Effects of Program Exposure and Engagement with Tailored Prevention Communication on Sun Protection by Young Adolescents

Published in the Journal of Health Communication (Vol. 13, pages 619-636), this evaluation report examines a family-based health communication intervention to stem the epidemic of skin cancer in the United States.

The study evaluated the effectiveness of a theory-based behaviour change communication (BCC) intervention designed to test the strategy of tailoring health messages to the characteristics, perceptions, and circumstances of at-risk populations. During the summer of 2002, adolescents aged 11-13 were drawn from the sample of a randomised trial which was testing school-based sun safety instruction through the Sunny Days Healthy Ways (SDHW) middle school curriculum. Delivered in the spring of 2002, SDHW had included sessions delivered in the classroom focusing on perceived risk for skin cancer, positive outcome and self-efficacy expectations for sun protection behaviours, key prevention skills (e.g., applying sunscreen), goal setting, self-monitoring, barrier resolution strategies, knowledge, and selected other attitudes (e.g., perceived norms for tanning). The programme was found to have demonstrated changes favouring intervention on a sun protection index, wearing protective clothing, and use of sunscreen. Significant intervention differences also were found for increased knowledge, decreased perceived barriers for sunscreen use, increased self-efficacy expectations about sun safety, and reduced positive attitudes toward sun tanning.

Adolescents and their parents were pretested in May of 2002 and post-tested from August to October. Adolescents (N = 599) were stratified on experimental condition in the in-school study (in-school intervention vs. control) and randomly were assigned from within strata to receive (N = 288) or not receive (N = 311) the summer intervention materials.

Similar to the school-based instruction, content in the summer programme was based on principles of social cognitive theory. The programme was delivered to adolescents and parents using cover letters, 4 Sun Scoop newsletters for parents, 4 Summer Raze newsletters for adolescents, and small gifts to enable adolescents to practice the recommended sun protection. All materials were mailed to participants in their homes. Specifically, parent intervention materials included an introductory cover letter, sent with the first newsletter, which described the summer programme and provided information about risk for skin cancer and sun-safe behaviours. A small portion of this letter was tailored based on the sun sensitivity of their adolescent (based on responses the student provided on the pretest survey in the main trial). The 4-page parent newsletters were personalised using their name and address and had generic information on sun safety organised into 4 topic categories (e.g., "Talking to Your Child"), which gave parents tips, facts, and strategies needed to promote sun-safe behaviours in the family. Finally, a Sun Scoop booklet was developed and distributed to each family. It included selected behavioural skill-based knowledge and forms to be used in behaviour change exercises completed with the adolescents.

The student materials also included an introductory cover letter and tailored newsletters. In addition, one gift was sent with each of the 4 mailings to facilitate skill development and behaviour change (e.g., a UV-sensitive card). The 4-page adolescent newsletters contained both generic and tailored messaging. For instance, the Summer Raze story followed the relationship between middle school students "Kirk" and "Kara"; messages advocating sun safety seamlessly integrated into the storylines. Just 4 U provided a fun fact related to sun safety. Amaze Me presented a myth about skin cancer or sun safety (e.g., having a suntan protects my skin from sunburns) and then provided information refuting and explaining this misstatement. Q & Aze posed questions about sun protection of interest to adolescents (e.g., are tanning beds more dangerous than the sun?) and answered these questions. The Family Activity provided an opportunity to complete a series of learning activities with parents and siblings. The Visual Skill Building section used pictures and graphics with minimal text to emphasise key skills for sun safety.

Tailoring in all 4 newsletters was based upon individuals' responses to the pretest and posttest surveys in the main trial completed before the summer began, and was embedded in the topic of each newsletter. The adolescent's name and address was personalised, with tailoring variables including: motivation to tan (high, low), perceived personal risk for skin cancer (high, medium, low), self-efficacy for sun protection (high, low), current sun protection (high, low with feedback on highest perceived barrier to sunscreen use and use of shade), and gender (male, female). A message library was developed and a scoring algorithm created to insert the appropriate tailored message into a predetermined field within a Quark graphics design file for each newsletter.

The main hypothesis was that children who were sent the tailored communications would report greater sun protection at the end of the summer than those not sent the tailored communications. Prior exposure to the school-based instruction was tested as a moderator of this effect. However, for students, treatment group (i.e., summer programme vs. no summer programme) had no effect on any of the sun protection outcomes tested. The researchers speculate that the lack of treatment effects in the primary comparisons may be due to an insufficient amount of the intervention material being read and utilised by the families. The sun protection messages delivered by mail had to compete for attention with other communications in the same medium (e.g., other direct mail or other health newsletters) and in other media (e.g., newspapers or television news stories).

There were, however, modest positive effects on parents' knowledge and self-reported propensity to have their children wear sunglasses. Parents were found to have increased knowledge (F = 5.52, p .05) and propensity to have their child wear sunglasses (F = 4.07, p .05). Greater programme exposure/engagement led to enhanced sun protection behaviour (e.g., fewer sunburns) and psychosocial factors among adolescents and parents. Greater exposure/engagement led to improvements in family interaction and home environment (e.g., shade audit completed). The researchers explain that, "[a]lthough limited in number, these changes might prove important. Knowledge can be a necessary precursor to behavior change."

The researchers conclude that "[s]imply sending tailored sun protection messages to children and parents during the summer did not improve sun protection of children in this trial....It may be unrealistic to expect large effects from health communication programs that rely on channels that allow audience members a high degree of selective attention. Thus, even with techniques that maximize program exposure and engagement, family interventions should be one of several efforts in a comprehensive multichannel community approach to the primary prevention of skin cancer."