions of the Society of Behavioral Medicine in San Francisco, had the conference been held as planned.

Recreational marijuana regulations have been designed, in part, to ensure that cannabis products are sold only to adults over the age of 21 who provide state-approved identification (ID). The Train to Tend online RMV training was developed with input from state regulators and recreational marijuana store personnel to train store staff. The training consists of five modules with interactive learning elements that cover state laws, ID checking, health effects of marijuana, driving under the influence, refusal of sales to intoxicated customers, and store processes, such as product labeling and tracking.

A sample of 175 recreational marijuana stores in Colorado and Washington were selected for a randomized controlled trial with sales to pseudo-underage customers. Of the 175 stores, 75 were assigned to the control condition (usual and customary training) and the remaining 100 were given the online RMV training. At baseline, sales of marijuana to pseudo-underage buyers were refused at 93% of 349 visits to stores across the two states. After adjusting for store characteristics, there was no difference in change in refusal rates between treatment groups from baseline, to a 3-month posttest, or a 9-month posttest. For the intervention stores, training uptake was not related to refusal rate and nearly all recreational cannabis stores refused sales to young patrons who failed to produce appropriate ID.

This research was funded by a grant from the National Institute on Drug Abuse at the National Institutes of Health (DA038933; Dr. David Buller, Principal Investigator). Co-authors include Dr. Robert Saltz from the Prevention Research Center at the Pacific Institute for Research and Evaluation; Dr. Gary Cutter from the University of Alabama, Birmingham; and Dr. Gill Woodall, Andrew Grayson, Mary Buller, Sierra Svendsen, and Lucia Liu from Klein Buendel.

Mothers’ Support for Laws Restricting Indoor Tanning by Minors

Mothers’ Support for Laws Restricting Indoor Tanning by Minors

The Health Chat research team published some findings related to indoor tanning from their Facebook-delivered cancer risk reduction intervention and randomized trial with mothers and teen daughters as an abstract in the Annals of Behavioral Medicine. The research team would have presented the work at the 41st Annual Meeting and Scientific Sessions of the Society of Behavioral Medicine in San Francisco, had the conference been held as planned.

Indoor tanning is associated with increased risk for melanoma, especially in young women. Several states restrict indoor tanning by minors or require parental permission. The authors of this abstract hypothesize that mothers’ awareness of state laws related to indoor tanning by youth may reduce their permissiveness for daughters to use tanning facilities.

A total of 777 mothers (and their daughters) from 34 states that do not ban indoor tanning participated in the trial. Less than 20% of mothers (and fewer daughters) accurately reported whether their state has an age restriction or parental permission requirement for minors to indoor tan. More than 50% of the mothers supported banning indoor tanning by minors. However, the mothers reported varying levels of advocacy that they would be willing to demonstrate related to enacting state-level policy to restrict indoor tanning by minors (e.g., sign a petition, contact an elected representative, testify to a state legislative committee). 

The authors conclude that: “Efforts to inform mothers and daughters may be needed to create a norm against indoor tanning, to prevent moms from permitting indoor tanning by daughters, and to build support for further restrictions on minors’ access.”

This research is funded by a grant from the National Cancer Institute (CA192652; Dr. David Buller, Klein Buendel, and Dr. Sherry Pagoto, University of Connecticut, Multiple Principal Investigators). Co-authors include Dr. Katie Baker, Dr. Joel Hillhouse, and Jessica Bibeau from East Tennessee State University; Dr. Kim Henry from Colorado State University; and Dr. Barbara Walkosz and Julia Berteletti from Klein Buendel.

E-Training to Enhance the Care of Aged and Dying Prisoners

E-Training to Enhance the Care of Aged and Dying Prisoners

The health care needs of aged, chronically ill, and dying inmates in correctional settings face growing demands. The Enhancing Care for the Aged and Dying in Prisons (ECAD-P) research team published insights from a geriatric care learning program for corrections staff as an abstract for the Annals of Behavioral Medicine. The ECAD-P research team is led by Dr. Susan Loeb from Penn State University and Dr. Valerie Myers from Klein Buendel. They would have presented the work at the 41st Annual Meeting and Scientific Sessions of the Society of Behavioral Medicine in San Francisco, had the conference been held as planned.

The number of older inmates in the United States continues to grow and best practices for managing geriatric issues and end-of-life (EOL) care have not been adapted for use in corrections settings. In response, ECAD-P team has developed a computer-based learning program for corrections staff comprised of six modules that address EOL and geriatric care concerns in prisons.

After conducting two rounds of usability testing at two prisons in different states, the ECAD-P program entered full-scale testing at seven state prisons. A total of 241 individuals consented to participate and 173 individuals completed all training modules and posttests. Outcomes revealed that the ECAD-P training program was acceptable, feasible, and usable in the corrections staff setting. The research team also found that corrections staff improved their knowledge of geriatric and EOL care of inmates overall after completing the training.

This research was funded by a Small Business Technology Transfer grant to Klein Buendel from the National Institute on Aging at the National Institutes of Health (AG049570; Dr. Susan Loeb and Dr. Valerie Myers, Multiple Principal Investigators). Collaborators and co-authors on this abstract also include Dr. Erin Kitt-Lewis from Penn State University; Dr. Rachel Wion from the Indiana University School of Nursing (formerly Penn State University); Julie Murphy from the King’s College Nursing Program; and Tiffany Jerrod, formerly of Klein Buendel.

Health Misinformation in Participant Comments in a Facebook-Delivered Cancer Risk Reduction Intervention

Health Misinformation in Participant Comments in a Facebook-Delivered Cancer Risk Reduction Intervention

Little is known about how how participants in a health intervention share health misinformation via social media platforms. The Health Chat research team published insights from their Facebook-delivered cancer risk reduction intervention and randomized trial with mothers and teen daughters as an abstract for the Society of Behavioral Medicine (SBM). The lead author, Kelsey Arroyo, from the University of Connecticut, would have presented the work at the 41st Annual Meeting and Scientific Sessions of the Society of Behavioral Medicine in San Francisco, had the conference been held as planned.

For this study, the researchers examined 175 comments made to 42 randomly-selected Facebook posts on different health topics such as substance use, indoor tanning, vaccines, mental health by study participants. The Facebook groups were moderated by health professionals. The participant comments were coded as sharing an opinion, a personal experience, an intention, or information. Comments were analyzed for whether misinformation was conveyed. According to the authors, “misinformation was defined as a fact, belief, opinion, or action that is not supported by scientific evidence.”

Analysis showed that more than three-quarters of comments shared a personal experience. Overall, less than one-fifth of the comments conveyed misinformation, and more than half of the misinformation was conveyed in comments that shared a personal experience.

This research is funded by a grant from the National Cancer Institute (CA192652; Dr. David Buller, Klein Buendel, and Dr. Sherry Pagoto, University of Connecticut, Multiple Principal Investigators). Collaborators and co-authors on the SBM abstract include Kelsey Arroyo, Jared Goetz, and Dr. Molly Waring from the University of Connecticut; Dr. Katie Baker and Dr. Joel Hillhouse from East Tennessee State University; Dr. Kim Henry from Colorado State University; Dr. Jerod Stapleton formerly from the Rutgers Cancer Institute of New Jersey; and Julia Berteletti and Dr. Barbara Walkosz from Klein Buendel.

Sun Safety Communication and Behavior for Students in a School Policy Intervention

Sun Safety Communication and Behavior for Students in a School Policy Intervention

In a recent publication in the Australian and New Zealand Journal of Public Health, Klein Buendel researchers and collaborators evaluated the Sun Safe Schools policy implementation intervention program in California school districts.

The United States has a high occurrence of skin cancer which has created a call to action for many organizations. The Sun Safe Schools program was created to help prevent skin cancer and to protect the nation’s youth by encouraging healthy sun safety habits for young students. In schools specifically, “children receive substantial solar ultraviolet radiation (UV) exposure, including while at school (1), and are frequently sunburned (2).”

In the study, primary schools who had existing sun safety policies were randomized into intervention and control groups and a posttest was distributed to parents. With parents in the intervention schools receiving more information about sun safety, their students on average were more likely to wear sun-protective clothing outside of school more frequently than the students of parents in the control schools. Parents in the intervention group also reported less sunburns and less time outdoors among children whose schools had implemented sun safety practices. A full description of the methods, analyses, results, conclusions, and limitations can be found in the publication.

Overall, support and implementation for a sun protection policy in school districts increased the amount of sun safety information to parents and increased the effectiveness of sun safety behaviors for children. However, experienced faculty and engaging parents are both important factors in the prevention of student skin cancer.

This 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 and Dr. David Buller, Multiple Principal Investigators). Other authors include 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 Claremont Graduate University; and Mary Buller and Julia Berteletti from Klein Buendel.

References

1. Buller DB, Borland R. Skin cancer prevention for children: a critical review. Health Educ Behav. 1999;26(3):317-43.

2. Buller DB, Cokkinides V, Hall HI, Hartman AM, Saraiya M, Miller E, et al. Prevalence of sunburn, sun protection, and indoor tanning behaviors among Americans: systematic review from national surveys. J Am Acad Dermatol. 2011;65(5 Suppl 1):114-23.

Supporting Implementation of Sun Safety Policies in Schools

Supporting Implementation of Sun Safety Policies in Schools

Many schools in California are working to increase sun protection practices by students, parents, teachers, and staff in an effort to reduce over-exposure to ultraviolet radiation and prevent skin cancer in the long term. A paper published recently in Preventive Medicine presents the results of a large randomized trial assessing an intervention designed to close a sun safety policy-practice gap in California elementary schools. The trial tested the hypothesis that schools with sun safety policies randomly assigned to receive the Sun Safe Schools intervention would implement more sun safety practices than schools in a minimal information control group.

Research collaborators from Claremont Graduate University, Klein Buendel, the Kaiser Permanente Center for Health Research, and Sun Safety for Kids, Inc. implemented the Sun Safe Schools program in 118 elementary schools from 40 California public school districts. Each school district had a school board-approved policy for sun safety (Board Policy 5141.7). The 20-month intervention was delivered to principals and included a coaching session, telephone and email contacts, resources for implementing sun protection practices, and a small grant program (for example, to purchase sunscreen for students).

The Sun Safe Schools intervention was effective at narrowing the sun safety policy-practice gap in participating California elementary schools. The program increased the total number of sun safety practices implemented by intervention schools compared to control schools. Also, more intervention schools’ sun safety practices reflected elements of district policy and sometimes went beyond the elements included in district policy. Detailed descriptions of the sample, measures, methods, analyses, outcomes, strengths, and limitations of the randomized controlled trial can be found in the Preventive Medicine publication.

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, Claremont Graduate University, and Dr. David Buller, Multiple Principal Investigators). Coauthors, in addition to Dr. Reynolds and Dr. Buller, include Kim Massie formerly from CGU; Dr. Jeff Ashley from Sun Safety for Kids in Los Angeles, California; Dr. Richard Meenan from the Kaiser Permanente Center for Health Research in Portland, Oregon; and Julia Berteletti and Mary Buller from Klein Buendel.