A Critique of the CDC’s Approach to Increasing Sun Safe Behaviors in Youth – Kaitlyn Moran

Skin cancer is an enormous cause for concern in the United States, as it is the most common type of cancer in the country. There are three forms of skin cancer—squamous cell, basal cell, and melanoma, with squamous and basal cell being the most common and melanoma being the most deadly. Skin cancer is caused by exposure to ultraviolet radiation from the sun, indoor tanning beds, and sun lamps. When UV radiation penetrates the skin cells, it can alter normal skin cells. Too much exposure to UV rays can change the texture of the skin, lead to premature aging in the skin, and cause skin cancer. While many factors can increase a person’s susceptibility to skin cancer, including a lighter natural skin color, family history, and certain diseases or medications, the sun’s radiation is the leading cause of skin cancer and anyone who is exposed to the sun is at risk of developing skin cancer (1).

Avoiding the direct sunlight is the main way to prevent exposure to the UV radiation and to avoid skin cancer. The Centers for Disease Control and Prevention (CDC) recommends seeking shade during the hazardous hours between 10 a.m. and 4 p.m., wearing protective clothing like long sleeves and a wide brim hat, wearing sunglasses, avoiding indoor tanning, and using sunscreen with a sun protective factor (SPF) of 15 or higher (2). Despite these measures being what the CDC terms “easy options” for preventing skin cancer, it is still a substantial and growing problem in the United States. In 2008, 59,695 people in the United States were diagnosed with melanomas of the skin and 8,623 people in the United States died, which are increases from previous years (3). Although skin cancer is one of the few forms of cancer in which the causes, risk factors, and preventative measures are well known, it still continues to be a problem. The American Academy of Dermatology estimates that one in five Americans will be diagnosed with skin cancer in their lifetime. Numerous studies have shown that the adolescents and young adults, especially females, continue to expose themselves to UV radiation through both outdoor and indoor tanning .

In an effort to reduce morbidity and mortality caused by skin cancer, the CDC is attempting to increase sun safety behaviors in America’s youth through educational school-based approaches and guidelines. They emphasize behavior change through classroom lessons and encourage teachers and coaches to serve as role models for proper sun safety behaviors. However, the initiatives and guidelines presented by the CDC are limited by their failure to take into account many social and behavioral science principles, theories, and research.

Critique 1: Disregard for the Theory of Psychological Reactance

             A potential problem that can interfere with the success of the CDC’s efforts to increase sun safety behaviors in youth is its reliance on authority figures to deliver the messages intended for adolescents. In its brochure outlining “Sun Safety Basics” for schools, the CDC calls on school administrators and board members, schools nurses, teachers, coaches, health care providers, and parents to promote sun safety awareness, model proper sun safety behaviors, and educate students about the importance of sun safety (2). While a method like this helps ensure that children will receive a comprehensive understanding of how to protect themselves from the sun, it does not ensure that they will always carry out this sun safety behavior. According to the Communications Theory, in order for a message to be persuasive, the person delivering the message should be likable, familiar, and similar (4).

This is not to say that a child’s coach or teacher is not likeable or familiar, just that they are not the most effective means of communication. Robert Cialdini found that persuasion tactics fall into six categories governed by six fundamental psychological principles, including likability. Likability encompasses many elements, according to social scientists, including physical attractiveness and similarity (4). The CDC’s guidelines for the promotion of sun safe behaviors in schools limits itself in its ability to persuade youth by only providing educational guidelines for those who serve as authority figures to youth.  In doing this, they expose their campaign to the threat of psychological reactance by threatening the freedom of youth.

The Theory of Psychological Reactance explains that people tend to want what they are told they cannot have, and that by telling people not to do a certain behavior, they feel that their control is being taken away (5). The only way to get it back is by doing what they were told they could not do, such as going outside without any form of sun protection. When parents, teachers, and other authority figures tell adolescents how to protect themselves from the sun, they are likely to feel a loss of freedom and will try to get it back by doing the opposite of what they were advised to do. Furthermore, people tend to feel more threatened when they receive messages from people who are not similar to them than they do when they receive messages from people similar to them (6). Similarly, people are more likely to model the behavior of people that they can identify with, and children and adolescents are not likely to be able to identify with authority (7). Taking into account the Communications Theory and the Theory of Psychological Reactance, the design of the CDC’s initiative is flawed in its chosen method of message delivery.

Critique 2: Assumption of Rational Behavior Through Emphasis on Safety and Facts

            Another flaw standing in the way of the CDC’s goal of decreasing the prevalence of skin cancer is their emphasis on safety and facts in an effort to change the behavior of adolescents. The CDC’s approach relies heavily on the Health Belief Model, which serves as the basis for many public health programs and interventions. The model weighs a person’s perceived benefits of changing his behavior, such as his susceptibility to a particular condition and the perceived severity of that condition, with his perceived costs of changing the behavior, such as the barriers or side effects that might stand in the way (8). According to the Health Belief Model, once these factors are weighed, a person makes a decision about their behavior and carries out that behavior.

            While this model has many benefits and is well known in the world of Public Health, it also has major limitations that can be seen in the CDC’s implementation of it in their efforts to increase sun safety behaviors in children and adolescents. In this specific case, it is particularly flawed in its assumption that a person’s behavior is rational. As Dan Ariely explains in Predictably Irrational, people often act irrationally, despite logical reasoning (9). According to the Health Belief Model, if a child knows that he can get skin cancer, but that wearing sunscreen and a hat will decrease his chances, then he will weigh his options and likely decide that the benefit of not getting skin cancer outweighs the inconveniences of wearing a hat/sunscreen. However, youth do not tend to think of long-term consequences, such as developing skin cancer, and do not feel threatened by them. It is well established that adolescents feel a sense of invincibility and have the common “it won’t happen to me” mentality.

Additionally, safety and health are not concepts that children typically value. In fact, according to Jeffrey Hicks, the “truth” campaign discovered “that a youth’s reason for using tobacco had everything to do with emotion and nothing to do with rational decision making” (10). All of the youth that were interviewed for that campaign were well-aware of the risks associated with tobacco, yet those health concerns did serve as a barrier to their decision to smoke. In the CDC’s approach to sun safety, a rational decision might be to listen to what your teachers, parents, doctor, and coach tell you and protect yourself from the sun, an emotional decision for an adolescent who wants to show his independence and autonomy would be to ignore the advice given to him, as explained in the Theory of Psychological Reactants. By relying solely on safety-related facts to implement behavior change, the CDC assumes that its target audience, youth, act as rational human beings. However, youth tend to act irrationally, particularly when they feel that their freedom and autonomy is being threatened.

Critique 3: Focus on Behavioral Change at the Individual Level Disregards Social Norms

            The goal of the CDC’s efforts is to increase sun safety behaviors in America’s youth to prevent skin cancer. Through their focus on education in a school-based setting, they hope to implement behavioral change in adolescents at an individual level. They repeatedly stress the importance of avoiding the sunlight during peak hours, wearing protective clothing and hats when if you do go outside during these times, and wearing sunscreen anytime you will be exposed to sunlight. Through their focus on education in a school-based setting, they hope to implement behavioral change in adolescents at an individual level. However, as much as a child’s teacher tells them to wear a hat and sunscreen during recess, it does nothing to change the fact that they may drive by multiple tanning salons on their way home from school, see bronzed celebrities on the cover of magazines, watch television shows where the characters are on vacation and seen tanning on the beach and be bombarded with images of tanned people and unsafe sun behaviors.

            Another limitation in the composition of the Health Belief Model is its failure to account for the effects that other people have on a person’s decision to make a change in their behavior (8). While constantly seeing tanned classmates or celebrities may not necessarily be considered a barrier to changing one’s behavior, it certainly affects a person’s decisions in regards to that behavior. An effort to change behavior solely at the individual level disregards these outside factors of behavior change.

            Failure to take into account environmental and social atmospheres when trying to implement behavioral change in children and adolescents can be detrimental to any public health campaign. It is particularly concerning for the issue of skin cancer, where the main cause is a socially acceptable activity—sun tanning. In fact, according to many studies, having a tan is viewed as more attractive than not having a tan. Adolescent and young adult females are the most prone to tanning, and they often state that they feel prettier, healthier, and better about themselves when they have a tan, as opposed to when they don’t (11). The CDC’s campaign does nothing to address this and largely ignores the social aspect of tanning. According to the Social Norm Theory, change can be implemented on a large scale by changing social norms that surround a particular behavior, such as tanning (12). Rather than focusing on individual behavior change, this theory takes into account the importance of social norms when trying to change behavior and focuses on change at the group level.

Humans tend to conform their behaviors to the behavior of others, and sometimes ignore their own rational senses to do so (5). Even if an adolescent is presented with and understands the risk of skin cancer and is provided with guidelines about how the prevent it, they are likely to ignore their knowledge in order to conform to how their peers act, or how they perceive their peers to act. In an experiment on perceived social norms and binge-drinking behaviors, participants who received more accurate information about the social norms regarding alcohol consumption before a night out, reportedly consumed less alcohol than their peers who were not told of the actual norms and only relied on their perceptions of the norm (12). Failure to take into account social norms and environments through a focus on individual level behavior change is a major flaw of the CDC’s approach to increase sun safety behaviors.

Intervention: Expanding the CDC’s Guidelines Into a Comprehensive Campaign

I propose the implementation of a public health campaign that reduces unhealthy sun-related behaviors and reinforces positive behaviors, much like the goals of the CDC’s guidelines, yet also addresses the flaws of the CDC’s proposed guidelines. Like they did, I agree in the importance of targeting youth. However, I think that a more widespread and comprehensive campaign, rather than one that is only based in schools, would be more successful, as it would remind people that sun safe behaviors should occur outside of a schools setting. Additionally, rather than relying on teachers, coaches, and authority figures to deliver the message of sun safety, gathering classmates and peers to form a club to promote sun safety behaviors would be a more beneficial aspect of this campaign. Furthermore, It would be vital to incorporate the media into this campaign, as that would help work towards ending the social norms surround sun behaviors. 

Use Peers to Deliver Message

            A major flaw in the design of the CDC’s skin cancer prevention guidelines was their use of authority figures to deliver the messages of skin cancer risks and sun safety behaviors, without garnering the input of their target audience. A better approach would take into account the Communication Theory, which explains that messages are more persuasive when the person delivering them is more relatable and likable. For this reason, I would enlist students to run the school-based portion of this campaign, as they are the most likely to know what messages appeals to their peers, and what would cause reactance. I would propose the development of “Sun Clubs” for students to join at elementary, middle, and high schools that were focused on increasing sun safe behaviors and altering the norms surrounding both outdoor and indoor tanning.

Because many students, particularly middle and high school students, will be likely to refute this idea of sun safety by citing the fact that having a tan is more attractive, incentives would be used to bring attention to the new club and, thus, get more students to join. Incentives could include field trips, missing a class once a week for a meeting, extra credit, or, for high school students, the promise that becoming a member would look good on college applications. Using the Theory of Cognitive Dissidence as a model, students join the “cause,” even if they do not completely believe in, practice, or have any desire to practice sun safety behaviors (4). Joining this cause will give them a sense of ownership so that they felt like they belong, much like the feeling that youth get by joining the school band, being involved in their student government, or joining a sports team. Instead of relying on teachers, principles, coaches, and other authority figures to educate and model behavior, this campaign uses these peer leaders to do so.

Having a wide representation of students from different social circles would be very important, as people are more likely to listen to a message from someone who they like and can relate to (7). The more people who join the cause, the more people there are for different students to relate to. Associating sun safe behavior with fun messages and a sense of belonging, students will be more likely to make behavior changes. Taking into account the Social Learning Theory, students will be able to identify more with their peers than with authority figures, and will be more likely to mimic their behaviors (7). Additionally, peers will be seen as more similar and likeable than adults, which enhances their credibility among youth. Doing so will make students feel less threatened that their freedom is being taken away and will decrease reactance and increase (13).

Use values and messages that appeal to adolescents

            The goal of the CDC is clearly to control disease and limit mortality, so it is understandable why they would focus on the core value of health in their program. However, the values of health and safety do not appeal to youth (11). Furthermore, they do not see themselves as susceptible to diseases or even death. Despite knowing the risks that come with excessive sun exposure, many adolescents still chose to tan both indoors and outdoors (11), as it is human nature to act irrationally. To incorporate the issues that are important to adolescents, I would use the Advertising Theory as a model for my campaign. This theory takes advantage of people’s irrationality and appeals to their core values, unlike the Health Belief Model, which assumes people both strongly value health and act rationally, which was previously proven to not be the case among most youth (10).

            Rather than placing the focus of this campaign on facts and guidelines about sun safety, I would put the focus on freedom and emphasize the free choices adolescents have in regards to their behavior. The school-based club would focus on the fact that adolescents have the choice to behave however they please—they have the freedom to not protect themselves from the sun if they wish. However, they also have the freedom to act any way they chose, even if that is not in accordance with perceived social norms. Taking into account the methods used in the Advertising Theory, the mission of the school-based “Sun Club” would be to emphasize and promote these points through personal accounts, stories, and images, rather than facts and statistics as the CDC does. However, solely implementing a school-based program limits the ability of the campaign to infiltrate society with the chosen message. Therefore, the campaign would extend to the media with commercials and advertisements influence change on the group level and to spread the messages that the school-based “Sun Club” develop and deem important.

Take Into Account Environment and Social Norms to Change Behavior at Group Level

            A huge limitation in the CDC’s guidelines was their focus on behavioral change at the individual level and their failure to take into account the social and environmental factors that influence behaviors. Social factors, particularly social norms, play a huge role in adolescents’ decisions about their sun safety behaviors. Most adolescents are hyper-focused on their appearance at this age, and proposing a behavioral change that may make them even more self-conscious of their appearance could prove to be futile; therefore, a successful campaign needs to alter the social norms and people’s perceptions of them. The Spotlight Effect explains people tend to conform to social fashions and norms, like tanning, because they think that other people are paying very close attention to what they are doing and, if they do not conform, then they may feel like an outsider (5). However, people do not actually pay as close attention to others as most people think (5). An important goal of the school-based club would be to emphasize this point and establish an understanding amongst students that people do not analyze the appearances of others nearly as much as they analyze their own appearances. However, rather than stating this fact outright, it would be more valuable to have students arrive at this conclusion on their own, as it emphasizes their freedom and capability to make choices on their own (13).

            Understanding the social norms that surround the attractiveness of being tan is vital to the success of any campaign that aims to reduce the burden of skin cancer. People often have beliefs about what they perceive to be a social norm, but learning the truth about that norm can alter a person’s behavior (12). In this campaign, I would point out the number of people who do practice sun-safe behaviors, to emphasize the point that, despite what people think, not everyone is tanning. According to the 2011 Youth Risk Behavior Surveillance System, only 13% of all high school students reported indoor tanning (14). In order so change people’s perceptions of social norms, I would flip this statistic and emphasize the fact that 87% of high school students do not tan indoors, despite perceptions that many more people are. A happy and positive commercial or advertisement could be developed that includes images of different “Sun Club” members and presents this statistic. A commercial with this basis would be effective, as other kids and teens will be able to identify with the model and relate to the message, while also working to change the perceived norms that surround tanning. Overall, correcting for the social and behavioral flaws presented in the CDC’s approach to increasing sun safe behaviors would need to take into account the opinions and values of youth, as well as the social norms and environments that surround their lives.

           

References

1. National Cancer Institute. What you need to know about Melanoma and other skin cancers. Bethesda, MD: National Institute of Health. http://www.cancer.gov/cancertopics/wyntk/skin/

2. Center for Disease Control and Prevention. Sun safety basics. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/cancer/skin/basic_info/indoor_tanning.htm

3. Center for Disease Control and Prevention. Skin cancer. Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/cancer/skin/

4. Cialdini RB. Influence: The Psychology of Persuasion. New York, NY: Harper Collins Publishers, 2007.

5. Thaler RH. Following the herd (pp. 53-71). In: Thaler RH. Nudge: Improving Decisions About Health, Wealth, and Happiness. New Haven, CT: Yale University Press, 2008.

6. Dillard JP, Shen L. On the nature of reactance and its role in persuasive health communication. Communication Monographs 2005; 72:2.

7. DeFleur ML, Ball-Rokeach SJ. Socialization and theories of indirect influence (pp. 202-227). In: DeFleur ML, Ball-Rokeach SJ. Theories of Mass Communications (5^th edition). White Plains, NY: Longman Inc., 1989.

8. Edberg M. Individual health behavior theories (pp. 35-49). In: Edberg M. Essentials of Health Behavior: Social and Behavioral Theory in Public Health. Sudbury, MA: Jones and Bartlett Publishers, 2007.

9. Ariely D. Predictably Irrational: The Hidden Forces that Shape out Decisions. New York, NY: Harper Collins Publishers, 2008.

10. Hicks JJ. The strategy behind Florida’s “Truth” campaign. Tobacco Control 2001; 10:305

11. Leary MR, Jones, JL. The social psychology of tanning and sunscreen use: Self-presentational motives as a predictor of health risk. Journal of Applied Social Psychology 2006; 23(17).

12. Johnson MB. Experimental test of social norms theory in a real-world drinking environment. Journal of Studies on Alcohol and Drugs 2012; 73:5.

13.  Silvia PJ. Deflecting reactance: The role of similarity in increasing compliance and reducing resistance. Basic and Applied Social Psychology 2005; 27:277-284.

14. Centers for Disease Control and Prevention. Indoor tanning.  Atlanta, GA: Centers for Disease Control and Prevention. http://www.cdc.gov/cancer/skin/basic_info/indoor_tanning.htm