A multi-method process evaluation for a skin cancer prevention diffusion trial

This article describes process evaluation methods for the Pool Cool diffusion trial across 4 years. Pool Cool is a skin cancer prevention program that was found to improve behaviors and environments for sun protection at swimming pools in a randomized efficacy trial, which was followed by a national diffusion trial. The process evaluation focus shifted from measuring program satisfaction to assessing widespread program implementation, barriers and facilitators to implementation, and program maintenance and sustainability. Data collection methods include training surveys, database tracking, field coordinator activity logs, e-mails, surveys of parents, lifeguards and pool managers, and process evaluation interviews and site visits. The data revealed high levels of implementation of major program components when disseminated in the diffusion trial, including sun safety lessons, sun safety signs, and sunscreen use. This article describes program features and participant factors that facilitated local implementation, maintenance and sustainability across dispersed pools such as linkage agents, a packaged program, and adaptations of program elements.