Melanoma risk: adolescent females’ perspectives on skin protection pre/post-viewing a ultraviolet photoaged photograph of their own facial sun damage

Abstract

Suntanning increases skin cancer risk and prematurely ages skin. Photoageing photography is an effective means of increasing adult ultraviolet radiation (UVR) awareness and skin-protection practices. While adults’ largely positive suntanning-deterrence responses to photoageing photography are well-documented, comparatively little is known about the deterrence effectiveness of photoageing photography with adolescents. To help fill this knowledge gap, in-depth interviews were collected from 10 adolescent females and were subsequently subjected to interpretive phenomenological analysis. The emergent central theme – Having a tan and looking good in the short-term is okay, however, in the longer-term you can end up looking far worse… but still a tan is worth it – and its component subthemes reveal that the adolescent female’s desire for a suntan is largely appearance driven. While photoaged photography is effective in increasing their awareness of the skin damage that UVR exposure causes, it does not alter their suntanning intentions. The analysis also revealed that one of the major barriers to adolescent females’ adoption of skin-protective behaviours is their belief in their own invincibility. Hence, skin-protection interventions that lessen the aura of invincibility around adolescent females’ understanding of their risk for developing skin cancers are vital to reducing the incidence of malignant melanoma.

Keywords

adolescents youth cancer screening cancer prevention health promotion risk factors

Introduction

While ultraviolet radiation (UVR) plays a role in vitamin D synthesis, overexposure to UVR is a harmful and preventable risk factor for developing skin cancer (1,2). The rate of Australia’s most deadly form of skin cancer, melanoma, remains one of the highest in the world (3 –5). Despite Australians having a high level of awareness of the cancer risk associated with UVR exposure, many adolescent Australians continue to suntan their bodies (6,7). The reason why 16–17-year-old females continue to suntan remains unclear. Hence, this study aims to broaden current understandings of the cognitions behind adolescent female involvement in suntanning activities, pre- and post-viewing an ultraviolet (UV) photoaged photograph of the sun damage already sustained to their face.

Skin cancer risk

Globally, approximately 2–3 million non-melanoma skin cancers and 132,000 melanoma skin cancers are diagnosed annually (8). The World Health Organisation’s (WHO) 2014 published data (9) lists the 20 countries with the highest rates of skin cancer deaths per 100,000 people as being New Zealand (7.68), Australia (6.52), Slovenia (5.42), Norway (4.80), Latvia (4.62), Macedonia (4.16), Denmark (4.15), Croatia (4.08), Netherlands (4.05), Sweden (3.79), Zimbabwe (3.78), Serbia (3.75), Austria (3.73), Israel (3.66), New Guinea (3.46), Hungary (3.37), Canada (3.29), Poland (3.25), United States of America (3.15) and Estonia (3.15).

In Australia, skin cancers account for 80% of all newly diagnosed cancers and Australians are four times more likely to develop skin cancer than any other form of cancer (3). Over 440,000 new cases are diagnosed annually (10,11). Of these, 2,209 died in 2013 (12). Taking into account treatment costs and lost work-hours, skin cancer is estimated to cost Australia approximately AUD$5 billion annually, making it one of the most expensive cancers (3). In an effort to reduce the impost on the country’s health system the Australian government has financed two nationwide skin-protective ‘Sun-Smart’ public health campaigns (11,13). Although these campaigns have been successful in heightening awareness of cancer risk factors in the adult population, sunbathing remains a popular pastime among female adolescents (1,7,14 –18).

Adolescent females’ sun-protective behaviours

Globally, adolescence is a developmental time period during which young people are at an elevated risk for melanomas and other skin cancers because this age cohort is particularly vulnerable to UV radiation (19,20). Melanomas account for 14%–23% of all skin cancers diagnosed in Australian adolescents aged 15–19 years (21,22). While adolescents are one of the better-informed Australian age cohorts of the dangers of UVR exposure (23,24), this knowledge has not necessarily translated into their adoption of skin-protective measures (17,25). Indeed, some studies have reported that not only are adolescents resistant to health education messages (4,26), they are less likely to adopt skin-protective measures than any other age cohort (15,27).

Adolescent motivations for acquiring a suntan are thought to arise from a belief that tanned skin increases attractiveness and from observing the praise that older people (e.g. relatives, celebrities) receive for their suntanned appearance. This vicarious motivational experience is strengthened in instances when they receive peer praise for their own tanned appearance (28). In this regard, adolescent females have been reported as having stronger pro-tanning attitudes than adolescent males (4,16,24), to sustain more serious sunburns than their adolescent male age-mates and to be twice as likely as adolescent males to be diagnosed with melanoma (16).

Sun-protection interventions

It is widely recognised that tanning is perceived to be an appearance-enhancing activity and, as such, appearance-orientated sun-protection interventions are likely to be effective in changing people’s pro-suntanning behaviours (20). Williams et al. (29) in their systematic review of appearance-based interventions found seven interventions that targeted female tanners. Of these, two involved providing females with instructional health promotional materials (see 30,31); one used motivational messages (see 32); two looked at facial sun damage either in yearbook photographs or computer altered images (see 33,34); and two looked at advertisements of models with and without a suntan (see 35). A further intervention not listed in the review (20) utilised a sun-protection educative intervention that was based on predictors identified in a prior study of adolescent protection intentions conducted with 207 students. The study results demonstrated that one 45-minute session accompanied by photoaged photographs was sufficient to make changes in the students’ future sun-exposure intentions.

UVR photoageing photography

Intentional UVR exposure is known to accelerate the ageing of the skin (36). Photoageing is the term used for premature-ageing sun-related skin changes (e.g. leathery appearance, wrinkles, blisters, blotches, uneven skin pigmentation, age spots). Characteristically, skin damage caused by unprotected exposure to UVR begins in early childhood, continues through adolescence and becomes progressively worse during adulthood (27,37,38). In recent years, a number of adult research studies have utilised UV-filtered cameras to expose the extent of UV facial damage in this age cohort and to induce a fear-driven increase in their adoption of skin-protective measures (e.g. 27,38,39). However, as a corresponding sizeable body of adolescent UV photoaged photography research has yet to be conducted, a knowledge gap exists in this area. It is this gap that this qualitative study aims to help fill, specifically, through uncovering female adolescents’ perspectives on suntanning and their attitudes towards adopting skin-protective measures both pre/post-viewing a UV photoaged photograph of their face.

Method

Research design

This phenomenological study is located within the symbolic interactionist tradition within Social Theory; phenomenology being the study of specific phenomena which develop within a sociocultural context. Its epistemology assumes that people construct and mediate their understanding of self through their interactions with others. Interpretive phenomenology draws upon the theoretical framework of symbolic interactionism, which emphasises that people assign meanings to their activities as a result of their daily interactions. Thus, this study’s use of interpretive phenomenological analysis was considered pertinent to developing an in-depth understanding of adolescent females’ attitudes towards suntanning and skin protection.

Participants

The study’s 10 participants were recruited based on four selection criteria. First, participants were female (because as a gender cohort they spend more time intentionally tanning than do males); second, they were aged between 16 and 17 years (an age when they were likely to take themselves independent of their parents to the beach to sunbathe); third, they were Caucasian; and fourth they resided in Western Australia. Being Caucasian was considered to be an important factor given that the WHO (5) has determined that fair-skinned people are particularly vulnerable to UVR-related skin damage.

Procedure

Following approval from the administrating institution’s Human Ethics Committee participants were recruited in one of two ways. First, through flyers distributed to female sporting clubs and, second, through a snowball sampling technique wherein seed participants recruited other participants. Once a prospective participant expressed a willingness to participate in the study they were forwarded an information letter and a consent form. No participation inducement was offered. On receipt of a returned signed consent form from the participant and their parent, a date, time and venue for the interview was arranged.

Prior to the commencement of the interview all participants were informed of both their participatory rights and the interview procedure. At this stage, participants were given an opportunity to withdraw from the study, but none chose to do so. On completion of the first five interview questions each interview was halted and two Polaroid photographs were taken of the participant’s face. The first photograph was taken using a normal flash and the second photograph was taken using a reflex camera equipped with an UV-filtered flash and a black and white Polaroid film (see Figure 1). Polaroid photographs were used for their quickness of developing and because the UV-filtered flash light is absorbed by the skin’s melanin and visualises the blotchy/freckled/spotted pigmentation blemishes that have occurred to date as a result of prior chronic UV exposure. The photographs self-developed and were displayed side by side in front of the participant. Participants were informed that dark freckled areas in the UV photo were indicative of skin damage. The photos were then left in full view while the remaining six interview questions were asked (see Table 1).

Figure 1.

Examples of a normal and photoaged photographs: (a) photograph under normal light; (b) photograph under UV light.

Table 1.

Interview schedule.

Q#	Questions
Questions before viewing UV photoaged photograph
1	When you think about tanning, what does it mean to you?
2	What do you know about the dangers of the sun and using sun protection?
3	Can you tell me about your experiences with tanning?
4	What things do/did you consider when deciding to tan (not tan)?
5	In what way, if at all, does having a tan changes the way you see yourself?
Questions after viewing UV photoaged photograph
6	Looking at your photoaged and your ordinary photo what is your first reaction?
7	In what ways does the photoaged photo make you aware of the dangers of the sun?
9	Will your photoaged photo influence your decision to tan in the future?
10	In what ways does your photoaged photo change the way you see yourself?
11	Were there any other questions you wished I had asked?

All of the interviews were audio recorded and as soon as feasible after the interview the audio recording was transcribed verbatim.

Data analysis

Interpretative phenomenological analysis was independently utilised by two authors to discern reoccurring patterns within the interview data (40,41). These patterns were subsequently coded, clustered, abstracted and condensed into four themes and nine subthemes. Where coding disagreement occurred, the third author adopted an adjudicating role, thus ensuring the study’s interpretive rigour (42). Participant anonymity was ensured by not ascribing any tracking identifier (e.g. pseudonym, numeral or initial) to the quotes. In addition, participant quotes were amalgamated, shortened and temporally ordered (as indicated by a … marker) so as to eliminate repetitive or off-topic remarks.

Findings

The overarching theme that emerged from the analysis – Having a tan and looking good in the short-term is okay, however, in the longer-term you can end up looking far worse, but still a tan is worth it – captured female adolescent participants’ attitudes towards suntanning and comprises four themes and nine subthemes (see Table 2).

Table 2.

Themes and subthemes.

#	Theme	#	Subtheme
One	Positive body image and self-regard	1	I never want to be pale… brown looks much nicer
		2	When I’m tanned I just feel better about myself
Two	Social influences	3	People think darker skin is more attractive
		4	Celebrities all have brown skin
		5	Lying in the sun with my friends is a cool thing to do
Three	UV protection and skin-risk behaviours	6	Don’t get burnt and don’t ruin your skin
		7	I know tanning is wrong, but I still do it because I want brown skin
Four	A reality check	8	OMG it’s disgusting
		9	I didn’t realise I already had done so much damage

Participants’ interview responses pre-viewing their UV photoaged photograph

The first three themes and seven subthemes relating to participants’ views prior to seeing their facial photoaged photograph are expanded upon below.

Theme one: positive body image and self-regard

Subtheme 1: I never want to be pale… brown looks much nicer

Prior to viewing their UV photoaged photograph, participants consistently revealed a desire to change their skin colour from ‘pasty white’ to ‘brown’. They explained that this desire was predicated on a belief that bronze-brown skin enhanced their physical attractiveness as in their estimation it made their bodies look thinner, healthier and more radiant:

When I’m darker in summer… I don’t know why… but I think I look healthier, rather than washed out and pale.

When my skin looks darker… it makes me look more radiated and I reckon that’s better than being really white and pasty… I know it sounds weird, but I feel skinnier with a tan. I think my legs look more appealing in shorts.

The belief that being tanned was an appearance enhancer was something that participants stated first occurred in mid-adolescence. Indeed, some participants revealed that their desire to improve their physical appearance became at this stage all-consuming and tanning became addictive:

When I started hanging out with my friends at the beach I kind of started to tan. I noticed it looked better, so now I’m kind of addicted to it.

I tan to make my skin go darker. I’ll consider what parts of my body I want to get more tanned… like if I wear shorts I have to try and even up my tan lines.

Subtheme 2: when I’m tanned I just feel better about myself

Participants maintained that their suntanning experiences were overwhelmingly positive, for not only in their estimation did a tanned appearance improve their physical appearance, but it also increased their feelings of self-confidence. They related that the combinational effect of ‘liking’ their tanned skin and ‘feeling happy inside’ enabled them to exude a radiant ‘glow’:

When a person is tanned, not sickly white, but like just nice olive-skinned it makes you… kind of like glow.

No one really wants to be white … you feel better about yourself if you’re tanned. I don’t know why, but it gives you confidence and… the “glow”.

Theme two: social influences

Subtheme 3: people think darker skin is more attractive

Participants maintained that the act of acquiring a tan provided them with four specific social benefits. They contended that a tan allowed them to ‘fit in’ better within their peer-group, to feel confident about going out and showing off their body, to stand out in a crowd and to gain their peers’ attention/approval:

The idea of getting a tan is to make you look better for other people. Being tanned changes the way I see myself because I look my best and present well.

Colouring your skin… relates to having like a hot body… you feel good… and like going out more, wearing shorter dresses and showing off your tan.

While participants stated that acquiring a tan was an interest that they had first developed during their mid-teenage years, they revealed that there was an element of peer conformity pressure involved, not only in their decision to obtain a tan, but also to maintain a bronzed look:

I never used to really worry about it, I didn’t care if I wasn’t tanned, but now it’s like more expected.

Subtheme 4: celebrities all have brown skin

Participants stated their decision to maintain their brown-bronzed tan was further influenced by the media’s representation of highly desirable and successful models/celebrities in magazines and films as similarly being bronzed-skinned individuals. Participants explained that the media presentation of successful, attractive, healthy and happy people as being tanned individuals was something that they had internalised and led them to think that they needed to look tanned like them if they wanted to be liked like them:

I’ve only started tanning since I started high school… I guess mainly because all the media, celebrities and models in magazines have brown skin. I think it looks nicer. It makes me want to look like that.

Subtheme 5: lying in the sun with my friends is a cool thing to do

A strong perception existed among participants that media-depicted sun-related activities (e.g. sunbathing, swimming, surfing) were ‘cool’ leisure-time activities that popular people did. Hence, they tried to emulate the ‘brown-bronzed-look’ and ‘hung-out’ at the beach on weekends and during school holidays:

I guess at my age it’s kind of like a cool thing to do to sit with your friends and lay in the sun… You’re in the open and you’re free to do whatever… It’s relaxing and calming.

Theme three: UV protection and skin-risk behaviours

Subtheme 6: don’t get burnt and don’t ruin your skin

Whereas participants were able to name a range of skin-protective measures (e.g. applying 30+ sunscreen, wearing a hat, using sunglasses, keeping in the shade, smearing on zinc, covering up exposed skin), individually they tended to offer just two suggestions, the most common being the application of sunscreen. When asked to elaborate on why sunscreen was necessary, most participants responded that it was to prevent sunburn and melanoma:

You should put sunscreen on, and protect your eyes because it [sun] hurts your eyes… It gives you melanomas. You can die from melanomas spreading to your blood and around the body… Also, you age quicker… so keep out of the sun. Don’t get sunburnt… I don’t know much more than that.

Subtheme 7: I know tanning is wrong, but I still do it because I want brown skin

While participants had a basic understanding of how to protect their skin and why such protection was necessary, this knowledge did not inhibit them from deliberately engaging in suntanning activities. They proffered a variety of explanations as to why this was so. For instance, sunscreen ‘is too much effort’, ‘it’s only worth doing when I’m out in the sun for a while’, ‘it makes my skin oily’ and ‘I don’t get sunburnt very easily’.

Other reasons related to forgetfulness:

I don’t usually think to put sunscreen on until I’m getting burnt…it’s something I forget to do.

Appearance:

I don’t wear hats or long sleeve shirts… Burning is the cost of looking nice I guess.

And invincibility:

It doesn’t really seem like having melanomas could actually happen to you! I kind of have that mindset that skin cancer won’t happen to me.

Participants’ interview responses post-viewing their UV photoaged photograph

The fourth theme and the final two subthemes relating to participants’ views on sun-induced skin damage are detailed below:

Theme four: a reality check

Subtheme 1: OMG it’s so disgusting

The skin damage visible in their UV facial photoaged photograph became a reality check for participants as it helped them to understand that skin damage was not an abstract construct, but something that was real and, disturbingly, was happening to them. Indeed, the photographs elicited a range of emotive shocked exclamations, such as, ‘Oh my God, wow!’, ‘Eww!’, ‘So gross!’, ‘It’s so scary!’, ‘Oh yuk’ and ‘OMG (oh my God) it’s so disgusting!’.

Subtheme 2: I didn’t realise I already had done so much damage

Once participants had expressed their initial shock over the damage that had already occurred to their face, they then started to assess the extent of the damage. Typically, their assessment related to the physical nature of the skin damage:

It’s a shock because you’ve never really pictured yourself like that. It makes you more aware of what the sun does to your skin, especially your face! I know in the future I’ll have more skin pigments than I have at the moment.

Second, to the amount of damage:

There’s lots of damage, I didn’t actually think I’d have this much damage… It’s like all my freckles are highlighted and more applied. All my sun-damaged areas have just gotten a lot worse.

Third, to the ageing effect:

It kind of makes you aware of the damage…that wouldn’t have shown up until I’m older. I look like I’m 60…. my skin looks all scaly, with wrinkles and freckles. They’re on my forehead, my eyelids, my nose, my chin. I can’t believe how many freckles have shown up. I look like an old lady.

Fourth, to the inefficiencies of their past sun-protection practices:

Sunscreen doesn’t really work… maybe if I’d put a lot more on… It’s interesting even when I thought I was being sun-safe it wasn’t enough so obviously I need to do more… It’s good for people to be able to see what they’re going to look like… I didn’t realise how fast the sun damages your skin… I’ll think about it more now.

Even after viewing the damage, the photoaged photographic evidence was only sufficient to modify their tanning behaviours, not completely deter them. For example:

I’ll probably be putting on sunscreen and renewing it throughout the day. Also, because the skin on my face is like hell sensitive, I’ll be putting a shirt on my face while I’m tanning so it’s not affected as much…I know I should cover-up and I shouldn’t tan, but I still think it’s more attractive to have a tan.

Such comments were encapsulated in the study’s central theme: Having a tan and looking good in the short-term is okay, however, in the longer-term you can end up looking far worse, but still a tan is worth it!

Discussion

Prior to viewing the UVR damage visible in their UV facial photoaged photographs, female adolescents considered suntanning to be a positive means of enhancing their physical appearance. They claimed that the healthy ‘glow’ their tanned skin radiated enabled them to stand out in a crowd and, in the process, increased the amount of attention they received from their peers. This increased attention had the effect of affirming their social status within their peer group and enabled them to ‘fit in’ and to ‘hang-out’ with an expanded friendship group, which, in turn, helped raise their self-confidence and self-esteem. For some females, peer admiration of their tanned appearance was so rewarding that suntanning became a consuming/addictive aspect of their adolescent lives (see 36,43). While other studies have similarly reported female adolescents engage in suntanning to enhance their appearance (see 16,44 –46), this study extends this knowledge by detailing three additional suntanning motivations, namely, a) to change their skin’s colour, b) to control how they are physically presented to others and c) to enhance their social standing.

The participants’ desire to change their skin colour from ‘pasty white’ to ‘bronzed-brown’ is an interesting and evolving social phenomenon. One which gives rise to the question: What is driving the Australian adolescent female desire for a ‘bronzed-brown’ look? For it marks a shift away from the quintessential lighter beach-bronze surfer look. Perhaps it may be that this shift is occurring because in recent decades Australia has become a more multicultural society in which students from different races and ethnicities are commonplace within its school system. In which case, it could be that the participants’ desire for ‘bronzed-brown’ skin is an indicator of greater social inclusion. Or, maybe their willingness to adopt a bronzed-brown skin colouring is just a superficial fashion trend? Or, possibly a consequence of greater racial variance in teen image marketing and the portrayal of celebrities/models in the wider media (see 47,48)? Calder and Aitken (47) suggest that the adolescent desire to emulate images of suntanned models/celebrities is driven by an inner desire to belong. To better understand and alter the centrality of the belonging desire in suntanned adolescent females’ lives, then future research ought to investigate how adolescent girls who do not suntan gain peer-group acceptance, as this would provide insights into what other pathways to social inclusion could be promoted as an alternative to suntanning.

Finally, given that a few adolescent females in this study remarked that their suntanning activities were addictive, this self-assessment of their suntanning behaviour raises the possibility that in severe cases a preoccupation with suntanning might be consistent with the diagnostic criteria for body dysmorphic disorder. This disorder typically develops in adolescence, is characterised by an intrusive preoccupation with appearance, a constant comparison of an aspect of one’s bodily appearance with the same aspect in others and repetitive attempts to overcome a perceived appearance flaw (49). Clearly, this is an area of research that requires further investigation.

Conclusion

The Health Action Process Approach (50) suggests that the process of changing health behaviours generally occur in two stages (51). The first being the initial stage when people become motivated to change their existing non-healthy behaviours and the second stage when they move from the cerebral intention phase to the action (post-intention) phase. This model has been previously successfully used by Craciun et al. (51) to explain sun-screen use among women. However, it is interesting to note that in the present study with female adolescents, although mentally aware that they needed to protect their skin in order to prevent skin damage and skin cancer, they typically only adopted two protective measures (i.e. sunscreen and one other). A tendency that has been noted also by McLoone et al. (4). They surmised that a disconnection exists between adolescents’ knowledge of skin-protective measures and their willingness to apply them. While female adolescents in this study detailed several previously documented sunscreen-application barriers, they also revealed a lesser-recognised barrier, namely, a belief in their own invincibility. Of all the known barriers to adolescent skin protection, it is likely that this invincibility barrier could be one of the hardest barriers to counteract. Primarily, because the majority of the interviewed teenagers had not yet been touched by skin cancer, so the risk of melanoma was perceived to be something that happened to other people and to other people’s families and not to them and their family (18). This finding concurs with a recent study conducted by Woodgate et al. (52) which examined the cognitive strategies adolescents use to assess their cancer risk in terms of their lifestyle choices. They surmised that adolescents justify their involvement in health-risk behaviours in light of the short-term benefits they provide, and that these benefits outweigh any long-term negatives.

It is interesting to note that Williams et al. (29), in their systematic review and meta-analyses of appearance-based interventions for reducing UV exposure and increasing sun protection, did not identify any significant differences in intervention effectiveness between the 11 studies that were guided by a theoretical model/theory (e.g. Trans-theoretical Model [x1]; Prototype Willingness Model [x2]; Prototype Model of Health Behaviour [x1]; Health Belief Model [x5]; Protection Motivation Theory [x4]; Jaccard Behavioural Alternative Model [x1]; Prospect Theory [x1]; Social Comparison Theory [x1];Theory of Planned Behaviour [x3]; Theory of Alternative Behaviour [x2]; and Theory of Reasoned Action [1]) and the six studies that were not. It would seem that appearance-based interventions in general are effective with young females. However, future sun-protection intervention research might seek to determine whether appearance-based intervention that also includes a component on adolescent females’ belief in their own invincibility (i.e. melanoma is something that happens to other people) are more effective in reducing the incidence of malignant skin cancers in this age cohort than are appearance-based interventions without an invincibility component (17).

Footnotes

Declaration of conflicting interests

None declared.

Funding

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

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