Medical Students Teach Sun Safety: How the SPOTS Program Is Scaling Global Skin Cancer Prevention

Table of Contents

1. Key Highlights:
2. Introduction
3. From Campus Idea to Global Classroom: The Origins and Structure of SPOTS
4. What SPOTS Teaches: Curriculum, Activities, and Age-Appropriate Messaging
5. Evidence of Effectiveness: Peer-Reviewed Data and Measured Outcomes
6. Real-World Reach: Events, Partnerships, and Community Engagement
7. Why Early Education Changes Lifelong Risk Trajectories
8. Addressing Diversity: Teaching Skin Cancer Recognition Across Skin Tones
9. The Role of Medical Students: Training, Motivation, and Career Impact
10. Translating Knowledge Into Practice: How Schools and Families Can Implement SPOTS Principles
11. Scalability and Measurement: What Success Looks Like Beyond Knowledge Gains
12. Partnerships, Funding, and Organizational Credibility
13. Challenges and Limitations: Where SPOTS and Similar Programs Must Improve
14. How Educators and Clinicians Can Collaborate with SPOTS
15. The Broader Context: Prevention, Policy, and Population Health
16. Practical Takeaways for Parents, Coaches, and Educators
17. Looking Forward: SPOTS’ Next Moves and Measures of Success
18. FAQ

Key Highlights:

• SPOTS, a student-led sun-safety education program, expanded to 76 medical schools and launched its first international chapter in Ireland; medical students taught nearly 5,000 adolescents and more than 400 younger children in the past year.
• A multi-institution, peer-reviewed study in Dermatologic Surgery demonstrates that SPOTS measurably improves adolescents' sun-safety knowledge and intentions; ASA renewed its eighth-year partnership to broaden reach, translate materials into Spanish, and create science-center exhibits.

Introduction

Skin cancer ranks among the most frequently diagnosed cancers in the United States. Preventive measures taken during childhood and adolescence—when sun exposure patterns and tanning behaviors often begin—have outsized effects on lifetime risk. Recognizing that educational intervention at the community level can change behavior, a coalition of medical students and dermatologists created SPOTS (Sun Protection Outreach Teaching by Students), a program that brings age-appropriate skin-health lessons directly into schools, science centers, and community events.

SPOTS started in Saint Louis as a collaboration between two medical schools and has scaled into a national movement. In the last year the program reached thousands of students, added the Royal College of Surgeons in Ireland as its first international chapter, and published peer-reviewed evidence supporting its efficacy. The American Skin Association (ASA), a nonprofit focused on skin disease research and public education, renewed a long-standing partnership with SPOTS to accelerate growth, fund translations and exhibits, and strengthen outreach.

This account examines how a student-driven program has grown into an evidence-backed public health initiative, how its lessons are delivered and measured, what real-world examples reveal about school-based sun-safety campaigns, and what challenges remain as SPOTS moves from pilot classrooms to broader community impact.

From Campus Idea to Global Classroom: The Origins and Structure of SPOTS

SPOTS began as a pragmatic response to a simple gap: young people often lack clear, practical instruction on how to protect skin from ultraviolet (UV) radiation and how to recognize early signs of skin cancer. Medical students at Saint Louis University and Washington University in St. Louis converted clinical knowledge into educational modules tailored for audiences ranging from preschoolers to high schoolers.

The model rests on three pillars:

• Medical-student instructors who receive training in age-appropriate pedagogy and dermatologic content.
• A modular curriculum that covers sun protection, skin self-exams, the risks of tanning beds, and how skin cancer can present across diverse skin tones.
• Partnerships with schools, science centers, and community events that supply venues and audiences.

Growth followed replication. Students trained one another, the curriculum was refined through classroom feedback, and faculties at additional medical schools endorsed the model. SPOTS expanded to 76 participating medical schools. That level of institutional engagement provides multiple advantages: continuity as students graduate, local adaptation of lessons, and access to medical expertise for accurate content.

The program also formalized operational components that make it scalable. Downloadable lesson plans and activity kits allow new chapters to launch with minimal administrative friction. Logistics—such as obtaining school permissions, aligning lessons with classroom schedules, and arranging materials—are now part of the standard onboarding package SPOTS offers to prospective chapters.

The decision to pursue an international chapter at the Royal College of Surgeons in Ireland signals confidence in the model's transferability across health systems and school cultures. It also opens the possibility of comparative data collection that can refine messaging for different climates, outdoor activity norms, and regulatory contexts.

What SPOTS Teaches: Curriculum, Activities, and Age-Appropriate Messaging

The instructional design prioritizes clarity and interactivity. Rather than lecture-heavy presentations, SPOTS sessions use hands-on activities and narratives that make abstract risks tangible.

Core curriculum components:

• Proper sun protection: sunscreen application (broad-spectrum, SPF 30+), reapplication rules, wearing protective clothing, hats, sunglasses, and seeking shade during peak UV hours.
• Skin self-exams: how to perform regular checks, the "ABCDE" criteria for suspicious moles (Asymmetry, Border irregularity, Color variation, Diameter, Evolving), and when to seek medical advice.
• Early signs of skin cancer: visual cues for melanoma as well as non-melanoma skin cancers to demystify what warrants concern.
• Risks of tanning beds: the additive UV exposure from indoor tanning and the strong association between early tanning bed use and later melanoma risk.
• Recognizing skin cancer on diverse skin tones: images and descriptions that counter the misconception that darker skin eliminates skin cancer risk.

Lesson formats vary by age:

Preschool and elementary: Simple, play-based activities reinforce physical behaviors—donning sun hats, applying pretend sunscreen, and identifying shady spots. Visual aids and UV-detecting bracelets help children associate sun exposure with an immediate, observable effect.

Middle school: Interactive demonstrations—such as showing how sunscreen blocks UV using UV-sensitive beads or lamps—pair with short discussions about risk-taking and peer influence. Role-playing exercises teach students how to encourage friends to adopt sun-safe habits.

High school: Deeper engagement on the science of UV damage, steps for regular skin self-exams, and frank discussions about tanning bed marketing and self-image pressures. High school sessions often include resources for parents and links to local dermatology clinics for follow-up.

SPOTS materials include brochures, bookmarks, lesson plans, and digital resources for continued reinforcement. The program also uses simple behavior-change prompts—like implementing "sunscreen days" for sports teams or attaching UV bracelets to backpacks—to turn one-off learning into routine practice.

Evidence of Effectiveness: Peer-Reviewed Data and Measured Outcomes

Health education programs must demonstrate not just reach but impact. SPOTS addressed this requirement by conducting a multi-institutional study, subsequently published in Dermatologic Surgery, evaluating the program's efficacy among adolescents.

Key outcomes reported:

• Substantial improvements in sun-safety knowledge among participating students following lessons.
• Increased intention to adopt protective behaviors, such as using sunscreen and seeking shade.
• Positive shifts sustained in short-term follow-up, suggesting that well-structured school sessions can move both knowledge and behavioral intent.

The academic rigor comes from multi-site data collection and standardized evaluation tools. By comparing pre- and post-session survey responses, researchers quantified gains in specific knowledge areas—proper sunscreen use, recognition of early signs, and the dangers of tanning beds. Multi-institution participation reduces bias from a single-site implementation and better approximates the variety of school contexts where SPOTS operates.

Peer-reviewed evidence matters for several reasons. It strengthens fundraising appeals, persuades school administrators and public-health officials to allow program access, and provides an empirical basis for future curriculum refinements. Many community health programs rely on anecdote; SPOTS now complements anecdotes with reproducible evidence supporting its educational claim.

Real-World Reach: Events, Partnerships, and Community Engagement

Growth depends on partnerships. SPOTS’ collaboration with the American Skin Association provided organizational support and visibility. In 2025 the program supplemented classroom sessions with public-facing activities.

Notable examples:

• SciFest at the Saint Louis Science Center: SPOTS set up an interactive booth during the festival and reached more than 500 students and families with brochures, bookmarks, and UV-detecting bracelets. Such events expose families that might not otherwise see school-based programming to practical sun-safety tools.
• School partnerships across districts: Local chapters integrate SPOTS lessons into health class units, athletics orientation, or science fairs.
• Conference and community displays: Preparing exhibits for science centers responds to how families consume informal education—by encountering accessible explanations while attending museum events.

These outreach strategies convert transient interactions into sustained interest. UV bracelets given at events act as behavioral nudges; a child who receives one at SciFest may later request sunscreen or shade for outdoor play. Public engagement also elevates parental awareness, which is crucial: parents make many decisions that influence a child’s sun exposure, from purchasing sunscreen to scheduling outdoor activities.

SPOTS’ planned expansion into science-center exhibits and translated materials targets two persistent limitations of public-health education: scale and accessibility. Exhibits create permanent or semi-permanent infrastructure that reaches visitors beyond scheduled school sessions. Spanish-language materials address linguistic barriers in communities where English is not the primary language, helping ensure that prevention messages reach broader demographics.

Why Early Education Changes Lifelong Risk Trajectories

Behavioral patterns that begin in childhood often persist into adulthood. Sun-exposure habits formed during adolescence—frequency of sunscreen use, acceptance of tanned appearance, and tanning bed use—affect cumulative UV dose, which correlates with later skin-cancer risk.

Evidence from population-level examples supports the value of early intervention:

• Australia’s SunSmart program: A sustained national campaign, combined with school policies and shade construction, coincided with stabilization and declines in melanoma incidence among younger cohorts in regions where interventions were adopted early. The program integrated school education with community-wide policy measures, showing that education combined with environmental change yields measurable benefits.
• U.S. state policies limiting tanning bed access for minors: Where strict regulations exist, early-age exposure to artificial tanning decreases. Each state-level policy adds a protective layer beyond classroom education.

Education alone does not eliminate risk, but it equips young people with knowledge and options. A teen who understands that tanning beds dramatically increase melanoma risk and who has practiced applying sunscreen is more likely to refuse indoor tanning and protect their skin during outdoor sports.

Medical-student instructors add credibility. Students trained in dermatology concepts can translate clinical concerns into practical guides. Their near-peer status aids communication; adolescents often respond better to instructors who are closer in age and who can relate to social pressures.

Addressing Diversity: Teaching Skin Cancer Recognition Across Skin Tones

One of the program’s distinguishing features is a deliberate focus on how skin cancer presents in diverse skin tones. Traditional educational materials have overemphasized photographs of lighter skin, inadvertently creating a false sense of security among people with darker skin.

SPOTS corrects this by:

• Including images and descriptors showing how melanoma and other skin cancers may appear on darker skin—often in less pigmented areas, such as palms, soles, and nail beds.
• Explaining that while melanin offers some natural UV protection, it does not eliminate risk.
• Encouraging regular self-exams and early reporting of suspicious lesions, irrespective of skin color.

This approach responds to known disparities. People with darker skin are often diagnosed at later stages and have worse outcomes. Awareness that skin cancer can appear on any skin tone can improve early detection and reduce disparities in prognosis.

Translation into Spanish further broadens cultural competence. Linguistic accessibility matters for immigrant communities and Spanish-dominant households where parental guidance and school communications must be intelligible for effective behavioral adoption.

The Role of Medical Students: Training, Motivation, and Career Impact

Medical students gain more than teaching experience through SPOTS; they acquire skills that enhance clinical practice. Preparing lessons requires reviewing dermatologic evidence, practicing patient-centered communication, and learning how to distill technical information for lay audiences.

Benefits for student volunteers:

• Improved knowledge retention: Teaching reinforces core dermatologic concepts.
• Communication skills: Developing age-appropriate messaging enhances future patient interactions.
• Professional identity formation: Engaging with prevention and community health fosters a broader view of medicine beyond diagnosis and treatment.

Medical schools that sponsor SPOTS chapters often integrate the work into service-learning requirements or elective coursework. Faculty oversight ensures scientific accuracy and helps students navigate ethical concerns—such as obtaining appropriate consent for school visits and safeguarding privacy when discussing case examples.

This reciprocal benefit—students teach and learn simultaneously—has practical recruitment advantages. Medical students seeking community engagement, public health experience, and opportunities to lead programs find SPOTS appealing. Retention of institutional knowledge across cohorts also becomes easier when SPOTS is recognized as part of a school’s extracurricular ecosystem.

Translating Knowledge Into Practice: How Schools and Families Can Implement SPOTS Principles

Schools and families can adopt several pragmatic steps immediately to reduce UV risk:

For schools:

• Integrate sun-safety modules into existing health or science curricula. A single class period can cover core behaviors, followed by reminders during peak sun seasons.
• Establish policies encouraging or requiring hats and sun-protective clothing for outdoor activities, especially for recess and sports.
• Provide sunscreen dispensers at athletic fields and outdoor gathering areas.
• Build shade structures where children gather—playgrounds, outdoor classrooms, and spectator areas.
• Coordinate with SPOTS or local health departments to host assemblies or booths during events like open houses and science fairs.

For families:

• Apply broad-spectrum sunscreen (SPF 30 or higher) to children before outdoor activities and reapply every two hours or after swimming or sweating.
• Choose UPF-rated clothing for extended outdoor play and wide-brim hats for added protection.
• Model sun-protective behavior. Children mimic adults; visible sun-safety practices increase the likelihood of adoption.
• Avoid tanning beds. If adolescents express interest in tanning for appearance reasons, discuss alternative options like sunless tanners and the long-term risks of UV exposure.
• Learn and practice skin self-exams together, establishing a routine to check key body areas and discuss any changes with a clinician.

Implementation need not be costly. UV-detecting bracelets and inexpensive brochures serve as reminders. Targeted policies—such as "no tanning bed" consent forms for school athletic teams—require administrative will more than elaborate budgets.

Scalability and Measurement: What Success Looks Like Beyond Knowledge Gains

SPOTS’ initial evaluation demonstrated improvements in knowledge and intent. Next-level success depends on three domains:

1. Sustained behavior change: Short-term intention does not always translate to long-term action. Measuring sunscreen use over months and tracking reductions in intentional tanning among teens are important metrics. Longitudinal surveys, partnerships with school health services, and embedding follow-up lessons into curricula can improve measurement fidelity.
2. Environmental and policy change: Schools that adopt sun-safety policies, install shade, and create access to sunscreen extend the program’s impact from individual knowledge to structural protection. Evaluating the extent of such policy adoptions offers a metric of institutionalization.
3. Health outcomes over decades: The ultimate public-health goal is reduced skin-cancer incidence and mortality. Detecting such reductions requires long time horizons and robust epidemiologic studies. While classroom interventions alone will not immediately alter national incidence rates, they are a necessary part of multi-level strategies that include regulation (e.g., tanning bed restrictions), clinical screening, and population-level messaging.

SPOTS’ strategy to create exhibits and increase social-media presence speaks to the scalability challenge. Physical exhibits provide repeated exposure; social media reaches adolescents where they spend substantial time. Both channels generate data—visitor counts, engagement metrics, and click-through rates—that can supplement traditional survey methods.

Partnerships, Funding, and Organizational Credibility

SPOTS’ collaboration with the American Skin Association anchors the program in an organization with decades of advocacy and research funding experience. ASA’s backing confers credibility when approaching school districts, public health departments, and donors.

ASA highlights:

• A multi-decade nonprofit focusing on skin disease research and public awareness.
• A network that connects patients, clinicians, and researchers—useful for program promotion and evidence translation.
• Recognition by philanthropic watchdogs, which helps assure donors and partners of governance standards.

Securing sustainable funding is a perennial challenge. Programs reliant solely on volunteer effort face constraints when student turnover and competing academic demands reduce capacity. Funding priorities include training materials, exhibit construction, translation services, and small stipends for coordination. ASA’s continued sponsorship reduces start-up barriers for new chapters and allows SPOTS to invest in evaluation.

Partnerships extend beyond nonprofits. Science centers, school districts, athletic leagues, and local government health departments provide venues, credibility, and channels for broader dissemination. Private-sector partners—manufacturers of sunscreen or apparel companies producing UPF clothing—can offer in-kind support, though program leaders must balance sponsorship with scientific independence and avoid conflicts of interest when choosing partners.

Challenges and Limitations: Where SPOTS and Similar Programs Must Improve

No public-health intervention scales without obstacles. SPOTS faces several plausible challenges as it grows:

• Measuring long-term behavioral change: Follow-up beyond immediate post-session surveys is resource intensive and subject to attrition. Tracking cohorts over years requires institutional partnerships and possibly longitudinal funding mechanisms.
• Ensuring consistent teaching quality: As chapters multiply, variability in instructor experience can affect lesson fidelity. Centralized training modules, mentorship programs, and periodic quality audits help, but require staff time.
• Overcoming cultural norms around tanning: Appearance ideals and social media trends that valorize tanned skin persist, especially among adolescents. Education that relies on factual messaging must be paired with positive alternatives and supportive peer networks to shift norms.
• Access in underserved communities: Schools in under-resourced districts may lack capacity to host programs or implement policy changes (like building shade structures). Targeted outreach and grant funding for materials or shade-installation can partially address these inequities.
• Digital misinformation: Adolescents receive health information from varied sources. Misinformation can undercut evidence-based messages. A stronger social-media strategy, planned by SPOTS, aims to create authoritative, youth-facing content that competes with inaccurate narratives.

Recognizing these limitations does not negate SPOTS’ achievements. Instead, it points to the need for multi-pronged strategies—policy, community engagement, clinical access, and media—to achieve sustained public-health gains.

How Educators and Clinicians Can Collaborate with SPOTS

Clinicians and educators interested in partnering with SPOTS have multiple entry points:

• Host a session: Schools and community organizations can request SPOTS visits through the program’s website. Sessions can be tailored by age group and duration.
• Sponsor materials and exhibits: Local clinics or health departments can fund brochures, UV bracelets, or a traveling exhibit for community events.
• Provide clinical follow-up: Dermatologists and primary-care clinicians can offer screening slots at reduced cost to students referred after school-based screenings or self-exams.
• Mentor student instructors: Faculty can support medical-student trainers, ensuring scientific accuracy and helping students translate clinical recommendations into accessible lessons.
• Advocate for policy: Clinicians can testify at school-board meetings or state legislatures supporting sunscreen availability, shade construction, and tanning bed restrictions for minors.

Such collaborations multiply the program’s effect. Schools supply the audience; clinicians provide credibility; community organizations maintain continuity. When these stakeholders align, lessons learned in a single classroom can influence district-level policies.

The Broader Context: Prevention, Policy, and Population Health

SPOTS occupies a practical intersection between education and prevention. The program does not replace clinical screening or policy change; it complements them.

Effective skin-cancer prevention at the population level requires:

• Individual behavior change: consistent use of sun protection and avoidance of indoor tanning.
• Environmental supports: availability of shade, sunscreen access, and protective clothing options.
• Policy interventions: restrictions on tanning bed access for minors and curriculum standards that include sun-safety education.
• Clinical systems: accessible dermatologic care for evaluation of suspicious lesions and for high-risk individuals to receive counseling and surveillance.

SPOTS contributes to the first pillar while nudging institutions toward the others. By educating students and families, the program generates demand for protective environments and supportive policies.

The public-health lens also emphasizes equity. Skin-cancer prevention must consider barriers that vary by socioeconomic status, language, and geography. Rural outdoor-worker populations, for instance, face occupational exposure that requires workplace protections; urban communities may need shade in schoolyards; migrant families may require multilingual programming to access services. SPOTS’ decision to translate materials into Spanish addresses one facet of these disparities.

Practical Takeaways for Parents, Coaches, and Educators

To convert program knowledge into practical action, consider the following checklist:

For parents:

• Keep a travel-size sunscreen in bags and reapply every two hours during outdoor activities.
• Choose clothing with built-in sun protection (UPF-rated), especially for water activities.
• Encourage shade-seeking behavior during peak UV hours (10 a.m.–4 p.m.) and plan outdoor play earlier or later.
• Discourage tanning bed use and educate teens about long-term risks.

For coaches and athletic directors:

• Incorporate sunscreen breaks and provide sunscreen on-site for athletes.
• Allow and encourage hats during practice sessions when medically safe for the sport.
• Schedule practices to avoid midday sun when feasible.

For teachers and administrators:

• Add a single sun-safety lesson to health curricula and repeat seasonally.
• Host SPOTS or similar programs for assemblies or parent nights.
• Assess playgrounds and outdoor common areas for shade needs and apply for grants or district funding to address gaps.

For students and adolescents:

• Practice monthly skin self-exams and report new or changing spots to a trusted adult and clinician.
• Learn to identify high-risk behaviors (e.g., indoor tanning) and discuss alternatives for appearance concerns.
• Share what you learn with peers—peer-to-peer counseling can be among the most effective influencers.

These steps emphasize routine and norms rather than one-off acts. A community that normalizes sunscreen, protective clothing, and reasoned attitudes toward tanning reduces cumulative UV exposure across lifespans.

Looking Forward: SPOTS’ Next Moves and Measures of Success

SPOTS plans to deepen its community footprint through several initiatives:

• Developing permanent and traveling exhibits for science centers to reach families outside school schedules.
• Translating materials into Spanish to increase accessibility.
• Expanding social-media engagement to meet adolescents where they are and counter misinformation.

Measuring success will involve both reach (number of students engaged, chapters launched) and impact (policy adoptions, documented behavioral changes). Extended evaluation projects could track sunscreen sales in participating districts, reductions in tanning-bed use among teens, or later-stage diagnosis trends when data allow.

Long-term, SPOTS could serve as a template for student-led, evidence-based health education programs in other domains—such as concussion prevention, nutrition, and mental health—where student instructors can translate clinical knowledge into community benefit.

FAQ

Q: Who created SPOTS and what does the acronym stand for? A: SPOTS stands for Sun Protection Outreach Teaching by Students. It originated as a collaboration between medical students and faculty at Saint Louis University and Washington University School of Medicine in Saint Louis, Missouri.

Q: How many schools and students has SPOTS reached? A: As of the most recent reporting, SPOTS involves medical students from 76 participating medical schools. In the referenced year, student instructors taught nearly 5,000 adolescents and over 400 preschool and elementary students. Outreach at public events, like SciFest, added hundreds more contacts.

Q: Is there scientific evidence that SPOTS works? A: Yes. A multi-institutional study published in Dermatologic Surgery evaluated the program and found substantial improvements in adolescents’ sun-safety knowledge and intentions to adopt protective behaviors after SPOTS lessons.

Q: What topics are covered in SPOTS lessons? A: Lessons include proper sun protection (sunscreen, clothing, shade), how to perform skin self-exams, early signs of skin cancer, the risks associated with tanning beds, and how skin cancer can appear on diverse skin tones.

Q: Can schools request a SPOTS visit? A: Yes. SPOTS provides downloadable teaching materials and coordinates with local chapters to schedule visits. Schools can find information and request support through the program’s website.

Q: Are materials available in languages other than English? A: SPOTS has committed to translating all educational materials into Spanish as part of its expansion plans; additional translations may be considered to meet community needs.

Q: How does SPOTS ensure age-appropriate instruction? A: The curriculum is modular and tailored to age groups. For young children, lessons are interactive and play-based. Older students receive more in-depth scientific information and practical behavioral prompts related to sports and social pressures.

Q: How can medical schools or students start a SPOTS chapter? A: Prospective chapters can download teaching materials from spotseducation.org, contact existing chapter leaders for mentorship, and coordinate with faculty sponsors to adapt lessons to local contexts.

Q: What role does the American Skin Association play? A: ASA supports SPOTS through partnership, providing resources, visibility, and coordination assistance. ASA renewed its eighth consecutive year of collaboration to help expand the program’s reach and resource base.

Q: How can parents reinforce SPOTS’ messages at home? A: Parents can model sun-safe behavior, ensure consistent sunscreen use, provide UPF clothing, discourage tanning-bed use, and practice regular skin self-examinations with their children.

Q: Is SPOTS free for schools? A: Many SPOTS chapters operate through volunteer medical-student instructors and provide in-school lessons at no cost. Costs for materials and exhibit development are supported through ASA partnerships and grants; schools interested in hosting exhibits or large events may need to discuss logistical arrangements with local chapter coordinators.

Q: What are common barriers to implementing sun-safety programs in schools, and how can they be addressed? A: Barriers include limited classroom time, resource constraints for shade structures, and cultural norms around tanning. Addressing these barriers involves embedding short lessons into existing curricula, seeking small grants or district funds for shade or sunscreen dispensers, and running peer-led campaigns that shift social norms.

Q: Can SPOTS help with professional development for teachers? A: SPOTS materials include lesson plans and instructor guides that educators can use. Some chapters may offer teacher-training sessions or co-teach initial lessons, depending on local capacity.

Q: Where can I learn more or contribute? A: Visit americanskin.org for information on ASA and spotseducation.org for details about SPOTS, downloadable materials, and how to start a chapter.

This coverage traces how a student-powered educational initiative evolved into an evidence-backed public-health tool. SPOTS demonstrates that medical students, when equipped with rigorous curricula and community partnerships, can deliver measurable improvements in knowledge and intention and contribute to a broader ecosystem of prevention that includes policy, clinical care, and environmental change.