Dark suntans are very dangerous to the health of young children. This intervention will examine the consequences of excessive sun exposure, prevention of sun-related skin damage, and the motivation for suntanning behavior. This intervention will also be used to change the perceptionof the children's mother that suntans are a sign of beauty and health.
Each year millions of people expose themselves to the sun in order to get a suntan. Along with darker complexions, suntanning brings a host of health problems ranging from simple sunburnsto deadly forms of skin cancer. A suntan is the result of the body's attempt to protect itself from ultraviolet radiation, which is the main component of sunlight. Ultraviolet radiation from the sun is divided into three categories called UVA, UVB, and UVC (Bargoil & Erdman, 1993).
No UVC radiation reaches the earth's surface from the sun. UVA radiation penetrates deeply into the lower layers of the skin causing wrinkling, connective tissue damage, and changes in the texture of the skin. The most powerful form of ultraviolet radiation which is present at the earth's surface is the UVB ray. The UVB ray is the principal cause of suntans, sunburns, and skin cancerin humans (Truhan, 1991).
When the skin is exposed to ultraviolet radiation, the body produces melanin. Melanin is a pigment which is responsible for the darkened skin produced by a suntan. The darker color helps protect the skin to a limited extent by reflecting solar radiation. However, the damage to the skin from a suntan is far greater than any beneficial effect (Bargoil & Erdman, 1993; Truhan, 1991; Prawer, 1991).
Damage to human skin from sunlight takes four forms: development of nonmelanoma skin cancer (NMSC); sunburn; actinic damage or skin aging; and malignant melanoma (Stern, Weinstein, Baker, 1986). There is a clear relationship between sun exposure and the development of NMSC. One study found that 90% of these cancers are the direct result of UVB radiation exposure (Stern et al., 1986). NMSCs are classified into two types: squamous cell carcinoma; and basal cell carcinoma (Prawer, 1991). Squamous cell carcinomas account for about 20% of all skin cancers, or about 100,000 new cases each year in the United States. Basal cell carcinomas account for approximately 75% of skin cancers, or 400,000 new cases annually in the United Stats (Prawer, 1991). NMSCs are not usually aggressive and must be left untreated for long periods of time to result in death. Prawer (1991) stated that "If left untreated for 10 to 20 years, l% to 3% of [NMSC] lesions around the eyes, nose or ears become aggressive and invade bones, nerves, and cartilage, which can result in death" (p. 60).
Sunburn is the most common form of skin damage caused by the sun. Pain, redness, itching, burning, blistering and peeling of the skin are the most common symptoms of sunburn. Most of the visible symptoms of sunburn begin to subside within three days. There is evidence to indicate that sunburns also damage the skin in more serious, but less visible ways. Sunburns damage the DNA contained in cells which normally protect the skin from ultraviolet light. The damage to these cells is permanent, but the cells do not die. Instead, the damaged cells continue to divide and can become the basis of squamous cell carcinoma (Fackleman, 1994).
Suntans are one form of actinic damage to the skin. More serious forms of actinic skin damage include deep wrinkling, changes in skin texture, irregular pigmentation, and loss of skin elasticity (Prawer, 1991). In severe cases, actinic skin damage can result in the formation of lesions called actinic keratoses. Actinic keratoses often result in disfigurement and can become the basis of squamous cell carcinoma (Prawer, 1991).
The most deadly form of skin cancer is malignant melanoma. The incidence of this cancer has increased to epidemic proportions in the United States. Dr. Sidney Hurwitz, a professor of pediatrics and dermatology at Yale University School of Medicine, stated in the Journal of the American Medical Association that in 1986 there were 23,000 cases of malignant melanoma and 5600 fatalities due to this cancer in the United States ("Paler Is Better, Say Skin Cancer Fighters," 1987, p. 893). By 1993, the number of malignant melanoma cases had increased to 32,000 and fatalities totaled 6800 (Adler, 1994). Since 1980, the incidence of malignant melanoma in the United States has risen by 100%. (Prawer, 1991).
There are several types of malignant melanoma. The most common form, superficial spreading malignant melanoma, appears as irregularly shaped and colored patches on the skin. The patch often increases in size and changes color as the disease progresses. The most deadly form of malignant melanoma is nodular melanoma. Nodular melanoma is characterized by the formation of a small nodule which becomes larger and turns brown or black in the center. If left untreated, the formative structure of the nodule penetrates the lower levels of the skin and cancer cells invade the body (Prawer, 1991).
Although nearly all skin cancers are found among adults, children are especially vulnerable to the harmful effects of the sun. According to Dr. Hurwitz, "One severe sunburn in the first 10 to 20 years of life probably doubles the risk of malignant melanoma" ("Paler Is Better, Say Skin Cancer Fighters," 1987, p. 893). Because nearly all skin cancers are the result of long-term, cumulative sun exposure, taking proper precautions in childhood is an excellent way to prevent this disease. Stern et al. (1986) found that the continuous use of sunscreens on children during periods of sun exposure from infancy until age 18 could reduce the risk of developing NMSC before age 55 by 88%.
Despite the apparent benefits, sunscreen use among children does not appear to be widespread. One study found that even though 90% of the mothers surveyed knew that over-exposure to the sun was associated with skin cancer, only 50% used sunscreens on themselves or their children (Sherertz, E. F., Pupo, R. A., Russin, N.M., 1986, in Truhan, 1991).
Staying out of the sun completely is the most certain way to avoid skin damage. It is not practical to expect most people to do this, however. Another way to avoid sun-induced skin damage is to stay out of the sun during the hours of 10 a.m. until 2 p.m., while the sun's rays are most intense. At other times, protective apparel, such as wide-brimmed hats, sunglasses, long-sleeved shirts, and pants, should be worn. If none of these choices are attractive, some form of sunscreen is the only other form of protection.
For most individuals, sunscreen is the most effective and practical form of protection from the sun. There are two types of topical sunscreens: chemical sunscreens and physical sunscreens. Chemical sunscreens use chemical agents to absorb ultraviolet radiation, while physical sunscreens form a protective barrier to sunlight (Truhan, 1991).
The ability of a chemical sunscreen to absorb ultraviolet radiation is denoted by its sun protection factor (SPF). The SPF is the ratio of the amount of ultraviolet radiation required to produce minimal pinkness in skin covered by a sunscreen, assessed 24 hours after exposure, to the amount of UV radiation required to produce a similar level of pinkness in unprotected skin (Stern, et al., 1986). The SPF rating is expressed as a number ranging from three or four to as high as 40 or 50. The level of protection from ultraviolet radiation provided by the product increases as the value of the SPF rating increases.
The actual protective ability of a sunscreen is determined by more than the SPF rating. The manner and frequency of application, exposure to water, and the rate of perspiration effect a sunscreen's ability to absorb ultraviolet radiation (Truhan, 1991). A sunscreen with an SPF rating of at least 15 should be selected and label directions for the product's use followed carefully. As one might expect, the beneficial effects of sunscreens can be greatly reduced if these products are used to justify an increase in sun exposure (Truhan, 1991).
The key to decreasing intentional over-exposure to the sun lies in changing the perception that suntanning enhances physical beauty and attractiveness (Leary & Jones, 1993; Miller et al., 1990). Recent attempts to change this perception have taken two forms (Leary & Jones, 1993). First, there have been warnings directed at the general public through the media. Other efforts have taken the form of individually oriented strategies, such as counseling and presentation of medical evidence.
When strategies to change suntanning attitudes are directed toward the individual, it is important to provide specific information about the effects of the sun on human skin and how to avoid these harmful consequences (Leary & Jones, 1993). As Leary and Jones (1993) have noted, it is not enough to increase the concern of an individual about the sun's harmful effects. The person must understand that skin cancer can be prevented and must develop positive attitudes toward the use of protective measures. Attitude change must produce safe-sun behavior change.
The population level methods described by Leary and Jones (1993) for reducing over-exposure to the sun are not suitable for use in this intervention. Individual education strategies are the only practical way to produce attitude change in this situation.
Jeffrey (1989) found that individual strategies for reducing risk behavior are most effective when three conditions are present. First, the benefits to be gained by reducing risk behaviors are substantial and virtually guaranteed. Second, the individual will see some benefit from the behavior change in a relatively short period of time. Finally, the cost of the behavior change is perceived to be less than the benefit expected to be gained as a result of the change.
Each of the three conditions identified by Jeffrey are present in this intervention. The benefits to be gained from this project are substantial and virtually assured. Education will show that it is possible to substantially reduce the risk that Andrew and Elizabeth will develop sun-related health problems in later years. What parent would not benefit from this realization? The interval within which the benefit from this intervention should be seen is relatively short, probably about one month.
In past years, Elizabeth and Andrew have become darkly tanned within two months. Both children have virtually no suntans at the beginning of summer. As the weather becomes warmer, fewer clothes are worn and the amount of time spent outside increases. The amount of exposure to the sun also increases. By July, both children have dark suntans on their entire legs and upper bodies.
If Pam can be shown through this intervention that tanned skin is damaged skin, she will benefit from the realization that Andrew and Elizabeth are not as darkly tanned as they have been in previous summers. This benefit should be apparent fairly quickly, probably during the first month of summer.
Finally, the response cost of the behavior change in comparison with the possible benefits of this intervention is very low. Safe-sun behaviors can be as simple as applying an inexpensive sunscreen product to each child before playing outside or requiring that a shirt and hat be worn when outdoors.
The educational strategy of this intervention will be based on the presentation of information about the harmful effects of the sun on young children. Specific information will be given about how sunscreens and proper attire can protect the skin. Also, knowing someone with skin cancer has been identified to be the best predictor of sunscreen use (Leary & Jones, 1993). Therefore, a close family friend who recently died from cancer (which began as malignant melanoma) will be used to "put a face" on the impersonal statistics about the sun and skin cancer. At present, this individuals story is unknown to Pam.
The story of this individual will not be used to persuade through fear. This individuals history of sun exposure during the early years of his life is very similar to that of Andrew and Elizabeth. This story presents a very logical, compelling argument for changing suntanning attitudes and will not be used as an attempt to persuade through "scare tactics" or emotional appeals.
The ELM states that in order for an individual to engage in a high degree of elaboration, which is one goal of this intervention, both the motivation and the ability to elaborate must be present (O'Keefe, 1990). O'Keefe (1990) stated that the motivation to elaborate depends on three factors, all of which will be present in this intervention. First, there is the degree of personal relevance of the topic to the receiver. The subject of this intervention will be very relevant to Pam. Second, multiple sources with multiple arguments have been found to increase elaboration. In this intervention, literature about the harmful effects of the sun and a personal appeal will be used, so multiple sources will be present. The final factor identified by O'Keefe (1990) which is necessary for high elaboration motivation is the receiver's level of need for cognition. "Need for cognition" is defined by the creator of the ELM as "the tendency for an individual to engage in and enjoy thinking" (Cacioppo & Petty, 1982, in O'Keefe, 1990 p. 100). Pam has a high level of need for cognition. She is very analytical and enjoys thinking about important subjects.
Two factors have been identified which determine the receiver's ability to engage in elaboration (O'Keefe, 1990). The first of these influences is distraction. Distraction has been shown to reduce elaboration in situations which call for extensive issue-relevant thinking (O'Keefe, 1990). This intervention will be conducted at a time and place in which there is no distraction. The second determinant of elaboration ability is the prior knowledge that an individual has about the persuasive topic. Pam has some general prior knowledge about the subject of this intervention due to her status as a registered nurse. It is obvious from the dark suntans of our children, however, that Pam has very little knowledge about how dangerous excessive sun exposure is to small children.
If both the ability and motivation to elaborate are present, then an individuals willingness and ability to think (WATT) should be high (S. Booth-Butterfield, personal communication, September 14, 1995). A high WATT should lead to high elaboration. These elaborations will either be positive or negative. Elaborations are stored by the receiver and eventually produce attitude change. If a receiver has predominantly positive thoughts about the persuasive topic, then the change in attitude on the part of the receiver should be favorable to the persuasive topic. Similarly, negative elaborations should produce negative attitudes about the persuasive topic (O'Keefe, 1990).
Both the motivation and ability to engage in elaboration should be present for Pam in this intervention. When presented with clear, logical, and sound information about a threat to her children's health, Pam will have a high WATT. Positive elaborations should be produced and will be stored until needed in the spring. As spring approaches, reminders will be used to stimulate further elaboration. Positive elaborations will produce positive attitude changes and Elizabeth and Andrew will receive far less skin damage during the next summer as a result.
This pamphlet is available free from the Skin Cancer Foundation and gives very thorough instructions on how to protect children from the sun. I felt that this publication would reinforce the arguments which were a vital part of this intervention. I also brought several photographs of Andrew and Elizabeth which were taken in August. Several of the photographs included other children. The contrast between the dark tans of Andrew and Elizabeth and the complexions of other children who had not been extensively exposed to the sun was immediately noticeable. I hoped that the photographs, like the pamphlet, would reinforce my arguments concerning safe-sun behavior.
On the evening of October 21, both children were asleep when we returned to their home. I had planned to keep them out later than usual in order to have a quiet, distraction-free environment in which to present the persuasive arguments of this intervention. After a short conversation with Pam about the highlights of the day, I asked if she knew that Luther Burns, our former neighbor, had recently passed away. Pam said that she did not and asked how he had died. I told her about his year-long battle with cancer, which had started as malignant melanoma. I also related his history of excessive sun exposure as a child and how one of his physicians at Duke University Medical Center had said that every malignant melanoma patient he had treated was overexposed to the sun during childhood and early adolescence.
I felt that this was the perfect time to mention my concern about the dark suntans that Andrew and Elizabeth had during the previous summer. I used the photographs mentioned earlier to illustrate how dark the children were in August. I also used the "Sensible Sun Protection" pamphlet to emphasize that tanned skin is damaged skin and effective protection from the sun was vital to the future health of young children. Another point I emphasized was that sunscreen, while better than nothing, did not offer complete protection from the sun. This is easily illustrated by the fact that one can become suntanned while usingsunscreen.
I believe that Pam's WATT was high during this conversation. Her responses, e.g., asking questions, rephrasing key points, and so forth, indicated that elaboration was occurring. I don't honestly believe, however, that Pam was persuaded to change her view of suntanning as a result of that single conversation. As suggested by social judgement theory, a persuader facing a highly involved receiver may be able to safely advocate only a small change at one time (O'Keefe, 1990). Because of Pam's history of "sun worship," she is obviously very ego-involved in the subject of tanning. Social judgement theory suggests that obtaining substantial change from the highly involved receiver may require a series of small changes over time (O'Keefe, 1990).
This is the approach I will use with Pam in the spring and early summer of next year. The foundation for changing her perception of suntanning has been built. Future persuasive efforts will involve relatively small attempts to keep the dangers of excessive sun exposure in mind, but not to the point that the issue becomes redundant or irritating.
Changing Pam's perception of suntanning as a sign of beauty or health can be accomplished by a combination of social judgement theory and ELM concepts. While neither theory suggests that changing a longstanding, closely-held belief will be fast or effortless, both models offer valuable insights on successful persuaon in this intervention.
Bargoil, S. C., & Erdman, L. K. (1993). Safe tan: An oxymoron. Cancer Nursing, 16, 139-144.
Jeffrey, R. W. (1989). Risk behaviors and health: Contrasting individual and population perspectives. American Psychologist, 44, 1194-1202.
Johnson, E. Y., & Lookingbill, D. P. (1984). Sunscreen use and sun exposure. Archives of Dermatology, 120, 727-731.
Keesling, B., & Friedman, H. S. (1987). Psychosocial factors in sunbathing and sunscreen use. Health Psychology, 6, 477-493.
Leary, M. R., & Jones, J. L. (1993). The social psychology of tanning and sunscreen use: Self-presentational motives as a predictor of health risk. Journal of Applied Social Psychology, 23, 1390-1406.
Miller, A. G., Ashton, W. A., McHoskey, J. W., & Gimbel, J. (1990). What price attractiveness? Stereotype and risk factors in suntanning behavior. Journal of Applied Sociology, 20, 1272-1300.
O'Keefe, D. J. (1990). Persuasion: Theory and research. Newbury Park, CA: Sage.
Paler is better, say skin cancer fighters. (1987, Feb. 20). Journal of the American Medical Association, 257, 893-894.
Prawer, S. E. (1991). Sun-related skin diseases. Postgraduate Medicine 89, 51-66.
Stern, R. S., Weinstein, M. C., Baker, S. G. (1986). Risk reduction for nonmelanoma skin cancer with childhood sunscreen use. Archives of Dermatology, 122, 537-545.
Truhan, A. P., (1991). Sun protection in childhood. Clinical Pediatrics, 30, 676-681.
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Used with permission of the author for the Comm 221 course