Background

Melanoma is a highly aggressive form of skin cancer, with four major histopathological subtypes: superficial spreading, nodular, lentigo maligna, and acral lentiginous melanoma1. Globally, its incidence has increased significantly, with a reported rise of over 60% from 1991 to 20112. In China, the prevalence of cutaneous melanoma is relatively low (0.49/100,000) but remains a serious concern due to its poor prognosis, particularly in advanced stages. Urban regions show a slightly higher incidence (0.54/100,000) compared to rural areas (0.44/100,000), possibly due to greater UV exposure and healthcare access differences. Because melanoma is typically resistant to radiotherapy, early surgical resection remains the primary treatment, while metastatic cases are far more challenging to manage3.

The theory of KAP (Knowledge, Attitude, and Practice) posits that knowledge serves as the foundation for behavioral change, while attitudes and beliefs act as the driving forces behind such changes4. According to this theory, the process of behavior change unfolds in three stages: knowledge acquisition, formation of attitudes/beliefs, and adoption of practices/behaviors5. However, it is important to note that cognitive shifts resulting from knowledge acquisition may not directly translate into behavioral changes; rather, they typically precede changes in perception, which then influence behavioral modifications6.

Given this theoretical framework, understanding the roles and influences of patients with melanoma and their family members in the decision-making process is of paramount importance. Family members play crucial roles not only in providing support and care but also in participating in medical decision-making and offering insights. Therefore, comprehending their levels of knowledge, attitudes, and behavioral patterns is essential for grasping the potential influencing factors in the decision-making process. Conducting comprehensive research on both these groups can enhance our understanding of their roles in decision-making, thereby facilitating the development of more comprehensive and effective medical decision-making and treatment strategies. This, in turn, can lead to improved treatment outcomes and survival rates for patients with melanoma, while also enhancing the sense of involvement and support capabilities among family members, thereby promoting the overall health and well-being of both patients and their families. Despite previous KAP study on melanoma7, there has been a lack of such research focusing on the Chinese population. Considering the differences in disease prevalence and types, particularly noting that the prevalence of subungual melanoma in the Asian population is notably higher than in the Western population8,9, this study fills an important gap in the literature. Therefore, this study was to investigate the KAP regarding Melanoma among Patients with melanoma and Their Family Members.

Methods

Study design and participants

This cross-sectional study was undertaken between April 1, 2023, and March 1, 2024, encompassing hospitals nationwide. It focused on patients diagnosed with cutaneous melanoma confirmed by histopathological examination, along with their respective family members. Patients with non-cutaneous melanoma subtypes such as uveal or mucosal melanoma were excluded, as these differ in biological behavior and clinical management. Therefore, only patients with cutaneous melanoma, regardless of histological subtype or anatomical location on the skin, were included for analysis. This ensured the sample was clinically homogeneous in terms of disease presentation and management, allowing for more meaningful analysis of KAP dimensions. Ethical approval for the study was obtained from the Longhai Hospital Ethics Committee (Approval No. LH-2023-041), and written informed consent was obtained from all participants. Inclusion criteria included individuals diagnosed with melanoma and family members of such patients, while exclusion criteria comprised individuals declining participation in the questionnaire.

Questionnaire introduction

The final questionnaire, administered in Chinese, encompassed four dimensions for data collection. Basic demographic information such as gender, age, education level, and current employment status was included. The knowledge dimension comprised 12 items, the attitude dimension contained 7 items, and the practice dimension encompassed 6 items. For statistical analysis, scores were allocated based on response options. In the knowledge dimension, correct answers were awarded 2 points, while incorrect or ambiguous responses received 0 points, yielding a score range of 0–24 points. The attitude dimension utilized a five-point Likert scale, ranging from very positive (5 points) to very negative (1 point), with a score range of 7–35 points. Similarly, the practice dimension employed a five-point Likert scale, with a score range of 6–30 points. Scores equal to or greater than 70% of the maximum possible in each section were considered to indicate sufficient knowledge, a positive attitude, and proactive practice. This threshold was adopted based on established practices in previous KAP research, including studies that applied similar criteria in evaluating knowledge and attitudes among healthcare workers10. The questionnaire was developed based on a review of existing literature on health-related KAP models and melanoma-specific knowledge and behavior7,11. Additionally, the questionnaire development process involved consultation with three domain experts to ensure content validity and clinical relevance. These experts included Dr. Chunyu Xue (Director, Department of Plastic Surgery, Changhai Hospital), Dr. Chuan Lü (Associate Professor, Department of Plastic Surgery, Changhai Hospital), and Dr. Jianguo Xu (Associate Professor, Department of Plastic Surgery, Changhai Hospital). Their areas of expertise encompass melanoma, vascular anomalies, chronic wounds, and skin tumors. They contributed to the formulation, revision, and refinement of questionnaire items to ensure the instrument adequately covered core topics related to melanoma diagnosis, treatment, and prevention in both patients and their family members. Due to the lack of a validated melanoma attitude scale applicable to our population, a custom instrument was designed to capture key concepts relevant to both patients and family members in the Chinese context. Prior to the formal survey, a pilot test was conducted with 72 respondents. After excluding 1 case without consent and 18 invalid cases due to inconsistent responses between mutually exclusive knowledge items (items 4 and 12), 53 valid questionnaires remained for reliability analysis. The Cronbach’s alpha coefficient for the attitude subscale was 0.875, indicating good internal consistency. To further assess the construct validity of the attitude subscale, we conducted a Kaiser-Meyer-Olkin (KMO) test. The KMO value was 0.914 (P < 0.001), indicating excellent sampling adequacy for factor analysis and suggesting that the attitude items were well-suited for identifying underlying latent constructs. Further psychometric testing, including factor analysis, is planned in follow-up research.

Questionnaire distribution and quality control

Questionnaires were distributed to participants via QR code provided by the Questionnaire Star platform12.

Sample representativeness

To assess the representativeness of our sample, we compared key demographic characteristics of our melanoma patients with published epidemiological data from China. According to the Chinese Cancer Registry, melanoma predominantly affects individuals aged 40–70 years, with a slight female predominance in certain regions13. Our sample characteristics align with these national patterns, with 51.98% residing in urban areas, consistent with the reported higher incidence in urban populations (0.54/100,000) compared to rural areas (0.44/100,000) as mentioned in our background. The age distribution in our study, with 33.89% aged 18–30 and 30.77% aged 31–40, reflects the inclusion of both patients and their younger family members, which is appropriate for our study objectives.

Statistical analysis

Data analysis was conducted using SPSS 27.0 and AMOS 26.0 (IBM, Armonk, NY, USA). Continuous data are presented as means and standard deviations (SD), while categorical data are expressed as n (%). Continuous variables underwent a normality test, with the t-test for normally distributed data and the Wilcoxon Mann-Whitney test for non-normally distributed data when comparing two groups. For three or more groups with normally distributed continuous variables and uniform variance, ANOVA was used for comparisons, while the Kruskal-Wallis test was employed for non-normally distributed data. Spearman analysis was utilized to examine the correlation between knowledge, attitude, and practice scores. Structural equation modeling (SEM) was utilized to explore the relationships between knowledge (K), attitude (A), and practice (P). A two-sided P-value less than 0.05 was considered statistically significant.

Results

A total of 524 questionnaires were collected in this study. We excluded 5 questionnaires from participants who did not agree to participate in the survey and 38 questionnaires with obvious response bias (all “A” options selected across the three KAP dimensions), indicating invalid participation patterns. The remaining 481 valid questionnaires yielded a response validity rate of 91.79%. This validity rate exceeds the commonly accepted threshold of 80% for cross-sectional KAP study14, ensuring the reliability of our findings. Among them, 268 (55.72%) were females, 250 (51.98%) were living in urban areas, 222 (46.15%) had bachelor’s degree or above, 266 (55.30%) were full-time employed, 97 (20.17%) were currently still smokers, and 146 (30.35%) were currently drinkers. In addition, 241 (50.10%) were patients themselves and the rest were family members of the patients. The mean knowledge, attitude, and practice scores were 12.25 ± 5.70, 22.87 ± 2.59, and 24.46 ± 4.91, separately. Knowledge, attitude, and practice scores were more likely to differ among participants with different age, work status, and marital status (all of P < 0.01). Participants with different alcohol consumption patterns (never, used to, or currently consume alcohol) were more likely to have different knowledge and attitude scores depending on their residence, smoking status, and drinking status (all of P < 0.05). Participants with different gender were more likely to have different practice scores (P = 0.003). Additionally, attitudes were more likely to differ between patients and family members (22.59 ± 2.56 vs. 23.14 ± 2.60, P = 0.020). Specifically, family members were more likely to strongly agree with statements such as “Regular skin self-examination is important” and “Treatment for melanoma is necessary.” Patients, on the other hand, were more likely to express neutral or less confident views regarding the efficacy of melanoma treatment (Table 1).

Table 1 Baseline and KAP Scores.
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The highest percentage of participants answering the knowledge section correctly were “Melanoma mostly develops from moles.” (K1) with 70.89% and “The earlier melanoma is detected, the greater the likelihood of cure.” (K7) with 66.74%. While the lowest correct rates were “The prognosis of melanoma is unrelated to gender, age, or location.” (K6) with 20.79% and “Histopathology is not the primary means of diagnosing melanoma.” (K12) with 22.45% (Table 2).

Table 2 Knowledge dimension response.
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Regarding related attitudes, nearly half of participants strongly agreed on the importance of regular skin self-examination and melanoma treatment, while around one-third expressed strong confidence in physicians. A considerable proportion remained neutral or uncertain about treatment efficacy. When comparing responses between patients with melanoma and their family members, we found that family members were more likely to strongly agree with statements related to early detection, treatment necessity, and trust in healthcare providers. For example, 52.3% of family members strongly agreed that regular skin self-examination is important, compared to 45.6% of patients. Additionally, 49.8% of family members strongly agreed that treatment is necessary versus 43.7% of patients. The proportion expressing high confidence in doctors was also slightly higher among family members (38.9%) than among patients (33.5%) (Table 3).

Table 3 Attitude dimension response.
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Responses to the practice dimension showed that 47.40% always cooperate with the doctor for regular follow-up (P6), and 44.7% always follow the treatment plan recommended by the doctor (P3). Meanwhile, 33.89% always go to the hospital on time for regular review as requested by the doctor (P2). However, there is still a small proportion of participants (less than 10%) who implement these practice items infrequently (occasionally or never) and need to be given more attention (Table 4).

Table 4 Practice dimension response.
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Correlation analysis showed that there were significant positive correlations between knowledge and attitude (r = 0.319, P < 0.001) as well as practice (r = 0.319, P < 0.001). Also, there was a correlation between attitude and practice (r = 0.353, P < 0.001) (Table 5).

Table 5 Correlation between knowledge, attitude, and practice scores.
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The fit of the SEM model yielded good indices demonstrating good model fit (Supplement Table 1), and the results showed that the direct effect of knowledge on both attitude (β = 0.442, P < 0.001) and practice (β = 0.174, P = 0.008), as well as of attitude on practice (β = 0.832, p < 0.001) (Table 6; Fig. 1). To explore differences between patients and family members, we conducted subgroup comparisons of KAP scores. As shown in Table 7, family members reported significantly higher attitude scores than patients (23.14 ± 2.60 vs. 22.59 ± 2.56, P = 0.020), whereas knowledge and practice scores did not differ significantly between the two groups. These findings suggest family members may hold more proactive or supportive views regarding melanoma management.

Table 6 SEM results.
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Fig. 1
figure 1

SEM.

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Table 7 Comparison of knowledge, attitude, and practice scores between patients and family Members.
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Discussion

Patients with melanoma and their family members exhibited inadequate knowledge but positive attitudes and proactive practices towards melanoma. Enhancing educational interventions tailored to improving knowledge levels while reinforcing positive attitudes and practices among patients with melanoma and their families is crucial for comprehensive melanoma care.

The outcomes of our investigation provide significant insights into the KAP regarding melanoma among individuals, illuminating commendable aspects and areas necessitating improvement within public health initiatives. These findings align with earlier scholarly inquiries, which have indicated a gap between public knowledge of melanoma and preventive practices15. Additionally, the disparity between knowledge and attitudes/practices may be partially attributable to individuals’ trust in healthcare professionals. Even in the absence of sufficient knowledge, individuals may exhibit positive attitudes and behaviors, possibly due to their trust in healthcare professionals. Healthcare professionals are often highly trusted when providing advice on melanoma prevention and treatment, which may prompt individuals to adopt recommended health behaviors despite their limited knowledge of the disease. This trust may stem from healthcare professionals’ expertise and experience, as well as societal and familial influences. Therefore, although individuals may lack comprehensive knowledge, their positive attitudes and behaviors may be partially influenced by their trust in healthcare professionals.

The observed variations across demographic groups offer valuable insights into the factors influencing knowledge, attitudes, and practices regarding melanoma. Notably, younger individuals aged 18–30 demonstrated higher scores across all domains, echoing findings from studies suggesting that younger age groups tend to be more receptive to health education interventions16. This underscores the importance of tailored educational strategies aimed at different age cohorts. Urban residents also exhibited higher knowledge and attitudes, potentially reflecting better access to healthcare resources and information dissemination channels in urban areas17. Strategies to bridge this urban-rural gap in knowledge and attitudes could involve leveraging telehealth and digital health platforms to disseminate information to remote or underserved populations.

Similarly, retirees and unmarried individuals showed higher scores across knowledge and attitude domains, indicating potential differences in health-seeking behavior and receptivity to health-related information based on socio-economic factors and life circumstances. Tailored interventions focusing on engaging these demographic groups through community-based programs or social support networks could enhance melanoma awareness and promote preventive behaviors. Additionally, the influence of lifestyle factors such as smoking and alcohol consumption on knowledge and attitudes underscores the need for holistic health promotion initiatives addressing behavioral risk factors alongside disease-specific education18.

The correlation analyses and SEM results further elucidate the complex interplay between knowledge, attitudes, and practices concerning melanoma. The positive correlations between knowledge and both attitudes and practices highlight the interconnected nature of these constructs, emphasizing the importance of enhancing knowledge as a precursor to fostering positive attitudes and behaviors19. The SEM findings corroborate these associations, revealing direct effects of knowledge on attitudes and practices, as well as the influence of attitudes on practices. These findings underscore the need for multifaceted interventions targeting not only knowledge acquisition but also attitudinal and behavioral changes to promote melanoma prevention and early detection efforts.

The study found that participants demonstrated varying levels of understanding regarding melanoma-related concepts. Notably, the highest scoring item, indicating that melanoma mostly develops from moles. This indicates a satisfactory understanding of basic melanoma etiology among the surveyed population. Conversely, the lowest scoring item, suggesting that histopathology is not the primary means of diagnosing melanoma, highlights potential misconceptions or gaps in knowledge regarding diagnostic modalities. This finding contrasts with established medical guidelines emphasizing the crucial role of histopathological examination in melanoma diagnosis20. To address this discrepancy, targeted educational interventions focusing on clarifying misconceptions regarding melanoma diagnosis and emphasizing the importance of histopathology in confirming diagnoses could be implemented. Incorporating interactive workshops or multimedia resources to enhance understanding of diagnostic procedures may help improve knowledge retention and comprehension among participants21,22. Furthermore, leveraging healthcare professionals as educators and providing accessible informational materials tailored to diverse literacy levels could facilitate dissemination of accurate information regarding melanoma diagnosis and management23.

Examining attitudes towards melanoma revealed nuanced perceptions among participants, with distinct patterns emerging across surveyed items. The item garnering the highest agreement pertained to the importance of undergoing treatment for melanoma, reflecting a positive attitude towards seeking medical intervention for the disease. Conversely, skepticism regarding the efficacy of melanoma treatment emerged as a prevalent attitude, indicating potential apprehensions or uncertainties among respondents regarding treatment outcomes. Addressing these attitudes necessitates fostering trust and confidence in melanoma treatment modalities through transparent communication and patient education. Healthcare providers play a pivotal role in addressing patient concerns and misconceptions, emphasizing evidence-based treatment approaches and discussing potential benefits and risks of interventions24,25. Implementing shared decision-making frameworks that involve patients in treatment decisions can enhance patient satisfaction and adherence to treatment regimens26,27. Additionally, community-based initiatives focusing on patient support networks and peer counseling can provide avenues for individuals to share experiences and gain reassurance regarding treatment efficacy.

Analysis of participants’ practices related to melanoma prevention and management highlighted notable variations in adherence to recommended behaviors. Participants demonstrated relatively high levels of engagement in certain practices, such as taking precautions against sun exposure and attending regular check-ups as advised by healthcare providers. However, inconsistencies were observed in other areas, with lower levels of adherence to self-examination and lifestyle adjustments as recommended by healthcare providers. This underscores the importance of addressing barriers to behavior change and promoting self-care practices among individuals at risk for melanoma. Interventions focusing on enhancing self-efficacy and self-monitoring skills, such as providing personalized risk assessments and tailored behavioral counseling, may facilitate sustained engagement in preventive behaviors28,29. Furthermore, leveraging digital health technologies, such as mobile applications for skin self-examination reminders and lifestyle tracking, can enhance accessibility and convenience, thereby promoting adherence to recommended practices30,31. By addressing these barriers and enhancing supportive environments for behavior change, public health initiatives can empower individuals to adopt and maintain melanoma preventive behaviors, ultimately reducing disease burden and improving long-term outcomes32,33.

This study has several limitations. First, its cross-sectional design prevents causal inferences between knowledge, attitudes, and practices. Second, all data were self-reported, which may introduce recall or social desirability bias. Third, the sample was hospital-based, potentially limiting generalizability to the broader population. In terms of data collection, we did not include clinical variables such as melanoma stage or disease duration, which may influence participants’ knowledge and attitudes. This also limited our ability to perform subgroup analyses based on clinical characteristics. The questionnaire design had some limitations. Certain items used subjective frequency terms (e.g., “sometimes”), which may be interpreted inconsistently across participants. Additionally, some items were double-barreled, combining multiple concepts (e.g., gender, age, and location), which could reduce clarity. Although the attitude subscale demonstrated good internal consistency, we did not conduct factor analysis or item-level evaluation, limiting the psychometric robustness of the instrument. Regarding statistical analysis, structural equation modeling (SEM) was conducted using total KAP scores as observed variables, rather than modeling latent constructs based on individual items. This approach may oversimplify the relationships among variables and increase the risk of conceptual overlap. In particular, the strong association between attitude and practice (β = 0.832) may reflect multicollinearity. Furthermore, we did not include potential moderating variables such as socioeconomic status or education level, which could have provided a deeper understanding of the factors influencing KAP outcomes. Finally, although the correlations between KAP dimensions were statistically significant, their strength was only weak to moderate, suggesting that other unmeasured factors may also contribute to participants’ behaviors and perceptions.

This study has several limitations that should be acknowledged. First, as a cross-sectional survey, it cannot establish causal relationships between knowledge, attitudes, and practices. Second, all data were self-reported, which may introduce response bias due to recall inaccuracies or social desirability. Third, the sample was drawn from hospital settings, which may limit the generalizability of the findings to the broader population. Additionally, the study did not collect clinical variables such as melanoma stage or duration of illness, which could potentially influence participants’ knowledge levels and attitudes toward treatment. In terms of questionnaire design, some items used vague frequency descriptors like “sometimes,” which may be interpreted differently across respondents. A few questions also combined multiple concepts in a single item (e.g., gender, age, and location), potentially affecting clarity. While the attitude subscale showed good internal consistency, we did not conduct factor analysis or item-level evaluation, which limits psychometric validation. Furthermore, our structural equation modeling used total KAP scores as observed variables rather than latent constructs based on individual items, which may have oversimplified the underlying relationships. Finally, no moderating variables (e.g., socioeconomic status) were included in the model. Future studies should address these issues through improved questionnaire design, inclusion of clinical data, and more comprehensive modeling approaches. Additionally, although the correlations among knowledge, attitudes, and practices were statistically significant, the observed r values indicate only weak to moderate associations, suggesting that other unmeasured factors may also influence these relationships. Moreover, we did not collect clinical information such as melanoma stage or disease duration, which limited our ability to perform subgroup analyses based on these important clinical variables. These factors may significantly influence patients’ and caregivers’ perceptions and should be considered in future research designs. Moreover, the strong association observed between attitude and practice (β = 0.832) in the SEM model may reflect conceptual overlap or multicollinearity, possibly arising from the use of total scores rather than latent constructs. This modeling limitation should be addressed in future studies through more refined psychometric approaches. Furthermore, although no multicollinearity was detected among the KAP dimensions based on correlation coefficients (all r < 0.7), the use of total scores in SEM rather than latent constructs may introduce conceptual overlap and limit the model’s interpretability. This modeling approach, while practical for the current dataset, should be refined in future studies through item-level analysis and latent variable modeling.

In conclusion, patients with melanoma and their family members exhibited inadequate knowledge but positive attitudes and proactive practices towards melanoma. Efforts should be directed towards enhancing educational interventions targeting both patients and their families to improve their understanding of melanoma and promote more informed decision-making regarding prevention and treatment measures.