Improving Adherence to Skin Self-examination in High-Risk Individuals


Patient adherence to self-management strategies can be difficult.

Researchers examined adherence to skin self-examination practices for the early detection of melanoma in individuals at high risk. In a recent scoping review, they sought to identify strategies that could be used to improve patient adherence to both skin self-examinations and other self-monitoring practices in this patient population across multiple randomized controlled trials.1

Investigators identified 76 full study texts for inclusion in the review, with a total of 18 studies reported across 24 papers ultimately included. Studies took place in the United States, United Kingdom, and Australia, and ranged in participant size from 40 to 724 participants over periods of time from 3 to 24 months.

Adherence strategies were identified as either a stand-alone intervention, a component of the intervention under investigation, or in the description of the study methods. Per the researchers, many of these strategies simultaneously targeted several of the 5 World Health Organization dimensions of adherence. Ultimately, 15 of the randomized controlled trials used trial design, 5 used social and economic support, 18 used intervention design, 10 used intervention support, and 18 used participant support, such as the provision of knowledge and skills for behavioral change.

Fourteen of the included studies limited eligibility criteria to participants “likely to be able to adhere to the intervention,” the researchers noted. Reasons for exclusion included visual or cognitive impairment, comorbidities, and a lack of internet or smartphone access.

Five clinical trials utilized strategies that provided participants with social support. In 2 trials, research staff facilitated urgent clinical appointments, while patients in 2 other trials were provided with information on how to access care; 1 trial facilitated calendar scheduling to make an appointment with the patient’s health care provider. However, no studies reported strategies to provide participants with economic support for direct or downstream costs related to trial participation, nor were there strategies targeting health inequity (for example, tailored support for individuals with socioeconomic disadvantages, low health literacy, non-English speakers, or older adults).

All trials included in the review used intervention design to increase patient adherence. Thirteen trials used theories of health behavior change in their intervention design, including social cognitive theory, the theory of planned behavior, and the health belief model; seven trials utilized pretrial user testing to establish the acceptability of the intervention and implement necessary revisions.

All trials also provided education around melanoma and the benefits of skin self-examination, as well as information explaining how to conduct the skin self-examination intervention, provided in the form of written materials, videos, internet-based tablet or smartphone apps, or in-person training. Seven trials included individually tailored information based on responses to baseline questions on risk factors, melanoma knowledge, and other relevant domains.

“Multiple strategies to support adherence were used in most of the trials of melanoma self-monitoring,” the researchers noted. “To our knowledge, this is the first review on adherence to [skin self-examination] and other melanoma self-management interventions in a trial setting.”

“There is currently limited practical guidance for the best practices to maximize adherence to [skin self-examination] in research or practice,” they continued. “Assessment of adherence to an intervention in a trial may provide valuable insights on the ease with which it can be translated into routine clinical practice.”

Study limitations include the use of multiple adherence strategies in each individual trial, “making it difficult to determine which elements were effective and necessary,” as well as a lack of generalizability to the pharmaceutical treatment of dermatological diseases.

“Supporting adherence to self-management strategies is a complex problem influenced by multiple interacting factors,” the researchers concluded. “These findings may support improvements in the design, evaluation, and reporting of adherence strategies for use in research and practice.”

1. Ackerman DM, Bracken K, Janda M, et al. Strategies to improve adherence to skin self-examination and other self-management practices in people at high risk of melanoma. A scoping review of randomized clinical trials. JAMA Dermatol. 2023;159(4):432-440. Doi:10.1001/jamadermatol.2022.6478
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