The effect of an educational brochure on knowledge and early detection of melanoma

Sun Safety at Work Canada: a multiple case-study protocol to develop sun safety and heat protection programs and policies for outdoor workers

BACKGROUND

CAREX Canada has identified solar ultraviolet radiation (UV) as the second most prominent carcinogenic exposure in Canada, and over 75 % of Canadian outdoor workers fall within the highest exposure category. Heat stress also presents an important public health issue, particularly for outdoor workers. The most serious form of heat stress is heat stroke, which can cause irreversible damage to the heart, lungs, kidneys, and liver. Although the need for sun and heat protection has been identified, there is no Canada-wide heat and sun safety program for outdoor workers. Further, no prevention programs have addressed both skin cancer prevention and heat stress in an integrated approach. The aim of this partnered study is to evaluate whether a multi-implementation, multi-evaluation approach can help develop sustainable workplace-specific programs, policies, and procedures to increase the use of UV safety and heat protection.

METHODS/DESIGN

This 2-year study is a theory-driven, multi-site, non-randomized study design with a cross-case analysis of 13 workplaces across four provinces in Canada. The first phase of the study includes the development of workplace-specific programs with the support of the intensive engagement of knowledge brokers. There will be a three-points-in-time evaluation with process and impact components involving the occupational health and safety (OHS) director, management, and workers with the goal of measuring changes in workplace policies, procedures, and practices. It will use mixed methods involving semi-structured key informant interviews, focus groups, surveys, site observations, and UV dosimetry assessment. Using the findings from phase I, in phase 2, a web-based, interactive, intervention planning tool for workplaces will be developed, as will the intensive engagement of intermediaries such as industry decision-makers to link to policymakers about the importance of heat and sun safety for outdoor workers.

DISCUSSION

Solar UV and heat are both health and safety hazards. Using an occupational health and safety risk assessment and control framework, Sun Safety at Work Canada will support workplaces to assess their exposure risks, implement control strategies that build on their existing programs, and embed the controls into their existing occupational health and safety system.

[Prevention of skin cancer: considerations on strategic communication]

In recent decades the numbers of cases of skin cancer have been increasing worldwide in light skinned populations. In Germany skin cancer is the most common form of cancer. To reduce the burden of skin cancer protection from ultraviolet radiation (primary prevention) and early detection (secondary prevention) of the disease play a decisive role. In this context information to the population about preventive behavior and the support of informed decision-making in skin cancer screening are important aspects in communication. This paper gives an overview about communicational aspects in the promotion of skin cancer prevention. In the development of communicational interventions it is important to identify the relevant target groups. Relevant key opinion leaders have to be included in the information process. Additionally, interventions should be based on a theoretical framework and be designed for the respective target group. Furthermore, different forms of communication and communication tools are provided for the realization of an information intervention. To appraise the intervention elements of summative and formal evaluation are available. The current results provide important findings about different effects of communicational aspects on knowledge and behavior of the population; however, due to the complexity of information interventions a particular effect cannot be explained by a single communicational element.

Interventions to decrease skin cancer risk in outdoor workers: update to a 2007 systematic review

Background

Outdoor workers are at high risk of harmful ultraviolet radiation exposure and are identified as an at risk group for the development of skin cancer. This systematic evidence based review provides an update to a previous review published in 2007 about interventions for the prevention of skin cancer in outdoor workers.

Results

This review includes interventions published between 2007-2012 and presents findings about sun protection behaviours and/or objective measures of skin cancer risk. Six papers met inclusion criteria and were included in the review. Large studies with extended follow-up times demonstrated the efficacy of educational and multi-component interventions to increase sun protection, with some higher use of personal protective equipment such as sunscreen. However, there is less evidence for the effectiveness of policy or specific intervention components.

Conclusions

Further research aimed at improving overall attitudes towards sun protection in outdoor workers is needed to provide an overarching framework.

Enhancing industry-based dissemination of an occupational sun protection program with theory-based strategies employing personal contact

PURPOSE

Industry-based strategies for dissemination of an evidence-based occupational sun protection program, Go Sun Smart (GSS), were tested.

DESIGN

Two dissemination strategies were compared in a randomized trial in 2004-2007.

SETTING

The North American ski industry.

SUBJECTS

Ski areas in the United States and Canada (n  =  69) and their senior managers (n  =  469).

INTERVENTION

Employers received GSS through a basic dissemination strategy (BDS) from the industry's professional association that included conference presentations and free starter kits. Half of the areas also received the enhanced dissemination strategy (EDS), in which project staff met face-to-face with managers and made ongoing contacts to support program use.

MEASURES

Observation of program materials in use and managers' reports on communication about sun protection.

ANALYSIS

The effects of two alternative dissemination strategies were compared on program use using PROC MIXED in SAS, adjusted for covariates using one-tailed p values.

RESULTS

Ski areas receiving the EDS used more GSS materials (x¯  =  7.36) than those receiving the BDS (x¯  =  5.17; F  =  7.82, p < .01). Managers from more areas receiving the EDS reported communicating about sun protection in employee newsletters/flyers (x¯  =  .97, p  =  .04), in guest e-mail messages (x¯  =  .75, p  =  .02), and on ski area Web sites (x¯  =  .38, p  =  .02) than those receiving the BDS (x¯  =  .84, .50, .15, respectively).

CONCLUSION

Industry professional associations play an important role in disseminating prevention programs; however, active personal communication may be essential to ensure increased implementation fidelity.

Expanding occupational sun safety to an outdoor recreation industry: a translational study of the Go Sun Smart program

A successful occupational sun-protection program was translated to 67 ski areas where the effectiveness of two dissemination strategies was assessed. An industry professional association distributed materials to the resorts. Half of the resorts received the basic dissemination strategy (BDS) in which the materials were simply distributed to the resorts. In a randomized trial, the BDS was compared with an enhanced dissemination strategy (EDS) that added interpersonal contact with managers. Employees (n=2,228) at worksites that received the EDS had elevated program exposure (74.0% at EDS vs. 57.5% at BDS recalled a message). Exposure increased at two levels of program use: from less than four (55% exposed) to four to eight (68%) and to nine or more (82%) program items in use. More employees exposed to messages engaged in sun-safety behaviors than those unexposed. At worksites using nine or more items (versus 4-8 or <4), employees engaged in additional sun-safety behaviors. Program effects were strongly mediated by increased self-efficacy. Partnerships with industry associations facilitate dissemination of evidence-based programs. Dissemination methods are needed to maximize implementation and exposure to reduce health risk behaviors.

Oncologists' use of patient educational materials about cancer and fertility preservation

BACKGROUND

This study sought to determine the prevalence of distribution of fertility preservation (FP) materials, source of the materials, and providers' perceived relevance of the materials among a sample of US oncologists.

METHODS

A 53-item survey was administered via mail and the Web to a stratified sample of oncologists from the American Medical Association Masterfile. This study represents a subset of results, reporting on three survey items.

RESULTS

Among the 511 oncologists (32% response rate), only 13.5% (n = 69) reported 'always or often' giving their patients educational materials about FP. Among those who reported ever distributing materials, 39.5% used American Cancer Society materials, 11.0% used Fertile Hope, 6.4% used Lance Armstrong Foundation, and 11.8% used 'other'. Among those who provided materials, only 27.4% believe the FP materials they provide are 'relevant to patient's specific cancer diagnosis'.

CONCLUSION

There is need to improve oncologists' distribution of FP educational materials to patients with cancer.

Marital status and stage at diagnosis of cutaneous melanoma: results from the Surveillance Epidemiology and End Results (SEER) program, 1973-2006

BACKGROUND

We evaluated the effect of marital status on risk of late-stage cutaneous melanoma diagnosis.

METHODS

Information about melanoma patients was obtained from Surveillance Epidemiology and End Results (SEER), 1973-2006. A multivariable logistic regression model was used to estimate relative risks of late-stage disease at diagnosis.

RESULTS

After exclusion criteria, 192,014 adult melanoma patients remained for analyses. After adjustment for age, race, year of diagnosis, tumor histology, anatomic site, socioeconomic status, and SEER site, the relationship between estimated risk of late-stage melanoma diagnosis and marital status was dependent on sex (P < .0001 for interaction). Although unmarried patients had a higher risk of being diagnosed at a late stage among men and women, the magnitude of the effect varied by sex. Moreover, among married, single, and divorced or separated patients, men had more than a 50% increase in risk of late-stage diagnosis when compared with women. Widowed men and widowed women, however, were not statistically different in their stage at diagnosis.

CONCLUSIONS

Results from this study are important and may be used by clinicians and public health practitioners interested in increasing the proportion of melanoma patients diagnosed at an early stage through screening, perhaps by specifically targeting unmarried individuals in addition to having broad-based skin cancer prevention programs.

Interventions to promote cancer awareness and early presentation: systematic review

Background:

Low cancer awareness contributes to delay in presentation for cancer symptoms and may lead to delay in cancer diagnosis. The aim of this study was to review the evidence for the effectiveness of interventions to raise cancer awareness and promote early presentation in cancer to inform policy and future research.

Methods:

We searched bibliographic databases and reference lists for randomised controlled trials of interventions delivered to individuals, and controlled or uncontrolled studies of interventions delivered to communities.

Results:

We found some evidence that interventions delivered to individuals modestly increase cancer awareness in the short term and insufficient evidence that they promote early presentation. We found limited evidence that public education campaigns reduce stage at presentation of breast cancer, malignant melanoma and retinoblastoma.

Conclusions:

Interventions delivered to individuals may increase cancer awareness. Interventions delivered to communities may promote cancer awareness and early presentation, although the evidence is limited.

Relationship and partner moderator variables increase self-efficacy of performing skin self-examination

OBJECTIVE

We sought to identify relationship and partner-related moderating variables that influence the effectiveness of both a couples and a solo learning intervention designed to increase skin self-examination behavior in a sample of patients at risk for developing melanoma.

METHODS

Patients received a brief intervention designed to teach skin self-examination skills and were randomly assigned into either a solo learning condition where the intervention was administered to the patient alone (n = 65) or a couple learning condition where the intervention was administered to the patient and patient's spouse or cohabiting partner (n = 65). The main outcome measure was skin self-examination self-efficacy, which is the strongest mediator of skin self-examination. The relationship moderator variables measured were quality of relationship, partner motivation, and ability to assist in implementation of the intervention.

RESULTS

When quality of the marital/partner relationship was high, the beneficial effects provided by the partner being included in the skin self-examination skills training were the highest and patients exhibited higher self-efficacy. Similar effects were observed for those with partners who were motivated to implement the intervention, and for those with partners high in ability to provide support.

LIMITATIONS

Study limitations include the need to evaluate whether the effects can be sustained long term and the exclusion of patients with melanoma without partners.

CONCLUSIONS

The amount of beneficial effects gained by the patient from the skin self-examination intervention was influenced by marital/partner relationships. Clinicians may need to consider these relationship and partner characteristics when communicating to patients about skin cancer screening.

Reducing ultraviolet radiation exposure among outdoor workers: state of the evidence and recommendations

OBJECTIVE

Outdoor workers have high levels of exposure to ultraviolet radiation and the associated increased risk of skin cancer. This paper describes a review of: 1) descriptive data about outdoor workers' sun exposure and protection and related knowledge, attitudes, and policies and 2) evidence about the effectiveness of skin cancer prevention interventions in outdoor workplaces.

DATA SOURCES

Systematic evidence-based review.

DATA SYNTHESIS

We found variable preventive practices, with men more likely to wear hats and protective clothing and women more likely to use sunscreen. Few data document education and prevention policies.

CONCLUSION

Reports of interventions to promote sun-safe practices and environments provide encouraging results, but yield insufficient evidence to recommend current strategies as effective. Additional efforts should focus on increasing sun protection policies and education programs in workplaces and evaluating whether they improve the health behavior of outdoor workers.

Skin Self-Examination in Patients at High Risk for Melanoma: A Pilot Study

PURPOSE/OBJECTIVES

To compare the effect of providing high-risk patients with standard brochures versus personalized photo books as part of a comprehensive nursing intervention on knowledge, awareness, and confidence with skin self-examination (SSE) performance, as well as compliance in performing SSE.

DESIGN

Randomized intervention design.

SETTING

The Lawrence E. Rockefeller Ambulatory Outpatient Cancer Center at Memorial Sloan-Kettering Cancer Center in New York, NY.

SAMPLE

100 patients at high risk for melanoma.

METHODS

Patients completed a baseline questionnaire before their initial photographs were taken and at the end of a nurse-teaching intervention at the clinic.

MAIN RESEARCH VARIABLES

Skin cancer knowledge, awareness, and self-confidence in SSE.

FINDINGS

A two-way analysis of variance with repeated measures was performed to examine differences within and among groups in relation to knowledge, awareness, and confidence. The group-time interaction was not significant. In group A (nursing intervention with photo book), 10% of the patients at baseline reported performing SSE three or more times during the prior four months. Mean knowledge scores, awareness, and confidence scores all increased. In group B (nurse-teaching intervention using brochures only, without a photo book), 20% reported practicing SSE three or more times during the prior four months. Mean knowledge, awareness, and confidence scores increased.

CONCLUSIONS

The main difficulty that patients experience with self-detection of melanoma is their limited recall of skin appearance; therefore, photographic records may be the most effective aid for detecting changes at longer intervals. The use of a photo book may help to diminish that difficulty.

IMPLICATIONS FOR NURSING

This study supports the fact that education can increase knowledge, awareness, and confidence regarding SSE, which is consistent with the findings of other investigators. Therefore, nurses should incorporate teaching patients how to perform SSE into their practice and recognize that personal involvement in health care has become a dominant theme in the cancer education literature in recent years. With this new emphasis, important self-care activities, such as testicular self-examination, breast self-examination, and now SSE, are being stressed because early detection has shown favorable effects in improving the prognosis of cancer.

Occupational exposure to ultraviolet radiation: the duality dilemma

Human exposure to ultraviolet (UV) radiation is a component of everyday life and a significant hazard for outdoor workers. In addition, a large range of artificial sources also has the potential to provide extreme occupational UV exposure. Even though the human health risks of overexposure to UV are well documented, to date relatively little is known quantitatively about UV exposure. For example, the evidence indicates that workers who are exposed to particular sources (for example, welding arcs) are exposed to extreme UV exposures, despite the use of current control measures. In contrast, increasing evidence points to significant health impacts resulting from underexposure to UV, particularly with the production (or more correctly lack of production) of vitamin D in the skin. The latter poses a serious issue for the work-force, with specific risks for workers lacking adequate sun exposure-underground miners, long-haul flight crews, shift workers, and perhaps indoor workers. Using a risk-management approach, this paper provides a comprehensive review of occupational UV sources, health impact of occupational UV exposure, occupational exposure standards, and levels of exposure in various settings, and discusses the appropriate control measures. In addition, the duality aspect of health impacts from overexposure and underexposure to UV and the associated occupational health implications are specifically explored.

Ethnoracial differences among outdoor workers in key sun-safety behaviors

BACKGROUND

Few sun-safety studies have included ethnoracially diverse groups. Comparison across such groups of sun-safety behaviors was the main objective of this analysis.

METHODS

Postal workers (n =2543) self-reported frequency of sunscreen, wide-brim hat, and sunglasses use during the last 5 workdays on 5-point Likert-type scales ranging from "never" to "always." Responses were dichotomized by "always" versus all other responses. Generalized estimating equations were used to assess the association between ethnicity/race and frequency of each sun safety behavior. The baseline data reported in this paper were collected in the summer of 2001, and the randomized trial was completed in the summer of 2004.

RESULTS

Ethnicity/race was significantly related to sunscreen and sunglasses use. For both sunscreen and sunglasses, the white group had significantly higher "always" rates than the other four groups (30% vs 14% to 23% and 63% vs 44% to 52%, respectively).

CONCLUSIONS

The results of this study indicated that although non-Latino white employees tended to have higher rates of sun-safety behaviors, the rates of adequate protection of all groups were low.

Interventions to prevent skin cancer by reducing exposure to ultraviolet radiation: a systematic review

The relationship between skin cancer and ultraviolet radiation is well established. Behaviors such as seeking shade, avoiding sun exposure during peak hours of radiation, wearing protective clothing, or some combination of these behaviors can provide protection. Sunscreen use alone is not considered an adequate protection against ultraviolet radiation. This report presents the results of systematic reviews of effectiveness, applicability, other harms or benefits, economic evaluations, and barriers to use of selected interventions to prevent skin cancer by reducing exposure to ultraviolet radiation. The Task Force on Community Preventive Services found that education and policy approaches to increasing sun-protective behaviors were effective when implemented in primary schools and in recreational or tourism settings, but found insufficient evidence to determine effectiveness when implemented in other settings, such as child care centers, secondary schools and colleges, and occupational settings. They also found insufficient evidence to determine the effectiveness of interventions oriented to healthcare settings and providers, media campaigns alone, interventions oriented to parents or caregivers of children, and community-wide multicomponent interventions. The report also provides suggestions for areas for future research.

Participation of older males in a study on photography as an aid to early detection of melanoma

OBJECTIVE

To examine the acceptability of photography as an aid to skin examinations in men over 50 years of age.

METHODS

A randomised trial of men selected from the electoral roll. All participants were photographed, but only half received their photographs. Skin examinations by GPs at years one and two.

RESULTS

55% of men consented to have photographs taken and 51% did so. 86% of respondents had risk factors for melanoma (compared to 68% of non-responders) and 47% had two or more risk factors (compared to 23% of non-responders). At year one, 91% of participants remaining in study regions had been examined. Photographs were lost by only six participants.

CONCLUSIONS

Men over 50 years of age respond to personalised health messages about melanoma and respondents include a high proportion of males with risk factors for melanoma.

IMPLICATIONS

These initial results suggest that photography may be a logistically acceptable approach for assisting in the early detection of melanoma.

Educating patients about malignant melanoma: computer-assisted learning in a pigmented lesion clinic

This prospective controlled study aimed to evaluate the effectiveness and acceptability of a computer program (CAL) designed to educate patients about skin protection including signs of melanoma. Two hundred and twenty-seven patients were recruited either from the Pigmented Lesion Clinic (PLC) or the Orthopaedic Fracture Clinic (OFC). A baseline measure of anxiety was obtained and subjects were allocated to either non-interactive, interactive or control conditions. Measures of anxiety and knowledge about malignant melanoma and skin protection were obtained prior to discharge from the clinic and knowledge was assessed again at 1-week follow-up. Results indicate that, although anxiety in the PLC subjects decreased significantly more than in the OFC patients, there was no significant effect of intervention. There was a significant effect of intervention on knowledge (F = 81.06, d.f. 2, 218, P < 0.0001) with participants having better knowledge on leaving the clinic in the interactive CAL condition than in both the Non-interactive condition and control. Non-interactive CAL was associated with higher knowledge than control. Knowledge gains were maintained at 1-week follow-up.

Factors involved in presentation of older people with thick melanoma

OBJECTIVE

To examine whether presentation of older people with thick melanoma is a result of the site and histological type or of their reduced ability to identify melanoma.

DESIGN AND SETTING

Retrospective analysis of the Newcastle Melanoma Unit patient database.

PATIENTS

2154 patients with melanoma for whom complete data (histological type, thickness and site of melanoma) were available and who presented from February 1981 to April 1997.

MAIN OUTCOME MEASURES

Histological type and site of melanoma in older (> or = 50 years) versus younger men and women; frequency with which these groups identified melanoma and the first changes of melanoma that were noticed.

RESULTS

Patients aged > or = 50 years, particularly men, were more likely to present with thicker lesions. Older men and, to a lesser extent, older women were more likely to present with nodular melanoma, which were more frequent on the scalp and face in older, compared with younger, men, and scalp and back in older men compared with older women. Failure to identify melanoma was associated with older age, sites on the scalp and back and histological type of the lesion, but was independent of sex once histological type, age, site and thickness were taken into account. Multivariate analysis indicated that the association of older age of patients with failure to identify melanoma applied irrespective of the site, type and thickness of their melanoma.

CONCLUSION

The higher frequency of thick melanoma in older people is accounted for by an increased proportion of nodular melanoma and decreased ability to recognise the changes of melanoma. These findings have important implications for examination of older patients by doctors and for design of strategies for early detection of melanoma in this age group.