Although both interventions resulted in increases in TCE, SSE, and sun protection habits, the tailored intervention evidenced stronger effects. Our results for the tailored intervention’s impact on TCE were notable in that there was almost a twofold increased probability of having a TCE. Effects were of a lesser magnitude for SSE and sun protection habits. The tailored intervention did not result in a significantly greater increase in SSE frequency among participants assigned to this group although it is encouraging that the increases noted at the first follow-up were maintained at the one year follow-up. Our findings for sun protection habits indicated non-significant effects at Time 2 but a significant effect in favor of the tailored intervention at Time 3. These findings demonstrate that tailored interventions may be more efficacious than generic interventions.
The fact that our tailored intervention resulted in a greater increase in the likelihood of TCE as compared with the generic intervention has not been reported in previous research targeting CM patients’ family members (Geller & Halpern, 2006
). Geller and colleagues (2006)
reported that both their active intervention and usual care interventions doubled TCE screening rates with no between group differences. In that study, families in the usual care arm received a standard physician practice of suggesting that patients with melanoma should notify their family members about their diagnosis and patients were encouraged to make appointments for relatives to be screened at the same site as where the patient was seen. Participants in the active intervention received a goal setting and motivational telephone session, computer-generated tailored print materials sent at three time points, three tailored telephone calls, and linkages to free screening programs. There were no group differences with regard to TCE. These findings differ from those in the present study. However, providing an explanation for differences across studies is complicated by the fact that they differed with regard to the target population, the pre-intervention level of compliance with surveillance and protection habits, and the intensity of the treatment arms.
We found that the tailored and generic interventions were equally effective in increasing SSE. Our tailored intervention’s effects on SSE frequency contrast with previous research which noted a stronger impact for the tailored intervention as compared to usual care (Geller & Halpern, 2006
). As noted above it is difficult to compare these two studies due to the different methodologies adopted. Nevertheless, it is possible that the fact that the comparison condition in the present, generic materials, was more intensive than the usual care intervention used by Geller and colleagues (2006)
(asking the proband to recommend TCE) explained the fact that their study reported a stronger effect for the tailored intervention. That is, our generic intervention provided education about SSE whereas the usual care intervention in the Geller study did not target SSE.
Our results suggest that information tailored to FDRs knowledge and attitudes may not be more effective than the widely-available educational information on SSE which is accompanied by a brief educational session reviewing this material. Our results for sun protection habits are encouraging because the previous intervention study for at-risk family members did not report improvements in sun protection habits (Geller & Halpern, 2006
). These findings are consistent with a number of different behavioral interventions that have successfully reduced sun protection practices (Glanz et al., 2002
; Jackson & Aiken, 2006
; Mahler et al., 2005
; Mahler, Kulik, Butler, Gerrard, & Gibbons, 2008
) and extend previous research to illustrate that tailored interventions can improve sun protection practices among FDRs of patients with melanoma.
Overall, our findings suggest that the tailored intervention was more effective than the generic intervention. The tailored intervention was viewed as more personalized, novel, valuable, and perceived as prompting participants to think more about changing their health practices than the generic intervention. These findings are consistent with previous research (e.g., Kreuter, Oswald, Bull, & Clark; 2000
; Campbell et al., 1994
). However, the effects of tailoring differed across the three behaviors with stronger effects noted on TCE and sun protection. An examination of the materials suggests that the tailored SSE pamphlet was more similar to the generic print intervention in that both focused on instructions about how to correctly perform an SSE. Other than the tailored content addressing benefits and barriers to SSE, the generic and tailored interventions were more similar in their content than the materials for TCE and sun protection. Future studies may improve effects by perhaps expanding tailoring on benefits and barriers to SSE and identifying additional attitudinal correlates associated with this behavior to improve the treatment effect.
The second aim was to evaluate possible mediators of treatment effects. We identified one mediator, TCE intentions, for the tailored intervention’s effects on TCE. This study represents the first examination of mechanisms for changes in TCE and, therefore, comparisons with previous work cannot be done. Sun protection intentions, sun protection benefits, and sunscreen self-efficacy mediated the effects of the tailored intervention on sun protection habits. Our findings are consistent with prior research suggesting that intentions are beneficially affected by sun protection interventions (Mahler et al., 2005
; Jackson & Aiken, 2006
) as well as studies indicating that sun protection intentions and sunscreen self-efficacy mediate the effects of sun protection interventions (Jackson & Aiken, 2006
). Our findings provide support for the theoretical underpinnings of the tailored intervention in that intentions, benefits, and self-efficacy served as mechanisms for effects on sun protection habits and intentions mediated effects for TCE. Our
findings have some potential clinical implications in that it may be important to bolster individuals’ confidence that they can incorporate sunscreen into their daily life. The fact that intentions mediated the effects of the tailored intervention on TCE and sun protection habits suggests that intentions could be targeted in behavioral interventions. For example, implementation intentions whereby participants are asked to commit to a time and place to have a TCE could be incorporated to enhance participants’ commitment to their intention to have screening. This intervention has been used effectively in other health behavior interventions (e.g., Arbour & Ginnis, 2009
). However, a number of proposed variables were not mediators for the tailored intervention’s effects. Because these factors cover the gamut of possible factors included in most health behavior models, future research should use interview methods to uncover other possible mechanisms potentially responsible for the tailored intervention’s effects.
The research has a number of strengths. We targeted a population at higher risk for CM not only because of a family history of this disease but because of behavioral risk factors. Our sample size was large and attrition was low (13.3%). We employed a multiple-risk reduction approach that was based upon theoretical and empirical considerations and compared publicly-available pamphlets with tailored pamphlets to determine if the widely-available information was just as effective. Counseling session treatment fidelity was high and the majority of participants received the counseling call. We evaluated long-term outcomes and mechanisms of change. Both interventions were evaluated highly.
However, there were weaknesses. An immediate post-intervention assessment of mediators was not conducted and therefore the possibility that changes in behavior preceded changes in attitudes cannot be ruled out. Self-reports of SSE and sun protection habits were used and we were not able to confirm TCEs in about a quarter of the reported procedures due to problems obtaining confirmation. The acceptance rate among eligible family members was 50% which is lower than other studies (Geller et al., 2008
). The majority of participants had medical insurance which may have biased the post-intervention uptake of TCE. Half of participants were offspring which may have biased the study’s results in favor of younger individuals. Participants were enrolled across seasons which may have affected the effects on sun protection habits. Approximately 44% of eligible FDRs approached participated which limits generalizability of the findings. The tailored counseling call was longer in duration than the generic call and it is possible that the greater level of interaction between counselor and participant and greater length accounted for the superiority of the tailored intervention. Although the importance of discussing TCE and SSE with the affected relative was addressed in the tailored intervention, communication about risk was not assessed as a possible mediator. It is possible that discussion with the affected proband was a mechanism of change in the tailored arm and should be assessed in future studies.
A next step in the research could be to disseminate the tailored intervention into the clinical setting such as a community dermatology clinic. However, dissemination may pose unique challenges. One major challenge is accessing relatives. Community recruitment through dermatology practices rather than cancer center clinics would necessitate reliance upon proband recruitment of their family members. This method of recruitment may be challenging. Even with researchers recruiting family members into the present study, acceptance rates were not high. It may be even more difficult for probands to garner sufficient interest among their relatives. A second challenge is cost. It may be expensive to obtain baseline survey data that can be used for producing tailored print and it may not be cost-effective to train individuals to deliver such an intervention. We did not conduct a cost effectiveness analysis of this intervention. However, Campbell and colleagues (2009)
have recently shown that, while more costly, a combined tailored print and motivational interviewing intervention was more cost-effective than either intervention alone for promoting fruit and vegetable consumption. Future research should evaluate cost-effectiveness of the tailored print and telephone counseling intervention. Dissemination for the tailored print would not be as difficult as the telephone counseling which might be challenging to disseminate into the community setting due to the resources and personnel needed to deliver a telephone intervention. Future research might examine the cost-effectiveness of the tailored print and telephone counseling separately. In clinical settings where resources are limited, the choice of tailored print alone may be reasonable but we do not yet know if the tailored print alone had significant effects when compared with generic prints.
In summary, this study was one of the first to address skin cancer risk reduction practices in a sample of family members of patients with melanoma who were non-adherent to risk reduction practices. Publicly-available print information along with an education session may improve SSE in this population of at-risk individuals. However, more intensive intervention efforts are likely necessary to promote TCE and may also prove beneficial for increasing sun protection habits.