The image on the left half of the start screen shows effects available within the app applied to the sample face on the right, encouraging the user to see the consequences of unprotected sun exposure on his or her own face. The blurred background is from the webcam live feed.
Elements used in the intervention are shown with instructions printed in English although they were printed in German for the study. The screen shows the selfie view, which appears after “start” is tapped on the start screen.
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Brinker TJ, Klode J, Esser S, Schadendorf D. Facial-Aging App Availability in Waiting Rooms as a Potential Opportunity for Skin Cancer Prevention. JAMA Dermatol. 2018;154(9):1085–1086. doi:10.1001/jamadermatol.2018.1907
Approximately 90% of skin cancers are caused by UV exposure. Although dermatologists agree on the importance of primary prevention, busy clinicians often lack time and interventions at hand. Middle-aged men and HIV-positive patients undergoing immunosuppressive therapy are especially at risk of skin cancer, while research for these patient subgroups remains scarce.1
A randomized clinical trial by Mahler et al2 showed increased sun protection behavior associated with the use of UV photographs, which indicated the UV damage currently on the participant’s face, among young adults at 4 to 5 months and 12 months of follow-up. However, the use of polaroid photography requires staff time, is outdated, does not illustrate future appearance, and is not readily available.
Thus, in the waiting room of our HIV outpatient clinic, we provided a standalone version of a free facial-aging app called Sunface that was developed by one of the authors (T.J.B.). The app altered a 3-dimensional, animated selfie of the participant to approximate his or her future appearance based on UV exposure3 (Figure 1). We aimed to develop a skin cancer prevention intervention that could be available to most patients visiting health care professionals and that would make salient the risks of UV exposure.
From October 9 to October 15, 2017, a tablet with the facial-aging app Sunface running was placed on a table in the middle of a waiting room and connected (“mirrored”) to a large monitor hanging on the opposite wall (Figure 2). An interviewer, who followed a pretested standardized protocol, encouraged all patients to try the app if they had not done so themselves within 30 seconds of entering the waiting room. All participants were asked to fill out an anonymous questionnaire that measured their perceptions of the intervention and requested sociodemographic data. Institutional review board approval was obtained from the ethics committee at the University of Essen (Essen, Germany) before any data were collected. The University Hospital of Essen ethics committee waived the need for obtaining written informed patient consent because the survey was anonymous and the intervention was the use of an app; however, all participants provided oral informed consent.
In total, 272 patients (207 men [76.1%]) entered the waiting room during the 13 days the facial-aging app was available. Of these, 202 patients (74.3%) were encouraged to try the app after 30 seconds of entering; 26 patients (9.6%) tried the app within 30 seconds of entering without interviewer encouragement; 44 patients (16.2%) waited beyond the waiting area or were in the waiting room for less than 30 seconds. A total of 119 patients tried the app and agreed thereafter to fill out the questionnaire. Of these, 44 patients (37.0%) had Fitzpatrick skin type 1 or 2, and 84 patients (70.6%) were men. The median age was 48 years (range, 24-74 years). Forty-six patients (16.9%) watched another patient without trying the app themselves. Thus, 165 (60.7%) of the 272 patients visiting our waiting room (mean wait time, 19.54 minutes) were exposed to the intervention.
Of the 119 patients who tried the app, 105 (88.2%) indicated that the intervention motivated them to increase sun protection (74 of 83 men [89.2%]; 31 of 34 women [91.2%]) and to avoid indoor tanning beds (73 men [87.9%]; 31 women [91.2%]) and that the intervention was perceived as fun (83 men [98.8%]; 34 women [97.1%]).
Facial-aging apps implemented in waiting rooms show potential to provide a new enjoyable opportunity to motivate a large fraction of patients who visit a health care setting to increase their UV protection. Future work should examine prospective effects on patient behavior, a potential increase in frequency of addressing UV protection at subsequent appointments with dermatologists, and different modes of initiation as well as analysis of effects in different patient subgroups.
Accepted for Publication: May 4, 2018.
Corresponding Author: Titus J. Brinker, MD, National Center for Tumor Diseases, Department of Translational Oncology, German Cancer Research Center (DKFZ), Im Neuenheimer Feld 460, 69120 Heidelberg, Germany (email@example.com).
Published Online: July 25, 2018. doi:10.1001/jamadermatol.2018.1907
Author Contributions: Drs Brinker and Schadendorf had full access to all of the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Brinker, Klode, Esser.
Acquisition, analysis, or interpretation of data: Brinker, Esser, Schadendorf.
Drafting of the manuscript: Brinker.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Brinker.
Obtained funding: Schadendorf.
Administrative, technical, or material support: Brinker, Esser, Schadendorf.
Supervision: Brinker, Klode, Esser.
Conflict of Interest Disclosures: Dr Brinker reported owning Smart Health Heidelberg GmbH, which licenses health-related apps.
Additional Contributions: We thank our colleagues Lea Herzig, MD (shown in Figure 1), who recently graduated, and Wiebke Sondermann, MD (shown in Figure 2), who is at the Department of Dermatology, University Hospital Essen, Essen, Germany, for granting permission to publish their photographs.
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