Abstract
Importance
Despite receiving dermatologic care, many patients with or without a history of skin cancer either do not use sun protection or fail to use it in an effective manner.
Objective
To examine the association of a brief dermatologist-delivered intervention vs usual care with patient satisfaction and sun protection behavior.
Design, Setting, and Participants
A longitudinal controlled cohort study among adults receiving dermatology care was conducted from April 25 to November 6, 2017, at 2 dermatologic clinic sites within a Northeastern health care system to compare outcomes associated with the intervention with that of usual care on 1- and 3-month patient outcomes. The sample consisted primarily of non-Hispanic white patients aged 21 to 65 years. Participants were assigned to the intervention group (n = 77) or the control group (n = 82) based on the site location of their dermatologists.
Interventions
The intervention (<3 minutes) was delivered by dermatologists during a skin examination or the suturing phase of skin cancer surgery. The intervention consisted of 6 components targeting sun risk and protective behaviors.
Main Outcomes and Measures
First, patient’s satisfaction with the dermatologist’s communication was assessed. Second, the association of the intervention with changing sun protection behavior of the patient was examined.
Results
Patients in the intervention group (46 women and 31 men; mean [SD] age, 52.4 [9.6] years) rated dermatologist-patient communication more positive compared with patients in the control group (59 women and 23 men; mean [SD] age, 51.4 [11.3 years]). Eighteen percent (14 of 77) of patients in the intervention group reported 1 or more sunburns 1 month after the intervention compared with 35% (29 of 82) of patients in the control group (P = .01). No differences in report of sunburns were seen at the 3-month follow-up. Patients in the intervention group reported increased use of sunscreen across 3 months (face: intervention, increased 12% and controls, decreased 4%; P = .001; body: intervention, increased 12% and controls, decreased 1%; P = .02; reapplication: intervention, increased 15% and controls, remained stable; P = .002).
Conclusions and Relevance
The intervention was delivered by dermatologists after minimal standardized training and resulted in a higher level of satisfaction with dermatologist-patient communication and improved sun protection behavior among patients across several months.
This longitudinal controlled cohort study examines the association of a brief dermatologist-delivered intervention with patient satisfaction and sun protection behavior among adults receiving dermatology care.
Key Points
Question
Can a brief dermatologist-delivered intervention (Addressing Behavior Change) lead to a change in sun protection behavior among patients at 1- and 3-month follow-ups during the summer in the Northeast?
Findings
In this longitudinal controlled cohort study, the 72 patients who received the Addressing Behavior Change intervention rated the quality of dermatologist-patient communication more positively compared with the 81 patients in the control group. Patients in the intervention group reported fewer sunburns than did patients in the control group 1 month after implementation of the intervention and higher rates of sunscreen use (on face, body, and reapplication) across time.
Meaning
The study provided evidence that a brief (<3 minutes) dermatologist-delivered intervention was associated with patients’ sun protection behavior across several months.
Introduction
Skin cancer is the most common malignant neoplasm in the United States, and the incidence of skin cancer is increasing.1,2 The primary modifiable risk factor implicated in skin cancer has been exposure to UV light.3,4 Individuals can decrease their risk of skin cancer by limiting intentional and unintentional sun exposure, as well as seeking shade when outdoors and wearing broad-spectrum sunscreens and protective clothing. Despite receiving dermatologic care and being educated about risks, many patients with or without a history of skin cancer either do not use sun protection or fail to use it in an effective manner.5,6,7 For example, 1 in 2 individuals seeking dermatologic care reported getting 1 or more sunburns during the past year.8
Dermatologists typically educate their patients about the importance of using sun protection to mitigate their risks.7,8,9 However, increasing patients’ knowledge in this manner does not reliably translate into behavior change.10,11 In contrast, conversations between physicians and patients that focus on assessing patients’ risks and their motivations and barriers to effective intervention readily translate into behavior change and improved health outcomes.10,11,12,13,14 However, dermatologists rarely focus on these topics owing to their concern about the limited time available for counseling in a busy practice.8,15 To address their concerns and facilitate changes in patients’ behavior, Mallett and colleagues16 developed the brief Addressing Behavior Change (ABC) intervention. The ABC intervention was designed to be brief in terms of dermatologist training and implementation. It has been integrated primarily into physician-patient conversations during a skin examination so that it does not add time to the visit but rather replaces customary knowledge-focused conversations about sun protection (<3 minutes).16 The ABC intervention consists of the following 6 primary components: assess patients’ risk of sun exposure, assess patients’ willingness to use sunscreen, assess patients’ barriers to using sunscreen, facilitate patients’ solution to barriers, assess other methods of sun protection, and offer additional options for sun protection.16
Dermatologists quickly and easily learned the ABC intervention, delivered the intervention competently, and showed minimal decrease in skill delivery during a 6-month period.16 Patients who received the ABC intervention rated the communications with their dermatologist as more positive compared with control patients and reported higher intentions to use sunscreen and other protective behaviors.15
Although these initial reports were promising, it was uncertain whether patients’ reports would translate into behavior change that is sustained over time. The goals of the present study were to examine patients’ satisfaction with communication with their dermatologists and the association of the ABC intervention with changing patient behavior (eg, history of sunburns and use of sunscreen and other sun protection) at 1- and 3-month follow-ups.
Methods
Sample and Procedure
This longitudinal controlled cohort study was conducted from April 25 to November 6, 2017. Patients were recruited from 2 sites of a Northeastern health care system. Inclusion criteria were as follows: patients had to be 21 to 65 years of age and scheduled for a skin examination or Mohs procedure with participating dermatologists (E.B.) who volunteered to be part of the study team. Exclusion criteria included a history of psoriasis or a demonstrated communication barrier (eg, mental disability or not fluent in English). Patients were assigned to intervention (n = 77) or control (n = 82) groups based on the site location of their dermatologists (Figure 1). Intervention and control sites were determined by site to prevent contamination. Patients were not randomly assigned to a group; patients who went to the intervention site dermatologists were in the intervention group and those who went to the control site dermatologists were in the control group. Participants received $25 to complete each assessment and provided written informed consent prior to the first assessment. The Penn State College of Medicine institutional review board approved the study.
Figure 1. Patients Enrolled in the Control and Intervention Groups.
At baseline (late spring and early summer), 1 month (midsummer), and 3 months (late summer and early fall), patients completed a 5- to 10-minute self-report survey. The paper-based baseline survey was completed in the clinic prior to their appointment; 1-month and 3-month surveys were completed online (the retention rate for both was 96.2% [153 of 159]). Study data were collected and managed using the research electronic data capture (REDCap) tools; REDCap is a secure web-based application designed to support data capture for research studies.17
Dermatologist Training Protocol for Standardized ABC Intervention
Dermatologists providing care to patients in the intervention condition attended a 1-hour didactic training session during a journal club meeting that included a description of the ABC intervention, a demonstration of the ABC intervention delivered by a trained dermatologist with a mock patient, and exercises in which they practiced delivering the intervention to a partner (see sample standardized ABC intervention training script in Figure 2). Dermatologists were then observed delivering the ABC intervention to 3 to 5 patients by the principal investigator (K.A.M.) or coinvestigator (R.T.) where the physician could ask questions and receive personalized coaching tips following the patient visit. In addition, intervention dermatologists received 7 weekly check-in emails from the principal investigator (K.A.M.) to reinforce intervention delivery skills using hypothetical case examples (eg, engaging patients, tips for resistant patients, and efficient methods of asking questions). Dermatologists providing care to participants at the control site were asked to continue with usual care and were offered information about the ABC intervention training after the study was completed.
Figure 2. Standardized Addressing Behavior Change (ABC) Intervention Training Script.
Measures
Quality of Dermatologist-Patient Communication (Assessed at 1-Month Follow-up)
Participants were asked questions regarding the quality of the dermatologists’ communication about specific topics (eg, use of sunscreen) and their general satisfaction with dermatologists’ communication during visits (eg, discussed your health worries and concerns). Response options ranged from 1 (poor) to 5 (excellent).
Sun Protection Behavior (Assessed at All Time Points)
Participants were asked “During the past year/month/three months on a typical summer day when you spent time outside, what percent of the time did you:” use sunscreen on your face (or a facial moisturizer with sun protection factor), use sunscreen on areas of your body exposed to the sun, reapply sunscreen often (eg, every 1-2 hours when outside), and cover your skin (eg, clothing, sunglasses, or hat). Response options were on a 6-point scale that ranged from 0 (0%) to 5 (100%).
Sunburn
Participants were asked to indicate the number of times in the past year (at baseline), past month (at 1-month follow-up), and past 3 months (at 3-month follow-up) that they experienced sunburn.
Demographics (Assessed at Baseline)
At baseline, participants were asked to provide a variety of demographic information such as age, sex, race, ethnicity, and history of skin cancer (eg, whether a dermatologist had diagnosed basal cell carcinoma and/or squamous cell carcinoma and/or melanoma).
Statistical Analysis
χ2 Analyses were conducted to test for baseline differences in demographics between the intervention and control groups. To test for the effects of attrition, participants were coded as “1” for completing the 3-month follow-up assessment and as “0” for not completing the 3-month follow-up assessment. Independent samples t tests and χ2 analyses were conducted to test for statistically significant differences between patients who did and patients who did not complete the 3-month assessment in regard to demographics, history of skin cancer, and baseline sun protection behavior. P < .05 (2-sided) was considered significant. A post hoc analysis indicated that the sample size of 159 participants (82 in the control group and 77 in the intervention group) would accommodate a 15% risk of attrition. For comparisons of the 2 groups, it was determined that sample size would allow for the detection of effect sizes that correspond to small η squares (ie, proportion of explained variance) in the range of 5% (or smaller). The sample sizes were expected to yield a power of greater than 0.80 for the contrasts of interest (eg, Tukey post hoc tests).
Quality of Dermatologist-Patient Communication
Independent samples t tests were used to compare participants’ perceptions of dermatologists’ communication by group at the 1-month follow-up. In each of these analyses, an observed t statistic greater than 1.96 was considered to reflect statistically significant differences between the groups.
Association of ABC Intervention With Changing Patient Behavior
To examine the outcomes associated with the intervention at the short-term (1-month) and long-term (3-month) assessments, 2 (group) × 3 (time) repeated measures analyses of variance were conducted on the self-reported sun protection–related outcomes (ie, sunscreen on face, body, reapplication, and covered skin with clothing). To reduce type 1 error, statistical adjustments were made to the numerator degrees of freedom to equal 1.18 Post hoc pairwise comparisons were conducted using Tukey tests to examine mean differences between the groups and within groups over time.19
Multiple regression was used to examine differences in the number of reported sunburns between groups. First, the number of sunburns reported at baseline (ie, past year) was regressed onto the group (1 = intervention and 0 = control). This analysis examined baseline equivalence across the groups. Second, the number of sunburns reported at the 1-month follow-up was regressed onto the group (1 = intervention and 0 = control) and baseline sunburns. This analysis examined differences across the conditions after the intervention, controlling for any preintervention differences. Last, the number of sunburns reported at the 3-month follow-up was regressed onto the group (1 = intervention and 0 = control) and baseline sunburns. This analysis also examined differences across the conditions after the intervention, controlling for any preintervention differences. In each of these analyses, an observed t statistic greater than 1.96 is considered to reflect statistically significant differences between the groups.
Participant retention was 96.2% (153 of 159) across the study. However, a covariate was included in all analyses in which 1 = participant completed all assessments and 0 = partial completer.
Results
Sample Characteristics
The mean age of the participants was 51.4 years in the control group and 52.4 years in the intervention group. Skin cancer diagnoses were reported for 36 (44%) of the control group and 45 (58%) of the intervention group. The majority of participants were female (59 [72%] in the control group and 46 [60%] in the intervention group) and white (81 [99%] in the control group and 73 [95%] in the intervention group). Examination of the demographics revealed no differences between the patients in the intervention group and the patients in the control group at baseline with regard to sex, ethnicity, history of skin cancer, and age. Differences were found for race; however, this was owing to 4 individuals in the intervention group reporting categories other than white relative to 1 individual in the control group (Table 1). Participant attrition at 1 and 3 months was 3.8% and was equivalent across groups (χ21 = 3.04; P = .08).
Table 1. Demographic Characteristics of the Participants at Baseline.
| Characteristic | Participants, No. (%) | Statistic | |
|---|---|---|---|
| Control Group (n = 82) | Intervention Group (n = 77) | ||
| Sex | |||
| Male | 23 (28) | 31 (40) | χ21 = 2.64 |
| Female | 59 (72) | 46 (60) | |
| Ethnicity | |||
| Hispanic or Latino | 0 | 0 | χ21 = 20 |
| Non-Hispanic or non-Latino | 82 (100) | 77 (100) | |
| Race | |||
| White | 81 (99) | 73 (95) | χ24 = 24.32 |
| Black | 0 | 1 (1) | |
| Asian | 0 | 1 (1) | |
| Native American or Native Alaskan | 0 | 1 (1) | |
| Other | 0 | 1 (1) | |
| Not reported | 1 (1) | 0 | |
| Skin cancer diagnosis | |||
| Yes | 36 (44) | 45 (58) | χ21 = 23.36 |
| No | 46 (56) | 32 (42) | |
| Age, mean (SD), y | 51.4 (11.3) | 52.4 (9.6) | t157 = −0.59 |
Quality of Dermatologist-Patient Communication
As shown in Table 2, comparisons of the quality of dermatologist-patient communication revealed that participants in the intervention group rated communications with their dermatologist more positive than did participants in the control group on all 5 items.
Table 2. Patients’ Satisfaction With Dermatologists’ Communication Skills.
| Communication Item | Mean (SD) Score | t Value | P Value | |
|---|---|---|---|---|
| Control Group | Intervention Group | |||
| Demonstrated caring, compassion, and understanding | 4.42 (0.79) | 4.76 (0.52) | −3.15 | .002 |
| Discussed your health worries and concerns | 4.45 (0.83) | 4.78 (0.59) | −2.79 | .006 |
| Suggested ideas to cover your skin (eg, wear hats or protective clothing) | 4.24 (1.09) | 4.71 (0.54) | −3.29 | .001 |
| Suggested ideas to use sunscreen daily | 4.18 (1.07) | 4.72 (0.59) | −3.86 | <.001 |
| Suggested ideas to reapply sunscreen often | 3.93 (1.17) | 4.54 (0.75) | −3.83 | <.001 |
Association of ABC Intervention With Sun Protection Behavior
Sunscreen Use
Analyses revealed that the differences between the intervention and control groups in the percentage of time participants reported using sunscreen on their face varied depending on the timing of the assessment (F1,311 = 7.53; P = .001). Participants in the intervention group reported that sunscreen use on their face increased 12% from baseline (67%) to 3 months after the intervention (79%) (P = .05), while those in the control group reported that sunscreen use on their face decreased 4% across this time (from 73% at baseline to 69% at 3 months) (Table 3).
Table 3. Data on Sunscreen Used on Face and Body and Reapplicationa.
| Type of Use | Mean (SD) % of Patients | ||
|---|---|---|---|
| Baseline | At 1 mo | At 3 mo | |
| Sunscreen on face | |||
| Intervention group | 67 (37)* | 78 (30)† | 79 (29)† |
| Control group | 73 (33)* | 70 (34)* | 69 (35)* |
| Sunscreen on body | |||
| Intervention group | 55 (33)* | 61 (32)*,† | 67 (27)† |
| Control group | 62 (31)* | 56 (35)*,† | 61 (32)*,† |
| Reapplication of sunscreen | |||
| Intervention group | 34 (32)* | 43 (38)† | 49 (32)† |
| Control group | 42 (35)† | 36 (34)*,† | 42 (36)*,† |
For each outcome, cells that contain the same symbols are not significantly different from one another, while cells that have different symbols (uncommon superscripts) are significantly different from one another (P = .05).
Similar differences were observed between the intervention and control groups in the percentage of time participants reported using sunscreen on their bodies (F1,311 = 4.28; P = .02). Participants in the intervention group reported that sunscreen use on their body increased 12% from baseline (55%) to 3 months after the intervention (67%) (P = .05), while controls reported that sunscreen use on their body decreased 1% across this time (from 62% at baseline to 61% at 3 months) (Table 3).
Last, participants in the intervention group reported increasing their reapplication of sunscreen 15% from baseline (34%) to 3 months after the intervention (49%) (P = .05), while those in the control group remained the same across this time (42% at baseline to 42% at 3 months) (F1,311 = 6.36; P = .002) (Table 3).
Protective Clothing
Between the intervention and control groups across the study, no differences were observed in the percentage of time patients reported covering their skin with clothing (F1,311 = 1.68; P = .19).
Sunburn
No differences between the groups in number of sunburns were observed at baseline (t = 0.06; P = .52). However, 35% (29 of 82) of participants in the control group reported having 1 or more sunburns 1 month after the intervention compared with 18% (14 of 77) of participants in the intervention group (t = 2.57; P = .01). No differences were observed at the 3-month follow-up (t = 1.62; P = .11).
Covariate Analysis
Finally, we performed all analyses again, adding covariates for type of office visit (surgery vs skin examination) and patient age, sex, and skin cancer history in the following 2 ways: examining each covariate separately to see if the specific variable mattered, and with all the covariates included at the same time. When examining each covariate separately, we found that the results remained consistent with the original findings for all outcomes. When we examined all the covariates simultaneously, the results were consistent with the original findings, except for the use of sunscreen on the body. The percentages of use did not change, but the statistical significance changed to P = .10. Together, these findings suggest that the outcomes associated with the ABC intervention were not altered by whether the patients were younger or older, male or female, or had a history of skin cancer or whether the intervention occurred during a skin examination or while the patient was receiving sutures.
Discussion
The findings of this study support the efficacy of the ABC intervention in increasing sun protection behavior among patients seeking dermatologic care. The study provided evidence that a very brief (<3 minutes) dermatologist-delivered intervention and was associated with patients’ sun protection behavior across several months. Participants who received the ABC intervention reported applying sunscreen on their face more frequently than did participants in the control group, and they maintained this behavior across time. Furthermore, they reported 50% fewer sunburns at the 1-month follow-up. The delivery of the ABC intervention in late spring and early summer may have helped patients avoid sunburn by increasing their proactive sun protection behavior during this relevant period of increasing sun intensity.
Notable within-group differences across time were also observed. Although no significant differences were detected between the groups in the percentage of time sunscreen was used on the body, patients in the intervention group reported significant increases in the use of sunscreen on the body over time, from 67% at baseline to 79% at 3 months (Table 3). A similar pattern emerged among the intervention group for reapplying sunscreen, from 34% at baseline to 49% at 3 months, suggesting that the outcomes associated with the ABC intervention increase, rather than decrease, over time (Table 3).
The ABC intervention was also associated with higher patient satisfaction regarding the quality of dermatologist-patient communication. Although dermatologists who delivered both the intervention (ABC) and usual care received high ratings for their communication skills, patients in the intervention group rated their dermatologists higher on their communication skills pertaining to sun protection behavior and their ability to discuss health concerns and demonstrate care and compassion. Overall, patients perceived that dermatologists who used the ABC intervention had better communication skills pertaining to sun protection and more satisfying interactions in the same amount of time compared with the dermatologists who provided usual care in the control group.
Contextualizing the Outcomes Associated With the ABC Intervention
Although some interventions targeting health behaviors require multiple sessions to detect change (eg, addictive behaviors, such as smoking), we observed modest effects in sun protection after 1 very brief session (<3 minutes). One consideration is that, although there is evidence for tanning addictions, the use of sun protection does have the same biological and behavioral processes that are deeply rooted in smoking or other addictions. This is perhaps 1 reason that this study observed changes in patient behavior after only 1 ABC intervention session. For most individuals who use sunscreen, but perhaps not regularly or not properly, the ABC intervention helped them resolve specific barriers to improve their use of sun protection (eg, forgetting to use or reapply sunscreen). Owing to the nature of the behavior, patients will not likely need as many iterations to experience some positive change.
Another possibility is that dermatology patients are primed with messages about sunscreen, and the ABC intervention is efficacious because it is part of a larger package of other components of sun protection care (eg, handouts and samples of sunscreen). As such, it can be expected that patients will not likely need as many iterations to experience some success in changing their sun protection behavior. Alternatively, the outcomes could increase over time if patients are exposed to the ABC intervention during subsequent office visits.
Limitations
This study has some limitations. First, although the sites were selected to be as similar as possible, our control site required fewer dermatologists to recruit approximately the same number of patients as the intervention site. No differences were observed between the sites in patient characteristics (age, sex, ethnicity, and skin cancer history), but there could be site-related factors that influence the findings (eg, patient flow). Future studies examining multiple sites, as well as incorporating a more diverse caregiver population that includes residents, attending dermatologists, physician assistants, and nurse practitioners, are recommended. Second, the study limited the follow-up period to 3 months. Future studies examining sun protection behavior and sunburns across 1 year and in varying seasons and environments that may increase risk (eg, beach vacation) would be beneficial. Finally, outcome measures were assessed using self-reported measures. Self-reported measures of sun protection have been validated in medical research.20 We followed published recommendations to reduce potential response bias. First, patients were informed that their responses were confidential and would not be shared with their dermatologist. Second, assessments took place independent of participants’ interactions with their physicians. Follow-up assessments were administered by research staff, who were not associated with the patient’s physician’s office and were completed using web-based encrypted survey procedures. Third, participants were blinded to condition to reduce the likelihood of biased responses.
Conclusions
Overall, the brief ABC intervention was associated with enhanced patient satisfaction with the communication skills of the dermatologist and subsequent sun protection behavior resulting in a 12% to 15% increase in the reported use of sunscreen after 3 months. The intervention was also associated with 50% fewer sunburns after 1 month compared with controls, but there were no differences seen in the sunburns at 3-month follow-up. Given the increasing rates of skin cancers and associated costs, modest increases in sun protection behavior on a large scale are potentially meaningful. The ABC intervention replaces less-effective customary conversations about sun protection without adding additional time to patient visits. It is optimally delivered during a skin examination or the suture placement phase of Mohs surgery, when conversations about sun protection typically occur. The training time for physicians is minimal, and dermatologists are able to learn the skills quickly and retain them over time.16 This efficient training model may be ideally suited to incorporate into residency training programs or used in continuing medical education for practicing dermatologists.
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