Sun Protection Strategies for Kidney Transplant Recipients

In the United States, the most common type of cancer is skin cancer, causing more than 10,000 deaths each year. More than five million people are treated for skin cancer annually, with a treatment cost of $8.1 billion, and rates of skin cancer incidence are increasing. People of all skin tones are at risk for skin cancer; although skin cancer is more common among people with a light complexion, people with darker skin are still at risk, even if their skin does not tend to get sunburned. Most cases of skin cancer are preventable by practicing sun protective behaviors (e.g., avoiding the sun during peak sunlight, wearing protective clothing, using sunscreen) and avoiding intentional tanning. Organ transplant recipients are at increased risk for skin cancer, especially squamous cell carcinomas, because the immunosuppressive drugs they take to prevent organ rejection make their skin more susceptible to sun damage. Interventions are needed to educate organ transplant recipients about sun safety and sun protection to decrease their risk of developing skin cancer. This education may be especially important for people with skin of color who view themselves as being at low risk.

Sun Protection Strategies for Kidney Transplant Recipients is an educational intervention that aims to increase sun protection behaviors among kidney transplant recipients (KTRs), who take immunosuppressive drugs that place them at increased risk of skin cancer. Based on the theory of reasoned action and planned behavior, the intervention comprises two components―an 11-page workbook and a set of three reminders sent electronically―to encourage sun safety behaviors to prevent skin cancer.

Patients receive the workbook when they go to an appointment with their nephrologist or transplant surgeon, and they are encouraged to read the workbook during the visit and at home. The workbook explains KTRs' increased probability of developing skin cancer, highlights the importance of sun protection to avoid skin cancer, describes and visually depicts types of skin cancer, and promotes the adoption of various sun protection behaviors. The workbook is designed to be culturally appropriate for non-Hispanic White, non-Hispanic Black, and Hispanic/Latino patients to reinforce the notion that all KTRs need to adopt sun safety behaviors, regardless of their ethnicity or skin tone, because of their increased risk. The workbook conveys messages that reflect values and beliefs about getting darker skin and skin cancer from sun exposure, includes photographs of skin cancers occurring in multiple skin types, and uses culturally appropriate language. For example, the workbook uses the phrase "skin irritation" in addition to "sun burn." Further, in explaining how people receive more sun exposure than they realize, the workbook uses culturally relevant outdoor activities as examples.

Over a 5-week period starting 2 weeks after getting the workbook, patients receive three messages by telephone text or email. These messages remind patients to use sun protection and are sent on a weekday, a weekend, and the Friday before a holiday weekend.

-- Adequate time to distribute the sun protection workbook to patients and recommend to them that they read it
-- Time to set up the automated text message reminders to be sent to patients

The intervention is intended for kidney transplant recipients.

The intervention is suitable for implementation by medical providers in nephrologists' and transplant surgeons' offices.

Required resources to implement the program include the following:

-- Sun Protection Strategies for Kidney Transplant Recipients workbook
-- Text messages

For costs associated with this program, please contact the developer, June Robinson. (See products page on the EBCCP website for developer contact information.)
 

A randomized controlled trial was conducted to compare sun protection behaviors and skin pigmentation among intervention participants and those receiving standard care. The study included patients who were receiving ambulatory care at Northwestern Medicine. They were recruited from a list of KTRs that were approved to participate in the study by their treating physician. Patients were recruited until all targeted racial/ethnic categories were filled for study purposes. Patients who received a kidney transplant within the past 2‒24 months, spoke and read English, could see to read, were between 18 and 85 years old, and lived in the greater Chicago area were eligible to participate. Those who had a prior history of skin cancer or a history of dermatologic disease treated with ultraviolet light, or who were under the care of a dermatologist within the past 5 years, were excluded from the study.

Patients were stratified to maximize representation of three racial/ethnic groups. Of the 601 eligible patients, 103 were enrolled (46 non-Hispanic Whites, 33 non-Hispanic Blacks, and 24 Hispanics/Latinos). Of enrolled participants, 68 (66%) were males, 35 (34%) were females, the average age was 54 years, 59 (57%) were married, and 43 (42%) were college educated. Forty-five (44%) of participants reported ever having a work-related sun exposure.

The study's primary outcomes were sun protection behaviors and skin pigmentation, which were assessed at baseline and 6-week follow-up. Sun protection behaviors were measured through a 79-item self-administered survey that included items on using sunscreen, wearing protective clothing, and seeking shade. The instrument also collected information on demographics, knowledge, and attitudes as well as number of hours spent outdoors per week and number of burns in the past year. Performance of sun protection was presented as a composite of self-reported use of sun protection behaviors in the summer on a warm sunny day and on a cloudy day. Skin pigmentation was measured on the right forearm using a Mobile Datacollector DC 3000 spectrophotometer including a Mexameter MX18 probe. The instrument measures the skin's melanin index on a 10‒2000 scale.

• Intervention group participants had significantly greater improvement in use of sun protection behaviors than participants in the standard care group (p=.013).

• Intervention group participants had significantly less increase in skin pigmentation than participants in the standard care group (p=.036).