- Email: [email protected]
Effects of video-based, online education on behavioral and knowledge outcomes in sunscreen use: A randomized controlled trial
Patient Education and Counseling 83 (2011) 273–277
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Short communication
Effects of video-based, online education on behavioral and knowledge outcomes in sunscreen use: A randomized controlled trial April W. Armstrong *, Nayla Z. Idriss, Randie H. Kim Department of Dermatology, University of California, Davis, School of Medicine, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 November 2009 Received in revised form 15 March 2010 Accepted 28 April 2010
Objectives: To compare online video and pamphlet education at improving patient comprehension and adherence to sunscreen use, and to assess patient satisfaction with the two educational approaches. Methods: In a randomized controlled trial, 94 participants received either online, video-based education or pamphlet-based education that described the importance and proper use of sunscreen. Sun protective knowledge and sunscreen application behaviors were assessed at baseline and 12 weeks after groupspecific intervention. Results: Participants in both groups had similar levels of baseline sunscreen knowledge. Post-study analysis revealed significantly greater improvement in the knowledge scores from video group members compared to the pamphlet group (p = 0.003). More importantly, video group participants reported greater sunscreen adherence (p < 0.001). Finally, the video group rated their education vehicle more useful and appealing than the pamphlet group (p < 0.001), and video group participants referred to the video more frequently (p = 0.018). Conclusion: Video-based learning is a more effective educational tool for teaching sun protective knowledge and encouraging sunscreen use than written materials. Practice implications: More effective patient educational methods to encourage sun protection activities, such as regular sunscreen use, have the potential to increase awareness and foster positive, preventative health behaviors against skin cancers. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Dermatology Sunscreen behavior Video Education Patient education Sun protection Sunscreen
1. Introduction Despite information available on the harms of excessive sun exposure, skin cancer is the most common form of cancer in the United States, as well as one of the most preventable cancers [1]. Primary prevention through sun avoidance, protective clothing, and sunscreen forms the cornerstone of intervention [2,3]. Although sunscreen is the most frequently used and well-known method of sun protection [4], increased public knowledge of the dangers of sun exposure may not translate to greater prevention behaviors [5]. Currently, the most widely used method of conveying health information has been through the administration of written material, such as pamphlets. Intensive interventions including community programs [6], school programs [7–9], and physician recommendation [10] have been successful at improving sunscreen use, particularly among parents and their children. However, these interventions require more resources to implement than the traditional pamphlet, limiting their widespread use
* Corresponding author at: Department of Dermatology, University of California, Davis, 3301 C Street, Suite 1300, Sacramento, CA 95816, USA. Tel.: +1 916 871 9688. E-mail address: [email protected] (A.W. Armstrong). 0738-3991/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2010.04.033
in the general public. Therefore, our goal is to develop an educational vehicle that not only improves sunscreen behavioral outcome and sunscreen application knowledge but also has potential to be convenient, inexpensive, and easily distributed among the general population. To that end, we developed an online ‘‘Sunscreen Patient Education Video’’ describing the importance of sunscreen use and proper sunscreen application techniques in order to enhance patient knowledge and adherence towards sun protection. In this study, we assessed the efficacy of online videos as an educational medium compared to an informational pamphlet, in a randomized controlled trial. 2. Methods This randomized controlled study was approved by the Institutional Review Board of University of California, Davis. The clinicaltrials.gov registration number is NCT00826306. We conducted the study between February and May 2009 at UC Davis in Sacramento, California. The study lasted for 12 weeks. To be eligible study, the participants had to be English-speaking, at least 18 years old, have Internet access, and be able to view videos online.
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Fig. 1. Randomization schema and participant flow diagram.
94 participants were randomized in a simple, non-stratified randomization scheme to online, video education (n = 47) or pamphlet education (n = 47) (Fig. 1). Online video participants were given instructions on how to access the online video, which addressed how sunscreens work to protect skin, different types of sunscreens, importance of sunscreen use, and proper application. Participants randomized to the control arm received identical educational content as the video but delivered in a pamphlet. Participants were instructed to view the material at least once during the study, and were allowed to view the material as often as desired.
the preceding 30 days. Improvement in sunscreen knowledge was defined as the improvement in sunscreen knowledge screen between baseline and at the end of the study. The secondary endpoint was satisfaction with the educational materials. Statistical analyses were based on an intention-to-treat approach using GraphPad Prism 4.0. Two-tailed tests were performed for all statistical analyses. Unpaired Student’s t-test was used to analyze continuous variables for between-group comparisons. Paired t-tests were used to analyze continuous variables in pre- and post-study comparisons within a comparison arm. Chi-square tests were performed for categorical variables. For all statistical analyses, p < 0.05 was considered statistically significant.
2.1. Assessment of sun protective behavior 3. Results Sunscreen application behavior was assessed before and after study intervention using standard questions from the National Health and Nutrition Examination Survey (NHANES) on sun protective behaviors.
Of the 94 randomized participants, 40 participants in the pamphlet group and 43 participants in the video group completed the study (Fig. 1). There were no statistically significant differences in baseline characteristics between the two arms (Table 1).
2.2. Assessment of sunscreen knowledge 3.1. Improvement in sunscreen knowledge Baseline knowledge regarding proper sunscreen use and the effects of ultraviolet light was assessed with a pre- and post-study questionnaire, consisting of the same questions.
Participants rated the usefulness and appeal of the educational method they received on a 10-point scale as well as indicated their preference for video versus written education. Lastly, the participants were asked the number of times they reviewed their educational material during the study.
With regards to knowledge on proper sunscreen use, the video group (6.9 1.3) and the pamphlet group (6.5 1.4) had similar baseline knowledge scores (p = 0.148). The pamphlet group showed a significant improvement in sunscreen knowledge with a post-test mean score of 7.6 1.2 (p < 0.001). Similarly, the video group also showed a significant improvement in sunscreen knowledge with a post-test mean score of 8.8 1.4 (p < 0.001). Inter-group analysis showed a significant difference in the improvement of post-study scores of the online-video group (2.0 1.5) compared to the pamphlet group (1.2 1.0), p = 0.003.
2.4. Study endpoints and statistical analysis
3.2. Improvement in sunscreen application behavior
Primary endpoints for the study included participants’ improvement in sunscreen application behavior and sunscreen knowledge. Sunscreen application behavior was defined as the average number of days that participants applied sunscreen during
The pamphlet group (2.0 3.0 days per week) and the video group (1.7 2.5) had comparable baseline frequencies of sunscreen application (p = 0.552). At the end of the study 3 months later, the pamphlet group showed a non-significant increase in the
2.3. Satisfaction survey
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Table 1 Comparison of demographic factors between the pamphlet and video groups. Pamphlet group (n = 47)
Video group (n = 47)
p value
Sex Female Male
44.7% (21) 55.3% (26)
55.3% (26) 44.7% (21)
0.409z
Age Mean
39.6 14 years
34.7 12 years
0.079*
Marital status Married Not married
53.2% (25) 46.8% (22)
61.7% (29) 38.3% (18)
0.532z
Highest grade at school or years in college completed 1st through 8th 9th through 12 or GED 1–3 years of college 4 or more years of college
0% (0) 4.3% (2) 19.1% (9) 76.6% (36)
2.1% 6.4% 23.4% 68.1%
(1) (3) (11) (32)
0.625y
Ethnicity White Black Hispanic Asian or Pacific Islander Native American Other
61.7% (29) 2.1% (1) 4.3% (2) 21.3% (10) 0% (0) 10.6% (5)
46.8% (22) 4.3% (2) 10.6% (5) 27.7% (13) 0% (0) 10.6% (5)
0.563y
14.9%(7) 61.7% (29) 12.8% (6) 4.3% (2) 2.1% (1) 4.3%(2)
0.604y
6.4% 10.6% 19.2% 34.0% 17.0% 12.8%
0.349y
Employment status Unemployed Employed full time (including self-employment) Employed part time (including self-employment) Student full time Student part time Retired Skin phototype Always burns, does not tan Burns easily, tans poorly Tans after initial burn Burns minimally, tans easily Rarely burns, tans darkly easily Never burns, always tans darkly
8.5%(4) 70% (31) 14.9% (7) 8.5% (4) 2.1% (1) 0% (0)
2.1% 21.3% 25.5% 29.8% 6.4% 14.9%
(1) (10) (12) (14) (3) (7)
(3) (5) (9) (16) (8) (6)
Number of sunburns in the past year 0.1277 0.3966 How often stay in the shade when out in the sun for more than 1 h Never Rarely Sometimes/most of the time Always
0.06383 0.2471
0.351*
(10) (26) (6) (4)
0.945y
How often wear a hat that shades their face, ears and neck when out in sun for more than 1 h Never 29.8% (14) Rarely 59.6% (28) Sometimes/most of the time 4.3% (2) Always 6.38% (3)
34.0% (16) 61.7% (29) 4.3% (2) 0% (0)
0.369y
How often wear long sleeved shirt when out in the sun for than 1 h Never Rarely Sometimes/most of the time Always
53.2% 19.2% 10.6% 17.0%
(25) (9) (5) (8)
57.5% 21.3% 8.5% 12.8%
(27) (10) (4) (6)
0.913y
How often wear sunscreen when out in the sun for more than 1 h Never Rarely Sometimes/most of the time Always
61.7% 23.4% 12.8% 2.1%
(29) (11) (6) (1)
57.5% 21.3% 12.8% 8.5%
(27) (10) (6) (4)
0.589y
17.0% 61.7% 12.8% 8.5%
(8) (29) (6) (4)
21.3% 55.3% 12.8% 8.5%
Percentages are followed by number of cases (in parentheses). y Chi-square test was used to determine significance. z Fisher’s exact test was used to determine significance. * Student’s t-test was used to determine significance.
frequency of sunscreen application (2.4 3.0 days per week, p = 0.058), whereas the video group exhibited a significant increase in sunscreen application behavior from baseline (3.4 2.6, p < 0.001).
Inter-group analysis revealed that the improvement in sunscreen application behavior was greater in the video group (1.9 2.3 increase in days per week) than the pamphlet group (0.2 0.5) with p < 0.001.
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3.3. Satisfaction survey 90.7% of the video group and 62.5% of the pamphlet group favored the video. The video group rated the appeal of their material 9.0 0.9, significantly higher than the pamphlet rating of 7.9 1.3 (p < 0.001). Furthermore, the video group rated the usefulness of the video significantly higher than the pamphlet group (7.7 1.3) p < 0.001. Lastly, the video was referred to an additional 1.5 0.8 times while the pamphlet was referred to an additional 1.2 0.5 times (p = 0.018). 4. Discussion and conclusion
application. Over half of American Internet users have searched for health care information online [23]. Interestingly, users who searched for skin cancer information were more likely to engage in sunscreen use [24]. Clinicians may easily provide online video on office web resources or directly to patients during routine care. Although many health systems have already implemented web resources linked to handouts for common health topics, online video may become an innovative and effective way to deliver patient education requiring complex and long-term health behaviors. Video demonstrating proper sunscreen application that can be widely distributed in practice and easily accessible has potential to improve behavioral outcomes over current traditional methods, particularly in primary prevention of UV-induced skin cancers.
4.1. Discussion Conflict of interest Ultraviolet radiation protection by sunscreen use reduces the number of sunburns [11] and actinic keratoses [12], two wellknown risk factors for skin cancer development. The factors that lead to poor patient adherence are numerous and complex [13], with lack of knowledge [14] and proper counseling [15] as significant barriers. To address both these issues, our two educational vehicles aimed to increase sunscreen knowledge and affect behavioral changes in sunscreen application. Participants from the video group had significantly higher frequency of sunscreen use per week while participants from the pamphlet group showed no statistically significant differences in behavior after the study. Since the information delivered in each arm was identical, greater adherence is attributed to the nature of the educational vehicle. Compared with the pamphlet group, participants in the video group referred back to the videos about 1.3 times more often during the study period. The cognitive model of learning suggests that audio-visual instruction is likely to be more effective than written material [16], and may be particularly useful for conceptual learning [17]. A review of 25 studies using video education revealed that video increased short-term knowledge and was as effective or better than traditional patient educational materials. Behavior demonstrated in video also led to remodeling in patient behavior, suggesting that video can affect behavioral outcomes [18]. Subsequent studies have shown that video education can improve clinical outcomes [19] and knowledge outcomes [20], particularly for complex health behaviors [21]. One limitation of this study was that the average education level of our participants is higher than that of the American public. Furthermore, the study was limited to adults over 18 years old; it will be useful to explore whether online video will be effective in older children and teens in a future study. However, Americans receive less than 25% of their lifetime UV exposure by the age of 18 [22], supporting the relevance of this study in adults. 4.2. Conclusion Patient education is a cornerstone of primary prevention models of skin cancer. In this study, we evaluated the efficacy of online video as an education vehicle for sunscreen use compared to a written module in a randomized controlled trial. Patients who viewed the online video scored significantly higher on the poststudy questionnaire than patients who were given the pamphlet. More importantly, this translated into greater adherence to sunscreen use over the previous month in the online video arm. 4.3. Practice implications These results support the efficacy of online video for educating patients on the importance of sunscreen use and proper sunscreen
The authors declare no relevant conflict of interest. Acknowledgements We would like to acknowledge Khalil Baba for his expertise in creating the online education video for this project and Christopher Sanders for his insight in providing feedback on the manuscript. Statement of funding: None. References [1] Society AC. Cancer facts & figures 2009. American Cancer Society; 2009. [2] Kasparian NA, McLoone JK, Meiser B. Skin cancer-related prevention and screening behaviors: a review of the literature. J Behav Med 2009. [3] McDonald CJ. American Cancer Society perspective on the American College of Preventive Medicine’s policy statements on skin cancer prevention and screening. CA. Cancer J Clin 1998;48:229–31. [4] Stanton WR, Janda M, Baade PD, Anderson P. Primary prevention of skin cancer: a review of sun protection in Australia and internationally. Health Promot Int 2004;19:369–78. [5] Keeney S, McKenna H, Fleming P, McIlfatrick S. Attitudes, knowledge and behaviours with regard to skin cancer: a literature review. Eur J Oncol Nurs 2009;13:29–35. [6] Escoffery C, Glanz K, Hall D, Elliott T. A multi-method process evaluation for a skin cancer prevention diffusion trial. Eval Health Prof 2009;32:184–203. [7] Gritz ER, Tripp MK, James AS, Carvajal SC, Harrist RB, Mueller NH, et al. An intervention for parents to promote preschool children’s sun protection: effects of sun protection is fun! Prev Med 2005;41:357–66. [8] Gritz ER, Tripp MK, James AS, Harrist RB, Mueller NH, Chamberlain RM, et al. Effects of a preschool staff intervention on children’s sun protection: outcomes of sun protection is fun! Health Educ Behav 2007;34:562–77. [9] Hughes BR, Altman DG, Newton JA. Melanoma and skin cancer: evaluation of a health education programme for secondary schools. Br J Dermatol 1993;128: 412–7. [10] Falk M, Anderson C. Prevention of skin cancer in primary healthcare: an evaluation of three different prevention effort levels and the applicability of a phototest. Eur J Gen Pract 2008;14:68–75. [11] Vainio H, Miller AB, Bianchini F. An international evaluation of the cancerpreventive potential of sunscreens. Int J Cancer 2000;88:838–42. [12] Thompson SC, Jolley D, Marks R. Reduction of solar keratoses by regular sunscreen use. N Engl J Med 1993;329:1147–51. [13] Dadlani C, Orlow SJ. Planning for a brighter future: a review of sun protection and barriers to behavioral change in children and adolescents. Dermatol Online J 2008;14:1. [14] Renzi C, Mastroeni S, Mannooranparampil TJ, Passarelli F, Caggiati A, Pasquini P. Skin cancer knowledge and preventive behaviors among patients with a recent history of cutaneous squamous cell carcinoma. Dermatology 2008;217: 74–80. [15] Hornung RL, Hansen LA, Sharp LK, Poorsattar SP, Lipsky MS. Skin cancer prevention in the primary care setting: assessment using a standardized patient. Pediatr Dermatol 2007;24:108–12. [16] Mayer RE. Multimedia aids to problem-solving transfer. Int J Educ Res 1999;31:611–23. [17] Yeung Jr P, Justice T, Pasic RP. Comparison of text versus video for teaching laparoscopic knot tying in the novice surgeon: a randomized, controlled trial. J Minim Invasive Gynecol 2009;16:411–5. [18] Gagliano ME. A literature review on the efficacy of video in patient education. J Med Educ 1988;63:785–92. [19] Niebel G, Kallweit C, Lange I, Folster-Holst R. Direct versus video-aided parent education in atopic eczema in childhood as a supplement to specialty physician treatment. A controlled pilot study. Hautarzt 2000;51:401–11.
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[23] Hesse BW, Nelson DE, Kreps GL, Croyle RT, Arora NK, Rimer BK, et al. Trust and sources of health information: the impact of the Internet and its implications for health care providers: findings from the first Health Information National Trends Survey. Arch Intern Med 2005;165: 2618–24. [24] Hay J, Coups EJ, Ford J, Dibonaventura M. Exposure to mass media health information, skin cancer beliefs, and sun protection behaviors in a United States probability sample. J Am Acad Dermatol 2009.
Contents lists available at ScienceDirect
Patient Education and Counseling journal homepage: www.elsevier.com/locate/pateducou
Short communication
Effects of video-based, online education on behavioral and knowledge outcomes in sunscreen use: A randomized controlled trial April W. Armstrong *, Nayla Z. Idriss, Randie H. Kim Department of Dermatology, University of California, Davis, School of Medicine, USA
A R T I C L E I N F O
A B S T R A C T
Article history: Received 11 November 2009 Received in revised form 15 March 2010 Accepted 28 April 2010
Objectives: To compare online video and pamphlet education at improving patient comprehension and adherence to sunscreen use, and to assess patient satisfaction with the two educational approaches. Methods: In a randomized controlled trial, 94 participants received either online, video-based education or pamphlet-based education that described the importance and proper use of sunscreen. Sun protective knowledge and sunscreen application behaviors were assessed at baseline and 12 weeks after groupspecific intervention. Results: Participants in both groups had similar levels of baseline sunscreen knowledge. Post-study analysis revealed significantly greater improvement in the knowledge scores from video group members compared to the pamphlet group (p = 0.003). More importantly, video group participants reported greater sunscreen adherence (p < 0.001). Finally, the video group rated their education vehicle more useful and appealing than the pamphlet group (p < 0.001), and video group participants referred to the video more frequently (p = 0.018). Conclusion: Video-based learning is a more effective educational tool for teaching sun protective knowledge and encouraging sunscreen use than written materials. Practice implications: More effective patient educational methods to encourage sun protection activities, such as regular sunscreen use, have the potential to increase awareness and foster positive, preventative health behaviors against skin cancers. ß 2010 Elsevier Ireland Ltd. All rights reserved.
Keywords: Dermatology Sunscreen behavior Video Education Patient education Sun protection Sunscreen
1. Introduction Despite information available on the harms of excessive sun exposure, skin cancer is the most common form of cancer in the United States, as well as one of the most preventable cancers [1]. Primary prevention through sun avoidance, protective clothing, and sunscreen forms the cornerstone of intervention [2,3]. Although sunscreen is the most frequently used and well-known method of sun protection [4], increased public knowledge of the dangers of sun exposure may not translate to greater prevention behaviors [5]. Currently, the most widely used method of conveying health information has been through the administration of written material, such as pamphlets. Intensive interventions including community programs [6], school programs [7–9], and physician recommendation [10] have been successful at improving sunscreen use, particularly among parents and their children. However, these interventions require more resources to implement than the traditional pamphlet, limiting their widespread use
* Corresponding author at: Department of Dermatology, University of California, Davis, 3301 C Street, Suite 1300, Sacramento, CA 95816, USA. Tel.: +1 916 871 9688. E-mail address: [email protected] (A.W. Armstrong). 0738-3991/$ – see front matter ß 2010 Elsevier Ireland Ltd. All rights reserved. doi:10.1016/j.pec.2010.04.033
in the general public. Therefore, our goal is to develop an educational vehicle that not only improves sunscreen behavioral outcome and sunscreen application knowledge but also has potential to be convenient, inexpensive, and easily distributed among the general population. To that end, we developed an online ‘‘Sunscreen Patient Education Video’’ describing the importance of sunscreen use and proper sunscreen application techniques in order to enhance patient knowledge and adherence towards sun protection. In this study, we assessed the efficacy of online videos as an educational medium compared to an informational pamphlet, in a randomized controlled trial. 2. Methods This randomized controlled study was approved by the Institutional Review Board of University of California, Davis. The clinicaltrials.gov registration number is NCT00826306. We conducted the study between February and May 2009 at UC Davis in Sacramento, California. The study lasted for 12 weeks. To be eligible study, the participants had to be English-speaking, at least 18 years old, have Internet access, and be able to view videos online.
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Fig. 1. Randomization schema and participant flow diagram.
94 participants were randomized in a simple, non-stratified randomization scheme to online, video education (n = 47) or pamphlet education (n = 47) (Fig. 1). Online video participants were given instructions on how to access the online video, which addressed how sunscreens work to protect skin, different types of sunscreens, importance of sunscreen use, and proper application. Participants randomized to the control arm received identical educational content as the video but delivered in a pamphlet. Participants were instructed to view the material at least once during the study, and were allowed to view the material as often as desired.
the preceding 30 days. Improvement in sunscreen knowledge was defined as the improvement in sunscreen knowledge screen between baseline and at the end of the study. The secondary endpoint was satisfaction with the educational materials. Statistical analyses were based on an intention-to-treat approach using GraphPad Prism 4.0. Two-tailed tests were performed for all statistical analyses. Unpaired Student’s t-test was used to analyze continuous variables for between-group comparisons. Paired t-tests were used to analyze continuous variables in pre- and post-study comparisons within a comparison arm. Chi-square tests were performed for categorical variables. For all statistical analyses, p < 0.05 was considered statistically significant.
2.1. Assessment of sun protective behavior 3. Results Sunscreen application behavior was assessed before and after study intervention using standard questions from the National Health and Nutrition Examination Survey (NHANES) on sun protective behaviors.
Of the 94 randomized participants, 40 participants in the pamphlet group and 43 participants in the video group completed the study (Fig. 1). There were no statistically significant differences in baseline characteristics between the two arms (Table 1).
2.2. Assessment of sunscreen knowledge 3.1. Improvement in sunscreen knowledge Baseline knowledge regarding proper sunscreen use and the effects of ultraviolet light was assessed with a pre- and post-study questionnaire, consisting of the same questions.
Participants rated the usefulness and appeal of the educational method they received on a 10-point scale as well as indicated their preference for video versus written education. Lastly, the participants were asked the number of times they reviewed their educational material during the study.
With regards to knowledge on proper sunscreen use, the video group (6.9 1.3) and the pamphlet group (6.5 1.4) had similar baseline knowledge scores (p = 0.148). The pamphlet group showed a significant improvement in sunscreen knowledge with a post-test mean score of 7.6 1.2 (p < 0.001). Similarly, the video group also showed a significant improvement in sunscreen knowledge with a post-test mean score of 8.8 1.4 (p < 0.001). Inter-group analysis showed a significant difference in the improvement of post-study scores of the online-video group (2.0 1.5) compared to the pamphlet group (1.2 1.0), p = 0.003.
2.4. Study endpoints and statistical analysis
3.2. Improvement in sunscreen application behavior
Primary endpoints for the study included participants’ improvement in sunscreen application behavior and sunscreen knowledge. Sunscreen application behavior was defined as the average number of days that participants applied sunscreen during
The pamphlet group (2.0 3.0 days per week) and the video group (1.7 2.5) had comparable baseline frequencies of sunscreen application (p = 0.552). At the end of the study 3 months later, the pamphlet group showed a non-significant increase in the
2.3. Satisfaction survey
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Table 1 Comparison of demographic factors between the pamphlet and video groups. Pamphlet group (n = 47)
Video group (n = 47)
p value
Sex Female Male
44.7% (21) 55.3% (26)
55.3% (26) 44.7% (21)
0.409z
Age Mean
39.6 14 years
34.7 12 years
0.079*
Marital status Married Not married
53.2% (25) 46.8% (22)
61.7% (29) 38.3% (18)
0.532z
Highest grade at school or years in college completed 1st through 8th 9th through 12 or GED 1–3 years of college 4 or more years of college
0% (0) 4.3% (2) 19.1% (9) 76.6% (36)
2.1% 6.4% 23.4% 68.1%
(1) (3) (11) (32)
0.625y
Ethnicity White Black Hispanic Asian or Pacific Islander Native American Other
61.7% (29) 2.1% (1) 4.3% (2) 21.3% (10) 0% (0) 10.6% (5)
46.8% (22) 4.3% (2) 10.6% (5) 27.7% (13) 0% (0) 10.6% (5)
0.563y
14.9%(7) 61.7% (29) 12.8% (6) 4.3% (2) 2.1% (1) 4.3%(2)
0.604y
6.4% 10.6% 19.2% 34.0% 17.0% 12.8%
0.349y
Employment status Unemployed Employed full time (including self-employment) Employed part time (including self-employment) Student full time Student part time Retired Skin phototype Always burns, does not tan Burns easily, tans poorly Tans after initial burn Burns minimally, tans easily Rarely burns, tans darkly easily Never burns, always tans darkly
8.5%(4) 70% (31) 14.9% (7) 8.5% (4) 2.1% (1) 0% (0)
2.1% 21.3% 25.5% 29.8% 6.4% 14.9%
(1) (10) (12) (14) (3) (7)
(3) (5) (9) (16) (8) (6)
Number of sunburns in the past year 0.1277 0.3966 How often stay in the shade when out in the sun for more than 1 h Never Rarely Sometimes/most of the time Always
0.06383 0.2471
0.351*
(10) (26) (6) (4)
0.945y
How often wear a hat that shades their face, ears and neck when out in sun for more than 1 h Never 29.8% (14) Rarely 59.6% (28) Sometimes/most of the time 4.3% (2) Always 6.38% (3)
34.0% (16) 61.7% (29) 4.3% (2) 0% (0)
0.369y
How often wear long sleeved shirt when out in the sun for than 1 h Never Rarely Sometimes/most of the time Always
53.2% 19.2% 10.6% 17.0%
(25) (9) (5) (8)
57.5% 21.3% 8.5% 12.8%
(27) (10) (4) (6)
0.913y
How often wear sunscreen when out in the sun for more than 1 h Never Rarely Sometimes/most of the time Always
61.7% 23.4% 12.8% 2.1%
(29) (11) (6) (1)
57.5% 21.3% 12.8% 8.5%
(27) (10) (6) (4)
0.589y
17.0% 61.7% 12.8% 8.5%
(8) (29) (6) (4)
21.3% 55.3% 12.8% 8.5%
Percentages are followed by number of cases (in parentheses). y Chi-square test was used to determine significance. z Fisher’s exact test was used to determine significance. * Student’s t-test was used to determine significance.
frequency of sunscreen application (2.4 3.0 days per week, p = 0.058), whereas the video group exhibited a significant increase in sunscreen application behavior from baseline (3.4 2.6, p < 0.001).
Inter-group analysis revealed that the improvement in sunscreen application behavior was greater in the video group (1.9 2.3 increase in days per week) than the pamphlet group (0.2 0.5) with p < 0.001.
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3.3. Satisfaction survey 90.7% of the video group and 62.5% of the pamphlet group favored the video. The video group rated the appeal of their material 9.0 0.9, significantly higher than the pamphlet rating of 7.9 1.3 (p < 0.001). Furthermore, the video group rated the usefulness of the video significantly higher than the pamphlet group (7.7 1.3) p < 0.001. Lastly, the video was referred to an additional 1.5 0.8 times while the pamphlet was referred to an additional 1.2 0.5 times (p = 0.018). 4. Discussion and conclusion
application. Over half of American Internet users have searched for health care information online [23]. Interestingly, users who searched for skin cancer information were more likely to engage in sunscreen use [24]. Clinicians may easily provide online video on office web resources or directly to patients during routine care. Although many health systems have already implemented web resources linked to handouts for common health topics, online video may become an innovative and effective way to deliver patient education requiring complex and long-term health behaviors. Video demonstrating proper sunscreen application that can be widely distributed in practice and easily accessible has potential to improve behavioral outcomes over current traditional methods, particularly in primary prevention of UV-induced skin cancers.
4.1. Discussion Conflict of interest Ultraviolet radiation protection by sunscreen use reduces the number of sunburns [11] and actinic keratoses [12], two wellknown risk factors for skin cancer development. The factors that lead to poor patient adherence are numerous and complex [13], with lack of knowledge [14] and proper counseling [15] as significant barriers. To address both these issues, our two educational vehicles aimed to increase sunscreen knowledge and affect behavioral changes in sunscreen application. Participants from the video group had significantly higher frequency of sunscreen use per week while participants from the pamphlet group showed no statistically significant differences in behavior after the study. Since the information delivered in each arm was identical, greater adherence is attributed to the nature of the educational vehicle. Compared with the pamphlet group, participants in the video group referred back to the videos about 1.3 times more often during the study period. The cognitive model of learning suggests that audio-visual instruction is likely to be more effective than written material [16], and may be particularly useful for conceptual learning [17]. A review of 25 studies using video education revealed that video increased short-term knowledge and was as effective or better than traditional patient educational materials. Behavior demonstrated in video also led to remodeling in patient behavior, suggesting that video can affect behavioral outcomes [18]. Subsequent studies have shown that video education can improve clinical outcomes [19] and knowledge outcomes [20], particularly for complex health behaviors [21]. One limitation of this study was that the average education level of our participants is higher than that of the American public. Furthermore, the study was limited to adults over 18 years old; it will be useful to explore whether online video will be effective in older children and teens in a future study. However, Americans receive less than 25% of their lifetime UV exposure by the age of 18 [22], supporting the relevance of this study in adults. 4.2. Conclusion Patient education is a cornerstone of primary prevention models of skin cancer. In this study, we evaluated the efficacy of online video as an education vehicle for sunscreen use compared to a written module in a randomized controlled trial. Patients who viewed the online video scored significantly higher on the poststudy questionnaire than patients who were given the pamphlet. More importantly, this translated into greater adherence to sunscreen use over the previous month in the online video arm. 4.3. Practice implications These results support the efficacy of online video for educating patients on the importance of sunscreen use and proper sunscreen
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