Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Trends in news coverage about skin cancer prevention, 1993‐2006: increasingly mixed messages for the public

Trends in news coverage about skin cancer prevention, 1993‐2006: increasingly mixed messages for... News media perform an important agenda‐setting function about cancer issues for the public. The volume and selection of news stories influences what issues are presented and given salience, while their framing of issues can shape public perceptions. With news media a major source of health information for the public, news coverage of health issues can influence people's health concerns and actions. For example, reports of celebrity cancer diagnoses have been shown to have a positive effect on cancer screening practices. The powerful nature of news media has led health organisations to apply media advocacy strategies in an effort to advance cancer prevention and education goals. Unlike paid mass media campaigns that are generally expensive and time‐restrictive, news media provide an inexpensive and continuous forum advocates can utilise through activities such as press releases, media launches and the fostering of relationships with media personnel. Indeed, media advocacy has proven to be a valuable tool for influencing public health policy and promoting changes in community attitudes, beliefs and behaviours. Generating unpaid media coverage is a key communication strategy of SunSmart, a comprehensive skin cancer prevention program that has been running in Victoria for over 20 years. Australia has the highest incidence of skin cancer in the world, and skin cancer is the most costly financial burden on the country's health system of all cancer types. In light of the enormity of this health issue, the SunSmart program has strived to maintain a media presence to ensure the sun protection message remains current and of priority for the public. Paid mass media campaigns have been used to educate the population of the need for sun protection. The program's media advocacy efforts have included campaign launches (e.g. National Skin Cancer Action Week), dissemination of and comment on recent research findings, timing press releases with popular sporting events (e.g. Australian Open tennis), lobbying for policy changes (e.g. regulation of solarium industry) and encouraging health and beauty editors to deliver facts and statistics along with key SunSmart messages. Given the importance of news media in furthering sun protection objectives, systematic monitoring of news coverage can provide valuable information on the way sun protection issues are presented in the news and also allow advocacy efforts to be tracked. Despite the huge burden of skin cancer in Australia, as yet no studies have sought to assess the nature of news coverage on this topic. Two recent studies examined newspaper coverage of skin cancer issues in the US, a nation where skin cancer prevention efforts have been more infrequent and less coordinated than Australia. Stryker et al.'s content analysis of 921 skin cancer articles released by the Associated Press from 1979 to 2003 found skin cancer receives minimal media attention with levels of coverage not increasing since the mid 1980s. In addition, their analysis revealed that stories on skin cancer tend not to contain important educational information regarding prevention such as sun protection practices and self‐detection. A study by Heneghan et al. of 874 articles relating to skin cancer published in The New York Times from 1980‐2004 observed a slight increase in the number of skin cancer articles over time. Yet, to put this in perspective, only about 2% of all cancer‐related stories during this period focused on skin cancer.Melanoma was the most dominant theme with sunscreen and tanning less widely covered. The present study was designed to provide a comprehensive overview of newspaper coverage of sun protection issues in an Australian setting. Specifically, it aimed to document trends in the volume, prominence, content and tone of articles relating to sun protection issues over a 14‐year period from 1993‐2006. Methods Sample The sample comprised the two daily and Sunday Melbourne metropolitan newspapers, The Age/Sunday Age and the Herald Sun/Sunday Herald Sun, published from 1993 to 2006. Articles from The Age were accessed via their annual CD‐ROM archives while articles from the Herald Sun were accessed via their news archive service ( http://www.newstext.com.au ). The following search string was developed to retrieve stories relevant to sun protection issues: (‘skin cancer’ and [tan or tanning or tanned or ‘sun protection’ or ‘skin protection’ or sunsmart or melanoma or sunburn or ‘slip slop slap’ or solarium or solaria]) or (‘vitamin D’ and [sun or skin]). This search strategy yielded 844 articles. For an article to be included in the study it had to be three or more sentences long and have at least one in three sentences referring to sun protection issues. Articles were excluded if they focused on skin cancer treatments, medical breakthroughs that may lead to improved skin cancer treatment (e.g. gene discovery), or sun protection for pets. Of the 844 articles retrieved, 547 (64.8%) met the inclusion criteria and were subsequently coded. Coding variables A coding system adapted from the methodological framework developed by Clegg Smith and colleagues to code newspaper coverage of tobacco issues was employed. Articles were coded on six aspects described below. Theme After reading the entire article, coders determined which sun protection topic was most dominant out of 11 options: health effects of UV radiation exposure; education/prevention information, programs, services and campaigns; sun protection attitudes/behaviour; early detection; school policies/issues; occupational health and safety (OH&S) issues; sun protection product issues and regulation; solaria issues; fake tans/tanning drugs; vitamin D issues; other. An example of a direct quote from an article to illustrate each theme is provided in Table 1 . 1 Percentage of newspaper articles by article theme. Article theme Example of direct quote from article % n Health effects of UV Deaths from melanoma skin cancers in Australia have risen by almost a third in seven years (Herald Sun, 20/1/1994, p9). 24 129 Education/prevention A shocking television campaign showing the bloody removal of a melanoma aims to scare people away from dangerous sun exposure (Herald Sun, 12/1/2000, p21). 14 78 Product issues Controversial Factor 30 sunscreens will be available on the Australian market late next year (Herald Sun, 13/11/1995, p3). 12 63 Vitamin D issues SunSmart Aussies are paying the price for covering up. While skin cancer rates have dropped, a lack of sunlight is causing serious vitamin D deficiencies (Herald Sun, 9/11/2002, p9). 9 49 Early detection Changes in the normal look or feel of a mole can be a warning sign of skin cancers, including malignant melanomas (Herald Sun, 30/8/1999, p102). 9 48 Attitudes/behaviour A third fewer Victorians want a suntan than a decade ago with sunscreen use almost doubling, research has found (Herald Sun, 18/2/1999, p16). 8 46 Solaria issues Solariums claiming that tanning is good for you and prevents cancer have received a warning from the consumer watchdog to stop misleading consumers or face court (The Age, 22/8/2001, p8). 7 40 Fake tans When it comes to tanning, more people are faking it (The Age, 3/5/1996, p6). 7 38 OH&S Employers have been warned to protect workers from sun exposure after a judge yesterday gave a retired truck driver the go‐ahead to sue his former employer after contracting skin cancer (The Age, 16/8/2003, p5). 4 23 School policies Playing in the sun without a hat may soon be banned in primary schools (Herald Sun, 25/1/1996, p9). 3 19 Other British holiday‐makers heading for the sun are being offered a new kind of travel insurance – against skin cancer (Herald Sun, 9/4/1996, p26). 3 14 Type Coders distinguished between news articles (factual accounts of issues and events) and commentary pieces (editorials, columns, letters). Articles not fitting into either of these categories were coded as ‘other’ (e.g. information, question & answer). Prominence This was assessed based on whether the article appeared in the first four pages of the main section of the newspaper. Spokesperson An article was coded as pro‐sun protection when a spokesperson made a comment in support of sun protection, or was the author of a letter or column advocating for sun protection. Articles were coded as anti‐sun protection when a spokesperson made a comment not in support of sun protection (e.g. spoke favourably about solarium use, advocated for sun exposure as a means of getting sufficient vitamin D without qualifying statements). The comment did not need to be a direct quote; a paraphrased statement attributed to the spokesperson was sufficient. For the purposes of this study, a spokesperson was defined as an organisation or individual identified as the representative of a health or industry organisation or a health professional or researcher/scientist. Topic slant For each article, coders identified the newsworthy event or item relevant to sun protection that was being covered and judged whether it was positive (e.g. reports on the negative health effects of sun exposure), negative (e.g. reports of increases in the number of solariums), mixed (e.g. articles about fake tan products), or neutral for sun protection objectives. Opinion slant This variable only applied to commentary and ‘other’ articles (i.e. not news articles), and related to the dominant view or opinion being put forth by the author and the extent to which this was positive, negative, mixed, or neutral for sun protection objectives. Coding procedures and analysis Coding procedures were developed and refined by the authors using an iterative process. Five sets of 20 articles were coded by two of the authors (MS and MW). At each iteration, the two authors discussed any discrepancies in coding and reached consensus as to how these should be coded. All articles were coded by one of these two authors. Intercoder reliability was established on a sample of 20 articles for theme, type, topic slant and opinion slant. Cohen's κ was 0.76 for topic slant and 0.88 for opinion slant. It was not possible to calculate κ values for theme or type, however, per cent agreement was 95% for theme and 85% for type. Poisson regression analysis was used to test for linear trends in coverage over time, accounting for the number of articles coded each year. Where a lack of model fit was observed, negative binomial regression analysis was used. Results Yearly coverage of sun protection issues over the study period ranged from 28 articles in 1998 to 54 articles in 2003 (M=39.07, sd=7.15). Two‐thirds (66%) of all articles appeared in the Herald Sun/Sunday Herald Sun. Theme As shown in Table 1 , nearly one‐quarter of articles focused on the health effects of UV radiation exposure. Media attention was moderately high for education/prevention, however, the proportion of articles on this theme fluctuated considerably over time with education/prevention receiving limited or no coverage in 1995 (0%) and 1996 (2%). Annual fluctuations were also evident in reporting of early detection, sun protection attitudes/behaviour and OH&S issues. Themes that became more dominant over time included vitamin D issues (rate ratio (RR) = 1.21, 95% CI: 1.12‐1.32, p <0.001), solaria issues (RR =1.12, 95% CI: 1.03‐1.21, p =0.009) and fake tans (RR = 1.13, 95% CI: 1.02‐1.26, p =0.016) (see Figure 1 ). By the latter stages of the survey period, vitamin D issues were the most dominant theme (19% in 2004 and 24% in 2005). 1 Themes that increased significantly over time (1993‐2006). As shown in Figure 2 , themes that became less dominant over time included sun protection product issues (RR = 0.90, 95% CI: 0.84‐0.96, p =0.001) and school policies/issues (RR = 0.82, 95% CI: 0.67‐0.99, p =0.044). Overall, articles that focused on school polices/issues were scarce, except for a single peak in 1995 when it was the equal most dominant theme (23%). 2 Themes that decreased significantly over time (1993‐2006). Type, prominence and spokesperson News articles accounted for 71% of all sun protection related coverage. Eleven per cent of articles were commentary pieces, comprising 28 letters, 26 columns, and five editorials. Of the 97 (18%) articles coded as ‘other’ for type, 77 were information articles. There was slight evidence indicating that over time the proportion of commentary articles decreased (RR = 0.94, 95% CI: 0.88‐1.00), p =0.049), while the proportion of ‘other’ articles increased (RR = 1.05, 95% CI: 1.00‐1.11, p =0.048). Overall, 12% of sun protection articles were prominently located in the early general news section of the newspaper, however, this varied significantly from year to year, ranging from 0% in 2000 to 30% in 1993. Prominence also varied with the theme ofthe article. For example, articles on sun protection product issues (21%) and solaria issues (18%) were most commonly published in the first four pages ofthe newspaper, while articles on fake tans and school policies were given least prominence (5% respectively). Sixty per cent of articles included a pro‐sun protection spokesperson and 12% included an anti‐sun protection spokesperson. However, the profile of anti‐sun protection spokespeople increased over time (RR = 1.12, 95% CI: 1.05‐1.20, p =0.001). Only five per cent of articles featured both a pro‐ and anti‐sun protection spokesperson. Slant Half (50%) of all articles reported on topics positive for sun protection objectives while 18% reported on negative topics. However, the difference in the proportion of positive and negative topics covered each year narrowed considerably from 2001 onwards (see Figure 3 ). This was mainly due to an escalation in the reporting of negative topics over time (RR = 1.08, 95% CI: 1.03‐1.14, p = 0.002). Approximately one‐fifth (22%) of articles were coded as mixed for topic slant, indicating they had both positive and negative implications for sun protection. Only 10% of articles were deemed to be reporting on neutral topics. 3 Percentage of newspaper articles by topic slant, a within each year (N=547). For the 156 articles coded for opinion slant, the majority of opinions voiced were positive for sun protection objectives (57%), with only 7% of articles reflecting negative opinions. Twenty‐one per cent of opinionated articles expressed a mixed opinion for sun protection, with this figure peaking at 38% and 40% in 2003 and 2004 respectively. Consequently, the proportion of opinionated articles containing positive opinions was lower during these years than in other years (see Figure 4 ). Overall, 15% of opinionated articles were judged to be voicing a neutral opinion for sun protection objectives. 4 Percentage of newspaper articles by opinion slant, a within each year (n=156). Themes that tended to be related to positive topics for sun protection objectives more frequently than others were education/prevention (91%), OH&S issues (83%), and sun protection product issues (73%). Negative topics were most frequent in articles focused on vitamin D issues (55%) and fake tans (45%). Nearly all other articles reporting on vitamin D issues and fake tans were coded as mixed for topic slant (37% and 53% respectively). Topics that were neutral for sun protection were most frequent in articles focused on early detection (77%). The majority of articles with themes relating to school policies, sun protection product issues, education/prevention, solaria issues, and, to a lesser extent, sun protection attitudes/behaviour and health effects of UV radiation exposure, contained positive opinions for sun protection objectives (all > 60%). From the 11 themes, only fake tans (18%), vitamin D issues (17%), sun protection attitudes/behaviour (13%), and education/prevention (10%) attracted negative opinions. As with topic slant, a notable proportion of articles on vitamin D issues and fake tans reflected mixed opinions (50% and 73% respectively). Discussion Overall, the results indicate that the mix of sun protection issues covered and views of sun protection changed over time between 1993 and 2006, resulting in greater coverage of controversies or issues not clearly positive for sun protection objectives and accordingly more mixed commentary from around 2001. Half the coverage of sun protection issues over the entire period focused on health effects of UV radiation exposure, education/prevention, and sun protection product issues. It is encouraging from a public health perspective that information on the health effects of UV radiation exposure as well as education and prevention messages have maintained their newsworthiness despite the emergence of more controversial topics. Several notable peaks in coverage of particular themes can be attributed to specific events. For example, the high volume of articles on sun protection product issues in 1996 was due to controversy surrounding the impending change in sunscreen labelling regulations to allow for SPF 30+ creams. Similarly, the increase in articles related to solaria issues in 2001 was driven by a change in voluntary standards for this industry. The impetus for the peak in coverage of school policies/issues in 1995 was the result of SunSmart's emphasis on further developing their schools program. Fluctuations in coverage of OH&S issues were mostly triggered by isolated legal cases. While the majority of articles were news items, sun protection issues did provoke some commentary, with 11% of articles being opinion pieces. Although editorials were scarce, the fact that a considerable amount of letters and columns were published suggests the public has engaged with sun protection issues. The high proportion of ‘other’ type articles (18%) and their growth over time was primarily due to information articles featured in health and lifestyle sections of the newspaper. Many of these information articles focused on providing consumers with educational material on the health effects of UV exposure and preventive measures, suggesting the SunSmart program's advocacy work with health and beauty editors has been beneficial. Pro‐sun protection spokespeople and/or organisations received substantial attention in the press, with three in five articles including comment from such advocates. While it is possible that some of these mentions may have been prompted by journalists seeking comment on particular stories, the ongoing media presence of pro‐sun protection spokespeople is positive and suggests advocacy efforts are indeed working. Of concern, though, is the proliferation of anti‐sun protection spokespeople over recent times. This trend has the potential to promote confusion in the community regarding specific sun protection issues, especially when their comments are reported without balance from the opposing point of view, as occurred in approximately half the instances observed. Overall, news coverage was nearly three times as likely to report on topics that were positive for sun protection objectives compared to negative. However, increases in the proportion of negatively focused articles led to a considerable narrowing of this gap over time. The coinciding shift towards greater media attention on controversial themes such as solaria use, fake tanning products and vitamin D issues is likely to have been a key contributor to this pattern of coverage. Almost one‐third of articles were related to topics that were mixed or neutral for sun protection objectives. Coverage pertaining to the early detection of skin cancer was typically coded as neutral due to the main message being that people should be more vigilant about checking their skin without any overt message about the need to protect skin from the sun. The opinions expressed by authors of non‐news items were generally positive or mixed for sun protection, with a minority expressing negative views. The link between vitamin D and sun exposure was arguably the most controversial sun protection issue covered in newspapers over the study period, with the majority of coverage either negative or mixed for sun protection objectives. The complexity of this escalating issue resides in the fact there are health consequences involved on both sides of the debate. While sun protection is crucial in the prevention of skin cancer, a certain amount of exposure to sunlight is necessary to ensure adequate vitamin D levels and maintain good bone and musculoskeletal health. Findings from recent Australian research indicate there is a high level of public uncertainty regarding vitamin D and sun protection, and that news reports on this issue are prompting a small, yet significant, proportion of teenagers and adults to believe they need to spend more time in the sun without sun protection. With the current focus on vitamin D issues likely to continue into the near future at least, there is the challenge for sun protection advocates to educate the media and the public about vitamin D and the sun in a way that promotes positive news coverage on this topic and appropriate sun protection behaviour among the public. Another contentious issue receiving increased media attention over time was the use of fake tanning products. This trend in coverage has mixed implications for sun protection objectives. Although it is promising that news media are conveying the message that it is unsafe to get a tan by sunbaking or visiting a solarium, the rise in articles in support of the use of fake tanning products perpetuates the notion that tanned skin is more desirable than pale skin. Such a perception among the public is potentially harmful, especially in light of data suggesting that use of fake tanning products is associated with sunburning and solaria use. While the findings of this content analysis indicate that advocacy efforts have had a positive impact on the way sun protection issues are covered in the print media, they also highlight areas with scope for improvement. Specifically, the predominantly negative and mixed coverage of vitamin D issues as well as the stronger media presence of anti‐sun protection spokespeople are causes for concern. Moving forward, strategies such as the establishment of joint position statements on vitamin D among relevant stakeholders will be important in trying to get a clear and consistent message across to the public that is positive for sun protection. For example, the Australian and New Zealand Bone and Mineral Society, Osteoporosis Australia, The Australasian College of Dermatologists, and The Cancer Council Australia recently collaborated to release new guidelines on how much sun exposure Australians need to maintain sufficient levels of vitamin D without increasing their risk of skin cancer. Specific educational messages to clarify the times of day when UV radiation levels are low and people can safely go out in the sun and get their vitamin D requirements could help alleviate the media and public confusion about when sun protection is warranted. An example of this approach is the SunSmart UV Alert. Whereas previous content analysis studies conducted in this area focused largely on skin cancer and treatment, the emphasis here was on sun protection issues pertaining to skin cancer prevention, with all treatment‐related articles excluded. This method provided us with the opportunity to explore a greater range of themes that either directly or indirectly impact on skin cancer, including controversial topics such as vitamin D and fake tanning. A key conclusion from both prior studies was the need for improved media advocacy to promote increased media attention on skin cancer prevention and education. This study extends prior research by recording the frequency of comments from pro‐ and anti‐sun protection spokespeople in order to track advocacy efforts. Furthermore, measuring the tone of articles rather than just the content, enabled assessment of not only what sun protection issues were presented in the news but also, importantly, how they were presented. Some study limitations should be noted. Due to the accessibility of data, newspaper coverage was used as a proxy measure for all news media coverage. Coverage of issues in newspapers is, however, typically similar to other media such as television and radio, with major daily newspapers often setting the agenda for other media. Although considerable care was taken in developing a comprehensive search string, this was necessarily balanced against minimising the amount of ineligible articles that were retrieved. Consequently, it is possible our study may not represent a census of articles on sun protection issues. A further limitation is that, for practical reasons pertaining to volume, our data was restricted to coverage in Melbourne's two daily newspapers. Future research that includes all major Australian state capital city newspapers would allow any variations in news coverage of sun protection issues in different states to be identified. This study provides a valuable perspective on the nature of news coverage of sun protection issues in an Australian setting over a 14‐year period. Although the volume of articles remained relatively stable during this time, there has been a clear shift towards greater coverage of controversies and issues that are not necessarily positive for sun protection objectives. These findings provide a continuing challenge for media advocacy efforts. Furthermore, they imply that evaluation of paid skin cancer prevention public education campaigns may need to take account of the changing news environment in which they take place. Acknowledgments This study was funded by The Cancer Council Victoria. We gratefully acknowledge the contribution of Kim McLeod in developing the study protocol and Matt Spittal for statistical advice. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Australian and New Zealand Journal of Public Health Wiley

Trends in news coverage about skin cancer prevention, 1993‐2006: increasingly mixed messages for the public

Download PDF
6 pages

Loading next page...
 
/lp/wiley/trends-in-news-coverage-about-skin-cancer-prevention-1993-2006-t4fvKpNWx8

References (37)

Publisher
Wiley
Copyright
© 2008 The Authors. Journal Compilation © 2008 Public Health Association of Australia
ISSN
1326-0200
eISSN
1753-6405
DOI
10.1111/j.1753-6405.2008.00280.x
pmid
18959551
Publisher site
See Article on Publisher Site

Abstract

News media perform an important agenda‐setting function about cancer issues for the public. The volume and selection of news stories influences what issues are presented and given salience, while their framing of issues can shape public perceptions. With news media a major source of health information for the public, news coverage of health issues can influence people's health concerns and actions. For example, reports of celebrity cancer diagnoses have been shown to have a positive effect on cancer screening practices. The powerful nature of news media has led health organisations to apply media advocacy strategies in an effort to advance cancer prevention and education goals. Unlike paid mass media campaigns that are generally expensive and time‐restrictive, news media provide an inexpensive and continuous forum advocates can utilise through activities such as press releases, media launches and the fostering of relationships with media personnel. Indeed, media advocacy has proven to be a valuable tool for influencing public health policy and promoting changes in community attitudes, beliefs and behaviours. Generating unpaid media coverage is a key communication strategy of SunSmart, a comprehensive skin cancer prevention program that has been running in Victoria for over 20 years. Australia has the highest incidence of skin cancer in the world, and skin cancer is the most costly financial burden on the country's health system of all cancer types. In light of the enormity of this health issue, the SunSmart program has strived to maintain a media presence to ensure the sun protection message remains current and of priority for the public. Paid mass media campaigns have been used to educate the population of the need for sun protection. The program's media advocacy efforts have included campaign launches (e.g. National Skin Cancer Action Week), dissemination of and comment on recent research findings, timing press releases with popular sporting events (e.g. Australian Open tennis), lobbying for policy changes (e.g. regulation of solarium industry) and encouraging health and beauty editors to deliver facts and statistics along with key SunSmart messages. Given the importance of news media in furthering sun protection objectives, systematic monitoring of news coverage can provide valuable information on the way sun protection issues are presented in the news and also allow advocacy efforts to be tracked. Despite the huge burden of skin cancer in Australia, as yet no studies have sought to assess the nature of news coverage on this topic. Two recent studies examined newspaper coverage of skin cancer issues in the US, a nation where skin cancer prevention efforts have been more infrequent and less coordinated than Australia. Stryker et al.'s content analysis of 921 skin cancer articles released by the Associated Press from 1979 to 2003 found skin cancer receives minimal media attention with levels of coverage not increasing since the mid 1980s. In addition, their analysis revealed that stories on skin cancer tend not to contain important educational information regarding prevention such as sun protection practices and self‐detection. A study by Heneghan et al. of 874 articles relating to skin cancer published in The New York Times from 1980‐2004 observed a slight increase in the number of skin cancer articles over time. Yet, to put this in perspective, only about 2% of all cancer‐related stories during this period focused on skin cancer.Melanoma was the most dominant theme with sunscreen and tanning less widely covered. The present study was designed to provide a comprehensive overview of newspaper coverage of sun protection issues in an Australian setting. Specifically, it aimed to document trends in the volume, prominence, content and tone of articles relating to sun protection issues over a 14‐year period from 1993‐2006. Methods Sample The sample comprised the two daily and Sunday Melbourne metropolitan newspapers, The Age/Sunday Age and the Herald Sun/Sunday Herald Sun, published from 1993 to 2006. Articles from The Age were accessed via their annual CD‐ROM archives while articles from the Herald Sun were accessed via their news archive service ( http://www.newstext.com.au ). The following search string was developed to retrieve stories relevant to sun protection issues: (‘skin cancer’ and [tan or tanning or tanned or ‘sun protection’ or ‘skin protection’ or sunsmart or melanoma or sunburn or ‘slip slop slap’ or solarium or solaria]) or (‘vitamin D’ and [sun or skin]). This search strategy yielded 844 articles. For an article to be included in the study it had to be three or more sentences long and have at least one in three sentences referring to sun protection issues. Articles were excluded if they focused on skin cancer treatments, medical breakthroughs that may lead to improved skin cancer treatment (e.g. gene discovery), or sun protection for pets. Of the 844 articles retrieved, 547 (64.8%) met the inclusion criteria and were subsequently coded. Coding variables A coding system adapted from the methodological framework developed by Clegg Smith and colleagues to code newspaper coverage of tobacco issues was employed. Articles were coded on six aspects described below. Theme After reading the entire article, coders determined which sun protection topic was most dominant out of 11 options: health effects of UV radiation exposure; education/prevention information, programs, services and campaigns; sun protection attitudes/behaviour; early detection; school policies/issues; occupational health and safety (OH&S) issues; sun protection product issues and regulation; solaria issues; fake tans/tanning drugs; vitamin D issues; other. An example of a direct quote from an article to illustrate each theme is provided in Table 1 . 1 Percentage of newspaper articles by article theme. Article theme Example of direct quote from article % n Health effects of UV Deaths from melanoma skin cancers in Australia have risen by almost a third in seven years (Herald Sun, 20/1/1994, p9). 24 129 Education/prevention A shocking television campaign showing the bloody removal of a melanoma aims to scare people away from dangerous sun exposure (Herald Sun, 12/1/2000, p21). 14 78 Product issues Controversial Factor 30 sunscreens will be available on the Australian market late next year (Herald Sun, 13/11/1995, p3). 12 63 Vitamin D issues SunSmart Aussies are paying the price for covering up. While skin cancer rates have dropped, a lack of sunlight is causing serious vitamin D deficiencies (Herald Sun, 9/11/2002, p9). 9 49 Early detection Changes in the normal look or feel of a mole can be a warning sign of skin cancers, including malignant melanomas (Herald Sun, 30/8/1999, p102). 9 48 Attitudes/behaviour A third fewer Victorians want a suntan than a decade ago with sunscreen use almost doubling, research has found (Herald Sun, 18/2/1999, p16). 8 46 Solaria issues Solariums claiming that tanning is good for you and prevents cancer have received a warning from the consumer watchdog to stop misleading consumers or face court (The Age, 22/8/2001, p8). 7 40 Fake tans When it comes to tanning, more people are faking it (The Age, 3/5/1996, p6). 7 38 OH&S Employers have been warned to protect workers from sun exposure after a judge yesterday gave a retired truck driver the go‐ahead to sue his former employer after contracting skin cancer (The Age, 16/8/2003, p5). 4 23 School policies Playing in the sun without a hat may soon be banned in primary schools (Herald Sun, 25/1/1996, p9). 3 19 Other British holiday‐makers heading for the sun are being offered a new kind of travel insurance – against skin cancer (Herald Sun, 9/4/1996, p26). 3 14 Type Coders distinguished between news articles (factual accounts of issues and events) and commentary pieces (editorials, columns, letters). Articles not fitting into either of these categories were coded as ‘other’ (e.g. information, question & answer). Prominence This was assessed based on whether the article appeared in the first four pages of the main section of the newspaper. Spokesperson An article was coded as pro‐sun protection when a spokesperson made a comment in support of sun protection, or was the author of a letter or column advocating for sun protection. Articles were coded as anti‐sun protection when a spokesperson made a comment not in support of sun protection (e.g. spoke favourably about solarium use, advocated for sun exposure as a means of getting sufficient vitamin D without qualifying statements). The comment did not need to be a direct quote; a paraphrased statement attributed to the spokesperson was sufficient. For the purposes of this study, a spokesperson was defined as an organisation or individual identified as the representative of a health or industry organisation or a health professional or researcher/scientist. Topic slant For each article, coders identified the newsworthy event or item relevant to sun protection that was being covered and judged whether it was positive (e.g. reports on the negative health effects of sun exposure), negative (e.g. reports of increases in the number of solariums), mixed (e.g. articles about fake tan products), or neutral for sun protection objectives. Opinion slant This variable only applied to commentary and ‘other’ articles (i.e. not news articles), and related to the dominant view or opinion being put forth by the author and the extent to which this was positive, negative, mixed, or neutral for sun protection objectives. Coding procedures and analysis Coding procedures were developed and refined by the authors using an iterative process. Five sets of 20 articles were coded by two of the authors (MS and MW). At each iteration, the two authors discussed any discrepancies in coding and reached consensus as to how these should be coded. All articles were coded by one of these two authors. Intercoder reliability was established on a sample of 20 articles for theme, type, topic slant and opinion slant. Cohen's κ was 0.76 for topic slant and 0.88 for opinion slant. It was not possible to calculate κ values for theme or type, however, per cent agreement was 95% for theme and 85% for type. Poisson regression analysis was used to test for linear trends in coverage over time, accounting for the number of articles coded each year. Where a lack of model fit was observed, negative binomial regression analysis was used. Results Yearly coverage of sun protection issues over the study period ranged from 28 articles in 1998 to 54 articles in 2003 (M=39.07, sd=7.15). Two‐thirds (66%) of all articles appeared in the Herald Sun/Sunday Herald Sun. Theme As shown in Table 1 , nearly one‐quarter of articles focused on the health effects of UV radiation exposure. Media attention was moderately high for education/prevention, however, the proportion of articles on this theme fluctuated considerably over time with education/prevention receiving limited or no coverage in 1995 (0%) and 1996 (2%). Annual fluctuations were also evident in reporting of early detection, sun protection attitudes/behaviour and OH&S issues. Themes that became more dominant over time included vitamin D issues (rate ratio (RR) = 1.21, 95% CI: 1.12‐1.32, p <0.001), solaria issues (RR =1.12, 95% CI: 1.03‐1.21, p =0.009) and fake tans (RR = 1.13, 95% CI: 1.02‐1.26, p =0.016) (see Figure 1 ). By the latter stages of the survey period, vitamin D issues were the most dominant theme (19% in 2004 and 24% in 2005). 1 Themes that increased significantly over time (1993‐2006). As shown in Figure 2 , themes that became less dominant over time included sun protection product issues (RR = 0.90, 95% CI: 0.84‐0.96, p =0.001) and school policies/issues (RR = 0.82, 95% CI: 0.67‐0.99, p =0.044). Overall, articles that focused on school polices/issues were scarce, except for a single peak in 1995 when it was the equal most dominant theme (23%). 2 Themes that decreased significantly over time (1993‐2006). Type, prominence and spokesperson News articles accounted for 71% of all sun protection related coverage. Eleven per cent of articles were commentary pieces, comprising 28 letters, 26 columns, and five editorials. Of the 97 (18%) articles coded as ‘other’ for type, 77 were information articles. There was slight evidence indicating that over time the proportion of commentary articles decreased (RR = 0.94, 95% CI: 0.88‐1.00), p =0.049), while the proportion of ‘other’ articles increased (RR = 1.05, 95% CI: 1.00‐1.11, p =0.048). Overall, 12% of sun protection articles were prominently located in the early general news section of the newspaper, however, this varied significantly from year to year, ranging from 0% in 2000 to 30% in 1993. Prominence also varied with the theme ofthe article. For example, articles on sun protection product issues (21%) and solaria issues (18%) were most commonly published in the first four pages ofthe newspaper, while articles on fake tans and school policies were given least prominence (5% respectively). Sixty per cent of articles included a pro‐sun protection spokesperson and 12% included an anti‐sun protection spokesperson. However, the profile of anti‐sun protection spokespeople increased over time (RR = 1.12, 95% CI: 1.05‐1.20, p =0.001). Only five per cent of articles featured both a pro‐ and anti‐sun protection spokesperson. Slant Half (50%) of all articles reported on topics positive for sun protection objectives while 18% reported on negative topics. However, the difference in the proportion of positive and negative topics covered each year narrowed considerably from 2001 onwards (see Figure 3 ). This was mainly due to an escalation in the reporting of negative topics over time (RR = 1.08, 95% CI: 1.03‐1.14, p = 0.002). Approximately one‐fifth (22%) of articles were coded as mixed for topic slant, indicating they had both positive and negative implications for sun protection. Only 10% of articles were deemed to be reporting on neutral topics. 3 Percentage of newspaper articles by topic slant, a within each year (N=547). For the 156 articles coded for opinion slant, the majority of opinions voiced were positive for sun protection objectives (57%), with only 7% of articles reflecting negative opinions. Twenty‐one per cent of opinionated articles expressed a mixed opinion for sun protection, with this figure peaking at 38% and 40% in 2003 and 2004 respectively. Consequently, the proportion of opinionated articles containing positive opinions was lower during these years than in other years (see Figure 4 ). Overall, 15% of opinionated articles were judged to be voicing a neutral opinion for sun protection objectives. 4 Percentage of newspaper articles by opinion slant, a within each year (n=156). Themes that tended to be related to positive topics for sun protection objectives more frequently than others were education/prevention (91%), OH&S issues (83%), and sun protection product issues (73%). Negative topics were most frequent in articles focused on vitamin D issues (55%) and fake tans (45%). Nearly all other articles reporting on vitamin D issues and fake tans were coded as mixed for topic slant (37% and 53% respectively). Topics that were neutral for sun protection were most frequent in articles focused on early detection (77%). The majority of articles with themes relating to school policies, sun protection product issues, education/prevention, solaria issues, and, to a lesser extent, sun protection attitudes/behaviour and health effects of UV radiation exposure, contained positive opinions for sun protection objectives (all > 60%). From the 11 themes, only fake tans (18%), vitamin D issues (17%), sun protection attitudes/behaviour (13%), and education/prevention (10%) attracted negative opinions. As with topic slant, a notable proportion of articles on vitamin D issues and fake tans reflected mixed opinions (50% and 73% respectively). Discussion Overall, the results indicate that the mix of sun protection issues covered and views of sun protection changed over time between 1993 and 2006, resulting in greater coverage of controversies or issues not clearly positive for sun protection objectives and accordingly more mixed commentary from around 2001. Half the coverage of sun protection issues over the entire period focused on health effects of UV radiation exposure, education/prevention, and sun protection product issues. It is encouraging from a public health perspective that information on the health effects of UV radiation exposure as well as education and prevention messages have maintained their newsworthiness despite the emergence of more controversial topics. Several notable peaks in coverage of particular themes can be attributed to specific events. For example, the high volume of articles on sun protection product issues in 1996 was due to controversy surrounding the impending change in sunscreen labelling regulations to allow for SPF 30+ creams. Similarly, the increase in articles related to solaria issues in 2001 was driven by a change in voluntary standards for this industry. The impetus for the peak in coverage of school policies/issues in 1995 was the result of SunSmart's emphasis on further developing their schools program. Fluctuations in coverage of OH&S issues were mostly triggered by isolated legal cases. While the majority of articles were news items, sun protection issues did provoke some commentary, with 11% of articles being opinion pieces. Although editorials were scarce, the fact that a considerable amount of letters and columns were published suggests the public has engaged with sun protection issues. The high proportion of ‘other’ type articles (18%) and their growth over time was primarily due to information articles featured in health and lifestyle sections of the newspaper. Many of these information articles focused on providing consumers with educational material on the health effects of UV exposure and preventive measures, suggesting the SunSmart program's advocacy work with health and beauty editors has been beneficial. Pro‐sun protection spokespeople and/or organisations received substantial attention in the press, with three in five articles including comment from such advocates. While it is possible that some of these mentions may have been prompted by journalists seeking comment on particular stories, the ongoing media presence of pro‐sun protection spokespeople is positive and suggests advocacy efforts are indeed working. Of concern, though, is the proliferation of anti‐sun protection spokespeople over recent times. This trend has the potential to promote confusion in the community regarding specific sun protection issues, especially when their comments are reported without balance from the opposing point of view, as occurred in approximately half the instances observed. Overall, news coverage was nearly three times as likely to report on topics that were positive for sun protection objectives compared to negative. However, increases in the proportion of negatively focused articles led to a considerable narrowing of this gap over time. The coinciding shift towards greater media attention on controversial themes such as solaria use, fake tanning products and vitamin D issues is likely to have been a key contributor to this pattern of coverage. Almost one‐third of articles were related to topics that were mixed or neutral for sun protection objectives. Coverage pertaining to the early detection of skin cancer was typically coded as neutral due to the main message being that people should be more vigilant about checking their skin without any overt message about the need to protect skin from the sun. The opinions expressed by authors of non‐news items were generally positive or mixed for sun protection, with a minority expressing negative views. The link between vitamin D and sun exposure was arguably the most controversial sun protection issue covered in newspapers over the study period, with the majority of coverage either negative or mixed for sun protection objectives. The complexity of this escalating issue resides in the fact there are health consequences involved on both sides of the debate. While sun protection is crucial in the prevention of skin cancer, a certain amount of exposure to sunlight is necessary to ensure adequate vitamin D levels and maintain good bone and musculoskeletal health. Findings from recent Australian research indicate there is a high level of public uncertainty regarding vitamin D and sun protection, and that news reports on this issue are prompting a small, yet significant, proportion of teenagers and adults to believe they need to spend more time in the sun without sun protection. With the current focus on vitamin D issues likely to continue into the near future at least, there is the challenge for sun protection advocates to educate the media and the public about vitamin D and the sun in a way that promotes positive news coverage on this topic and appropriate sun protection behaviour among the public. Another contentious issue receiving increased media attention over time was the use of fake tanning products. This trend in coverage has mixed implications for sun protection objectives. Although it is promising that news media are conveying the message that it is unsafe to get a tan by sunbaking or visiting a solarium, the rise in articles in support of the use of fake tanning products perpetuates the notion that tanned skin is more desirable than pale skin. Such a perception among the public is potentially harmful, especially in light of data suggesting that use of fake tanning products is associated with sunburning and solaria use. While the findings of this content analysis indicate that advocacy efforts have had a positive impact on the way sun protection issues are covered in the print media, they also highlight areas with scope for improvement. Specifically, the predominantly negative and mixed coverage of vitamin D issues as well as the stronger media presence of anti‐sun protection spokespeople are causes for concern. Moving forward, strategies such as the establishment of joint position statements on vitamin D among relevant stakeholders will be important in trying to get a clear and consistent message across to the public that is positive for sun protection. For example, the Australian and New Zealand Bone and Mineral Society, Osteoporosis Australia, The Australasian College of Dermatologists, and The Cancer Council Australia recently collaborated to release new guidelines on how much sun exposure Australians need to maintain sufficient levels of vitamin D without increasing their risk of skin cancer. Specific educational messages to clarify the times of day when UV radiation levels are low and people can safely go out in the sun and get their vitamin D requirements could help alleviate the media and public confusion about when sun protection is warranted. An example of this approach is the SunSmart UV Alert. Whereas previous content analysis studies conducted in this area focused largely on skin cancer and treatment, the emphasis here was on sun protection issues pertaining to skin cancer prevention, with all treatment‐related articles excluded. This method provided us with the opportunity to explore a greater range of themes that either directly or indirectly impact on skin cancer, including controversial topics such as vitamin D and fake tanning. A key conclusion from both prior studies was the need for improved media advocacy to promote increased media attention on skin cancer prevention and education. This study extends prior research by recording the frequency of comments from pro‐ and anti‐sun protection spokespeople in order to track advocacy efforts. Furthermore, measuring the tone of articles rather than just the content, enabled assessment of not only what sun protection issues were presented in the news but also, importantly, how they were presented. Some study limitations should be noted. Due to the accessibility of data, newspaper coverage was used as a proxy measure for all news media coverage. Coverage of issues in newspapers is, however, typically similar to other media such as television and radio, with major daily newspapers often setting the agenda for other media. Although considerable care was taken in developing a comprehensive search string, this was necessarily balanced against minimising the amount of ineligible articles that were retrieved. Consequently, it is possible our study may not represent a census of articles on sun protection issues. A further limitation is that, for practical reasons pertaining to volume, our data was restricted to coverage in Melbourne's two daily newspapers. Future research that includes all major Australian state capital city newspapers would allow any variations in news coverage of sun protection issues in different states to be identified. This study provides a valuable perspective on the nature of news coverage of sun protection issues in an Australian setting over a 14‐year period. Although the volume of articles remained relatively stable during this time, there has been a clear shift towards greater coverage of controversies and issues that are not necessarily positive for sun protection objectives. These findings provide a continuing challenge for media advocacy efforts. Furthermore, they imply that evaluation of paid skin cancer prevention public education campaigns may need to take account of the changing news environment in which they take place. Acknowledgments This study was funded by The Cancer Council Victoria. We gratefully acknowledge the contribution of Kim McLeod in developing the study protocol and Matt Spittal for statistical advice.

Journal

Australian and New Zealand Journal of Public Health – Wiley

Published: Oct 1, 2008

There are no references for this article.