The Effects of Gain-, Loss-, and Balanced-Framed Messages for Preventing Indoor Tanning among Young Adult Women

Indoor tanning (IT) increases the risks of skin cancer, but evidence on how to design health education messaging targeting IT among young adult women remains limited. This study investigated the effects of theory-guided gain-, loss-, and balanced-framed IT prevention messages. Young adult women ages 18–30 who indoor tan (n = 552, mean age = 24.9 years [standard deviation = 3.1]) were recruited online, completed pre-exposure measures, and were randomized to view a gain-, loss-, or balanced-framed message. Participants completed post-exposure measures of message response (emotional response, message receptivity), IT risk (perceived severity, susceptibility), and efficacy (self-efficacy, perceived benefits of avoiding IT) beliefs, and IT behavioral intentions. Loss- and balanced-framed messages promoted significantly greater emotional response and message receptivity and lower IT behavioral intentions than gain-framed messages. The effects of loss- and balanced-framed messages on IT behavioral intentions were mediated by greater emotional response and message receptivity compared with the gain-framed message. These results can inform the development of public health education campaigns to prevent and reduce IT among young adult women. Future research can build from these findings by investigating additional message themes and tailoring strategies to maximize their effects, examining the effects of framed messages prospectively, and investigating ways to enhance message receptivity, such as through novel message delivery channels (e.g., mobile devices).     

Assessing the Potential Effectiveness of Pictorial Messages to Deter Young Women from Indoor Tanning: An Experimental Study

The recent Surgeon General’s call-to-action to prevent skin cancer indicates an urgent need for research on messages to deter young women from tanning indoors. Answering this call, the current study assessed differences in the potential effectiveness of pictorial indoor tanning messages. We randomly assigned undergraduate female participants (N = 568) to one of three message conditions visually depicting health effects, appearance damage, or immediate risks, or to a text-only control. All participants viewed three messages within their condition and answered questions after message exposure. Factorial ANOVAs indicated that compared to the text-only condition, pictorial messages produced greater negative emotional reactions and were perceived as more effective than text-only messages. Text-only messages, however, were significantly more believable than pictorial messages. We observed several differences among the pictorial conditions and among the messages within the pictorial conditions. We conclude that messages discouraging indoor tanning should use pictorial messages illustrating the negative health and appearance damaging effects of indoor tanning, focusing on particular health and appearance consequences. Additional research is needed to guide the selection of images that are believable and will most discourage indoor tanning behavior.     

Tanning behavior among young frequent tanners is related to attitudes and not lack of knowledge about the dangers

OBJECTIVE: To examine the importance of tanning among students in relation to attitudes and knowledge regarding skin cancer prevention. DESIGN: A cross-sectional survey. SETTING: College students at a major Midwestern university METHODS: Students were recruited to complete a self-administered questionnaire that included information on sun-sensitivity, knowledge and tanning attitudes and behaviors. Survey sampling statistical techniques that account for clustering among the 163 students recruited were used. RESULTS: We found a high level of skin cancer prevention knowledge; however knowledge was not related to a reduction in the importance of tanning. In many cases, higher levels of knowledge corresponded to a greater emphasis on the importance of tanning. Sunscreen use was low among this population. Those who placed an importance on tanning more often checked that they believed that "sunless tanning creams are safer than the sun". CONCLUSIONS: This population's belief that they look healthier and feel better with a tan strongly influences the desire to tan. Therefore, future cancer information campaigns or other prevention efforts should directly address the desire to tan by encouraging the use of sunless tanning products as an alternative method of tanning.     

Increasing the intent to receive a pandemic influenza vaccination: Testing the impact of theory-based messages

ObjectiveVaccination is an effective preventive measure to reduce influenza transmission, especially important in a pandemic. Despite the messages encouraging vaccination during the last pandemic, uptake remained low (37.6% in clinical risk groups). This study investigated the effect of different types of messages regarding length, content type, and framing on vaccination intention.MethodAn online experiment was conducted in February 2015. A representative sample of 1424 people living in England read a mock newspaper article about a novel influenza pandemic before being randomised to one of four conditions: standard Department of Health (DoH) (long message) and three brief theory-based messages - an abridged version of the standard DoH and two messages additionally targeting pandemic influenza severity and vaccination benefits (framed as risk-reducing or health-enhancing, respectively). Intention to be vaccinated and potential mediators were measured.ResultsThe shortened DoH message increased vaccination intention more than the longer one, by increasing perceived susceptibility, anticipated regret and perceived message personal relevance while lowering perceived costs, despite the longer one being rated as slightly more credible. Intention to be vaccinated was not improved by adding information on severity and benefits, and the health-enhancing message was not more effective than the risk-reducing.ConclusionA briefer message resulted in greater intention to be vaccinated, whereas emphasising the severity of pandemic influenza and the benefits of vaccination did not. Future campaigns should consider using brief theoretically-based messages, targeting knowledge about influenza and precautionary measures, perceived susceptibility to pandemic influenza, and the perceived efficacy and reduced costs of vaccination.     

Agenda-Setting Effects of Sun-Related News Coverage on Public Attitudes and Beliefs About Tanning and Skin Cancer

The topics and framing of news stories relevant to skin cancer prevention have shifted over time. This study examined agenda-setting effects of such news stories on public attitudes and beliefs about tanning and skin cancer. Content analysis data on 516 articles published in two major daily newspapers in Melbourne, Australia, from 1994 to 2007 were combined with circulation data to generate indices of potential news exposure. Associations between these indices and cross-sectional telephone survey data from the same period on 6,244 adults’ tanning attitudes and perceived susceptibility to skin cancer were examined using logistic regression models, accounting for the temporal precedence of news content. Pro-sun protection stories on attitudes and behavior were associated with older adults not thinking a tan looks healthy. Pro-sun protection stories on solaria were associated with less preference for a deep tan among young adults who like to suntan. Stories on vitamin D that were unsupportive of or ambiguous about sun protection were associated with a number of pro-tan attitudes among younger adults. Results indicate news coverage during 1994–2007 served an important agenda-setting role in explaining the public's attitudes and beliefs about tanning and skin cancer. Vitamin D stories appeared most influential, particularly among young adults.     

A Web-Based Intervention to Reduce Indoor Tanning Motivations in Adolescents: a Randomized Controlled Trial

Youthful indoor tanning as few as ten sessions can increase the risk of melanoma by two to four times with each additional session adding another 2 % to the risk. Recent research estimates that indoor tanning can be linked to approximately 450,000 cases of skin cancer annually in the USA, Europe, and Australia. Despite these risks, indoor tanning remains popular with adolescents. This study tested the efficacy of a web-based skin cancer prevention intervention designed to reduce indoor tanning motivations in adolescent females. A nationally representative sample of 443 female teens was enrolled from an online panel into a two-arm, parallel group design, randomized controlled trial. Treatment participants received an appearance-focused intervention grounded in established health behavior change models. Controls viewed a teen alcohol prevention website. Outcome variables included willingness and intentions to indoor tan, willingness to sunless tan, and measures of indoor tanning attitudes and beliefs. The intervention decreased willingness and intentions to indoor tan and increased sunless tanning willingness relative to controls. We also examined indirect mechanisms of change through intervening variables (e.g., indoor tanning attitudes, norms, positive and negative expectancies) using the product of coefficient approach. The web-based intervention demonstrated efficacy in changing adolescent indoor tanning motivations and improving their orientation toward healthier alternatives. Results from the intervening variable analyses give guidance to future adolescent skin cancer prevention interventions.     

Factors that influence health risk behaviors among tanning salon patrons

A principal components analysis identified the immediate convenience of indoor tanning (i.e., relaxation, perceived attractiveness of tans) as a major factor that motivates people to visit commercial tanning salons frequently and continually. Long-term considerations, such as price, socializing, and perceived health, also emerged as a motivating factor that was related to tanning frequency. Furthermore, almost half of the participants mentioned that regulations restricting indoor tanning would not make them more cautious in their tanning behavior. Findings confirm several other studies indicating that knowledge of the danger of UV exposure may have little influence on actual tanning behavior. Suggestions for alternative approaches that focus on the perceived attractiveness of tanned skin rather than the susceptibility of frequent tanners to skin cancer are discussed.     

Framing Indoor Tanning Warning Messages to Reduce Skin Cancer Risks Among Young Women: Implications for Research and Policy

Objectives. We investigated the impact of indoor tanning device warnings that communicate the risks associated with indoor tanning (i.e., loss framed) or the benefits of avoiding indoor tanning (i.e., gain framed).Methods. A convenience sample of non-Hispanic White women aged 18 to 30 years who tanned indoors at least once in the past year (n = 682) participated in a within-subjects experiment. Participants completed baseline measures and reported indoor tanning intentions and intentions to quit indoor tanning in response to 5 warning messages in random order. A text-only control warning was based on Food and Drug Administration–required warnings for indoor tanning devices. Experimental warnings included graphic content and were either gain or loss framed.Results. In multivariable analyses, gain-framed warnings did not differ from the control warning on women’s intentions to tan indoors, but they prompted stronger intentions to quit than the control message. Loss-framed warnings significantly reduced intentions to tan indoors and increased intentions to quit indoor tanning compared with control and gain-framed warnings.Conclusions. The public health impact of indoor tanning device warnings can be enhanced by incorporating graphic content and leveraging gain- and loss-framed messaging.Skin cancer is the most common malignancy in the United States, where approximately 3.5 million cases of nonmelanoma skin cancer and 75 000 cases of melanoma are diagnosed each year.1,2 Although most skin cancers are preventable by reducing ultraviolet radiation exposure, their incidence is increasing.3–6 An estimated 9000 deaths occur each year as a result of melanoma,2 and the costs of skin cancer treatment exceed $8 billion annually.7Indoor tanning is major concern for skin cancer prevention.4,8 Approximately 380 000 skin cancer cases are attributable to indoor tanning annually in the United States.9 Recent meta-analyses have indicated that indoor tanning increases lifetime risks of nonmelanoma skin cancer by 29% to 67% and melanoma by approximately 20%.10,11 Among US adults, the prevalence of indoor tanning is highest among young adult, non-Hispanic White women, with nearly 30% tanning each year and 15% tanning 10 or more times each year.12,13 Indoor tanning before age 30 years and tanning more frequently further increase lifetime skin cancer risks,10,11,14,15 and tanning at a young age is associated with early-onset skin cancer.16As in other areas of public health, policies are advocated as part of a comprehensive approach to skin cancer prevention.4,17 Until recently, the US Food and Drug Administration (FDA) regulated indoor tanning devices as class I medical devices presenting minimal risks and largely exempt from premarket controls.18 In part because of advocacy for tighter regulations,17 the FDA recently published a new rule changing indoor tanning devices to class II devices with additional premarket controls and revised labeling requirements. Now, indoor tanning devices are required to display a text-only warning reading “Attention: This sunlamp product should not be used on persons under the age of 18 years.”19 Consumer-facing information for indoor tanning devices is also required to include several contraindication and warning statements.19Unfortunately, the required warnings do not reflect evidence for skin cancer prevention messaging20,21 and are inconsistent with warnings for other FDA-regulated products with associated health risks, such as tobacco.22 The FDA’s strategic plan for regulatory science emphasizes designing evidence-based public health messages to empower consumers to make healthy decisions about regulated products.23 The public health impact of indoor tanning device warnings could be enhanced through additional research to determine how to best promote preventive behavior. Under federal rulemaking procedures, the FDA could issue new labeling requirements based on the available evidence, and this evidence could also inform state and local policies on indoor tanning. Unlike warnings for tobacco,24 little published research is available on how to design indoor tanning warnings to enhance their public health impact.According to prospect theory, framing health messages in terms of the costs of engaging in risky behavior (i.e., loss framed) or the benefits of avoiding risky behavior (i.e., gain framed) differentially affects behavioral outcomes.25,26 The message-framing concept draws from fundamental tenets of behavioral economics and communication science that postulate that health messages can be crafted around gains or losses to shape perceptions and motivate behavior.25 Although recent reviews have indicated that loss-framed skin cancer prevention messages can promote behavior change,20,21 2 meta-analyses drew different conclusions regarding gain- and loss-framed skin cancer prevention messages,27,28 and no study has tested message-framing effects for indoor tanning warnings. Research has also consistently demonstrated that graphic warnings incorporating imagery to depict the health risks of tobacco use are more effective for promoting behavior change than text-only warnings because they more effectively attract attention, evoke an emotional response, and affect perceived risks and attitudes toward tobacco use.24,29–32 Although the available evidence on skin cancer prevention messages has suggested that graphic messages can promote preventive behaviors,20,21 no study has investigated the effects of graphic content for indoor tanning warnings.Given the theoretical support and empirical evidence indicating that gain- and loss-framed messages incorporating graphic imagery may be important to prevent and reduce indoor tanning, we examined the impact of these message features on indoor tanning intentions and intentions to quit indoor tanning in a convenience sample of young adult women. We compared gain- and loss-framed warnings with graphic imagery with a text-only warning, such as those required by the FDA. We focused on young adult women because of the high prevalence of indoor tanning in this population and evidence that indoor tanning early in life further increases skin cancer risks.10,11 This makes young adult women a priority population for public health skin cancer prevention efforts. We hypothesized that graphic, loss-framed messages conveying the health risks associated with indoor tanning would produce the greatest impact.     

When Is Congruency Helpful? Interactive Effects of Frame,Motivational Orientation,and Perceived Message Quality on Fruit and Vegetable Consumption

Health messages framed to be congruent with people’s motivational orientation have been shown to be generally effective in promoting health behavior change, but some inconsistencies have been found. This study tested whether the perceived quality of a health message moderated the congruency effect in the domain of fruit and vegetable (FV) consumption. Undergraduate participants (N = 109) read a health message promoting FV intake in which the frame (gain vs. loss) was either congruent or incongruent with their approach/avoidance motivational orientation. Perceived message quality and intention to increase FV intake were assessed after message exposure, and self-reported FV intake was assessed one week later. A significant interaction between congruency and perceived message quality was found on both intention and FV intake. When messages were congruent, higher intentions and FV intake were observed when perceived message quality was high, but the reverse pattern was observed when perceived message quality was low. The findings support the potential utility of using congruently-framed messages to promote fruit and vegetable consumption, while also underscoring the necessity of using high-quality messages in order for congruency to influence health-related behaviors.     

Self-Determination Theory and Risk Behavior in a Collectivistic Society: Preventing Reckless Driving in Urban Nepal

Traffic road accidents are one of the leading causes of mortality in Nepal and around the world. Drivers in Nepal are not adequately educated about road safety rules. Road conditions are chaotic as traffic regulations are also not strictly enforced. Public safety campaigns may be able to alter drivers’ attitudes and behaviors; however, little is known about which persuasive strategies may be most effective. Drawing on self-determination theory and the Health Belief Model, the current study used a post-only experimental design to test the impact of a short video message. The video included collective vs. individual appeals, and messages emphasizing one’s ability to make the right choice (autonomy support) vs. directive language. Participants were Nepali college students (mean age 20, N = 199). Using structural equation modeling, the study found that directive messages rather than autonomy support influenced an individual seeing value in the recommended behavior (identified regulation), which in turn influenced perceived susceptibility, perceived severity, and behavioral intention. The study also proposed a behavior change model by incorporating the stage of identification with the message upon exposure. This model aims to expand the model proposed by the Health Belief Model, to include a stage of value identification before cues to action influence perception of threat. Further implications are discussed.     

Enhancing Web-Based Kidney Disease Prevention Messages for Hispanics Using Targeting and Tailoring

The goal of this experiment was to assess the effects of targeted and tailored web-based messages on Hispanics' perceived susceptibility to kidney disease, and on their intention to talk to a doctor about kidney disease (the recommended behavior). Two-hundred-seventeen English-speaking Hispanics age 40 and older were recruited using an online survey service, and they were assigned randomly to read one of four messages (i.e., control, generic, targeted, and tailored). The hypothesis predicted a positive linear trend between type of message received and perceived susceptibility and intentions. Results were partially consistent with this hypothesis. Specifically, perceived susceptibility to kidney disease was highest in the tailored condition, followed by the generic and targeted conditions (which did not differ from each other), followed by the control condition where perceived susceptibility was the lowest. For behavioral intention, those in the tailored, targeted, and generic conditions did not differ from one an other; however, all three did report greater intentions to ask a doctor about kidney disease than those in the control condition. The theoretical and practical insights and implications of these findings are discussed.     

Effects of a Brief Theory-Based Intervention on the Practice of Testicular Self-Examination by High School Males

This preliminary study evaluated a brief intervention, based on the theory of planned behavior, designed to encourage high school students to practice testicular self-examination (TSE). Ninety-nine male ninth and 10th grade students were exposed to a message challenging beliefs about outcomes of performing TSE as suggested by the theory of planned behavior, a message providing information about TSE and testicular cancer, or a control message, after which they completed a questionnaire operationalizing components of the theoretical model. Four weeks later, students reported their practice of TSE. As predicted, students exposed to the theory-based message reported a stronger intention to perform TSE and, at follow-up, were more likely to report having performed the exam than study participants exposed to other messages. Data provide partial support for the utility of the theory of planned behavior as a framework for constructing health-promoting messages. Future research recommendations are offered.     

Time Matters: Framing Antismoking Messages Using Current Smokers’ Preexisting Perceptions of Temporal Distance to Smoking-Related Health Risks

This study examined the effects of temporal framing used in messages about the future likelihood of developing smoking-related diseases on intention to quit smoking. Based on construal level theory (CLT), a causal model delineating the relationships among four variables—perceived temporal distance, personal relevance, perceived susceptibility, and behavioral intention—was proposed. The model was validated by an online experiment with a sample of 222 current smokers, revealing the effects of perceived temporal distance on behavioral intention via personal relevance and perceived susceptibility. Following the CLT-grounded model, the effects of different temporal frames (near future vs. distant future) on the four variables were tested. The near-future frame featured a risk perceived to be more temporally proximal (i.e., heart attack), and the distant-future frame featured a risk perceived to be more temporally distant (i.e., larynx cancer) among current smokers. Participants exposed to the near-future frame reported significantly shorter perceived temporal distance, greater personal relevance and perceived susceptibility to the risk portrayed in the message, and greater intention to quit smoking than participants exposed to the distant-future frame. Implications for antismoking communications are discussed.     

Psychosocial correlates of sunburn among young adult women

Skin cancer is an increasingly common disease, particularly among young adult women. Sunburn early in life is a risk factor for skin cancer. Few studies have reported on psychosocial correlates of sunburn. The current study consisted of an online survey of undergraduate women from a university in the northeastern part of the USA. A logistic regression demonstrated that young women who reported a history of four or more sunburns were significantly more likely to report fair skin, higher perceived susceptibility to skin cancer, greater perceived benefits of tanning (e.g., appearance enhancement), lower perceived control over skin protection, and more frequent sunscreen use. Sunbathing was not associated with a greater number of sunburns. These results suggest that young women who sunburn more often possess other skin cancer risk factors, are aware of their susceptibility to skin cancer, and try to use sunscreen, but feel limited control over their skin protection behavior and are not less likely to sunbathe than others. Therefore, interventions are needed to assist high risk young women in asserting more control over their sun protection behavior and perhaps improve the effectiveness of the sunscreen or other skin protection methods they do employ.     

Australian adolescents' sun protection behavior: who are we kidding?

PURPOSE: To examine the influence of tan preference and skin type on sun protection behaviors of Australian adolescents. METHODS: The Australian Secondary School Alcohol and Drug Questionnaires were conducted in 1993, 1996, 1999 and 2002 among randomly selected students aged 12--17. Schools were randomly selected from each education sector in each state. The self-administered questionnaire contained questions about tan preferences, skin type and usual SunSmart behavior (use of sunscreen, hats and covering clothing). RESULTS: The routine use of SunSmart behavior was low in all survey years. There was a significant decrease over time in the proportion of students who practiced SunSmart behavior, with prevalence rates lower in 2002 than in any other survey year (males: p<0.01 and females: p<0.01). As desire for a tan increased, routine practice of SunSmart behaviors decreased. Across the four survey periods, male (p<0.01) and female (p<0.01) students who preferred no tan were significantly more likely to practice SunSmart behavior than students who preferred any sort of tan. Across the four survey years, male (p<0.01) and female (p<0.01) students with skin that 'just burns' were most likely to routinely practice SunSmart behavior. CONCLUSIONS: Sun protection practices among adolescents have continued to decline significantly over time. Future educational programs require an innovative approach to modify adolescent behaviors in relation to sun exposure and sun protection.     

Sun protection motivational stages and behavior: skin cancer risk profiles

OBJECTIVE: To create skin cancer risk profiles that could be used to predict sun protection among Midwest beachgoers. METHOD: Cluster analysis was used with study participants (N=239), who provided information about sun protection motivation and behavior, perceived risk, burn potential, and tan importance. Participants were clustered according to their risk profiles; 4 distinct risk profiles emerged. RESULTS: Analyses revealed that risk profiles were significantly different on sun protection motivation and behavior and marginally different in terms of sun tanning behavior. CONCLUSION: Given the complexity of risk factors, an examination of clusters, rather than factors in isolation, may more accurately depict sun protection behavior.     

Designing Anti-Binge Drinking Prevention Messages: Message Framing vs. Evidence Type

We investigated whether presenting anti-binge drinking health campaign messages in different message framing and evidence types influences college students’ intention to avoid binge drinking, based on prospect theory (PT) and exemplification theory. A 2 (message framing: loss-framed message/gain-framed message) X 2 (evidence type: statistical/narrative) between-subjects factorial design with a control group was conducted with 156 college students. College students who were exposed to the loss-framed message condition exhibited a higher level of intention to avoid binge drinking in the near future than those who did not see any messages (the control group). This finding was mainly among non-binge drinkers. Regardless of evidence type, those who were exposed to the messages exhibited a higher level of intention to avoid binge drinking than those in the control group. This is also mainly among non-binge drinkers. We also found the main effects of message framing and evidence type on attitude toward the message and the main effect of message framing on attitude toward drinking.