Patient adherence to skin self-examination: effect of nurse intervention with photographs

doi:10.1016/j.amepre.2003.10.006

American Journal of Preventive Medicine

Volume 26, Issue 2, February 2004, Pages 152-155

https://doi.org/10.1016/j.amepre.2003.10.006 Get rights and content

Abstract

Background

Results from a single case–control study suggest that skin self-examination (SSE) has the potential to reduce mortality from melanoma by 63%. Despite these encouraging results, SSE rates are low. Few prospective studies of interventions to increase SSE in high-risk cohorts have been performed. The purpose of this study was to assess the impact of a brief nurse-delivered intervention using digital photographs on patients' adherence to performing SSE.

Design setting/participants

Patients at high risk for melanoma skin cancer (five or more dysplastic nevi) (N=100) were recruited from the outpatient Pigmented Lesion Clinic at Memorial Sloan–Kettering Cancer Center. All participants had baseline whole-body digital photography as part of their clinical evaluation.

Intervention

Patients were randomized: Group A (n =49) received a teaching intervention (physician and nurse education module) with a photo book (personal whole-body photographs compiled in the form of a booklet, with nurse instruction on how to use the photographs); and Group B (n =51) received the teaching intervention only without a photo book.

Main outcome/measures

Self-administered questionnaires were provided at three intervals: baseline, post-teaching intervention, and at the 4-month post-baseline visit. To assess adherence with SSE, patients were asked, “How many times in the past 4 months did you (or someone else) usually, thoroughly examine your skin?”

Results

In Group A (teaching intervention with photo book), 10.2% of the patients at baseline reported skin examination three or more times during the past 4 months, while 61.2% reported skin examination three or more times at the 4-month follow-up (p =0.039 for paired comparison). In Group B (teaching intervention only), nearly 20% of the patients at baseline reported skin examination three or more times during the past 4 months, while 37% reported skin examination three or more times at the 4-month follow-up (p =0.63). The increase in reported skin examination was compared between the two groups (>51% v >17.6%, p =0.001).

Conclusions

The results suggest that a brief nurse-delivered intervention is effective at increasing patient adherence with SSE. Utilizing digital photographs as an adjunct to screening appeared to increase patient adherence to performing SSE.

Introduction

I t is estimated that there will be 54,200 new cases of malignant melanoma and 7600 melanoma deaths in the United States during 2003.1 The direct relationship between survival of patients with melanoma and thin lesions (thicker lesions have been associated with a poorer prognosis) suggests that the identification and excision of thin lesions may be important in reducing mortality from melanoma.2, 3, 4, 5 The American Academy of Dermatology has recommended that individuals practice skin self-examination (SSE) to detect new and changing lesions.6 Individuals have the potential to make a significant impact on identifying early melanoma (when still curable) by conducting periodic SSE and detecting new lesions or significant changes in pre-existing lesions.7 Self-screening is important because detection by patients, spouses, and families is the most common way skin cancer is currently detected, even though SSE may not be performed routinely or thoroughly.8, 9, 10

Patients with large numbers of common and dysplastic nevi present a unique challenge; they have a dramatically elevated risk for developing melanoma and the number and atypia of their moles complicate attempts at early detection.11 For example, the relative risk for patients with five or more dysplastic nevi have ranged from five- to six-fold.12, 13 In this high-risk population, baseline photography is being used at specialized centers to facilitate the recognition of new or changing lesions during professional surveillance for melanoma detection. To date, no studies have investigated the value of formal patient training in SSE by nurses or of making baseline photographs available to patients for the performance of SSE. A pilot study using nurse education to increase SSE was conducted by Berwick et al.14 Results suggested that increases in SSE were associated with increases in knowledge about melanoma. Providing patients with photographs provides a baseline measure and may encourage the patient to carefully watch lesions,15 better detect changes in their lesions, or perform SSE more regularly if they have an opportunity to repeatedly view the original lesion with photographs.16 The purpose of this study was to assess the impact of a brief, nurse-delivered, randomized-design intervention utilizing digital photographs on patients' adherence to performing SSE.

Section snippets

Study subjects

The study base included patients who attended the outpatient Pigmented Lesion Clinic of the Dermatology Service (Memorial Sloan–Kettering Cancer Center, New York) for new dermatology-related visits. Patients aged ≥18 years and with five or more clinical dysplastic/atypical nevi (as determined by the physician), who were willing to have digital whole-body photography and agreed to be randomized to an intervention arm, were recruited and informed consent obtained (N=100). Patients who were

Results

Characteristics of the study population are presented in Table 1. The participation rate for this study was 95%; 100/105 patients agreed to participate and provided informed consent. In Group A and Group B, 86% and 84% completed the 4-month follow-up, respectively. Patient adherence with SSE is presented in Table 2.

Discussion

This study was the first to assess the effect of a nurse-delivered intervention utilizing digital photographs to enhance adherence with SSE. A major limitation of this study was the short duration of follow-up (4 months) and the potential for the intervention effects to degrade over time. This time period was chosen to evaluate the short-term impact of the intervention on the primary outcomes of interest, but ideally assessment and evaluation would also occur at other defined endpoints. This

Acknowledgements

We are grateful to the patients at Memorial Sloan–Kettering Cancer Center for their participation in this study. We thank Jennifer Bragg for her helpful comments and suggestions during the revising of this manuscript.

References (28)

H.K. Koh et al.
Who discovers melanoma? Patterns from a population-based survey
J Am Acad Dermatol
(1992)
D.R. Miller et al.
Melanoma awareness and self-examination practicesresults of a United States survey
J Am Acad Dermatol
(1996)
M.A. Weinstock et al.
Thorough skin examination for the early detection of melanoma
Am J Prev Med
(1999)
C. Garbe et al.
Risk factors for developing cutaneous melanoma and criteria for identifying persons at riskmulticenter case-control study of the Central Malignant Melanoma Registry of the German Dermatological Society
J Invest Dermatol
(1994)
R.A. Knight et al.
The relevance of the health belief model to Australian smokers
Soc Sci Med
(1989)
R. Guibert et al.
What factors determine whether individuals found to have hypercholesterolaemia at mass screening accept advice to visit their physician
Public Health
(1999)
A. Jemal et al.
Cancer statistics, 2003
CA Cancer J Clin
(2003)
A. Breslow
Thickness cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma
Ann Surg
(1970)
D.J. Margolis et al.
Validation of a melanoma prognostic model
Arch Dermatol
(1998)
S. Sahin et al.
Predicting ten-year survival of patients with primary cutaneous melanomacorroboration of a prognostic model
Cancer
(1997)

A. Breslow

Tumor thickness, level of invasion and node dissection in stage I cutaneous melanoma

Ann Surg

(1975)

H.K. Koh et al.

The early detection of and screening for melanoma. International status

Cancer

(1995)

M.A. Weinstock

Early detection of melanoma

JAMA

(2000)

M.A. Tucker et al.

Clinically recognized dysplastic nevi. A central risk factor for cutaneous melanoma

JAMA

(1997)

Cited by (66)

Operationalization of skin self-examination in randomized controlled trials with individuals at increased risk for melanoma: A systematic review
2020, Patient Education and Counseling
Citation Excerpt :
For the continuously scored outcomes, the answer choices indicated different frequency ranges for SSE across different trials (specific details included in Table 2). The timeframe for the assessment of SSE behavior ranged from “last 2 months” [34] to “last 12 months” [35,46], with the most frequent timeframe being “last 4 months” [41,43,44]. Generally, there was substantial variability between trials with respect to the item content, response format, scoring procedures, and timeframe of assessment for SSE measures, with no two trials using identical methods.
To investigate how skin self-examination was operationalized and the psychometric properties of the scales used to assess this behavior in randomized controlled trials (RCTs) testing interventions that promote SSE among individuals at increased risk for melanoma.
Eight scientific databases (e.g., Medline, EMBASE, CINAHL, PsycINFO) and four trial registries (e.g., Clinicaltrials.gov, UK Clinical Trails Gateway) were searched from inception through April 2, 2019. Three reviewers carried out the selection of relevant trials and conducted data extraction.
The review identified 13 unique RCT’s. The definition of skin self-exams, extrapolated from instructions provided to participants during the trials and reported in only 6/13 trials, included periodically checking the skin of the entire body, individually or with partners/mirrors, with or without tracking or monitoring tools, and using the ABCDE criteria to identify early signs of melanoma. There was variability in how skin self-examination behavior was measured with respect to item content, number of items, response format, and type of outcome variable used: continuous or binary). No validity evidence and minimal reliability evidence for the measures were identified.
Future studies are needed to establish the psychometric properties of measures assessing skin self-examination.
Development and initial validation of the Self-Efficacy for Skin Self-Examination Scale in a Canadian sample of patients with melanoma
2019, European Journal of Oncology Nursing
Melanoma is the deadliest type of skin cancer, although survival rates are high if detected early. Skin self-examination (SSE) is a health behaviour that can lead to early detection of melanoma and more positive health outcomes. Self-efficacy for SSE is a potential predictor of engaging in skin self-exams. However, no standardized measures of self-efficacy for SSE are currently available. The present study reports on the development and initial validation of a measure assessing self-efficacy for SSE.
Based on a literature review, including previous studies assessing this construct, the research team developed 9 items capturing confidence in one's ability to conduct SSE. Items were subsequently revised by the research team and two dermatologists, resulting in the elimination of 4 items and modifications to the response options. The final 5-item Self-Efficacy for SSE scale was administered to a sample of 242 melanoma patients recruited from local hospitals. We assessed the scale's factor structure through exploratory factor analysis and the internal consistency with Cronbach's alpha. Scale scores were correlated with intentions to perform SSE, physician support for SSE, skin cancer-specific distress, general distress, and sociodemographic variables to assess convergent and divergent validity.
The scale was found to be unifactorial with adequate model fit, have acceptable internal consistency (Cronbach alpha = 0.74), and initial evidence of convergent and divergent validity, as indicated by the scale correlating with physicians' support for SSE (r = 0.30, p < 0.01), intention to perform SSE (r_s = 0.21, p < 0.01) and a weak correlation with general distress (r = 0.15, p < 0.05).
Pending future research corroborating these findings, this measure has potential for use by nurses and other health professionals in follow-up care to identify individuals at risk for low self-efficacy for SSE requiring more targeted educational SSE interventions.
The role of patient education and physician support in self-efficacy for skin self-examination among patients with melanoma
2017, Patient Education and Counseling
Citation Excerpt :
For example, in a study of 483 melanoma patients, it was reported both immediately after the diagnosis and at a 10-year follow-up, that the two most frequently endorsed ways of coping were “trusting my doctors” and “following the medical advice exactly” [38]. Teaching SSE to patients has an impact on their SSE performance [29,34,39–43]. However, the reality of many healthcare systems around the world is that the physicians have little time to teach prevention skills to every patient [44,45].
This project aims to elucidate the relationships between skin self-examination (SSE), perceived physician support of SSE, and self-efficacy for SSE among melanoma patients.
A longitudinal study of patients diagnosed with melanoma was conducted over the span of 18 months. Participants filled out questionnaires at four assessment points and participated in an SSE education about the early signs of melanoma.
Among the 242 patients enrolled, the level of self-efficacy for SSE was 23% higher immediately after the educational intervention (p < .001) and the increase was retained three months (p < .001) and twelve months later (p < .001). Additionally, a one-way repeated measures ANOVA revealed that the perceived physician support of SSE positively corresponded to the level of patient self-efficacy with higher patient-reported physician support being related to higher self-efficacy (p = .001).
Patient education and perceived physician support of SSE are positively associated with patients’ level of self-efficacy.
Physicians caring for melanoma survivors should be aware that, both SSE education and patients’ perception of high physician support of SSE may be associated with higher self-efficacy for checking one’s own skin for signs of cancer recurrence.
Cutaneous melanoma: A current overview
2016, Seminars in Diagnostic Pathology
A systematic review of interventions to improve adherence to melanoma preventive behaviors for individuals at elevated risk
2016, Preventive Medicine
Citation Excerpt :
There were significant improvements in sunscreen application as assessed via a diary, but not when assessed via the Sun Habits Survey. Most interventions targeting SSE behaviors (9 out of 12 interventions, 75%) led to statistically significant improvements in the frequency and/or thoroughness of SSEs at least one follow-up assessment post-intervention (Aspinwall et al., 2008, 2013; Berwick et al., 2000; Boone et al., 2009; Geller et al., 2006; K. Glanz et al., 2010, 2013; Glazebrook et al., 2006; Hay et al., 2006; Kasparian et al., 2009; Manne et al., 2010; Oliveria et al., 2004; Rat et al., 2014; Robinson et al., 2007, 2010; Taber et al., 2013). At the first assessment post-intervention, the majority of interventions targeting SSE reported significant improvements in SSE frequency (8 out of 12, 67%), but fewer targeting SSE thoroughness (1 out of 4, 25%) or both frequency and thoroughness (1 out of 3, 33%) reported improvements.
To examine the effectiveness of behavioral interventions for melanoma prevention targeted to individuals at elevated risk due to personal and/or family history.
Through literature searches in 5 search databases (through July 2014), 20 articles describing 14 unique interventions focused on melanoma prevention among individuals at elevated risk for the disease were identified. Interventions targeting only patients undergoing active treatment for melanoma were excluded.
The average study quality was moderate. The majority of interventions (6 out of 9, 66% of studies) led to improvements in one or more photoprotective behaviors, particularly for improvements in use of protective clothing (3 out of 5, 60% of studies), and frequency and/or thoroughness of skin self-examinations (9 out of 12, 75%). Fewer interventions (5 out of 14, 36%) targeted uptake of total body skin examinations (60% led to improvements). Also, fewer interventions targeted all three preventive behaviors (5 out of 14, 36%).
Findings suggest that future interventions should aim to improve adherence across multiple preventive behaviors, over a longer time period (past 8 months post-intervention), and target high-risk children. Studies should include adequate sample sizes to investigate moderators and mediators of intervention effectiveness. Interventions may be strengthened by new techniques, such as incorporating family members (e.g., to improve thoroughness of skin self-examinations) and eHealth technology.
Visual images for patient skin self-examination and melanoma detection: A systematic review of published studies
2013, Journal of the American Academy of Dermatology
Citation Excerpt :
Descriptive statistics were conducted using software (SPSS, Version 20.0, IBM Corp, Armonk, NY). The systematic search of the literature resulted in 25 studies22-46 that were included in the review. Table I (available at http://www.jaad.org) outlines the critical appraisal of these studies using the modified Downs and Black21 checklist.
Early detection of skin cancer by patients is an important strategy for reducing morbidity and mortality caused by melanoma. However, the effectiveness of interventions or educational aids that use visual images to promote skin self-examination (SSE) and early melanoma detection has not been systematically investigated.
We undertook a systematic review of peer-reviewed research on SSE for skin cancer to examine the outcomes of studies that used visual images as part of their methodology. Our objective was to describe the impact of visual images on patient SSE knowledge, attitudes, behaviors, and accuracy.
Seven databases were searched resulting in 5330 citations. A total of 25 studies met the inclusion criteria.
Images positively affected knowledge and self-efficacy related to SSE. Images motivated the performance of SSE and increased the accuracy of SSE and melanoma detection. The types of visual images that were effective are described and the implications are discussed.
Articles not uncovered by the search strategy may have been unintentionally excluded. Lack of image description in the studies made specific recommendations challenging.
The use of visual images to promote accurate and frequent SSE is encouraged.

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Brief reportPatient adherence to skin self-examination: effect of nurse intervention with photographs

Abstract

Background

Design setting/participants

Intervention

Main outcome/measures

Results

Conclusions

Introduction

Section snippets

Study subjects

Results

Discussion

Acknowledgements

J Am Acad Dermatol

J Am Acad Dermatol

Am J Prev Med

J Invest Dermatol

Soc Sci Med

Public Health

Cancer statistics, 2003

CA Cancer J Clin

Thickness cross-sectional areas and depth of invasion in the prognosis of cutaneous melanoma

Ann Surg

Validation of a melanoma prognostic model

Arch Dermatol

Predicting ten-year survival of patients with primary cutaneous melanomacorroboration of a prognostic model

Cancer

Tumor thickness, level of invasion and node dissection in stage I cutaneous melanoma

Ann Surg

The early detection of and screening for melanoma. International status

Cancer

Early detection of melanoma

JAMA

Clinically recognized dysplastic nevi. A central risk factor for cutaneous melanoma

JAMA

Brief report
Patient adherence to skin self-examination: effect of nurse intervention with photographs