Response Across the Health-Literacy Spectrum of Kidney Transplant Recipients to a Sun-Protection Education Program Delivered on Tablet Computers: Randomized Controlled Trial

June K Robinson, John J Friedewald, Amishi Desai, Elisa J Gordon, June K Robinson, John J Friedewald, Amishi Desai, Elisa J Gordon

Abstract

Background: Sun protection can reduce skin cancer development in kidney transplant recipients, who have a greater risk of developing squamous cell carcinoma than the general population.

Objective: A culturally sensitive sun-protection program (SunProtect) was created in English and Spanish with the option of choosing audio narration provided by the tablet computer (Samsung Galaxy Tab 2 10.1). The intervention, which showed skin cancer on patients with various skin tones, explained the following scenarios: skin cancer risk, the ability of sun protection to reduce this risk, as well as offered sun-protection choices. The length of the intervention was limited to the time usually spent waiting during a visit to the nephrologist.

Methods: The development of this culturally sensitive, electronic, interactive sun-protection educational program, SunProtect, was guided by the "transtheoretical model," which focuses on decision making influenced by perceptions of personal risk or vulnerability to a health threat, importance (severity) of the disease, and benefit of sun-protection behavior. Transportation theory, which holds that narratives can have uniquely persuasive effects in overcoming preconceived beliefs and cognitive biases because people transported into a narrative world will alter their beliefs based on information, claims, or events depicted, guided the use of testimonials. Participant tablet use was self-directed. Self-reported responses to surveys were entered into the database through the tablet. Usability was tested through interviews. A randomized controlled pilot trial with 170 kidney transplant recipients was conducted, where the educational program (SunProtect) was delivered through a touch-screen tablet to 84 participants.

Results: The study involved 62 non-Hispanic white, 60 non-Hispanic black, and 48 Hispanic/Latino kidney transplant recipients. The demographic survey data showed no significant mean differences between the intervention and control groups in age, sex, income, or time since transplantation. The mean duration of program use varied by the ethnic/racial group, with non-Hispanic whites having the shortest use (23 minutes) and Hispanic/Latinos having the longest use (42 minutes). Knowledge, awareness of skin cancer risk, willingness to change sun protection, and use of sun protection increased from baseline to 2 weeks after the program in participants from all ethnic/racial groups in comparison with controls (P<.05). Kidney transplant recipients with inadequate (47/170, 28%) and marginal functional health literacy (59/170, 35%) listened to either Spanish or English audio narration accompanying the text and graphics. After completion of the program, Hispanic/Latino patients with initially inadequate health literacy increased their knowledge more than non-Hispanic white and black patients with adequate health literacy (P<.05). Sun protection implemented 2 weeks after education varied by the ethnic/racial group. Outdoor activities were reduced by Hispanics/Latinos, non-Hispanic blacks sought shade, Hispanic/Latinos and non-Hispanic blacks wore clothing, and non-Hispanic whites wore sunscreen (P<.05).

Conclusion: Educational program with a tablet computer during the kidney transplant recipients' 6- or 12-month follow-up visits to the transplant nephrologist improved sun protection in all racial/ethnic groups. Tablets may be used to provide patient education and reduce the physician's burden of educating and training patients.

Trial registration: ClinicalTrials.gov NCT01646099; https://ichgcp.net/clinical-trials-registry/NCT01646099.

Keywords: culturally sensitive; electronic health intervention; kidney transplant recipients; mobile health; patient education; post-transplant outcomes; skin cancer; squamous cell carcinoma; sun protection; tablet computer.

Conflict of interest statement

Conflicts of Interest: Dr Robinson owns the trademark on the software.

©June K Robinson, John J. Friedewald, Amishi Desai, Elisa J Gordon. Originally published in JMIR Cancer (http://cancer.jmir.org), 18.08.2015.

Figures

Figure 1
Figure 1
Introduction to the program showed the range of ethnicities and races.
Figure 2
Figure 2
Users toggled between the 2 pie graphs presenting the risk of developing skin cancer in kidney transplant recipients and in the general population.
Figure 3
Figure 3
Users selected daily activities with commonly unrecognized sun exposure.
Figure 4
Figure 4
Personalized sun-protection recommendation from the doctor.
Figure 5
Figure 5
Explanation of squamous cell carcinoma with examples in kidney transplant recipients with skin of color.
Figure 6
Figure 6
Testimonial from a non-Hispanic black kidney transplant recipient relating skin irritation from the sun on his bald scalp because he forgot his hat.

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Source: PubMed

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