Preliminary Effects of a Rural Skin Cancer Prevention Intervention for Youths

Abstract

Objectives:

To pilot and assess the feasibility, acceptability and preliminary effects of the Rural Adult and Youth Sun Protection (RAYS) program, a multilevel skin cancer preventive intervention for young children living in rural US communities, delivered through community-organized team sports.

Methods:

Three rural counties in Utah participated with two receiving the intervention and the third serving as a control. Youth sports leagues were recruited through recreation departments and the study took place from May through October 2021. Intervention leagues received sun protection supplies for players and coaches, educational materials for parents, and coaches were offered training on skin cancer and sun protection behaviors.

Results:

The RAYS program is both feasible to deliver and acceptable to coaches, parents and players. The intervention also demonstrates beneficial preliminary effects on components of observed child sun protective behaviors, coach sun protection behaviors, knowledge of skin cancer prevention recommendations and self-efficacy in skin cancer prevention.

Conclusions:

Multilevel interventions for skin cancer prevention among young children can be successfully delivered through community organizations and their settings. A priority moving forward is the identification of ways to optimize delivery of such programs to positively influence skin cancer preventive behaviors among children living in diverse rural areas.

Skin cancer is the most commonly diagnosed form of cancer and it disproportionately affects residents of rural areas of the United States (Blake et al., 2017; Centers for Disease Control and Prevention, 2017). Although the causes of this health disparity remain elusive, differences in sun protection practices and cancer risk behaviors, outdoor occupations and recreational patterns, and access to healthcare and prevention education are all contributors (Bowles et al., 2021; Cunningham et al., 2019; Wu et al., 2022). Skin cancer primary prevention programming should focus on youth because childhood ultraviolet radiation (UVR) exposure (and resulting sunburns) is the strongest modifiable risk factor for melanoma: outdoor leisure activities in childhood (e.g., playground time, recreational sports participation) co-occur with harmful UVR (Balk, 2011; Wu et al., 2022). For some children residing in rural communities, their chances of developing skin cancer are often greater than those in urban areas because of lower usage of certain forms of sun protection, and higher participation in outdoor recreation (Nagelhout et al., 2021; Wu et al., 2022). Programmatic behavioral modifications include, wearing protective clothing and sunscreen, seeking shade, avoiding being outdoors during peak UVR hours (10 am – 4 pm) and avoiding tanning.

Consistent with national guidelines recommending that cancer prevention efforts in rural areas should address multilevel contributors to increased cancer risks (Zahnd et al., 2019), skin cancer prevention programs for youth in these rural communities could benefit from more engaged methodologies that incorporate multiple stakeholder perspectives and build upon civic strengths, with ample opportunities for ecological shifts that improve cancer preventive behaviors (Cacari Stone et al., 2021). Recreational sports are a common focal point of rural community life, and developmental sports programs offer children opportunities for physical activity and structured interactions (Kellstedt et al., 2021). At the same time, they often co-occur with high UVR exposures and therefore UVR exposure should be mitigated by preventive strategies (Mahé et al., 2011; Melville et al., 1991).

It is essential to help support the early adoption of sun protection behaviors among young children (e.g., ages 3–7) because, in their developmental stage, they are unable to independently implement such behaviors on their own, and rely heavily on adults to teach them why and how to do so effectively (Thoonen et al., 2019). Young children are strongly influenced by adult guidance and behavioral modeling, yet often lack school-based skin cancer prevention programming. Further, improving sun protection behaviors early in life could establish healthy habits that carry into later life, including those in the context of sun safety during leisure activities and outdoor occupations, and ultimately positively impact community norms. However, existing recommendations from the Centers for Disease Control and Prevention for skin cancer preventive efforts do not address the sun safety needs for young children (ages 3–7) participating in sports, like those in rural settings (The Community Guide, 2022). To our knowledge, no interventions have delivered skin cancer messaging through youth sports teams in rural areas in a comprehensive, evidence-based, and multilevel manner (Zahnd et al., 2019).

In responding to these needs, we developed the “Rural Adult and Youth Sun” (RAYS) protection program, using a community-participatory approach whereby we solicited feedback from community stakeholders when designing RAYS and considering how it could impact sports-related policies (Israel et al., 2010; Sanders Thompson et al., 2021). RAYS is grounded in the Behavioral Ecological Model (BEM; Hovell et al., 2009). The BEM integrates behavior change strategies, such as shaping and conditioning, with environmental adaptations to promote desired actions. RAYS is a multilevel and multimodal skin cancer preventive intervention for young children living in rural US communities and is delivered through community-organized team sports. Guided by the BEM, RAYS promotes recommended sun safety strategies and adaptations at the individual, social, and environmental levels. In addition, components of RAYS target conditioning of the child’s and coaches’ sun safety behaviors and shaping of sun safety behaviors over time; coach and parent knowledge, self-efficacy for using sun protection, modeling of sun safety behaviors, and facilitating child sun safety behaviors through specific instruction, direct aide to children in implementing sun safety behaviors, and reinforcement of child sun protection behaviors; and, league and community level reinforcement of sun safety behaviors. We piloted RAYS in two rural counties in a Western region of the US with high melanoma burden (Doherty et al., 2018). This community-based trial documents a participatory and engaged approach to developing RAYS. It presents the program’s feasibility, acceptability, and preliminary effects on child sun protection behaviors. Additionally, it identifies change agents influencing coach behaviors, such as coaches’ knowledge and self-efficacy for supporting young players’ sun safety, and highlights barriers and facilitators to the program’s use to inform future scale-up. We hypothesized that RAYS would improve coach and child sun safety behaviors, as well as coach knowledge and self-efficacy for supporting players’ sun safety.

Methods

Setting and Intervention Planning and Development

For this project, rurality was defined using the Rural Urban Commuting Area (RUCA) coding system whereby census-tract based population estimates and work commuting information is utilized to assign census tracts and zip codes to a code to classify an area as urban or rural (2010 Census Urban and Rural Classification and Urban Area Criteria, 2012). Areas with a RUCA code of 4–10 are considered rural. Three rural counties in Utah were selected for inclusion based on similarity in geographic and sociodemographic characteristics (i.e., RUCA code, percent in poverty, percent of population from racial/ethnic minority populations). Utah has the highest incidence of melanoma in the US and reflecting national trends, melanoma incidence is higher among rural areas relative to urban areas (Blake et al., 2017; Bowles et al., 2021; Doherty et al., 2018).

Guided by a community-participatory research approach to influencing health-related policies (Israel et al., 2010; Sanders Thompson et al., 2021), recruitment for the RAYS program began in Spring 2021 (March/April). The research team approached community leaders and other residents in the rural areas by building on past collaborations with similarly situated communities in Utah. Several introductions were facilitated by the Community Outreach team from Huntsman Cancer Institute, located in Utah, which serves a largely rural catchment area including the 5 Mountain West states. Initial discussions with community members centered on their access to cancer prevention resources, including for skin cancer prevention, and on desirable settings through which to deliver skin cancer prevention programming for youth. Community-organized youth sports leagues emerged as a key context for which neighborhood members came together (e.g., to watch and support youth baseball practices and games), and as a popular extracurricular and physical activity for children living in rural areas.

Researchers subsequently contacted local recreation departments and other community-based sports leagues in the rural areas of interest to understand the types of sports programming they provided, existing sun safety policies or resources, and to discuss their potential willingness in partnering on developing and implementing a sun safety program delivered through and to their teams (coaches, players, and parents/caregivers). Sports directors and coordinators within the recreation departments and organizations reported not having existing sun safety policies or any resources to address young children’s sun safety (e.g., sun safety supplies and materials for educating coaches, players, parents, and the broader community about sun safety) and expressed interest in collaborating on designing and implementing a sun safety program and integrating it within their programs.

Based on this feedback from recreation departments, the research team outlined, presented, and iteratively developed RAYS as a multilevel intervention that provided behavioral supports and change strategies to promote youth sun safety at the player (child), coach, parent, and community levels. RAYS is grounded in the Behavioral Ecological Model (BEM; Hovell et al., 2009), which posits that preventive health behavior interventions for children should incorporate multilevel components that target health behaviors (e.g., sun protection behaviors) within their daily environments (i.e., sports), and should be done by leveraging existing influences on their behaviors (i.e., sports coaches, parents, opportunity to use sun safety supplies). Unlike other models of behavior change, the purpose of the BEM does not rely on intra-individual mechanisms of change (e.g., motivation or knowledge). Rather, the BEM emphasizes that change agents are strategically placed outside of persons, and especially through health-promoting modification at the environmental and policy levels. In that way, the power of the BEM and its application to the current trial rests in its foundation of restructuring treatment length (e.g., throughout the naturally-occurring sports season), contingent consequences (e.g., UVR exposure with or without painful sunburn, but contributing to cumulative cancer risk), and operant behavioral principles such as reinforcement (e.g., coach praise of players’ use of sun protection strategies). Toward that end, RAYS includes player-, team-, community-, and policy-level components and was delivered in steps across the teams and counties.

The first step was provision of individual and environmental sun safety supplies for players and coaches to be used during sports practices and games, including sun safe uniforms (e.g., athletic long-sleeved shirts for the sports uniform, broader-brimmed hat, sunglasses), sunscreen dispenser pumps available for player and coach use, and other modifications such as portable shade structures for use when not on the field. In the second step, the research team provided coaches with written educational materials on skin cancer, prevention methods, importance of reinforcing sun safety with players, and specific strategies (i.e. encouraging parents to pack sun protection supplies in player’s bags, modeling sun protective behavior for team, allowing breaks for sunscreen reapplication, encouraging use of provided shade structures) for encouraging sun safety amongst their players during practices or games, and praise/reward statements to promote adherence. A one-time, phone or video telehealth information session with a research educator was held with coaches to review information and answer any questions they may have had about the program. Coaches were provided with skin cancer prevention print materials to provide to parents that summarized the same information coaches received. On the community level, recreation departments were provided with large banners reminding community members to engage in sun safety which were to be placed at the sporting fields for the duration of the sun safety program. Regarding policy, as part of the RAYS program, teams and leagues were encouraged to adopt sun safe policies and practices (e.g., allowing time for players to apply sunscreen, making shade structures provided by the RAYS program available to coaches and teams), and were given expert guidance that was consistent with CDC recommendations for UVR exposure mitigation and prevention. The RAYS pilot program was implemented during the summer and fall sports seasons, which concluded at the end of October 2021.

Participants and Procedures

Of the three communities available for this trial, one was chosen to serve as the control and two were chosen to receive the RAYS intervention (non-randomized). Control and intervention counties were matched on state-level characteristics such as proportion in poverty and percent ethnic minority. The teams in the control county were observed for sun protection behaviors among players and coaches and did not receive any component of the intervention or participate in the coach survey. Under our CBPR approach, directors of the recreation departments and sports programs in the intervention counties provided information about RAYS to the sports team coaches via flyers, during sports season preparation meetings, and electronically via email or text message. The research team followed up with coaches via text message and phone to share information about RAYS and to invite them to participate. In total, 40 youth sports teams (t-ball, coach pitch, flag football) from the 3 counties participated in the current study. All teams were coached by volunteer coaches (e.g., parents of players), were co-ed, and players ranged in age from 3–10 years old. Research assistants directly observed player and coach sun protection behaviors at the games or practices at the beginning and end of the season (pre- and post-intervention). Players’ behaviors were later aggregated at the team level for analysis. Coaches were asked to complete an electronic survey pre- and post-intervention and were invited to complete an in-depth interview with the research team post-intervention. A consent cover letter was included at the beginning of the pre-intervention electronic survey. All study procedures were approved by the relevant Institutional Review Board.

Measures

Directly-observed sun protection and facilitation behaviors at the team level.

All teams in the control and intervention counties were observed at the beginning and end of the sports season (2-month timespan) for coach and player sun protection behaviors, as well as for coach behaviors and environmental factors that could facilitate player sun protection use. Observations were conducted by trained bachelor’s-level research assistants who were not blinded to condition. Training consisted of an orientation to the overall study and observational data collection methods by the research coordinator and/or principal investigator (PI), and a follow-up orientation to review additional guidelines for observational data collection. During the training, coders were taught how to code the relevant behaviors during games, and this was demonstrated and practiced.

For coaches, the research assistant coded whether each sun protection behavior (enforcement of: sunscreen application and re-application, hat, sunglasses, shirt with sleeves, long skirt or pants, shade use, avoidance of peak UVR hours, reminder to players to use sun protection) was observed at any point during the team practice or game. For players, the research assistant tallied the number of children who engaged in the aforementioned sun protection behaviors at any point during the practice or game. For analyses, the proportion of players on the team exhibiting each sun protection behavior was used. The research assistant also coded for coach behaviors that could facilitate sun protection (e.g., coach sunscreen application/re-application, coach wearing a shirt with sleeves, long pants, hat, sunglasses, coach shade use) and the presence/absence of sun protection materials during the practices and games, including presence of (spare) protective uniforms and sunscreen, and use of the provided shade structures.

Coach demographic characteristics.

Coaches in the intervention counties provided demographic information on the baseline questionnaire, including gender, age, race/ethnicity, educational attainment, income, employment status, and personal and family melanoma history.

Coach knowledge, self-efficacy, attitudes about sun safety programs.

Coaches’ knowledge was assessed using 3 investigator-designed items on awareness of sun safety practices and a coach’s role in skin cancer prevention for athletes: 1) Utah has the highest rate of melanoma in the country; 2) Sport coaches can help athletes prevent skin cancer by modeling sun safety practices; and 3) Sunscreen should be applied at least 15 minutes before going outside. The response options were provided on a 5-point Likert-type scale from Strongly Disagree to Strongly Agree (1 to 5) and dichotomized for analysis to 0 (incorrect: neutral/disagree/strongly disagree) or 1 (correct: agree/strongly agree) and totaled to create an overall knowledge score. Self-efficacy for implementing sun protection behaviors for themselves and players was assessed using 6 items adapted from 4 previously validated and reliable subscales related to parents’ self-efficacy for sun protective behaviors—particularly sunscreen use, hats and protective clothing, shade, and limiting time outdoors— with their children (Tripp et al., 2012). Cronbach’s alpha for the modified self-efficacy measure was .86 at pre-intervention and .83 at post-intervention. Coach attitudes about sun safety programs were assessed using 3 items on whether coaches thought that players would benefit from a sun safety program, whether the sports league believed improving player sun safety is important, and to what extent coaches had a sense of personal responsibility for improving their players’ sun safety behaviors (Helfrich et al., 2009; Wilcox et al., 2021). Self-efficacy and coach attitudes were assessed pre- and post-intervention, and response options were on the same 5-point Likert-type scale from Strongly Disagree to Strongly Agree (1 to 5). Coding, scoring and totaling of response options followed the same procedure as for coach knowledge.

Coach-reported sun protection and facilitation behaviors.

Coaches reported on the frequency of their own sun protection behaviors (sunscreen and protective clothing use during practices and games), and facilitation of players’ sun protection behaviors (e.g., encouraging players to apply sunscreen, wear protective clothing, or take breaks in the shade, providing time for players to apply sunscreen). These items were assessed pre- and post-intervention.

Qualitative interview with coaches who received RAYS training.

Coaches who received RAYS program training were invited to participate in a brief follow-up interview with a research assistant after the sports season. The semi-structured interview covered coach perspectives on the feasibility and acceptability of RAYS at the team and organizational levels, barriers and facilitators to implementation, perceived intervention effects, and suggestions for improvement. The interviews were audio-recorded and transcribed verbatim.

Analytic Plan

For this preliminary community-level pilot trial, we drew from guidance outlined by Murray et al (Murray et al., 2020) on studies involving community-based research. Descriptive statistics (i.e., mean, SD, frequencies) were calculated for coach demographic characteristics and coach and player sun protection behaviors aggregated at the team-level both overall and by intervention and control. To account for potential seasonal influences on outcomes of interest, preliminary effects for RAYS on player sun protection behaviors were examined among teams who received RAYS in the summer (n=18 teams) and were compared with control county teams (n=12 teams), who were also assessed in the summer. Specifically, linear regression examined the potential impact of intervention group (intervention vs. control) on a team’s collective change in sun protective behaviors (pre to post), controlling for baseline sun protection. In addition, the proportion of RAYS teams and of non-RAYS teams using sun protection supplies at pre- and post-assessment was summarized and tested, with the one-sample binomial test, to see if the proportion was different from a half. Among RAYS-trained coaches, paired samples t-tests were used to examine pre/post differences in coach-reported knowledge, self-efficacy, and attitudes, and self-reported sun protection and facilitation behaviors. The feasibility and acceptability of RAYS was examined across all teams in the two intervention counties.

The coach interview transcripts were analyzed using a directed content analysis approach (Hsieh & Shannon, 2005). Research team members created a codebook, which utilized constructs within the Practical Robust Implementation and Sustainability Model (PRISM) to understand contextual factors that may influence the use, effectiveness and future scale-up of RAYS (McCreight et al., 2019). PRISM organizes contextual factors into 4 categories 1) multilevel perspectives on the intervention (e.g. coach, parent, player perspectives), 2) characteristics of multilevel recipients of the intervention (e.g. coach, parent, players), 3) implementation and sustainability infrastructure (e.g. training and support) and 4) the external environment (e.g. community resources). The codebook also included a construct to assess coach perspective on the efficacy of RAYS. The codebook was developed and finalized using a step-wise procedure where groups of two transcripts were coded by the primary coder and second master’s level research assistant (reliability coder). Coding discrepancies were discussed and resolved by consensus between the two coders, with feedback from the study PI (YW) and investigator (CS). After this process, all coach interviews were coded (or re-coded) by the primary coder, with 20% of the transcripts re-coded by the reliability coder. Inter-coder agreement for 20% of the transcripts was 87.5%. After review of the coded segments, the primary and reliability coders identified subthemes.

Program feasibility and acceptability.

The feasibility of RAYS was assessed via participation rates of teams and coaches, and coach-completed questionnaires (e.g., components of the RAYS program completed, barriers to program completion). Acceptability of RAYS was assessed via an investigator-designed, coach-completed questionnaire assessing how easy the program was to understand, to what extent RAYS was well received by parents and players, and the ease with which to integrate RAYS into practices/games (Proctor et al., 2011). These assessments were guided by community-based implementation frameworks consistent with program planning and evaluation, including in youth sports (Holt et al., 2020).

Results

Player Sun Protection Behaviors Measured at the Team Level

To evaluate the effect of RAYS on player sun protection behaviors, teams who received RAYS during the summer were compared with season/sport-matched control teams (n=12 teams). Linear regression analyses indicated that after adjusting for [the baseline proportion of players observing a sun behavior], there was a significant increase in the proportion of players wearing hats among RAYS teams compared to control teams (b=0.18, p=0.007, d=0.16). There was also a marginal increase in the proportion of players avoiding peak UVR hours among RAYS teams compared to control teams (b=0.15, p=0.076, d=0.42). There were no differences between RAYS and control teams in changes pre-post on other observable sun protection behaviors (Table 2). Almost no players were observed wearing sunglasses, wearing long-sleeved shirts, or applying sunscreen during games or practices, which precluded a formal comparison between intervention and control arm teams.

Table 2.

Directly-Observed Sun Protection Behaviors among Players/Teams Pre- to Post-Intervention by Study Condition

Item	M(SD) Baseline	M(SD) Post-Intervention	Unstand. Coefficient	Stand. Coefficient	p-value
Wearing Sunscreen			.056	.343	.163
Intervention	0% (0)	5.6% (.136)
Control	0% (0)	0% (0)
Wearing Shirts			−.032	−.047	.793
Intervention	100% (0)	95.8% (.102)
Control	83.3% (.380)	100% (0)
Wearing Long-sleeved Shirts			.000	.000	--
Intervention	2.1% (.051)	0% (0)
Control	0% (0)	0% (0)
Wearing Long Pants			.178	.367	.100
Intervention	66.0% (.317)	47.1% (.179)
Control	31.9% (.207)	21.3% (.106)
Wearing Hats			.270	.637	.007
Intervention	45.1% (.294)	67.0% (.244)
Control	32.5% (.161)	32.6% (.102)
Seeking Shade			.335	.377	.595
Intervention	0% (0)	41.7% (.492)
Control	97.5% (.087)	91.7% (.289)
Avoiding Peak UV Hours			.151	.308	.076
Intervention	81.9% (.403)	98.2% (.045)
Control	100% (0)	100% (0)
Wearing Sunglasses			.000	.000	--
Intervention	0% (0)	0% (0)
Control	1% (.036)	0% (0)

Coach and Team-Level Outcomes related to Sun Protection

The following coach and team-level outcomes only pertain to RAYS-trained coaches (Table 3).

Table 3.

RAYS-trained coach sun protection behaviors, knowledge and attitudes pre-to-post-intervention

Measure	M (SD) Baseline	M (SD) Post-Intervention	t-test	df	p-value
Coaches’ sun protection
Sunscreen	3.4 (1.5)	4.3 (1.1)	−3.29	6	.017
Protective clothing	3.6 (1.3)	3.9 (1.1)	−1.55	6	.172
Coach facilitation of players’ sun protection
Encourage sunscreen use	2.4 (1.6)	4.1 (1.2)	−3.29	6	.030
Sunscreen provided by coach	1.7 (1.5)	4.1 (1.1)	−4.60	6	.004
Dedicated time for sunscreen application	3.1 (1.8)	4.9 (0.4)	−2.83	6	.030
Breaks in shade during practice	4.1 (1.1)	4.7 (0.5)	−1.19	6	.280
RAYS-provided sun protection supplies available	.00 (.00)	0.4 (0.5)	−2.95	6	.009
Coach knowledge	0.8 (0.2)	1.0 (.00)	−3.87	6	.008
Self-efficacy for sun protection	.09 (0.1)	1.0 (.00)	−1.00	6	.356
Coach attitudes about sun protection	4.3 (0.7)	4.7 (0.5)	−1.62	6	.156
I think my players will benefit from a sun safety program	4.6 (0.5)	4.7 (0.5)	−.55	6	.604
Our youth sport organization believes improving youth sun safety behaviors is important	4.1 (0.9)	4.6 (0.8)	−1.44	6	.100
I have a sense of personal responsibility for improving my players’ sun safety behaviors	4.3 (0.8)	4.7 (0.5)	−2.12	6	.078

Coach knowledge and awareness of risk and sun protective behaviors.

RAYS-trained coaches evidenced significant improvements in their knowledge about skin cancer and prevention (t(6)=−3.87, p=0.008, d=0.49). This was corroborated by increased awareness of skin cancer and prevention strategies during key informant interviews (Table 4) by 57% of coaches.

Table 4.

Summary of Themes from Coach Interviews Drawing from PRISM

Theme	Sub-Theme	Proportion of Coaches Endorsing	Example Quotations
Characteristics of multilevel recipients of the intervention
Player and coach: Knowledge about skin cancer	Existing and new awareness of risk and sun protective behaviors	2/14 14%	“I guess just the how simple it is to get it. Like the meloma, Melanoma or how you say it. Um, like I said, it runs in my family, so I’m aware of it, but I didn’t know. And I, and I can’t think of the numbers off the top of my head, but you just like 15–20 minutes in the sun is enough to start forming those, those Melanoma pockets. And I mean that was new info for me and kind of an eye opener that even walking out to do yard work or whatever that I need, to be more careful.” (Fall Sport Coach) I think they’re aware. I think they’re aware now well, and they probably were before too. I have, there were a couple kids that would always come with sunscreen, so I know that they’re aware and if not before they are now. (Summer Sport Coach)
	Change in awareness of skin cancer risk and sun protective behaviors	8/14 57%	“But I liked the information that came from it because it, it made me more aware and want to take more of an active role. I know meaning the players on my team’s, I know their lives. Four or five of them come from farms farming communities. So they’re there and as soon as they get home from school they are outside moving water or they’re outside doing, doing stuff for their dads.” (Fall Sport Coach) “So it made me think, cause I coach, I coach a lot of sports. And I coach baseball in the spring um, and ya know we’re outside eight hours some days and I wear sunscreen and I make my, my kid wear sunscreen. But, I was always uncomfortable about offering it to other kids but um…I think I’ll start to offer it if kids want it. And parents are okay with it.” (Fall Sport Coach)
External Environment
External Environment and Impact on RAYS	Physical layout and structure of sports fields	6/14 43%	“I don’t think it’s the greatest, I think it could be better. Um. Like I said, there’s not a lot of shady areas to take precautions to be out of the sun here. Like I mean our dugouts for softball and stuff they are covered. But, when the Suns beating right into the dugout, the cover dugout doesn’t serve its purpose. You know what I mean? Like when the kids are playing soccer or flag football, there’s just. There’s no means for shade.” (Summer Sport Coach)
	RAYS is best implemented in the spring and summer league seasons	7/14 50%	“Yeah, I think that’s, that’s …I don’t know the other challenge, well I don’t want to say challenge…given it was a fall sport, um it cooled off incredibly, I think 3 of our games were like rainy like we played on days that were super rainy so like the sun was never out, so the sun was never out. So I just think that given the time frame of, of this sport uh, the the sun by the time like, for the first couple of times like it was super-hot but after that, I uh ya know, these kids were in long-sleeve shirts and hoodies.” (Fall Sport Coach)
Implementation and Sustainability Infrastructure
Barriers to Implementation of RAYS	Challenges with league & community support and involvement with RAYS	4/14 29%	“Uhhh, maybe [avoiding] a middle party like the rec center and just come in and run it yourself [laughs]…Yeah I bet you’re fully capable, people to do that. When I, when we got all this information about two weeks into practices if this information would have come to us sooner. We were practicing at 5:00 o’clock in the middle of August and it’s pretty dang hot. I, I would have taken a more proactive stance. We were always in shade when we got done. We always took water breaks but there was never, I never encourage some sunscreen until you made me aware of that. So, maybe when the season starts when we get our teams, when we get everything, send us the expectations. But again I don’t think that comes from you it probably comes from the rec center.” (Fall Sport Coach)
Future Strategies to Improve the RAYS Intervention and its Reach	Social media and community events as a recruitment strategies	8/14 57%	“I don’t know, maybe, maybe I know a lot of them do like Facebook and. Things like that around here. But you could do like surveys. You know online surveys reach out kind of that way. Just kind of get a feel for what parents think.” (Fall Sport Coach) “Uh, probably just events. We have events at the lake and events every Tuesday night downtown at a farmers market. If there was information there it would reach more people. We don’t have a TV station so a lot of stuff, local geared things, is all radio and maybe Facebook I guess.” (Fall Sport Coach)
	Timing of recruitment	5/14 36%	“The only suggestion that I would have is to front-load some of the stuff. Um, so when parents sign up their kids for a sporting event then at that point the rec center or whoever, notifies the parent and says “hey this is sponsored by such and such study, that they’ll being doing this throughout the year. The coaches will be talking about skin care awareness.” (Fall Sport Coach)
	Parent support key for RAYS’ success	7/14 50%	“Trying to think of a way that’s like maybe to get good parents to be more involved in it, if that makes sense. I, I just don’t know how. You guys could incorporate, incorporate into that. I guess maybe that’s something else that like us as coaches would need to do, but it’s just, I mean, it’s kind of hard to go in and track down all the parents and be like hey listen, so I don’t know if there was like maybe that slide show like… But I don’t know, or maybe if you offer the parents on the team some type of incentive to watch this video on how important it is and to you know actually do it or even host like a one night class for 30 minutes or something. I don’t know. Yeah, I mean coaches can do it while they’re there, but as far as like informing them when they’re outside of there, I feel like that would be the parents that should do that.” (Summer Sport Coach) “I think primarily the parents buying in would be huge. And then having, having I mean it pushed through the rec center for coaches to help. I think those would be the two. So uh, buy in from parents and that comes from communicating up front with the parents what’s going on. And then getting the rec center to help. Um, and sending that message to each of them.” (Fall Sport Coach)
	Strategies to improve reach	12/14 86%	“I don’t know it of how to do it down here, but like an online, like a technology thing for parents to take their teenagers to. You know about Internet safety and things like that and they just did a class here one night and I think they offered some type of incentive, which I think made a lot more parents go than they would have. And they just, they just went over all the information and it was really beneficial and so something like that I feel could really get the community like more on board. And like I said with like one night a month, a one-time thing or something you could even do more than that I guess. But just as far as like our little community, I feel something like that might be beneficial.” (Summer Sport Coach) “If there’s some way to get that training to all the parents. Even if there’s like a 5 or 10 minute video. Or like you sent it to the coaches and they sent it to the parents and they parents can watch it you know?” (Fall Sport Coach)
Intervention Design/Characteristics
Acceptability of RAYS Intervention	RAYS was a turn-key intervention, simple and efficient	14/14 100%	“It was easy. It wasn’t hard at all. Um, just being able to have the resources available like you guys providing the sunscreen and the shirts and like the sunglasses. So like we didn’t have to, you know. Getting things out of our own. Use our money out of our own pocket. It was very helpful.” (Summer Sport Coach) “I thought it’s actually really easy to deliver […] put it all in a package and we were able to kind of just really easily, you know, send the information out and then hang up and supplies at one of our games. That was what made it. What made it, like I guess, what made it easy[…] it was really helpful that you guys provided that all. Because if I would have been like, oh, educate your players on skin safety or skin cancer stuff. And like, well, I don’t know what to pick and what is actually factual and so it was really helpful just to know that you guys had it all there for us and, and made it really easy to get it to the parents and the players.” (Summer Sport Coach) “Everyone was pretty receptive on my text messages to remind what time to show up for practice or games. I just put along with you know, bringing water and to apply sunscreen and wear sleeves and a hat. So whether or not they did I don’t know.” (Fall Sport Coach) “.where there was shade there was a ton of people. And then the first thing kids did when they got done playing or taking a break ran to the shade.” (Fall Sport Coach)
	Positive feedback and support for RAYS as a whole	14/14 100%	“I liked everything about it. The meeting was very helpful and explanatory. I just I liked everything about it…I don’t think there wasn’t, there wasn’t really anything that I didn’t like. Yeah, nothing. I liked everything about it.” (Summer Sport Coach) “I like that it made me more cognizant of the, of what’s going on in general. So one I was more aware of it. Two, I did like the fact that it helped subsidize the cost for the rec center for a program sponsoring it. Um, and I thought it was a helpful time to be able to pass out that information to parents as well. So, I guess those are the, those are the points that I liked.” (Fall Sport Coach)
	RAYS content was helpful and interesting for coaches	10/14 71%	“I just, I liked being informed. I didn’t know Utah was so high in the country. And I didn’t know that rural communities in Utah were so high and so once I knew that I thought yeah there’s something to that. I can take an active role as a coach pretty easily and helping these kids at a young age.” (Fall Sport Coach) “Oh I loved all that information I keep um reading it. I thought it was educational. Makes me realize, ya know just have more awareness. Ya know, the, the damages that the sun can do on our skin and the possibility of getting cancer and I don’t know. Ya know, just the, I thought that was good information. I really liked the packet.” (Fall Sport Coach)
	RAYS was helpful to players and parents	10/14 71%	“I thought it was very informative, even as a parent and a parent coach and the kids really liked the sunglasses and my little boy we really liked that. So I guess it was nice to get that and for the kids.” (Summer Sport Coach) “I think they’re aware. I think they’re aware now well, and they probably were before too. I have, there were a couple kids that would always come with sunscreen, so I know that they’re aware and if not before they are now.” (Summer Sport Coach)

Coach self-efficacy and attitudes.

Coach self-efficacy for implementing sun protection for themselves and their players was high at baseline (M=27.4, SD=1.0 out of possible 30 total score) and remained high post-intervention (M=28.1, SD=0.8), with no significant change over time (see Table 3 for t-value, Ms, SDs). In terms of coach attitudes about sun safety, they “strongly agreed” that their players would benefit from a sun safety program pre- and post-intervention, and “agreed” pre-intervention and “strongly agreed” post-intervention that their league believes improving youth sun safety is important. There was a marginal improvement (p=0.08) in coaches reporting their personal sense of responsibility for improving their players’ sun safety behavior from pre- to post-intervention (from “agree” to “strongly agree”; see Table 3).

Coach sun protection behaviors and facilitation of player sun protection behaviors.

Coaches reported significant improvements in their own sun protection behaviors across time, and in their facilitation of players’ sun protection behaviors. Coaches reported significant increases in their own use of sunscreen (t(6)=−3.29, p=0.017, d=0.69) but not protective clothing. They also reported increases in the frequency with which they encouraged their players to use sunscreen (t(6)=−2.83, p=0.030, d=1.60), providing sunscreen for players (t(6)=−4.56, p=0.004, d=1.40), and providing time for players to apply sunscreen during practices or games (t(6)=−2.83, p=0.030, d=1.60). There was no significant change in how often coaches reported that their team practiced or played in the shade or took breaks in the shade, or in the frequency with which they encouraged players to wear protective clothing. However, coaches reported in interviews that they may have been limited in their ability to modify some sun safety behaviors due to environmental/external limitations such as absence of shade and uniform requirements set by the league. Furthermore, the average highest daytime ambient temperature during the summer sports season varied between 68- and 91-degrees Fahrenheit, which may have limited coach encouragement of players’ use of protective clothing (e.g., pants, long-sleeved shirts).

Almost all RAYS-trained coaches who received the program during the summer season (86%, n=6) reported that they made the sun protection supplies provided through RAYS available to their players. RAYS teams had significant improvements in observed sun safety supplies present during practices or games pre- to post-intervention (sunscreen and sunglasses: 0% pre, 33.3% post, CI 0.04, 0.78; banner: 0% pre, 100% post, CI 0.54, 1.00), whereas control teams had no observed sun safety supplies present (Figure 1).

Figure 1.

Pre to post changes in presence of sun safety supplies among RAYS and control teams in the summer

External Environment Factors Impacting RAYS

In the qualitative interviews, which were conducted among RAYS-trained coaches who received the program during both the summer and fall seasons (n=17), coaches shared external factors that impacted RAYS related to the physical layout of the fields and seasonal influences (see Table 4). For example, coaches expressed that seasonal changes in weather affected which components of RAYS were easier or more difficult to implement. Coaches who participated in RAYS during the summer expressed challenges related to the physical environment that affected their implementation, such as lack of available shade (e.g. trees, dugouts) in the built environment. For example, one coach said, “I don’t think it’s the greatest, I think it could be better. Um. Like I said, there’s not a lot of shady areas to take precautions to be out of the sun here. Like I mean our dugouts for softball and stuff they are covered. But, when the sun’s beating right into the dugout, the cover dugout doesn’t serve its purpose. You know what I mean? Like when the kids are playing soccer or flag football, there’s just. There’s no means for shade.” In the summer months, the shade structures provided by the RAYS program were therefore particularly important. In the fall sports season when there was cooler weather and practice spanned into hours when sun light and ambient UVR is lower, other components of RAYS (e.g., sleeved uniforms) were easier to implement.

Implementation and Sustainability Infrastructure for RAYS

Coaches provided feedback to guide future implementation of RAYS and strategies to promote its sustainability over time (see Table 4). Coaches also provided recommendations for how to improve the RAYS program and its reach in the future. For instance, more than half (57%) of coaches suggested a variety of approaches to increase awareness of RAYS, such as through social media, community festivals and parades, presentations in schools and increased RAYS staff presence at sporting events to answer parent questions (see Table 4). One coach said “I think primarily communicating up front with the parents about what’s going on and getting their buy-in and then getting the city people and rec center to help…so when parents sign up their kids for a sporting event and the rec center says ‘hey this is sponsored by such and such study and this will be done throughout the year, the coaches will be talking about skin cancer prevention’…that would be huge.”

Some coaches (36%) also expressed that having the RAYS program introduced to coaches and parents, for example, at their primary orientation meeting before the season begins would be beneficial (see Table 4). Coaches (50%) also provided ideas for how to better engage parents in RAYS in the future, including offering more formal parent-focused sessions on skin cancer prevention and child sun protection and providing communication strategies to better inform parents about RAYS from the program outset (see Table 4). And the vast majority of coaches (86%) provided ideas for how the reach of RAYS could be augmented, including extension of the program to school sports settings, and creating other forums in which to provide parents with education on child sun safety (e.g., online). One coach said “I don’t know it of how to do it down here, but like an online, like a technology thing for parents to take their teenagers to. You know about Internet safety and things like that and they just did a class here one night and I think they offered some type of incentive, which I think made a lot more parents go than they would have. And they just, they just went over all the information and it was really beneficial and so something like that I feel could really get the community like more on board. And like I said with like one night a month, a one-time thing or something you could even do more than that I guess. But just as far as like our little community, I feel something like that might be beneficial.”

Feasibility and Acceptability of the RAYS program

The RAYS program was delivered in two rural counties in Utah, with a total of 4 leagues and 28 sports teams which were offered the program. All teams received the first step of access to sun safety supplies, including portable shade tents and sunscreen dispensers, and sun protective sports uniforms. Of the 28 teams, 10 in one county (n=121 players) and 7 in the second county (n=139 players) also received the second step coach training on RAYS. In interviews, all (100%) of the coaches expressed that RAYS was feasible to participate in and deliver (see Table 4). Some coaches (29%) expressed feasibility challenges that occurred related to delays in the provision of RAYS supplies to coaches and teams that were beyond the control of the investigators (e.g., supplies not delivered to coaches on time by recreation center).

In total, 17 coaches (represents approximately 50% of coaches, as some teams had multiple coaches) who had received both steps of the intervention provided feedback on RAYS’ acceptability (see Table 1 for demographic characteristics). Coaches who received RAYS training and provided feedback reported that RAYS was acceptable, with all (100%) coaches endorsing “agree” or “strongly agree” that RAYS was clear and easy to understand, RAYS was well-received by parents and players, and RAYS was easy to integrate into practices/games. The qualitative interviews also supported the feasibility and acceptability of the RAYS intervention (see Table 4). All (100%) of coaches provided positive feedback on the RAYS program as a whole and the vast majority of coaches (71%) expressed that RAYS content was helpful and interesting for coaches, players, and parents. A smaller proportion (21%) provided negative or constructive feedback about the RAYS program to help improve it in the future.

Table 1.

Demographic characteristics of summer coach participants (N=17)

	N (% unless otherwise noted)
Mean age (SD)	35.8 (3.9)
Gender
Female	9 (53%)
Male	8 (47%)
Race and Ethnicity
Non-Hispanic White	16 (94.1)
Other/Not reported	1 (5.9)
Education Level
High school graduate or G.E.D	3 (17.6)
Vocational or technical school after high school	4 (23.5)
Bachelor’s degree or higher	10 (58.9)
Household Income
$30,000 – $69,999	7 (41.2)
$70,000 – $99,999	5 (29.4)
$100,000 or more	4 (23.5)
Missing	1 (5.9)
Employment
Employed full time/part time	10 (58.8)
Homemaker/Self-employed	7 (41.2)
Family history of melanoma	3 (5.67%)

Discussion

The results of this preliminary/pilot investigation suggest that multilevel approaches to skin cancer prevention for young children living in rural settings, informed by community-provided needs and preferences, could be feasibly delivered and acceptable to coaches, parents, and players. Consistent with CDC guidance on community-level sun protection (The Community Guide, 2022), this pilot intervention demonstrated beneficial, preliminary effects on observed child sun protective behaviors (hat use), coaches’ own sun protection behaviors, presence of sun safety supplies during practices and games, and change agents influencing coach behaviors, such as knowledge about skin cancer prevention and their facilitation of players’ sun protection behaviors. These signals of RAYS’ effects based on our pilot data are consistent with recommended approaches to youth skin cancer prevention in the larger literature (The Community Guide, 2022). However, unlike RAYS, prior interventions have not been able to specifically address the skin cancer prevention needs of rural youths and through the youth sports setting.

The feasibility, acceptability, and promising effects on sun protection and coach behaviors and knowledge in this preliminary investigation of RAYS was likely due to several factors including the incorporation of community needs and preferences early in the development of the program, implementation through a setting (sports) that is common for rural youth as well as a source of community camaraderie and pride, and incorporation of behavior change strategies with environmental adaptations to promote sun safety behaviors (Wu et al., 2022). Qualitative feedback corroborated this with coaches expressing that receipt of the sun protection supplies for use during sports paired with education for them and parents was useful and increased their awareness of skin cancer prevention, as well as the ability to reinforce sun protection behaviors during games and practices.

Prior programs within rural communities have typically included older children and have been delivered through everyday settings that are not recreational in nature (e.g., childcare, school, doctors’ offices; Cariou et al., 2014; Chen et al., 2015; Dietrich et al., 1999; Loescher et al., 2019; Velasques et al., 2016). This represents a missed opportunity for skin cancer prevention given that the vast majority of youths (at least 76%; Aspen Institute, 2021) participate in sports, a setting in which children can receive high levels of UVR exposure. Further, existing skin cancer prevention programs for youths delivered through beaches and pools (Saraiya et al., 2004) may not reach all underserved communities, where outdoor playing fields are more widely available and there are national efforts to increase accessibility to organized sports (Aspen Institute, 2021).

Despite its preliminary and encouraging nature, RAYS must be further optimized before further scale-up. Drawing on PRISM (McCreight et al., 2019) and the current findings, modifications to the process, content, and delivery of the intervention may contribute to increased effectiveness, implementation, and reach. To improve intervention effects across a wider range of child sun protection behaviors, RAYS could augment its multilevel intervention components, such as better involving parents (e.g., pre-season training, providing intervention materials during registration), so that they can reinforce the education their children receive at practices and games. Further, through organization-level targets of change, RAYS could seek to address and acknowledge external factors outside of coaches’ control such as limited shade from the built environment and pre-set league uniform requirements. To maximize reach, RAYS could use additional recruitment methods such as social media and increase study staff presence at community events.

Our study took place within rural areas in a state with high melanoma burden (Doherty et al., 2018). While our trial was unable to fulfill all the steps outlined in Murray et al. (Murray et al., 2020) and there were not a priori hypotheses about levels of feasibility and acceptability and magnitude of preliminary effects, we were able to pilot a group (sports team)-based cancer preventive intervention that targets multilevel contributors to skin cancer prevention among youths. Future work could test the efficacy of RAYS across rural areas in other regions of the US and include a larger number of leagues and teams and use a randomized trial design. In terms of measurement, we analyzed individual sun protection behaviors (e.g., sunscreen, hat) as hypothesized and results were in the a priori expected direction, but we did not correct for multiple comparisons. Future studies could benefit from including other outcome measures, such as parent-reported child sun protection, to supplement direct observation. In addition, self-reported behaviors among coaches could be tested by correlation with directly observed behaviors. Multilevel interventions for skin cancer prevention among young children can be successfully delivered through community organizations and their settings. A priority moving forward is the identification of ways to optimize delivery of such programs to positively influence skin cancer preventive behaviors among children living in diverse rural areas.

Youth sports, which are ubiquitous, offer a unique opportunity for intervening on children’s health behaviors directly and through their coaches, parents, the larger league, and the broader community (Aspen Institute, 2021). A large proportion of children participate in sports (e.g., 76% of children ages 6–12)(Aspen Institute, 2021) and sports settings offer a structured opportunity for children to practice relevant health behaviors such as sun protection practices. Prior interventions for other health behaviors (e.g., physical activity, smoking, alcohol/drug use, and nutrition) have similarly been delivered through youth sports teams, although not necessarily targeting youth in rural areas (Hansell et al., 2021; Priest et al., 2008; Stölzel et al., 2020; Trigwell et al., 2015; Van der Veken et al., 2019). Interventions such as RAYS that provide access to sun protection resources are particularly important for rural areas with higher poverty levels and less access to community skin cancer prevention resources (Weber et al., 2005).

Statement of Public Significance.

This study suggests that multilevel approaches to skin cancer prevention among young children can be successfully delivered through youth sports leagues and are acceptable to rural communities. While beneficial effects were demonstrated for child and coach sun protection behaviors, a priority moving forward is the identification of ways to optimize program delivery to positively influence a wider range of skin cancer preventive behaviors among children living in diverse rural areas.