Challenging Dogma


...Using social sciences to improve the practice of public health

Thursday, April 26, 2007

The “Choose Your Cover” Campaign Does Little To Reduce Skin Cancer Prevalence In The United States - MaryKate Martelon

The incidence of skin cancer cases, which includes malignant melanoma, basal cell and squamous cell carcinomas, continues to increase by 4% each year(1). Many of these cases are caused by the exposure to ultraviolet (UV) light that occurs during childhood (2) and much of this increase is due to the high prevalence of sunburns, an indicator of sun exposure, among young adults (3). To reduce and prevent this high prevalence, the Centers for Disease Control and Prevention (CDC) and the United States Department of Health and Human Services (DHHS) created a campaign titled, “Choose Your Cover.” This campaign aims to show young people that they can have fun outdoors while protecting themselves from the sun using five different methods: seeking shade, covering up, getting a hat, wearing sunglasses, and rubbing on sunscreen (4).

The campaign’s materials are designed in accordance with the attributes of the Health Belief Model, a psychological model used to predict an individual’s behavior. It states that a person will examine their perceived susceptibility, the perceived severity of the outcome and weigh the benefits and barriers of adopting the behavior before performing an action (5). In only using this model however, the campaign fails to fully address the attitudes, behaviors, and social norms that define the young adult population. Also, even if the Health Belief Model were the correct model to use, this campaign does not convince young adults of their perceived susceptibility, the perceived severity of skin cancer or address the benefits and barriers of covering up. Therefore, although the “Choose Your Cover Campaign” has an important message in preventing skin cancer, its use of the Health Belief Model does little to address the thoughts and actions of today’s youth, causing it to fail in its preventive measures.

Perceived Susceptibility

Most young adults are concerned with the present and worry little about diseases that could affect them in adulthood. Until recently, skin cancer has been shown to affect mostly adults, but this statistic is changing as doctors are now diagnosing people at a younger age, some even as young as in their twenties (6). The campaign does not address this fact however, because it only shows adults developing skin cancer and young adults developing sunburns. By not mentioning that they can develop skin cancer, the campaign is unable to convince teens of their susceptibility.

In addition, many people who do not have fair or pale skin believe they are not susceptible to developing skin cancer. Even though the campaign targets the high-risk group of fair-skinned individuals, it does not state that every race can develop a sunburn after sun exposure and in turn develop skin cancer. One study reported that 21.5 percent of white Hispanics, 27.4 of American Indian/Alaskans, 18 percent of Asian/Pacific Islanders, 14.2 of Black Hispanics, 5.3 of Black non-Hispanics, and 44.1 of White non-Hispanic men had at least one sunburn in 1999 (7). Similar trends were seen for women. From this data, it is evident that all races should be targeted, not just the high-risk group.

For the campaign to succeed, it is necessary to show that all ages and races are susceptible of developing skin cancer.

Perceived Severity

The “Choose Your Cover” campaign attempts to convince young adults that skin cancer is dangerous, but fails to address its severe effects. The campaign does discuss sunburns, skin cancer, sun spots, wrinkles, and leathery skin, but does not include photos of people with these attributes.

In a study conducted by Mahler, images of these characteristics actually increased the use of sun protective behaviors. Mahler used UV photographs and photo-aging information to show people the abnormalities caused by sun exposure on their skin that would not normally be seen under regular light. Once people were shown these images, they were more inclined and more likely to practice sun-protective behaviors (8). Although this exact method is impractical for this widespread campaign, it is still possible for the CDC to include UV photographs of young adults. After seeing these images, it is probable that young adults would comprehend the harmful effects of sun exposure.

Also, the campaign does not emphasize the point that it is possible to die from malignant melanoma. Even though skin cancer does not kill as many people as other cancers, it still caused 9,904 deaths in 2002 (9). Therefore, it is necessary for the CDC to include more information on all of the effects of skin cancer and not just discuss the mild ones in order for young adults to fully grasp the lethality of this disease.

Barriers

Many of the barriers in promoting sun protective behaviors result from the social norms of the young adult population. Many young people are preoccupied with their appearance and are concerned with the actions and thoughts of their peers. As a result, most of the covers are considered to be a nuisance to them.

Young men are more likely than young women to wear the majority of the promoted covers, but are less likely to wear sunscreen resulting in a higher prevalence of sunburns (10). Many men feel uncomfortable applying sunscreen to their male friends or asking another male friend to help them. Also, many find sunscreen to be too similar to a female cosmetic product because of its smell and texture. In addition, men accumulate most of their sun exposure through outdoor activities. They refrain from wearing sunscreen during these activities because it becomes painful once it enters the eye and causes the hands to be too slippery for most sports. As a result, sunscreen is too bothersome for most men to wear (11).

Young women are less likely to wear these covers because today’s culture defines beauty as being in fashion and having a tan. In order to get a tan, many women will remain under the sun for hours diminishing the effects of the sunscreen they have applied. Also, as many as 2.3 million teens will frequent a tanning salon at least once a year in order to preserve their tan during the winter months (12). In addition, the promoted wide-brimmed hats and shirts are considered to be out of fashion and therefore will not be worn by most young females. Finally, many will not wear greasy sunscreen in order to prevent acne from forming on their faces (13).

Furthermore, many women are misguided by the fact that tanning indoors is safer than tanning outdoors. In truth, UVA radiation from tanning salons and UVB radiation from the sun are both considered to be known human carcinogens. The UV emission of many tanning salons is actually equivalent to or exceeds the UV emission of the midday sun in southern Europe (14). In order to protect themselves from sunburns, some women even will go to a tanning salon before they go to a beach which offers “virtually no protection against sun-induced DNA damage” (15).

The CDC does not and cannot address any of these barriers because of their use of the Health Belief Model. The Health Belief Model does not take into consideration that an individual’s behavior may be influenced by outside factors including peers or social norms. Therefore, in order for the campaign to address these barriers, the CDC needs to choose a psychological model that is not solely concerned with an individual.

If the Health Belief Model were the correct model to use, it would be necessary for the campaign to include multiple options for the promoted covers in order to help young adults overcome these barriers. For example, the campaign should mention that there are non-greasy and non-pore clogging forms of sunscreen as well as ones specifically made for athletics. Also, covers that are considered to be in fashion and information about the hazards of tanning salons should also be mentioned.

Benefits

The campaign does in fact discuss many of the benefits of wearing the promoted covers including preventing sunburns, leathery skin, skin cancer, and sunburns (16). Most of these benefits however, can only be appreciated during adulthood. Therefore, for young adults to understand the benefits of these protective behaviors, the CDC should find and discuss ones that young people could see currently.

For the Future

The “Choose Your Cover Campaign,” ended in 2003 and did not increase the prevalence of sun protective behaviors as skin cancer cases are still on the rise. In order for a campaign such as this to succeed, the developers must correctly use a psychological model that will allow them to fully address the social norms, attitudes, and beliefs of the young adult population.

REFERENCES

1. Hall I, May D, Lew R. Sun Protection Behaviors of the U.S. White Population. Preventive Medicine 1997; 26:401-407.

2. Cokkinides V, Weinstock M,Glanz K. Trends in Sunburns, Sun Protection Practices, and Attitudes Toward Sun Exposure Protection and Tanning Among US Adolescents, 1998-2004. Pediatrics 2006;118:853-864.

3. Saraiya M. Sunburn prevalence among adults in the United States, 1999. American Journal of Preventive Medicine; 23:91-97.

4. Centers for Disease Control and Prevention, Choose Your Cover. Atlanta, GA:Centers for Disease Control and Prevention. http://www.cdc.gov/cancer/skin/chooseyourcover/.

5. Wikipedia. Health Belief Model. http://en.wikipedia.org/wiki/Health_Belief_Model.

6. Rawe J. Why Teens Are Obsessed with Tanning. Time. http://www.time.com/time/magazine/article/0,9171,1220506,00.html.

7. Saraiya M. Sunburn prevalence among adults in the United States, 1999. American Journal of Preventive Medicine; 23:91-97.

8. Mahler H. Effects of UV Photographs, Photoaging Information, and Use of Suncless Tanning Lotion on Sun Protection Behaviors. Archives of Dermatology 2005; 141:373-379.

9. Centers for Disease Control and Prevention, Basic Info. Atlanta, GA: Centers for Disease Control and Prevention.http://www.cdc.gov/cancer/skin/basic_info/.

10. Abroms L. Gender Differences in Young Adults’ Beliefs About Sunscreen Use. Health Education and Behavior 2003; 30: 29-43.

11. Abroms L. Gender Differences in Young Adults’ Beliefs About Sunscreen Use. Health Education and Behavior 2003; 30: 29-43.

12. Rawe J. Why Teens Are Obsessed with Tanning. Time. http://www.time.com/time/magazine/article/0,9171,1220506,00.html.

13. Abroms L. Gender Differences in Young Adults’ Beliefs About Sunscreen Use. Health Education and Behavior 2003; 30: 29-43.

14. The International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer. International Journal of Cancer 2006; 120:1116-1122.

15. The International Agency for Research on Cancer Working Group on artificial ultraviolet (UV) light and skin cancer. International Journal of Cancer 2006; 120:1116-1122.

16. Centers for Disease Control and Prevention, Choose Your Cover. Atlanta, GA:Centers for Disease Control and Prevention. http://www.cdc.gov/cancer/skin/chooseyourcover/.

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