Optimizing Texting Interventions for Melanoma Prevention and Early Detection: A Latin Square Crossover RCT


      Text messaging is an effective way to reach large populations with health promotion support. This study aims to establish the optimal text messaging intervention to achieve behavior change in young adults at risk of skin cancer.

      Study Design

      Latin square crossover RCT.


      Participants were women and men aged 18–40 years living in Queensland, Australia who owned a smartphone and had ≥2 skin cancer risk factors.


      Participants were enrolled from December 2018 to February 2019 and completed an eligibility survey. Eligible participants were randomized to 4 different text message interventions using a Latin square design with varying personalization, interactivity, and message frequency (February 2019‒July 2019). Each intervention lasted for 1 month; between interventions, participants had a 1-week washout period in which they completed an online questionnaire. Participants completed a 6-month follow-up online survey in January 2020.

      Main outcome measures

      Measures included self-reported sun protection habits and sunburns.


      A total of 277 (71.2% response rate) participants completed the 6-month follow-up. The sun protection habits index was significantly higher in all the 4 text messaging interventions (p<0.01 for each intervention) than at baseline, with similar sun protection habits improvements among all interventions (p=0.27). Sunburn rates decreased significantly over time (p<0.01 each intervention), with all the 4 interventions achieving reductions in sunburn rates during the intervention periods (p=0.78). Overall, the sunburn rates decreased from 40.3% at baseline to 7.0% at the end of the intervention, and at 6-month follow-up, it remained significantly below baseline levels at 23.5% (p<0.01).


      Regular text messaging interventions result in significantly increased sun protection and decreased sunburn in young adults.

      Trial registration

      This study is registered at the Australian and New Zealand Clinical Trials Registry ACTRN12618001299291.
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        • Jemal A
        • Saraiya M
        • Patel P
        • et al.
        Recent trends in cutaneous melanoma incidence and death rates in the United States, 1992-2006.
        J Am Acad Dermatol. 2011; 65: S17-25.e253
      1. Cancer stat fact sheets: melanoma of the skin. NIH, National Cancer Institute, Surveillance, Epidemiology, and End Results Program. Accessed April 12, 2021.

        • U.S. Cancer Statistics Working Group. U.S
        Cancer Statistics Data Visualizations Tool, based on 2019 submission data (1999-2017).
        HHS, Centers for Disease Control and Prevention and National Cancer Institute, Atlanta, GAJune 2020
        Date accessed: February 16, 2021
        • Guy Jr., GP
        • Machlin SR
        • Ekwueme DU
        • Yabroff KR.
        Prevalence and costs of skin cancer treatment in the U.S., 2002-2006 and 2007-2011.
        Am J Prev Med. 2015; 48: 183-187
        • Ferlay J
        • Soerjomataram I
        • Dikshit R
        • Eser S
        • Mathers C
        • Rebelo M
        • et al.
        Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012.
        J Int J Cancer. 2015; 136: E359-E386
        • Australian Institute of Health and Welfare
        Cancer in Australia 2019. Cancer series no. 119. Cat. no. CAN 123.
        Australian Institute of Health and Welfare, Canberra, Australia2019 (Accessed December 1, 2020)
        • Montague M
        • Borland R
        • Sinclair C.
        Slip! Slop! Slap! and SunSmart, 1980-2000: skin cancer control and 20 years of population-based campaigning.
        Health Educ Behav.28. 2001: 290-305
        • Tabbakh T
        • Volkov A
        • Wakefield M
        • Dobbinson S.
        Implementation of the SunSmart program and population sun protection behaviour in Melbourne, Australia: results from cross-sectional summer surveys from 1987 to 2017.
        PLoS Med. 2019; 16e1002932
        • Vos T
        • Carter R
        • Barendregt J
        • et al.
        Assessing cost-effectiveness in prevention (ACE-prevention): final report.
        The University of Queensland and Deakin University, Bisbane, AustraliaSeptember 2010 (Accessed 01 December 2020)
        • Andersen PA
        • Buller DB
        • Voeks JH
        • et al.
        Testing the long-term effects of the Go Sun Smart worksite health communication campaign: a group-randomized experimental study.
        J Commun. 2008; 58: 447-471
        • Queensland Health
        The health of Queenslanders 2018. Report of the Chief Health Officer Queensland.
        Queensland Government, Brisbane, AustraliaNovember 2018 (Accessed 01 December 2020)
        • Holman DM
        • Ding H
        • Guy Jr., GP
        • Watson M
        • Hartman AM
        • Perna FM.
        Prevalence of sun protection use and sunburn and association of demographic and behaviorial characteristics with sunburn among U.S. adults.
        JAMA Dermatol. 2018; 154: 561-568
      2. National Center for Chronic Disease Prevention and Health Promotion. Youth Risk Behavior Surveillance System (YRBSS), 2015-2017. Centers for Disease Control and Prevention. Accessed 16 February 2021

        • Potente S
        • Coppa K
        • Williams A
        • Engels R.
        Legally brown: using ethnographic methods to understand sun protection attitudes and behaviours among young Australians ‘I didn't mean to get burnt–it just happened!’.
        Health Educ Res. 2011; 26: 39-52
        • Aitken JF
        • Janda M
        • Lowe JB
        • et al.
        Prevalence of whole-body skin self-examination in a population at high risk for skin cancer (Australia).
        Cancer Causes Control. 2004; 15: 453-463
        • Dieng M
        • Smit AK
        • Hersch J
        • et al.
        Patients’ views about skin self-examination after treatment for localized melanoma.
        JAMA Dermatol. 2019; 155: 914-921
        • Manne SL
        • Heckman CJ
        • Kashy D
        • et al.
        Prevalence and correlates of skin self-examination practices among cutaneous malignant melanoma survivors [published correction appears in Prev Med Rep. 2020;20:101284].
        Prev Med Rep. 2020; 19101110
        • Hall AK
        • Cole-Lewis H
        • Bernhardt JM.
        Mobile text messaging for health: a systematic review of reviews.
        Annu Rev Public Health. 2015; 36: 393-415
        • Orr JA
        • King RJ.
        Mobile phone SMS messages can enhance healthy behaviour: a meta-analysis of randomised controlled trials.
        Health Psychol Rev. 2015; 9: 397-416
        • Yasmin F
        • Banu B
        • Zakir SM
        • Sauerborn R
        • Ali L
        • Souares A.
        Positive influence of short message service and voice call interventions on adherence and health outcomes in case of chronic disease care: a systematic review.
        BMC Med Inform Decis Mak. 2016; 16: 46
        • Armanasco AA
        • Miller YD
        • Fjeldsoe BS
        • Marshall AL.
        Preventive health behavior change text message interventions: a meta-analysis.
        Am J Prev Med. 2017; 52: 391-402
        • Loescher LJ
        • Rains SA
        • Kramer SS
        • Akers C
        • Moussa R.
        A systematic review of interventions to enhance healthy lifestyle behaviors in adolescents delivered via mobile phone text messaging.
        Am J Health Promot. 2018; 32: 865-879
        • Chambergo-Michilot D
        • Tellez WA
        • Becerra-Chauca N
        • Zafra-Tanaka JH
        • Taype-Rondan A.
        Text message reminders for improving sun protection habits: a systematic review.
        PLoS One. 2020; 15e0233220
        • Dombrowski SU
        • O'Carroll RE
        • Williams B
        Form of delivery as a key ‘active ingredient’ in behaviour change interventions.
        Br J Health Psychol. 2016; 21: 733-740
        • Walker LO
        • Czajkowski SM.
        Designing interventions to improve the health of women using the ORBIT Model.
        J Obstet Gynecol Neonatal Nurs. 2019; 48: 197-204
        • Whiteman DC
        • Neale RE
        • Aitken J
        • et al.
        When to apply sunscreen: a consensus statement for Australia and New Zealand.
        Aust N Z J Public Health. 2019; 43: 171-175
        • Queensland Government
        Climate change in Queensland version 1. 2019; (Published)
        • Michie S
        • van Stralen MM
        • West R.
        The behaviour change wheel: a new method for characterising and designing behaviour change interventions.
        Implement Sci. 2011; 6: 42
        • Glanz K
        • McCarty F
        • Nehl EJ
        • et al.
        Validity of self-reported sunscreen use by parents, children, and lifeguards.
        Am J Prev Med. 2009; 36: 63-69
        • Heckman CJ
        • Handorf E
        • Darlow SD
        • Yaroch AL
        • Raivitch S.
        Refinement of measures to assess psychosocial constructs associated with skin cancer risk and protective behaviors of young adults.
        J Behav Med. 2017; 40: 574-582
        • Rubin DB.
        Multiple imputation for survey nonresponse.
        John Wiley & Sons, New York, NY1987 (Accessed December 1, 2020)
        • Head KJ
        • Noar SM
        • Iannarino NT
        • Grant Harrington N
        Efficacy of text messaging-based interventions for health promotion: a meta-analysis.
        Soc Sci Med. 2013; 97: 41-48
        • Kreuter MW
        • Wray RJ.
        Tailored and targeted health communication: strategies for enhancing information relevance.
        Am J Health Behav. 2003; 27: S227-S232
        • Armstrong AW
        • Watson AJ
        • Makredes M
        • Frangos JE
        • Kimball AB
        • Kvedar JC
        Text-message reminders to improve sunscreen use: a randomized, controlled trial using electronic monitoring.
        Arch Dermatol. 2009; 145: 1230-1236
        • Hingle MD
        • Snyder AL
        • McKenzie NE
        • et al.
        Effects of a short messaging service-based skin cancer prevention campaign in adolescents.
        Am J Prev Med. 2014; 47: 617-623
        • Youl PH
        • Soyer HP
        • Baade PD
        • Marshall AL
        • Finch L
        • Janda M.
        Can skin cancer prevention and early detection be improved via mobile phone text messaging? A randomised, attention control trial.
        Prev Med. 2015; 71: 50-56
        • Cust AE
        • Jenkins MA
        • Goumas C
        • et al.
        Early-life sun exposure and risk of melanoma before age 40 years.
        Cancer Causes Control. 2011; 22: 885-897
        • Olsen CM
        • Wilson LF
        • Green AC
        • et al.
        Cancers in Australia attributable to exposure to solar ultraviolet radiation and prevented by regular sunscreen use.
        Aust N Z J Public Health. 2015; 39: 471-476
      3. Free Sunsmart App. SunSmart. Accessed February 12, 2021.