Knowledge and practices of primary care providers on skin cancer and skin self-examination

Objective: To determine the knowledge and practices related to skin cancer and skin self-examination of primary care providers. Method: This cross-sectional descriptive study was conducted in Turkey. The study was carried out in primary health centers such as family health centers, community health centers, early cancer detection centers and family planning centers in 2016-2017. Participants’ socio-demographic characteristics, their knowledge and practices related to skin cancer, skin cancer risk factors and skin self-examination were determined. Results: The study population included 94 primary care providers. The symptoms of which the participants were most aware were changes in the color of moles or skin spots (95.71%), and of which participants were the least aware was the itching of a mole (71.43%). Among participants, the most recognized risk factor was having fair skin (97.14%), whereas the least known was the presence of birthmarks (24.29%). The mean scores the participants obtained from the questionnaire were as follows: 5.39±1.61 for skin cancer risk factors and 10.47±2.73 for skin cancer symptoms. Of the participants, 14.29% received training on skin self-examination, 38.57% knew how to perform skin self-examination, and 67.14% did not perform skin self-examination. Of the participants, 61.7% did not perform skin self-examination because they did not know what to look for. Of the participants, 85.71% did not have continuing education/workshop about skin self-examination after graduation. Conclusion: Although the primary care providers’ knowledge of skin cancer symptoms was adequate, their knowledge of skin cancer risk factors was not sufficient. Primary care providers’ knowledge of skin self-examination was good, but they did not perform skin self-examination adequately. DESCRIPTORS Skin Neoplasms; Self-Examination; Primary Health Care; Primary Care Nursing; Professional Practice.


INTRODUCTION
Skin cancer is the most common form of cancer worldwide, and thus it is a global public health issue (1) .Changes in the ozone layer have increased the harmful effects of ultraviolet (UV) A and UVB rays, and exposed the skin, the largest organ of our body, to these harmful effects (2) .The Disability-Adjusted Life Year lost due to UV is calculated as 1.5 million days per year worldwide (3) .This is mainly caused by the increased incidences of skin cancer globally (2) .The World Health Organization has reported that one in three people diagnosed with cancer has skin cancer (4) .In Australia, skin cancer is the most commonly diagnosed form of cancer among people aged 15 to 44 years.It also has the highest mortality rate.In the United States (USA), melanoma ranks the fifth most common form of cancer in males and ranks seventh in females (3) .The incidence of melanoma in the UK is estimated to increase by 88% in men and 66% in women by 2020 (5) .The incidence of melanoma in Turkey is 1.6 per 100,000 people, and the mortality rate is 1.0 per 100,000 people (6) .It was also reported that the incidence of melanoma in Turkey is 1.8 per 100,000 people in males and 1.2 per 100,000 people in females (7) .The incidence rates of malignant melanoma across the southeastern region of Europe are increasing.Significant increases in mortality rates were observed in older men in the Czech Republic, Serbia and Turkey (8) .In one Turkish study that took place in two different centers over a twenty-year and ten-year study period (9) , 239 and 183 cases of primary cutaneous melanoma were diagnosed after screening and the mean melanoma diagnosis per year was 11.9 and 18.3, respectively.It was reported that the number of melanoma diagnosis markedly increased over time in both centers (9) .
Factors leading to skin cancer include overexposure to sunlight, gender, phenotypic traits, family history, Fitzpatrick I-II skin type, childhood sunburn, immunosuppression, ionizing radiation, Psoralen-UVA (PUVA) treatments, environmental carcinogens, HPV infection, artificial light sources, nevi and genetic syndromes.Even though everyone is at risk of developing skin cancer, fair-skinned individuals, and individuals having: a large number of moles and spots, extended sun exposure, and/or childhood history of sunburn are at a greater risk of developing skin cancer (10)(11)(12)(13) .According to the list released by the National Comprehensive Cancer Network (NCCN), wearing sunscreen products with at least sun protection factor (SPF) 30, wearing sun protective clothing, wearing sunglasses with UV protection, avoiding sun exposure between 10 a.m. and 4 p.m. unless necessary, refraining from solariums, regular self-examining skin spots, moles and freckles seasonally are skin cancer prevention methods (14) .The most important known fact about skin cancer is that it is a preventable disease with early diagnosis.When diagnosed early, the survival rate in melanoma patients is more than 98% (15) .Therefore, skin self-examination is of great importance in the early diagnosis and treatment of skin cancers (15) .Skin self-examination (SSE) is an early diagnostic method recommended by organizations such as the American Cancer Society, The Cancer Council Australia, and The Skin Cancer Foundation (15)(16)(17) .It is recommended that SSE be performed every month.An examination takes about 10 minutes.In SSE, any mole, freckle or spot on the skin, whether congenital or acquired should be evaluated according to the ABCDE rule.ABCDE rule involves the following criteria: A-Asymmetry, B-Border, C-Color, D-Diameter, and E-Evolving (16)(17) .
Raising public awareness plays an important role in the prevention and early diagnosis of skin cancer.In this context, health personnel should play a fundamental role, and if they are to be role models and enlighten the public, they should first protect their own health (18) .It is especially important for primary care providers to have accurate and adequate knowledge of the issue based on their roles as educators and counselors in cancer preventive health services.The purpose of this study is to determine primary care providers' knowledge of skin cancer, and their SSE practices.

METHOD
The study is a cross-sectional descriptive study.The study was carried out in several primary health centers ( The study population included 94 physicians, nurses and midwives working in primary health services.No sampling method was implemented in the present study.All the study population was intended to be included in the study.Of the study population, 70 health workers volunteered to participate in the research.The participation rate was 75%. The study data were collected with a questionnaire developed by the researchers through a literature review (19)(20)(21) .The questionnaire contains 43 items and three sections.The first section included health workers' socio-demographics and individual risk factors for skin cancer.The second section focused on their level of knowledge about the risk factors and symptoms of skin cancer.The third section assessed their knowledge and practices regarding SSE."The participants' socio-demographics and individual risk factors for skin cancer"; this section contains 14 items questioning healthcare workers socio-demographic characteristics such as age, gender, workplace, and occupation and physical characteristics such as eye, skin, hair color, etc. with regards to posing a risk for skin cancer.The participants were also asked whether they considered themselves at risk for skin cancer and whether they visited a dermatologist for skin cancer screening."The participants' knowledge levels about the symptoms and risk factors for skin cancer"; the participants were asked the following twelve questions to determine their levels of knowledge about the symptoms of skin cancer (21) : "An unusual change in the skin in any part of the body (the sudden growth of a skin formation and the bright brown, black, or multicolored appearance)", "The presence of wound that does not heal in more than three weeks", "congenital or acquired moles or skin spots changing in color, size, thickness, surface, developing irregularity of outer border, becoming larger than 6 mm or the diameter of a pencil", "the emergence of new spots after the age of 21", "itching, crusting, disintegration and/or bleeding of a mole or wound".For each correct answer, 1 point was given, and for each wrong answer 0 points were given.The minimum and maximum possible scores obtainable from the responses regarding the symptoms of skin cancer were 0 and 12, respectively.High scores indicate that the level of knowledge is sufficient.The questionnaire was evaluated for validity and reliability (21) .In the original study (21) , content validity and Kuder-Richardson value of the questionnaire were found to be 0.81 and 0.83, respectively.In this study content validity and Kuder-Richardson value of the questionnaire were found to be 0.85 and 0.88, respectively.To determine the participants' knowledge levels regarding their risks for skin cancer, they were asked 8 questions (20) .The participants obtained 1 point for each correct response and 0 points for each incorrect response on the following items: "having fair skin", "having light-colored eyes", "having a family history of skin cancer", "the presence of brown/large moles on the skin", "the presence of a birthmark on the skin", "having ever had sunburn blisters", "tanning in a solarium", "lifetime, long-term exposure to sun".The minimum and maximum possible scores to be obtained from the responses regarding the risks for skin cancer were 0 and 8, respectively.High scores indicate that the participant has adequate knowledge about factors that increase the risk of skin cancer.The questionnaire was found valid and reliable (20) .In this study, content validity (0.84) and Kuder-Richardson (0.86) value of the questionnaire were calculated."The participants' knowledge and practices related to skin self-examination (SSE)"; this section contains 8 items.The items question whether the participants were knowledgeable of SSE practices and the ABCDE rule.The participants were expected to choose the correct answer "once a month" in response to the question "How often should self--skin examination be performed", the correct answer; "Yes, always" in response to the questions "a full-length mirror is used during SSE" and "a hand-held mirror is used during SSE" and the correct answer "all parts of the body" in response to the question "which areas should be examined when self--skin examination is performed".The participants were asked whether they performed self-skin examination.Those who did not were also asked "why not?"The responses to these questions were not rated.In October 2016, a pilot application was conducted with 30 primary health care workers working in another city who were not participating in the study.The study design is presented in Figure 1.The data were analyzed using the SPSS 16.0 program.Descriptive statistics such as number and percentage distributions were calculated.
To carry out the research, written permissions were obtained from the ethics committee of the university (

RESULTS
The participants' socio-demographic characteristics and risks of skin cancer; of the participants, 70% were female, 30% were in the 33-38 age group.37.14% were physicians, 31.43% were nurses, 31.43% were midwives, 15.7% had sandy red/ blonde hair, 20% had blue-gray-light color eyes, 12.86% had fair skin, 40% had more than 10 moles, 7.4% had blood relatives diagnosed with skin cancer, 55.71% considered themselves at risk for skin cancer, and 97.14% did not have any skin cancer screening previously (Table 1).The participants' knowledge and practices regarding skin cancer and skin self-examination (SSE); the mean score that the participating primary care providers obtained for the knowledge of skin cancer risk factors was 5.39 ± 1.61 (min: 0, max: 8).Of the risk factors, the ones that the participants were aware of most were having a fair skin (97.14%), life--time long-term exposure to sun rays (95.71%), and having a family history of skin cancer (91.43%).The risk factors of which the participants were least aware were the presence of birthmarks (24.29%), having had sunburn blisters (31.43%) and light eye color (34.29%).
The mean score the participants obtained for the knowledge of skin cancer symptoms was 10.47±2.73(min: 0, max: 12).The symptoms of which the participants were most aware were changes in the color of congenital or acquired moles or skin spots (95.71%), increases in the size and thickness of congenital or acquired moles or skin spots (95.1%), and the bleeding of a mole or wound (90%).The symptom of which the participants were least aware was the itching of a mole (71.43%).The participants' knowledge regarding skin cancer risks and symptoms are given in Table 2.
In Table 3, the participants' knowledge and practices of skin self-examination are given.Of the participants, 14.29% had continuing education/workshop about SSE after graduation.Of the participants, 67.14% did not perform SSE.Of the participants who did not perform SSE, 61.7% did not perform SSE because they did not know what to look for.Of the participants, 41.3% were aware that SSE should be performed once a month, 87.14% and 60% knew that when performing SSE they should always use a full-length mirror or a hand-held mirror, respectively; and 97.14% pointed out that all parts of the body should be examined during SSE (Table 3).

DISCUSSION
Skin cancers which constitute nearly half of all cancer cases are the most common type of cancer.By raising societal awareness of skin cancer, morbidity and mortality due to skin cancer, which is common, can be reduced.Education is of great importance in raising awareness of the risks and symptoms of skin cancers and in their diagnosis and treatment.In this respect, health workers, in particular primary care providers, assume great tasks and responsibilities.This study was conducted to determine primary care providers' knowledge and practices regarding the issue.
In the present study, one in four participants had light skin, one in five participants had light-colored eyes and www.ee.usp.br/reeuspKnowledge and practices of primary care providers on skin cancer and skin self-examination Rev Esc Enferm USP • 2018;52:e03359 four in ten participants had more than 10 moles.In the literature, it is indicated that light hair color, light eyes and the presence of more than one mole/freckle increase the risk of skin cancer (10)(11)22) . In lght of this literature data, a significant part of the participants were at risk of developing skin cancer because they had light skin and color eyes.More than half of the participants in the present study stated that they considered themselves at risk for skin cancer.In several studies conducted on the issue, it has been reported that an individual's perception of risk affects his/her health behavior, medical decision-making and acquisition of health information (23)(24)(25)(26) .In the current study, although more than half of the participants considered themselves at risk of skin cancer, the rate of those who visited a dermatologist was low.In a study conducted in Turkey, 67.3% of the physicians did not visit a dermatologist for skin cancer screening (19) .These results suggest that health workers who do not disease prevention methods do not recommend these methods to their patients or do not refer them to a dermatologist.It is clear that not only should healthcare professionals encourage their patients to pay regular visits to a dermatologist but they also should pay more attention to their own skin health.
In the present study, although the participants' scores for their knowledge about the skin cancer symptoms were high, their scores for knowledge about skin cancer risks were lower than expected.It is noteworthy that more than half of the participants did not know the relationship between skin cancer and risk factors such as birthmarks, sunburn blisters and light eye color.In a study conducted in North Carolina, 23% of the participants reported that they were aware of skin cancer risks (27) .In a study conducted in Morocco, 66.7% of the participants had never heard of skin cancer before, and 18% of them had moderate levels of knowledge about skin cancer (28) .
In three similar studies (29)(30)(31) it was reported that the participants' knowledge levels about skin cancer were low.However, given the fact that the aforementioned studies were conducted with patients rather than healthcare workers, the importance of the results of the present study becomes even more obvious.
Primary care providers should appreciate the importance of gathering a detailed patient history to identify patients with the highest risk of developing skin cancer (23)(24) .Awareness of the risks and symptoms of skin cancers and of the ways to prevent skin cancer play an important role in avoiding behaviors posing risks in the development of cancer and in taking the necessary precautions (23) .Accordingly, the importance of providing information and raising awareness about skin cancer whose incidence is on the rise becomes more evident.In the literature, it is reported that if health workers are aware of skin cancer risk factors and adopt SSE practices, they would have an advantage in accessing a large population in terms of taking precautions to prevent skin cancer (32) .
In the present study, although a significant number of the primary care providers knew when and how often SSE should be performed and which parts of the body should be examined, they did not perform SSE because they did not know how to do it.A study (33) reported that health care workers' skin cancer and sun protection behaviors were not different from those of patients, although they knew the importance of the improvement of health and primary prevention.In studies conducted in Mediterranean countries, it has been determined that although primary care physicians are well aware of recommendations on sun protection, their skin cancer and sun protection practices are inadequate (32,34) .
That the rate of the participants who performed SSE was lower than expected in the current study supports the findings in the relevant literature, which suggests that the health workers who participated in the present research were inadequate about SSE in general and they needed training on the issue.Only a small proportion of the participants (14%) participated in post-graduate training on skin cancer and SSE.The participants' inadequate participation rate in post-graduate continuing education and workshops regarding SSE might be associated with the fact that they did not know what to look for in SSE.If health workers are to teach primary and secondary skin cancer prevention tips to the public, first of all, they should know and implement them.Inadequate precautionary behaviors of health workers to protect themselves from skin cancer may lead to failures in role modeling, and provision of information and counseling to people.
The limitations of this study are that it was carried out with only those working in primary healthcare centers in one city.The results cannot be generalized to all health professionals in the country.The results of the study were based on self-reported data.On the other hand, the questionnaire was considered a valid and reliable tool to measure health professionals' knowledge and practices regarding skin cancer and SSE.

CONCLUSION
The present study aimed at determining whether the knowledge and practices of primary care providers about skin cancer and SSE contributed to the determination of their health behaviors towards skin cancer.
Although the participants' knowledge of skin cancer symptoms was adequate, their knowledge of skin cancer risk factors was not sufficient.It was also determined that their knowledge of SSE was good but SSE practices were inadequate.Another point determined in the study was that very few of the participants performed SSE and that although they considered themselves at risk for skin cancer; the great majority of them did not visit a dermatologist.In light of these results obtained from the present study, it was concluded that healthcare professionals' knowledge and practices of SSE should be improved, because the main task of healthcare workers is to implement preventive health services, and to inform and guide society.According to estimates, until 2030, the rate of cancer worldwide is expected to double.While 80% of cancer patients are in low and middle income countries, these countries receive only 10% of the total funds spent on cancer globally.For this reason, early diagnosis and screening programs should be emphasized.Working on early diagnosis of cancer and conducting public education in this regard is among the tasks of primary health care workers in Turkey.Within this context, health workers should teach people how to perform SSE in order to detect skin cancer and what to observe in this examination and should enhance their knowledge of SSE and raise awareness of SSE.Therefore, it is important for health workers, who are role models in society, to have adequate knowledge and practice about skin cancer, and to be aware of the risks and symptoms of skin cancers and of the ways to prevent them.Patient assessment is important for the detection of skin cancer in primary care.Continuing education is the way in which healthcare workers gather new knowledge and practices.Therefore, organizing post-graduation training and certification programs for health workers will positively contribute to the community's health.After which, if they have knowledge and skills they can become public counselors and educators.It may be recommended to perform further studies with a larger sample to determine health workers' levels of knowledge and prevention practices related to skin cancers in Turkey.Because the determination of knowledge and practices of primary care providers who are to encourage people to participate in campaigns on skin cancer prevention will be effective in planning interventions, the results of this study are expected to shed light on attempts to be planned to prevent skin cancer in the future.
7 Family Health Centers, 1 Community Health Center, 1 Early Cancer Detection Center and 1 Family Planning Center) affiliated with the Provincial Directorate of Public Health in a province located in the Central Anatolian Region of Turkey between November 2016 and February 2017.
13Oct 2016; number 2016/03) where the study was to be conducted and the Provincial Directorate of Public Health.The participants gave their verbal consent after they were informed about the research.The participants filled out the questionnaires in the health centers where they worked.It took each participant approximately 15 minutes to complete the questionnaire.
www.ee.usp.br/reeuspKnowledge and practices of primary care providers on skin cancer and skin self-examination Rev Esc Enferm USP • 2018;52:e03359

Table 1 -
Descriptive variables and skin cancer risk status of primary care providers -Çankırı,Turkey, 2016-2017.

Table 2 -
Knowledge of primary care providers about risks and symptoms of skin cancer -Çankırı,Turkey, 2016-2017.
* The total was not expressed since one participant selected more than one statement.Note: (n=70).
*The total was not expressed since one participant selected more than one statement.Note: (n=70).