Visual and Text Coverage of Skin Cancer and Recreational Tanning in Popular North American Magazines from 2000 to 2012
McWhirter, Jennifer E.
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Background: Skin cancer is the most common type of cancer in North America and its incidence is increasing globally. It is a largely preventable disease through avoiding ultraviolet (UV) exposure and, when detected early, survival is high. The public’s knowledge about skin cancer is poor, and sun protection behaviours and early detection through skin self-examination are infrequent. Moreover, despite the 2006 International Agency for Research on Cancer’s (IARC) report linking indoor tanning and skin cancer, and the classification of indoor tanning as carcinogenic by IARC in 2009, the behaviour remains popular. The mass media is a popular and influential source of health information, including about skin cancer. Moreover, magazines are an important source of information about aesthetic ideals for the body, including tanned skin. Articles in the mass media often are accompanied by visual images, which can influence health behaviours. Little is known about mass media coverage (both article text and images) on skin cancer and tanning. Objectives: The primary objectives of this doctoral research were to: describe and analyze how popular North American magazines report on skin cancer and recreational tanning (i.e., risk factors, UV behaviours, and early detection information); determine how magazine coverage has changed over time relative to the 2006 IARC report linking indoor tanning and skin cancer and the 2009 classification of tanning beds as carcinogenic; test how coverage differed by content type (text vs. images) and target audience (women vs. men, women vs. teenage girls, Canadians vs. Americans); and determine the extent to which constructs from the Health Belief Model (HBM) were conveyed in articles and images about skin cancer and tanning. Methods: Popular Canadian and U.S. magazines (n = 31) were selected for inclusion based on circulation, genre, and target audience. Using online databases and tables of contents, the magazines were searched for articles about skin cancer and tanning published between 2000 and 2012. Articles and their accompanying images were obtained from online databases and library archives. The quantity of articles and images published were determined and, using directed content analysis, detailed information was collected from articles and images. Descriptive statistics were used; chi-square and Fisher’s exact tests enabled comparisons. The codebooks were developed based on previous research and the HBM constructs. Inter-rater reliability was conducted using a 10% sample of articles (n = 86) and images (n = 127) and kappa scores were high (0.82 to 1.00). Results: Between 2000 and 2012, 855 articles (and 1372 accompanying images) were published about skin cancer and tanning in 31 popular North American magazines. The total number of articles about skin cancer and tanning increased modestly after (n = 410) compared to before (n = 351) the IARC report (χ2 = 4.57, df = 1, p < .05); however, key IARC report messages (e.g., avoid indoor tanning, UV exposure as a risk factor) were no more likely to be reported after than before the report. Magazines were more likely to encourage sunscreen use and less likely to promote the tanned look as attractive after the IARC report. The was no change in volume of coverage on skin cancer and recreational tanning before the 2009 classification of tanning beds as carcinogenic (n = 212) vs. after the classification (n = 198) (χ2 = 0.48, df = 1, p = .49). Key related messages (UV exposure is a risk factor; avoid indoor tanning) were not reported on more frequently after the classification, but the promotion of the tanned look as attractive was conveyed more often afterwards, as was the use of high Sun Protection Factor (SPF) sunscreens. In terms of overall coverage of the variables of interest, UV exposure was the most common risk factor mentioned (37.7%) and sunscreen use the most common protection behaviour encouraged (60.0%); coverage of other risk factors and UV protective or avoidance behaviours was uncommon. Just 21.1% of articles, and even fewer images (7.0%), contained information about early detection. For nearly all variables, article text contained more information about risk factors, behaviours, and early detection compared to images. An important exception was that a greater proportion of images (36.9%) promoted the tanned look compared to text (25.2%). Women’s magazines (n = 456) published more articles than men’s magazines (n = 125) (χ2 = 188.57, df = 1, p < .0001) and the nature of the messages differed between them (e.g., women’s magazines more often promoted the tanned look, men’s magazines more often promoted protective clothing). Women’s magazines also published more articles about skin cancer and tanning (n = 79) than teenage girl’s magazines (n = 43) (χ2 = 10.62, df = 1, p = .001), with important differences in coverage (e.g., girls’ magazines more often discouraged indoor tanning). There was no significant difference in the quantity of articles published in Canadian (n = 154) vs. U.S. magazines (n = 178) (χ2 = 1.74, df = 1, p = .188), but the nature of the coverage differed (e.g., there was a greater emphasis on risk factors and early detection in U.S. coverage). Regarding the HBM constructs, perceived susceptibility (48.1%) and severity (60.3%) information was common in text. Perceived benefits (36.4%) and barriers (41.5%) to prevention of skin cancer were equally mentioned in articles; barriers to prevention were also depicted in images (31.7%). Self-efficacy information focused on prevention (48.4%). There was little emphasis on HBM constructs related to early detection and few explicit cues to action. In most cases, HBM constructs were present to a significantly greater extent in text compared to images. Conclusions: Coverage focused narrowly on one risk factor (UV exposure) and one behaviour (sunscreen use), while simultaneously promoting the tanned look as attractive and containing little information about early detection. Key international public health reports and decisions had limited impact on magazine coverage of skin cancer and tanning. Women were targeted with more and different information compared to men. Visual images infrequently offered helpful information and even promoted unhealthy UV behaviours. Magazine skin cancer and tanning content may contribute to inaccurate public understanding of risks, prevention, and early detection, and may not contain sufficient information to positively influence healthy skin behaviours. Cancer educators, public health communication specialists, and journalists should work together to improve mass media messages around skin cancer and tanning. Future Directions: This body of research is the largest content analysis on magazine coverage of skin cancer and recreational to date and one of the only to include visual images. Two promising areas for further study are: to examine skin cancer and tanning messages in social and online media; and to assess the impact of mass media information on the public’s knowledge and behaviours about skin cancer and recreational tanning.