Mass Media Barriers to Social Marketing Interventions:
The Example of Sun Protection in the UK
Summary
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.
Introduction
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
1
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
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., 1999) 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),
2
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
3
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.
4
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.,
5
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.
INSERT TABLE 1 ABOUT HERE
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
6
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’.
7
INSERT TABLE 2 ABOUT HERE
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 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.
8
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)
9
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.
INSERT FIGURE 1 ABOUT HERE
Sunbeds
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
date
29 July
30 July
30 July
Headline
Medium
Sunbeds now seem to be as
deadly as great white sharks
Experts issue powerful
Tanning bed warning
‘No doubt’ sunbeds cause
cancer
Telegraph
http://www.telegraph.co.uk
CBS News
http://www.cbsnews.com
BBC News
http://newsvote.bbc.co.uk
10
This appeared in tandem with editorial illustrating graphically that sunbed users were
prepared to ignore the risk in pursuit of a tan, as the following three examples
illustrate:
Publication
date
30 July
31 July
6 August
Headline
Medium
Why I’d rather die by using a
sunbed than be pale
Skin cancer? They don’t care.
Tanning bed users ignore
warning
Tanning beds moved into top
cancer risk, tanners remain
undeterred
Mirror
http://www.mirror.co.uk
News & Observer
http://www.newsobserver.co
m
http://www.gastongazette.co
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; however this may not be a particularly strong tool,
11
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
12
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.
Funding:
Declaration of funding sources: This work was supported by funding from the South
West Public Health Observatory
References
Abroms, L., Jorgensen, C. M., Southwell, B. G., Geller, A. C., & Emmons, K. M.
(2003) Gender Differences in Young Adults' Beliefs About Sunscreen Use. Health
Educ Behav, 30, 29-43.
Ackerman, J. (2007) The Great Sunlight Standoff. Psychology Today, 40, 96 - 102.
Affleck, P. (2005) Sun Exposure and Health. Nursing Standard, 19, 50 - 54.
13
Alberink, A. M., Valery, P. C., Russell, A., & Green, A. (2000) Do Forecasts of UV
Indexes Influence People's Outdoor Behaviour? Australian & New Zealand Journal of
Public Health, 24, 488.
Autier, P. (2004) Perspectives in Melanoma Prevention: The Case of Sunbeds.
European Journal of Cancer, 40, 2367-2376.
BBC (2006), Media Sensationalising Science, 3rd March, Accessed from
http://news.bbc.co.uk
Blunden, A., Lower, T., & Slevin, T. (2004). Knowledge, Awareness, and Use of the
UV Index Amongst the West Australian Public. Journal of Health Communication,
9(3), 207-221.
Branstrom, R., Ullen, H., & Brandberg, Y. (2004) Attitudes, Subjective Norms and
Perception of Behavioural Control as Predictors of Sun-related Behaviour in Swedish
Adults. Preventive Medicine, 39, 992-999.
Burnet, N.G., Jefferies, S.J., Benson, R.J., Hunt, D.P., & Treasure, F.P. (2005)
Years of life lost (YLL) from cancer is an important measure of population burden —
and should be considered when allocating research funds. British Journal of Cancer
(2005) 92, 241–245.
Cafri, G., Thompson, J. K., Roehrig, M., van den Berg, P., Jacobsen, P. B., & Stark,
S. (2006). An investigation of appearance motives for tanning: The development and
evaluation of the Physical Appearance Reasons For Tanning Scale (PARTS) and its
relation to sunbathing and indoor tanning intentions. Body Image, 3(3), 199-209.
Canales, M. K., Breslau, E. S., Nelson, D. E., & Ballard-Barbash, R. R. (2008) Did
News Reporters Get It Right?: Translation of the 2002 Hormone Study Findings.
American Journal of Preventive Medicine, 34, 61-68.
Cancer Research UK Sunsmart (2009) available at
http://www.cancerresearchuk.org/sunsmart
Cancer Research UK (2010), Sunsmart Statistics, Accessed from
http://www.sunsamrt.org.uk
Carter, O., & Donovan, R. (2007). Public (Mis)understanding of the UV Index.
Journal of Health Communication, 12(1), 41-52.
Chan, L. K. W. (2007) Sunbeds-Still a Hotbed for the Burning Issue. Burns, 33, 536537.
Clarke, J. N., & Everest, M. M. (2006) Cancer in the mass print media: Fear,
uncertainty and the medical model. Social Science & Medicine, 62, 2591-2600.
14
Crane, L. A., Schneider, L. S., Yohn, J. J., Morelli, J. G., & Plomer, K. D. (1999).
"Block the Sun, Not the Fun": Evaluation of a Skin Cancer Prevention Program for
Child Care Centers. American Journal of Preventive Medicine, 17(1), 31-37.
Curtis, B. (2008) “We Just want to look good” A qualitative study into adolescent
girls and sun exposure in the UK. Sourced from edissertations-dev.nottingham.ac.uk
Daily Mail (2008) Skin Cancer cases increase by 46% in just seven years, Daily
Mail, on line edition Accessed 22/02/08 from http://www.dailymail.co.uk/health/article517677/Skin-cancer-cases-increase-46-cent-just-seven-years.html
Del Mar, C. B., Green, A. C., & Battistutta, D. (1997). Do public media campaigns
designed to increase skin cancer awareness result in increased skin excision rates?
Australian & New Zealand Journal of Public Health, 21, 751.
Diffey, B. L. (2004) The Future Incidence of Cutaneous Melanoma within the U.K.
British Journal of Dermatology, 151, 868-872.
Diffey, B., & Taylor, S. (2004) SPF - Sun Protection Fact(or) Fantasy? Journal of
Cosmetic Dermatology, 3, 59-61.
Diffey, B. (2001) Sunscreen Isn't Enough. Journal of Photchemistry and
Photobiology B: Biology, 64, 105 - 108.
Dixon, H., Dobbinson, S., Wakefield, M., Jamsen, K., & McLeod, K. (2007) Portrayal
of Tanning, Clothing Fashion and Shade Use in Australian Women's Magazines, 1987
2005. Health Education Research,23, 791- 802.
Del Mar, C. B., Green, A. C., & Battistutta, D. (1997). Do public media campaigns
designed to increase skin cancer awareness result in increased skin excision rates?
Australian & New Zealand Journal of Public Health, 21, 751.
Dobbinson, S. J., Wakefield, M. A., Jamsen, K. M., Herd, N. L., Spittal, M. J.,
Lipscomb, J. E., et al. (2008). Weekend Sun Protection and Sunburn in
Australia: Trends (1987-2002) and Association with SunSmart Television
Advertising. American Journal of Preventive Medicine, 34(2), 94-101.
Donovan, R., & Henley, N. (2003). Social Marketing Principles and Practice.
Melbourne, Australia: IP Communications.
Dorset Cancer Network (2009) Social Markeitng Intervention to reduce adolescent and young
people’s sun bed usage in Dorset. NHS Bournmouth and Poole
Eadie, D., & MacAskill, S. (2007). Results from an Exploratory Study of Sun
Protection Practice. Health Education, 107(3), 250 - 260.
15
Eagle, L., Kemp, G. & Jones, S. (2009). Social Marketing-Based Sun Protection Intervention
Strategy for Cornwall PCT. Report for South West Public Health Observatory
Eagle, L.C., Kemp, G. & Tapp, A. (2008). “Social Marketing Based Strategy for Sun
Protection Interventions”. Report for South West Public Health Observatory, Bristol
Festinger, L. (1954) A Theory of Social Comparison Processes. Human Relations, 7,
117-140.
Fiala, B., Kopp, M., & Gunther, V. (1997) Why Do Young Women use Sunbeds? A
Comparative Psychological Study. British Journal of Dermatology, 137, 950-954.
Fishbein, M. (2000) The Role of Theory in HIV Prevention. Aids Care, 12, 273 - 278.
Gandini, S., Sera, F., Cattaruzza, M. S., Pasquini, P., Picconi, O., Boyle, P., et al.
(2005). Meta-analysis of risk factors for cutaneous melanoma: II. Sun
exposure. European Journal Of Cancer (Oxford, England: 1990), 41(1), 4560.
Gelb, B. D., Boutwell, W. B. & Cummings, S. (1994). Using mass media
communication for health promotion: Results from a cancer center effort. Hospital &
Health Services Administration, 39, 283.
Geller, A. C., Colditz, G., Oliveria, S., Emmons, K., Jorgensen, C., Aweh, G. N., et al.
(2002) Use of Sunscreen, Sunburning Rates, and Tanning Bed Use Among More
Than 10 000 US Children and Adolescents. Pediatrics, 109, 1009-1014.
Gillie, O. (2006) A New Government Policy Is Needed For Sunlight And Vitamin D.
British Journal of Dermatology, 154, 1052-1061.
Glerup, H., Mikkelsen, K., Poulsen, L., Hass, E., Overbeck, S., Thomsen, J., et al.
(2000) Commonly Recommended Daily Intake of Vitamin D is Not Sufficient if
Sunlight Exposure is Limited. Journal of Internal Medicine, 247, 260-268.
Grant, W. B. (2005) Vitamin D Reduces the Risk of Cancer and Multiple Sclerosis.
British Medical Journal (BMJ), 7507, 3 - 4.
Grunfeld, E. A. (2004). What influences university students' intentions to practice safe
sun exposure behaviors? Journal of Adolescent Health, 35(6), 486-492.
Hargreaves, I., Lewis, J., & Speers, T. (2003) Towards a Better Map: Science, the
Public and the Media. London: Economic & Social Research Council.
Harris, P., Middleton, W., & Joiner, R. (2000) The Typical Student as an In-group
Member: Eliminating Optimistic Bias by Reducing Social Distance. European
Journal of Social Psychology, 30, 235-253.
16
Hedges, T., & Scriven, A. (2008) Sun safety: what are the health messages? Journal
of The Royal Society for the Promotion of Health, 128, 164-169.
Heneghan, M. K., Hazan, C., Halpern, A. C., & Oliveria, S. A. (2007) Skin cancer
coverage in a national newspaper: a teachable moment. Journal of Cancer Education,
22, 99-104.
Hiom, S. (2006) Public Awareness Regarding UV Risks and Vitamin D--The
Challenges for UK Skin Cancer Prevention Campaigns. Progress in Biophysics and
Molecular Biology, 92(1), 161-166.
International Agency for Research on Cancer Working group on artificial ultraviolet
(UV) light and skin cancer (2006) The association of use of sunbeds with cutaneous
malignant melanoma and other skin cancers: A systematic review. International
Journal of Cancer, 120, 1116 -1122.
International Agency for Research on Cancer (2008). Vitamin D and Cancer,
International Agency for Research on Cancer, Lyon, France.
ISD Online. Cancer Incidence and Mortality Data (website) Accessed 2008
Janda, M., Kimlin, M. G., Whiteman, D. C., Aitken, J. F., & Neale, R. E. (2007). Sun
Protection Messages, Vitamin D and Skin Cancer: Out of the Frying Pan and Into the
Fire? Medical Journal of Australia, 186(2), 52 - 54.
Jones, F., Harris, P., & Chrispin, C. (2000) Catching the Sun: An Investigation of
Sun-Exposure and Skin Protective Behaviour. Psychology, Health & Medicine, 5, 131
- 141.
Kemp, G. & Eagle, L.C. (2008) “Shared Meanings or Missed Opportunities? The
Implications of Functional Health Literacy for Social Marketing Interventions”. The
International Review on Public and Nonprofit Marketing. December 2008.
Kline, K. (2006) A Decade of Research on Health Content in the Media: The Focus
on Health Challenges and Sociocultural Context and Attendant Informational and
Ideological Problems. Journal of Health Communication, 11, 43 - 59.
Ladhani, S., Srinivasan, L., Buchanan, C., & Allgrove, J. (2004) Presentation of
vitamin D deficiency. Archives of Disease in Childhood, 89, 781-784.
Larsson, A., Oxman, A. D., Carling, C., & Herrin, J. (2003) Medical Messages in the
Media - Barriers and Solutions to Improving Medical Journalism. Health
Expectations, 6, 323 - 331.
Lazovich, D., & Forster, J. (2005) Indoor Tanning by Adolescents: Prevalence,
Practices and Policies. European Journal of Cancer, 41, 20-27.
17
Leventhal, H., Kelly, K., & Leventhal, E. A. (1999) Population Risk, Actual Risk,
Perceived Risk, and Cancer Control: a Discussion. Journal of the National Cancer
Institute Monographs, 25, 81-85.
Lowe, J. B., Borland, R., Stanton, W. R., Baade, P., White, V., & Balanda, K. P.
(2000). Sun-safe Behaviour among Secondary School Students in Australia. Health
Educ. Res., 15(3), 271-281.
Lucas, R. M., Repacholi, M. H., & McMichael, A. J. (2006) Is the Current Public
Health Message on UV Exposure Correct? Bulletin of the World Health Organization,
84, 485 - 491.
Luo, J., & Isaacowitz, D. M. (2007). How optimists face skin cancer information: risk
assessment, attention, memory, and behavior. Psychology & Health, 22(8), 963-984.
MacKenzie, R., Chapman, S., Barratt, A., & Holding, S. (2007). "The news is [not] all
good": misrepresentations and inaccuracies in Australian news media reports on
prostate cancer screening. The Medical Journal of Australia, 187(9), 507-510.
McDermott, L. J., Lowe, J. B., Stanton, W. R., & Clavarino, A. M. (2005) Suntans
and Sun Protection in Australian Teen Media: 1999 to 2000. Health Education
Behavior, 32, 504-513.
McGreevy, D. (2005) Risks and Benefits of the Single versus the Triple MMR
Vaccine: How Can Health Professionals Reassure Parents? The Journal of the Royal
Society for the Promotion of Health, 125, 84 - 86.
McMurray, R., Cheater, F., Weighall, A., Nelson, C., Schweiger, M., & Mukherjee, S.
(2004) Managing Controversy Through Consultation: A Qualitiative Study of
Communication and Trust Around MMR Vaccination Decisions. British Journal of
General Practice, 54, 520 - 525.
Miranda, C. (2008) Poms Topple Aussies in Melanoma Deaths, Herald Sun, online
edition, December 20. Accessed 12 January 2009 from
http://www.news.com.au/heraldsun/story/0,21985,24824277-663,00.html
Moriarty, C. M., & Stryker, J. E. (2008) Prevention and Screening Efficacy Messages
in Newspaper Accounts of Cancer. Health Education Research, 23, 487-498.
National Institute for Health and Clinical Excellence, (2006) Press Release: NICE
issues guidance to improve healthcare services for skin cancers, 21st February 2006
Nelkin, D. (1996) An Uneasy Relationship: The Tensions Between Medicine and the
Media. The Lancet, 347, 1600-1603.
Ness, A. R., Frankel, S. J., & Smith, G. D. (1999). Are We Really Dying For A Tan?
British Medical Journal (BMJ), 319, 114 - 116.
Peattie, K., Peattie, S. & Clarke P (2001) Skin Cancer Prevention: Re evaluating the
Public Policy implications, Journal of Public Policy & Marketing, 20, 268-279
18
Petts, J., & Niemeyer, S. (2004). Health Risk Communication and Amplification:
Learning from the MMR Vaccination Controversy. Health, Risk & Society, 6, 7 - 23.
Poorsattar, S. P., & Hornung, R. L. (2008). Television Turning More Teens Toward
Tanning. Journal of the American Academy of Dermatology, 58, 171-172.
Pribble, J. M., Goldstein, K. M., Fowler, E. F., Greenberg, M. J., Noel, S. K., &
Howell, J. D. (2006). Medial News for the Public to Use? What's On Local TV
News. The American Journal of Managed Care, 12, 170 - 176.
Richards, R., Reeder, A. I., & Bulliard, J. L. (2004) Fine Forecasts: Encourageing the
Media to Include Ultraviolet Radiation Information in Summertime Weather
Forecasts. Health Education Research., 19, 677-685.
Rose, D. (2009) Surge in measles blamed on MMR vaccine scare. Times Online,
January 9. Retrieved 12 January 2009, from
http://www.timesonline.co.uk/tol/life_and_style/health/article5478060.ece
Sinclair, C., & Foley, P. (2009). Skin cancer prevention in Australia. British Journal
of Dermatology, 161(0 suppl.), 116-123.
Sjoberg, L., Holm, L.-E., Ullen, H., & Brandberg, Y. (2004). Tanning and risk
perception in adolescents. Health, Risk & Society, 6(1), 81-94.
Smith, R. (2010) Children banned from using sunbeds in new law. The Telegraph,
April 8 Accessed from
http://www.telegraph.co.uk/health/healthnews/7567712/Children-banned-from-usingsunbeds-in-new-law.html
Social Market Foundation. (2006) Experts Take on the Media's Sensationalising of
Scientific Issues. Retrieved 19 October, 2006, from
http://www.smf.co.uk/print.php?sid+180
Speers, T., & Lewis, J. (2004) Journalism and Jabs: Media Coverage of the MMR
Vaccine. Communication & Medicine, 1, 171 - 181.
Wakefield, A. J., Murch, S. H., Anthony, A., Linnel, J., Casson, D., Malik, M., et al.
(1998). Ileal-lymphoid-nodular Hyperplaisa, Non-specific Colitis, and Pervasive
Development Disorder in Children. The Lancet, 351, 637 - 664`.
Weinstock,J., & Rossi, J.S., (1998) The Rhode Island Sun Smart Project: A scientific
approach to skin cancer prevention, Clinics in dermatology, 16, pp 411-413
Wood-Harper, J. (2005) Informing Education Policy on MMR: Balancing Individual
freedoms and Collective Responsibilities for the Promotion of Public Health. Nursing
Ethics, 12, 43 - 58.
19
Youl, P., Janda, M., & Kimlin, M. (2009). Vitamin D and Sun Protection: The Impact
of Mixed Public Health Messages in Australia. International Journal of Cancer, 124,
1963-1970.
20
Table 1: Examples of Media Headlines Regarding Benefits of Vitamin D
Date
1 May
2009
5 May
2009
12 May
2009
13 May
2009
13 May
2009
14 May
2009
15 May
2009
16 May
2009
16 May
2009
21 May
2009
22 May
2009
25 May
2009
26 May
2009
26 May
2009
29 May
2009
31 May
2009
June 1
2009
2 June
2009
3 June
2009
17 June
2009
24 June
2009
24 June
2009
24 June
2009
Headline
Aid could be found in Vitamin D
No proof: Study could not link low
Vitamin D to colds
Is there a link between Vitamin D, flu
immunity?
Vitamin D helps reduce diabetes risk
Source
The Boston Globe
http://www.boston.com
The Washington Post (via
http://www2.journalnow.com)
Virgo Publishing www.vpico.com
Private Healthcare UK
Vitamin D deficiency common in
premenopausal women with breast caner
despite supplementation
Wrong sunlight can lower your Vitamin D
levels
High Doses of Vitamin D may prevent
relapses
Millions face serious health risks over lack
of Vitamin D in diets
Elderly need more ‘sun vitamin’
http://professional.cancerconsultants.c
om
Vitamin D ‘key to healthy brain
http://newsvote.bbc.co.uk
New model of Cancer development: Low
Vitamin D levels may have role
Nutrition: Vaginal Infection Tied to Low
Vitamin D
Vitamin D may lessen Age-related
Cognitive Decline
Vitamin D doesn’t protect against cancer
Science Daily
www.sciencedaily.com
The New York Times
www.nytimes.com
http://www.medicalnewstoday.com
Low Vitamin D levels may impair
thinking
Boosting levels of Vitamin D ‘could cut
cancer by up to 25%’
Promote Vitamin D testing for public Joint
Canadian Tanning Association urges
Canadian Cancer Society
How avoiding the sun to protect against
skin cancer has left Georgia Coleridge
facing the threat of brittle bones
MS research highlights role of Vitamin D
www.thehealthierlife.co.uk
http://ms.about.com
www.dailymail.co.uk
http://newsvote.bbc.co.uk
Doctor NDTV
http://doctor.nvtv.com
www.reuters.com
www.dailymail.co.uk
http://www.newswire.ca
www.dailymail.co.uk
www.abc.net.au
Vitamin D call as march bids to cut MS
rate
Vitamin D guidelines and beauty benefits
http://news.scotman.com
Vitamin D and depression
http://www.examiner.com
Huge Vitamin D study planned
http://www.privatemdlabs.com
21
http://www.examiner.com
Table 2: Open Ended Responses to Ways the Body can Acquire Vitamin D
Sources of Vitamin D
% of respondents indicating this
source
Food
13
Fruit and vegetables
10
Sunlight
36
Vitamin Supplements
18
22
Figure 1: Fishbein et al. Integrative Model of Behavioural Prediction and
Change (Fishbein, 2000)
Background influence
Past behaviour
Demographics &
culture
Attitudes towards
targets (stereotypes &
stigma)
Personality Moods and
emotions
Behavioural
Beliefs
and Outcome
Evaluations
Attitude
Environmental
factors
Normative
Beliefs and
Motivation to
Comply
Other individual
difference variables
(perceived risk)
Intervention exposure
Media exposure
Control Beliefs
and Perceived
Power
23
Norm
Intention
Self
Efficacy
Skills and abilities
Behaviour
24