Efficacy of a sun protection workbook for kidney transplant recipients: a randomized controlled trial of a culturally sensitive educational intervention

Effect of education on sun-safe behaviour in kidney transplant recipients

BACKGROUND

Organ transplant recipients (OTR) are more likely to develop skin cancer than the general population. One of the main components of the exposome that triggers the development of skin tumours is solar ultraviolet (UV) radiation. To reduce the incidence of harmful consequences of sun exposure, sun protection education is needed for patients taking long-term immunosuppressive drugs.

METHODS

In a previous study, we assessed the sun-safe behaviour of 221 OTR using a questionnaire before and after transplantation and personally educated the patients about proper sun protection. After the education, there were no further reminder presentations. Presently, the sun protection and sun seeking habits of the available 176 of these patients were questioned to assess the long-term effect of the previous sun protection education.

RESULTS

Two-four years after the education, more patients wore hats and protected their skin with long-sleeved clothing than before the education. In terms of sun seeking habits, both occupational and recreational sun exposure decreased significantly. Significantly fewer people went on holiday after transplantation, but those who went on holiday spent significantly less time in the sun.

CONCLUSION

The long-term positive effects of education can be seen both in the patients' sun protection and in their sun seeking habits. However, the long-term goal is to maintain these results and thereby reduce the likelihood of skin tumours and consequently the associated tumour death.

Clinical and economic burden of benign and malignant skin lesions in renal transplant recipients

BACKGROUND

Studies evaluating the economic burden of dermatological care in the transplant setting are currently not available in Australia.

AIMS

To evaluate the clinical and economic burden of benign and malignant skin lesions in renal transplant recipients in Central Queensland.

METHODS

A bottom-up approach was used to determine the clinical burden and direct costs from patient-level Medicare data obtained from Service Australia for skin lesions.

RESULTS

Seventy-six percent of the renal transplant population in Central Queensland participated in this study. The median age was 57.0 years (standard deviation ± 13.6) and the majority (61.8%) of participants were men. The mean duration after transplant surgery was 99.9 months (interquartile range, 73.2-126.6 months). During a 2-year follow-up, 22 (40%) patients were diagnosed with benign skin lesions, 21 (38%) with nonmelanoma skin carcinoma (NMSC) and one (2%) with melanoma. There was a total of 231 visits to clinicians for diagnostic and therapeutic skin procedures and the direct costs to Medicare was $48 806 Australian Dollars (AUD) or $30 427 US Dollars (USD). Approximately 86% of the total direct costs was spent for nonNMSC and mean direct costs for NMSC was $763 AUD (or $476 USD).

CONCLUSION

This Medicare data-based study provides further insight into the burgeoning clinical and economic burden of the care for benign and malignant skin lesions in the renal transplantation setting in Australia.

Multimodal Transplant-clinic-based Skin Cancer Prevention Education for Organ Transplant Recipients: Feasibility Study

We studied the feasibility of transplant-clinic staff routinely providing primary prevention advice to lung transplant recipients at high risk of skin cancer.

Methods

Patients enrolled by a transplant-clinic study nurse completed baseline questionnaires and received sun-safety brochures. For the 12-mo intervention, transplant physicians were alerted to provide standard sun-protection advice (use of hat, long sleeves, and sunscreen outdoors) by sun-advice prompt cards attached to participants' medical charts at each clinic visit. Patients indicated receiving advice from their physician and from study personnel via an exit-card postclinic, and at final study clinics, they also reported their sun behaviors by questionnaire. Feasibility of the intervention was measured by patients' and clinic staff's study engagement; effectiveness was assessed by calculating odds ratios (ORs) for improved sun protection, using generalized estimating equations.

Results

Of 151 patients invited, 134 consented (89%), and 106 (79 %) (63% male, median age 56 y, 93% of European descent) completed the study. Odds of receiving sun advice from transplant physicians and study nurses rose after the intervention compared with baseline (ORs, 1.67; 95% confidence interval [CI], 0.96-2.96 and 3.56; 95% CI, 1.38-9.14, respectively). After 12 mo of regular transplant-clinic advice, odds of sunburn decreased (OR, 0.59; 95% CI, 0.13-2.60), and odds of applying sunscreen (OR, 1.93; 95% CI, 1.20-3.09) almost doubled.

Conclusions

Encouragement of primary prevention of skin cancer among organ transplant recipients by physicians and nurses during routine transplant-clinic visits is feasible and appears to be effective.

Evaluation of sun-protective behaviors in transplant clinic patients: a longitudinal analysis

Organ transplant recipients (OTRs) are at a significantly elevated risk for developing cutaneous malignancies. In recent years, the advent of dermatology clinics dedicated to this specific patient population has aimed to provide increased access and specialized care, including important sun-protective behavior education. It has been shown that OTRs tend to have poor sun-protective practices, and care at these specialized dermatology clinics has facilitated an improvement in sun-protective behavior. Previously, sun-protective behavior of patients within these specialized clinics has been characterized longitudinally, though only for a short duration of 3 months. We retrospectively analyzed a cohort of 230 OTRs seen at a single academic institution's transplant clinic between 2016-2020 and sought to characterize sun-protective behavior at baseline and longitudinally. 78 patients returned for at least one follow-up visit, and the median follow-up duration was 15.1 months (IQR 8.4-24.3 months). Sun-protective behavior was quantified using the average score of questions addressing sunscreen usage frequency, consistency, circumstance of application, reapplication, and sun avoidance. We utilized paired Wilcoxon signed-rank tests to analyze changes in sun-protective behavior between initial visits and subsequent follow-up visits. Sun-protective behavior was increased at the first follow-up visit (median change in sun-protective score - 0.04, p = 0.017) and second follow-up visit (median change in sun-protective score - 0.25, p = 0.026) compared to the initial visit. Multivariable logistic regression and mixed effects modeling were employed to quantify patient features associated with increased sun-protective behavior. Female sex [OR 3.79, 95% CI (1.83, 8.04)] and personal history of skin cancer [OR 3.06, 95% CI (1.25, 7.76)] were associated with stronger sun-protective behaviors at baseline. Female sex [OR 13.77, 95% CI (2.44, 77.52)] was the only characteristic associated with increased sun-protective behavior over time. Our findings identify patient characteristics that are associated with increased sun-protective behavior after education in a dermatology clinic dedicated to OTRs.

Interventions for improving health literacy in people with chronic kidney disease

BACKGROUND

Low health literacy affects 25% of people with chronic kidney disease (CKD) and is associated with increased morbidity and death. Improving health literacy is a recognised priority, but effective interventions are not clear.

OBJECTIVES

This review looked the benefits and harms of interventions for improving health literacy in people with CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 12 July 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched MEDLINE (OVID) and EMBASE (OVID) for non-randomised studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) and non-randomised studies that assessed interventions aimed at improving health literacy in people with CKD.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed studies for eligibility and performed risk of bias analysis. We classified studies as either interventions aimed at improving aspects of health literacy or interventions targeting a population of people with poor health literacy. The interventions were further sub-classified in terms of the type of intervention (educational, self-management training, or educational with self-management training). Results were expressed as mean difference (MD) or standardised mean difference (SMD) with 95% confidence intervals (CI) for continuous outcomes and risk ratios (RR) with 95% CI for dichotomous outcomes.

MAIN RESULTS

We identified 120 studies (21,149 participants) which aimed to improve health literacy. There were 107 RCTs and 13 non-randomised studies. No studies targeted low literacy populations. For the RCTs, selection bias was low or unclear in 94% of studies, performance bias was high in 86% of studies, detection bias was high in 86% of studies reporting subjective outcomes and low in 93% of studies reporting objective outcomes. Attrition and other biases were low or unclear in 86% and 78% of studies, respectively. Compared to usual care, low certainty evidence showed educational interventions may increase kidney-related knowledge (14 RCTs, 2632 participants: SMD 0.99, 95% CI 0.69 to 1.32; I² = 94%). Data for self-care, self-efficacy, quality of life (QoL), death, estimated glomerular filtration rate (eGFR) and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed self-management interventions may improve self-efficacy (5 RCTs, 417 participants: SMD 0.58, 95% CI 0.13 to 1.03; I² = 74%) and QoL physical component score (3 RCTs, 131 participants: MD 4.02, 95% CI 1.09 to 6.94; I² = 0%). There was moderate-certainty evidence that self-management interventions probably did not slow the decline in eGFR after one year (3 RCTs, 855 participants: MD 1.53 mL/min/1.73 m², 95% CI -1.41 to 4.46; I² = 33%). Data for knowledge, self-care behaviour, death and hospitalisations could not be pooled or was not reported. Compared to usual care, low-certainty evidence showed educational with self-management interventions may increase knowledge (15 RCTs, 2185 participants: SMD 0.65, 95% CI 0.36 to 0.93; I² = 90%), improve self-care behaviour scores (4 RCTs, 913 participants: SMD 0.91, 95% CI 0.00 to 1.82; I² =97%), self-efficacy (8 RCTs, 687 participants: SMD 0.50, 95% CI 0.10 to 0.89; I² = 82%), improve QoL physical component score (3 RCTs, 2771 participants: MD 2.56, 95% CI 1.73 to 3.38; I² = 0%) and may make little or no difference to slowing the decline of eGFR (4 RCTs, 618 participants: MD 4.28 mL/min/1.73 m², 95% CI -0.03 to 8.85; I² = 43%). Moderate-certainty evidence shows educational with self-management interventions probably decreases the risk of death (any cause) (4 RCTs, 2801 participants: RR 0.73, 95% CI 0.53 to 1.02; I² = 0%). Data for hospitalisation could not be pooled.

AUTHORS' CONCLUSIONS

Interventions to improve aspects of health literacy are a very broad category, including educational interventions, self-management interventions and educational with self-management interventions. Overall, this type of health literacy intervention is probably beneficial in this cohort however, due to methodological limitations and high heterogeneity in interventions and outcomes, the evidence is of low certainty.

An integrated skin cancer education program in renal transplant recipients and patients with glomerular disease

Sun-protective strategies focusing on skin cancer awareness are needed in immunosuppressed patients at risk of skin cancers. The study aims to determine the effect of an integrated skin cancer education program on skin cancer awareness and sun-protective behaviours in renal transplant recipients (RTRs) and patients with glomerular disease (GD) treated with long-term immunosuppressants. A pilot prospective cohort study in Central Queensland, Australia was undertaken among adult RTRs and patients with GD, who completed survey questionaries on skin cancer and sun-health knowledge (SCSK), sun-protection practices and skin examination pre- and post-education. Fifty patients (25 RTRs, 25 patients with GD) participated in the study. All of them completed questionnaires at pre-, 3-month post-education and 92%(n = 46) at 6-month post-education. There was a significant increase in SCSK scores from baseline at 3-months (p < 0.001) and 6-months post-intervention (p < 0.01). Improved knowledge was retained for 6 months after education. There were changes in 2 of 8 photoprotective behaviours at 6 months. Interventional education enhanced regular self-skin examination rate (p < 0.001) as well as the frequency of full skin checks by general practitioners (GPs) (p < 0.001). Overall, RTRs had better compliance with sun-protective methods and higher skin examination rates by themselves and/ or GPs before and after the intervention of education compared to patients with GD. To conclude, an integrated skin cancer education program improved knowledge of skin cancer and skin health as well as the frequency of self-skin examination and formal skin assessments. However, improvement in patient compliance did not extend to other sun-protective practices.

Sun exposure reduction by melanoma survivors with wearable sensor providing real-time UV exposure and daily text messages with structured goal setting

Despite knowledge of subsequent melanoma risk and the benefit of sun protection in risk reduction, melanoma survivors often do not engage in adequate sun protection and continue to sunburn at rates similar to individuals without a history of skin cancer. This novel intensive intervention provided a wearable UV sensor delivering real-time UV exposure with a smartphone and daily text messages. On days 1-10 (period 1), behavioral facilitation and outcome expectancies messages were provided. On day 10, participants reviewed and reflected on their daily UV exposure on the previous 10 days and set goals for improving sun protection. Then on days 11-21 (period 2) self-efficacy and self-regulation messages were provided. Sixty melanoma survivors were randomized (1:1) to receive structured or unstructured goal setting queries on day 10. Controlling for cloudy/rain conditions with less UV due to weather, there was a time effect with a significant decrease in UV exposure from periods 1-2 [period 1-2, F (59) = 22.60, p < 0.0001]. In this short-term study, melanoma survivors managed their daily UV exposure to stay below their maximum tolerated UV dose. ClinicalTrials.gov Protocol Record NCT0334796, date of registration Nov 15, 2017.

Therapeutic education as a tool to improve patient-reported and clinical outcomes after renal transplantation: results of the EPHEGREN multicenter retrospective cohort study

Patients are not always aware of the inconveniences associated with renal transplantation, which they compare with a « rebirth », and from which they expect complete recovery. Therapeutic education is proposed to prepare patients for their life after transplantation. This study evaluated the impact of pretransplant therapeutic education on patient-reported outcomes and rejection-free survival over the first year. We collected data from 383 renal transplant patients followed-up in seven centers. Patients who benefited from therapeutic education before transplantation (N = 182) were compared with patients who did not (N = 139) for quality-of-life, adherence and adverse events using the Pearson's chi-square test, one-way ANOVA or t-test. The association between therapeutic education and time to acute rejection was investigated using Cox models. The patients who benefited from therapeutic education reported adverse events less frequently (e.g., tremor: 9% vs. 32.4%, P = 0.01) and better quality-of-life (MCS-QOL: 50.7 ± 8.1 vs. 47.7 ± 9.5, P = 0.02; PCS-QOL: 49.1 ± 7.1 vs. 46.0 ± 9.2, P = 0.013). No difference was found on adherence. Rejection-free survival was slightly better in the therapeutic education group (HR = 0.44, 95% CI = [0.19-1.01]). This multicenter retrospective cohort study suggests that integrating therapeutic education to care pathways entails clinical benefit, in terms of quality-of-life, self-reported adverse events and rejection-free survival. Randomized clinical trials are necessary to confirm this.

Sun protection behaviour in organ transplant recipients and non-transplant patients attending a dermatology outpatient clinic in Sweden: A questionnaire survey

BACKGROUND/PURPOSE

Organ transplant recipients (OTRs) are at high risk of developing skin cancer and are therefore advised to protect their skin against ultraviolet radiation from the sun. Specialized OTR clinics with dermatological follow-up may improve sun habits among OTRs. In this study, we compared self-reported sun exposure and sun protection behaviour between OTRs and non-transplant patients (non-TPs) and between OTRs with and without special dermatological follow-up.

METHODS

Patients from Sahlgrenska University Hospital, Gothenburg, Sweden, completed a sun exposure questionnaire. Between 2011 and 2015, 282 OTRs transplanted in the period 1976-2014 and 414 non-TPs were recruited among dermatological outpatients. Participants were stratified into five groups by their status as OTRs or non-TPs and by attendance to dermatological follow-up.

RESULTS

More non-TPs than OTRs reported one or more sunburns in the past year, 46% vs. 20%, P < .0001). More OTRs with than OTRs without dermatological follow-up reported frequent use of sunscreens (63% vs 44%, P = .006). More OTRs with follow-up used one or more sun protection measure such as covering clothes, than other OTRs (54% vs 34%, P = .016).

CONCLUSION

In this study, OTRs reported less sun exposure than non-TPs. Specialized dermatological follow-up seems to improve sun protection behaviour among OTRs. We suggest that specialized OTR clinics should be more broadly implemented.

Reducing non-melanoma skin cancer risk in renal transplant recipients

With an increasing number of renal transplant recipients (RTRs) and improving patient survival, a higher incidence of non-melanoma skin cancer (NMSC) has been observed. NMSC in RTRs are often more numerous and biologically more aggressive than the general population, thus contributing towards an increase in morbidity and to a lesser degree, mortality. The resultant cumulative health and financial burden is a recognized concern. Proposed strategies in mitigating risks of developing NMSC and early therapeutic options thereof include tailored modification of immunosuppressants in conjunction with sun protection in all transplant patients. This review highlights the clinical and financial burden of transplant-associated skin cancers, carcinogenic mechanisms in association with immunosuppression, importance of skin cancer awareness campaign and integrated transplant skin clinic, and the potential role of chemoprotective agents. A scheme is proposed for primary and secondary prevention of NMSC based on the available evidence.

Real-Time UV Measurement With a Sun Protection System for Warning Young Adults About Sunburn: Prospective Cohort Study

Background

Melanoma is attributable to predisposing phenotypical factors, such as skin that easily sunburns and unprotected exposure to carcinogenic UV radiation. Reducing the proportion of young adults who get sunburned may reduce the incidence of melanoma, a deadly form of skin cancer. Advances in technology have enabled the delivery of real-time UV light exposure and content-relevant health interventions.

Objective

This study aims to examine the feasibility of young adults performing the following tasks daily: wearing a UV dosimeter, receiving text messages and real-time UV-B doses on their smartphone, and responding to daily web-based surveys about sunburn and sun protection.

Methods

Young adults aged 18-39 years (n=42) were recruited in the United States in June 2020 via social media. Participants received the UV Guard sun protection system, which consisted of a UV dosimeter and a smartphone app. During 3 consecutive periods, intervention intensity increased as follows: real-time UV-B dose; UV-B dose and daily behavioral facilitation text messages; and UV-B dose, goal setting, and daily text messages to support self-efficacy and self-regulation. Data were self-reported through daily web-based surveys for 28 days, and UV-B doses were transmitted to cloud-based storage.

Results

Patients’ median age was 22 years (IQR 20, 29), and all patients had sun-sensitive skin. Sunburns were experienced during the study by fewer subjects (n=18) than those in the preceding 28 days (n=30). In July and August, the face was the most commonly sunburned area among 13 body locations; 52% (22/42) of sunburns occurred before the study and 45% (19/42) occurred during the study. The mean daily UV-B dose decreased during the 3 periods; however, this was not statistically significant. Young adults were most often exercising outdoors from 2 to 6 PM, walking from 10 AM to 6 PM, and relaxing from noon to 2 PM. Sunburn was most often experienced during exercise (odds ratio [OR] 5.65, 95% CI 1.60-6.10) and relaxation (OR 3.69, 95% CI 1.03-4.67) relative to those that did not exercise or relax in each category. The self-reported exit survey indicated that participants felt that they spent less time outdoors this summer compared to the last summer because of the COVID-19 pandemic and work. In addition, 38% (16/42) of the participants changed their use of sun protection based on their app-reported UV exposure, and 48% (20/42) shifted the time they went outside to periods with less-intense UV exposure. A total of 79% (33/42) of the participants were willing to continue using the UV Guard system outside of a research setting.

Conclusions

In this proof-of-concept research, young adults demonstrated that they used the UV Guard system; however, optimization was needed. Although some sun protection behaviors changed, sunburn was not prevented in all participants, especially during outdoor exercise.

Trial Registration

ClinicalTrials.gov NCT03344796; http://clinicaltrials.gov/ct2/show/NCT03344796

Prospective single-centre clinical observational study on electronically monitored medication non-adherence, its psychosocial risk factors and lifestyle behaviours after heart transplantation: a study protocol

INTRODUCTION

In heart transplant recipients (HTRs), non-adherence (NA) to immunosuppressive (IS) medication and to recommended lifestyle behaviours are a common phenomenon and associated with higher risk of allograft rejection, organ loss and mortality. Risk factors for NA are highly diverse and still insufficiently researched. Precise measures of NA and an accurate understanding of its aetiology are of undisputable importance to detect patients at risk and intervene accordingly. The aim of this study is to assess the accuracy and concordance of different measures for NA as well as to determine potential risk factors.

METHODS AND ANALYSIS

This is a single-centre prospective observational trial. HTRs who are at least aged 18 are no less than 6 months post-transplant and receive tacrolimus (Prograf or Advagraf), cyclosporine (Sandimmun) or everolimus (Certican) as their prescribed IS medication are eligible for participation. We only include patients during the phase of medication implementation. At study enrolment, we assess depression, health-related quality of life, self-efficacy, social support, attachment, experiences and attitudes towards IS medication, emotional responses after transplantation, satisfaction with information about IS medication and perceptions and beliefs about medications. We further ask patients to rate their lifestyle behaviours concerning alcohol, smoking, diet, physical activity, sun protection and appointment keeping via questionnaires. Three different measurement methods for NA are applied at T0: self-reports, physician's estimates and IS trough levels. NA is monitored prospectively using an electronic multicompartment pillbox (MEMS, VAICA) over a 3-month period. Meanwhile, participants receive phone calls every second week to obtain additional self-reports, resulting in a total of seven measurement points.

ETHICS AND DISSEMINATION

The study was approved by the Clinical Ethics Committee of the University Hospital Erlangen (Friedrich-Alexander-University, Erlangen-Nürnberg). Written informed consent is attained from all participants. The results of this study will be published in peer-reviewed journals and presented at conferences.

TRIAL REGISTRATION NUMBER

DRKS00020496.

eHealth Interventions for Solid Organ Transplant Recipients: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Lack of support for self-management may contribute to adverse health outcomes. eHealth has the potential to support self-management, but evidence in solid organ transplantation remains unclear. This review aims to evaluate the benefits and harms of eHealth interventions to support self-management in solid organ transplant recipients.

METHODS

We searched Cochrane Central Register of Controlled Trials, MEDLINE, and Embase databases for randomized trials of eHealth interventions in solid organ transplant recipients. We calculated the risk ratios or standardized mean difference of outcomes, and summary estimates were determined using random-effects models. The Cochrane risk of bias tool and Grading of Recommendations, Assessment, Development, and Evaluations were used to assess trial quality.

RESULTS

Twenty-one trials from 6 countries involving 2114 participants were included. Compared with standard care, eHealth interventions improved medication adherence (risk ratio, 1.34; CI, 1.12-2.56; I = 75%) and self-monitoring behavior (risk ratio, 2.58; CI, 1.56-4.27; I = 0%) up to 12 mo posttransplant. The treatment effects were largely consistent across different subgroups except for intervention functionality and mode of delivery. The effects on other outcomes were uncertain. Nine trials reported harms. The overall risk of bias was considered high or unclear, and the quality of evidence was low to very low for all outcomes.

CONCLUSIONS

eHealth interventions may improve medication adherence and self-monitoring behavior in the short term, but high-quality intervention studies are needed to determine whether eHealth will improve long-term patient-relevant outcomes.

Behavioural and pharmaceutical interventions for the prevention of skin cancers in solid organ transplant recipients: a systematic review of randomised controlled trials

OBJECTIVES

Solid organ transplant recipients are at increased risk of skin cancer, affecting more than 50% of recipients. We aimed to determine the effectiveness of interventions for behavioural change for sun protection or skin cancer prevention in solid organ transplant recipients.

DESIGN

Systematic review.

DATA SOURCES

We searched MEDLINE, Embase, the Cochrane Central Register of Controlled Trials (CENTRAL) and CINAHL from inception to November 2019.

ELIGIBILITY CRITERIA

We included randomised controlled trials that evaluated the effect of behavioural or pharmaceutical interventions on behavioural change or skin cancer prevention in solid organ transplant recipients.

DATA EXTRACTION AND SYNTHESIS

Risks of bias and evidence certainty were assessed using Cochrane and the Grading of Recommendations Assessment Development and Evaluation framework.

RESULTS

Twenty trials (n=2295 participants) were included. It is uncertain whether behavioural interventions improve sun protection behaviour (n=3, n=414, standardised mean difference (SMD) 0.89, 95% CI -0.84 to 2.62, I²=98%) and knowledge (n=4, n=489, SMD 0.50, 95% CI 0.12 to 0.87, I²⁼ 76%) as the quality of evidence is very low. We are uncertain of the effects of mammalian target of rapamaycin inhibitors on the incidence of non-melanocytic skin cancer (n=5, n=1080, relative risk 0.46, 95% CI 0.28 to 0.75, I^{2 =}72%) as the quality of evidence is very low.

CONCLUSIONS

Behavioural and pharmaceutical preventive interventions may improve sun protective behaviour and knowledge, and reduce the incidence of non-melanocytic skin cancer, but the overall quality of the evidence is very low and insufficient to guide decision-making and clinical practice.

PROSPERO REGISTRATION NUMBER

CRD42017063962.

Randomised controlled trial to evaluate the influence of mHealth and eHealth skin cancer prevention education among young organ transplant recipients: the HIPPOlino intervention study

OBJECTIVES

To determine whether a multicomponent sun protection intervention programme (mHealth) for young organ transplant recipients (OTR) leads to a higher increase of preventive knowledge and behavioural change than an e-learning education programme (eHealth).

DESIGN

Randomised controlled trial with one preintervention baseline survey and three follow-up surveys after 6 weeks, 6 and 12 months. Comparison of two different intervention schedules with a control group (CG).

SETTING

Multicomponent sun protection trainings in Germany, the Netherlands and Austria between June 2013 and September 2015.

PARTICIPANTS

137 OTRs (5-22 years of age, 61 females/76 males) participated in the study.

INTERVENTIONS

(A) Intervention group 1 (IG1): personal training with subsequent forwarding of individual ultraviolet index-dependent sun protection recommendations via short message service (SMS); (B) intervention group 2 (IG2): e-learning training without SMS; (C) CG: regular information letters, online training after 1 year.

OUTCOME MEASURES

Key questions were used to form a knowledge and a behavioural score. Behavioural strategies and knowledge were quantified through self-administered questionnaires.

RESULTS

Analyses 6 weeks after the intervention showed a higher knowledge increase in both IG compared with the CG (IG1 to CG: OR 12.64, 95% CI 4.20 to 38.20; IG2 to CG: OR 2.59, 95% CI 0.95 to 7.04). Sun protection behaviour improved slightly but not significantly in both IG (IG1 to CG: OR 2.56, 95% CI 0.93 to 7.00; IG2 to CG: OR 1.22, 95% CI 0.45 to 3.32). One year after the intervention, no behavioural changes were observed in either IG compared with the CG. IG1 but not IG2 still scored significantly higher in sun protection knowledge than the CG 1 year after intervention (IG1 to CG: OR 4.46, 95% CI 1.48 to 13.43; IG2 to CG: OR 1.41, 95% CI 0.51 to 3.93).

CONCLUSIONS

This multicomponent sun protection programme provides a promising strategy to increase sun protection knowledge and possibly also protective behaviour in young OTR.

TRIAL REGISTRATION NUMBER

DRKS00011393.

eHealth interventions for people with chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is associated with high morbidity and death, which increases as CKD progresses to end-stage kidney disease (ESKD). There has been increasing interest in developing innovative, effective and cost-efficient methods to engage with patient populations and improve health behaviours and outcomes. Worldwide there has been a tremendous increase in the use of technologies, with increasing interest in using eHealth interventions to improve patient access to relevant health information, enhance the quality of healthcare and encourage the adoption of healthy behaviours.

OBJECTIVES

This review aims to evaluate the benefits and harms of using eHealth interventions to change health behaviours in people with CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 14 January 2019 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) and quasi-RCTs using an eHealth intervention to promote behaviour change in people with CKD were included. There were no restrictions on outcomes, language or publication type.

DATA COLLECTION AND ANALYSIS

Two authors independently assessed trial eligibility, extracted data and assessed the risk of bias. The certainty of the evidence was assessed using GRADE.

MAIN RESULTS

We included 43 studies with 6617 participants that evaluated the impact of an eHealth intervention in people with CKD. Included studies were heterogeneous in terms of eHealth modalities employed, type of intervention, CKD population studied and outcomes assessed. The majority of studies (39 studies) were conducted in an adult population, with 16 studies (37%) conducted in those on dialysis, 11 studies (26%) in the pre-dialysis population, 15 studies (35%) in transplant recipients and 1 studies (2%) in transplant candidates We identified six different eHealth modalities including: Telehealth; mobile or tablet application; text or email messages; electronic monitors; internet/websites; and video or DVD. Three studies used a combination of eHealth interventions. Interventions were categorised into six types: educational; reminder systems; self-monitoring; behavioural counselling; clinical decision-aid; and mixed intervention types. We identified 98 outcomes, which were categorised into nine domains: blood pressure (9 studies); biochemical parameters (6 studies); clinical end-points (16 studies); dietary intake (3 studies); quality of life (9 studies); medication adherence (10 studies); behaviour (7 studies); physical activity (1 study); and cost-effectiveness (7 studies).Only three outcomes could be meta-analysed as there was substantial heterogeneity with respect to study population and eHealth modalities utilised. There was found to be a reduction in interdialytic weight gain of 0.13kg (4 studies, 335 participants: MD -0.13, 95% CI -0.28 to 0.01; I² = 0%) and a reduction in dietary sodium intake of 197 mg/day (2 studies, 181 participants: MD -197, 95% CI -540.7 to 146.8; I² = 0%). Both dietary sodium and fluid management outcomes were graded as being of low evidence due to high or unclear risk of bias and indirectness (interdialytic weight gain) and high or unclear risk of bias and imprecision (dietary sodium intake). Three studies reported death (2799 participants, 146 events), with 45 deaths/1000 cases compared to standard care of 61 deaths/1000 cases (RR 0.74, CI 0.53 to 1.03; P = 0.08). We are uncertain whether using eHealth interventions, in addition to usual care, impact on the number of deaths as the certainty of this evidence was graded as low due to high or unclear risk of bias, indirectness and imprecision.

AUTHORS' CONCLUSIONS

eHealth interventions may improve the management of dietary sodium intake and fluid management. However, overall these data suggest that current evidence for the use of eHealth interventions in the CKD population is of low quality, with uncertain effects due to methodological limitations and heterogeneity of eHealth modalities and intervention types. Our review has highlighted the need for robust, high quality research that reports a core (minimum) data set to enable meaningful evaluation of the literature.

Evaluating Retention of Skin Cancer Education in Kidney Transplant Recipients Reveals a Window of Opportunity for Re-education

BACKGROUND

Skin cancer is the most common malignancy after solid organ transplant and can lead to significant morbidity. The likelihood of developing squamous cell carcinomas and melanomas is 100 and 2.4 times more likely, respectively, in kidney transplant recipients when compared with the general population. There are few data regarding the assessment and influence of solid organ transplant recipient (SOTR) knowledge of skin cancer and its effect on short- and long-term awareness and behavior.

METHODS

The purpose of this study was to assess the baseline knowledge of SOTR immediately after transplantation, and then to reassess their knowledge following a 5-minute educational video. We also wanted to determine whether lifestyle modifications had been implemented 4 to 8 months after the intervention.

RESULTS

Forty patients were enrolled within 2 months of transplantation. Eighty-seven percent of patients were renal transplant recipients, and 75% of patients were available for long-term follow-up. There was a significant increase in knowledge in the immediate postintervention period, which was sustained at 4- to 8-month follow-up, as assessed by patient questionnaire. Patients appeared to be applying this knowledge by participating in lifestyle risk modification and positive sun-protective behavior.

CONCLUSIONS

Our study suggests that incorporating additional skin cancer education into the early transplant timeline (perhaps in the first one or two outpatient follow-up visits) with an easy to administer educational video and question and answer form increases patient knowledge and influences positive sun-protective behavior.

Effects of Messages Delivered by Mobile Phone on Increasing Compliance With Shoulder Exercises Among Patients With a Frozen Shoulder

PURPOSE

The aim of this study was to examine the effects of reminders, encouragement, and educational messages delivered by mobile phone on shoulder exercise compliance and improvements in shoulder function among patients with a frozen shoulder.

DESIGN AND METHODS

A randomized controlled trial design was used. A convenience sample of patients with a frozen shoulder in an orthopedic outpatient clinic was recruited. All participants were instructed on how to do shoulder exercises and were provided with a printed pamphlet about shoulder exercises. Then, the intervention group received reminders, encouragement, and educational messages by mobile phone daily for the next 2 weeks, while the comparison group did not.

FINDINGS

The intervention group had higher compliance with shoulder exercises than did the comparison group (t = 2.263, p = .03) and had significant improvements in shoulder forward flexion (F = 12.067, p = .001), external rotation (F = 13.61, p = .001), and internal rotation (F = 5.903, p = .018) compared to those in the comparison group after the 2-week intervention.

CONCLUSIONS

The text messages significantly increased patient compliance with shoulder exercises and thus improved patients' shoulder range of motion.

CLINICAL RELEVANCE

Hospital or clinics can send appropriate messages to patients via text message platforms in order to remind and encourage them to do shoulder exercises.

Sun Protection Belief Clusters: Analysis of Amazon Mechanical Turk Data

This study aimed (i) to determine whether people could be differentiated on the basis of their sun protection belief profiles and individual characteristics and (ii) explore the use of a crowdsourcing web service for the assessment of sun protection beliefs. A sample of 500 adults completed an online survey of sun protection belief items using Amazon Mechanical Turk. A two-phased cluster analysis (i.e., hierarchical and non-hierarchical K-means) was utilized to determine clusters of sun protection barriers and facilitators. Results yielded three distinct clusters of sun protection barriers and three distinct clusters of sun protection facilitators. Significant associations between gender, age, sun sensitivity, and cluster membership were identified. Results also showed an association between barrier and facilitator cluster membership. The results of this study provided a potential alternative approach to developing future sun protection promotion initiatives in the population. Findings add to our knowledge regarding individuals who support, oppose, or are ambivalent toward sun protection and inform intervention research by identifying distinct subtypes that may best benefit from (or have a higher need for) skin cancer prevention efforts.

A qualitative systematic review of the efficacy of sun protection education in organ transplant recipients

BACKGROUND

Transplant recipients are at increased risk of developing skin cancer as a result of chronic immunosuppression. Educating patients on sun protection has been routine posttransplantation, but to our knowledge, no systematic review has yet analyzed the efficacy of such education measures in this high-risk population.

OBJECTIVE

We sought to examine the efficacy of educating transplant recipients on skin cancer and sun protection.

METHODS

A literature search of interventional patient education studies published between January 1995 and March 2016 was performed in PubMed, CINAHL, Cochrane, and EMBASE databases.

RESULTS

Data from 7 studies meeting inclusion criteria were analyzed. No study attempted to examine the direct effect of sun protection education on skin cancer incidence in transplant recipients. Two randomized controlled trials showed that educational intervention can improve sun-protective behavior and decrease skin pigmentation or skin damage in sun-exposed areas. Three other randomized controlled trials compared the efficacy of 2 different forms of patient education at changing sun-protective behavior, but did not examine patient-oriented outcomes.

LIMITATIONS

A lack of high-quality randomized controlled trials with patient-oriented evidence and a dependence on self-reported data are limitations.

CONCLUSION

Sun protection education can be effective at altering patient behavior in transplant recipients, but its effect on posttransplantation skin cancer incidence remains to be elucidated.

Efficacy of an Intervention to Alter Skin Cancer Risk Behaviors in Young Adults

INTRODUCTION

Skin cancer is the most common cancer, and its incidence is increasing. Young adults expose themselves to large amounts of ultraviolet radiation (UV) and engage in minimal skin protection, which increases their risk. Internet interventions are effective in modifying health behaviors and are highly disseminable. The current study's purpose was to test an Internet intervention to decrease UV exposure and increase skin protection behavior among young adults.

STUDY DESIGN

RCT conducted in 2014, with data analyzed in 2015.

SETTING/PARTICIPANTS

A national sample of adults aged 18-25 years at moderate to high risk of developing skin cancer by a self-report measure was recruited online.

INTERVENTION

Participants were randomized to one of three intervention conditions: assessment only, the website of a skin cancer organization, or a tailored interactive multimedia Internet intervention program (UV4.me) based on the Integrative Model of Behavioral Prediction.

MAIN OUTCOME MEASURES

Self-reported overall UV exposure and skin protection assessed at 3 and 12 weeks after baseline. Secondary outcomes were self-reported intentional and incidental UV exposure, sunburns, sunscreen use, and skin cancer screening.

RESULTS

For the intervention arm, there were significant decreases in UV exposure and increases in skin protection at both follow-up time points compared with the assessment-only condition (p<0.001). The effect sizes (Cohen's d) comparing the experimental and assessment-only arm for exposure behaviors were 0.41 at 3-week follow-up and 0.43 at 12-week follow-up. The effect sizes for protection behaviors were 0.41 at 3-week follow-up and 0.53 at 12-week follow-up. The control condition was not significantly different from the assessment only condition. All three conditions exhibited decreased exposure and increased protection at both follow-ups (p<0.01), but the effect was much stronger in the intervention group. Secondary outcomes were generally also significantly improved in the intervention condition compared with the other conditions.

CONCLUSIONS

This is the first published report describing the results of an RCT of an Internet intervention to modify skin cancer risk behaviors among young adults. The UV4.me intervention significantly improved self-reported skin cancer prevention behaviors. Future research will investigate mechanisms of change and approaches for dissemination.

TRIAL REGISTRATION

This study is registered at www.clinicaltrials.gov NCT02147080.

Perceptions of Risk of Developing Skin Cancer for Diverse Audiences: Enhancing Relevance of Sun Protection to Reduce the Risk

Sixty-five percent of kidney transplant recipients (KTRs) develop squamous cell carcinoma (SCC). Perceptions of risk of developing skin cancer, amelioration of this risk with sun protection, and having choices among sun protection strategies may enhance sun protection use by KTRS, who are at greater risk than the general population. Thirty KTRs stratified among non-Hispanic Whites, non-Hispanic Blacks, and Hispanic/Latinos evaluated three versions of the interactive, web-based, electronic sun protection program and suggested refinements. The sequence of content presentation prepared the participant to accept the credibility, accuracy, and relevance of the message. Beginning with informing participants that using sun protection reduces the chance of developing skin cancer made the information credible to KTRs. Showing skin cancer on all skin types and patient testimonials enhanced participants' awareness of their susceptibility to develop skin cancer and primed patients to receive their personal risk of developing skin cancer. Coupling presentation of knowledge about the benefits of sun protection in reducing the risk of developing skin cancer with the personal risk of getting the disease was essential to KTRs believing that they could influence their health outcome.

A Randomized Controlled Trial of a Mobile Medical App for Kidney Transplant Recipients: Effect on Use of Sun Protection

BACKGROUND

Perception of skin cancer risk, belief that sun protection prevents skin cancer, and having sun protection choices enhance sun protection behaviors by kidney transplant recipients, who are at greater risk of developing skin cancer than the general population.

METHODS

A randomized controlled trial used stratified recruitment of non-Hispanic White, non-Hispanic Black, and Hispanic/Latino kidney transplant recipients, who received a transplant 2-24 months prior to the study. The same culturally sensitive SunProtect™ program was delivered to all recipients with tablet personal computers in two urban ambulatory offices. Text messages reminders were provided at two week intervals. Self-reported surveys and skin pigmentation measured prior to the intervention and six weeks later were analyzed.

RESULTS

Among 552 eligible participants, 170 participated (62 non-Hispanic Whites, 60Blacks, and 48 Hispanics). Among participants receiving the intervention with skin that burns after sun exposure and becomes tan or becomes irritated and gets darker, there was a statistically significant increase in self-reported knowledge, recognition of personal skin cancer risk, confidence in sun protection preventing skin cancer, and sun protection behaviors in participants compared to those receiving usual education (p<0.05). At the six week follow-up, participants in the intervention group with skin that burns or becomes irritated, had significantly less darkening of the sun-exposed forearm than control participants (p<0.05).

CONCLUSIONS

Providing sun protection education with SunProtect™ in the springwith reminders during the summer facilitated adoption of sun protection behaviors among kidney transplant recipients with skin that burns or becomes irritated.

Response Across the Health-Literacy Spectrum of Kidney Transplant Recipients to a Sun-Protection Education Program Delivered on Tablet Computers: Randomized Controlled Trial

BACKGROUND

Sun protection can reduce skin cancer development in kidney transplant recipients, who have a greater risk of developing squamous cell carcinoma than the general population.

OBJECTIVE

A culturally sensitive sun-protection program (SunProtect) was created in English and Spanish with the option of choosing audio narration provided by the tablet computer (Samsung Galaxy Tab 2 10.1). The intervention, which showed skin cancer on patients with various skin tones, explained the following scenarios: skin cancer risk, the ability of sun protection to reduce this risk, as well as offered sun-protection choices. The length of the intervention was limited to the time usually spent waiting during a visit to the nephrologist.

METHODS

The development of this culturally sensitive, electronic, interactive sun-protection educational program, SunProtect, was guided by the "transtheoretical model," which focuses on decision making influenced by perceptions of personal risk or vulnerability to a health threat, importance (severity) of the disease, and benefit of sun-protection behavior. Transportation theory, which holds that narratives can have uniquely persuasive effects in overcoming preconceived beliefs and cognitive biases because people transported into a narrative world will alter their beliefs based on information, claims, or events depicted, guided the use of testimonials. Participant tablet use was self-directed. Self-reported responses to surveys were entered into the database through the tablet. Usability was tested through interviews. A randomized controlled pilot trial with 170 kidney transplant recipients was conducted, where the educational program (SunProtect) was delivered through a touch-screen tablet to 84 participants.

RESULTS

The study involved 62 non-Hispanic white, 60 non-Hispanic black, and 48 Hispanic/Latino kidney transplant recipients. The demographic survey data showed no significant mean differences between the intervention and control groups in age, sex, income, or time since transplantation. The mean duration of program use varied by the ethnic/racial group, with non-Hispanic whites having the shortest use (23 minutes) and Hispanic/Latinos having the longest use (42 minutes). Knowledge, awareness of skin cancer risk, willingness to change sun protection, and use of sun protection increased from baseline to 2 weeks after the program in participants from all ethnic/racial groups in comparison with controls (P<.05). Kidney transplant recipients with inadequate (47/170, 28%) and marginal functional health literacy (59/170, 35%) listened to either Spanish or English audio narration accompanying the text and graphics. After completion of the program, Hispanic/Latino patients with initially inadequate health literacy increased their knowledge more than non-Hispanic white and black patients with adequate health literacy (P<.05). Sun protection implemented 2 weeks after education varied by the ethnic/racial group. Outdoor activities were reduced by Hispanics/Latinos, non-Hispanic blacks sought shade, Hispanic/Latinos and non-Hispanic blacks wore clothing, and non-Hispanic whites wore sunscreen (P<.05).

CONCLUSION

Educational program with a tablet computer during the kidney transplant recipients' 6- or 12-month follow-up visits to the transplant nephrologist improved sun protection in all racial/ethnic groups. Tablets may be used to provide patient education and reduce the physician's burden of educating and training patients.

TRIAL REGISTRATION

ClinicalTrials.gov NCT01646099; https://clinicaltrials.gov/ct2/show/NCT01646099.