Mass_Media_Health_Promotion_International_ by lanyuehua


									             Mass Media Barriers to Social Marketing Interventions:
                   The Example of Sun Protection in the UK


The role of mass media in communicating health related information to the wider

population is the focus of this paper. Using the example of sun protection within the

UK, we highlight some of the major challenges to raising awareness of steadily

increasing melanoma rates and of effective sun protection strategies. The

implications of potential barriers to official sun protection messages via conflicting

messages in the media are discussed in terms of editorial on sun protection and in the

way in which television programme content portrays the issues. Implications for

public policy and future research conclude the paper.


Mass media such as television and newspapers can potentially enhance social

marketing activity through reinforcing the key messages regarding desired

behaviours. Conversely, it can weaken the impact of social marketing

communications through confusing or conflicting messages. Those planning social

marketing interventions need to appreciate these factors and to seek ways of working

with media organisations to ensure consistency of messages sent and maximise the

potential impact of activity.

Sun Protection / Skin Cancer – Context

Skin cancer rates in the UK have doubled over the past decade (NICE, 2006), with

estimates of the annual cost of skin cancer treatment in England in excess of £190

million (Hiom, 2006). While UK skin cancer rates are one-quarter of those of more

high profile countries such as Australia (Jones et al., 2000), more Britons die of

melanoma each year than in Australia (Cancer Research UK., 2008). This can be

attributed to both earlier detection and higher levels of awareness of effective sun

protection strategies in the latter country; some 20 years of life are lost for each

melanoma death (Miranda, 2008). In the UK Malignant melanoma (MM), rates have

risen steadily by some 8% per year, faster than the increase in any other cancer

(Cancer Research UK., 2008).

Gandini et al (2005) state that IARC “has reviewed in great detail the relationship      Formatted: Font: (Default) Times New Roman

between melanoma and sun exposure and has accepted sun exposure as the main

cause of cutaneous melanoma in humans” (p. 46)

Young age groups are at particular risk; research has shown that one incidence of

serious childhood sunburn can double the risk of malignant melanoma (Crane et al.,

19993) and that simple behavioural changes such as avoiding the strongest sun and

appropriate use of sunscreen, hats and ‘long’ clothes could prevent 90% of cases

(Peattie et al., 2001).

Influence of Media Coverage on Health Behaviour

News items carried via mass media such as television are primary sources of health

information and 76% of people are reported to act on information provided, however

a review of ten years of US local TV news coverage of medical news found frequent

factually incorrect and potentially dangerous advice broadcast (Pribble et al., 2006).

Recent analysis of news coverage of prostate cancer in Australia identified 10% as

being inaccurate or misleading (Mackenzie et al., 2007)

Mass media is claimed to be at least as important as health care providers as

information sources regarding health-related topics (Clarke and Everest, 2006),

creating and maintaining assumptions, beliefs and perceptions (Nelkin, 1996). This is

illustrated by media coverage of the controversy over the combined measles, mumps

and rubella (MMR) vaccine that began in the late 1990s following media reports of a

study by Wakefield et al (1998) that appeared to imply a link between the MMR

vaccine and adverse health consequences such as autism. Some consumer media

were cited as “campaigning on the issue” to persuade parents that there was a

potential risk (Speers and Lewis 2004: 172), the Daily Mail running some 700 articles

around the topic in 1998 alone (Social Market Foundation, 2006; BBC 2006).

However the subsequent studies that refuted the speculative causal link made by

Wakefield and his co-authors (McMurray et al., 2004; Petts and Niemeyer, 2004),

were not extensively reported in the mass media (McGreevy, 2005; Speers and Lewis,

2004). The public may have reacted to the repetition of the general theme of the

controversy, rather than to the scientific evidence as the percentage of UK children

being vaccinated with the combined MMR vaccine fell from 92% to around 80%, and

as low as 50% in some metropolitan areas (Speers and Lewis, 2004; Wood-Harper,

2005). Low vaccination rates – and a corresponding substantial increase in the

incidence of measles are being directly blamed on the consumer media on the MMR

controversy (Rose 2009).

Additional areas in which news media coverage of health-related topics has

substantially influenced behaviours include mammography and hormone replacement

therapy (Canales et al., 2008).

Social Marketing and Sun Protection

With the incidence of skin cancer having doubled over the last decade (NICE, 2006) it

is surprising that the UK Department of Health has not highlighted sun protection

strategy awareness and early skin cancer detection as a key health promotion area.

Large-scale communication programmes have been implemented with success in

countries such as Australia (Sinclair & Foley, 2009; Dobbinson et al, 2008), and the

USA (Del Mar et al., 1997; Gelb et al., 1994). However, such programmes have not

been funded in the UK and Government funding for Cancer Research UK’s SunSmart

campaign actually reduced from £180,000 in 2006/07 to £127,000 in 2007/08 (Cancer

Research, 2009), This is at a time when additional investment in awareness and

detection programmes and support from mass media coverage would appear to be

more appropriate.

The current UK funding levels have facilitated the development of web-based

activity, including downloadable resources such as leaflets and posters for schools and

other organizations. It does not allow for the use of mass consumer media which

Donovan & Henley ( 2003) suggest play an important role in educating and

informing, as part of an integrated programme aimed ultimately at behavior change.

As information about sun protection and skin cancer is largely passively acquired via

consumer media, with active searching only undertaken to resolve a specific problem

(Eadie & MacAskill, 2007) over-reliance on leaflets distributed via the Internet and /

or print-based resources may not be effective with all target segments.

News Media Coverage regarding Sun Protection

In addition to the lack of awareness of skin cancer as a major health risk, there are a

number of additional barriers to effective communication of a consistent sun

protection message. Confusing and contradictory messages are often apparent: “news

values can conflict with science, media and public health agendas” (Kline, 2006: 50)

and the information presented by mass media outlets is criticised for its lack of

accuracy and tendency to ‘hype’ reports (Larsson et al., 2003).

This is particularly evident in the context of sun protection in coverage of the role of

Vitamin D as the following section illustrates

News Media Coverage of Vitamin D related issues

.Vitamin D has numerous health benefits and, while it can be obtained from food

sources and dietary supplements as well as sunlight, debate in the media has centred

on sun exposure (see for example, Akerman, 2007; Gillie, 2006). There is

considerable debate in the academic literature regarding positives and negatives (see,

for example, Gillie, 2006, Diffey, 2004; Ness et al., 1999) of sun exposure: little

balanced debate filters through to consumer media. There is a growing perception

that sun protection may result in not having enough Vitamin D, potentially

undermining the effectiveness of long-running sun protection campaigns (Janda et al.,

2007). Vitamin D deficiency is a recognised problem within some minority groups

whose cultural norms dictate that most skin is covered by clothing (Ladhani et al,

2004). The issue is further complicated by the lack of a readily comprehendible guide

to optimal quantities of Vitamin D across different population groups (Glerup et al.,

2000); concerns are even evident on this issue within the WHO (Lucas et al., 2006)

but not discussed by the consumer media.

While the association between Vitamin D deficiency and increased risk of some

cancers, cardio-vascular disease, diabetes, multiple sclerosis and rheumatoid arthritis

is acknowledged in the scientific literature, causality is noted as not being determined

(Youl et al., 2009). Further, the relative influences of factors including diet, lifestyle

and environmental factors on these illnesses are not yet understood (Hedges and

Scriven, 2008; IRAC 2008)). The coverage of Vitamin D in consumer media must

give cause for concern, given the somewhat simplistic treatment of the topic, as the

examples from main media on-line editions in Table 1 illustrate. Note: many of the

topics were covered in multiple media; we have shown only the first medium to carry

the story.


Attention-grabbing headlines do not reflect Vitamin D’s contribution to health and

well-being relative to other factors. For example, a Times newspaper article with the

headline ‘Secret to summer loving: Vitamin D’ which implied exposure to sunlight

might improve male fertility through higher levels of Vitamin D. Only in the article

copy was the greater impact of other factors noted (Affleck (2005).

Implications of Vitamin D media overage for Sun Protection

More worrying is the challenge to official sun protection messages in some popular

media, as illustrated by the following extract from an article in Psychology Today

which sums up the battle of images and perceptions faced in developing interventions

in this area.

   “Hold the sunscreen –at least for a few minutes. Evidence is emerging that

   some unfiltered sun exposure repels ills from heart disease to cancer to multiple

   sclerosis, not to mention depression – enough to add seven years to your life.

   Are you ready for a more nuanced view of sunshine” (Ackerman, 2007: 97).

While no UK specific studies could be located regarding the impact of news media

coverage, findings from Australia should give cause for concern. A large-scale (over

two thousand respondents) survey of the Queensland population found significant

increases since 2004 in the percentage of the population believing that the use of sun

protection creams increases the risk of Vitamin D deficiency and that Vitamin D helps

prevent cancer. In addition, many people significantly overestimated the amount of

sunlight needed to maintain healthy Vitamin D levels. The authors suggest that

misconceptions regarding these issues may influence people to reduce existing sun

protection behaviours (Youl et al., 2009).

A study of sun protection behaviours among undergraduate university students (Eagle

et al 2008) included an open-ended question to determine knowledge of sources of

Vitamin D. Table 2 indicates that there is little meaningful awareness of sources

among this group. While the percentage identifying sunlight is higher than the other

sources, several respondents indicated some awareness’ of the dangers of

overexposure by qualifying their responses with comments such as ‘limited

exposure’, or ‘early morning sun’.


Influence of Editorial and Programme Content

In addition to media news coverage, editorial and programme content also play a role

in building and maintaining the implicit relationship between having a suntan and

perceptions of health / attractiveness, consistent with the Integrative Model of

Behaviour Change, an extension of the widely used Theory of Planned Behaviour,

shown in Figure 1. Young adults must be a significant target for communication as

they are still able to alter their behaviour and thus possibly reduce their risk of skin

cancer (Hedges and Scriven, 2008).

Editorial and programme content cancontent can influence behaviour (Moriarty and

Stryker, 2008). The Theory of Social Comparison, originally developed in the 1950s,

(Festinger, 1954) has been used to demonstrate that young people compare their

perceived attractiveness with that of models or celebrities featured in the media and

are motivated to change their physical appearance to emulate these people

(McDermott et al., 2005). Thus, models, celebrities or actors in television

programmes with tanned skin may be used as perceived ‘aspirational norms’.

In Australia at least, portrayal of models in magazines contradicts public health

messages regarding sun protection behaviour (Dixon et al., 2007) and in the USA,

television programmes glamorising tanning salons, including featuring celebrities

who have used sunbeds etc, have been heavily criticised (Poorsattar and Hornung,

2008) for failure to include any warnings regarding potential negative effects.

Adolescent Optimism and Perceptions of Behavioural Risk

Among adolescents international research indicates that a tan is perceived as‘sexy’

(Curtis, 2008; Grunfeld. 2004; Cafri. et al. 2006; & Lowe et al., 2000), increasing

perceived attractiveness and raising adolescents’ sense of self esteem; young female

sunbed users have been identified as being more anxious about relationships than

others and thus more reliant on tans to increase their perceived appeal (Fiala et al.,

1997). There are several dangerous attitudes prevalent within this group particularly

that it is ‘worth’ getting sunburnt in order to get a tan (Geller et al., 2002) and that

less protection is needed as tan progresses (Hiom et al., 2006).

Adolescents are also prone to optimism bias, believing that they are personally at less

risk of ill-health than the general population (Harris et al., 2000). This is consistent

with Leventhal’s Self Regulatory Model (Leventhal et al., 1999) whereby rational

knowledge of risk is shown to be countered, if not over-ridden by, the emotional

desire of adolescents to be seen as part of an ‘in’ group. In addition, young women

have a higher knowledge of skin cancer than do their male counterparts, but are also

more likely to sunbathe and to use sunbeds (Abroms et al., 2003). Conversely, young

males see sunscreen as cosmetic and not masculine, leading to a reluctance to apply it

when with their peers (Jones et al., 2000). Although Malignant Melanoma is twice as

prevalent among young women than young men (aged 15 – 34) more men die from it

(ISD, 2008) and, as noted previously, on average, about 20 years of life are lost for

each melanoma death (Burnet et al., 2005; Diffey, 2005)

There are numerous studies indicating that adolescents are aware of risks but that

social norms and perceptions over-ride consideration of personal actions if they are

not compatible with peer behaviour (see for example, Luo & Issaacowitz, 2007;

Brandstrom et al., 2004; Sjoberg et al., 2004). These studies all highlight the potential

influence of the way media portray social impacts of sun tanning behaviours such as

attractiveness in both editorial and programme content.



There is a large body of literature stressing concerns regarding the use of sunbeds

(Autier, 2004), coupled with an acknowledgement of a lack of awareness among

sunbed users of the dangers of excessive use (Chan, 2007). There is specific evidence

to support a causal relationship between sunbed use and skin cancer, particularly with

exposure before the age of 35 years (IARC, 2006). However, even when some

knowledge is gained, evidence from both the USA and Europe indicates that

behaviour, particularly among a key user group of adolescents, does not change

(Lazovich and Forster, 2005).

In July 2009, media prominence was given to research that confirmed the
carcinogenic dangers of sunbeds, with headings such as the following:

Publication        Headline                           Medium
29 July            Sunbeds now seem to be as          Telegraph
                   deadly as great white sharks
30 July            Experts issue powerful             CBS News
                   Tanning bed warning      
30 July            ‘No doubt’ sunbeds cause           BBC News

This appeared in tandem with editorial illustrating graphically that sunbed users were   Formatted: Line spacing: Double

prepared to ignore the risk in pursuit of a tan, as the following three examples


Publication        Headline                            Medium
30 July            Why I’d rather die by using a       Mirror
                   sunbed than be pale       
31 July            Skin cancer? They don’t care.       News & Observer
                   Tanning bed users ignore  
                   warning                             m
6 August           Tanning beds moved into top
                   cancer risk, tanners remain         m

Despite growing awareness of the dangers of sunbeds many men and women continue

to use sunbeds regularly (Autier, 2004). As long as the psychological association

between having a tan and health continues to be reinforced in the promotional

materials used by tanning salons and in editorial and programme content, the use of

sunbeds is likely to continue to increase, especially amongst teenagers and young

adults (Dorset Cancer Network 2009). The recently announced ban on the use of

sunbeds by under 18s (Smith, 2010) may go some way to reducing sunbed use, but

there is a need also to recognise the potential of a ‘rebound’ effect due to the

perceived social value of a sun tan.

UV Indexes

In the absence of mass communications regarding sun protection, efforts should be

made to ensure that awareness can be leveraged off any form of news or publicity that

may be linked to sun protection. Many media, especially radio stations, report the

UV index data in the summer,summer; however this may not be a particularly strong

tool, given evidence from other markets. There has been considerable effort placed

on promoting UV indexes in several markets such as Australasia, but utilisation is low

( Carter & Donovan, 2007; Blunden et al., 2004; Alberink et al., 2000). In the UK,

there is evidence of a lack of understanding of its implications for sun exposure

behaviour ( Eagle et al., 2009). Additionally, there is a lack of understanding of

correct use and the effects of sunscreen use, the meaning of SPF factors on sunscreen

product labels and holistic sun protection behaviours Hedges and Scriven, 2008).

Implications / Directions for Future Research

The UV Index is just one possible area where collaboration with the media to educate

people as to the relevance of personal sun protection behaviours is recommended.

Collaboration to assist media such as radio stations in developing simple,

understandable formats for presenting the information would also be beneficial

(Richards et al., 2004).

At an even more basic level, there appears to be confusion about what sunscreens do

and somewhat muddled perceptions as to the amount of protection they offer, and by

how much they can prolong time spent in the sun (Diffey and Tayler, 2004; Diffey,

2001). Again, collaboration with the media could have significant positive benefits.

While mass media sun protection interventions appear from the experience, of other

countries, to be warranted, current UK funding levels at just over £500,000 prevent

this (Cancer Research, 2010). Planners of social marketing interventions, not just

within the sun protection / skin cancer detection area, need to understand the influence

of the media on attitudes and beliefs. They can then develop strategies for liaising

with media organisations regarding editorial / news and programme content regarding

balanced coverage of issues and ways in which recommended behaviours can be

‘modelled’. However, specifically within sun protection all parties would benefit

from a greater understanding of the major issues. There is a need for a coordinated

research agenda to determine the relative importance of a range of health-related

information sources across specific topic areas and population segments. There is also

a need to understand how and why the news media portray specific issues (Heneghan

et al, 2007) in order to help develop more effective communication strategies. News

media and the Internet should be monitored for coverage of specific topics and

changes to coverage over time, with this data being used to inform strategies aimed at

ensuring accurate and balanced coverage of issues. In addition, a survey of the

developers of a range of major social marketing programmes and news media editors

should be undertaken to identify best practice in addressing social norms and effective

media liaison strategies. Furthermore although it is known that media can influence

behaviour (Moriarty and Stryker, 2008) the extent of that influence relative to other

factors requires further investigation.

Declaration of funding sources: This work was supported by funding from the South
West Public Health Observatory


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Table 1: Examples of Media Headlines Regarding Benefits of Vitamin D

Date      Headline                                       Source
1 May     Aid could be found in Vitamin D                The Boston Globe
5 May     No proof: Study could not link low             The Washington Post (via
2009      Vitamin D to colds                   
12 May    Is there a link between Vitamin D, flu         Virgo Publishing
2009      immunity?
13 May    Vitamin D helps reduce diabetes risk           Private Healthcare UK
13 May    Vitamin D deficiency common in                 http://professional.cancerconsultants.c
2009      premenopausal women with breast caner          om
          despite supplementation
14 May    Wrong sunlight can lower your Vitamin D
2009      levels
15 May    High Doses of Vitamin D may prevent  
2009      relapses
16 May    Millions face serious health risks over lack
2009      of Vitamin D in diets
16 May    Elderly need more ‘sun vitamin’      
21 May    Vitamin D ‘key to healthy brain      
22 May    New model of Cancer development: Low           Science Daily
2009      Vitamin D levels may have role       
25 May    Nutrition: Vaginal Infection Tied to Low       The New York Times
2009      Vitamin D                            
26 May    Vitamin D may lessen Age-related     
2009      Cognitive Decline
26 May    Vitamin D doesn’t protect against cancer       Doctor NDTV
29 May    Low Vitamin D levels may impair      
2009      thinking
31 May    Boosting levels of Vitamin D ‘could cut
2009      cancer by up to 25%’
June 1    Promote Vitamin D testing for public Joint
2009      Canadian Tanning Association urges
          Canadian Cancer Society
2 June    How avoiding the sun to protect against
2009      skin cancer has left Georgia Coleridge
          facing the threat of brittle bones
3 June    MS research highlights role of Vitamin D
17 June   Vitamin D call as march bids to cut MS
2009      rate
24 June   Vitamin D guidelines and beauty benefits
24 June   Vitamin D and depression             
24 June   Huge Vitamin D study planned         

Table 2: Open Ended Responses to Ways the Body can Acquire Vitamin D
Sources of Vitamin D                           % of respondents indicating this
Food                                           13
Fruit and vegetables                           10
Sunlight                                       36
Vitamin Supplements                            18

Figure 1: Fishbein et al. Integrative Model of Behavioural Prediction and
Change (Fishbein, 2000)
    Background influence

       Past behaviour
                                and Outcome
       Demographics &           Evaluations                     Environmental
       culture                                                  factors

       Attitudes towards
       targets (stereotypes &
       stigma)                  Normative            Norm
                                Beliefs and
                                                                Intention              Behaviour
       Personality Moods and    Motivation to
       emotions                 Comply

       Other individual
       difference variables                          Self       Skills and abilities
       (perceived risk)                              Efficacy
                                Control Beliefs
                                and Perceived
       Intervention exposure    Power
       Media exposure


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