This study was reviewed by the Georgetown University Institutional Review Board and granted an exemption (Institutional Review Board ID: STUDY00007990) on August 23, 2024. In lieu of a traditional informed consent process, all community advisory board (CAB) and multistakeholder advisory board (MAB) members were required to sign a formal agreement form prior to participation, which outlined the roles and responsibilities of both the research team and the board members. The agreement detailed the research team's commitments, including ensuring fair participation opportunities, providing feedback on member engagement, and offering compensation. This form also detailed members' responsibilities, which included attending all 3 remote advisory board meetings via Zoom between January and March 2025, actively participating with cameras on and from distraction-free environments, and promptly notifying the research team of any scheduling conflicts or changes in contact information. Agreement forms were made available in both English and Spanish, according to each member's preference, to ensure accessibility and comprehension across membership. To protect member confidentiality, all members agreed, as part of their signed agreement form, to refrain from sharing names, addresses, phone numbers, or other identifying information about fellow members outside the group or on social media. All member contact information was stored securely in Box, a password-protected platform accessible only to members of the research team. Regarding compensation, advisory board members were offered US $150 per meeting attended, for a maximum total of US $450 per member across 3 meetings. MAB members were compensated via honorarium payments; prior to payment, members independently completed Georgetown University's online supplier registration process through the GU Supplier Registration portal, after which payment was directly deposited upon completion of their 3-meeting commitment. Notably, a few of the MAB members preferred to waive compensation and provided their expertise voluntarily to support the study's goals. CAB members were compensated via their choice of mailed check or direct deposit, also issued upon completion of their 3-meeting commitment. These payment methods were intentionally selected to prioritize convenience and accessibility for each respective group. Specifically, streamlined direct payment options requiring minimal paperwork were chosen for community board members specifically to reduce potential barriers associated with sharing sensitive personal or financial information.

The script was developed using an integrated approach grounded in 3 established behavioral theories: the Health Belief Model (HBM), the Theory of Planned Behavior (TPB), and Social Cognitive Theory (SCT). HBM explains health behaviors as a function of individuals’ perceptions of risk and the benefits of taking action [49]. HBM constructs addressed in the script include perceived susceptibility, perceived severity, perceived benefits, perceived barriers, and cues to action. TPB posits that behavior is shaped by intention, which in turn is influenced by attitudes, perceived subjective norms, and perceived behavioral control [50]. Tenants of TPB used in the script include attitudes toward behaviors, subjective norms, and perceived behavioral control. SCT emphasizes learning through observation and the role of self-efficacy and social support in behavior change [51]. SCT constructs integrated into the script include modeling, self-efficacy, social support, and outcome expectations.

We also included anticipatory emotions, as previous work, including our own, demonstrates that the inclusion of anticipatory emotions enhances the predictive capacity of behavioral health models [52-55]. Anticipatory emotions are emotions experienced in the present when thinking about future events (eg, feeling fear now when thinking about the possibility of a skin cancer diagnosis). Emotional appeals in health-related messages are effective in motivating behavior [52-55]. For instance, fear appeals can prime individuals to avoid harm by engaging in protective behaviors. However, they can also generate defensiveness when the message leads to higher perceived threat than self-efficacy [52-56]. Fear appeals should thus be accompanied with messages that increase self-efficacy and treatment effectiveness [52-55]. Cancer prevention and control interventions have mostly targeted negative emotions [52-55]. Nevertheless, mixed messages that sequentially introduce both negative and positive emotions toward a health behavior (vs only negative) generate lower defensiveness, increase response efficacy, and strengthen intentions to follow the health recommendation [52-55].

To complement these behavioral frameworks, the Narrative Immersion Model (NIM) was integrated to guide the story structure and improve message engagement [57]. The NIM builds on broader theories of narrative persuasion (eg, entertainment-education), which explain the mechanisms by which narratives engage audiences more effectively than purely informational messages [57]. Following the NIM, we incorporated structural elements shown to enhance the processes of immersion, including temporal structure, realism, perceived similarity, humor, and surprise, through an outcome narrative focused on the consequences of unprotected sun exposure [57].

We leveraged our ongoing partnerships with community-based organizations (ie, Spanish Catholic Charities) to connect with and interview 25 outdoor workers across 3 focus groups [58]. Participants were predominantly male (22/25, 88%), 48% (12/25) had a middle school education or less, 52% (13/25) reported incomes ≤US $39,999, and 60% (15/25) were uninsured [58]. Results from these discussions gave the research team insight regarding existing skin cancer awareness, risk perception, risk reduction strategies, and barriers and facilitators for skin cancer prevention among Hispanic outdoor workers [58]. Findings from this study have been reported elsewhere [58]. The script also drew on existing literature and recommendations from organizations dedicated to skin cancer prevention [8,29,32,34,35,59,60].

Following the analysis of our data, the research team assembled both a MAB and a CAB. The MAB consisted of members representing dermatologists, oncologists, family medicine clinicians, occupational health experts, national skin cancer prevention organizations, patient navigators, and Hispanic melanoma survivors. The CAB included Spanish-speaking outdoor workers from various outdoor sectors including agriculture, construction, and landscaping. Table 1 provides a description of the specific organizations and individuals on each board.

We met with each advisory board separately for 2 hours across 2 sessions to review and gather suggestions for the script. The research team chose to establish 2 separate boards in order to create a space where CAB members could speak in Spanish and express their perspectives openly. For both cycles of input on the formative findings and script review, the CAB meeting was always held ahead of the MAB meeting. Recommendations from the CAB were then presented at each MAB meeting for consideration. The research team collaborated with the NCDA in Washington, DC, to develop the script and produce the video. NCDA members were present at every MAB meeting to engage with the board and ensure that suggestions were clearly understood before incorporating them in the script.

In the first meeting with our CAB, we presented the findings from our focus groups and asked about their thoughts regarding the results and content for the script. We subsequently met with our MAB and similarly discussed the focus group findings, the suggestions from our first CAB meeting, and gathered their recommendations. A first draft of the script was then developed by the NCDA. Upon obtaining the first draft of the script, the research team distributed the script to all board members for review.

Following a multiweek review period, we held a second meeting with our CAB to hear their thoughts on the script and gather their recommendations for refinement. We then met with our MAB to present the CAB’s suggestions and obtain the MAB’s recommendations. The research team subsequently consolidated and triangulated all suggestions before sending the script to the NCDA for final development.

After receiving the final version of the script, the research team translated the script into Spanish and consulted with a Spanish-speaking dermatologist on our MAB to ensure the medical terminology was accurate and consistent with dermatologic terms in Spanish.

Previously unreported recommendations from participants addressed video content and dissemination, including presenting clear information about skin cancer and sun protection, featuring relatable characters, and sharing the video through workplaces, community networks, and social media (Table 2).

CAB recommendations focused on explaining the causes of skin cancer, signs to look for, and how to protect oneself. MAB feedback emphasized clear clinical details, dialogue about the most common skin cancer diagnoses, and concise and relevant information on melanoma and nonmelanoma skin cancer types. Both boards suggested incorporating family-centered activities, including culturally relevant foods and sports, and providing national and local resources. Table 3 shows a detailed breakdown of the specific recommendations from each advisory board and the resulting adaptations to the video script.

The 27-minute video consists of 8 scenes, each designed to address specific behavioral constructs. The video narrates the story of Miguel, a landscape worker who is transitioning to lead his father’s landscaping company when he is diagnosed with BCC. The cancer is detected early and he undergoes a minor surgery, but the diagnosis raises concerns about the potential skin cancer risks for his family and employees. In his visits with the doctor, Miguel and his wife, Sofía, learn about different types of skin cancers (BCC, SCC, and melanoma), skin cancer signs, the importance of early detection, and key sun-protective behaviors. Following these visits, Miguel and Sofía share the information with their relatives and implement new sun safety practices at their workplace. Throughout the video, we target key Integrated Behavioral Model theoretical constructs as well as the barriers and facilitators we found in our formative work [58]. For instance, the video dispels common misconceptions (eg, skin cancer cannot occur in people with darker skin) and addresses knowledge gaps (eg, most efficient protective clothing). The video also models behaviors (eg, how to properly apply sunscreen) to increase self-efficacy and illustrates how subjective norms change throughout the narrative, from many coworkers being reticent about sunscreen use to then valuing and using sunscreen by the end. Finally, we included superficial cultural tailoring, such as having Hispanic actors, filming the video in Spanish, and including traditional Hispanic foods and popular sports such as soccer. Deep structure tailoring, addressing key core values and beliefs, included appealing to familismo as a core motivation to engage in sun-protective behavior and in portraying family support. Table 4 provides a detailed description of the video by scene, outlining the content and the theoretical constructs addressed in each segment.

The development of our educational video aimed at promoting sun protection among Hispanic outdoor workers and their families incorporated lessons learned from prior community outreach materials as well as guidance from workers, community leaders, and other stakeholders. In contrast to past approaches, our video uses entertainment-education, using a culturally contextualized narrative and visual demonstrations to impact knowledge, risk perception, and self-efficacy. Entertainment-education is unique among other approaches in that it delivers health messages through engaging stories that increase identification and reduce resistance to achieve lasting changes in attitudes and behaviors, demonstrating effectiveness in diverse contexts with empirical evidence and practical experiences [61,62].

Collaboration with national organizations, medical specialists, occupational health professionals, and community advisory members was crucial to the development of the video. Advisory boards built from personal experiences along with professional knowledge helped make the content practical and culturally sensitive. As reported by Cargo and Mercer [63], keeping community voices at the forefront of decision-making minimized technical or distant messaging, ensuring that behavior change strategies mirror real-life situations. Iterative review between the research and production teams was vital to preserving scientific accuracy while supporting the development of scenes that would resonate with our target audience. For instance, feedback from the CAB led to more scenes illustrating family members practicing sun safety and a soccer game to showcase healthy habits in culturally meaningful settings. These suggestions were consistent with findings from Perez et al [58], which highlight the value of a family-centric approach as well as appealing to the use of sunscreen by cultural role models (eg, soccer players). Feedback from the MAB, which was always informed by CAB suggestions, similarly resulted in expanding the doctor-patient conversation to clarify the differences in risks between BCC, SCC, and melanoma, as well as their prognosis and treatment timelines. It also prompted the inclusion of brief information regarding acral lentiginous melanoma because of its higher incidence among Hispanic White individuals than among non-Hispanic White individuals, despite being unrelated to occupational UV exposure [64,65]. Each scene thus reflects the integration of advisory board recommendations with theoretical concepts, behavioral goals, and cultural adaptations. This ensured that the video remained connected to both research and community priorities in concise, clear, and meaningful ways. Several challenges emerged from this development process, revealing key lessons about creating a culturally tailored, theory-driven video for health behavior change.

Producing an engaging video required balancing essential health information about skin cancer prevention with a culturally meaningful storyline, while keeping the length short enough for dissemination across various platforms. This meant trimming scenes, limiting transitions, and reducing extraneous lines, all of which required iterative reviews of the script, as well as weighing which elements were essential for educational impact versus narrative appeal. This demonstrated the value of not only developing the scenes based on specific health messaging but also discussing potential time distributions for each scene with the production team at the onset of script development.

Creating a gender-inclusive video required balancing culturally tailored content for a Hispanic outdoor workforce, which is predominantly men, while carefully integrating the representation of female workers [66]. To achieve this, Sofía acts as a primary educator in the video. She specifically educates female outdoor workers in scene 7 and addresses their specific concerns about workplace challenges to sun protection. Outside the workplace, Sofía demonstrates family-focused sun protection by showing how protective habits can fit into everyday life. In addition to discussing practical strategies for outdoor workers and their families, she models them in many ways (eg, sharing a basket of sunscreen with the children playing soccer in scene 8). Through these interactions, Sofía emphasizes the key role women have in promoting sun-safe behaviors both at work and home. Importantly, these strategies were shaped by female viewpoints. This included insights from 2 female members of the CAB and collaborations with female-led groups, such as Latinas in Construction, ensuring that women’s voices were consistently included throughout the process.

As reported by Hurtado-de-Mendoza et al [67], scenes discussing medical information require strict adherence to the script. When making this video, we had to ensure that the actors delivered their lines exactly as written, as even minor paraphrasing, which is common in filmmaking, could misrepresent important health information. For example, describing a new skin change as a “pimple,” which suggests something temporary and harmless, instead of as a “bump,” which can indicate a concerning change, is critical. Translating these terms into Spanish with precision in ways that are understandable added a layer of complexity, but it was facilitated by our MAB, which included a Spanish-speaking dermatologist. This process highlighted the additional time and effort it may take to film content that is both medically accurate and engaging, especially when there are time and budget constraints.

Managing input from 2 advisory boards required careful planning and execution. Scheduling across time zones and differing availability among clinicians, researchers, organizations, and community members often resulted in longer timelines. However, creating a distinct space in which community members could use their native language allowed us to build rapport and elicit conversations that yielded genuine and thorough suggestions. This approach underscored the importance of structuring engagement in a way that welcomes differing perspectives without diminishing the contributions of any group.

Prevention-based messaging for modifiable behavioral risks such as UV exposure, which are shaped by a range of daily behaviors, contexts, and environments, must anticipate multiple pathways of action and resistance. This includes but is not limited to addressing various considerations such as why outdoor workers may avoid sunscreen, the range of protective methods available, and the questions participants may have about each option. Messaging must not only provide guidance across multiple scenarios, but it must also recognize and support the agency associated with behavioral risks to encourage choices that directly influence risk.

Throughout our board discussions, we remained intentional about creating a video that would be clear for diverse audiences and remain accurate and relevant over time. A topic we extensively discussed, for example, was whether to show images of skin cancers. While we illustrated the ABCDEs (Asymmetry, Border, Color, Diameter, Evolution) of melanoma and described how skin cancers may look through dialogue, we ultimately chose not to include specific images as we recognized that Hispanic individuals have a wide range of skin tones. Thus, a particular image of how skin cancer looks in one person may not reflect how cancer appears on someone else. Showing such images could mislead viewers, leading them to think that a skin change that looks different from the example shown is harmless. Additional information and resources can be included as complementary materials to the video in future interventions. Furthermore, although questions about the role of government in preventing occupational skin cancer were raised by various collaborators, the prospects for action were unclear, and the decision was made to focus on empowering outdoor workers directly, as we recognize that not all employers provide resources regarding skin cancer awareness and prevention [68,69]. Therefore, all information in the video was limited to factual content, avoiding anything that could be misunderstood or become outdated. This logic was helpful as we considered other recommendations, and it also supported our aim of creating a video focused primarily on prevention among outdoor employees.

This project was strengthened by its theory-based and community-involved process. Most psychoeducation interventions follow a traditional didactic approach. Our video is innovative because it uses a narrative communication approach to convey health information through a story developed in collaboration with our advisory boards to ensure that the narrative resonates with the target population. The use of constructs from the HBM, TPB, and SCT ensured that the script addressed multiple determinants of behavior change, while input obtained through separate advisory boards allowed for open dialogue within each board and minimized the influence of professional hierarchies. Additional strength was provided by our partnership with a range of stakeholders, including dermatologists, occupational health experts, and representatives from various national organizations involved in skin cancer prevention. Outdoor workers consulted on the project also represented diverse geographic areas, including the District of Columbia, Maryland, Virginia, and Florida, increasing the cultural and contextual applicability of the script. The video format also provides practical benefits for sharing and scalability. Its visual and narrative style can overcome literacy barriers, demonstrate protective behaviors, and stress socially supported practices in ways that traditional print or educational materials cannot. Recognizing that the video was produced in Spanish and not all Hispanic outdoor workers may speak Spanish, however, we also created a version with English subtitles. In addition to helping it remain accessible in a lens that still resonates with non-Spanish speakers, given the overarching cultural values and experiences it is grounded in, the video can be broadly shared via various channels, including workplace training, community health clinics, and online platforms. Despite these strengths, the script was developed for a particular demographic and may require modification for use in alternate populations or settings beyond landscaping and construction. Additionally, although the CAB included representatives who were small business owners, we recognize that this level of representation was not sufficient to ensure comprehensive incorporation of employer-level perspectives. As a result, important organizational perspectives relevant to workplace implementation may not have been fully captured. Furthermore, while the development process was informed by theory and stakeholder feedback, the impact of the intervention on behavior change has yet to be evaluated and should be the focus of future research.

Additional research needs to be conducted to assess the acceptability and efficacy of our video on sun protection behaviors, psychosocial (eg, knowledge and self-efficacy) outcomes, and process evaluation outcomes. In addition to obtaining preliminary feedback from outdoor workers, future approaches could include a randomized controlled trial in which the video is compared with a control arm (eg, traditional didactic video or fact sheet) with longitudinal follow-up. This may also include the development and piloting of complementary tools or resources on sun protection, followed by studies comparing their efficacy to the video. Subsequent studies could also explore knowledge and behavioral changes not only among workers but also among their families to provide insight into the broader effects of the video, recognizing that its plot and call to action were guided by the principle of familismo. Pending these findings, future work should also consider adapting the video into English for non–Spanish-speaking outdoor workers and engaging a broader range of employers to ensure that workplace perspectives and implementation insights are fully incorporated. This could include a multilevel intervention addressing individual behaviors and organizational supports for sun protection, including workplace facilitators and barriers, integrating the video into workplace wellness and safety programs, input on acceptability, and alignment with existing training.

By combining formative research with input from both CAB and MAB, we developed a theory-driven, contextually relevant intervention that is responsive to the gaps reported in the work of others as well as our own. The resulting video is both a reflection of and response to the occupational realities faced by Hispanic outdoor workers, demonstrating how codeveloped interventions can bridge the gap between evidence and experience. Rather than imposing predefined messages, our approach relied on active listening and iterative content-tailoring, representing a departure from passive information transfer. We present this as an innovative approach in an effort to increase engagement, comprehension, and sun-protective behaviors among this population relative to traditional didactic methods. Based on the active participation from the workers who were involved in the video’s development, the video appears to have strong potential for effective implementation in real-world settings. More broadly, this project illustrates how integrating community participation with theory-based frameworks can enhance translation from research to practice, foster engagement among underserved populations, and promote health equity through culturally resonant prevention strategies.