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Jacobsen AA, Galvan A, Lachapelle CC, Wohl CB, Kirsner RS, Strasswimmer J. Defining the Need for Skin Cancer Prevention Education in Uninsured, Minority, and Immigrant Communities. JAMA Dermatol. 2016;152(12):1342–1347. doi:10.1001/jamadermatol.2016.3156
Copyright 2016 American Medical Association. All Rights Reserved.
What are appropriate strategies and education topics for skin cancer prevention interventions in uninsured, minority, and immigrant communities?
In a survey of 206 participants, 25.4% had never heard of skin cancer or melanoma, 20.7% believed that people with dark skin cannot get skin cancer, and 58.2% never or rarely conducted self–skin checks. Video (37.3%) and text messaging (30.8%) were the most popular outreach methods.
Intervention efforts in uninsured, minority, and immigrant communities need to focus on increasing knowledge capacity and promoting self–skin checks. Video and text messaging may be appropriate intervention methods.
As the minority population increases in the United States, the incidence of skin cancer has important public health consequences, including poor skin cancer outcomes, in part because of late-stage diagnosis. Therefore, it is important to identify obstacles in skin cancer prevention in these communities.
To characterize skin cancer prevention and education needs in uninsured, minority, and immigrant communities in South Florida.
Design, Setting, and Participants
At a large free medical clinic in Florida, a convenience sample of people completed a 23-question survey in English, Spanish, or Haitian Creole assessing their skin cancer risk perception, knowledge, sun protective behaviors and barriers, and desirable outreach methods. All participants were uninsured and living at least 200% below the federal poverty level. Participants were adults recruited from the general waiting room who understood 1 of the 3 languages and were not present for a scheduled dermatology visit.
Main Outcomes and Measures
The survey used Likert-type scales, true or false, and yes or no questions. Data were analyzed with SPSS IBM statistical software (version 22) using 1-way analysis of variance, χ2 tests, and Pearson correlations.
Among the 219 people invited, 206 participants (mean [SD] age, 43 [13.2] years) completed the survey; 75% of respondents were women who usually worked indoors. Almost a quarter (49 [24.5%) had never heard of skin cancer or melanoma. Nearly half (89 [44.3%]) had never conducted a self–skin examination. One in 5 (41 [20.7%]) believed that people with dark skin cannot get skin cancer. Three quarters (156 [75.7%]) of respondents fell into the “low/inconsistent” sun protective behavior category. Barriers to sun-protective behaviors were “using sun protection is too hot” (75 participants [39.3%]) and “I forget.” (72 [37.7%]). More than 85% (175 [87.9%]) wanted to learn more about how to prevent skin cancer. Watching a video (37.3%) and text messaging (30.8%) were identified as the most popular outreach methods.
Conclusions and Relevance
Important barriers to skin cancer prevention were lack of knowledge, the belief that dark skin was protective, and using sun protection made them feel too hot. Skin cancer education and intervention efforts in uninsured, minority, immigrant populations may be provided by videos and text messaging.
The incidence of skin cancer in minority populations is rising,1 with a 22% increase observed since 1992 in Hispanics.1 Others estimate that the incidence in Hispanics is rising by 2.9% annually.2 In addition, minorities are more likely to present with stage IV and thicker melanomas,3,4 resulting in higher mortality rates in blacks and Hispanics with melanoma.4 Thus, a disparity in prevention and diagnosis exists. Because the minority population in the United States is expected to reach over 50% by the year 20445 research to determine appropriate interventions is warranted.
Prevention interventions such as SunSmart,6 a large-scale public education campaign originating in Australia, have successfully targeted behavior change in white individuals who are at highest risk of developing skin cancer. While there are some data on risk perception and preventive behavior in minorities,2 there is a paucity of information on approaches to intervention. Therefore, we sought to identify appropriate strategies for skin cancer prevention in uninsured, minority, immigrant populations in the United States.
Following University of Miami institutional review board approval, from October 2015 through January 2016, we conducted a 23-question needs assessment survey in Spanish, English, and Haitian Creole of uninsured patients who were at or below 200% of the federal poverty level at one of the largest nonprofit volunteer-staffed free medical clinics in the United States. Participants were eligible for inclusion if they were a current registered adult patient at the clinic and could understand spoken English, Spanish, or Haitian Creole. Those younger than 18 years, anyone who did not understand the these 3 languages, and those who were being seen for a dermatology visit were excluded.
Survey questions were adapted to a sixth-grade level or below from previously validated questionnaires to meet an anticipated low-health literacy level.7-11 Of the 23 questions, 8 were left unaltered, 8 were simplified, and 6 were new items specific to our study goals. Bilingual health care professionals confirmed questions were culturally appropriate, approached each consecutive patient in the waiting room, obtained verbal consent, conducted the survey verbally, and recorded responses on a written form. Patients were not compensated for their participation.
In addition to Fitzpatrick skin-type classification, we used a validated color bar tool for skin-type self-identification that is more appropriate for nonwhite skin tones.12 We summed responses from a 5-level Likert-type scale to categorize patients into “low/inconsistent” (3-9 points) or “consistent” (10-15 points) sun-protective groups. Data were analyzed using IBM SPSS Statistics software (version 22).
A total of 219 people were approached, with 206 completing the survey (a 94.1% response rate). Participants had a mean (SD) age of 43 years (13.1), and most (75.7%) were women. Immigrants from Central America (37.9%), Mexico (27.7%), South America (14.1%), and the Caribbean (12.1%) comprised the largest proportion of participants. Nearly 1 in 10 (18 [8.8%]) had no formal education, 75 (36.8%) had a primary-level education, 74 (36.3%) had a secondary-level education, 30 (14.7%) had a college-level education, and 7 (3.4%) had a graduate-level education. Over three-quarters (161 [78.2%]) spoke Spanish, 20 (9.7%) spoke Creole, 16 (7.8%) spoke English, and 9 (4.4%) spoke another as their first language. Pigment levels, graded on a validated 6-point scale,12 varied with 134 (65.7%) having a high-risk skin type (tone 1 or 2), 50 (24.5%) medium-risk (tone 3 or 4), and 20 (9.8%) low-risk (tone 5 or 6). Demographics are listed in Table 1.
Nearly a quarter of participants (49 [24.5%]) had never heard of skin cancer or melanoma. Nearly 40% (80 [39.6%]) believed they were “very unlikely” or “unlikely” to get skin cancer in their lifetime. Forty-one (20.7%) believed that “people with dark skin cannot get skin cancer.” Skin tone negatively correlated with higher risk perception (r = −0.167; P = .02).
Only 32 (15.8%) had ever asked a physician about a suspicious spot on their skin, 46 (23.0%) had seen a dermatologist as an adult, and 47 (23.4%) had received information about skin cancer. One hundred seventeen (58.2%) had never or rarely checked their skin for suspicious spots. Higher education correlated with increased frequency of self–skin checks (r = 0.274; P < .001). More hours spent in the sun during work correlated with less frequency of self–skin checks (r = −0.213; P = .02) and sunscreen use (r = −0.213, P = .002), but increased long-sleeved shirt use (r = 0.260; P < .001) and hat use (r = 0.245; P < .001).
Nearly 90% (of participants 175 [87.9%]) indicated they would like to learn more about how to prevent skin cancer. Watching a video was the most popular outreach method (37.3%), followed by text messaging (30.8%), taking a class (19.4%), email (16.4%), and talking to a health educator (16.4%). There was no difference between preferred method of outreach and sex or age but differences between education levels were observed (Table 2).
Three-quarters of respondents (156 [75.7%]) fell into the “low/inconsistent” sun-protective behavior category. Wearing a hat was the most consistent behavior (73 respondents [35.9%]). South Americans were more likely to use sunscreen than those from the Caribbean, Central America, and Mexico (P < .001), but hat and long-sleeved shirt use did not differ between nationalities. Increased sunscreen use correlated with higher education level (r = 0.259; P < .001) (Table 3).
Barriers to sun-protective behavior, from most common to least, included “it’s too hot to wear” (75 participants [39.3%]), “I forget” (72 [37.7%]), “it’s inconvenient” (39 [20.4%]), “I don’t have sunscreen, hat, and/or long-sleeved shirt” (23 [12.0%]), “it takes too much time to put on” (12 [6.3%]), and “it’s too expensive” (9 [4.7%]).
This study identified appropriate outreach methods for underserved, uninsured, and immigrant populations. We reinforced what is already known about sun-protective behavior and risk-perception in Hispanics2 and expand on the work by Weiss et al2 in describing sun-protective behavior and knowledge in vulnerable, uninsured subgroups.
We also identified culturally appropriate topics for populations with low health literacy, including defining skin cancer and melanoma, dispelling the misbelief that dark-skinned individuals are not at risk, and emphasizing skin self-checks. Nearly a quarter of the study population had never heard of skin cancer or melanoma. This basic definition is absent from many existing skin cancer education programs, making them inappropriate for communities with low health care literacy. We specifically need to emphasize the importance of self–skin checks because 117 participants (58.2%) never or rarely conducted self–skin checks.
Furthermore, a fifth of the participants (20.7%) believed that people with dark skin cannot get skin cancer. In a study by Coups et al,14 researchers found that a quarter of Hispanic participants felt that their natural skin tone offered protection. Similarly, a focus group study of African Americans, Hispanics, and Asians found that participants associated a greater risk of skin cancer with lighter skin tones.15 However, the misbelief that people with dark skin cannot get skin cancer, as found in our study, is much more extreme than the belief that pigmentation offers a degree of protection. This demonstrates a need for skin cancer education in all populations regardless of skin tone.
Nearly 90% of our study population wanted to learn more about how to prevent skin cancer. The preferred delivery of education was by video and text messages, with email least applicable, particularly for less-educated patients (Table 2). The use of technology to reach underserved communities may not seem intuitive at first, especially because email and Internet access is limited in low-income families. However, 84% of households earning less than $30 000 per year have a cell phone.16 Another study showed that income was actually inversely proportional to number of texts sent and received per day.17 An important point, as our study suggests, is that low-income communities are interested in receiving health information via texting. In 2 separate studies, the first with 468 WIC participants (Special Supplemental Nutrition Program for Women, Infants and Children)18 and the second with a group of 54 low-income urban Latino parents,19 both reported that participants wanted to receive text messages for pregnancy and/or postpartum support and immunization reminders, respectively. There are no reported skin cancer interventions using texting reminders for underserved communities. However, a recent multicomponent intervention using text message reminders delivered to caregivers was associated with increased sun-protective behaviors in children,20 showing promise for mobile technology in prevention efforts. Successful public health interventions in other medical specialties should be further examined for their applicability to preventing skin cancer in underserved populations. When discussing skin cancer interventions for minorities, it is important to distinguish between ethnic, regional, and cultural differences.21 Our results indicate that sun-protective practices and beliefs may differ by nationality, culture, and education level. For example, South American participants reported sunscreen use and self–skin checks more frequently than other participants. However, participants from Central America reported the highest use of long-sleeved shirts (Table 3). Weiss et al2 also found a high level of heterogeneity among different Hispanic populations in the United States. This supports the need for tailored, cultural- and socioeconomic-specific intervention programs.
Too often, minorities are assumed to have “skin of color,” which is considered to be darker than that of whites. However, our study clearly shows that in our predominantly Hispanic minority, immigrant population, skin tones heavily favor the lighter end of the spectrum. We believe that dermatologists need to be careful when using the term skin of color because it may not accurately represent the population they are referring to. For example, 1 study22 examined the diversity of skin phenotypes in various ethnicities. While they also found that lighter skin tones exist in populations considered to be “of color,” their study was split into 3 groups: whites, Hispanics, and African Americans. These groups are not mutually exclusive because “Hispanic” is no longer considered a descriptor of race, but of ethnicity.
There are 2 objective tools that can be used to describe people of color. The first, the Fitzpatrick skin type classification, describes a patient’s physiologic response to UV light exposure, specifically their propensity to burn. However, it does not classify people by skin tone, nor is it a valid measure for skin cancer risk in many ethnically diverse groups.15 A more recent skin-tone scale described by Ho and Robinson12 clarifies skin color. It is applied to a patient based on the patient’s subjective response to a standard skin color chart and correlates with melanin index and sunburn potential. Most participants were Hispanic and self-reported a high-risk skin type (65.7%) using this new skin tone scale,12 placing them in a higher-risk group than what is typically anticipated for patients with skin of color. Therefore, we agree that the Fitzpatrick skin type classification scale is not appropriate for ethnically diverse groups.12,15
Furthermore, in many nation-wide surveys, such as the National Health and Nutrition Examination (NHANES), skin tone is politicized into 2 categories of ethnicity (Hispanic or non-Hispanic), and 5 of race (American Indian or Alaskan Native, Asian, black or African American, Native Hawaiian or other Pacific Islander, or white).23 These federal categories are social constructs,23,24 and allow only for broad categorical assumptions to made about skin tone. Some have even argued that lumping patients into categories of race/ethnicity has been detrimental to addressing health care disparities.24 Skin cancer risk stratification and prevention efforts need to avoid generalizing Hispanics into 1 group.21
A limitation of our study includes using a clinic population, which mainly included female participants. However, by using this approach we were able to include only economic disadvantaged and uninsured patients who are underrepresented in studies of skin cancer. In addition, the sample size for Caribbean participants is small, which limits conclusions we can make for this demographic.
While recommendations for appropriate skin cancer education in ethnic minorities have been made,15 limited pilot studies have been conducted with mixed results.25,26 One study26 suggests that lay health workers may be able to promote skin checks in Latino communities, while another25 suggests that short knowledge-based education sessions prior to a physician’s visit may increase knowledge and self–skin checks. Another study27 showed that informational Spanish language videos may have an impact on risk perception. While these studies may prove to be a launching point for new interventions, none of them specifically target broadly underserved populations with low health care literacy, a goal of our survey. Our results, coupled with the mounting evidence of increased skin cancer mortality in minorities, support a strong need for more research-tested intervention programs in underserved communities.
Specifically, interventions will need to include primary, secondary, and tertiary prevention to have an impact on skin cancer disparities. Primary intervention will address solar exposure avoidance and culturally sensitive protection methods. Secondary prevention will result in identification of potential cancerous lesions by increasing both self– and physician skin checks. As awareness increases and more research-tested interventions become available, it will be important to integrate dermatologic access to care for underserved communities. Tertiary prevention, including treatment of malignant neoplasms before patients experience clinically significant morbidity and mortality represents a final goal in improved access to care. While increased knowledge of skin cancer risk and screening programs represent 1 way to address access to care, detecting skin cancer is useful only if there are appropriate opportunities for treatment interventions and follow-up.
Corresponding Author: John Strasswimmer, MD, PhD, Strasswimmer Mohs Surgery, 2605 W Atlantic Ave, Ste D-204, Delray Beach, FL 33445 (firstname.lastname@example.org).
Accepted for Publication: July 7, 2016.
Published Online: September 14, 2016. doi:10.1001/jamadermatol.2016.3156
Author Contributions: Dr Strasswimmer had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Jacobsen, Canaan Lachapelle, Kirsner, Strasswimmer.
Acquisition, analysis, or interpretation of data: Jacobsen, Galvan, Wohl, Strasswimmer.
Drafting of the manuscript: Jacobsen, Galvan, Canaan Lachapelle, Wohl.
Critical revision of the manuscript for important intellectual content: Jacobsen, Kirsner, Strasswimmer.
Statistical analysis: Jacobsen.
Obtained funding: Canaan Lachapelle, Strasswimmer.
Administrative, technical, or material support: Wohl, Kirsner, Strasswimmer.
Study supervision: Kirsner, Strasswimmer.
Other (Translations): Galvan.
Conflict of Interest Disclosures: None reported.
Funding/Support: This study was funded by an Independent Grant for Learning and Change awarded by Pfizer and the American Academy of Dermatology to the Palm Beach County Society of Dermatology and Cutaneous Surgery, the Caridad Center and Dermatology Medical Missions Inc.
Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.