Jennifer E. McWhirter

Visual images for patient skin self-examination and melanoma detection: A systematic review of published studies

BACKGROUND Early detection of skin cancer by patients is an important strategy for reducing morbidity and mortality caused by melanoma. However, the effectiveness of interventions or educational aids that use visual images to promote skin self-examination (SSE) and early melanoma detection has not been systematically investigated. OBJECTIVE We undertook a systematic review of peer-reviewed research on SSE for skin cancer to examine the outcomes of studies that used visual images as part of their methodology. Our objective was to describe the impact of visual images on patient SSE knowledge, attitudes, behaviors, and accuracy. METHODS Seven databases were searched resulting in 5330 citations. A total of 25 studies met the inclusion criteria. RESULTS Images positively affected knowledge and self-efficacy related to SSE. Images motivated the performance of SSE and increased the accuracy of SSE and melanoma detection. The types of visual images that were effective are described and the implications are discussed. LIMITATIONS Articles not uncovered by the search strategy may have been unintentionally excluded. Lack of image description in the studies made specific recommendations challenging. CONCLUSION The use of visual images to promote accurate and frequent SSE is encouraged.

A Systematic Review of Visual Image Theory, Assessment, and Use in Skin Cancer and Tanning Research

Visual images increase attention, comprehension, and recall of health information and influence health behaviors. Health communication campaigns on skin cancer and tanning often use visual images, but little is known about how such images are selected or evaluated. A systematic review of peer-reviewed, published literature on skin cancer and tanning was conducted to determine (a) what visual communication theories were used, (b) how visual images were evaluated, and (c) how visual images were used in the research studies. Seven databases were searched (PubMed/MEDLINE, EMBASE, PsycINFO, Sociological Abstracts, Social Sciences Full Text, ERIC, and ABI/INFORM) resulting in 5,330 citations. Of those, 47 met the inclusion criteria. Only one study specifically identified a visual communication theory guiding the research. No standard instruments for assessing visual images were reported. Most studies lacked, to varying degrees, comprehensive image description, image pretesting, full reporting of image source details, adequate explanation of image selection or development, and example images. The results highlight the need for greater theoretical and methodological attention to visual images in health communication research in the future. To this end, the authors propose a working definition of visual health communication.

Systematic review of population-based studies on the impact of images on UV attitudes and behaviours

Visual images have been shown to influence health behaviours. The effectiveness of population interventions, which use visual images to influence skin cancer prevention behaviours, has not been systematically evaluated. We, therefore, undertook a systematic review of peer-reviewed, health education and health promotion research on skin cancer and tanning to examine the outcomes of studies, which used visual images as part of their methodology. Our objective was to describe the impact of visual images on UV protection and exposure attitudes and behaviours across the studies. Twenty-three studies met the inclusion criteria. Images positively impact knowledge, attitudes and behaviours related to UV exposure and UV protection. Images also influence the perceived attractiveness of untanned or tanned skin, which in turn, influences UV exposure attitudes and behaviours. Implications for future health promotion research and practice are discussed.

Visual Images for Skin Cancer Prevention: A Systematic Review of Qualitative Studies

Visual images play an important role in educating the public about skin cancer prevention. The objectives of this systematic review were to: 1) determine how visual images are evaluated in skin cancer and tanning qualitative research studies (including theoretical and methodological approaches) and 2) summarize and discuss the image-related findings of the studies with respect to cancer education and public health. Seven databases were searched (PubMed-MEDLINE, EMBASE, PsycINFO, Sociological Abstracts, Social Sciences Full Text, ERIC, and ABI/INFORM) using multiple search terms, including MeSH terms, resulting in 5330 citations. Studies were included if they were in English, peer-reviewed, qualitative in design or methodology, dealt with skin cancer or UV exposure, used visual images, and had a focus on the public or patients (i.e., not medical professionals). Eight studies met the inclusion criteria: seven content analyses and one focus group study. Content analysis studies in this review suggest the mass media portray Caucasian men and women as unprotected from the sun and with tanned skin, and thus, may inform behaviors related to skin cancer risk. The focus group study suggests visible minorities may benefit from the incorporation of images of melanoma on ethnic skin in cancer education materials. None of the studies used visual communication theory to explicitly guide the research, nor were standardized tools used for image assessment. The lack of guiding theory and standardized assessment instruments can introduce bias in how images are selected and used in research on skin cancer education.

Can You See What They Are Saying? Breast Cancer Images and Text in Canadian Women's and Fashion Magazines

Media are an important source of breast cancer information for women. Visual images influence recall and comprehension of information. Research on breast cancer in the media has infrequently focused on images. Using directed content analysis, we compared content, tone, and themes in images (n = 91) and articles (n = 31) in Canadian women’s and fashion (n = 6) magazines (2005–2010). About half of the articles (51.6%) had both positive and negative tone; in contrast, 87.7% of women in the images had positive facial expressions. Women in the images were Caucasian (80.9%), young (81.3%), attractive (99.2%), had a healthy body type (93.8%), and appeared to have intact breasts (100%). Images of screening/treatment (5.5%) and visual impact of disease/treatment on the body (4.4%) were rare. The most common theme in the articles was medical issues (35.5%); in the images, it was beauty or fashion (15.4%). The potential impact of these divergent messages for breast cancer education is discussed.

Public Policy and Aboriginal Peoples in Canada: Taking a Life-Course Perspective

L’état de santé et les conditions sociales des Premières nations, des Inuits et des Métis au Canada reste une question de politiques sociales préoccupante. Certains chercheurs ont proposé l’approche des parcours de vie comme cadre d’analyse pour la conception de politiques qui favoriseraient l’inclusion sociale des peuples autochtones. Dans cet article, tout en expliquant que nous sommes d’accord avec cette démarche, nous soutenons que le cadre d’analyse doit aussi prendre en compte la situation particulière des peuples autochtones en matière de politiques sociales. Nous illustrons notre propos en donnant quelques exemples que nous avons élaborés à partir des données de l’Enquête auprès des peuples autochtones de 2001.

Beliefs about Causes of Colon Cancer by English-as-a-Second-Language Chinese Immigrant Women to Canada

Colon cancer is the second leading cause of cancer death for Canadians. Immigrants underutilize screening and may be at greater risk of late stage diagnosis and death from the disease. This mixed-methods study investigated the self-reported causes of colon cancer by 66 English-as-a-Second-Language Chinese immigrant women to Canada after reading a fact sheet which listed two causes of colon cancer (polyps and cause unknown) and six ways to help prevent colon cancer (lifestyle, diet, weight, smoking, alcohol, and screening). Women correctly named or described both causes (6.1%) or one cause (22.7%), could not name or describe either cause (19.7%), or named or described causes not included on the fact sheet (54.5%). The most common causes reported by participants were “risk factors”: diet (53.0%), family history (28.8%), and lifestyle (22.7%). Women confused cause with risk factor and infrequently mentioned screening. Possible reasons for their reported beliefs are discussed.

Comparing Written and Oral Measures of Comprehension of Cancer Information by English-as-a-Second-Language Chinese Immigrant Women

The Short Test of Functional Health Literacy for Adults (S-TOFHLA) and Cloze test are commonly used tools to measure comprehension of health information (i.e., health literacy); however, little is known about their use in English-as-a-Second-Language (ESL) populations. In this study, we compared written (Cloze test) and oral (Teach Back) measures of colon cancer information comprehension among ESL Chinese immigrant women to Canada. Performances on colon cancer-specific measures were compared to a general measure of health literacy (S-TOFHLA). On the S-TOFHLA, Cloze, and Teach Back, respectively, the following percentage of participants had adequate comprehension: 62.1%, 14.8%, and 89.7%. Correlation between performance on the Cloze and Teach Back was significant albeit weakly so (r = 0.38, p = 0.04); performances on the S-TOFHLA and Teach Back were not correlated. Measures of health literacy skill that require written English language skills may not be appropriate for measuring understanding of health information for ESL populations.

North American Magazine Coverage of Skin Cancer and Recreational Tanning Before and After the WHO/IARC 2009 Classification of Indoor Tanning Devices as Carcinogenic

The mass media is an influential source of skin cancer information for the public. In 2009, the World Health Organization’s International Agency for Research on Cancer classified UV radiation from tanning devices as carcinogenic. Our objective was to determine if media coverage of skin cancer and recreational tanning increased in volume or changed in nature after this classification. We conducted a directed content analysis on 29 North American popular magazines (2007–2012) to investigate the overall volume of articles on skin cancer and recreational tanning and, more specifically, the presence of skin cancer risk factors, UV behaviors, and early detection information in article text (n = 410) and images (n = 714). The volume of coverage on skin cancer and recreational tanning did not increase significantly after the 2009 classification of tanning beds as carcinogenic. Key-related messages, including that UV exposure is a risk factor for skin cancer and that indoor tanning should be avoided, were not reported more frequently after the classification, but the promotion of the tanned look as attractive was conveyed more often in images afterwards (p < .01). Content promoting high-SPF sunscreen use increased after the classification (p < .01), but there were no significant positive changes in the frequency of coverage of skin cancer risk factors, other UV behaviors, or early detection information over time. The classification of indoor tanning beds as carcinogenic had no significant impact on the volume or nature of skin cancer and recreational tanning coverage in magazines.

Application of the Health Belief Model to U.S. Magazine Text and Image Coverage of Skin Cancer and Recreational Tanning (2000–2012)

The health belief model (HBM) has been widely used to inform health education, social marketing, and health communication campaigns. Although the HBM can explain and predict an individual’s willingness to engage in positive health behaviors, its application to, and penetration of the underlying constructs into, mass media content has not been well characterized. We examined 574 articles and 905 images about skin cancer and tanning risks, behaviors, and screening from 20 U.S. women’s and men’s magazines (2000–2012) for the presence of HBM constructs: perceived susceptibility, perceived severity, perceived benefits, perceived barriers, self-efficacy, and cues to action. Susceptibility (48.1%) and severity (60.3%) information was common in text. Perceived benefits (36.4%) and barriers (41.5%) to prevention of skin cancer were fairly equally mentioned in articles. Self-efficacy (48.4%) focused on sunscreen use. There was little emphasis on HBM constructs related to early detection. Few explicit cues to action about skin cancer appeared in text (12.0%) or images (0.1%). HBM constructs were present to a significantly greater extent in text versus images (e.g., severity, 60.3% vs. 11.3%, respectively, χ2 = 399.51, p < .0001; benefits prevention, 36.4% vs. 8.0%, respectively, χ2 = 184.80, p < .0001), suggesting that readers are not visually messaged in ways that would effectively promote skin cancer prevention and early detection behaviors.