Health Promotion International Advance Access originally published online on November 1, 2004
Health Promotion International 2004 19(4):437-444; doi:10.1093/heapro/dah405
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
HEALTH PROMOTION INTERNATIONAL Vol. 19. No. 4 © Oxford University Press 2004; All rights reserved.
Acceptability and feasibility of a community-based screening programme for melanoma in Australia
1Department of Community and Behavioral Health, College of Public Health, University of Iowa, USA, 2Information and Communications Division, Commonwealth Department of Health and Ageing, Australia, 3Queensland Cancer Fund, Brisbane, Queensland, Australia, 4Queensland Health, Brisbane, Queensland, Australia, 5School of Public Health, Queensland University of Technology and Queensland Cancer Fund, Brisbane, Queensland, Australia, 6School of Health and Rehabilitation Sciences, Department of Physiotherapy, University Queensland, Queensland, Australia and 7School of Population Health, University of Queensland, Queensland, Australia
Address for correspondence: J. F. Aitken, Queensland Cancer Fund, PO Box 201, Spring Hill, Queensland 4004, Australia E-mail: joannea{at}qcfepi.org.au
 |
SUMMARY |
|---|
 TOP SUMMARY INTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
The evaluation of a community-based screening programme for melanoma (SkinWatch) in 18 regional communities (total adult population >30 years 63 035) in Queensland, Australia is described. The aim of the SkinWatch programme was to promote whole-body skin screening for melanoma by primary care physicians. The programme included community education, education and support for local medical practitioners and open-access skin screening clinics. Programme delivery was achieved through assistance of local volunteers. All programme activities and resources were recorded for process evaluation. A baseline telephone survey (n = 3110) and a telephone survey four months after programme launch (n = 680) assessed community awareness of the SkinWatch programme and, 37 face-to-face interviews with community members, doctors and community leaders were conducted to assess satisfaction with the programme. A sample of 1043 of 16 383 residents who attended the skin screening clinics provided as part of the programme were interviewed to assess reasons for attending, and positive and negative aspects of SkinWatch programme. Community awareness of the SkinWatch programme increased by over 30% (p < 0.001) within four months of the start of the programme. Interview participants described the SkinWatch programme as a useful service for the communities and 90% stated they would revisit the clinics. A total of 43% of all attendees were over 50 years old, and nearly 50% were men. These findings demonstrate the acceptability and feasibility of a community-based screening programme for melanoma in rural areas. Volunteers were instrumental in increasing community ownership of and involvement in the SkinWatch programme.
Key words: community-based melanoma screening trial; process evaluation; volunteers
|
INTRODUCTION |
|---|
|
TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
Melanoma is an invasive cancer of the skin whose incidence has increased in recent decades. About 54 200 new cases of melanoma are expected to occur in 2003 in the US and about 7600 deaths from melanoma have been estimated for the same year (Jemal et al., 2003
). In Australia, 8531 new cases of melanoma were recorded in 2000 within a population of just over 19 000 000 [Australian Institute of Health and Welfare (AIHW), 2003]. Melanoma is potentially curable if the tumour is detected and treated at an early stage (Rigel et al., 2000). In theory, screening for melanoma by whole-body skin examination may achieve earlier diagnosis and improve survival, however, no randomized trials have been completed and there is no conclusive evidence that population screening for melanoma actually reduces mortality in practice (Elwood et al., in press).
The initial phase of a randomized controlled trial of a community-based screening programme for melanoma (the Melanoma Screening Trial, MST) has recently been conducted in Queensland, Australia, involving a total of 63 035 adults (
30 years) in 18 regional and rural communities (Aitken et al., 2002). Nine of the 18 communities were randomized to receive the melanoma screening programme (SkinWatch), the remaining nine communities comprised the control group. Within the intervention communities, the aim of the SkinWatch programme was to increase community participation in skin screening by medical practitioners working in primary care. This is the first large-scale community-based melanoma screening intervention yet to be undertaken in Australia or elsewhere.
A number of community-based trials of health promotion programmes have been completed in recent years [e.g. (COMMIT, 1995a; COMMIT, 1995b; Luepker et al., 2000; Hancock et al., 2001], in which the interventions were less effective than expected in achieving behavioural change. It has been suggested that a systematic presentation of all intervention components and an evaluation of their implementation (process evaluation) would allow for a better understanding of outcomes and criteria for success or failure of community-based trials (Altman, 1986; Koepsell et al., 1992; McKinlay, 1996; Sanson-Fisher et al., 1996; Nutbeam, 1998). Such an evaluation should include: (1) assessment of the delivery of the intervention (including whether the intervention had been implemented as intended, whether all subjects received the same intensity of the intervention and barriers to implementation); (2) its level of penetration; (3) the effectiveness of the intervention and individual materials in communicating key messages; and (4) whether there were competing programmes or activities that could have affected the intervention's success (Hawe, 1996; McKinlay, 1996).
The aim of this study was to outline the key components of the SkinWatch programme, to systematically evaluate the delivery of the programme and to describe the key role of volunteers, the delivery and reach of the programme, and appraisal of the programme by community members and local doctors.
|
METHODS |
|---|
|
TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
Nine communities were randomized to receive the SkinWatch melanoma screening programme (total adult population
30 years of 35 058) and nine communities (total adult population 30 years of 27 977) served as control communities.
Outcome measures
The three-year SkinWatch melanoma screening programme was designed as an integrated, community-based intervention whose primary purpose was to promote whole-body skin examination by medical practitioners, defined as visual examination of the skin, excluding areas covered by underwear, for early signs of skin cancer. The programme also encouraged whole-body skin self-examination and presentation of suspicious lesions to doctor.
The SkinWatch programme had three main components: a community education component, an education and support component for medical practitioners and the provision of free skin screening services. The goal of the intervention was that 60% of residents >30 years would receive a whole-body skin examination within three years.
Community education component
The community education component aimed to provide accurate information about skin cancer and skin screening for community members.
Community education materials
A self-help guide on skin examination and melanoma risk factors (the SkinBook) was delivered, unaddressed, to all households within the selected communities and promoted through local newspaper advertisements and posters. A stand holding brochures (surgery resource) was placed in all local doctors' waiting rooms to facilitate patient initiated discussion about early detection of melanoma and skin examination.
These written materials underwent two rounds of consumer focus group testing; were tested for readability [National Institute of Health (NIH), readability [National Institute of Health (NIH), 1982] and underwent a review by two expert national panels to assess face validity, acceptability and style. To test the reach of non-addressed mail, the SkinBook was delivered to the mailboxes of 70 randomly selected households outside the trial areas. Residents of these 70 households were later contacted by telephone and surveyed about who had been reached by the SkinBook, its contents and suggestions for improvements.
The household residents and the scientific panel recommended the addition of photographs of melanomas in the SkinBook. Men were reached by unaddressed mail less frequently than were women. Consequently, photographs were added to the SkinBooks and the SkinBooks were also placed at important community delivery points where men could easily access them (shops, hard ware stores, libraries, pubs and banks).
Media campaign
A media campaign for local newspapers was developed and implemented. This included press releases about the melanoma screening programme, paid advertorials, advertisements signalling the delivery of the SkinBook and other programme activities, advice columns endorsed by local doctors, and testimonials. In order to minimize contamination across communities, television was not used.
Volunteer recruitment and activities
A critical element within the SkinWatch trial was the recruiting and training of a champion within each community, the local Volunteer SkinWatch Coordinator (VSC) (Levine, 1994; Rogers, 1995). All VSC's received a manual, which included programme strategies, a media kit, suggested SkinWatch activities, and reporting forms and participated in a two-day training workshop. The VSC's served as a liaison officer between the community and the research team, to coordinate and deliver local SkinWatch activities. These activities included SkinWatch weeks, information evenings, media presentations and public education seminars.
Evaluation of the community education component
The implementation of all SkinWatch activities were documented through postal delivery records; a record of the number of community seminars (including the number sex and age of participants) given by the VSCs or their delegates; records of placement date and refilling of surgery resources; a record of media activity; and a record of all other SkinWatch activities initiated by the VSC and other groups in the community.
Community awareness
A baseline telephone survey prior to the launch of the intervention was conducted amongst 3110 randomly selected residents of all 18 communities (Janda et al., 2004). Community awareness of the SkinWatch programme was assessed by a second telephone survey four months after the programme launch. In four intervention communities, 170 interviews were conducted for a total sample of 680 (with equal numbers of men and women). Questions elicited overall awareness of SkinWatch; knowledge about the key messages of the SkinWatch programme; prompted recognition of various elements of the community education programme (SkinBook, SkinBook Poster, GP surgery resource, media presentations about SkinWatch); and participants' socio-demographic information.
Acceptability of, and community satisfaction with, the programme
Approximately 12 months after the start of the three-year intervention, consultants invited 49 key leaders (including mayors, directors of nursing from local hospitals and community club representatives) from a sample of five intervention communities to participate in semi-structured face-to-face interviews to assess the acceptability of the SkinWatch programme and satisfaction with the programme delivery. A total of 37 (75%) interviews were completed.
Medical practitioner education and support component
The aim of the medical practitioner education and support programme was to inform doctors of the SkinWatch programme, its potential impact on their practices, to improve doctors' skills in early diagnosis and management of melanoma, and to encourage doctors to promote the SkinWatch messages to patients. All medical practitioners working in primary care within hospital settings or in private practice were invited to a formal presentation of the SkinWatch programme at which they received an information package. Doctors received regular mailed updates on the programme and twice yearly telephone calls. Doctors were again visited during the second year of the programme for an update and exchange of information through in-depth interviews.
Information package for medical practitioners
The information material for medical practitioners contained a flip-chart, which outlined clinical guidelines for the diagnosis and management of melanoma, interpretation of histopathology reports, information on patient communication, a flowchart for conducting skin examinations (Del Mar and Green, 1995), and a collection of abstracts of 11 articles on malignant melanoma. All materials were developed with and reviewed by an expert advisory group of medical practitioners.
Comprehensive self-paced education programme on diagnosis and management of melanoma for medical practitioners
A self-paced educational programme based on a needs assessment (Raasch, 1998; Raasch, 1999) was developed in consultation with the Royal Australasian College of Dermatologists. The materials included a summary of melanoma epidemiology; current information and guidelines on diagnosis (with photos of look-alike lesions); management and follow-up of melanoma; and a guide to conducting whole-body skin examinations. The self-paced education programme was offered to 55 medical practitioners working full-time within intervention communities
Evaluation of the medical practitioner education and support component
Initial support of the programme by medical practitioners was assessed through their participation in the initial SkinWatch information sessions and placement of surgery resources. Participation by medical practitioners in the self-audit activity was recorded. Doctor's perspective on the SkinWatch programme was assessed through face-to-face in-depth interviews with doctors in five intervention towns after the clinics had been held.
Skin cancer screening services
Local medical practitioners and hospitals were encouraged to offer whole-body skin examination to patients within day-to-day practice and to establish regular skin screening clinics. However, early in the programme, feedback from doctors, community members and VSCs suggested that local doctors could not meet the demand for skin screening created by the SkinWatch programme because of their existing workload.
SkinWatch skin cancer screening clinics
Therefore, free, open-access skin cancer screening clinics were provided as part of the programme in workplaces, community venues and local hospitals. Twice-yearly clinics in each intervention community were staffed by local doctors and doctors hired from outside the community on a fee-for-service basis. Skin checks were provided by appointment only. Patients received an information sheet, signed a consent form and completed a brief questionnaire on previous skin cancers, melanoma risk factors and lesions of concern. All patients with suspicious lesions detected at the screening examination were referred to their own doctor for diagnosis and management.
Personal invitations for screening signed by well-known sporting and media personalities were posted to residents aged 30 years in each community. Men received a brochure accompanying the letter. Other recruitment strategies included advertisements in newspapers; street banners; workplace promotion kits; community talks, leaflet drops; and other advertizing organized by VSCs.
Evaluation of skin cancer screening services
A complete log was kept of all skin clinics, including clinics in local doctors' practices and SkinWatch skin clinics, and the number of patients attending.
Professional telephone interviewers contacted 1043 SkinWatch clinic attendees selected at random from the SkinWatch clinic database in 1999 to asses reasons for attending, satisfaction with the clinics, likelihood of having/not having skin examination by local medical practitioners and intention to participate in subsequent screening rounds.
Monitoring of concordant skin cancer-related activity
Cross-over of intervention components to control communities and concurrent publicity about skin cancer and skin screening in general within control communities could dilute the contrast between the intervention and control groups. A media monitoring service reviewed newspapers, popular magazines and journals, and major television and radio broadcasts in the geographical areas of the trial. Monitoring began prior to the launch of the SkinWatch programme and included publicity and activity on screening or early detection of skin cancer within control and intervention communities.
|
RESULTS |
|---|
|
TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
Community education component
Table 1 summarizes measures of community participation in the programme. A total of 4075 residents (among whom were represented 108 community clubs or groups), or over 11% of the total adult population in the intervention communities, attended talks conducted by the VSC's or their delegates. A total of 38 621 SkinBooks were delivered to households, and posters and SkinBooks were displayed in 255 additional locations. All but one (26 of 27; 96%) of the local medical practices carried the surgery resources for patients holding a total of 16 190 patient brochures. A total of 195 newspaper articles appeared within intervention communities publicising the SkinWatch programme over the course of the three-year intervention (Table 1).
|
Awareness at baseline and four-month follow-up
At baseline, 393 (17.3%) of 3110 telephone survey participants stated they had heard of SkinWatch and 195 (8.6%) were able to describe an activity related to SkinWatch such as that it involves a skin examination. As there had been no publicity about SkinWatch prior to the first survey, we can only assume that these 393 participants confused SkinWatch with other skin cancer prevention programmes that may have been run in the past. At four-month follow-up, a significantly greater proportion of survey participants (336 of 680, 49.4%;
2 = 277.9, p < 0.001) was aware of the SkinWatch programme and almost 60% of those correctly identified that the programme was about "You or your doctor checking your skin for early signs of skin cancer". About half of those who were aware of the SkinWatch programme recalled a media presentation on SkinWatch (49.6%), 36.1% recalled having received the SkinBook and 35.0% of respondents who had been to a doctor in the last four months recalled the surgery resource.
Medical practitioner education and support component
Almost all (72 of 75 invited; 96%) local doctors and hospital staff in intervention communities attended the information session and received the information package on melanoma. A total of 23 (43%) of the 55 full-time doctors who were approached received the self-paced education programme and participated in the clinical self-audit of skin excisions.
In-depth interviews conducted in five intervention towns 12 months after the programme launch indicated that doctors generally supported the SkinWatch programme because of its community focus and community ownership. Overall, doctors felt that SkinWatch clinics complemented existing primary care practice and reduced the burden on practices in the area of skin screening. Many stated that, in principle, they would prefer to undertake skin screening through their own practices, but time restrictions did not allow them to do so. Regardless, doctors wished to improve their skills in diagnosis and treatment of skin lesions.
SkinWatch screening clinics
The clinics were held in community venues, workplaces and eight local hospitals. A total of 16 383 residents attended the SkinWatch screening clinics for a whole-body examination during the three-year intervention period. Eighty five percent of the attendees were over 30 years of age (comprising 37% of the total adult population of these communities) and 43% were over 50 years of age, 48.5% were men. Altogether, 2302 (14.1%) of SkinWatch clinic patients were referred to their local doctor for diagnosis and management of a suspicious skin lesion.
In telephone interviews with 1043 SkinWatch clinic attendees, participants reported they were motivated to attend the clinic by the personal SkinWatch invitation letter (14.1%), by word of mouth (10.3%), information within the workplace (34.1%) or by media reports (42.9%). The most commonly stated reasons for attending were perceived susceptibility towards skin cancer, and the opportunity to receive a skin examination free of charge. A total of 68.7% of those interviewed stated that they would not have had a skin examination in the absence of the clinic. A majority (87.2%) stated they would visit the SkinWatch clinics again in the future.
Monitoring of concordant skin cancer related media activity
In the months prior to the launch of the SkinWatch programme, there were similar, moderate levels of media activity (average 2.38 media items per months) about skin screening in both intervention and control communities. Non-programme media activity on skin screening increased to 3.17 and 3.14 items per month in intervention and control communities, respectively, after the launch of the SkinWatch programme. During the intervention, one article per month specifically about SkinWatch (a total of 195 articles) was registered within intervention communities, while there was no article covering the SkinWatch programme in control communities.
|
DISCUSSION |
|---|
|
TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
This is the first attempt to describe systematically the development, implementation and process evaluation of a community-based health promotion intervention for screening for melanoma. Both quantitative and qualitative data are presented to allow a comprehensive evaluation of the delivery of the SkinWatch programme (Nutbeam, 1998
).
The SkinWatch intervention was theoretically grounded in community organization models and the theory of the diffusion of innovations (Rogers, 1995; Minkler and Wallerstein, 1997). According to diffusion theory, the adoption of preventive health behaviours can be facilitated effectively if the intervention is able to lend itself to different settings and situations, is compatible with community values and experiences, and is endorsed by influential individuals (Rogers, 1995). The SkinWatch intervention was designed to address these key components of diffusion theory. The SkinWatch intervention was delivered within a "real" environment (COMMITT, 1995a; COMMITT, 1995b; Fortman et al., 1995; Winkleby, 1994; Luepker et al., 2000; Hancock et al., 2001). It involved community volunteers in the organization and running of the SkinWatch programme and the use of community infrastructure such as the local hospital and worksites for the screening clinics to emphasize the intervention's compatibility with the existing environment. Residents' awareness of the SkinWatch programme and its aims increased by >30% within four months of the programme launch and resulted in more than 16 000 visits to SkinWatch skin screening clinics.
During its implementation the programme was continuously evaluated and adjusted to meet local circumstances (Rogers, 1995; McKinlay, 1996). For example, in-depth interviews with the VCS's, community members and community leaders identified the lack of access to skin screening services within existing private practices as a barrier to increased screening participation even among motivated residents. Consistent with this, local doctors expressed concern about their ability to meet the anticipated demand from patients for whole-body skin examinations arising from the community education programme. To address this problem, the SkinWatch skin cancer screening clinics were introduced and motivated over one third of the adult population of these communities to attend the SkinWatch skin screening clinics at least once.
Satisfaction with the clinics was high and nearly 90% of attendees interviewed stated they would revisit a SkinWatch skin clinic. Setting of the clinics in worksites, hospitals and other easily accessible community venues is likely to have contributed to their success in attracting older men, the group at highest risk of dying from melanoma (Hanrahan et al., 1998). The letters of personal invitation signed by a sports/media celebrity were specifically mentioned as motivating attendance at the clinics. Such letters of invitation have been used successfully in recruitment for breast cancer and colorectal cancer screening (Vernon, 1997; Snell and Buck, 1998; McCauld and Wold, 2002), and this appears to hold similar value for melanoma screening clinics.
The local medical community actively supported the programme. Almost all medical practices within intervention communities distributed the SkinWatch brochures in their waiting rooms and >50% of local medical practitioners participated in the self-paced SkinWatch education programme on skin excisions. While local doctors would have preferred to conduct all skin examinations themselves, they accepted the centrally organized SkinWatch clinics as the second best option in the light of limited work capacity.
The state of Queensland covers a broad geographical area, most of it rural with small regional and remote communities. It is expensive and difficult logistically to reach communities in such a setting with cancer prevention or early detection messages. The SkinWatch programme relied on local volunteer support to introduce the intervention into communities and to build community recognition and ownership of the programme. Although volunteers were extensively trained and highly motivated, strategies to maintain volunteers' motivation over an extended period are essential. One such strategy recommended by the VSC's was to provide volunteers with a self-audit system, which will allow volunteers to compare their own activities with those of volunteers within other communities, while at the same time increasing the precision of record keeping by the VSCs.
In conclusion, our results demonstrate the acceptability and feasibility of implementing a community-based melanoma screening programme, including skin cancer screening clinics, with the assistance of local, committed volunteers and broad community support. Specific potential barriers were identified and the programme was modified successfully to deal with these before they had an adverse effect on the intervention. No competing skin cancer related programmes in control communities were identified. Monitoring of the SkinWatch intervention is ongoing to assess its impact on overall screening rates and on earlier diagnosis of melanoma within intervention communities.
|
ACKNOWLEDGEMENTS |
|---|
This study was funded by the Queensland Cancer Fund, Australia and supported by Queensland Health.
|
REFERENCES |
|---|
|
TOPSUMMARYINTRODUCTIONMETHODSRESULTSDISCUSSIONREFERENCES |
|---|
Aitken, J. F., Elwood, J. M., Lowe, J. B., Firman, D. W., Balanda, K. P. and Ring, I. T. (2002) A randomised trial of population screening for melanoma. Journal of Medical Screening, 9, 33–38.
Altman, D. G. (1986) A framework for evaluating community-based heart disease prevention programs. Social Science and Medicine, 222, 479–487.
Australian Institute of Health and Welfare (AIHW) and Australasian Association of Cancer Registries (AACR) (2003) Cancer in Australia 2000. Canberra, AIHW Cat No. CAN 18. AIHW (Cancer Series no. 23).
COMMIT Research Group (1995a) Community intervention trial for smoking cessation (COMMIT): I. Cohort results from a four-year community intervention. American Journal of Public Health, 85, 183–192.
COMMIT Research Group (1995b) Community intervention trial for smoking cessation (COMMIT): II. Changes in adult smoking prevalence. American Journal of Public Health, 85, 193–200.
Del Mar, C. B. and Green, A. C. (1995) Aid to diagnosis of melanoma in primary medical care. British Medical Journal, 310, 492–495.
Elwood, M., Aitken, J. and English, D. (2003) Risk Factors, Prevention and Screening. In Balch C. M., Houghton A. N., Sober A. J. and Soong S. (eds) Cutaneous Melanoma, 4th edition. QMP, Inc., St Louis.
Hanrahan, P. F, Hersey. P and D'Este, C. A. (1998) Factors involved in presentation of older people with thick melanoma. Medical Journal of Australia, 169, 410–414.[ISI][Medline]
Hancock, L., Sanson-Fisher, R., Perkins, J., Corkey, R., Burton, R. and Reid, S. (2001) Effect of a community action intervention on cervical cancer screening rates in rural Australian towns: the CART project. Preventive Medicine, 32, 109–117.[CrossRef][ISI][Medline]
Hawe, P. (1996) Needs assessment must become more change-focused. Australian and New Zealand Journal of Public Health, 20, 473–478.[ISI][Medline]
Janda, M., Elwood, M., Ring, I. T., Firman, D. W., Lowe, J. B., Youl, P. and Aitken, J. F. (2004) Prevalence of skin screening by general practitioners in regional Queensland Medical Journal of Australia, 180, 10–15.[ISI][Medline]
Jemal, A., Murray, T., Samuels, A., Ghafoor, A., Ward, E. and Thum, M. J. (2003) Cancer Statistics 2003. CA Cancer Journal for Clinicians, 53, 5–26.
Koepsell, T. D., Wagner, E. H., Cheadle, A. C., Patrick, D. L., Martin, D. C., Dier P. H., et al. (1992) Selected methodological issues in evaluating community-based health promotion and disease prevention programs. Annual Review of Public Health, 13, 31–57.[CrossRef][ISI][Medline]
Levine, D. M., Becker, D. M., Bone, L. M., Hill, M. N., Tuggle, M. B. and Zeger, S. L. (1994) Community-Academic Health Center Partnerships for underserved minority populations. Journal of the American Medical Association, 272, 309–312.[CrossRef][ISI][Medline]
Luepker, R. V., Raczynsky, J. M. and Osganian, S. (2000) Effect of a community intervention on patient delay and emergency medical service use in acute coronary heart disease: the Rapid Early Action for Coronary Treatment (REACT) Trial. Journal of the American Medical Association, 284, 60–67.
McCaul, K. D. and Wold, K. S. (2002) The effects of mailed reminders and tailored messages on mammography screening. Journal of Community Health, 27, 181–190.[CrossRef][ISI][Medline]
McKinlay J. B. (1996) More appropriate evaluation methods for community-level health interventions. Evaluation Review, 20, 237–243.
Minkler, M. and Wallerstein, N. (1997) Improving Health Through Community Organizations and Community Building. In Glanz K., Lewis F. M. and Rimer B. K. (eds) Health Behaviour and Health Education: Theory, Research and Practice, 2nd edition. Jossey Bass Inc, San Francisco, pp. 241–269.
National Institute of Health (1982) Pretesting in Health Communication. Methods, Examples and Resources for Improving Health Messages and Materials. NIH Publication No. 83–1493. US Department of Health and Human Services.
Nutbeam, D. (1998) Evaluating health promotion – progress, problems and solutions. Health Promotion International, 13, 27–42.
Raasch, B. (1998) The epidemiology, diagnosis and management of nonmelanoma skin cancer in general practice in Townsville. Unpublished PhD Thesis, James Cook University, Townsville, QLD, Australia.
Raasch, B. A. (1999) Suspicious skin lesions and their management. Australian Family Physician, 28, 466–471.[Medline]
Rigel, D. S and Carucci, J. A. (2000) Malignant melanoma: prevention, early detection and treatment in the 21st century. CA Cancer Journal for Clinicians, 50, 215–236.[Abstract]
Rogers, E. (1995) Diffusion of Innovations. Free Press, New York.
Snell, J. L. and Buck, E. L. (1998) Increasing cancer screening: a meta-analysis. Preventive Medicine, 14, 64–70.
Vernon, S. W. (1997) Participation in colorectal cancer screening: a review. Journal of the National Cancer Institute, 89, 1406–1422.
Winkleby, M. A. (1994) The future of community-based cardiovascular disease intervention studies. American Journal of Public Health, 84, 1369–1372.
CiteULike 
Connotea 
Del.icio.us What's this?
This article has been cited by other articles:
|
|
 |
|
  A. B. Francken, H. M. Shaw, N. A. Accortt, S.-J. Soong, H. J. Hoekstra, and J. F. Thompson Detection of First Relapse in Cutaneous Melanoma Patients: Implications for the Formulation of Evidence-Based Follow-up Guidelines Ann. Surg. Oncol., June 1, 2007; 14(6): 1924 - 1933. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||