Launch of the PASS Project

Launch of the PASS Project

Dr. David Buller, Klein Buendel Director of Research, has launched a new sun safety research project for Kindergarten-6 schools and parents. The goal of this study (Parents and Schools for Sun Safety; PASS) is to establish the feasibility of a parent intervention that can be delivered by schools to instruct parents and students in sun protection and, ultimately, skin cancer prevention by establishing lifelong health habits.

Policy and instruction on sun protection in U.S. schools are recommended by the Centers for Disease Control and Prevention and Surgeon General to reduce students’ lifetime risk for skin cancer. With advocacy efforts from the American Society for Dermatologic Surgery Association, more than half of U.S. states (n=29) and the District of Columbia (DC) have passed laws on sun protection of children in public schools. In our past research on implementation of school sun safety policy, many school principals and teachers engaged in communication about sun safety with parents. Moreover, parents who reported receiving the sun safety messages from schools increased sun protection behavior for their children compared to parents who did not recall receiving these messages. However, there are few evidence-based parent-focused interventions available to schools to help themcomply with the state sun safety legislation.

This Phase I feasibility study will consist of a needs analysis and technology assessment by parents and staff in the 29 states and DC with sun safety legislation, production of a PASS prototype, and a pilot study evaluating the prototype’s feasibility. In the Parent Perspectives survey, 300 parents of children in grades Kindergarten-6 will complete the needs analysis by completing a survey on sun protection behaviors, skin type, barriers to sun protection, PASS content, and preferences for content delivery. In the technology assessment, 150 school staff (principals, teachers, and other staff) will complete the Barriers & Supports survey answering questions about communications and technology at school, competing priorities for implementation, and barriers to engaging with PASS.

A prototype of one module of the PASS program promoting sun safety in family outdoor activities outside of school will be produced, containing a video introduction, video parent testimonials, interactive activities, knowledge checks, and collaborative family activity. It will be tested with 40 parents of children in grades K-6 over four weeks. Parents will complete pretest and posttest surveys measuring students’ sun protection behavior, parents’ knowledge, self-efficacy, barriers, and motivation for child sun safety, and acceptability and usability of the prototype. Usage of the prototype will be recorded to assess parent engagement. A multidisciplinary Expert Advisory Board will review Phase I research protocols and the PASS prototype and advise on markers of PASS feasibility such as user accessibility; prototype acceptability, usability, and engagement; and evidence of collaborative family activity.

This research is sponsored by a Phase I SBIR grant from the Centers for Disease Control and Prevention (DP006971; Dr. David Buller, Principal Investigator). Dr. Buller’s collaborators include Mary Buller from Klein Buendel. The PASS prototype will be programmed by the Technology Team at Klein Buendel.

Launch of the Momentum+ Project

Launch of the Momentum+ Project

Dr. Kayla Nuss, Klein Buendel Scientist, has launched a new research project to develop and assess a prototype of the Momentum+ physical activity app for older cancer survivors. The app will leverage the staircase method, a progressive, incremental goal-setting framework, and is grounded in self-determination theory, which emphasizes autonomy, competence, and relatedness as essential drivers of sustained behavior change. 

In the United States, nearly 80% of cancer survivors are aged 60 or older. Older cancer survivors are at increased risk for cancer recurrence, co-morbidities, and reduced quality of life, in part due to insufficient physical activity and high levels of sedentary behavior. Despite strong evidence linking physical activity engagement and sedentary behavior reduction to improved health outcomes, few scalable, theory-driven mobile health solutions exist that are specifically designed for older cancer survivors.

An initial list of planned Momentum+ app components includes: integrated wearable activity tracker (Fitbit) data, progressive activity promotion plans, personalized activity prompts, weekly summaries and aggregated feedback, options for rest weeks to account for illness fatigue, or travel, exercise instructional videos appropriate for older cancer survivors, a caregiver/family member portal, and features optimized for older adults, including large fonts, and simple navigation.

A varied sample of 32 older cancer survivors (age 65 years and older) will review the app concept (interest in the app, desired components) in focus groups. Once 70% of focus group participants express a desire for the app, the research team will develop an interactive prototype of the mobile app. The prototype will be usability tested by 10 older cancer survivors to assess navigation, clarity, satisfaction, and functionality. The team will use a validated scale, the System Usability Scale, to collect quantitative data on prototype usability. 

The primary Phase I outcomes will include app acceptability, and prototype usability ratings, as well as qualitative feedback on design and content. Successful completion of Phase I will yield a user-informed, functionally tested prototype of Momentum+, ready for refinement, full development, and extensive testing against a commercially available physical activity app in a Phase II project. If proven effective in a future Phase II project, Momentum+ has the potential for broad dissemination as a scalable, evidence-based tool to promote physical activity, reduce sedentary behavior, and improve health outcomes in older cancer survivors.

This research is sponsored by a Phase I SBIR grant from the Centers for Disease Control and Prevention (DP006972; Dr. Kayla Nuss, Principal Investigator). Dr. Nuss’s collaborators include Dr. Dori Rosenberg from Kaiser Permanente and Dr. Heather Leach from Colorado State University. The Momentum+ app will be developed by the Klein Buendel Creative Team.

Body Neutrality Workbook to Increase Physical Activity

Body Neutrality Workbook to Increase Physical Activity

Dr. Kayla Nuss, Klein Buendel Scientist, and her research team have published the results of a pilot study on the use of a body neutrality workbook intervention to improve physical activity and motivation in insufficiently active women. The paper has been published online ahead of print in the American Journal of Lifestyle Medicine, a Sage publication.

Nearly half of adult women in the United States do not meet recommended levels of moderate-to-vigorous physical activity (MVPA), despite well-established health benefits. Sociocultural pressures emphasizing thinness and appearance may promote controlled, appearance-based motivation for physical activity, a motivational orientation that has been associated with less sustained engagement.

This pilot study examined whether a 6-week, self-guided body neutrality workbook intervention was associated with changes in MVPA and psychological mediators of physical activity among insufficiently active adult women. Body neutrality shifts attention away from physical appearance and toward body functionality, self-care, and self-worth independent of body size. The workbook uses daily exercises, journaling, and reflection prompts to foster self-acceptance. Instead of forcing body positivity or loving one’s appearance, the guide teaches the user to view their body as a neutral vessel focused on function and respect.

Twenty participants who did not meet physical activity guidelines at baseline completed pre- and post-intervention assessments of MVPA, motivation, basic psychological needs, body image constructs, and physical intentions and planning. Results indicated a moderate increase in MVPA. Improvements were also observed in autonomy, competence, intrinsic and integrated motivation, body functionality appreciation, body compassion, and physical intentions and planning, alongside reductions in introjected regulation and appearance-based social comparison.

The findings suggest that a body neutrality approach may support more autonomous motivation for physical activity. Although limited by small sample size and lack of a control group, this study provides preliminary evidence that body neutrality-based interventions may represent a promising, scalable strategy to promote both psychological well-being and physical activity engagement among adult women. Research significance, intervention methods, data collection and analysis, and conclusions are detailed in the American Journal of Lifestyle Medicine paper.

This research was sponsored by Klein Buendel and led by Dr. Kayla Nuss, in collaboration with Ms. Anne Poirier from Shaping Perspective LLC. Shaping Perspectives is a women’s wellness education and coaching company that specializes in body image, body neutrality, intuitive eating, and sustainable health behavior change. Ms. Poirier is a Certified Intuitive Eating Counselor, Eating Disorder Specialist, and author. She has authored three best-selling books and has three more publishing this year, including the second, expanded edition of her seminal work, The Body Joyful.  

An Observational Study of Alcohol and Cannabis Sales

An Observational Study of Alcohol and Cannabis Sales

Klein Buendel Senior Scientists, Drs. W. Gill Woodall and David Buller, presented recent research findings on sales of cannabis to intoxicated patrons at the 10th Annual Scientific Meeting of the Research Society on Marijuana in Albuquerque, New Mexico in July, 2026.

Adult-use recreational cannabis stores in Oregon had a low rate of compliance with a state law prohibiting sales to apparently intoxicated customers. This analysis explored two potential explanations for this low compliance: geographic distance between alcohol and cannabis premises as a proxy for the influence of the alcohol market and socioeconomic disadvantage of the neighborhoods.

Research assistants displaying behavioral signs of alcohol intoxication visited adult-use cannabis stores (n=189) and alcohol outlets for on-premises and off-premises consumption (n=91) in 2024 and 2026 in two large metropolitan areas in Oregon and attempted to purchase cannabis or alcohol (0=no sale; 1=sale). Effects of distance between pair-mates and Neighborhood Deprivation Index (NDI) were tested as predictors of correspondence in sales behavior (both sold or both refused) among pairs of cannabis stores and alcohol outlets using crossed random-intercept generalized linear mixed models.

Assessments were completed at 166 cannabis stores (n=16 closed stores and n=7 distance outliers were excluded) and 89 alcohol outlets (n=2 closed outlets excluded) (n=10,847 pairs). A majority of cannabis stores (77.1%) and off-premises alcohol outlets (63.4%) sold to pseudo-intoxicated buyers, while refusals were more frequent at on-premises (60.4%) than off-premises (36.6%) alcohol outlets. Proximity of cannabis stores and alcohol outlets was associated with more concordance in sales behavior between pairs of cannabis stores with off-premises and on-premises alcohol outlets. NDI had no effect on concordance in sales behavior.

The well-established alcohol market in Oregon may influence whether cannabis stores comply with state laws on responsible sales behavior, due to common regulators and enforcement actions and store owners and personnel with experience selling alcohol. Contacts and competition among alcohol and cannabis premises and neighborhood expectations also may influence cannabis store sales behavior.

This research was supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (AA031591; Drs. W. Gill Woodall and David Buller, MPI). Collaborating authors include Dr. Robert Saltz from the Pacific Institute for Research and Evaluation; Dr. James Fell from Fell Consulting; Dr. Ian Buller from DLH; Dr. Gary Cutter from the University of Alabama Birmingham; and Noah Chirico, Lila Martinez, and Amanda Brice from Klein Buendel.

Perceived Costs and Rewards of Sun Protection among High School Students

Perceived Costs and Rewards of Sun Protection among High School Students

Adolescents frequently engage in behaviors that increase ultraviolet radiation (UVR) exposure, elevating their lifetime risk for skin cancer. Project Shine examined cross-sectional associations between high school students’ perceptions of the costs of UVR protection, the rewards of tanning, and their engagement in UVR-protective behaviors to identify opportunities for intervention.

New findings from this study have been published in Cancer Epidemiology. Biomarkers, and Prevention, a journal of the American Association for Cancer Research. The project was led by Dr. Yelena Wu from the Huntsman Cancer Institute at the University of Utah. Dr. David Buller from Klein Buendel was a member of the multi-institutional team.

Data were analyzed from 2,105 students (46% male; 77% White; and 33.4% rural) at baseline who enrolled in the Sun-safe Habits Intervention and Education cluster-randomized trial conducted in Utah high schools from 2021 to 2023. Students completed self-reports of skin cancer prevention knowledge, time spent outdoors, perceived costs of UVR protection, perceived rewards of tanning, and UVR-protective behaviors. Analyses included bivariate tests and multivariable regression, adjusted for demographics and knowledge.

Methods, analyses, and findings are described in detail in the Cancer Epidemiology, Biomarkers, and Prevention publication. In summary, students who perceived higher costs of UVR protection and greater rewards of tanning engaged in fewer UVR-protective behaviors. In an adjusted model, lower sun-safe behavior was independently predicted by lower knowledge of UVR safety, higher perceived protection cost, and greater tanning reward. Perceived costs of UVR protection and appearance-based rewards of tanning are key attributes of adolescent UVR exposure.

The authors suggest that school-based skin cancer prevention should incorporate appearance-focused and tailored strategies (such as UV photography or photoaging feedback) to promote sustainable sun safety behaviors. Addressing both cognitive and motivational barriers to UVR protection during adolescence could strengthen early prevention efforts and reduce future skin cancer burden.

This research was supported by a grant from the National Cancer Institute (CA244674; Dr. Yelena Wu, Principal Investigator). Co-authors include Omar Anwar, Marcelo Sleiman, Jr., Muriel Statman, and Dr. Kenneth Tercyak from the Lombardi Comprehensive Cancer Center at Georgetown University; Dr. Tammy Stump, Dr. Jakob Jensen, Dr. Douglas Grossman, Dr. Jincheng Shen, and Dr. Benjamin Haaland from the Huntsman Cancer Institute at the University of Utah; Dr. Jennifer Hay from Memorial Sloan Kettering Cancer Center in New York; and Dr. David Buller from Klein Buendel. Support was also provided by Georgetown University, the University of Utah, and Memorial Sloan Kettering Cancer Center.

KB Research Presented at SBM

KB Research Presented at SBM

Klein Buendel researchers, Dr. Kayla Nuss and Ms. Julia Berteletti, and their collaborators presented two novel posters at the 47th Annual Meeting and Scientific Sessions of the Society of Behavioral Medicine (SBM) in Chicago, IL on April 22-25, 2026.  

*Klein Buendel authors are bolded.

POSTER 1 

Title: Applying Body Neutrality Principles to Physical Activity Promotion: A Pilot Test of the Body Neutrality Playbook 

Presenter: Dr. Kayla Nuss 

Collaborators: Anne Poirier, Amanda Brice, Sierra Held, Taylor Sullivan, Noah Chirico

This pilot study examined preliminary effects of the Body Neutrality Playbook on physical activity behavior, Self-determination Theory (SDT) motivation, and body image–related constructs in women insufficiently active at baseline. 

Body image concerns and weight stigma can undermine motivation for physical activity, particularly among women not meeting public health recommendations. The Body Neutrality Playbook is a six-week, self-guided workbook grounded in body neutrality principles, designed to promote sustainable physical activity by fostering autonomous motivation, self-compassion, and body appreciation while reducing harmful appearance-based cognitions. 

Twenty adult women completed the Body Neutrality Playbook over six weeks. Measures were collected at baseline and post-intervention, including self-reported weekly minutes of moderate-to-vigorous physical activity (MVPA), physical activity intention, physical activity planning, SDT-based motivation (intrinsic, integrated, identified, introjected, external), basic psychological needs satisfaction (competence, autonomy, relatedness), body functionality appreciation, body compassion (body kindness, motivated action, common humanity), internalized weight bias, and physical appearance comparison. Analyses examined mean change scores and Cohen’s d effect sizes to assess preliminary intervention impact. 

Post-intervention, participants demonstrated meaningful increases in MVPA minutes per week, physical activity intention, and physical activity planning. SDT outcomes showed increased competence and autonomy, decreased introjected regulation, and increased integrated regulation and intrinsic motivation. Body image–related outcomes indicated increases in body appreciation, decreases in physical appearance comparison, and improvements in two of three body compassion subscales (body kindness and motivated action). Effect sizes for these changes were in the small-to-large range, suggesting practical significance despite the small sample. 

Preliminary findings suggest the Body Neutrality Playbook may promote both autonomous physical activity motivation and positive body image while reducing appearance-based self-comparisons among women who are insufficiently active. The combination of body neutrality principles and SDT-informed behavior change strategies may address both psychological and behavioral barriers to physical activity. Future research with larger, more diverse samples and a controlled design is warranted to evaluate efficacy and mechanisms of change. 

This research was sponsored by Klein Buendel and led by Dr. Kayla Nuss. Anne Poirier is from Shaping Perspectives.

POSTER 2 

Title: Delivering online parent training program usage data in real-time: the iterative development of an administrative dashboard  

Presenter: Julia Berteletti 

Collaborators: Dr. Susie Breitenstein, Dr. Nathan Helsabeck, Dr. Kayla Herbell, Charlie Barger, Alishia Kinsey 

Julia Berteletti

Online parent training programs help strengthen parent-child relationships by providing parents with practical knowledge and evidence-based strategies for managing child behavior. In a hybrid parent training model, facilitators engage with parents while parents complete online modules. Administrative dashboards offer an integrated platform for program staff (administrators, facilitators, researchers) to track parent progress and activity in online parent training modules in real time. 

The research team iteratively developed and tested an administrative data delivery dashboard of the online ezParent Parent Training program. Using a single-group design with administrators and facilitators who deliver ezParent, 15 participants spent 30 minutes reviewing the ezDashboard and completed a survey about their experience. The survey included the validated 10-item System Usability Scale (SUS) and open-ended questions focusing on navigation ease and overall usefulness of the ezDashboard. Following the usability testing, we made additional refinements (adding exportable reports) to the dashboard. Based on feedback from an Expert Advisory Board (EAB) made of experts in community programming and parent training delivery, we also created a new metric, the Engagement Index, to measure and summarize parent participation within modules to provide facilitators with insights into how parents used the program. The EAB reviewed the revised dashboard and completed the SUS survey. Final refinements have been completed. 

In the initial usability testing, participants indicated high usability of the ezDashboard with a total mean SUS score of 83.5. Most participants (n=13, 87%) rated the overall user-friendliness of the ezDashboard as good (n=3, 20%), excellent (n=9, 60%), or best imaginable (n=1, 7%).  Open-ended questions showed the ezDashboard is or would be useful to monitor parent progress and trends in engagement (n=8, 53%). To facilitate that, we created the Engagement Index (0-100% per module) to assist facilitators’ understanding of how parents interact with ezParent. After revisions, the EAB rated the ezDashboard as 83.6. 

Results from iterative testing indicate that the ezDashboard is easy to use and provides functional information to those delivering ezParent.  Next, the ezDashboard will be used in a randomized controlled trial testing hybrid delivery of ezParent. The usefulness of the Engagement Index as a more robust measure of program use will be assessed.  

This STTR grant was awarded to Klein Buendel by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (HD116627; Dr. Susan Breitenstein, Principal Investigator from Ohio State University). Research collaborators include Julia Berteletti from Klein Buendel, and Dr. Amie Bettencourt and Dr. Deborah Gross from Johns Hopkins University.

The ezParent technology was designed and programmed by the Creative Team at Klein Buendel. 

Cancer Prevention Research Presented at ASPO

Cancer Prevention Research Presented at ASPO

Klein Buendel investigators and their collaborators presented research from two large studies at the 50th Annual Meeting of the American Society of Preventive Oncology on April 12-14 in Denver, Colorado. The theme of the conference was “50 Years of Impact: Empowering Communities Through Cancer Prevention Research.” 

*Klein Buendel authors are bolded.

ORAL PRESENTATION 1

Title: A Confederate Study of Indoor Tanning Facility Compliance with Laws

Presenter: Dr. Carolyn Heckman

Co-authors: Anna Mitarotondo, Melissa Goldstein, Rucha Janodia, Ileana Gonzalez, Dr. David Buller, Julia Berteletti

  • This submission was designated as a Best of ASPO Abstract.

Because indoor tanning is a known cause of skin cancer, state laws and federal regulations restricting indoor tanning for minors have been implemented: 22 states and the District of Columbia (DC) ban minors under age 18 from indoor tanning, 22 states have other age and parental involvement restrictions, and 6 states have no restrictions on minor access to indoor tanning. The assessed indoor tanning facility law compliance, hypothesized to be insufficient and inconsistent.

Trained and supervised pseudo-patrons called randomly selected indoor tanning facilities (indoor tanning salons, beauty salons/spas, gyms, apartment buildings) in 50 states and DC, posing as minors one year younger than the state’s permitted age to indoor tan (age 17 in states banning indoor tanning under 18) or age 16 in states with no age restriction. Using a semi-structured script, pseudo-patrons asked about scheduling an indoor tanning session, unlimited indoor tanning (contrary to FDA guidelines), risk of skin burns, and parental involvement requirements. Responses were coded, with discrepancies resolved by consensus, and summarized descriptively.

A total of 504 calls were completed to 206 indoor tanning salons, 111 gyms, 101 spas/beauty salons, and 86 apartment buildings. Overall, 55% of facilities would allow pseudo-patrons to book an appointment or “walk in” for indoor tanning, despite being underage, compared to 32% in states with under-18 bans. In states with minor restrictions, indoor tanning salons were least likely (48%) to permit minor indoor tanning and gyms, most likely to do so (56%). Twenty-six percent (26%) of staff did not ask pseudo-patrons their age, irrespective of law type. Forty-four percent (44%) of gyms/apartments did not require membership/tenancy to indoor tan. Most facilities (92%) offered unlimited indoor tanning packages or unlimited access to tanning beds when open. Only 52% of facility staff acknowledged that pseudo-patrons’ skin could be burned, when asked.

Although many states have laws restricting indoor tanning by minors, indoor tanning facilities were commonly non-compliant with age restrictions, suggesting inadequate law awareness and/or enforcement. Strategies must be identified to implement indoor tanning laws effectively and realize their benefits, including preventing skin burns, skin cancer, and other health consequences. Ongoing analyses are evaluating compliance when scheduling appointments online and by additional law provisions, state demographics, and U.S. region.

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 1 

Title: Correlates of Human Papillomavirus Vaccination Among a Sample of Emerging Adults Aged 18-26 Living in Rural Locations in the Western United States

Presenter: Dr. David Buller

Co-authors:  Dr. Deanna Kepka, Dr. Echo Warner, Dr. Evelinn Borrayo, Dr. Andrew Sussman, Alishia Kinsey, Dr. W. Gill Woodall, Dr. David Buller

Dr. Borrayo, Dr. Buller and Dr. Warner

Human Papillomavirus (HPV) vaccination status and correlates were examined in a sample of emerging adults living in rural locations in the western United States. Eight hundred and ten (n=810) emerging adults residing in rural areas in 17 western U.S. states were recruited from online survey panels or by social media advertising from August 2024-2025 for a randomized trial. Emerging adults reported at baseline their HPV vaccine uptake status, including number of doses received. Using logistic regression analysis, we tested the association of demographics, attitudes, health care, and social media use with HPV vaccine uptake status (0=no/don’t know; 1=vaccinated) and vaccine doses received (0=0 or 1 dose/don’t know; 1=2 or 3 doses).

Overall, 424 (52.3%) rural emerging adults reported being vaccinated for HPV and 184 (22.7%) not being vaccinated, and 202 (24.9%) did not know. Of the 424 emerging adults vaccinated, 41 emerging adults (9.7%) recalled receiving one dose, 88 (20.7%) two doses, and 101 (23.8%) three doses of the vaccine, but 194 emerging adults (45.8%) did not know. More rural emerging adults who were vaccinated were female, more educated, attended religious services less frequently, had a personal/family history of cancer, were more confident vaccines are safe, and had less constraints on getting vaccinated. More rural emerging adults with multiple vaccine doses were older, female, visited a physician for a routine health check-up more recently, were more confident that vaccines are safe, and had less constraints on getting vaccinated.

Uptake of HPV vaccination among rural emerging adults (52.3%) was slightly higher than the national rate in the 2022 National Health Interview Survey (47.4%). Emerging adults need advice on how to confirm vaccination status (such as checking with parent, physician, or vaccine registry) when promoting catch-up HPV vaccination. HPV vaccination interventions should educate on vaccine safety/ constraints, how it can reduce personal/family cancer concerns, and religious groups that support it. Medical providers should offer HPV vaccination to emerging adults during routine health check-ups. Male and less educated emerging adults would benefit from intervention.

This research from the #4Corners4Health study was supported by a grant to Klein Buendel from the National Cancer Institute (CA268037; Dr. David Buller and Dr. Andrew Sussman, Multiple Principal Investigators). Other collaborators are from the University of Arizona, the University of Colorado, the University of Utah, and Colorado State University.

POSTER 2 

Title: Associations Between Food Insecurity and Dietary Intake and Nicotine Use Among Rural Emerging Adults in the Western United States

Presenter: Dr. Megan Skiba

Co-authors:  Dr. Doug Taren, Dr. Dolores Guest, Dr. Kim Henry, Dr. Judith Gordon, Noah Chirico, Dr. Echo Warner, Alishia Kinsey, Angela Jung, Dr. Andrew Sussman, Dr. David Buller

Dr. Skiba

The purpose of the study was to evaluate the associations between food insecurity, dietary intake, and tobacco/nicotine use among emerging adults aged 18-26 years living in rural areas of the western United States. 

This analysis used baseline data from 810 rural emerging adults participating in a randomized trial evaluating a social media-delivered cancer prevention intervention. Emerging adults completed self-report surveys assessing demographics, dietary intake (NCI Dietary Screener Questionnaire), and any nicotine product use (yes/no) in the past 30 days. Dietary measures included predicted intake of fruit and vegetable (servings/day), fiber (g/day), added sugar from sugar sweetened beverages (tsp/day), and red/processed meat (frequency/week). Food insecurity was categorized as very low food secure, low food secure, and high food secure from a single item measuring worry about running out of food before having money to buy more. Associations between food insecurity and dietary intake or tobacco/nicotine use were examined using linear or logistic regression models, adjusting for significant demographic covariates. Linear trend tests assessed graded relationships across food insecurity levels.

Of emerging adults (mean age 22.7 years), 62% reported low or very low food security. Food insecurity was associated with race, sex, education, and employment and were used as model covariates. A positive linear trend was observed between food insecurity and added sugar from sugar sweetened beverages, with very low food secure emerging adults consuming an average of 13.0 tsp/day from sugar sweetened beverages. There were no significant associations between food insecurity and fruit and vegetable, fiber, or red/processed meat intake, although fruit and vegetable and fiber intake were low overall (2.3 ± 0.6 servings/day and 15.1 ± 3.4 g/day, respectively). Percent of emerging adults using nicotine was greater with increasing levels of food insecurity: 24% among those with high food security, 41% among those with low food security, and 53% among those with very low food security. Odds increased 2.5 times for each stepwise increase in food insecurity.

Experiencing food insecurity may be a determinant of cancer-preventive health behaviors in rural emerging adults. Very low food security may be an important target for interventions aimed at improving multiple cancer preventive health behaviors among rural emerging adults.

This research from the #4Corners4Health study was supported by a grant to Klein Buendel from the National Cancer Institute (CA268037; Dr. David Buller and Dr. Andrew Sussman, Multiple Principal Investigators). Other collaborators are from the University of Arizona, the University of Colorado, the University of Utah, and Colorado State University.

Noncompliance with laws to prevent polysubstance misuse

Noncompliance with laws to prevent polysubstance misuse

The effectiveness of statutes to combat hazardous polysubstance use (for example, alcohol and cannabis together) has rarely been evaluated. A multi-institutional team led by Klein Buendel researchers assessed compliance with a state law prohibiting recreational cannabis sales to apparently intoxicated customers in one of the first states to legalize cannabis sales. The assessment has been published in Alcohol: Clinical and Experimental Research.

In January to June 2024, pseudo-patrons visited 189 recreational cannabis stores twice in two large metropolitan areas and attempted to purchase cannabis while displaying alcohol intoxication behaviors. Observers recorded whether sellers were willing to sell the product along with characteristics of the stores (busyness, cleanliness, and signage) and cannabis sellers (sex, race and ethnicity, and age). Neighborhood characteristics by U.S. census tract were obtained (income, race, and ethnicity; population density). Sex and race and ethnicity of the pseudo-patrons, and extent and type of intoxication cues, were recorded. Descriptive statistics and logistic regression were used to describe the sales rate and predictors of the sales rate.

Assessments were completed at 173 stores. Sellers were willing to sell cannabis to pseudo-intoxicated buyers at 255 of 346 visits (73.7%). Sellers refused buyers at both visits in 6.9% of stores but in 54.3% were willing to sell at both visits. Sellers refused cannabis sales at higher rates in stores with signs saying, “no sales to intoxicated customers” (34.3%), particularly when buyers displayed more obvious signs of intoxication (39.8%).

Low compliance with the state regulation possibly occurred because sellers were unaware of the law, perceived little deterrence by the law, or lacked the skills to recognize and refuse intoxicated customers. Noncompliance with the law on selling cannabis to apparently alcohol-intoxicated customers increases the risks of polysubstance impairment and harm.

This research is supported by a grant from the National Institute on Alcohol Abuse and Alcoholism (AA031591; Dr. W. Gill Woodall and Dr. David Buller, Multiple Principal Investigators). Additional collaborating authors include Dr. Robert Saltz from the Pacific Institute for Research and Evaluation; Dr. James Fell from Fell Consulting; Dr. Gary Cutter from the University of Alabama; and Lila Martinez, Amanda Brice, and Noah Chirico from Klein Buendel.

Development of an Online Cancer Prevention Intervention for Rural Emerging Adults

Development of an Online Cancer Prevention Intervention for Rural Emerging Adults

A multi-state research team from Arizona, Colorado, New Mexico, and Utah has published research on a rural health intervention in the Journal of Medical Internet Research. The study developed and pilot tested a theory-based intervention via the web to reduce six cancer risk factors among rural emerging adults through community-engaged research.

The rapid growth of user-generated web-based health information increases the complexity of cancer information seeking. One promising strategy for promoting high-quality cancer information consumption is through targeted interventions that are intentionally designed to reach individuals in the online spaces they occupy. However, there is a paucity of evidence-based information on the best strategies for designing and implementing web-based health behavior change interventions to improve individuals’ cancer-related knowledge and prevent cancer.

This mixed methods approach describes the development of an online cancer prevention intervention aimed at rural emerging adults aged 18-26 years in the United States and delivered in Facebook private groups. The intervention was guided by behavior change theory and co-created with young adults and Stakeholder Organization Advisory Boards to ensure relevance, accessibility, and appropriateness. The paper reported on three formative surveys, a pilot intervention, protocol development, and the community-engaged process for intervention development.

The authors developed 400 posts for a Facebook feed aimed at reducing six cancer risk behaviors (unhealthy diet, lack of physical activity, tobacco use, alcohol use, sun exposure, and human papillomavirus infection) with iterative input from the emerging adults and stakeholder advisory boards. Formative surveys with rural 297 emerging adults and a pilot study of the intervention with this 26 people from this population were conducted. In the pilot study, the intervention reached a sample of participants across several rural counties, with sustained engagement over a one-month period. Key modifications to the intervention content and design emerged from both advisory boards, the formative surveys, and the pilot intervention, focusing on using perceived reliable sources and direct links to source material.

The authors concluded that this web-based cancer prevention intervention is scalable and delivers engaging, evidence-informed health information to rural emerging adults. They offered key insights into the design and implementation of web-based cancer prevention interventions for emerging adults by describing the resources, timelines, and expertise needed to design and implement the intervention. Considerations for fully engaging young people and community stakeholder partners are presented, and how their involvement resulted in modifications that strengthened the intervention was discussed. Finally, the authors highlighted the importance of theory-based health-behavior messaging, digital messaging skillsets, and platform-tailored dissemination strategies for maximizing web-based intervention acceptability.

The research is supported by a grant from the National Cancer Institute (CA268037; Dr. David Buller and Dr. Andrew Sussman, Multiple Principal Investigators). Dr. Buller is the Director of Research at Klein Buendel. 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. The lead author of the Journal of Medical Internet Research paper is Dr. Echo Warner from the College of Nursing and the Huntsman Cancer Institute at the University of Utah.

2025 Research Highlights

2025 Research Highlights

In 2025, Klein Buendel scientists and staff pursued rigorous behavioral science research with numerous national collaborators. Our Creative Team designed and engineered multiple web-based programs to positively impact the health and safety of people’s everyday lives. Our Research Team started three new research projects with current and new collaborators. We published 17 research papers in peer-reviewed journals, including the American Journal of Public Health, and our research was presented at four national conferences.

In February, Dr. David Buller was an invited presenter at the Policy-based Research Workshop sponsored by New York University. His presentation was entitled “Research on Implementation of Alcohol and Cannabis Sales Policies.”

In April, the Creative Team’s development of the electronic version of the STAC bystander anti-bullying intervention for middle school students was illuminated in a life-size digital graphic LUMINARY presentation of the STAC-T Program at Boise State University.

Projects Launched in 2025

  1. “No Weigh Body Neutrality.” A Phase I SBIR award from the Eunice Kennedy Shriver National Institute of Child Health and Human Development (DK142209; Dr. Kayla Nuss, Principal Investigator, Klein Buendel). 
  2. The Phase II Project of “Hybrid Delivery to Increase Access and Sustainability: Evaluating ezParent Implementation.” A Fast Track STTR grant to Klein Buendel from the National Institute (HD116627; Dr. Susan Breitenstein, Principal Investigator, Ohio State University). The primary Co-Investigator from Klein Buendel is Ms. Julia Berteletti.
  3. An Administrative Supplement was awarded to “Policy and training intervention in responsible marijuana sales practices to reduce the risk of selling to intoxicated customers.” A 5-year R01 grant from the National Institute on Alcohol Abuse and Alcoholism (AA031591; Dr. W. Gill Woodall and Dr. David Buller, Multiple Principal Investigators). 

For these new projects, we are collaborating with: 

  • Dr. Anne Poirier, a nationally recognized body image expert and the author of The Body Joyful and Not a Fat Annie; and
  • Dr. Susan Breitenstein from Ohio State University; and
  • Dr. Robert Saltz from the Prevention Research Center at the Pacific Institute for Research and Evaluation.

2025 Publications*

  1. McCrady BS, Woodall WG, Berteletti J, Starling R, Martinez L, Westerberg V, Brooks M, Starke T. Developing a smartphone web app to help DWI offenders and their families. J Subst Use Addict Treat. 2025 Jan:168:209565. doi: 10.1016/j.josat.2024.209565.
  2. Heckman CJ, Mitarotondo A, Buller D, Berteletti J, Schroth KRJ, Stapleton JL, Dellavalle RP, Balk SJ, Hudson SV. Analysis of facilitators of and barriers to enactment of state regulation of indoor tanning by minors, Transl Behav Med. 2025 Jan 16;15(1):ibaf044. doi: 10.1093/ tbm/ ibaf044.
  3. Nuss K, Jones ED, Brice AN, Udovich CC, Fullmer SE, Freeberg KA, McCarty NP, Seals DR, Craighead DH. Feasibility and design of a novel smartphone app to deliver blood pressure-lowering high-resistance inspiratory muscle strength training. Mhealth. 2025 Jan;11:6. doi:10.21037/mhealth-24-33.
  4. Buller DB, Berteletti J, Heckman C, Schroth KRJ, Gellar AC, Stapleton JL, Adjei A, Mitarotondo Am Guild SR, Gershenwald JE, Dellavalle D, Pagoto S. Bills to restrict access to and harm from indoor tanning facilities in US state legislatures, 1992‒2023. Am J Public Health. 2025 Feb;115(2):191-200. doi:10.2105/AJPH. 2024. 307894.
  5. Nuss K, Berteletti J, Walkosz B, Adjei I, Small A, Beltran LS, Chirico N, Poirier A, Arigo D. What is in a hashtag? A comparative content analysis of fitspiration, body positivity, and body neutrality posts on Instagram. Psychol Pop Media. 2025 Feb;14(4):560-571. doi: 10.1037/ppm0000585. 
  6. Midgett A, Doumas DM, Peralta C, Peck M, Reilly B, Buller MK. Usability testing of a bystander bullying intervention for rural middle schools: Mixed methods study. JMIR Hum Factors. 2025 Feb;12: e67962. doi: 10.2196/67962. 
  7. Salafia C, Banerjee S, Hamilton JG, Schofield E, Yuelin L, Buller DB, Hunley K, Sussman AL, Guest DD, Kaphingst KA, Berwick M, Hay JL. Salafia C, Banerjee S, Hamilton JG, et al. Prospective changes in primary care patients’ family communication after skin cancer genetic test offer. PEC Innov. 2025 Jun;7:100409. doi:10.1016/j.pecinn.2025.100409.
  8. Nuss K, Brice A, Hebert C, Nauta P, Stull AJ, Swift DL, Griffith DM, Buller DB, Newton RL Jr. A culturally tailored mHealth intervention (MobileMen app) to promote physical activity in African American men: Protocol for a comparative effectiveness trial. JMIR Res Protoc. 2025 Jul;14:e67809. doi:10.2196/67809.
  9. Meenan R, Buller DB, Berteletti J, Henry KL, Buller MK, Cutter GR, Pagoto S, Adjei I, Chirico N. Economic evaluation of two scalability strategies for nationwide dissemination of an occupational sun safety intervention in a randomized trial. J Occup Environ Med. 2025; 67(7):498-506. doi: 10.1097/JOM.0000000000003390.
  10. Buller DB, Kinsey A, Sullivan T, Gruetter P, Morrisey-Basler MC, Buller ID, Heckman CJ. Descriptive analysis of municipal policies addressing shade in eight southwest and northeast states in the United States. Front Public Health. 2025 Jul 14:13:1565251. doi: 10.3389/fpubh.2025.1565251.  eCollection 2025. PMCID: PMC12302959.
  11. Brice AN, Fullmer S, Barger C, Serbinski J, Gallik M, Nauta P, Swift DL, Stull AJ, Buller DB, Griffith DM, Nuss K, Newton RL Jr. MobileMen: the development of a mobile application to promote physical activity in African American men. Mhealth. 2025 Jul 14;11:32. doi: 10.21037/mhealth-24-82. eCollection 2025. 
  12. Manne SL, Kashy DA, Pagoto S, Peterson SK, Heckman CJ, Gallo J, Berger A, Buller DB, Kulik A, Frederick S, Pesanelli M. Engagement in and correlates of total cutaneous exams and skin self-exams among young melanoma survivors and their family. J Behav Med. 2025 Oct;48(5):834-847. doi:10.1007/s10865-025-00589-4. 
  13. Woodall WG, Buller DB, Zimet G, Kong AS, Reither J, Chilton L, Martinez L, Brooks M, Chirico N, Ginossar T. TeenVac.org: A mobile web app to improve human papillomavirus vaccine uptake for adolescent boys. J Adolesc Health. 2025 Oct;77(4):749-755. doi: 10.1016/j.jadohealth.2025.06.015. 
  14. Doumas DM., Midgett A, Hausheer R, Winburn A, Buller M, Perron T, Shelton J, Herbeck B. Acceptability, relevance, and short-term outcomes of the STAC-T bullying bystander app: Feasibility quantitative study. JMIR Form Res. 2025 Nov 18:9:e76830. doi: 10.2196/76830. 
  15. Saltz R, Paschall MJ, O’Hara S, Buller DB, Woodall WG, Martinez L. Mandatory responsible beverage service training in California associated with higher refusals of service to apparently intoxicated patrons. J Stud Alcohol Drugs. 2025 Nov:10.15288/jsad.25-00161. doi: 10.15288/jsad. 25-00161.
  16. Woodall WG, McCrady BS, Westerberg V, Berteletti J, Martinez L, Brooks M, Starke T, Chirico N. Randomized trial shows smartphone support app for DWI offenders and their families reduced alcohol use and ignition interlock device lockouts. J Stud Alcohol Drugs. 2025 Dec. doi:10.15288/ jsad.25-00171. Online ahead of print. 
  17. Buller DB, Adjei I, Agarwal R, Peterson SR, Escoffery C, Buller MK, Walkosz BJ, Anderson K, Morshed A. Systematic review and narrative synthesis of behavioral interventions to improve heat-related illness prevention in community and occupational populations. BMC Pub Health. 2025 Dec. https://doi.org/10.1186/s12889-025-25499-7. 

*KB investigators and staff are indicated in bold type  

2025 Conference Presentations 

Multiple presentations on research progress, procedures, analyses, and outcomes were given by Klein  Buendel scientists, staff, and their collaborators at the following national conferences: 

  • 46th Annual Meeting of the Society of Behavioral Medicine (March) 
  • 48th Annual Scientific Meeting of the Research Society on Alcohol (June) 
  • Gerontological Society of America Annual Scientific Meeting (November) 
  • 18th Annual Conference of the Science of Dissemination and Implementation in Health (December)