Skin Tone in Patient Education Images Shapes Melanoma Awareness Across Ethnic Groups

Acral lentiginous melanoma, or ALM, is one of the most deceptive and dangerous forms of skin cancer, and a new study suggests that something as seemingly simple as the skin tone of the models pictured in patient education materials can dramatically change how well people absorb its warning signs. The research, published in the Journal of Behavioral Medicine, tested three versions of ALM education illustrations—one featuring white-skinned models, one with light brown skin, and one with dark brown skin—among Hispanic/Latino and African American participants. The results reveal a striking pattern: the most effective visuals differ depending on who is looking at them, and the reason appears to lie in how memorable a message feels when it arrives.

The stakes of this research are far from academic. ALM is an aggressive melanoma subtype that does not follow the usual rules of skin cancer. While most melanomas are driven by ultraviolet exposure and occur more frequently in people with fair skin, ALM develops on the palms of the hands, the soles of the feet, and underneath the nails—places that rarely see the sun. Its incidence is rising among Hispanic/Latino populations, and African Americans face the highest mortality rate of any group. Because ALM lesions do not display the classic features captured by the widely taught ABCDE method—Asymmetry, Border irregularity, Color variation, Diameter greater than six millimeters, and Evolving over time—the standard prevention campaigns built around sun safety and mole checking simply do not apply.

The consequences of this knowledge gap are measurable and severe. People of color are twice as likely to be diagnosed with melanoma at stage IV and 1.4 times more likely to be diagnosed at stage III compared with their White non-Hispanic counterparts, according to prior studies cited by the research team. Delayed diagnosis translates directly into greater morbidity and mortality. Part of the problem is that both patients and physicians struggle to recognize ALM’s warning signs, and ethnic minority patients report that their primary care providers rarely discuss melanoma during wellness visits. Compounding all of this, there is a sheer absence of quality, representative patient education materials aimed at ethnic populations; most materials in the public domain feature non-Hispanic White models, showing ALM lesions on lighter skin.

That absence of representation is not a neutral oversight, the researchers argue. When every educational image shows a dark lesion on pale skin, it can indirectly communicate that people with darker skin tones are not vulnerable to the disease—a long-standing and harmful belief. The problem is especially acute because older adults and ethnic populations, who face higher ALM incidence, often have lower health literacy, and visuals are known to be one of the most effective ways to educate people with lower literacy and numeracy. Illustrations can carry information that dense text cannot, making them a critical tool in communities that are medically underserved.

To test whether targeted visuals could close this gap, the team built on an earlier study in which they had commissioned a professional designer, using a crowdsourced design marketplace, to create ALM education materials featuring darker-skinned models. That first study found that participants with darker skin tones showed greater knowledge gains when viewing materials with darker-skinned models, and that the effect flowed through message memorability—when people found the materials memorable, their knowledge increased. For the new study, the same designer refined and expanded the illustrations, creating three versions calibrated to the Fitzpatrick skin type scale, the standard dermatological classification that sorts skin into six types based on color and reaction to ultraviolet light. White materials depicted skin types I and II, light brown materials types III and IV, and dark brown materials types V and VI.

The experiment enrolled 313 participants, roughly half Hispanic/Latino and half African American, with an average age of 46.2 years. About half were male, half had a high school education or less, and slightly more than half reported household incomes below $49,000. Recruited through a Qualtrics panel, participants were randomly assigned to view one of the three education material versions and then completed an immediate post-test. Knowledge was assessed with a fourteen-item composite scale combining nine text-based questions with five visual identification tasks in which participants had to pick which of five images could depict ALM. Memorability was measured with a validated seven-point semantic differential scale asking whether the material would stick in the head, was memorable, would be thought about again, and was unforgettable.

The statistical analysis, using factorial ANOVAs and a moderated mediation model with 5,000 bootstrap samples, uncovered an interaction that neither simple demographic targeting nor a one-size-fits-all approach would have predicted. Hispanic/Latino participants perceived the dark brown materials as more memorable than the white ones, and the light brown materials as more memorable than the white ones as well; correspondingly, their knowledge scores were significantly higher after viewing either the light brown or dark brown versions compared with the white version. African American participants showed a different profile: they rated the dark brown and white materials as more memorable than the light brown version, and their knowledge scores were higher with dark brown and white materials than with light brown ones. In other words, the light brown materials—perhaps the intuitive middle-ground choice for reaching both communities—were actually the weakest option for African American participants.

The mediation analysis added a crucial theoretical layer. For Hispanic/Latino participants, exposure to the dark brown materials compared with white ones had a significant indirect effect on ALM knowledge through memorability, and the index of moderated mediation confirmed that race/ethnicity significantly moderated this indirect pathway. Memorability once again emerged as the key mechanism of effect, consistent with the theory of memorable messages, which holds that messages remembered over long periods can reshape attitudes, beliefs, and behaviors. The researchers frame their materials as disrupting messages—interventions that correct unproductive prior messaging, in this case the entrenched belief among people of color that skin cancer is not their problem. Rather than recalling information word for word, people retain the essence of memorable messages and reinterpret it across their lives, which makes memorability a powerful lever for health communication aimed at marginalized communities.

Some findings defied easy explanation, and the authors are candid about that. It was unexpected that African American participants did not respond better to light brown models than to white ones. One possibility is that African American audiences are accustomed to seeing white-skinned models in health and advertising materials and have learned to extrapolate that the information applies to them too. Another is that ALM lesions may be visually more distinct against lighter skin because of contrast. A third, more socially complex explanation involves colorism—the documented discourse around skin tone differences within African American communities—which may trigger stronger identification with dark brown models. Meanwhile, Hispanic/Latino participants were less influenced by white models despite some of them having fair skin types themselves, suggesting that identification operates through cultural and ethnic channels rather than skin tone alone. The authors note that, absent a manipulation check confirming participants perceived the models’ skin tones as intended, they cannot rule out that the conditions differed in perceived representation in unanticipated ways.

The practical implications are concrete. Patient education materials designed for Hispanic/Latino audiences should depict models with either light brown or dark brown skin, while materials for African American audiences should feature dark brown or white models. Beyond that, the study charts a methodological path forward: qualitative interviews to understand how people construct meaning from these visuals, paired with psychophysiological measures such as eye tracking, physiological arousal, and facial expression analysis to verify that participants actually attend to and process model skin tone. The authors also acknowledge limitations—no behavioral outcomes were measured, the mediation analysis relied on cross-sectional data, three skin tone categories cannot represent every shade, and the visual knowledge questions used wording that may have introduced ambiguity. Still, the core message stands: in the fight against a melanoma that hides on palms, soles, and nailbeds, who appears in the picture can determine whether the warning is remembered at all.

Subject of Research: Targeted visual health communication for acral lentiginous melanoma awareness among Hispanic/Latino and African American populations

Article Title: The effectiveness of targeted visuals: Improving awareness of acral lentiginous melanoma among Hispanic and African American participants

Article References: Pokharel, M., John, K. K., Liao, Y., Wu, Y. P., & Jensen, J. D. (2026). The effectiveness of targeted visuals: Improving awareness of acral lentiginous melanoma among Hispanic and African American participants. Journal of Behavioral Medicine. https://doi.org/10.1007/s10865-026-00716-9

Image Credits: AI Generated

DOI: 10.1007/s10865-026-00716-9

Keywords: acral lentiginous melanoma, patient education materials, skin tone, Hispanic/Latino health, African American health, memorable messages, demographic targeting, health communication, skin cancer disparities, visual knowledge, melanoma awareness, Fitzpatrick skin type scale