This study examines the skin cancer-related correlates of mass media health information exposure in 1,633 individuals from the general population with no skin cancer history. The HINTS national probability sample afforded us the opportunity to examine the extent to which exposure to mass media health communication and skin cancer beliefs are related to skin cancer prevention behaviors. The study also allowed us to examine demographic differences in mass media health communication, skin cancer beliefs, and skin cancer prevention behaviors. This research represents an important step in determining the most appropriate skin cancer prevention messages, and channels for those messages, among individuals from diverse general-population subgroups.
Mass media exposure in this general population sample was characterized by frequent Internet use, and high levels of exposure to health information in print (magazine or newspaper) media and local television news. Exposure to Internet-based health, sun-protection, and cancer-related information was less common, however. Given that a large proportion of United States Internet users who access health information online2
, it is possible that individuals in our sample are accessing health information less often than average; alternatively, our divergent findings may be due to the fact that the HINTS questions ask separately about reading unsolicited Internet health information and proactive health information-seeking on the Internet, which were both endorsed by approximately a third of our participants. Indeed, both passive exposure and active information gathering processes are likely operative and contribute to exposure to available health information5
. Our findings point to the continued importance of mainstream print media and television as critical channels for dissemination of health and cancer information in the general population. The ongoing development of high-quality public health messages for these media channels is warranted, as such messages will reach as large or potentially a larger segment of the population than the Internet.
In general, individuals in this sample reported that skin cancer was preventable and survivable. This finding is consistent with recent large United States population surveys 17, 18
, as we found the sample reported inconsistent use of sunscreen, shade-seeking, and clothing during sunny activities. For example, Coups and colleagues (2008) examined data from over 28,000 individuals in the 2005 National Health Interview Survey 18
and found that about half (43%–51% across age groups) reported frequent (sometimes/most of the time/always) use of sunscreen, 65% to 80% did not usually stay in the sun when outside on a sunny day, and 15% to 51% used sun-protection clothing. Accordingly, our study is consistent with the available literature in terms of the great variation in level of consistency with which sun protection are used as documented in large general population samples.
We found patterns of findings across demographic groups and mass media exposure, skin cancer beliefs, and sun protection behaviors that will be useful in planning skin cancer awareness and prevention messaging across diverse demographic groups. First, we found that young people are receptive to mass media health information but less knowledgable about skin cancer (causes, prevention strategies, symptoms, survivability, timeline) and less likely to be consistent users of sun protection, making them a useful target for skin cancer prevention messages using the Internet and other (newspapers, magazines, television) channels that would aim to increase their awareness of skin cancer and recommended strategies for prevention. These findings also indicate the importance of bringing Internet-based information on skin cancer prevention - especially sun avoidance and minimizing exposure through the use of clothing - to Internet-savvy audiences.
Second, those individuals with lower education levels, as well as those from non-Caucasian subgroups are more consistently receptive to health information via television news; skin cancer prevention messages using television may be an important route to increasing their awareness of skin cancer and recommended strategies for prevention. Finally, men appear to favor the use of sun-protective clothing but are less likely to use sunscreen or seek shade than do women. This dictates targeted messages for men regarding the importance of sunscreen when clothing use is less feasible; of note, given that married individuals were more likely to use sunscreen than unmarried individuals, it may be that unmarried men could be a particular focus for these messages. After controlling for age, education, racial/ethnic group, gender and marital status, those who searched for health information on the Internet in the past 12 months, and those who searched for sun-protection information on the Internet in the past 12 months were more likely to use sunscreen. Those who searched for sun-protection information on the Internet in the past 12 months reported greater use of sun-protective clothing. These findings dictate the importance of providing accurate Internet-based skin cancer information as one strategy to “get the word out” regarding skin cancer prevention.
These findings also indicate the importance of examining sunscreen use, shade-seeking, and use of sun protective clothing separately, as they were not highly correlated with each other and may respond differently to intervention. It is important to consider the need to develop separate interventions, or separate intervention components, in order to address the different barriers and facilitators of sunscreen use, shade-seeking, and use of protective clothing. It is possible some individuals may perceive that sunscreen alone will adequately protect against skin cancer. Adequate consideration of the wholistic mass media environment surrounding skin cancer and skin cancer prevention (public health messages as well as promotional or commercial messages) is important in the development of messages targeted to those with different levels of exposure to the mass media.
Family history of skin cancer was not related to sun protection strategies after controlling for demographics. This may be because those with a family history of skin cancer may feel that cancer is inevitable, which may lead to reduced use of sun-protective clothing. Second, it has been documented previously that first-degree family members of melanoma patients do not have adequate sun protection19, 20. Finally, the family skin cancer history variable used in this HINTS survey may have been too general, as it did not limit endorsement to those with only first-degree relatives with skin cancer.
There are implications of this current work for physicians as well as those who develop public health messages regarding skin cancer prevention. First, younger mass media-savvy individuals don’t necessarily practice adequate sun protection. Therefore, clinicians need to educate patients and inform them of the importance of multiple protective behaviors, including sunscreen use, shade-seeking, as well as use of sun-protective clothing. Secondly, those who may be informed about sunscreen may not be the same people who appreciate the importance of other forms of sun avoidance and protection, dictating the need to be explicit in counseling on the use of hats, clothing, and shade – as well as sunscreen - during high risk time periods.
Additionally, very few people are seeking information about sun protection on the Internet, so clinicians have an obligation to educate patients at routine visits, and those devising new public health messages may want to consider presenting sun protection messages on health, well-being, or vacation/recreation websites and in other mass media in order to capture the attention of those who may remain uninformed. Studies have documented inaccuracies and incomplete Internet information regarding the risk factors, diagnosis, treatment, prevention, and prognosis for skin cancer 21–23
which should be remedied.
There are limitations of the work described here. First, this study is cross-sectional so we cannot distinguish causal relationships between health communication and skin cancer beliefs and behaviors. Second, sun protection behaviors were collected via self-report, which may not accurately reflect actual behavior. Third, the HINTS sunscreen question did not ask participants to report sunscreen SPF, or reapplication of sunscreen, so our knowledge of the actual protection conveyed by this behavior is limited. Additionally, we did not have assessments regarding month of the year or region of the country which may have influenced reported sun protection behaviors. Finally, the question about family history of skin cancer did not ask specifically about skin cancer in first-degree relatives, and even when this is assessed skin cancer family history reports can be unreliable 24
In conclusion, given the frequency with which individuals in the United States may seek information about skin cancer via the Internet 4
, there are useful opportunities for targeted messaging dictated by our study findings. In particular, messages targeting younger people who are heavily-exposed to the Internet but less adherent to sun-protection practices, those from lower educational groups with diverse ethnicity, as well as men would usefully address preferred sources of health information exposure to increase awareness and behavior change in skin cancer prevention. Future transdisciplinary research should include dermatologists in collaboration with behavioral and communication scientists could document trends in mass media content regarding skin cancer, general population awareness of available mass media information about skin cancer, and examination of perceived informational needs and preferences of those individuals seeking skin cancer information. Skin cancer prevention intervention studies would ideally measure baseline frequency of use of mass media channels, and preferences for, diverse mass media channels where individuals may encounter health information about skin cancer as these factors may moderate intervention effects. The findings reported here will be relevant to those devising mass media messages regarding skin cancer, and will also be useful to clinicians addressing the content and deficits of mass media messages regarding skin cancer with their patients.