摘要：Objectives. We compared 2 strategies for disseminating an evidence-based skin cancer prevention program. Methods. We evaluated the effects of 2 strategies (basic vs enhanced) for dissemination of the Pool Cool skin cancer prevention program in outdoor swimming pools on (1) program implementation, maintenance, and sustainability and (2) improvements in organizational and environmental supports for sun protection. The trial used a cluster-randomized design with pools as the unit of intervention and outcome. The enhanced group received extra incentives, reinforcement, feedback, and skill-building guidance. Surveys were collected in successive years (2003–2006) from managers of 435 pools in 33 metropolitan areas across the United States participating in the Pool Cool Diffusion Trial. Results. Both treatment groups improved their implementation of the program, but pools in the enhanced condition had significantly greater overall maintenance of the program over 3 summers of participation. Furthermore, pools in the enhanced condition established and maintained significantly greater sun-safety policies and supportive environments over time. Conclusions. This study found that more intensive, theory-driven dissemination strategies can significantly enhance program implementation and maintenance of health-promoting environmental and policy changes. Future research is warranted through longitudinal follow-up to examine sustainability. Skin cancer is the most commonly diagnosed form of cancer in the United States, with 1 in 5 Americans expected to develop skin cancer during their lifetime. 1–4 Although skin cancer rates are increasing, most skin cancers could be prevented by consistent use of sun protection, including sunscreen, hats, sunglasses, shirts, and shade. 1–3,5,6 Behavioral recommendations for primary prevention of skin cancer include limiting time spent in the sun, avoiding the sun during peak hours (10:00 am to 4:00 pm ), using sunscreen with a sun protection factor of 15 or higher when outside, wearing protective clothing (hats, shirts, pants) and sunglasses, seeking shade, avoiding sunburn, and making sun safety a habit. 2,4 Although awareness about skin cancer is growing, preventive behaviors remain relatively low in the United States. 7 Childhood exposure to the sun’s UV rays increases the risk for skin cancer later in life. 8 Prevention programs for children in outdoor aquatic settings may influence youths, their parents, and swimming pool environments. These programs can achieve significant public health benefits if they are widely disseminated and successfully adopted, maintained, and continued. 9 The Community Preventive Services Task Force 10 recommends outdoor recreation and tourism setting–based interventions to prevent skin cancer on the basis of strong evidence of effectiveness in improving participants’ sun protective behaviors (e.g., use of sunscreen and sunglasses, avoidance of sun exposure), reducing UV exposure, and decreasing incidence of sunburn. Nevertheless, few skin cancer prevention programs that have been formally evaluated have continued for more than 1 year, 11 and few evidence-based skin cancer prevention programs have been disseminated beyond an initial efficacy trial. 12–14 Because long-term sun safety is critical to preventing the development of skin cancer, more evidence is needed about how best to disseminate interventions to vulnerable populations. Also, despite the growing body of research on the initial adoption of evidence-based public health interventions, less research has focused on strategies to improve the maintenance and sustainability of programs, organizational policies, and supportive environmental changes over time. Because effective cancer prevention programs must be sustained in the long term to have public health effect, 15,16 it is critical to develop and evaluate efforts to create sustainable programs that would ensure long-term effects of public health initiatives. 17 The Pool Cool Diffusion Trial was an innovative test of strategies to effect a lasting program and associated organizational changes within swimming pool environments across several years. The main aims of the Pool Cool Diffusion Trial (2003–2010) were to evaluate the effects of 2 strategies (basic vs enhanced) for dissemination of the Pool Cool skin cancer prevention program on (1) program implementation, maintenance, and sustainability; (2) improvements in organizational and environmental supports for sun protection at swimming pools; and (3) sun protection habits and sunburns among children. We describe the main results of the trial at the swimming pool, or organizational, level.
