A Digital Intervention to Educate Primary Care Providers to Perform Clinical Skin Examination for Melanoma in Underserved Patients

Abstract

Background: Skin cancer is the most common cancer in the U.S. and melanoma is the deadliest type. Family nurse practitioners (FNPs) commonly work as primary care providers (PCPs) to care for underserved patients who are at risk of melanoma, but PCPs generally have a low knowledge of melanoma and low likelihood of performing clinical skin examination (CSE) for those patients. The U.S. Preventative Services Task Force recommends that PCPs conduct a thorough skin examination during patient examinations to aid in early detection of suspicious skin lesions. There is little information on how PCPs learn about CSE for melanoma or perform it in practice for their underserved patients. Purpose/Aims: To provide a digital video intervention to educate PCPs including FNPs, about CSE for melanoma in underserved patients. CSE was defined as melanoma risk assessment, head-to-toe skin examination, and skin lesion assessment. Aims were to determine whether scores improved postintervention for 1) CSE knowledge, motivation, and skills and 2) self-reported CSE in practice. Methods: This quality improvement (QI) project targeted a healthcare organization in Southern Arizona that served homeless, low income, Medicaid-eligible, Native American, migrant farmworkers, and rural populations. Recruited were 14 PCPs working in the organization’s six regional clinics. The Information-Motivation-Behavioral Skills (IMB) model guided the project. Participants completed an online pretest measuring CSE information (melanoma in underserved populations, risk factors), motivation (for conducting CSE), behavior skills (for CSE) and behavior change outcomes for CSE (number performed in practice). The intervention consisted of four brief videos previously tested for feasibility, each less than seven minutes long and delivered digitally. The videos covered melanoma in underserved populations and the CSE components. Participants completed an identical online posttest two weeks postintervention. Results: All data were self-reported and analyzed using descriptive statistics. Six PCPs recruited (42.9%) participated: all were FNPs with a mean age of 39.83 years and a mean of 3.33 years of primary care experience. Scores for information, motivation and behavioral skills all improved from pretest to posttest: the proportion of correct scores for information improved from 62.5% to 81.2%. Mean scores for motivation improved from 3.81 to 3.98 (1=strongly disagree, 5=strongly agree). Mean percent of correct responses for head-to-toe skin examination steps improved from 16.7% to 50%. Overall mean percent of correct answers for skin lesion assessment improved from 70.8% to 71.9%. The mean number of CSEs performed in practice increased from 1.33 to 9.50. Conclusion: The results show potential to provide a video intervention within this and other organizations to improve FNPs’ CSE skills and motivate FNPs to use those skills while caring for underserved patients. FNPs may need further instruction on skin lesion assessment. Future research directions include conducting a randomized controlled trial to determine the effect of the intervention on CSE outcomes and to further inform evidence-based practice for FNPs. Future directions considered by the organization are 1) showcasing the videos at upcoming provider meetings and 2) integrating the videos into PCP orientations. Future directions for education include securing continuing education credits for the intervention.