Trends in news coverage about skin cancer prevention, 1993-2006: increasingly mixed messages for the public

Sun-protective clothing and shade use in public outdoor leisure settings from 1992 to 2019: Results from cross-sectional observational surveys in Melbourne, Australia

Skin cancer presents a significant public health burden in Australia. The present study aimed to supplement population-based estimates of sun protection behaviour by examining setting-specific trends in directly observed sun protection in public outdoor leisure settings. Repeated cross-sectional observational surveys of adolescents and adults were conducted on summer weekends between 11 am and 3 pm from 1992 to 2002, 2006 to 2012, and 2018 to 2019 (N = 44,979) at pools/beaches and parks/gardens within 25 km of the centre of Melbourne, Victoria. The primary outcome was a binary index representing individuals having above or below the median level of body surface covered by hat, shirt, and leg garments in each setting type. The prevalence of above-median body coverage increased between 1992 and 2002 in both settings. At pools/beaches, a slight decline in above-median body coverage between 2006 and 2019 in males and females (adjusted odds ratio, AOR = 0.96 [0.94, 0.97]; 0.94 [0.93, 0.95]) appeared to be driven by a decline in leg coverage, while arm coverage, hat, sunglasses, and shade use remained stable. At parks/gardens, a decline in above-median body coverage between 2006 and 2019 (AOR = 0.90 [0.89, 0.91]; 0.94 [0.93, 0.95]) was accompanied by small declines across other protective behaviours that varied between males and females. Patterns in protective behaviours observed in outdoor leisure settings may reflect the changing composition of individuals choosing to remain outdoors during peak UV times and highlight the importance of continued promotion and monitoring of the use of multiple measures to protect against UV damage in Australia.

Concerns about vitamin D and sun exposure behaviour among Australians

ISSUES ADDRESSED

Australians' concerns about vitamin D and influence on sun protection were last quantified a decade ago in Queensland amidst media attention on emerging evidence of non-skeletal benefits of vitamin D. Meanwhile these circumstances persist and impact is worth assessing.

METHODS

Measures of concern about vitamin D were included in three recent population-based cross-sectional surveys of Australians' sun-related behaviours during summer months (2010-2011, 2013-2014 and 2016-2017). We analysed characteristics, beliefs and behaviours associated with vitamin D concerns regarding regular sunscreen use among adults in 2016-2017 (N = 3614).

RESULTS

Concerns about vitamin D continued to persist among adults surveyed between 2010-2011 and 2016-2017. Vitamin D concerns regarding the sunscreen use were more common among women, older respondents and adults with skin that tans or is not susceptible to sunburn. Respondents concerned about vitamin D were more likely to exhibit pro-tanning beliefs, scepticism about sunscreen safety and have attempted a suntan. They were also less likely to use sun protection in everyday activities outdoors and less likely to use sunscreen on summer weekends.

CONCLUSIONS

Vitamin D concerns related to sunscreen use remained common among Australian adults. Skin cancer control advocates may be reassured that those with the greatest skin cancer risk (burn only) were less likely to hold these concerns, while the related infrequent sun protection and tanning among concerned adults are problematic. SO WHAT?: Continued education and research is needed to ensure that the general public understand the risks and benefits of sun exposure in Australia.

Awareness of cancer risk factors and protective factors among Australian adults

ISSUE ADDRESSED

Up to one-third of incident cancers in Australia are attributable to modifiable factors. Understanding the general public's awareness of cancer risk and protective factors is important for identifying knowledge gaps and informing the development of effective and targeted health promotion strategies.

METHODS

In a telephonic survey of 355 Western Australian adults aged 18-54 years (48% male), with a sample skewed towards low-socio-economic status areas, respondents rated the effect on cancer risk of 11 established cancer risk factors and seven established cancer protective factors.

RESULTS

Most respondents correctly recognised the increased cancer risk from sun tanning (94%), asbestos (92%), pesticide use (92%) and being overweight or obese (86%), and the protective effect of being physically active (82%). Half (52%) of respondents incorrectly believed that red wine decreased or had no effect on cancer risk. One in five respondents (19%) incorrectly believed that sunscreen use increased cancer risk. Only 18% of respondents were aware that human papillomavirus (HPV) vaccination confers a protective effect, while 17% believed it increases risk.

CONCLUSIONS

Although the majority of respondents were aware of certain established cancer risk and protective factors, a sizeable proportion held misconceptions about the cancer risk associated with red wine consumption, sunscreen use and HPV vaccination. SO WHAT?: Health promotion programs designed to educate the public about modifiable cancer risk factors may need to increase public awareness of the safety of preventive factors such as HPV vaccination and sunscreen, and the increased cancer risk from consumption of all alcoholic beverage types, including red wine.

An examination of Australian newspaper coverage of the link between alcohol and cancer 2005 to 2013

Background

Alcohol is a Class-1 carcinogen but public awareness of the link between alcohol and cancer is low. The news media is a popular, readily-accessible source of health information and plays a key role in shaping public opinion and influencing policy-makers. Examination of how the link between alcohol and cancer is presented in Australian print media could inform public health advocacy efforts to raise awareness of this modifiable cancer risk factor.

Method

This study provides a summative qualitative content analysis of 1502 articles that included information about a link between alcohol and cancer, as reported within Australian newspaper media (2005–2013). We use descriptive statistics to examine the prominence of reports, the nature and content of claims regarding the link between alcohol and cancer, and the source of information noted in each article.

Results

Articles were distributed throughout newspapers, most appearing within the main (first) section. The link between alcohol and cancer tended not to appear early in articles, and rarely featured in headlines. 95% of articles included a claim that alcohol causes cancer, 5% that alcohol prevented or did not cause cancer, 1% included both. Generally, the amount of alcohol that would cause or prevent cancer was unspecified or open to subjective interpretation. Coverage increased over time, primarily within community/free papers. The claim that alcohol causes cancer often named a specific cancer, did not name a specific alcohol, was infrequently the focus of articles (typically subsumed within an article on general health issues), and cited various health-promoting (including advocacy) organisations as information sources. Articles that included the converse also tended not to focus on that point, often named a specific type of alcohol, and most cited research institutions or generic ‘research’ as sources. Half of all articles involved repetition of materials, and most confirmed that alcohol caused cancer.

Conclusions

Information about a link between alcohol and cancer is available in the Australian newsprint media, but may be hidden within and thus overshadowed by other health-related stories. Strategic collaboration between health promoting organisations, and exploitation of ‘churnalism’ and journalists’ preferences for ready-made ‘copy’ may facilitate increased presence and accuracy of the alcohol-cancer message.

Self-Reported Changes in Sun-Protection Behaviors at Different Latitudes in Australia

Sun exposure is the most important source of vitamin D, but is also a risk factor for skin cancer. This study investigated attitudes toward vitamin D, and changes in sun-exposure behavior due to concern about adequate vitamin D. Participants (n = 1002) were recruited from four regions of Australia and completed self- and interviewer-administered surveys. Chi-square tests were used to assess associations between participants' latitude of residence, vitamin D-related attitudes and changes in sun-exposure behaviors during the last summer. Multivariate logistic regression analyses were used to model the association between attitudes and behaviors. Overall, people who worried about their vitamin D status were more likely to have altered sun protection and spent more time in the sun people not concerned about vitamin D. Concern about vitamin D was also more common with increasing latitude. Use of novel item response theory analysis highlighted the potential impact of self-reported behavior change on skin cancer predisposition due concern to vitamin. This cross-sectional study shows that the strongest determinants of self-reported sun-protection behavior changes due to concerns about vitamin D were attitudes and location, with people at higher latitudes worrying more.

Skin Cancer Prevention, Tanning and Vitamin D: A Content Analysis of Print Media in Germany and Switzerland

BACKGROUND

Print media are a major source of health information.

OBJECTIVES

To analyse press coverage related to skin cancer prevention.

METHODS

We conducted a content analysis of print media articles pertaining to skin cancer prevention, solaria and vitamin D published in Germany and Switzerland over a 1-year period between 2012 and 2013.

RESULTS

Overall, 2,103 articles were analysed. Applying sunscreen was by far the most common sun protection recommendation. A considerable number of articles on solaria and vitamin D advocated exposure to ultraviolet radiation to enhance physical appearance and vitamin D photosynthesis, often without mentioning any precaution measures. In total, 26.8% of the articles contained misleading or erroneous statements mostly related to sunscreen use and vitamin D issues.

CONCLUSIONS

Print media can serve as powerful education tools to foster skin cancer prevention. However, misleading or erroneous reports may negatively impact sun-safe behaviour.

Continued Impact of SunSmart Advertising on Youth and Adults' Behaviors

INTRODUCTION

Televised advertising campaigns play a central role in public education for skin cancer prevention in Australia. Continued impact on behavior is crucial to optimize these investments. This study examines whether exposure to increased intensity of summer campaigns in the past decade has continued to influence sun protection behaviors and to examine behavioral impact across age groups.

METHODS

Cross-sectional weekly telephone surveys of Melbourne residents were conducted over summers from 1987-1988 to 2010-2011, and analyzed in 2012-2014. Respondents' sun-related attitudes and their sun protection and sunburn on the weekend prior to interview were assessed. Population exposure to campaign TV advertising was measured as cumulated weekly target audience rating points (TARPs) for 4 weeks prior to interviews. Multiple logistic and linear regression models examined the relationship of campaign advertising with tanning preference and behavioral outcomes (N=11,881).

RESULTS

Respondents' attitudes and behaviors in 1987-2011 were associated with TARPs. Increasing TARPs were related to increased preference for no tan (OR=1.12, 95% CI=1.07, 1.17); sunscreen use (OR=1.09, 95% CI=1.02, 1.17); and overall reduced mean percentage of skin exposed to the sun (B=-0.01, 95% CI=-0.01, 0.00). These effects had limited interaction with time period, age group, gender, or skin type. There was evidence of diminishing returns at the highest TARP quartile for tan preference but not for behavioral outcomes.

CONCLUSIONS

Sustained youth-focused advertising campaigns (for adolescents and young adults), when broadcast with sufficient TARPs during the summer months, continue to provide consistent beneficial impact on sun protection behaviors population-wide.

The impact of indoor tanning legislation: newspaper coverage of the risks of indoor tanning before and after the California indoor tanning ban for minors

On June 1, 2011, the California Senate passed a bill banning minors from indoor tanning. We aimed to determine whether the bill's passage was associated with longer-term media coverage regarding skin protection and the risks associated with indoor tanning. Articles from 31 English-language California newspapers between June 2010-May 2011 (PRE) and June 2011-May 2012 (POST) were searched using terms related to skin protection. Ninety articles were found for in-depth coding and analysis. There were more skin protection articles in the POST period than in the PRE period (57 vs 33; p < .05). In addition, there were more POST articles mentioning the risks of indoor tanning (33 vs 10; p < .001), and a POST article was more likely to mention the risks (58 vs 30%; p < .05). The higher number of POST articles mentioning the risks persisted throughout all quarters. Therefore, the California indoor tanning ban was associated with increased longer-term news coverage of skin protection and the risks associated with indoor tanning. This finding has potential influence on the many states that are considering comparable legislation.

Changes in coverage of sun protection in the news: threats and opportunities from emerging issues

This study aimed to determine whether there have been shifts in news coverage of sun protection issues over a 12-year period in the context of an evolving skin cancer prevention agenda. A content analysis was performed on all relevant articles (N = 552) published in the two metropolitan daily newspapers in Melbourne, Australia, from 2001 to 2012. Coding variables included theme, article type, prominence, spokesperson and topic slant. Articles were collapsed into three 4-year blocks and a series of chi-square analyses conducted to examine changes over time in coverage of topical issues (i.e. vitamin D and sunbeds) and established sun protection themes [i.e. health effects of ultraviolet (UV) exposure, education/prevention, attitudes/behaviour]. Coverage of vitamin D and sunbed issues increased over time and became more positive for sun protection objectives. The proportion of articles reporting on established sun protection themes remained steady over time (range: 36-38%) and there were no changes observed in the way these topics were presented in the news media. These results highlight that potentially competing sun protection issues that emerge over time need not pose a threat to existing skin cancer prevention programmes but instead can provide opportunities to further spread programme messages while increasing credibility.

'Something's brewing': The changing trends in alcohol coverage in Australian newspapers 2000-2011

AIMS

The portrayal of alcohol in the news media, including newspapers, plays an important role in influencing societal norms and setting public agendas. We present the first large-scale examination of news coverage of alcohol-related issues in Australian newspapers.

METHOD

Content analysis was performed on a sample of alcohol-related newspaper articles (n = 4217) published across Australia from 2000 to 2011. Articles were coded for type, theme, prominence, topic slant, opinion slant and sources/spokesperson.

RESULTS

Across the period, the most common themes were promotion (21%), drink-driving (16%) and restrictions/policy (16%). Themes of restrictions/policy and responsible beverage services became more common over time. Promotion and business-related articles significantly declined over time. Overall, the topic slant of the majority of news related articles disapproved of alcohol use. Disapproval increased over time while approval of alcohol use decreased. While the slant of opinion pieces was predominantly approving of alcohol, this decreased over time. Presence of an alcohol industry representative in articles declined over time.

CONCLUSION

The presentation of alcohol use in Australian newspapers became more disapproving over time, which may suggest that harmful alcohol use has become less acceptable among the broader Australian community.

Assessing population-wide behaviour change: concordance of 10-year trends in self-reported and observed sun protection

OBJECTIVES

Increases in socially desirable responses in self-reports might occur in the context of ongoing public education. We examine concordance of trends in two long-term studies monitoring population impact for SunSmart.

METHODS

One study employed telephone interviews of Melbourne residents; the other entailed observations at public recreation venues across Melbourne. The studies assessed people's sun protection on identical weekend dates (Nw = 33 dates). Data from five summers between 1992 and 2001 (n ~ 23,000 individuals) were analysed. A body cover index score was calculated for participants on each date. Outcomes were aggregated separately for Saturdays and Sundays by date and year. Regression analyses tested whether these trends differed by survey method.

RESULTS

The pattern of change in body cover over time was similar for both surveys. Self-reported body cover was consistently higher than observed body cover, suggesting that social desirability bias may be present. Regression analyses showed no divergence between self-reported and observed trends in mean body cover, suggesting no evidence of significant increased social desirability bias in self-reporting over time.

CONCLUSION

Findings suggest that self-report offers a valid means of assessing change in a population's sun protection compliance over time, at least when self-reports are precisely focussed for time and activity context.

The ABC of vitamin D: a qualitative study of the knowledge and attitudes regarding vitamin D deficiency amongst selected population groups

Objective: In Australia, vitamin D supply in food is limited, and sun exposure is the main source of vitamin D. However skin cancer risk is high, and the need to gain some sun exposure for adequate vitamin D is challenging public health messages to use protection in the sun. The complex vitamin D public health message may be confusing the public and, in particular, those at highest risk for vitamin D deficiency. This study explored vitamin D and sun exposure attitudes, knowledge and practices of some groups considered at risk of vitamin D deficiency and those delivering healthy sun exposure messages to children. Method: 52 adults participated in six focus groups. Results: Results corroborated with previous research showing low levels of vitamin D knowledge. Individual and environmental barriers to receiving adequate sun exposure were also identified. Conclusions and Implications: The message advocating balanced sun exposure to produce adequate vitamin D needs to be made clearer and be more effectively communicated. Findings provide insights to aid development of appropriate public health messages for safe sun exposure and vitamin D, especially for vulnerable groups.

Agenda-setting effects of sun-related news coverage on public attitudes and beliefs about tanning and skin cancer

The topics and framing of news stories relevant to skin cancer prevention have shifted over time. This study examined agenda-setting effects of such news stories on public attitudes and beliefs about tanning and skin cancer. Content analysis data on 516 articles published in two major daily newspapers in Melbourne, Australia, from 1994 to 2007 were combined with circulation data to generate indices of potential news exposure. Associations between these indices and cross-sectional telephone survey data from the same period on 6,244 adults' tanning attitudes and perceived susceptibility to skin cancer were examined using logistic regression models, accounting for the temporal precedence of news content. Pro-sun protection stories on attitudes and behavior were associated with older adults not thinking a tan looks healthy. Pro-sun protection stories on solaria were associated with less preference for a deep tan among young adults who like to suntan. Stories on vitamin D that were unsupportive of or ambiguous about sun protection were associated with a number of pro-tan attitudes among younger adults. Results indicate news coverage during 1994-2007 served an important agenda-setting role in explaining the public's attitudes and beliefs about tanning and skin cancer. Vitamin D stories appeared most influential, particularly among young adults.

Sun-seeking behavior to increase cutaneous vitamin D synthesis: when prevention messages conflict

OBJECTIVES

The public has long been encouraged to engage in sun-safe practices to minimize exposure to sunlight, the major cause of nonmelanoma skin cancer. More recently, some have advocated unprotected sun exposure to increase cutaneous synthesis of vitamin D as a way to promote health. We assessed the net result of these conflicting messages.

METHODS

In a cross-sectional survey in 2007, questionnaires were mailed to participants of an ongoing cohort study in Washington County, Maryland. The study population consisted of 8,027 adults (55% response rate).

RESULTS

Thirty percent of respondents were aware that unprotected sun exposure increased endogenous vitamin D levels. Among those who were aware of this benefit, 42% reported going out into the sun to increase vitamin D levels. Sun-seeking to increase vitamin D production did not significantly differ according to self-reported personal history of skin cancer, but was significantly higher among women, older age groups, those with less education, and vitamin D supplement users.

CONCLUSION

A substantial proportion of respondents reported sun-seeking behavior expressly to increase endogenous vitamin D levels. The message about sun exposure and vitamin D is reaching the general public; however, this finding poses challenges to skin cancer prevention efforts.

Does the Portrayal of Tanning in Australian Women’s Magazines Relate to Real Women’s Tanning Beliefs and Behavior?

Content analysis data on the tans of 4,422 female Caucasian models sampled from spring and summer magazine issues were combined with readership data to generate indices of potential exposure to social modeling of tanning via popular women’s magazines over a 15-year period (1987 to 2002). Associations between these indices and cross-sectional telephone survey data from the same period on 5,675 female teenagers’ and adults’ tanning attitudes, beliefs, and behavior were examined using logistic regression models. Among young women, greater exposure to tanning in young women’s magazines was associated with increased likelihood of endorsing pro-tan attitudes and beliefs. Among women of all ages, greater exposure to tanned models via the most popular women’s magazines was associated with increased likelihood of attempting to get a tan but lower likelihood of endorsing pro-tan attitudes. Popular women’s magazines may promote and reflect real women’s tanning beliefs and behavior.

The human health effects of ozone depletion and interactions with climate change

Depletion of the stratospheric ozone layer has led to increased solar UV-B radiation (280-315 nm) at the surface of the Earth. This change is likely to have had an impact on human exposure to UV-B radiation with consequential detrimental and beneficial effects on health, although behavioural changes in society over the past 60 years or so with regard to sun exposure are of considerable importance. The present report concentrates on information published since our previous report in 2007. The adverse effects of UV radiation are primarily on the eye and the skin. While solar UV radiation is a recognised risk factor for some types of cataract and for pterygium, the evidence is less strong, although increasing, for ocular melanoma, and is equivocal at present for age-related macular degeneration. For the skin, the most common harmful outcome is skin cancer, including melanoma and the non-melanoma skin cancers, basal cell carcinoma and squamous cell carcinoma. The incidence of all three of these tumours has risen significantly over the past five decades, particularly in people with fair skin, and is projected to continue to increase, thus posing a significant world-wide health burden. Overexposure to the sun is the major identified environmental risk factor in skin cancer, in association with various genetic risk factors and immune effects. Suppression of some aspects of immunity follows exposure to UV radiation and the consequences of this modulation for the immune control of infectious diseases, for vaccination and for tumours, are additional concerns. In a common sun allergy (polymorphic light eruption), there is an imbalance in the immune response to UV radiation, resulting in a sun-evoked rash. The major health benefit of exposure to solar UV-B radiation is the production of vitamin D. Vitamin D plays a crucial role in bone metabolism and is also implicated in protection against a wide range of diseases. Although there is some evidence supporting protective effects for a range of internal cancers, this is not yet conclusive, but strongest for colorectal cancer, at present. A role for vitamin D in protection against several autoimmune diseases has been studied, with the most convincing results to date for multiple sclerosis. Vitamin D is starting to be assessed for its protective properties against several infectious and coronary diseases. Current methods for protecting the eye and the skin from the adverse effects of solar UV radiation are evaluated, including seeking shade, wearing protective clothing and sunglasses, and using sunscreens. Newer possibilities are considered such as creams that repair UV-induced DNA damage, and substances applied topically to the skin or eaten in the diet that protect against some of the detrimental effects of sun exposure. It is difficult to provide easily understandable public health messages regarding "safe" sun exposure, so that the positive effects of vitamin D production are balanced against the negative effects of excessive exposure. The international response to ozone depletion has included the development and deployment of replacement technologies and chemicals. To date, limited evidence suggests that substitutes for the ozone-depleting substances do not have significant effects on human health. In addition to stratospheric ozone depletion, climate change is predicted to affect human health, and potential interactions between these two parameters are considered. These include altering the risk of developing skin tumours, infectious diseases and various skin diseases, in addition to altering the efficiency by which pathogenic microorganisms are inactivated in the environment.

Knowledge and attitudes about Vitamin D and impact on sun protection practices among urban office workers in Brisbane, Australia

BACKGROUND

Sun exposure is the main source of vitamin D. Increasing scientific and media attention to the potential health benefits of sun exposure may lead to changes in sun exposure behaviors.

METHODS

To provide data that might help frame public health messages, we conducted an online survey among office workers in Brisbane, Australia, to determine knowledge and attitudes about vitamin D and associations of these with sun protection practices. Of the 4,709 people invited to participate, 2,867 (61%) completed the questionnaire. This analysis included 1,971 (69%) participants who indicated that they had heard about vitamin D.

RESULTS

Lack of knowledge about vitamin D was apparent. Eighteen percent of people were unaware of the bone benefits of vitamin D but 40% listed currently unconfirmed benefits. Over half of the participants indicated that more than 10 minutes in the sun was needed to attain enough vitamin D in summer, and 28% indicated more than 20 minutes in winter. This was significantly associated with increased time outdoors and decreased sunscreen use. People believing sun protection might cause vitamin D deficiency (11%) were less likely to be frequent sunscreen users (summer odds ratio, 0.63; 95% confidence interval, 0.52-0.75).

CONCLUSIONS

Our findings suggest that there is some confusion about sun exposure and vitamin D, and that this may result in reduced sun-protective behavior.

IMPACT

More information is needed about vitamin D production in the skin. In the interim, education campaigns need to specifically address the vitamin D issue to ensure that skin cancer incidence does not increase.

Changes in skin tanning attitudes. Fashion articles and advertisements in the early 20th century

Historical reviews suggest that tanning first became fashionable in the 1920s or 1930s. To quantitatively and qualitatively examine changes in tanning attitudes portrayed in the popular women's press during the early 20th century, we reviewed summer issues of Vogue and Harper's Bazaar for the years 1920, 1927, 1928, and 1929. We examined these issues for articles and advertisements promoting skin tanning or skin bleaching and protection. We found that articles and advertisements promoting the fashionable aspects of tanned skin were more numerous in 1928 and 1929 than in 1927 and 1920, whereas those promoting pale skin (by bleaching or protection) were less numerous. These findings demonstrate a clear shift in attitudes toward tanned skin during this period.

Skin cancer-related prevention and screening behaviors: a review of the literature

Primary prevention and early detection continue to be of paramount importance in addressing the public health threat of skin cancer. The aim of this systematic review was to provide a comprehensive overview of the prevalence and correlates of skin cancer-related health behaviors in the general population. To achieve this aim, 91 studies published in international peer-reviewed journals over the past three decades were reviewed and synthesized. Reported estimates of sunscreen use varied considerably across studies, ranging from 7 to 90%. According to self-report, between 23 and 61% of individuals engage in skin self-examination at least once per year, and the documented prevalence of annual clinical skin examination ranges from 8 to 21%. Adherence to sun protection and screening recommendations is associated with a range of factors, including: female gender, sun-sensitive phenotype, greater perceived risk of skin cancer, greater perceived benefits of sun protection or screening, and doctor recommendation for screening. The literature suggests that a large proportion of the general population engage in suboptimal levels of sun protection, although there is substantial variability in findings. The strongest recommendation to emerge from this review is a call for the development and widespread use of standardized measurement scales in future research, in addition to more studies with a population-based, multivariate design. It is also recommended that specific targeted interventions are developed to increase the prevalence of preventative and early intervention behaviors for the control of skin cancer.