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Strategies to Improve Adherence to Skin Self-examination and Other Self-management Practices in People at High Risk of MelanomaA Scoping Review of Randomized Clinical Trials

To identify the key insights or developments described in this article
1 Credit CME
Key Points

Question  What evidence exists on adherence to self-management practices among people at high risk of melanoma in trials of melanoma self-monitoring practices?

Findings  This scoping review of 18 randomized clinical trials, ranging in size from 40 to 724 participants, found that the most common adherence strategies used targeted trial design (limiting eligibility, theory-based intervention) and participant support (educational materials). There were no strategies reported for supporting underserved groups (eg, people who are socioeconomically disadvantaged, have low health literacy, non-English speakers, or older adults) to adhere to self-monitoring practices, limited strategies targeting provider (referring to both clinicians and researchers) adherence, and underutilization of patient behavioral support strategies, such as reminders and motivational tools; reporting on nonadherence was limited and rarely included in implementation recommendations.

Meaning  Clearer definition, measurement, reporting, and discussion of intervention adherence in trial settings is needed to successfully guide implementation into practice.


Importance  Adherence, both in research trials and in clinical practice, is crucial to the success of interventions. There is limited guidance on strategies to increase adherence and the measurement and reporting of adherence in trials of melanoma self-management practices.

Objective  This scoping review aimed to describe (1) strategies to improve adherence to self-management practices in randomized clinical trials of people at high risk of melanoma and (2) measurement and reporting of adherence data in these trials.

Evidence Review  Four databases, including MEDLINE, Embase, CENTRAL, and CINAHL, were searched from inception to July 2022. Eligible studies were randomized clinical trials of self-monitoring interventions for early detection of melanoma in people at increased risk due to personal history (eg, melanoma, transplant, dysplastic naevus syndrome), family history of melanoma, or as determined by a risk assessment tool or clinical judgment.

Findings  From 939 records screened, 18 eligible randomized clinical trials were identified, ranging in size from 40 to 724 participants, using a range of adherence strategies but with sparse evidence on effectiveness of the strategies. Strategies were classified as trial design (n = 15); social and economic support (n = 5); intervention design (n = 18); intervention and condition support (n = 10); and participant support (n = 18). No strategies were reported for supporting underserved groups (eg, people who are socioeconomically disadvantaged, have low health literacy, non-English speakers, or older adults) to adhere to self-monitoring practices, and few trials targeted provider (referring to both clinicians and researchers) adherence (n = 5). Behavioral support tools included reminders (n = 8), priority-setting guidance (n = 5), and clinician feedback (n = 5). Measurement of adherence was usually by participant report of skin self-examination practice with some recent trials of digital interventions also directly measuring adherence to the intervention through website or application analytic data. Reporting of adherence data was limited, and fewer than half of all reports mentioned adherence in their discussion.

Conclusions and Relevance  Using an adaptation of the World Health Organization framework for clinical adherence, this scoping review of randomized clinical trials identified key concepts as well as gaps in the way adherence is approached in design, conduct, and reporting of trials for skin self-examination and other self-management practices in people at high risk of melanoma. These findings may usefully guide future trials and clinical practice; evaluation of adherence strategies may be possible using a Study Within A Trial (SWAT) framework within host trials.

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Article Information

Accepted for Publication: December 16, 2022.

Published Online: March 1, 2023. doi:10.1001/jamadermatol.2022.6478

Corresponding Author: Deonna M. Ackermann, MPH, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Edward Ford Building, Room 301A, Sydney, New South Wales 2006, Australia (deonna.ackermann@sydney.edu.au).

Author Contributions: Dr Ackermann had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Ackermann, Janda, Turner, Hersch, Bell.

Acquisition, analysis, or interpretation of data: Ackermann, Bracken, Turner, Hersch, Drabarek, Bell.

Drafting of the manuscript: Ackermann, Janda, Bell.

Critical revision of the manuscript for important intellectual content: All authors.

Obtained funding: Ackermann, Hersch, Bell.

Administrative, technical, or material support: Ackermann, Bell.

Supervision: Bracken, Janda, Turner, Hersch, Bell.

Conflict of Interest Disclosures: Dr Janda reported grants from the National Health and Medical Research Council (NHMRC) outside the submitted work. Dr Hersch reported grants from NHMRC (Early Career Fellowship) outside the submitted work. No other disclosures were reported.

Funding/Support: This research project is funded by an NHMRC Project grant (1163054) and a University of Sydney Research Accelerator (SOAR) Prize. Dr Bell is supported by an NHMRC Investigator Grant (1174523). Dr Hersch is supported by a Cancer Institute New South Wales Early Career Fellowship (2020/ECF1158). Dr Ackermann is supported by an NHMRC Postgraduate Scholarship (2014163).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the submitted work; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

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