Melanoma incidence and mortality rates in Idaho are higher than national averages. The importance of increased awareness of skin cancer has been cited by state and local organizations. St. Luke’s Mountain States Tumor Institute (MSTI) prioritized educational outreach efforts to focus on the implementation of a skin cancer prevention program in rural Idaho.
As a community cancer center, MSTI expanded cancer education services to include dedicated support to rural communities. Through this expansion, an MSTI educator sought to partner with a community organization to provide sun-safety education. MSTI selected, adapted, and implemented an evidence-based program, Pool Cool.
The education program was implemented in 5 phases. In Phase I, we identified and recruited a community partner; in Phase 2, after thorough research, we selected a program, Pool Cool; in Phase 3, we planned the details of the program, including identification of desired short- and long-term outcomes and adaptation of existing program materials; in Phase 4, we implemented the program in summer 2012; in Phase 5, we assessed program sustainability and expansion.
MSTI developed a sustainable partnership with Payette Municipal Pool, and in summer 2012, we implemented Pool Cool. Sun-safety education was provided to more than 700 young people aged 2 to 17 years, and educational signage and sunscreen benefitted hundreds of additional pool patrons.
Community cancer centers are increasingly being asked to assess community needs and implement evidence-based prevention and screening programs. Clinical staff may become facilitators of evidence-based public health programs. Challenges of implementing evidence-based programs in the context of a community cancer centers are staffing, leveraging of resources, and ongoing training and support.
Melanoma incidence and mortality rates in Idaho are higher than national rates; thus, skin cancer prevention education has been cited as both a regional and local priority (
Community outreach and engagement to implement evidence-based programs has been studied in the context of academic and community partnerships (
St. Luke’s Mountain States Tumor Institute (MSTI), a 2010–2012 participant in the National Cancer Institute’s Community Cancer Centers Program (NCCCP), determined through a review of the literature that the best approach to skin cancer control was to implement an evidence-based intervention focusing on prevention in an outdoor-based recreational setting (
St. Luke’s Health System is the only nonprofit health system in Idaho. It is an active member of the communities it serves, with local physicians and boards who further the organization’s mission “to improve the health of people in our region.” MSTI is southern Idaho’s largest provider of cancer services and is nationally recognized by the American Society of Clinical Oncology as a leader in cancer research. Providing advanced care to thousands of patients (3,200 new patients in 2013) at 5 locations across the region, spanning western to south central Idaho, MSTI is also Idaho’s only cancer treatment center for children.
As part of NCCCP, MSTI expanded efforts to achieve the goals of reducing disparities in cancer health care and serving a greater number of medically underserved patients across the full cancer care continuum (
The rural community of Payette, Idaho, was selected as the implementation site for a sun-safety educational program because of its community demographics, potential risk factors, and lack of availability of cancer prevention education programs. Payette County, Idaho, is in southwestern Idaho and borders Oregon; it has a population of approximately 22,639; 80.5% are non-Hispanic white, 27.3% are younger than 18 years, and agriculture is a primary form of employment (
The Payette Municipal Pool is a hub of activity for the community. It provides recreational opportunities and a convenient location for residents to learn aquatic safety. The facility has a full-sized indoor and outdoor pool, which provides a venue for exercise classes, adult lap swim, regular open swim times, and swim lessons. During the summer, swim lesson enrollment reaches up to 800 young people. Pool users come from both the city of Payette and the surrounding communities.
Availability of cancer prevention programs in Payette is limited. The schools provide education aligned with the curriculum of the Idaho State Department of Education Content Standards for Health: Sun Safety (
Strengths:
Help all students learn more by demanding higher student proficiency and providing effective methods to help students achieve high standards.
Provide parents, schools, and communities with an unprecedented opportunity to debate and reach agreement.
Reinforce the best teaching and educational practices already found in classrooms and make them the norm.
Help the public and local and state educators evaluate which programs work best.
Limitations:
Vague and unclear standards.
Careless implementation of standards, and assessment may have negative consequences for students.
Impose content specifications without taking into account the different needs, opportunities to learn, and skills that may be appropriate for specific districts or regions.
MSTI sought to provide focused sun-safety education to young people aged 2 to 17 years in partnership with a community organization. The implementation of an evidence-based sun-safety program in partnership with the Payette Municipal Pool accomplished the goals of providing a sun-safety program through a sustainable community partnership.The objective of this case study is to describe the process taken by MSTI to engage and partner with a community organization to implement an evidence-based sun-safety program.
In 2011, after historically serving only central Idaho urban communities, MSTI expanded an existing community cancer education program to include the rural communities of southwestern and south central Idaho. Before the sun-safety program was selected, potential community partners were identified on the basis of various factors, including population served by the organization, resources available for participation in a mutual educational effort, interest in collaborating on a sun-safety program, and potential for sustainable participation for the organization and MSTI. The MSTI cancer educator applied the principles of community engagement during the identification and selection process (
Potential partners were identified by using an asset-mapping strategy. Several organizations were especially attractive as partners because they served young people or engaged young people in outdoor activities. We approached several organizations, including athletic and faith-based organizations, to assess interest in a partnership. The Payette Municipal Pool was identified as the key community partner for southwest Idaho. We selected this organization because of the interest of pool leadership in providing sun-safety education to pool patrons. The Payette Municipal Pool had not only supportive leadership but also a history of providing sun-safety educational inservices to pool staff, in partnership with local dermatologists, and a willingness to collaborate with MSTI and support educational programs through staff time.
The
The geographical service area of the MSTI community cancer education program ranges over 300 miles across southwestern Idaho and into eastern Oregon. Pool Cool was not only sustainable because of its train-the-trainer model program but it could also be implemented concurrently at multiple pool settings across the MSTI service area.
First implemented in 1999 at pools in Hawaii and Massachusetts, the Pool Cool program is a multicomponent sun-safety education program designed for use at swimming pools (
The Pool Cool program teaches children about the risks of overexposure to the sun and encourages them to develop healthy habits for a lifetime. Lessons are taught in conjunction with regular swim lessons, with the Pool Cool curriculum combining education, interactive activities at the pool, and pool-wide environmental changes. The main components are the following:
A lifeguard/aquatics instructor training module.
A Leader’s and Decision Maker’s Guidebook for pool staff.
An 8-lesson curriculum on sun safety presented by aquatics instructors.
Interactive activities on sun protection conducted for children aged 5 to10 and their parents. Includes demonstrations, games, and puzzles to supplement and support the lessons.
Provision of shaded areas, signage, and sunscreen dispensers at the pool.
Promotion of sun-safe environments.
The
The MSTI cancer educator began development of an implementation plan. Initial steps included assessment of resources and activities necessary to implement the program and identification of expected program outputs. Short- and long-term outcomes were also identified in a logic model (
| Resources | Activities | Outputs | Short- and Long-Term Outcomes | Impact |
|---|---|---|---|---|
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| ||||
| To accomplish our set of activities we will need the following | To address our problem or asset we will accomplish the following activities | We expect that once accomplished these activities will produce the following evidence or service delivery | We expect that if accomplished these activities will lead to the following changes in 1 to 3 years and 4 to 6 years | We expect that if accomplished these activities will lead to the following changes in 7 to 10 years |
|
Program coordinator. Pool director support. Pool staff (eg, lifeguards, swim instructors). Adaptation of Pool Cool program to meet the needs and branding of MSTI and Payette Municipal Pool. Supplies to facilitate education intervention: leader and decision maker guidebook, laminated lesson cards. Supplies to promote sun-safe behaviors and environment: 3 sunscreen dispensers, sunscreen refills, signage in changing rooms and on fencing. Incentives to staff and students for participating in Pool Cool program. |
Obtain support of pool director on any materials to be posted in pool areas (eg, signage, sunscreen dispensers). Conduct training with pool staff; provide detailed overview of Pool Cool lesson plans and supported activities. Install signage and sunscreen dispensers on pool deck and in changing rooms. |
Pool environment (signage, availability of sunscreen) will promote a sun-safe environment. Pool staff educated on sun-safe behaviors. Young people enrolled in swim lessons to be educated on sun-safe behaviors (4 Pool Cool rules). |
Young people enrolled in swim lessons will know the 4 Pool Cool rules: 1) Protect your skin — use sunscreen. 2) Cover up — after swimming cover your shoulders with a shirt and your legs with long shorts. 3) Protect your face and eyes — wear shades and a hat. 4) Seek shade, limit your time in the sun between 10 Pool users/staff will have increased awareness of sun-safe behaviors (from pool education and signage). Increased use of sunscreen during outdoor pool usage (from pool education, signage, and sunscreen availability). |
Increased use of sunscreen in community (measured by BRFSS data). Decreased number of sunburns in community (measured by BRFSS data). |
Abbreviations: MSTI, Mountain States Tumor Institute; BRFSS, Behavioral Risk Factor Surveillance System.
Although Pool Cool is an existing research-tested program and provides the resources necessary to implement the program, including a Leader’s and Decision Maker’s Guidebook, we needed to adapt the educational and training materials to ensure the program would be feasible for the community partner (
| Program Component | Action | Program Adjustments |
|---|---|---|
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| Adapted | Included MSTI logo and contact information, removed references to activities no longer included in program, provided reference materials, combined Leader’s and Decision Maker’s Guidebook. |
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| Adapted | Content maintained, added MSTI branding. |
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| Adapted, new material created | New educational signage created. Existing verbiage used, images of local pool participants included, MSTI branding and final product reviewed by community partner. |
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| Maintained, removed, or adapted | Weather Watch: the ultraviolet index — maintained. |
| Sun Jeopardy — maintained. | ||
| Blue and Purple People — removed because it required additional resources, supplies (eg, colored sunscreens), and time. | ||
| The Emperor’s Clothes — removed because it required additional resources, supplies (eg, assorted clothing items to demonstrate appropriate sun protection), and time. | ||
| Solartech sun exposure card and ultraviolet warning patch/wristband — adapted to provided Pool Cool participants with only an ultraviolet-sensitive card to demonstrate strength of ultraviolet rays. | ||
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| Adapted | Removed content and added additional brochures and reference materials: St. Luke’s What you need to know NOW — Skin Cancer Prevention; American Cancer Society — Sun Basics; American Cancer Society — A Parent’s Guide to Skin Protection. |
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| Maintained | Shaded areas were already in place at the pool; sunscreen dispensers were added. |
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| Developed | Training materials were created with a focus on skin cancer in Idaho, protective factors and risk factors for skin cancer, Pool Cool program overview, and daily sun-safety lessons. Training allowed for time to practice sun safety lessons. |
Abbreviation: MSTI, Mountain States Tumor Institute.
We incorporated organizational branding into the guidebook and revised it to better reflect the activities and lessons that were within the scope of feasibility.
We eliminated some of the optional poolside activities described by the guidebook and retained the few that were feasible based on available pool resources.
We adapted print materials and educational signage by revising text and images to increase the number of educational action items and images from the local pool. Signage was reviewed by the community partner; to assess community response before implementation, we asked community members and pool staff to provide feedback on materials.
Additional adaptation included the development of a pool staff training program. MSTI is a regional oncology treatment facility, and its community cancer educators are content experts in cancer prevention and early detection opportunities. As the facilitator of the pool staff training program, the MSTI cancer educator responsible for Pool Cool implementation was a resource for not only the initial train-the-trainer session but also the duration of the Pool Cool program. Staff training for the Pool Cool program included an overview of skin cancer in Idaho, behaviors that increase and decrease cancer risk, and a review of the Pool Cool program and sun-safety lessons. Additional time was provided for pool staff to practice lessons and gain confidence in their ability to teach them. Pool staff completed retrospective posttest training evaluations to assess the benefit of the information provided.
Pool Cool implementation occurred in conjunction with the opening of the outdoor areas of the Payette Municipal Pool in summer 2012. Educational signage and sunscreen dispensers were provided by MSTI, and an initial training session for 13 pool staff members took place in June 2012. An additional training session was provided midway through the summer to orient new staff to the Pool Cool program. Pool Cool lessons were provided to children and adolescents aged 2 through 17 years enrolled in swim lessons from June through August 2012.
MSTI made a long-term commitment to Payette Municipal Pool to provide sun-safety education to young people. Although no formal contract was signed, both MSTI and Payette Municipal Pool are fully invested in sustaining the current role of Pool Cool in swim lessons for young people. MSTI has defined skin cancer prevention as a focused effort for community cancer education as part of NCCCP participation. MSTI intends to expand the Pool Cool program to additional facilities throughout its service area.
With dedicated resources to providing community cancer prevention education, MSTI was able to provide the educational signage, sunscreen dispensers, sunscreen refills, and program incentives to pool staff and swim lesson participants. Additional resources, including staff time for training, sun-safety lessons, and installation of signage and sunscreen dispensers were provided by the Payette Municipal Pool.
The primary objectives of this program were to adapt and implement a sustainable sun-safety education program for young people in a rural community and create a sustainable partnership with a community organization. Through the implementation of Pool Cool at the Payette Municipal Pool, all objectives were met. The partnership between MSTI and the Payette Municipal Pool will be a template for future partnerships for community cancer education initiatives in southwestern Idaho.
During summer 2012, the Pool Cool program served more than 700 young people aged 2 to 17 years enrolled in swim lessons at the Payette Municipal Pool. In addition, hundreds of others benefited from the availability of sunscreen and educational signage at multiple locations throughout the facility. Ultimately, the greatest success was the partnership formed between MSTI and the Payette Municipal Pool. A sustainable partnership was demonstrated through ongoing staff training, commitment to support future programs in MSTI activity planning, and proposed expansion to sites in additional rural communities. Not only was this sustainable partnership formed but MSTI also successfully adapted and implemented its first evidence-based cancer control education program in a community setting.
The literature has multiple examples of community-engagement activities and evidence-based programs implemented through partnerships between academic institutions and community organizations (
Community cancer centers are ideal organizations to support cancer prevention efforts. They are required to provide at least 1 cancer prevention program to maintain accreditation or become accredited by the Commission on Cancer of the American College of Surgeons. Community cancer centers are located throughout the United States in both urban and rural settings, treating 85% of those who have a cancer diagnosis (
Throughout the implementation of Pool Cool, MSTI followed the principles of community engagement (
We acknowledge the Payette Municipal Pool for their partnership and ongoing support for the Pool Cool program. Implementation of this program occurred as part of author participation in the National Cancer Institute’s Research to Reality Mentorship program. We also acknowledge the Research to Reality program staff as well as the other participating mentor–mentee pairs. During program implementation, Ms Cariou was a rural community cancer education coordinator with MSTI. This project was funded in whole or in part with federal funds from the National Cancer Institute, National Institutes of Health, under contract no. HHSN261200800001E. The content of this article does not necessarily reflect the views or policies of the US Department of Health and Human Services, nor does mention of trade names, commercial products, or organizations imply endorsement by the US Government.
The opinions expressed by authors contributing to this journal do not necessarily reflect the opinions of the U.S. Department of Health and Human Services, the Public Health Service, the Centers for Disease Control and Prevention, or the authors' affiliated institutions.