Text message reminders may encourage sunscreen use

November 16, 2009

Daily text-message reminders appear to increase sunscreen use over a six-week period, according to a report in the November issue of Archives of Dermatology, one of the JAMA/Archives journals.

Skin cancer accounts for one in three cancer cases worldwide and more than 1 million new cases are diagnosed in the United States each year, according to background information in the article. "Many of these cases could be prevented if the population took consistent measures to avoid direct sunlight by wearing protective clothing and applying sunscreen," according to the study.

April W. Armstrong, M.D., of the University of California-Davis Health System, Sacramento, and colleagues assessed effectiveness of receiving daily text-message reminders to wear sunscreen over a six-week period. Seventy individuals (age 18 and older) participated in the study and were asked to apply sunscreen daily. Half were randomly assigned to receive text-message reminders, while the other half did not receive any reminders. The text-messages consisted of two components: a text detailing daily local weather information and a text reminding users to apply sunscreen. Adherence was assessed through electronic adherence monitors adapted to participants' sunscreen tubes that would send electronic messages to a central station every time the cap of a tube was removed.

"At the end of the 42-day (six-week) study period, the control group had a mean [average] adherence of 12.6 days of sunscreen application, which corresponded to a 30-percent daily adherence rate. In comparison, the group that received daily reminder messages had a mean adherence of 23.6 days and a daily adherence rate of 56.1 percent," the authors write. Twenty-four (69 percent) participants in the reminder group reported that they would continue to use the text-message reminders after the study and 31 (89 percent) said they would recommend the reminder system to others. There were no significant demographic factors that predicted adherence.

"Despite continuing educational efforts, a wide gap persists between patients' understanding of the harmful effects of excessive sun exposure and their regular application of sunscreens," the authors conclude. "The short-term results of our study suggest that cellular telephone text-message reminders are a low-cost, scalable and effective method of bridging this knowledge-action gap. Introduction of a program that incorporates text-message reminders to a large population may be an innovative preventive health measure against the development of skin cancer."

(Arch Dermatol. 2009;145[11]:1230-1236. Available pre-embargo to the media at www.jamamedia.org.)

Editor's Note: This study was supported by an institutional grant from Information Systems Council of Massachusetts General Hospital and Brigham and Women's Hospital. Study sunscreen was provided by Neutrogena. Co-author Dr. Makredes was a Doris Duke Clinical Research Fellow and Dr. Armstrong was a Stiefel/Connetics Research Fellow for Improving Access to Dermatologic Care at the time of the study. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, funding and support, etc.

Editorial: Study Shows Technology Could Be Used to Improve Treatment Adherence

"Armstrong et al document that even people who know they are being monitored do not use their sunscreen well," write Bridgit V. Nolan, B.A., and Steven R. Feldman, M.D., Ph.D., of Wake Forest University School of Medicine, Winston-Salem, N.C., in an accompanying editorial. "Their study has profound implications for how we view our patients' use of sunscreen and other treatments."

"Adherence, also termed compliance, refers to whether patients use their treatment and whether they use it according to the assigned regimen," they write. "While we recognize that patients may not be using their sunscreen well, much dogma in dermatology is based on the assumption that patients are following medical treatment routines as directed. The assumption that adherence is invariant is grossly inaccurate, such that many conclusions about the relationship between disease and treatment may be erroneous."

"Blaming patients for nonadherence is not productive or necessary because physicians have a degree of control over patients' adherence behaviors. The strength of the physician-patient interaction affects adherence," the authors conclude. "The study by Armstrong et al suggests that new technologies may provide additional means by which we can help our patients use recommended treatments better. Their study targeted one cause of poor adherence, forgetfulness, and found that simple reminders can considerably improve sunscreen use. Innovative thinking may help us use the potential of technology to target other causes of poor adherence and to develop effective new tools to promote better adherence behavior."

(Arch Dermatol. 2009;145[11]:1319-1321. Available pre-embargo to the media at www.jamamedia.org.)

Editor's Note: Please see the article for additional information, including author contributions and affiliations, financial disclosures, funding and support, etc.

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