Challenging Dogma - Spring 2008

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

Monday, April 21, 2008

Current Skin Cancer Prevention is Not Effective: Could Restructuring Prevention Campaigns be the Missing Link? - Rachael Levitz

As seen in data published by the Center for Disease Control and Prevention, cancer is now the second leading cause of death in United States(1,8,9). Though there are many types of cancer, skin cancer in particular has been become the most common form of cancer in the United States. Throughout the last three of decades, the incidence of skin cancer has been on the rise. Currently more than one million patients are diagnosed with skin cancer each year, and approximately one in five Americans is likely to develop skin cancer over the course of a lifetime(9). Compared to the daunting statistics correlated to skin cancer there is a positive aspect to this disease. Skin cancer is known to be the most preventable form of cancer. In a recent statistic published by the Skin Cancer Foundation, approximately ninety percent of all skin cancers are caused by excess sun exposure(8). The fact that skin cancer is so preventable makes this a desirable intervention for public health campaigns.

The National Comprehensive Cancer Control Program, NCCCP, is one organization that has helped to develop skin cancer prevention campaigns. The NCCCP acts as a mentor and benefactor of smaller organizations, giving them not only a model to base their campaigns upon, but also funds to develop a state-wide cancer prevention plan(1). Certain information must first be gathered when administrators plan a state campaign. First, data is collected from national surveys to calculate the prevalence of skin cancer. Secondly, the objectives for the campaign relating to the state’s awareness, policy change, and reduction of sunburns is determined(1). Lastly, a detailed analysis for the incidence and trends relating to the different subpopulations are calculated(1). After the collection of this initial information, the barriers, goals, and action plans for the campaign can be determined.

The North Carolina Department of Public Health advertising campaign for the summer of 2006 is an example of one of the campaigns developed by the NCCCP. The campaign consisted of print ads that would run in newspapers across North Carolina in May 2006 (Figure 1). The ads were aimed at parents of young children and were used in correlation with the saying “It only takes five sunburns to double the risk of skin cancer.” Underneath the campaign’s slogan in smaller writing is a list of other ways, in addition to sunscreen, that parents can help limit their children’s risk of skin cancer: limit sun exposure, cover up, wear a hat, and wear sunglasses(7). The campaigns goal was to show that skin protection is needed not just for the obvious times like at the beach, but for anytime you step out into the sun. Though this campaign’s message is enlightening, the advertisement is a classic example of the Health Belief Model. To make significant advances in decreasing the prevalence of this preventable cancer, campaigns must: 1) use alternative public health models that are geared toward changing the social norms of sun protection, 2) aim the campaign toward adolescent populations as well as adults, and 3) stress that parental skin cancer prevention behavior is indeed modeled by children.

Altering the social norm, being tan is un-cool.

The print ad shown in Figure 1 reflects the Health Belief Model (HBM). As one of the most frequently used behavior theories in public health, it is no wonder the department of North Carolina Public Health chose this model for their campaign. The HBM states that in order to know whether a person will change a health behavior, that individual will compare the benefits of changing that behavior, to the barriers of changing the behavior(15). After weighing the pros and cons of altering their current health behavior an individual will then decide whether they want to change their behavior. If an individual possesses the intention to change their behavior, the HBM says that an individual will indeed do so(15). Unfortunately evidence shows that this is not always the case; sometimes intention is not a catalyst of a change in behavior. In 1999, the Behavioral Risk Factor Surveillance System (BRFSS) survey reported that the sunburn rate among the caucasian population in North Carolina was approximately 32%(5). When the 2006 BRFSS survey results for North Carolina were published, just five months after the 2006 North Carolina department of Public Health ran their print ad campaign, the percentage of the caucasian population that wore sunscreen when going outside during the summer months had stayed the same at about 3o%(6). This proves that the print ad had little to no effect on getting people to protect themselves from the sun.

When considering today’s society, it can be seen why the HBM lacks the ability to get people to protect themselves from the sun. Tanning has increasingly become a social status symbol that began in the 1920s, but it didn't always used to be that way(10-12). Throughout history, being pale has been considered attractive. During the Victorian period, women chalked their skin to make it seem as if they had a paler complexion. Paleness represented a life of a higher class because only people who performed manual labor were tan(10-12). It wasn’t until the 1920s, when women’s fashion trends allowed for more freeing clothing that sun tanning really became a modern status symbol(10-12). From the 1920s on, a person’s tan level became a direct social status marker. The more financially secure you were, the more you could afford to not work and instead enjoy your time outside. Tanning became an instant way for people to identify others by their socioeconomic bracket. Due to this new status symbol, a different behavioral model is needed to truly change the social ideals attached to tanning. The Theory of Reasoned Action is one of these alternative models. It takes into account not only the individual but also the group factors that affect a person’s decision to change a health behavior(15). This behavioral theory could be an alternative model that the North Carolina Department of Public Health should have used to make their campaign more effective. In this behavior model, an individual considers two factors before they decide to change a specific health behavior. These factors are: a person’s attitude toward a specific health behavior and the opinion of a person’s social group(15). In the case of the skin cancer print campaign, the Public Health Department was going up against an entire nation’s social norm. In order for the campaign to be more effective, the Department of Public Health needs to creatively alter these social norms to show that skin cancer prevention is ultimately the safest and most stylish choice.

Truth Campaign, at the Right Level

The North Carolina print campaign’s target audience is another factor where this campaign missed its mark. Currently, most public health advertisements are targeted towards the caregivers; but instead a campaign must target the adolescent population. The Truth campaign is an excellent example of how significant results can be obtained by not only targeting the youth population but also by incorporating Social Marketing Theory (SMT).

The SMT is a behavioral theory that looks at four marketing aspects: the product, price, place, and promotion in order to help customize a more effective health campaign(15). This theory generally begins with focus groups to compile information in order to identify values within a specific population. After the information is collected, the campaign organizers will have a better understanding of what their target population wants. As used by the Florida Department of Public Health Truth campaign, the initial research used to develop the Truth campaign was to first interview hundreds of Florida’s adolescents. It quickly became evident through the interviews that 100% of the adolescent population in Florida knew that tobacco kills(13). During the interviews, adolescents said that the reason they still smoked had to do with the fact that smoking made them feel in control(13).

SMT enabled the Truth campaign to decrease the percentage of youth smokers. In 1998 when the Florida Truth campaign began, approximately 56% of all middle and high school students had never smoked(14). After only two years, the percentage of students who have never smoked increased dramatically to 69%(14). The Florida Truth campaign was so successful was because the basis of the campaign was aimed at the adolescent population. Instead of just telling adolescents not to smoke this campaign showed them that it was their choice. The main Truth message was designed to deglamorize tobacco use and portray the tobacco industry as manipulating adolescents for a profit gain(14). It was through this message that the adolescent population realized that they were the ones in control and they began to change their views of tobacco use.

As seen in the Florida Truth campaign, the North Carolina Department of Public Health needs to use SMT to develop a more successful campaign. Conducting focus groups will be the best determinate to establish how the adolescent population views skin cancer prevention. Once the thoughts of the adolescent population are determined, the North Carolina Department of Public Health will be able to remodel their campaign. When considering a new campaign, the Department of Public Health must first show adolescents that the tanning industry is manipulative, second, show them that they are the ones taking control and making the decision to apply sunscreen, and third, show that applying sunscreen is an easy way to protect oneself from skin cancer. By borrowing these three key aspects from the Truth campaign, a more successful skin cancer prevention campaign will be designed that will also lead to a significant reduction in the amount of sunburns.

Model see, model do

When analyzing the success of the Florida Truth campaign, it seems logical that a skin prevention campaign should target the adolescent population, but what about all the children who are too young to put on their own sunscreen? The North Carolina Department of Public Health also needs to maintain their campaign that targets its secondary audience, the parents of young children. What many parents tend to forget is that children instinctively model their parents’ behaviors. If a child sees that their parents are not putting on sunscreen, they will not understand why they have to put it on. In a nationally representative telephone survey conducted in 1999, for parents who have children ages five to twelve, it was seen that parents who reported sunburns were more likely to then have children who become sunburnt(3). The parents who practiced safe sun protection behaviors were then less likely to have children who got sunburnt. This then insists that modeling is something that should not be overlooked when a skin cancer prevention campaign is developed.

The Modeling Theory is a behavioral theory that states that the most important predictor of behavior is what a person has seen in their lifetime(15). When examining sunscreen practices, there seems to be a direct correlation between a parent’s sunscreen practices and those of their child. In another study that looked into the role of caregivers on youth sunscreen use, three factors were found that were associated with frequent sunscreen use in adolescents. These factors were: 1) parents who frequently insisted that their child use sunscreen, 2) parents who reported no difficulty with protecting their child from the sun, and 3) parents who frequently applied sunscreen on themselves(2). To create a more effective skin cancer prevention campaign the North Carolina Department of Public Health should not discard their previous campaign but look to the Modeling Theory to strengthen the preexisting campaign in order to target a broader population.

The Ultimate Campaign

When considering real life scenarios there is no question as to why campaigns based on the Health Belief Model are unsuccessful. To truly have an effect on the rate of sun protection in the population, public health practitioners need to branch out to alternative behavior models. More specifically, a successful campaign will not just use alternative behavior models like SMT, Modeling Theory, or the Theory of Reasoned Action, but will incorporate more than one behavioral theory into a campaign. As seen in the skin cancer prevention campaign the classic approach used by public health practitioners is just not enough to increase sun protection and ultimately decrease skin cancer. Perhaps the public health field needs to look at modern advertisements to see what exactly gets people to protect themselves from the sun.

When looking at modern advertisements, many alternative behavior theories can be seen. These theories do not only give the consumer facts about why they should buy and use a product, but instead are aimed at getting a consumer emotionally attached to a product. Figure 2, an Australian sunscreen billboard, represents what I believe is a more modern approach to a public health campaign. This ad successfully uses alternative theories like those modeled advertising. Instead of showing sunscreen as something you need to use, this ad makes applying sunscreen a ‘cool’ and even sexy behavior. If public health officials were to embrace these edgier behavioral theories instead of clinging to the Health Belief Model, I believe that a more successful campaign would be created that would significantly lower skin cancer rates in the United States.


skin cancer ad

Figure 1.) North Carolina Public Health ad campaign for 2006.

Figure 2.)Australia sunscreen billboard.


1)Glanz K, Saraiy M. Using Evidence-based Community and Behavioral Interventions to Prevent Skin Cancer: Opportunities and Challenges for Public Health Practice. Preventing Chronic Disease 2005; 2: A03.

2)Cokkinides Ve, Weinstock MA, Cardinez CJ, O’Connel MA. Sun-Safe Practices in U.S. Youth and their parents: Role of Caregiver on Youth sunscreen use. American Journal of Preventative Medicine 2004; 2: 147-51.

3)O’ Riordan DL, Geller Ac, Brooks DR, Zhang Z, Miller DR. Sunburn reduction though parental Role Modeling and Sunscreen Vigilance. Journal of Pediatrics 2003; 1: 67-72.

4)Martin SC, Jacobsen PB, Lucas DJ, Branch KA, Ferron JM. Predicting Children’s Sunscreen Use: Application of the Theories of Reasoned Action and Planned Behavior. Preventative Medicine 1999; 1:37-44.

5)Center for Disease Control. Sunburn Prevalence Among Young Adults- United States, 1999, 2003, 2004. Morbidity and Mortality Weekly Report. 2007; 52: 524-528.

6)North Carolina State Center for Health Statistics. 2006 BRFSS Survey Results: North Carolina. http//

7)North Carolina Department of Health and Human Services. New Public Health Ad Campaign Warns parents of Children’s Skin Cancer Risk.

8)Center for Disease Control and Prevention. National Skin Cancer Prevention Education Program, At-A-Glance. Atlanta, GA, 1996.

9)Center for Disease Control and Prevention. A Message from the CDC’s Skin Cancer Primary Prevention and Education Initiative. Atlanta, GA: the division of Cancer Prevention and Control, 2006/2007.

10)Segrave, K. Suntanning in 20th Century America. Jefferson, NC: McFarland and Co., 2005.

11)Miller A., Ashton W., McHoskey J., and Gimbel J. The History of Suntanning. Journal of Applied Social Psychology 1990; 15: 1272-1300.

12)Sikes R. A Love/Hate Affair. Journal of Aesthetic Science 1998; 2:6-7.

13)Hicks J. The Strategy Behind Florida’s “truth” campaign. Tobacco Control 2001; 10:3-5.

14)Bauer UE, Johnson TM, Hopkins RS, Brooks RG. Changes in youth cigarette use and interventions following implementation of tobacco control program: Findings from the Florida Youth Tobacco Survey, 1998-2000. JAMA 200;284:723-728.

15)Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

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