Impact of a multimedia intervention “Skinsafe” on patients' knowledge and protective behaviors
Introduction
The incidence of cutaneous malignant melanoma (MM) has been rising in white populations (Lens and Dawes, 2004), with characteristics such as red hair and freckling further increasing risk (Grulich et al., 1996). Preventive strategies include promoting behaviors that protect skin from strong ultraviolet light (Saraiya et al., 2004) and education to facilitate early identification of melanoma. Lack of knowledge has been linked to delay in consultation and a thicker tumor at excision (Richard et al., 2000, Schmid-Wendtner et al., 2002). Studies in the Northern Hemisphere have found low levels of public knowledge about melanoma (Osterlind et al., 1997, Melia et al., 2000, Richard et al., 2000, Sefton et al., 2000) with unreliable signs such as bleeding considered more important than reliable early indicators such as change in shape of a mole (Jackson et al., 1999, Melia et al., 2000, Richard et al., 2000).
Theories of social cognition have been used to predict how changes in beliefs and knowledge can influence health protective behavior. The Health Belief Model has particular strengths in terms of guiding information design (Kinzie, 2005). It proposes that health protective behavior is influenced by the degree of threat associated with a particular condition. Beliefs concerning the benefits associated with carrying out protective behavior such as skin self-examination are also considered influential together with barriers to behavior such as lack of expertise. Cues to action such as communication from a health professional can impel behavior if the benefits of action outweigh the costs or barriers.
A range of methods have been used to improve knowledge about MM, including nurse education (Berwick et al., 2000), postal leaflets (Richard et al., 1999) and multimedia (Sefton et al., 2000). Arguably design strategies for health education should use a framework for learning which identifies key events such as gaining attention and enhancing retention of knowledge (Kinzie, 2005). Interactive computer-based education programs have obvious strengths here as they can both target those at risk and individualize health information messages. By using pictorial images, animation and sound, they can also engage the user and reinforce learning (McPherson et al., 2001). Information gains in low risk populations may have little impact on clinical outcomes (Brandberg et al., 1996, Jackson et al., 1999, Melia et al., 2001), and arguably, health promotion resources should be directed at patients with high-risk skin characteristics (Martin, 1995, Katris et al., 1996, Jackson et al., 1999, Glanz et al., 2003).
This study aimed to evaluate the effectiveness and acceptability of a targeted multimedia health education program in a Family Practice setting. It was hypothesized that the Skinsafe intervention would increase knowledge and skin protective behaviors in patients at higher risk for developing MM.
Section snippets
Design and participants
Five pairs of Family Practices within Nottinghamshire, England, matched for catchment area [one pair rural, one urban and three suburban) and list size, were included in this cluster-randomized, controlled study. Practices were numbered in pairs, and one practice in each pair was randomly allocated to the Skinsafe intervention, by an independent researcher blind to identity of practices, using the toss of a coin. Participants in the intervention and control group were recruited concurrently
Characteristics of participants
Two hundred and fifty nine participants were recruited to the intervention group and 330 to the control group. (Fig. 1). More patients consented in the intervention group than control (93.6% vs. 79%) (χ2 = 26.16, df = 1, P < 0.001). There were no overall gender differences in rates of consent. The response rate for the 6-month follow-up was 77.9% (459/589). Significantly more participants in the intervention group responded at follow-up compared to control (82.6% vs. 74.2%) (χ2 = 5.45, df = 1, P
Summary of main findings
As in previous studies, baseline knowledge levels were low and participants tended to underestimate their relative risk of developing melanoma (Jackson et al., 1999, Richard et al., 2000, Sefton et al., 2000). The Skinsafe intervention was associated with modest increases in knowledge, in a higher risk population. Free recall questionnaires obviously produce lower knowledge scores than true/false formats since there is no possibility of guessing. This improvement could therefore be considered
Conclusion
This study confirmed previous findings that multimedia health education about malignant melanoma is acceptable in clinical settings and showed further that such an intervention is associated with improvements in knowledge and protective behavior at 6-month follow-up.
Acknowledgments
We would like to thank Trent NHS Executive for funding this project, Dr. Irshad Zaki for helping with Skinsafe development, Lynette Tomlinson for the data collection, Rosemary Kwienscki for the data entry and Ian Crook of Showme Multimedia (www.showme.uk.com) for the design and production of the Skinsafe program. We are also grateful to the 11 international experts who provided extremely helpful comments on the original Skinsafe script. Skinsafe is available free on CD-ROM to any NHS Trust or
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