Protect against skin cancer

Why does the topic of sun protection need to be addressed?

Whilst many people are aware that the sun causes skin cancer, it seems to be the case that many people do not tend to take it seriously. For example, as shown in Figure 1, Suppa, Cazzaniga, Fargnoli, Naldi and Peris (2012) found that only 13% of 1000+ Italian adolescents used sun protection despite having some knowledge of skin cancer. But why would people avoid putting sunscreen on if they know the dangers? Well whilst this seems shocking, it could be explained by the optimism bias. The optimism bias states that we tend to believe that bad things are less likely to happen to us compared to other people (Sharot, 2011). If this is the case, then we can’t really blame people for engaging in behaviours that have health risks if they are biased to think that it will never happen to them. However, it still frustrates me when I see people slathering oil on their bodies at the beach, as the consequences can be awful! So, I thought that if I can challenge the bias that people have by making them aware that anyone can get skin cancer, then people would think twice before spending their summer days unprotected in the sun… However, I didn’t just rely on this one technique - I included others which I will explain later on.

Figure 1. A figure to show the results from Suppa et al.'s study, showing the number of people who follow sun-safe practices in comparison to the number of people who have knowledge about skin cancer and the sun

So, what did I do?

I decided to make a short stop-motion video, using a variety of techniques to encourage behaviour change:

  

Theory of Planned Behaviour

When I was reading the literature on this topic, I came across Branström’s (2004) work which inspired some of the methods that I used in my video. Branström conducted research in relation to Ajzen’s (1991) Theory of Planned Behaviour, within the context of sun protection. He gave questionnaires to over 1700 people, and the findings relate to all three of the main components of the Theory of Planned Behaviour (1. Attitudes; 2. Subjective norms; 3. Perceived Behavioural Control), and I applied the theory and their findings to my project, as described below.

Figure 2 - A diagram of the Theory of Planned Behaviour

1.1 Attitudes: challenging positive attitudes

Branström (2004) found that positive attitudes towards tanning are strongly associated with intentional tanning. This is particularly problematic because research has found that our perception of tanned skin seems to be very positive. For example, Cho, Lee, and Wilson (2010) found that women tend to perceive tanned women as fit and fashionable, and having this positive perception is associated with having positive attitudes towards actual tanning behaviour. Therefore, in my video, I challenged the commonly-held positive beliefs associated with tanned skin by crossing the words out and pairing ‘tanned skin’ with ‘damaged’ instead, in order to increase negative attitudes and reduce positive attitudes so that people will be less likely to engage in tanning behaviour.

1.2 Attitudes: emphasising the risk

Crucially, Bramström (2004) also found that perceiving sunbathing as a risk to health is associated with the use of sun protection. Most campaigns have focused on delivering the information about correct sun protection but have tended to avoid focusing on skin cancer due to the fear of worrying people, but it is important to communicate risk in order for people to have a more realistic perception (Bränström, Kristjansson, & Ullén, 2005). Notably, actually changing risk perception consequently changes health behaviour, which further highlights the importance of communicating the risks (Ferrer & Klein, 2015). In light of these findings, I decided to emphasise the number of diagnoses in a year, the number of cases which are preventable, and end with the quote ‘anyone can get skin cancer’ to influence people’s perception of risk. Using the quote ‘anyone can get skin cancer’ specifically targets risk perception, and it addresses the optimism bias by making sure people realise that they are at risk too. I also repeated the risk-based message, as repeating a message can result in increased likeability and believability, and this is known as the mere exposure effect (Zajonc, 1968; Pratkanis & Aronson, 2001). Not only did I repeat the message, but I also mentioned the source of the message which was ‘The President of the American Academy of Dermatology’, as this increases the credibility, and messages from credible sources are more likely to lead to attitude change than messages from sources of lower credibility (Hovland & Weiss, 1951). By using these various techniques, I hope that people become more aware of the risk and change their attitudes (and subsequently their intentions and behaviour).

2. Subjective norms

The ‘subjective norms’ component is primarily based on social influence: if everyone around us is tanning, then that sets the belief of what is expected of ourselves, so we’re more likely to want to engage in tanning behaviour too. A recent example of research in which subjective norms influenced people's intentions was conducted by Wang et al. (2017). They asked participants to imagine that they had homework due the next day, but that they wanted to play games instead. Whilst imagining this scenario, they were asked to decide whether they intend to complete the homework, or play online games. The subjective norm was then introduced: they were asked to either imagine that their friends had invited them to play the game (the subjective norm is the perceived 'peer support' to play games) or to imagine that their parents think that they should be doing their homework instead of playing (the subjective norm is the perceived pressure to not play games). After this, they were asked the intention question again. It was found that the perceived peer support increased the likelihood of intending to choose to play games, whereas the perceived disapproval from parents significantly decreased the number of participants who intended to play games. This research highlights the effectiveness of subjective norms in influencing people's intended actions. Relating back to Bramström's study (2004), he also found links between subjective norms and behaviour. He found that participants who hang around those who spend time sunbathing were more likely to engage in intentional tanning themselves. With the concept of subjective norms in mind, I included the quotes from famous people who said that they cover up in the sun, as it demonstrates the acceptability towards covering up and this sets a new norm (away from the one in which tanning is normal) meaning that people are less likely to believe that tanning is expected, and more likely to believe that they are expected to protect themselves.

3. Perceived behavioural control (self-efficacy)

Both ‘self-efficacy’ and ‘perceived behavioural control’ are terms which are sometimes used interchangeably in the literature, and whilst a few researchers argue that there is a slight difference, the main concept is the same: if people feel that they are able to do something with ease, they are more likely to do it (Ajzen, 1991). Relating back to Bramström (2004) who inspired the methods I used in my video, he found that perceived behavioural control is associated with the use of sunscreen. But how do you increase perceived behavioural control or self-efficacy? Well, Ratner and Riis (2014) found that involving only a small number of steps in recommendations can increase self-efficacy, so that the behaviour is more likely to be performed. Therefore, I showed an image of a person on the beach demonstrating a few simple behaviours (holding sunscreen, going under an umbrella, and wearing more clothes), to show how simple it is to incorporate the health behaviours into the scenario. Furthermore, by including the quotes from celebrities who cover up, it shows that other people are able to do it, implying that they should be able to as well.

Moving from Intention to Behaviour

I wanted to keep my short video focused on a simple message because communication which involves simple and easy-to-visualise ideas are more appropriate and memorable for people who are non-experts in the topic area (Ratner & Riis, 2014). I also made sure that the context was very clear, providing environmental cues such as the sun and the beach. By including environmental cues, people are more likely to act on the information, and for this reason, the cues are also known as ‘action triggers’ (Heath & Heath, 2007). When the behaviour is triggered by an environmental cue, individuals are able to perform the action without using too much cognitive effort (Ratner & Riis, 2014). This increases the chances of intentions turning into behaviour when they find themselves in the appropriate scenario.

Whilst intentions do not always lead to the desired behaviour, I have still chosen to focus particularly on elements which lead to intentions through the Theory of Planned Behaviour. Trying to form an intention, as well as creating implementation intentions that come after the intention is formed, would have been quite a big task. Implementation intentions are 'if-then' plans which specify what behaviour you want to do, and when and where you will do it e.g. if someone wants to stop falling asleep on the sofa during the day, their if-then plan might be 'if I start to fall asleep on the sofa before 9pm, I will get up and drink a cup of coffee' (Gollwitzer, 1999).  However, suggesting if-then plans in my video would have been ineffective, and this is actually something that has been looked at within the context of sunscreen use. Craciun, Schuz, Lippke and Schwarzer (2012) found that intention plans work best for people who already have the intention to wear sunscreen, but those who do not intend to use sunscreen actually benefit from information regarding the risks, in order to increase awareness of the health problem. For this project, I posted the video in specific forums, such as ones in which people discuss tanning by exchanging tips and advice, as well as forums in which people discuss their holidays. As I specifically targeted people who are likely to already spend time tanning, it means that they are unlikely to have any intention of wearing sunscreen and protecting themselves from the sun. Therefore, I have focused on using attitudes, subjective norms, and perceived behavioural control in order to build intentions to be safe in the sun. If the intention is strong enough, it will lead to the desired behaviour as shown in the Theory of Planned Behaviour diagram, and hopefully the action triggers will help with that too.

Persuading one person can have a knock-on effect…

Having just one person watch the video may have a bigger effect than just changing one person’s behaviour. For example, if it changes the attitudes and behaviour of someone who normally advocates tanning behaviour, they would probably stop posting positive posts about the health-damaging behaviour, and consequently, stop influencing others to tan. I hope that exposing tanning-advocates to a negative message about tanning makes them reconsider their behaviour, and maybe even go on to trying to persuade their friends to wear sunscreen too. Also, anyone who looks at the forum to read about tanning will also be exposed to my message, not just those who post on there, so over time, more people who are into tanning will see it. Overall, due to the nature of this project, an exact measurement of behaviour change is not possible - but I hope that when the sunny weather comes around this summer, people will take extra care of their skin after seeing my video! 

References


Ajzen, I. (1991). The theory of planned behavior. Organizational Behavior and Human Decision Processes, 50(2), 179-211.


Branstrom, R. (2004). Attitudes, subjective norms and perception of behavioural control as predictors of sun-related behaviour in Swedish adults. Preventive Medicine, 39(5), 992-999.


Bränström, R., Kristjansson, S., & Ullén, H. (2005). Risk perception, optimistic bias, and readiness to change sun related behaviour. European Journal of Public Health, 16(5), 492-497.


Cho, H., Lee, S., & Wilson, K. (2010). Magazine exposure, tanned women stereotypes, and tanning attitudes. Body Image, 7(4), 364-367.


Craciun, C., Schuz, N., Lippke, S., & Schwarzer, R. (2012). Enhancing planning strategies for sunscreen use at different stages of change. Health Education Research, 27(5), 857-867.

Ferrer, R., & Klein, W. (2015). Risk perceptions and health behavior. Current Opinion in Psychology, 5, 85-89.



Gollwitzer, P. M. (1999). Implementation Intentions: Strong effects of simple plans. American Psychologist, 54, 493-503.


Heath, C., & Heath, D. (2007). Made to stick. New York: Random House.


Hovland, C., & Weiss, W. (1951). The Influence of Source Credibility on Communication Effectiveness. Public Opinion Quarterly, 15(4), 635.


Ratner, R., & Riis, J. (2014). Communicating science-based recommendations with memorable and actionable guidelines. Proceedings of The National Academy Of Sciences, 111(4), 13634-13641.


Sharot, T. (2011). The optimism bias. Current Biology, 21(23), R941-R945.


Suppa, M., Cazzaniga, S., Fargnoli, M., Naldi, L., & Peris, K. (2012). Knowledge, perceptions and behaviours about skin cancer and sun protection among secondary school students from Central Italy. Journal of The European Academy Of Dermatology And Venereology, 27(5), 571-579.


Wang, J., Liu, R., Ding, Y., Liu, Y., Xu, L., & Zhen, R. (2017). What Influences Chinese Adolescents’ Choice Intention between Playing Online Games and Learning? Application of Theory of Planned Behavior with Subjective Norm Manipulated as Peer Support and Parental Monitoring. Frontiers In Psychology, 8, 589.

Zajonc, Robert B. (1968). Attitudinal Effects of Mere Exposure. Journal of Personality and Social Psychology. 9 (2, Pt.2): 1–27