0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Study |

Text-Message Reminders to Improve Sunscreen Use:  A Randomized, Controlled Trial Using Electronic Monitoring FREE

April W. Armstrong, MD; Alice J. Watson, MD, MPH; Maryanne Makredes, MD; Jason E. Frangos, MD; Alexandra B. Kimball, MD, MPH; Joseph C. Kvedar, MD
[+] Author Affiliations

Author Affiliations: Teledermatology Program, Department of Dermatology, University of California–Davis Health System, Sacramento (Dr Armstrong); and Center for Connected Health (Dr Watson) and Clinical Unit for Research Trials in Skin (Dr Kimball), Department of Dermatology (Drs Watson and Kimball), Massachusetts General Hospital; Departments of Internal Medicine, Beth Israel Deaconess Medical Center (Dr Makredes) and Brigham and Women's Hospital (Dr Frangos); Department of Dermatology, Harvard Medical School (Drs Kimball and Kvedar); and Center for Connected Health, Partners HealthCare System (Drs Watson and Kvedar), Boston.


Arch Dermatol. 2009;145(11):1230-1236. doi:10.1001/archdermatol.2009.269.
Text Size: A A A
Published online

Objective  To evaluate the effectiveness of cellular telephone text messaging as a reminder tool for improving adherence to sunscreen application.

Design  We conducted a randomized, controlled trial of the effect of an electronic text-message reminder system on adherence to sunscreen application. Adherence to daily sunscreen use was evaluated using a novel electronic monitoring device.

Setting  Participants were recruited from the general community.

Participants  Seventy participants constituted a volunteer sample from the general community. The inclusion criteria required participants to be 18 years or older, to own a cellular telephone with text-message features, and to know how to retrieve text messages.

Intervention  Half of the participants received daily text-message reminders via cellular telephone for 6 weeks, and the other half did not receive reminders. The text-message reminders consisted of 2 components: a “hook” text detailing daily local weather information and a “prompt” text reminding users to apply sunscreen.

Main Outcome Measure  The primary end point of the study was adherence to sunscreen application measured by the number of days participants applied sunscreen during the 6-week study period.

Results  All 70 participants completed the 6-week study. There were no statistically significant differences in baseline characteristics between the 2 study groups. At the end of the study period, the 35 participants who did not receive reminders had a mean daily adherence rate of 30.0% (95% confidence interval, 23.1%-36.9%). In comparison, the 35 participants who received daily text-message reminders had a mean daily adherence rate of 56.1% (95% confidence interval, 48.1%-64.1%) (P < .001). Among the participants in the reminder group, 24 (69%) reported that they would keep using the text-message reminders after the study, and 31 (89%) reported that they would recommend the text-message reminder system to others. Subgroup analysis did not reveal any significant demographic factors that predicted adherence.

Conclusions  Despite awareness of the benefits of sunscreen, adherence is low, even in this population, for whom adherence was knowingly monitored. Short-term data demonstrate that using existing cellular telephone text-message technology offers an innovative, low-cost, and effective method of improving adherence to sunscreen application. The use of ubiquitous communications technology, such as text messaging, may have implications for large-scale public health initiatives.

Trial Registration  clinicaltrials.gov Identifier: NCT00535769

Figures in this Article

The use of sunscreen is a preventive health behavior aimed at reducing the risk of developing skin cancers.14 The rates of skin cancer have increased steadily during the past 4 decades, and skin cancer now accounts for 1 in 3 cancer cases worldwide.5 In the United States, more than 1 million new cases of skin cancer are diagnosed each year, exceeding all other types of cancers combined.5 Exposure to UV light is strongly associated with the development of most skin cancers, especially basal cell carcinomas, squamous cell carcinomas, and some types of melanomas.68 Many of these cases could be prevented if the population took consistent measures to avoid direct sunlight by wearing protective clothing and applying sunscreen.3,913

During the past 30 years, steadfast patient education efforts have increased public awareness of the harmful effects of excessive sun exposure as well as the benefits of using sunscreen.1416 Nevertheless, only about 20% of adults in the United States report regular use of sunscreens, and many do not use sufficient amounts of sunscreen, according to the National Health and Nutrition Examination Survey.17 This persistent discrepancy between many individuals' awareness of evidence-based recommendations and their subsequent lack of adherence is not well understood.

Although adherence to oral medications used in the treatment of chronic diseases averages 50%,18,19 adherence to topical treatments averages only 20% to 30%.2024 The frequently cited barriers to regular sunscreen use include forgetting, inconvenience of application, and a desire to be tanned. Individuals who exhibit high adherence to sun-protective behaviors, including sunscreen use and wearing sun-protective clothing, are more likely to have been counseled by a physician about sun safety.11,2527 Given the enormous number of people at risk for skin cancer, improving adherence to sunscreen application demands a cost-effective solution.

During the past decade, the increasing availability of affordable consumer-grade technologies has made the cellular telephone virtually ubiquitous. As of 2008, more than 80% of the US population owned a cellular telephone, and approximately 28 billion text messages were sent every month.28 Appropriate leveraging of these novel communication tools may enable more effective delivery of health care education and increase the feasibility of public health interventions on a population-wide scale.

In this study, we used cellular telephone text messaging as a reminder tool to affect participants' preventive health behavior. By using an electronic monitoring device, we were able to assess the effect of text-message reminders on participants' adherence to daily sunscreen application. The long-term goal of this research is to implement effective strategies that will increase adherence to daily sunscreen application in the general population. The primary end point of the study was daily adherence to sunscreen application; secondary end points included weekly adherence rates, subgroup analysis examining whether certain demographic factors were predictive of adherence, and participants' attitudes toward the reminders.

ADHERENCE TECHNOLOGY DEVELOPMENT

We developed an electronic adherence monitor for topical agents that was adaptable to tubes of varying sizes (Figure 1). Each time the cap on the tube was removed, the electronic monitor sent an SMS (Short Message Service) message in real time to a secured, central data repository, where the dates and times of openings were recorded. The electronic monitors underwent a 2-month technology testing and evaluation process, during which any device malfunctions were addressed before study initiation.

Place holder to copy figure label and caption
Figure 1

Electronic monitoring of sunscreen use and text-message reminders to improve adherence. A, Electronic adherence monitor. B, Example of a text-message reminder.

Graphic Jump Location
STUDY DESIGN AND TRIAL ORGANIZATION

We conducted a randomized, controlled trial of the effect of an electronic text-message reminder system on adherence to sunscreen application. This study was approved by the Institutional Review Board at Massachusetts General Hospital and Brigham and Women's Hospital. Participants were recruited from the general population in the Boston area. Specifically, advertisements were placed in the major local newspapers as well as the Web site Craigslist. The inclusion criteria required participants to be 18 years or older, to own a cellular telephone with text-message features, and to demonstrate the ability to retrieve text-messages. Seventy participants (Figure 2) were compensated nominally for their involvement in the study.

Place holder to copy figure label and caption
Figure 2

Flow diagram of participant progress through the randomized trial.

Graphic Jump Location

All 70 participants were asked to apply sunscreen daily for 6 weeks in the autumn of 2007. Autumn was defined as September 1 through November 30, according to the standard definition for the meteorological autumn for the northern hemisphere.29 All participants had an initial visit that lasted approximately 80 minutes in which the study staff explained about and showed the participants how to dispense the study sunscreen. Furthermore, the participants were asked to demonstrate their ability to dispense sunscreen using the study device. All participants were also given written instructions regarding the proper frequency of sunscreen application and how much to apply (Table 1). Participants' adherence was captured in real time using transmitting electronic monitors. A 1:1 simple, nonstratified randomization scheme was generated using GraphPad randomization software (San Diego, California). Randomization sequences were concealed within numbered envelopes until interventions were assigned. Half the participants received daily text-message reminders via cellular telephones, and the other half did not receive reminders (control participants). With a sample size of 35 participants in each arm, the study had 80% power to detect a 15% difference in adherence between the reminder and control groups, assuming a standard deviation of 0.25.

Table Graphic Jump LocationTable 1 Instructions for Study Participants

The text-message reminders consisted of 2 components: a “hook” text detailing daily local weather information and a “prompt” text reminding users to apply sunscreen. For example, a reminder message would read, “Wed. Partly Cloudy. High 70, Low 55. Your skin would appreciate some sunscreen today.” The reminders were sent daily between 6:30 AM and 7 AM, and a variety of “prompt” messages were used to help maintain participant interest. At the end of the study, we surveyed participants in the reminder group regarding their attitudes toward text-message reminders.

We also collected weather information in the Boston area during the study period and categorized the daily weather patterns as “sunny,” “cloudy,” and “rainy.” If 2 weather patterns were present within the same day (sunny and then cloudy), we recorded the weather pattern that persisted for greater than 50% of the time between 7 AM and 7 PM.

STUDY END POINTS AND STATISTICAL ANALYSIS

The primary end point of the study was adherence to sunscreen application measured by the number of days participants applied sunscreen during the 6-week study period. The adherence rate for a given participant was defined as the number of days that the participant applied sunscreen divided by the total number of days of the study. Secondary end points were (1) weekly adherence between the 2 study groups, (2) subgroup analysis examining whether certain demographic factors were predictive of adherence, and (3) participants' attitudes toward the reminders. All statistical analyses were performed based on intention-to-treat analysis using SAS statistical software, version 9.1 (SAS Inc, Cary, North Carolina). The normality of the primary end point was examined separately in each group. We deemed the data to be normally distributed in the reminder and control groups based on the Wilk-Shapiro test for normality. A 2-tailed t test was performed to examine the difference in the mean number of days participants were adherent between the 2 groups.

Demographic factors of sex, race, educational level, and age were analyzed in a subgroup analysis to determine whether they were predictive of adherence. Within the no-reminder and reminder arms, participants were dichotomized according to their number of “adherent” days along the medians of each arm (no-reminder arm at 11 days and reminder arm at 21 days). Those at or above the median were defined as having higher adherence, and those below the median were defined as having lower adherence. Sex was dichotomized into men and women; race was categorized as white, black, Asian, and Hispanic; educational level was dichotomized as college education or below college education. In addition, χ2 tests were performed relating adherence to sex, race, or educational level. Age was used as a continuous variable in a t test examining the relationship between adherence and age.

The baseline demographic characteristics of the study population are shown in Table 2. The mean age of participants was 33.6 years (age range, 18-72 years), 49 were women (70%), 34 identified themselves as white (49%), and 56 had 1 or more years of college education (80%). Data on sun-protective behaviors were collected from all participants at baseline, including frequency of staying in the shade, frequency of wearing broad-brimmed hats, frequency of wearing long-sleeved shirts, frequency of sunscreen application, SPF (sun protection factor) of sunscreen used, and number of sunburns in the past year. There were no statistically significant differences in baseline demographic characteristics or sun-protective behaviors between the 2 study groups.

Table Graphic Jump LocationTable 2 Baseline Characteristics of the Study Populationa

At the end of the 42-day (6-week) study period, the control group had a mean adherence of 12.6 days (95% confidence interval [CI], 9.7-15.5) of sunscreen application, which corresponded to a 30.0% (23.1%-36.9%) daily adherence rate. In comparison, the group that received daily reminder messages had a mean adherence of 23.6 days (95% CI, 20.2-26.9) and a daily adherence rate of 56.1% (48.1%-64.1%). A 2-sample t test with equal variances assessing the difference in daily adherence between these 2 groups yielded a P value of less than .001.

The weekly adherence rates in the reminder and control groups are shown in Figure 3. During week 1, the mean adherence rates were similar between the 2 groups: 50% in the control group and 58% in the reminder group (P = .21). However, the mean adherence rates between the 2 groups began to differ significantly in week 2 (P = .01), and this difference persisted throughout the remainder of the study (P < .001 in weeks 3-6).

Place holder to copy figure label and caption
Figure 3

Mean weekly adherence rates. Error bars indicate standard error of the mean.

Graphic Jump Location

Adherence data were also stratified based on the 3 predominant types of daily weather patterns—sunny, cloudy, and rainy. After adjusting for the daily weather conditions, we compared the percentage of participants who were adherent to daily sunscreen application between the 2 study arms (Figure 4). During the 8 rainy days of the study period, a mean of 13.3 of the participants in the reminder group (38%) and 3.2 in the control group (9%) were adherent to daily sunscreen application (P < .001). On the 31 cloudy days, a mean of 19.3 of the reminder participants (55%) and 10.5 of the control participants (30%) were adherent (P < .001). Finally, during the 17 sunny days, a mean of 23.5 of the reminder participants (67%) and 14.4 of the control participants (41%) were adherent to sunscreen application (P < .001).

Place holder to copy figure label and caption
Figure 4

Adherence rates stratified by weather. P <.001 for all comparisons.

Graphic Jump Location

We also investigated whether weather conditions affected the adherence rate after adjusting for the reminder intervention. A Mantel-Haenszel χ2 test demonstrated that the weather conditions (rainy, cloudy, and sunny) were significantly associated with the adherence rate after adjusting for the reminder intervention (P < .001).

Subgroup analysis revealed that, in the control group, no significant relationship was found between adherence and sex (P = .52), race (P = .17), educational level (P = .77), or age (P = .64). Similarly, in the reminder group, no significant relationships were identified between adherence and sex (P = .80), race (P = .76), educational level (P = .58), or age (P = .24).

In a poststudy survey, the participants from both comparison arms were asked to recall their frequency of sunscreen application based on a 5-point scale (0, never used sunscreen; 1, forgot to apply ≥3 times per week; 2, forgot to apply 1-2 times per week; 3, forgot to apply 1-2 times per month; and 4, always remembered). The mean (SD) frequency of sunscreen application recalled by participants in the reminder group was 2.42 (0.95); for the control group, the mean (SD) was 2.14 (1.17) (P = .44 by the Wilcoxon rank-sum test).

Participants in the reminder group were also asked to report their opinions about the extent to which the text-message reminder system improved their adherence to sunscreen application. On a scale of 0 to 10 (0, not useful at all; 10, most useful), the mean (SD) rating for the usefulness of the text-message reminders was 8.31 (1.99). Among participants in the reminder group, 24 (69%) reported that they would like to continue using the text-message reminders as a way of improving adherence, and 31 (89%) reported that they would recommend the text-message reminder system to others.

Although sunscreen use is recommended as a preventive health behavior against sunburns and the development of certain types of skin cancers,10,11,30 data from a nationally administered questionnaire estimated that only 20% of the US adult population uses sunscreen regularly.17 To our knowledge, our study is the first to electronically monitor daily sunscreen adherence. We demonstrated a mean adherence rate of 30% in the control group, which is slightly higher than the 20% reported sunscreen adherence rate in the general US population and could be attributed to the participants' awareness of being monitored during the study.17

We used cellular text messaging as a reminder strategy to improve adherence to sunscreen application. Participants who received text-message reminders were nearly twice as adherent to a regimen of daily sunscreen application compared with control participants who did not receive reminders. These differences in the adherence rates between the reminder and control groups remained significant after adjusting for daily weather patterns.

A closer examination of the weekly adherence data showed that the adherence rate between the 2 groups started to differ significantly by week 2 of the study, with this difference persisting throughout the remainder of the study. In the control group, the adherence rate continued to decrease throughout the study, with stabilization at approximately 20% adherence at the end of the study, whereas the adherence rate remained stable in the reminder group. Because participants knew that their adherence was monitored and were therefore more likely to be motivated than the general population to comply with sunscreen application, the rapid decline in the adherence rate in the control group is striking and suggests that true adherence in the wider population is likely even lower.

Although adherence rates in the control group decreased during the study, the reminder group maintained a relatively stable level of adherence. The data showed that a simple daily reminder could maintain adherence to sunscreen application during a 6-week study period, thereby encouraging sun-protective behavior on a short-term basis.

Results of the poststudy survey asking participants to recall their adherence rate revealed that the participants in both comparison arms overestimated their actual sunscreen adherence. The overestimation is especially large for participants in the control group, for whom the mean subjective estimation of adherence was approximately 70%, whereas the electronic monitors recorded a mean adherence rate of only 30%. This data corroborate with existing literature that patient recall about medication adherence is often unreliable.18

Several studies examining the use of text messaging in health care have found that text-message reminders improve outpatient clinic attendance,3135 encourage weight loss,36 provide support to diabetic patients,37 and serve as a useful system for critical value notification.38 The results of this study corroborate and extend findings from prior studies that text messages can promote behavioral changes. Cellular text messaging may be an effective reminder tool to promote preventive health behaviors or help individuals adhere to medication regimens for several reasons. In the United States, wireless network coverage is geographically widespread, and many wireless plans have become affordable for the general population. The portability of cellular telephones renders their owners readily accessible through a variety of communications media, and text messaging is a simple, low-cost, and immediate method of delivering reminders without the need for computers. More important, text messaging may be especially attractive to younger individuals, an important target population for development of positive preventive health habits.

It is relevant to note that, despite the ubiquity of cellular telephones, certain socioeconomic groups have a significantly lower rate of cellular telephone ownership compared with the rest of the US population, according to national survey data.39 Specifically, those who do not own a cellular telephone tend to be older, less educated, having lower income, or unemployed.39

The results of this study need to be interpreted in the context of the study design. The long-term benefit of this technology has not yet been demonstrated. This study lasted 6 weeks, and a longer follow-up period would be required to comment on the long-term effects of text-message reminders. However, it has been suggested that 21 to 42 days may be an adequate time frame to develop a new habit.40,41 Our study used text-message reminders to target forgetfulness, one of the primary reasons for nonadherence to sunscreen use. However, other reasons, such as concern about adverse effects or not understanding the benefits of using sunscreen, may also contribute to nonadherence. The participants were provided with sunscreen in this study, whereas individuals in the community would need to purchase sunscreen to practice this sun-protective behavior. In addition, although electronic monitors instantaneously transmitted information on the dates and times the sunscreen bottle was opened, they were not able to assess how much and where the sunscreen was applied. It is also theoretically possible that some participants might open and close the cap without actually applying the sunscreen. Finally, seasonality may play a part in the observed differences. We chose to conduct this study in the autumn and avoided seasons with excessively high or low sun exposure, such as the summer or winter. It is important to note that adherence to sunscreen application may be greater in the summer when people are more likely to engage in water-related and other outdoor recreational activities. Similarly, sunscreen adherence may be lower in the winter when some people are more likely to stay indoors. Therefore, had the trial been conducted in the summer or winter, the adherence rate for the control group might have been either higher or lower, respectively, than what was observed in this study.

Several technical lessons from this study are applicable to the future development of more effective monitoring and reminder methods to increase adherence. The strengths of the adherence monitors used in this study include objective and instantaneous capturing of adherence data and immediate data upload onto a secure server for viewing. These important features can be further explored in future studies. For example, reminders could be linked to adherence patterns such that the frequency or type of reminders that participants receive is adjusted in response to fluctuations in their individual adherence patterns. The monitor technology could also be improved in several ways to measure adherence more effectively. First, the size of the electronic monitor could be reduced to minimize the “monitoring effect.” Second, an electronic weight-sensing mechanism could be engineered in the device to measure dispensing of the medication.

The suggestions offered by study participants to improve reminder strategies could be grouped into 2 categories: customizing delivery time of the reminder text messages and personalizing the “hook” messages. Future efforts to use text-message reminders as a platform to increase adherence need to focus on designing ultra-compact adherence monitors as well as personalizing the delivery times and the “hook” messages. Moreover, the “prompt” component of the text messages will need to contain relevant instructions about how to take oral medication or apply topical agents. For example, text-message reminders could be sent to students during summer breaks or to people vacationing in sunny regions. The messages may be customized according to individual user preferences, such that the users would be able to choose the time of delivery and the content of the “hook” message (eg, weather report, stock quotes, sports statistics) that accompanies the reminder texts.

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 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

Correspondence: April W. Armstrong, MD, Teledermatology Program, Department of Dermatology, University of California–Davis Health System, 3301 C St, Ste 1400, Sacramento, CA 95816.

Accepted for Publication: June 23, 2009.

Author Contributions: Drs Armstrong, Watson, and Frangos had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis. Study concept and design: Armstrong, Watson, Makredes, Frangos, Kimball, and Kvedar. Acquisition of data: Armstrong, Makredes, Frangos, and Kimball. Analysis and interpretation of data: Armstrong, Watson, Makredes, Kimball, and Kvedar. Drafting of the manuscript: Armstrong and Watson. Critical revision of the manuscript for important intellectual content: Armstrong, Watson, Makredes, Frangos, Kimball, and Kvedar. Statistical analysis: Armstrong and Kimball. Obtained funding: Watson and Kvedar. Administrative, technical, or material support: Makredes, Frangos, and Kimball. Study supervision: Watson, Kimball, and Kvedar.

Financial Disclosure: None reported.

Funding/Support: 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. 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.

Role of the Sponsors: The sponsors played no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; and preparation, review, or approval of the manuscript.

Moloney  FJCollins  SMurphy  GM Sunscreens: safety, efficacy and appropriate use. Am J Clin Dermatol200233185191
PubMed
Moyal  DDFourtanier  AM Broad-spectrum sunscreens provide better protection from solar ultraviolet-simulated radiation and natural sunlight-induced immunosuppression in human beings. J Am Acad Dermatol2008585(suppl 2)S149S154
PubMed
Gasparro  FPMitchnick  MNash  JF A review of sunscreen safety and efficacy. Photochem Photobiol1998683243256
PubMed
Vainio  HMiller  ABBianchini  F An international evaluation of the cancer-preventive potential of sunscreens. Int J Cancer2000885838842
PubMed
Rigel  DFriedman  RDzubow  LMReintgen  DMarks  RBystryn  JC Cancer of the Skin.  Philadelphia, PA: WB Saunders Co; 2004
Epstein  JH Photocarcinogenesis: a review. Natl Cancer Inst MonogrDec 1978501325
PubMed
Urbach  FForbes  PDDavies  REBerger  D Cutaneous photobiology: past, present and future. J Invest Dermatol1976671209224
PubMed
Kopf  AWKripke  MLStern  RS Sun and malignant melanoma. J Am Acad Dermatol1984114, pt 1674684
PubMed
Thompson  SCJolley  DMarks  R Reduction of solar keratoses by regular sunscreen use. N Engl J Med19933291611471151
PubMed
Task Force on Community Preventive Services Recommendations to prevent skin cancer by reducing exposure to ultraviolet radiation. Am J Prev Med2004275467470
PubMed
Saraiya  MGlanz  KBriss  PA  et al Interventions to prevent skin cancer by reducing exposure to ultraviolet radiation: a systematic review. Am J Prev Med2004275422466
PubMed
Green  AWilliams  GNeale  R  et al Daily sunscreen application and betacarotene supplementation in prevention of basal-cell and squamous-cell carcinomas of the skin: a randomised controlled trial [published correction appears in Lancet. 1999;354(9183):1038]. Lancet19993549180723729
PubMed
Ley  RDReeve  VE Chemoprevention of ultraviolet radiation-induced skin cancer. Environ Health Perspect1997105(suppl 4)981984
PubMed
Swindler  JELloyd  JRGil  KM Can sun protection knowledge change behavior in a resistant population? Cutis2007796463470
PubMed
Walkosz  BVoeks  JAndersen  P  et al Randomized trial on sun safety education at ski and snowboard schools in western North America. Pediatr Dermatol2007243222229
PubMed
Hornung  RLHansen  LASharp  LKPoorsattar  SPLipsky  MS Skin cancer prevention in the primary care setting: assessment using a standardized patient. Pediatr Dermatol2007242108112
PubMed
Bergman  HArmstrong  AKvedar  JWatson  A Predicting harmful sun behaviors: results from a national survey. Paper presented at: Canadian Dermatology Association 83rd Annual Meeting; June27 , 2008; Montreal, Quebec, Canada
Haynes  RBMcDonald  HGarg  AXMontague  P Interventions for helping patients to follow prescriptions for medications. Cochrane Database Syst Rev20022CD000011
PubMed
Sackett  DHaynes  RBGibson  ESTaylor  DWRoberts  RSJohnson  AL Patient compliance with antihypertensive regimens. Patient Couns Health Educ1978111821
PubMed
Krejci-Manwaring  JTusa  MGCarroll  C  et al Stealth monitoring of adherence to topical medication: adherence is very poor in children with atopic dermatitis. J Am Acad Dermatol2007562211216
PubMed
Krejci-Manwaring  JMcCarty  MACamacho  F  et al Adherence with topical treatment is poor compared with adherence with oral agents: implications for effective clinical use of topical agents. J Am Acad Dermatol2006545(suppl)S235S236
PubMed
Hodari  KTNanton  JRCarroll  CLFeldman  SRBalkrishnan  R Adherence in dermatology: a review of the last 20 years. J Dermatolog Treat2006173136142
PubMed
Balkrishnan  RCarroll  CLCamacho  FTFeldman  SR Electronic monitoring of medication adherence in skin disease: results of a pilot study. J Am Acad Dermatol2003494651654
PubMed
Feldman  SRCamacho  FTKrejci-Manwaring  JCarroll  CLBalkrishnan  R Adherence to topical therapy increases around the time of office visits. J Am Acad Dermatol20075718183
PubMed
Boggild  AKFrom  L Barriers to sun safety in a Canadian outpatient population. J Cutan Med Surg200374292299
PubMed
Dadlani  COrlow  SJ Planning for a brighter future: a review of sun protection and barriers to behavioral change in children and adolescents. Dermatol Online J. 2008;14(9):1. http://dermatology.cdlib.org/149/commentaries/sunprotection/dadlani.html. Accessed January 8, 2009
Kirsner  RSParker  DFBrathwaite  NThomas  ATejada  FTrapido  EJ Sun protection policies in Miami Dade County Public Schools: opportunities for skin cancer prevention. Pediatr Dermatol2005226513519
PubMed
 CTIA, The Wireless Association.  Wireless facts: year-end figures. http://www.ctia.org/media/industry_info/index.cfm/AID/10323. Accessed April 19, 2008
National Weather Service glossaryhttp://www.crh.noaa.gov/crh/. Accessed August 3, 2007
Diffey  BL When should sunscreen be reapplied? J Am Acad Dermatol2001456882885
PubMed
Geraghty  MGlynn  FAmin  MKinsella  J Patient mobile telephone “text” reminder: a novel way to reduce non-attendance at the ENT out-patient clinic [published online ahead of print May 1, 2007]. J Laryngol Otol20081223296298
PubMeddoi:10.1017/S0022215107007
Koshy  ECar  JMajeed  A Effectiveness of mobile-phone short message service (SMS) reminders for ophthalmology outpatient appointments: observational study. BMC Ophthalmol200889
PubMeddoi:10.1186/1471-2415-8-9
Downer  SRMeara  JGDa Costa  ACSethuraman  K SMS text messaging improves outpatient attendance. Aust Health Rev2006303389396
PubMed
Foley  JO’Neill  M Use of mobile telephone short message service (SMS) as a reminder: the effect on patient attendance. Eur Arch Paediatr Dent20091011518
PubMed
Fairhurst  KSheikh  A Texting appointment reminders to repeated non-attenders in primary care: randomised controlled study. Qual Saf Health Care2008175373376
PubMed
Patrick  KRaab  FAdams  MA  et al A text message-based intervention for weight loss: randomized controlled trial. J Med Internet Res2009111e1
PubMeddoi:10.2196/jmir.1100
Waller  AFranklin  VPagliari  CGreene  S Participatory design of a text message scheduling system to support young people with diabetes. Health Informatics J2006124304318
PubMed
Park  HIMin  WKLee  W  et al Evaluating the short message service alerting system for critical value notification via PDA telephones. Ann Clin Lab Sci2008382149156
PubMed
Sullivan  NP Cell phones provide significant economic gains for low-income American households: a review of literature and data from two new surveys. http://newmillenniumresearch.org/archive/Sullivan_Report_032608.pdf. Accessed April 5, 2009
Burn  SA Installing a new habit and breaking an old one. http://www.stephanieburns.com/articles/article06_habit.asp. Accessed April 19, 2008
Nikolajsen  LJensen  TS Phantom limb pain. Br J Anaesth2001871107116
PubMed

Figures

Place holder to copy figure label and caption
Figure 1

Electronic monitoring of sunscreen use and text-message reminders to improve adherence. A, Electronic adherence monitor. B, Example of a text-message reminder.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2

Flow diagram of participant progress through the randomized trial.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3

Mean weekly adherence rates. Error bars indicate standard error of the mean.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4

Adherence rates stratified by weather. P <.001 for all comparisons.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1 Instructions for Study Participants
Table Graphic Jump LocationTable 2 Baseline Characteristics of the Study Populationa

References

Moloney  FJCollins  SMurphy  GM Sunscreens: safety, efficacy and appropriate use. Am J Clin Dermatol200233185191
PubMed
Moyal  DDFourtanier  AM Broad-spectrum sunscreens provide better protection from solar ultraviolet-simulated radiation and natural sunlight-induced immunosuppression in human beings. J Am Acad Dermatol2008585(suppl 2)S149S154
PubMed
Gasparro  FPMitchnick  MNash  JF A review of sunscreen safety and efficacy. Photochem Photobiol1998683243256
PubMed
Vainio  HMiller  ABBianchini  F An international evaluation of the cancer-preventive potential of sunscreens. Int J Cancer2000885838842
PubMed
Rigel  DFriedman  RDzubow  LMReintgen  DMarks  RBystryn  JC Cancer of the Skin.  Philadelphia, PA: WB Saunders Co; 2004
Epstein  JH Photocarcinogenesis: a review. Natl Cancer Inst MonogrDec 1978501325
PubMed
Urbach  FForbes  PDDavies  REBerger  D Cutaneous photobiology: past, present and future. J Invest Dermatol1976671209224
PubMed
Kopf  AWKripke  MLStern  RS Sun and malignant melanoma. J Am Acad Dermatol1984114, pt 1674684
PubMed
Thompson  SCJolley  DMarks  R Reduction of solar keratoses by regular sunscreen use. N Engl J Med19933291611471151
PubMed
Task Force on Community Preventive Services Recommendations to prevent skin cancer by reducing exposure to ultraviolet radiation. Am J Prev Med2004275467470
PubMed
Saraiya  MGlanz  KBriss  PA  et al Interventions to prevent skin cancer by reducing exposure to ultraviolet radiation: a systematic review. Am J Prev Med2004275422466
PubMed
Green  AWilliams  GNeale  R  et al Daily sunscreen application and betacarotene supplementation in prevention of basal-cell and squamous-cell carcinomas of the skin: a randomised controlled trial [published correction appears in Lancet. 1999;354(9183):1038]. Lancet19993549180723729
PubMed
Ley  RDReeve  VE Chemoprevention of ultraviolet radiation-induced skin cancer. Environ Health Perspect1997105(suppl 4)981984
PubMed
Swindler  JELloyd  JRGil  KM Can sun protection knowledge change behavior in a resistant population? Cutis2007796463470
PubMed
Walkosz  BVoeks  JAndersen  P  et al Randomized trial on sun safety education at ski and snowboard schools in western North America. Pediatr Dermatol2007243222229
PubMed
Hornung  RLHansen  LASharp  LKPoorsattar  SPLipsky  MS Skin cancer prevention in the primary care setting: assessment using a standardized patient. Pediatr Dermatol2007242108112
PubMed
Bergman  HArmstrong  AKvedar  JWatson  A Predicting harmful sun behaviors: results from a national survey. Paper presented at: Canadian Dermatology Association 83rd Annual Meeting; June27 , 2008; Montreal, Quebec, Canada
Haynes  RBMcDonald  HGarg  AXMontague  P Interventions for helping patients to follow prescriptions for medications. Cochrane Database Syst Rev20022CD000011
PubMed
Sackett  DHaynes  RBGibson  ESTaylor  DWRoberts  RSJohnson  AL Patient compliance with antihypertensive regimens. Patient Couns Health Educ1978111821
PubMed
Krejci-Manwaring  JTusa  MGCarroll  C  et al Stealth monitoring of adherence to topical medication: adherence is very poor in children with atopic dermatitis. J Am Acad Dermatol2007562211216
PubMed
Krejci-Manwaring  JMcCarty  MACamacho  F  et al Adherence with topical treatment is poor compared with adherence with oral agents: implications for effective clinical use of topical agents. J Am Acad Dermatol2006545(suppl)S235S236
PubMed
Hodari  KTNanton  JRCarroll  CLFeldman  SRBalkrishnan  R Adherence in dermatology: a review of the last 20 years. J Dermatolog Treat2006173136142
PubMed
Balkrishnan  RCarroll  CLCamacho  FTFeldman  SR Electronic monitoring of medication adherence in skin disease: results of a pilot study. J Am Acad Dermatol2003494651654
PubMed
Feldman  SRCamacho  FTKrejci-Manwaring  JCarroll  CLBalkrishnan  R Adherence to topical therapy increases around the time of office visits. J Am Acad Dermatol20075718183
PubMed
Boggild  AKFrom  L Barriers to sun safety in a Canadian outpatient population. J Cutan Med Surg200374292299
PubMed
Dadlani  COrlow  SJ Planning for a brighter future: a review of sun protection and barriers to behavioral change in children and adolescents. Dermatol Online J. 2008;14(9):1. http://dermatology.cdlib.org/149/commentaries/sunprotection/dadlani.html. Accessed January 8, 2009
Kirsner  RSParker  DFBrathwaite  NThomas  ATejada  FTrapido  EJ Sun protection policies in Miami Dade County Public Schools: opportunities for skin cancer prevention. Pediatr Dermatol2005226513519
PubMed
 CTIA, The Wireless Association.  Wireless facts: year-end figures. http://www.ctia.org/media/industry_info/index.cfm/AID/10323. Accessed April 19, 2008
National Weather Service glossaryhttp://www.crh.noaa.gov/crh/. Accessed August 3, 2007
Diffey  BL When should sunscreen be reapplied? J Am Acad Dermatol2001456882885
PubMed
Geraghty  MGlynn  FAmin  MKinsella  J Patient mobile telephone “text” reminder: a novel way to reduce non-attendance at the ENT out-patient clinic [published online ahead of print May 1, 2007]. J Laryngol Otol20081223296298
PubMeddoi:10.1017/S0022215107007
Koshy  ECar  JMajeed  A Effectiveness of mobile-phone short message service (SMS) reminders for ophthalmology outpatient appointments: observational study. BMC Ophthalmol200889
PubMeddoi:10.1186/1471-2415-8-9
Downer  SRMeara  JGDa Costa  ACSethuraman  K SMS text messaging improves outpatient attendance. Aust Health Rev2006303389396
PubMed
Foley  JO’Neill  M Use of mobile telephone short message service (SMS) as a reminder: the effect on patient attendance. Eur Arch Paediatr Dent20091011518
PubMed
Fairhurst  KSheikh  A Texting appointment reminders to repeated non-attenders in primary care: randomised controlled study. Qual Saf Health Care2008175373376
PubMed
Patrick  KRaab  FAdams  MA  et al A text message-based intervention for weight loss: randomized controlled trial. J Med Internet Res2009111e1
PubMeddoi:10.2196/jmir.1100
Waller  AFranklin  VPagliari  CGreene  S Participatory design of a text message scheduling system to support young people with diabetes. Health Informatics J2006124304318
PubMed
Park  HIMin  WKLee  W  et al Evaluating the short message service alerting system for critical value notification via PDA telephones. Ann Clin Lab Sci2008382149156
PubMed
Sullivan  NP Cell phones provide significant economic gains for low-income American households: a review of literature and data from two new surveys. http://newmillenniumresearch.org/archive/Sullivan_Report_032608.pdf. Accessed April 5, 2009
Burn  SA Installing a new habit and breaking an old one. http://www.stephanieburns.com/articles/article06_habit.asp. Accessed April 19, 2008
Nikolajsen  LJensen  TS Phantom limb pain. Br J Anaesth2001871107116
PubMed

Correspondence

CME
Also Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
Please click the checkbox indicating that you have read the full article in order to submit your answers.
Your answers have been saved for later.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 65

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Collections
PubMed Articles