Sun protection in Iranian kidney transplant recipients: knowledge, attitude and practice

Skin Cancer Awareness and Knowledge About Sun Protection Practices in Solid Organ Transplant Recipients: Patient Survey Study

BACKGROUND

Adequate sun protection practices in chronically immunosuppressed patients can minimize the burden of the most common type of skin cancer in this population. In addition, early recognition of skin cancer by patients can lead to decreased morbidity, and possibly mortality from the disease. Nevertheless, there are significant gaps in the knowledge of sun protection measures and early recognition of skin cancer.

OBJECTIVE

The aim of this study is to determine the risk factors of solid organ transplant recipients (SOTRs) for developing skin cancer and their sun exposure education and behavior post-transplantation.

MATERIALS AND METHODS

This study evaluates the responses of 107 SOTRs on their outlooks and beliefs of sunscreen usage, skin cancer, and sun exposure knowledge.

RESULTS

Our study identified several significant risk factors for the development of actinic keratosis or keratinocyte carcinoma in SOTRs including history of sunburn before age 18, blue eyes, history of tanning bed use, performing monthly skin exams, ability to identify precancerous skin lesions, and history of previous skin examinations.

CONCLUSION

A patient-centered approach needs to be used to properly educate patients on effective ways to reduce excessive sun exposure. Regular skin examinations, and patients continued education are necessary components in reducing the burden of skin cancer in SOTRs.

An integrated skin cancer education program in renal transplant recipients and patients with glomerular disease

Sun-protective strategies focusing on skin cancer awareness are needed in immunosuppressed patients at risk of skin cancers. The study aims to determine the effect of an integrated skin cancer education program on skin cancer awareness and sun-protective behaviours in renal transplant recipients (RTRs) and patients with glomerular disease (GD) treated with long-term immunosuppressants. A pilot prospective cohort study in Central Queensland, Australia was undertaken among adult RTRs and patients with GD, who completed survey questionaries on skin cancer and sun-health knowledge (SCSK), sun-protection practices and skin examination pre- and post-education. Fifty patients (25 RTRs, 25 patients with GD) participated in the study. All of them completed questionnaires at pre-, 3-month post-education and 92%(n = 46) at 6-month post-education. There was a significant increase in SCSK scores from baseline at 3-months (p < 0.001) and 6-months post-intervention (p < 0.01). Improved knowledge was retained for 6 months after education. There were changes in 2 of 8 photoprotective behaviours at 6 months. Interventional education enhanced regular self-skin examination rate (p < 0.001) as well as the frequency of full skin checks by general practitioners (GPs) (p < 0.001). Overall, RTRs had better compliance with sun-protective methods and higher skin examination rates by themselves and/ or GPs before and after the intervention of education compared to patients with GD. To conclude, an integrated skin cancer education program improved knowledge of skin cancer and skin health as well as the frequency of self-skin examination and formal skin assessments. However, improvement in patient compliance did not extend to other sun-protective practices.

Awareness, knowledge, and attitudes towards sun protection among patients with melanoma and atypical mole syndrome

BACKGROUND

Patients with atypical mole syndrome (AMS) have a 3- to 20-fold higher risk of developing malignant melanoma (MM) than individuals without. The most modifiable risk factor for developing MM is the ongoing ultraviolet exposure.

AIM

To assess awareness, knowledge, and attitudes towards sun protection among patients with MM and AMS.

METHODS

From January 2020 till December 2021, a written survey was administered to patients with MM and AMS and a control group who attended a specialist mole clinic at the Dermatology Department of the University Hospital of Heraklion in Heraklion, Crete, Greece. Demographic data and photoprotective practices, knowledge, and perceived barriers were collected. Relevant statistical analyses were performed using SPSS IBM 25.

RESULTS

In total, 121 subjects consented and participated in the survey. Their mean age was 43.92 ± 12.55 years. There were 66 (54.4%) females and 55 (45.4%) males. Forty-seven (38.8%) patients had AMS, 26 (21.5%) had a past medical history of MM, and 48 (39.7%) attended the clinic for a full skin checkup for their naevi without having AMS or MM. Although 104 (86%) participants reported using sunscreen with the majority of them (59/121 = 48.8%) wearing sunscreen with a sun protection factor of > 50, only 22 (18.2%) patients did so every day and only 20 (16.5%) all year round. Approximately 74.4% of patients recalled having received advice on how to protect their skin from sunlight, and 73% were interested in receiving education about sun protection. The most mentioned barriers in photoprotection were concerns over adequate vitamin D and lack of time.

CONCLUSION

Despite mentioning having received adequate education in photoprotection, adherence to photoprotection practices is suboptimal in patients with MM and AMS.

Reducing non-melanoma skin cancer risk in renal transplant recipients

With an increasing number of renal transplant recipients (RTRs) and improving patient survival, a higher incidence of non-melanoma skin cancer (NMSC) has been observed. NMSC in RTRs are often more numerous and biologically more aggressive than the general population, thus contributing towards an increase in morbidity and to a lesser degree, mortality. The resultant cumulative health and financial burden is a recognized concern. Proposed strategies in mitigating risks of developing NMSC and early therapeutic options thereof include tailored modification of immunosuppressants in conjunction with sun protection in all transplant patients. This review highlights the clinical and financial burden of transplant-associated skin cancers, carcinogenic mechanisms in association with immunosuppression, importance of skin cancer awareness campaign and integrated transplant skin clinic, and the potential role of chemoprotective agents. A scheme is proposed for primary and secondary prevention of NMSC based on the available evidence.

Implementing a tailored education programme: renal transplant recipients' experiences

BACKGROUND

Patient-centred education is a key element in the care of patients undergoing kidney transplantation. We implemented a tailored, evidence-based education programme for the post-transplant phase.

OBJECTIVE

The aim of the study was to explore renal transplant recipients' experiences of participating in a new, tailored, evidence-based education programme.

METHODS

An explorative qualitative design was chosen to elicit knowledge, insight and understanding of the renal transplant recipients' perspectives. Twelve renal transplant recipients participated in semi-structured interviews about eight weeks post-transplant. The interviews were audiotaped and analysed using thematic data analysis inspired by Kvale and Brinkmann's method for meaning condensation.

FINDINGS

Two main themes emerged: 'Situated tailoring to the person's everyday life knowledge', and 'Tailoring as a standard procedure regardless of the person'.

CONCLUSION

The findings of the present study indicate that the renal transplant recipients experienced the new education programme to be tailored to individual needs. Our study also revealed that the recipients experienced the health care personnel to take different considerations into account when educating. Viewing knowledge as continuously changing from controlled study contexts into clinical settings, we here demonstrate the need to evaluate new knowledge also after being implemented.

Skin Cancer-Sun Knowledge and Sun Protection Behaviors of Liver Transplant Recipients in Turkey

The aim of this study was to compare liver transplant recipients (LTRs) with the general population regarding their knowledge of skin cancer, sun health, sun protection behaviors, and affecting factors. This cross-sectional study was conducted in Turkey between March 2016 and September 2016 with 104 LTRs and 100 participants from the general population group (GPG). The mean age of the LTRs was 53.2 ± 11.8 and that of the GPG was 42.7 ± 14.5. The LTRs' skin cancer and sun knowledge were significantly lower than in the GPG, but there was no difference between the two groups in terms of their sun protection behavior scores. The most commonly used sun protection behaviors of LTRs were not being outside and not sunbathing between 10 a.m. and 4 p.m., wearing clothing that covers the skin, and avoiding the solarium. Behaviors commonly practiced by the GPG were wearing sunglasses, wearing sunscreen with a sun protection factor of 15 or higher before going outside, wearing sunscreen at the beach, while swimming or doing physical activity outside, and reapplying it every 2 h. Results of our study will contribute to the development of education and training programs for LTRs on skin cancer. The results also demonstrated the importance of practicing adequate sun protection behaviors which will certainly impact their future health.

Perceptions and Practices of the Iranian Population regarding Skin Cancers: A Literature Review

Despite being preventable, more than 15% of all cancer cases in Iran occur in the skin, making them the most commonly diagnosed malignancy in the country. The purpose of this study is to gain an insight into the current skin cancer related knowledge, attitudes, beliefs, and practices among the Iranian population. A systematic computer based literature search was conducted using databases for articles published through April 2017. Research studies included those that measured skin cancer or sun protection related knowledge, attitudes, beliefs, and behaviors in different Iranian population groups. Exclusion criteria for the articles included (1) irrelevant topics to the review article's aim, (2) articles that focused on the treatment of skin cancers instead of prevention practices, and (3) similar studies conducted on populations not indigenous to Iran. A total of 25 articles that met the eligibility criteria were included in the review. Predominant data were collected via questionnaires. Skin cancer related knowledge varied from low to high across the studies. Moreover, there was a pattern of low perceived skin cancer susceptibility and severity. Overall, there was low usage of sun protection methods among the Iranian population. The findings of this study show that efforts to prevent skin cancer are needed. Education concerning the dangers of sun exposure as well as strategies used to prevent or lower the risk of developing skin cancer should be stressed.

Nonadherence Behaviors and Some Related Factors in Kidney Transplant Recipients

BACKGROUND

Kidney transplantation is the renal replacement therapy of choice for most patients with end-stage renal disease (ESRD), however, adherence to the recommended lifestyle is critical for a positive prognosis. The purpose of this study was to assess adherence to immunosuppressive therapy and lifestyle recommendations along with some related factors among kidney transplant patients.

MATERIALS AND METHODS

In this descriptive analytical study, all patients completed a questionnaire regarding medication intake and lifestyle recommendations (preventing of infection, self-monitoring, prevention of cardiovascular disease (CVD), and sun protection). The participants were divided into 4 groups according to the level of adherence (good, partial, poor, and nonadherent) indicated in their responses.

RESULTS

Most kidney recipients were adherent to their drug prescriptions, but were partial, poor, or nonadherent regarding lifestyle recommendations. Increased passage of time since transplantation and low family support and educational level resulted in nonadherence. Men showed greater adherence to medication intake than women. Patients with lower number of drugs and reported drug side-effects illustrated better adherence to medication intake. Women adhered to infection protection recommendations more than men, and older and married patients adhered to cardiovascular prevention recommendations more than others. However, younger patients showed greater adherence to self-monitoring recommendations, and singles, young individuals, and women were adherent to sun protection recommendations.

CONCLUSIONS

Nonadherence is common among kidney transplant recipients. Thus, it is necessary to determine patients who are at risk of nonadherence and to introduce more educational programs to improve their adherence and their quality of life (QOL).

Photoprotection Knowledge and Behaviours Among Organ Transplant Recipients

BACKGROUND

Organ transplant recipients (OTRs) are at an increased risk of developing a de novo malignant neoplasm compared to the general population. The primary contributor to skin cancer in all patients is sun exposure.

OBJECTIVE

In this study, we aim to ascertain both OTR skin cancer awareness and photoprotection practices.

METHODS

A questionnaire-based study of Saskatchewan transplant recipients.

RESULTS

Nearly all respondents were aware that sun exposure is the best-known cause of skin cancer and that as an OTR, they are at increased risk of skin cancer (99.3% and 90.5%, respectively). Approximately half of respondents reported wearing a hat regularly, sun avoidance between 10 am and 3 pm, or wearing sunscreen regularly (53.7%, 33.1%, and 47.9%, respectively).

CONCLUSION

Many OTRs are not engaging in photoprotection. Further intervention, which may include access to a dermatologist, is necessary to ensure ORTs do not experience undue morbidity and mortality secondary to skin cancer.

A qualitative systematic review of the efficacy of sun protection education in organ transplant recipients

BACKGROUND

Transplant recipients are at increased risk of developing skin cancer as a result of chronic immunosuppression. Educating patients on sun protection has been routine posttransplantation, but to our knowledge, no systematic review has yet analyzed the efficacy of such education measures in this high-risk population.

OBJECTIVE

We sought to examine the efficacy of educating transplant recipients on skin cancer and sun protection.

METHODS

A literature search of interventional patient education studies published between January 1995 and March 2016 was performed in PubMed, CINAHL, Cochrane, and EMBASE databases.

RESULTS

Data from 7 studies meeting inclusion criteria were analyzed. No study attempted to examine the direct effect of sun protection education on skin cancer incidence in transplant recipients. Two randomized controlled trials showed that educational intervention can improve sun-protective behavior and decrease skin pigmentation or skin damage in sun-exposed areas. Three other randomized controlled trials compared the efficacy of 2 different forms of patient education at changing sun-protective behavior, but did not examine patient-oriented outcomes.

LIMITATIONS

A lack of high-quality randomized controlled trials with patient-oriented evidence and a dependence on self-reported data are limitations.

CONCLUSION

Sun protection education can be effective at altering patient behavior in transplant recipients, but its effect on posttransplantation skin cancer incidence remains to be elucidated.

A preliminary study of a video intervention to inform solid organ transplant recipients about skin cancer

PURPOSE

To obtain preliminary evidence on the effect of a skin cancer prevention video for adult solid organ transplant recipients (SOTR) and informational brochures on outcomes of skin cancer knowledge, beliefs, prevention and detection behaviors, and personal agency (self-confidence/personal control) for behaviors.

BACKGROUND

SOTR have a high risk of skin cancer potentiated by life-long immunosuppressive therapy posttransplantation. Skin cancer in SOTR is aggressive and difficult to treat. Prevention and early detection are important for reducing risk and improving skin cancer outcomes, but methods to inform SOTR about their risk are understudied.

METHODS

A brief, evidence-based skin cancer informational video tailored to SOTR was evaluated using a quasi-experimental design that compared the outcome variables in two groups of SOTR seen in 4 transplantation clinics within 4-6 weeks posttransplantation. The video/brochure group (VBG) viewed the video once and received skin cancer information brochures. The brochure group (BG) received brochures only. Participants completed a survey on sun protection behavior (6 items; alpha = 0.75), personal agency (6 items; alpha = 0.64), beliefs (6 items; alpha = 0.60), skin cancer knowledge (6 items), and skin self-examination (SSE; 1 item) at baseline and 3 months postintervention. Data were analyzed using descriptive statistics and 2 × 2 analysis of variance.

RESULTS

Of 113 participants, 90 completed both surveys (VBG, n = 46; BG, n = 44). Both groups had a significant increase in sun protective behavior (P < .001), skin cancer knowledge (P < .001), beliefs (P = .003), and personal agency (P = .003). There was no effect of either intervention on SSE.

CONCLUSION

Both interventions effectively informed SOTR about skin cancer and sun protection, promoted favorable beliefs, and improved personal agency, but were not differentially effective, suggesting that the addition of the video may not be necessary or that the video may need to be viewed more than once. More in-depth SSE teaching strategies may be necessary.

A systematic review of factors influencing decision-making in adults living with chronic kidney disease

OBJECTIVE

To identify factors influencing patient involvement in decision-making in the context of chronic kidney disease (CKD) and effective interventions to support their decision-making needs.

METHODS

A systematic review included studies and decision support tools that involved: (1) adults with CKD, (2) studies published from 1998-2008; and (3) a focus on patient decision-making needs, and/or barriers and facilitators to shared decision-making. Studies were quality appraised.

RESULTS

Forty studies were appraised. These studies mainly focused on the decisions patients with CKD faced around the choice of renal replacement therapy and withholding/withdrawing dialysis. Moreover, studies typically focused on health care professional's provision of information about the decision rather than identifying decisional conflict and supporting patients in decision-making. No studies were found that identified the patient's point of view about factors that might influence or inhibit quality decision-making. Factors influencing CKD patient's participation in decision included: (1) interpersonal relationships; (2) preservation of current well being, normality and quality of life; (3) need for control; and (4) personal importance on benefits and risks. Of the four patient decision aids identified, none had been evaluated for effectiveness.

CONCLUSION

Patients with CKD face decisions that are likely to cause decisional conflict. Most studies focused on information needs related to renal replacement therapy and withdrawing or withholding dialysis. There was less focus on other decision-making needs in the context of those choices and across the trajectory of CKD. Although patient decision aids and implementation of shared decision-making have been evaluated in patients with other medical conditions, little is known about interventions to support patients with CKD making quality decisions.

PRACTICE IMPLICATIONS

Patients with CKD have decision-making needs across the trajectory of their illness. Although little is known about supporting patients with CKD decision-making, support could be provided with protocols and tools that have been developed for other chronic illness situations. Development of CKD-specific clinical practice guidelines that include decision support best practices could benefit CKD patients. Research priorities include development and evaluation of CKD focused decision support tools and processes.

Health literacy skills of kidney transplant recipients

CONTEXT

Although low health literacy can affect patients' treatment decision making, comprehension of health information, and medication adherence, little is known about health literacy skills of kidney transplant recipients.

OBJECTIVE

To examine the relationship among kidney transplant recipients' health literacy levels, transplant knowledge, and graft function.

DESIGN

Cross-sectional study of 124 adult kidney transplant recipients.

MAIN OUTCOME MEASURES

Health literacy was assessed via the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine-Transplantation (REALM-T). Data on recipients' transplant numeracy, knowledge needs, and demographics were collected via semistructured interviews. Multivariable linear regressions were used to assess the relationship between health literacy and graft function.

RESULTS

Most kidney recipients (91%) had adequate health literacy (S-TOFHLA); however, 81% were unfamiliar with at least 1 kidney transplant-related term (REALM-T). The 5 least familiar terms were sensitization (50%), urethra (45%), trough level (41%), blood urea nitrogen (32%), and toxicity (31%). Numeracy levels varied: 21% knew the likelihood of 1-year graft survival; 29% knew that half of kidney recipients have problems with the transplant in the first 6 months; 68% were aware of the risk of death within the first year after transplantation; and 86% knew the normal range for creatinine in kidney recipients. Patients with lower health literacy (REALM-T) had higher creatinine levels.

CONCLUSIONS

Transplant providers should intervene with better patient education materials to improve patients' health literacy, which may improve patients' medication adherence or transplant outcomes.

Health Literacy Skills of Kidney Transplant Recipients

Context

Although low health literacy can affect patients' treatment decision making, comprehension of health information, and medication adherence, little is known about health literacy skills of kidney transplant recipients.

Objective

To examine the relationship among kidney transplant recipients' health literacy levels, transplant knowledge, and graft function.

Design

Cross-sectional study of 124 adult kidney transplant recipients.

Main Outcome Measures

Health literacy was assessed via the Short Test of Functional Health Literacy in Adults (S-TOFHLA) and the Rapid Estimate of Adult Literacy in Medicine-Transplantation (REALM-T). Data on recipients' transplant numeracy, knowledge needs, and demographics were collected via semistructured interviews. Multivariable linear regressions were used to assess the relationship between health literacy and graft function.

Results

Most kidney recipients (91%) had adequate health literacy (S-TOFHLA); however, 81% were unfamiliar with at least 1 kidney transplant–related term (REALM-T). The 5 least familiar terms were sensitization (50%), urethra (45%), trough level (41%), blood urea nitrogen (32%), and toxicity (31%). Numeracy levels varied: 21% knew the likelihood of 1-year graft survival; 29% knew that half of kidney recipients have problems with the transplant in the first 6 months; 68% were aware of the risk of death within the first year after transplantation; and 86% knew the normal range for creatinine in kidney recipients. Patients with lower health literacy (REALM-T) had higher creatinine levels.

Conclusions

Transplant providers should intervene with better patient education materials to improve patients' health literacy, which may improve patients' medication adherence or transplant outcomes.