Challenging Dogma - Spring 2008

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

Thursday, April 24, 2008

The SunSmart Skin Cancer Campaign: An Intervention That Fails To Recognize Social And Behavioral Components – Deep Patadia

Over the last two decades, the rates of skin cancer have been increasing. As a result, over 90% of skin cancers are caused by sun exposure (1). One in five Americans and one in three Caucasians will develop skin cancer during the course of their lifetime (2). Moreover, research from the American Cancer Society suggests that more than twenty people die each from skin cancer (3).
There exist three types of skin cancers: squamous cell carcinoma, basal cell carcinoma, and melanoma. Non-melanoma (or squamous cell and basal cell carcinomas) is the most common; however melanoma skin cancer is the most lethal. In 2004, the total direct cost associated with the treatment of melanoma amounted $291 million, which included office visits, hospital inpatient and outpatient treatment, prescription drugs, and emergency room treatment. On the flip side, the cost of non-melanoma skin cancer during that year was much higher, totaling $1.5 billion (4).
In an attempt to raise awareness and practice safe habits with regards to excess exposure to the sun, The Cancer Council Victoria launched the SunSMART campaign in 1988. Their goals involve reducing the prevalence of skin cancer, decreasing the mortality rate, and assessing baseline levels of UV radiation awareness to the public with regards to all types of skin cancer. Multiple countries such as the United States, Great Britain, and Australia have taken part in this program. The program proposes a five-letter acronym: S.M.A.R.T.:
Spending time in the shade between 11am and 3pm
Making sure you never burn
Aiming to cover up with a t-shirt, hat, and sunglasses
Remembering to take extra care with children
Then using factor 15+ sunscreen (5)

This is not an effective acronym because it is not well thought out nor does it consider social and behavioral standards carried out in society. The SunSMART campaign lacks credibility as a practical public health intervention because it is too age-specific, violates the social expectations theory, and disregards occupational and nutritional consequences.
SunSMART proposes to take special care of children. The reason for this is that one sunburn in childhood more than doubles the chances of a person developing skin cancer later in their life (6). While it is important to target these issues towards younger individuals, it is also equally as necessary to include adults.
This program fails to direct any attention towards the adolescent and adult population, skewing their overall message. Skin cancer is a progressive disease and will develop later in life, where more than 90% of skin cancers cases are attributed to those over 40 years of age (7). Less than 0.1% of children acquire skin cancer, predominantly because skin cancer is a progressive disease (8). However, this program’s intention in preventing skin cancer in the long run is contradicted by the research that claims men and women born in 1970, now in their mid-30s, are being diagnosed with melanoma at the same rate as people who were born in 1930 and didn't develop melanoma until their 50s (9). Thus, the age of incidence of skin cancer is occurring much earlier than it has been in the past and protecting children is not sufficient enough.
Though the incidence of obtaining skin cancer decreases if one is protected from the sun as a child, it is not adequate considering that the skin cancer latency period is narrowing and that there should be more of an effort to target the older generation. If SunSMART were more comprehensive in their program’s protocol by expanding their age-window, it would raise awareness to individuals off all ages, fulfilling their ultimate aim to reduce the prevalence and mortalities associated with skin cancers.
History, Beaches, and Social Norms
Culturally, a skin tan is viewed as attractive, which dated back to the time of the end of World War II. During this time, the middle class citizen got more time and money to spend on leisurely activities due to the economic boom. As a result, vacationing became a standard practice, especially going to tropic areas. Thus a socioeconomic shift occurred, where dark and tanned skin (usually of a lower-economic status) labor worker transformed into a sign of a well-cultured and wealthy individual that enjoyed life at beaches, pools, barbeques, and exotic vacations, and dinner parties. It also became an indication of health and strength as the bodybuilding and fitness industries vastly promoted tanning to highlight muscle tone and definition (10).
Sun tanning is acquired through skin exposure to UV rays from the sun. The greatest exposure to UV rays for a majority of the population occurs on shores and beaches, where over 50% of people in these locations do not wear hats, large sunglasses, or sufficient clothing necessary to protect against sunlight (7). SunSMART urges individuals to make sure to stay covered up, which violates the Social Expectations Theory and Social Learning Theory. The Social Expectations Theory suggests that social norms affect an individual’s expectations while the Social Learning Theory states that individuals model what they see (11,12).
It is socially acceptable and expected for individual to go to a beach in order to relax and be minimally clothed to engage in sun bathing. However, it would be socially unfavorable for an individual to be in an environment, such as a beach, in which he or she is fully clothed. According to Miles’ study, 50.7% people feel a suntan makes them look more attractive and 66.3% feel a suntan makes them look healthier (7). According to the Social Expectations Theory and Social Learning Theory, if an individual is in an environment where the population wears minimal clothing, they will be inclined to behavior almost synonymously.
Violation of the Social Expectations Theory and Social Learning Theory could lead to various effects for the individual. One may feel ostracized, embarrassed, neglected, or simply out of place. This could lead to lead various psychological affects, such as neglect, loss of self-esteem, or in the extreme case, depression (9).
Thus, SunSMART does not take into account the violation of the Social Expectation Theory or Social Learning Theory with regards to beaches and other outdoor recreational areas, places where UV rays are most prevalent. Failure to address these social and cultural issues makes this intervention’s goals even more difficult to obtain, an angle at which SunSMART neglected to address.

Occupation, Race, and Vitamin D
It is well understood that sunlight is the most efficient way to absorb vitamin D. This vitamin D is an essential vitamin protects against osteoporosis, heart disease, cancers, diabetes, osteomalacia, and rickets (13). SunSMART stresses to avoid the sun as much as possible between the hours of 11am and 3pm. However, according to Michael Holick’s study, the greatest amount of vitamin D is absorbed between noon and 4pm (13). To avoid these particular times could be detrimental to an individual’s health in the long run because these are periods at which the greatest amount of vitamin D can be absorbed. The economic burden for the nation of chronic disease due to inadequate vitamin D is estimated at $25–36 billion- a significant amount of money spent on a deficiency that can be easily addressed (14).
In response to SunSMART’s lack of consideration for vitamin D, this campaign just recently suggested that people can supplement themselves with vitamin D by eating eggs, fatty fish, and liver oils (15). However, this diet is not pertinent to vegetarians, a large portion of the population. Various individuals and communities do not eat meat or eggs due to religious or ethical reasons. In a sense, SunSMART is asking to these people to go against their principles and morals to absorb vitamin D into their diets. As a result, most individuals would not eat eggs, fish, or liver oils to obtain adequate amount of vitamin D. Thus, rather than making the program more comprehensive, SunSMART can now only be attributed to non-vegetarians, failing to address eating habits of various communities.
The 11am to 3pm time restriction also affects the portion of individuals that work outdoors. Over 40% of the working class in the United States works outdoors, in which over 85% of these people work between 11am and 3pm, the time where SunSMART advises individuals to avoid (16). This restriction fails to address the issue to the majority of the outdoor working class. If put in this predicament, an individual will choose to work outdoors rather than be “at risk” for acquiring skin cancer. If one does not to work out doors, it could potentially mean a reduction in wages or getting fired by their employer. Most individuals will do what it takes to be financially stable, whether it means involves buying food to eat, supporting the family, or having heat under a roof. Most American’s would choose their job over not working long hours outdoors to prevent skin cancer because of the economic advantage. Thus, SunSMART does not take account for the occupational risks their program has on the outdoor working force.
In addition to the outdoor working class in America, 64% of workers are African-American (17). Those with darker skin are less likely to get skin cancer because they absorb less UV light than light-skinned people (13). Thus, darker-skinned individuals need to stay in the sun for a longer period of time to absorb more vitamin D. Limiting African Americans to less sun exposure outdoors will put them at risk for possibly losing their job and a lower concentration of vitamin D absorption, resulting in various health complications, such as osteoporosis, heart disease, cancers, diabetes, osteomalacia, and rickets. Thus, SunSMART should standardize their interventions based on different ethnicities and races with regards to their time restriction in the sun because it impacts the occupational, nutritional, and racial levels separately and together.
In summation, the SunSMART program should adopt new guidelines to allow it to be more age-specific, in addition to socially, behaviorally, nutritionally, racially, and occupationally acceptable standards. The SunSMART acronym is intended to be catchy and memorable; however the acronym is too weak to publicize a growing epidemic around the world. Its phrases are too long to memorize and intervention regulations do not attack the issue from all angles.
Since this campaign was launched, the rate of skin melanoma has increased by 107%, proving that their model is insufficient to prevent against skin cancer (18). This program should be framed to publicize the issue from a power-coercive and normative-re-educative standpoint rather than a rational-empirical. This way, there may be more persuasive techniques that could encourage individuals to change social norms and make it more acceptable. For example, a bill could be passed asking employers to have their employees wear more appropriate clothing to protect against the effects of skin cancer. Implementing this change could bring forth much more positive results from a occupational standpoint so they can get the same wage, a nutritional standpoint so they can absorb the appropriate amount of vitamin D, a physiological standpoint so that they would be at a lower risk for obtaining skin cancer, and an economic standpoint so they would keep the national costs low. In addition, opening up the age-window to all group and not specifically younger individuals could also bring about some more comprehensive solutions to the problem since the latency period is decreasing.
SunSMART’s intentions in preventing the rising epidemic of skin cancer were appropriate. However, the measures they took to carry out those objectives were not fully thought out from a cultural and social standpoint. Maybe with some changes to the program, we would see more positive results with regards to skin cancer prevalence and mortalities.

1- Fayid, Lisa. About Cancer- “Top 8 Shocking Facts About Cancer.
June21, 2007.
2 - Pfahlberg A, Kolmel KF, Gefeller O. Adult vs childhood susceptibility to melanoma. Is there a difference? Arch Dermatol, Sept 2002; 138: 1234-1235.
3 - American Cancer Society's 2007 Facts & Figures. American Cancer Society, Inc.
4 - SunSMART- Cost to Employeers. National Business Group on Health. Jul. 6, 2008.>
5 - SunSMART. Cancer Council Victoria. 1988.
6 – Mayo Clinic Skin Cancer Facts 2006
7- A. Miles. SunSmart? Skin cancer knowledge and preventive behaviour in a British population representative sample. Health Education Research. 2005: 20(5), 579-585.
8- Hoey, S.E.H. Skin cancer trends in Northern Ireland and consequences for provision of dermatology services. British Journal of Dermatology. 2007: 156, 301-307
9- Medical News Today. Deadly Skin Cancer Set to Treble.

10 – Sikes, Ruth G. The History of Suntanning. A Love/Hate Affair. Journal of Aesthetic Science, 1998: I, 2: 6 -7
11 - Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, Massachusetts: Jones and Bartlett Publishers:2007.
12 - Bandura, A. Social Learning Theory. New York: General Learning Press: 1977.
13- Holick, Michael F. Vitamin D: importance in the prevention of cancers, type 1 diabetes, heart disease and osteoporosis. American Journal of Clinical Nutrition. 2004: 79, 362-371.
14 - Grant WB, Garland CF, Holick MF. Comparisons of estimated economic burdens due to insufficient solar ultraviolet irradiance and vitamin D and excess solar UV irradiance for the United States. Photochem Photobiol. 2005 Nov-Dec;81(6):1276-86.
15- SunSMART. Vitamin D.

16- Green, Adele, et. al. Skin cancer in a subtropical Australian population: Incidence and Lack of Association with Occupation; American Journal of Epidemiology. 1996: 144(11), 1034-1041.
17 – US Bureau of Labor Statistics. United States Department of Labor. Employment status of the civilian population by race, sex, and age. Table A-2.Apr. 4, 2008.
18- Center for Disease Control and Prevention. Comparing Melanoma of the Skin by Race and Ethnicity. 2007.

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