(A) Survey response
A total number of 50 patients (25 RTRs, 25 patients with GD, n = 100%) completed a questionnaire at pre-education and 3-month post-education. Of these, 46 (23 RTRs and 23 patients with GD, n = 92%) completed a questionnaire at 6-month post-education.
(B) Demographics
The mean age of all participants was 59 years (standard deviation, SD = 13.5 years) and 58% were male. 94% of all participants were Caucasians and 54% (26 Caucasians and 1 Asian) had a history of skin cancer. The mean time spent in formal education was 11.9 years (SD = 3.3 years). The median time since the first dose of immunosuppressants was 62 months (interquartile range, IQR = 36.8-108.5 months). There was no significant difference in mean age, sex, race, time spent in formal education and median time since the first dose of immunosuppressants between RTR cohort and GD group. 72% of RTRs and 36% of patients with GD had a history of skin cancer (p = 0.022). Participant demographics are shown in Table 1.
Table 1
Demographics of participants
| All participants (N = 50) | RTRs (N = 25) | GD Patients (N = 25) | p-value |
Mean age (years) (Min-Max) (SD) | 59 (20–78) (13.5) | 59 (37–74) (11.38) | 61 (20–78) (15.3) | 0.253 |
Sex (N) Female Male | 21 (42.0) 29 (58.0) | 9 (36.0) 16 (64.0) | 12 (48.0) 13 (52.0) | 0.567 |
Race (N, %) Caucasian Asian | 47 (94.0) 3 (6.0) | 50 (100.0) 0 | 22 (88.0) 3 (12.0) | 0.235 |
Personal history of skin cancer (N, %) Yes No | 27 (54.0) 23 (46.0) | 18 (72.0) 7 (28.0) | 9 (36.0) 16 (64.0) | 0.022 |
Formal education (years) (Min-Max) (SD) | 11.9 (4.0–19.0) (3.3) | 11.9 (4.0–19.0) (3.4) | 11.9 (6.0-18.5) (3.3) | 0.983 |
Median time since the first dose of immunosuppressants (months) (interquartile range, IQR) | 62.0 (36.8-108.5) | 63.0 (35.5-111.5) | 61.0 (38.5–97.5) | 0.512 |
(C) Skin cancer and sun health knowledge
The mean SCSK score of all participants at baseline was 19.3 (SD = 3.3). The SCSK score was improved significantly at 3 months (all participants 21.0, p < 0.001, RTR cohort 21.8, p = 0.004 and GD group 20.2, p = 0.039) and 6 months (all participants 20.9, p < 0.001, RTR cohort 21.0, p = 0.040 and GD group 20.9, p = 0.004) after the education. SCSK scores are detailed in Table 2. There was no significant difference in SCSK score between RTRs and patients with GD before receiving skin cancer education (mean: 19.7 vs 19.0, p = 0.473) and 6 months after education (mean score 21.0 vs 20.9, p = 0.939) as shown in Table 5. However, RTRs had higher mean SCSK score at 3 months post-education, compared with patients with GD (21.8 vs 20.2, p = 0.031). However, this result was not significant (p = 0.278) when accounting for SCSK scores pre-education (change in SCSK score from pre-education at 3 months: mean = 2.2 (RTRs) vs mean = 1.2 (GD); see Table 5).
Table 2
Intervention | N | Mean SCSK score (SD) | p value | Change in SCSK score from baseline (95%CI) |
Pre-education (0 months) | 50 | 19.3 (3.3) | Ref | Ref |
Post-education 1 (3 months) | 50 | 21.0 (2.7) | < 0.001 | 1.9 (0.8–2.6) |
Post-education 2 (6 months) | 46 | 20.9 (1.8) | < 0.001 | 1.6 (0.8–2.5) |
Table 2B: RTR cohort |
Intervention | N | Mean SCSK score (SD) | | Change in SCSK score from baseline (95%CI) |
Pre-education (0 months) | 25 | 19.7 (3.1) | Ref | Ref |
Post-education 1 (3 months) | 25 | 21.8 (1.5) | 0.004 | 2.2 (0.8–3.6) |
Post-education 2 (6 months) | 23 | 21.0 (1.6) | 0.040 | 1.3 (0.1–2.5) |
Table 2C: GD cohort |
Intervention | N | Mean SCSK score (SD) | | Change in SCSK score from baseline (95%CI) |
Pre-education (0 months) | 25 | 19.0 (3.5) | Ref | Ref |
Post-education 1 (3 months) | 25 | 20.2 (3.4) | 0.039 | 1.2 (0.1–2.3) |
Post-education 2 (6 months) | 23 | 20.9 (1.9) | 0.004 | 2.0 (0.7–3.3) |
(D) Outdoor activities and photoprotective behaviours
The frequency of participant outdoor activities for work or recreation or exercise under the sun and compliance with sun-protective practices used by the patients are summarized in Table 3 and Figs. 2 to 3. The frequency of outdoor activities of all participants did not change significantly before and after education. In the whole participant cohort and GD cohort, the mean total number of sun-protective methods used also did not changed significantly between baseline and 3-months (whole cohort, 4.8 vs 4.7, p = 0.757, GD cohort, 4.4 vs 4.0, p = 0.268) and 6-months post-intervention (whole cohort, 4.8 vs 5.1, p = 0.170, GD cohort, 4.4 vs 4.2, p = 0.842) (Table 3). However, the number of sun-protective methods practised did increase significantly at 6 months post-education in the RTR cohort (5.1 vs 6.0, p = 0.038). There was no difference in mean total number of sun-protective methods used between RTR cohort and GD cohort at pre-education (5.1 vs 4.4, p = 0.239) whereas there was a significant difference demonstrated at 3 months (5.4 vs 4.0, p = 0.023) and 6 months (6.0 vs 4.2, p = 0.004) post-education (Table 5). Relative to the number of sun-protective methods practised pre-education, the mean number of sun-protective methods used changed by 0.3 (RTRs) and − 0.4 (GD) at 3 months (p = 0.082), and at 6 months by 1.0 (RTRs) and − 0.1 (GD) with p = 0.047. Overall, RTRs had better compliance with sun-protective practices before and after the education when compared to patients with GD as shown in Table 3 and Figs. 2 to 3. In the whole cohort, a higher number of participants wore light coloured clothes (p = 0.039) and sunglasses (p = 0.039) at 6 months after education, compared to pre-education. In the RTR cohort, the number of patients who wore sunglasses (p = 0.031) and stayed in the shade (p = 0.031) increased significantly. In GD cohort, there was no significant change in compliance with each sun-protective practice after the education.
Table 3
Outdoor activities and compliance with sun-protective practices
| All participants | p value | RTR cohort | p value | GD Cohort | p value |
Outdoor activity under the sun (N, %) |
Pre-education (0 months) Daily/Almost daily Weekly Fortnightly Monthly Never/Almost Never Post-education 1 (3 months) Daily/Almost daily Weekly Fortnightly Monthly Never/Almost Never Post-education 2 (6 months) Daily/Almost daily Weekly Fortnightly Monthly Never/Almost Never | 32/50 (64%) 7/50 (14%) 4/50 (8%) 1/50 (2%) 6/50 (12%) 28/50 (56%) 8/50 (16%) 5/50 (10%) 2/50 (4%) 7/50 (14%) 25/46 (54%) 7/46 (15%) 3/46 (7%) 6/46 (13%) 5/43 (11%) | Ref 0.340 0.402 | 16/25 (64%) 5/25 (20%) 3/25 (12%) 0/25 (0%) 1/25 (4%) 14/25 (56%) 5/25 (20%) 3/25 (12%) 1/25 (4%) 2/25 (8%) 13/23 (57%) 4/23 (17%) 2/23 (9%) 3/23 (13%) 1/23 (4%) | Ref n/a n/a | 16/25 (64%) 2/25 (8%) 1/25 (4%) 1/25 (4%) 5/25 (20%) 14/25 (56%) 3/25 (12%) 2/25 (8%) 1/25 (4%) 5/25 (20%) 12/23 (52%) 323 (13%) 1/23 (4%) 3/23 (13%) 4/23 (18%) | Ref 0.261 0.549 |
Mean total number of sun-protective methods used (N, SD) |
Pre-education Post-education 1 Posy-education 2 | 4.8 (SD 2.1) 4.7 (SD 2.3) 5.1 (SD 2.2) | Ref 0.757 0.170 | 5.1 (2.3) 5.4 (2.1) 6.0 (1.9) | Ref 0.403 0.038 | 4.4 (2.0) 4.0 (2.3) 4.2 (2.2) | Ref 0.268 0.842 |
Sun-protective methods (N, %) |
Avoiding outdoor between 10am and 4pm Pre-education No Yes Post-education 1 No Yes Post-education 2 No Yes | 20/50 (40%) 30/50 (60%) 22/50 (44%) 28/50 (56%) 17/46 (37%) 29/46 (63%) | Ref 0.687 1.000 | 8/25 (32%) 17/25 (68%) 10/25 (40%) 15/25 (60%) 8/23 (35%) 15/23 (65%) | Ref 0.687 1.000 | 12/25 (48%) 13/25 (52%) 12/25 (48%) 13/25 (52%) 9/23(39%) 14/23 (61%) | Ref 1.000 0.687 |
Staying in the shade Pre-education No Yes Post-education 1 No Yes Post-education 2 No Yes | 19/50 (38%) 31/50 (62%) 19/50 (38%) 31/50 (62%) 15/46 (33%) 31/46 (67%) | Ref 1.000 0.581 | 10/25 (40%) 15/25 (60%) 7/25 (28%) 18/25 (72%) 4/23 (17%) 19/23 (83%) | Ref 0.453 0.031 | 9/25 (36%) 16/25 (54%) 12/25 (48%) 13/25 (52%) 11/23 (48%) 12/23 (52%) | Ref 0.508 0.453 |
Wearing a hat Pre-education No Yes Post-education 1 No Yes Post-education 2 No Yes | 7/50 (14%) 43/50 (86%) 9/50 (18%) 41/50 (82%) 5/46 (11%) 41/46 (89%) | Ref 0.687 0.625 | 3/25 (12%) 22/25 (88%) 2/25 (8%) 23/25 (92%) 4/23 (17%) 19/23 (83%) | Ref 1.000 0.500 | 4/25 (16%) 21/25 (84%) 7/25 (28%) 18/25 (72%) 1/23 (4%) 22/23 (96%) | Ref 0.375 1.000 |
Using an umbrella Pre-education No Yes Post-education 1 No Yes Post-education 2 No Yes | 41/50 (82%) 9/50 (18%) 42/50 (84%) 8/50 (16%) 39/46 (85%) 7/46 (15%) | Ref 1.000 1.000 | 21/25 (84%) 4/25 (6%) 20/25 (80%) 5/25 (20%) 17/23 (74%) 6/23 (26%) | Ref 1.000 0.687 | 20/25 (80%) 5/25 (20%) 22/25 (88%) 3/25 (12%) 22/23 (96%) 1/23 (4%) | Ref 0.625 0.375 |
Wearing shirts with long sleeves Pre-education No Yes Post-education 1 No Yes Post-education 2 No Yes | 18/50 (36%) 32/50 (64%) 24/50 (48%) 26/50 (52%) 16/46 (35%) 30//46 (65%) | Ref 0.146 1.000 | 8/25 (32%) 17/25 (68%) 11/25 (44%) 14/25 (66%) 11/23 (48%) 12/23 (52%) | Ref 0.375 0.625 | 10/25 (40%) 15/25 (60%) 13/25 (52%) 12/25 (48%) 5/23 (22%) 18/23 (78%) | Ref 0.453 0.687 |
Wearing light coloured clothes Pre-education No Yes Post-education 1 No Yes Post-education 2 No Yes | 33/50 (66%) 17/50 (34%) 29/50 (58%) 21/50 (42%) 22/46 (48%) 24/46 (52%) | Ref 0.289 0.039 | 13/25 (52%) 12/25 (48%) 11/25 (44%) 14/25 (66%) 8/23 (35%) 15/23 (65%) | Ref 0/625 0.453 | 20/25 (80%) 5/25 (20%) 18/25 (72%) 7/25 (28%) 14/23 (61%) 9/23 (39%) | Ref 0.625 0.063 |
Wearing sunglasses Pre-education No Yes Post-education 1 No Yes Post-education 2 No Yes | 18/30 (36%) 32/50 (64%) 16/30 (32%) 34/50 (68%) 9/46 (20%) 37/46 (80%) | Ref 0.754 0.039 | 7/25 (27%) 18/25 (73%) 5/25 (25%) 20/25 (75%) 1/23 (4%) 22/23 (96%) | Ref 0.625 0.031 | 11/25 (44%) 14/25 (66%) 11/25 (44%) 14/25 (66%) 8/23 (35%) 15/23 (65%) | Ref 1.000 0.687 |
Using sunscreens Pre-education No Yes Post-education 1 No Yes Post-education 2 No Yes | 7 (14%) 43 (86%) 8 (16%) 42 (84%) 8/46 (17%) 38/43 (83%) | Ref 1.000 1.000 | 2/25 (8%) 23/25 (92%) 2/25 (8%) 23/25 (92%) 1/23 (4%) 22/23 (96%) | Ref 1.000 1.000 | 5/25 (20%) 20/25 (80%) 6/25 (24%) 19/25 (76%) 7/23 (30%) 16/23 (70%) | Ref 1.000 0.687 |
Mean total number of seasons by sunscreen use (N, SD) Pre-education Post-education 1 Post-education 2 | 2.6 (SD 1.6) 2.8 (SD 1.6) 2.7 (SD 1.7) | Ref 0.322 0.437 | 3.1 (1.4) 3.4 (1.3) 3.5 (1.2) | Ref 0.335 0.153 | 2.1 (1.7) 2.2 (1.6) 1.9 (1.7) | Ref 0.660 0.601 |
Number of seasons by sunscreen use (N, %) Pre-education 4 3 2 1 0 Post-education 1 4 3 2 1 0 Post-education 2 4 3 2 1 0 | 25/50 (50%) 4/50 (8%) 4/50 (8%) 9/50 (18%) 8/50 (16%) 29/50 (58%) 4/50 (8%) 3/50 (6%) 7/50 (14%) 7/50 (14%) 27/46 (59%) 1/46 (2%) 3/46 (7%) 7/46 (15%) 8/46 (17%) | Ref 0.322 0.437 | 16/25 (64%) 2/25 (8%) 2/25 (8%) 3/25 (12%) 2/25 (8%) 20/25 (80%) 1/25 (4%) 0/25 (0%) 2/25 (8%) 2/25 (8%) 19/23 (84%) 1/23 (4%) 0/23 (0%) 2/20 (8%) 1/21 (4%) | Ref 0.335 0.153 | 9/25 (36%) 2/25 (8%) 2/25 (8%) 6/25 (24%) 6/25 (24%) 9/25 (36%) 3/25 (12%) 3/25 (12%) 5/25 (20%) 5/25 (20%) 8/23 (35%) 0/23 (0%) 3/23 (13%) 5/23 (22%) 7/23 (30%) | Ref 0.660 0.601 |
Frequency of sunscreen use among users (N, %) Pre-education Often/Always Sometimes Rarely Never/Almost Never Post-education 1 Often/Always Sometimes Rarely Never/Almost Neve Post-education 2 Often/Always Sometimes Rarely Never/Almost Never | 18/50 (36%) 20/50 (40%) 4/50 (8%) 8/50 (16%) 16/50 (32%) 20/50 (40%) 6/50 (12%) 8/50 (16%) 20/46(43%) 16/46 (35%) 3/46 (7%) 7/43 (15%) | Ref 0.639 0.745 | 13/25 (52%) 10/25 (40%) 0/25 (0%) 2/25 (8%) 13/25 (52%) 8/25 (32%) 1/25 (4%) 3/25 (12%) 13/23 (56%) 7/23 (31%) 2/23 (9%) 1/23 (4%) | Ref n/a n/a | 5/25 (20%) 10/25 (40%) 4/25 (16%) 6/25 (24%) 3/25 (12%) 12/25 (48%) 5/25 (20%) 5/25 (20%) 7/23 (31%) 9/23 (39%) 1/23 (4%) 6/23 (26%) | Ref 0.406 0.406 |
Note: n/a – the p-value cannot be computed due to the presence of zero observed value at pre-education. |
(E) Skin examination
Regular self-skin examination rate was increased significantly at 3 months (72%, p < 0.001) and 6 months (76%, p < 0.001) post-education in all participants when compared with the baseline rate at 28%. The same finding was noted in both, RTR (p = 0.004 at 3 months, p = 0.002 at 6 months), and GD (p < 0.001 at 3 and 6 months) cohorts. In addition, regular full skin checks by general practitioners (GPs) increased significantly in the whole cohort from 44% at baseline to 74% at 3 months (p < 0.001) and 78% at 6 months (p < 0.001). This finding was also observed in the GD cohort (p < 0.001 at 3 and 6 months) after the education. In the RTR cohort, the rate of full skin checks by GPs at baseline was high at 80% and there was not much room for improvement at 3- and 6-months post-education. Although the rate at baseline increased to 92% at 3 months (p = 0.250) and 96% at 6 months (p = 0.219), these changes were not statistically significant. Further details are shown in Table 4.
Table 4
Regular skin examination by patients and general practitioners
| | All participants | RTR cohort | GD cohort |
Intervention | Type of skin examination | N (%) | p value | N (%) | p value | N (%) | p value |
Pre- education | Self-examination No Yes | 36/50 (72%) 14/50 (28%) | Ref | 12/25 (48%) 13/25 (52%) | Ref | 24/25 (96%) 1/25 (4%) | Ref |
Post-education 1 | No Yes | 14/50 (28%) 36/50 (72%) | < 0.001 | 3/25 (12%) 22/25 (88%) | 0.004 | 11/25 (44%) 14/25 (56%) | < 0.001 |
Post- education 2 | No Yes | 11/46 (24%) 35/46 (76%) | < 0.001 | 1/23 (4%) 22/23 (96%) | 0.002 | 10/23 (43%) 13/23 (57%) | < 0.001 |
Pre- education | Examination by general practitioners No Yes | 28/50 (56%) 22/50 (44%) | Ref | 5/25 (20%) 20/25 (80%) | Ref | 23/25 (93%) 2/25 (8%) | Ref |
Post- education 1 | No Yes | 13/50 (26%) 37/50 (74%) | < 0.001 | 2/25 (8%) 23/25 (92%) | 0.250 | 11/25 (44%) 14/25 (56%) | < 0.001 |
Post- education 2 | No Yes | 10/46 (22%) 36/46 (78%) | < 0.001 | 1/23 (4%) 2/23 (96%) | 0.219 | 9/23 (39%) 14/23 (61%) | < 0.001 |
Table 5
Comparison of skin cancer awareness and sun-protection (RTRs vs GD patients)
Skin cancer awareness |
| RTRs (N = 25) | GD Patients (N = 25) | p-value |
Mean SCSK score (SD) Pre-education Post-education (3-months) Post-education (6-months) | 19.7 (3.1) 21.8 (1.5) 21.0 (1.6) | 19.0 (3.5) 20.2 (3.4) 20.9 (1.9) | 0.473 0.031 0.939 |
Change in SCSK score from baseline (95%CI) Pre-education Post-education (3-months) Post-education (6-months) | Ref 2.2 (0.8–3.6) 1.3 (0.1–2.5) | Ref 1.2 (0.1–2.3) 2.0 (0.7–3.3) | 0.278 0.391 |
Sun Protection |
| RTRs (N = 25) | GD Patients (N = 25) | p-value |
Mean total number of sun-protective methods used (SD) Pre-test Post-education (3-months) Post-education (6-months) | 5.1 (2.3) 5.4 (2.1) 6.0 (1.9) | 4.4 (2.0) 4.0 (2.3) 4.2 (2.2) | 0.239 0.023 0.004 |
Change in total number of sun-protective methods used from baseline (95%CI) Pre-test Post-education (3-months) Post-education (6-months) | Ref 0.3 (-0.4, + 1.0) 1.0 (0.1–1.9) | Ref -0.4 (-1.2, + 0.4) -0.1 (-1.0, + 0.8) | 0.082 0.047 |