Spot of Sun
South East London Cancer Network’s Spot of Sun campaign aimed to raise awareness of the risk factors associated with the development of skin cancer and the early signs of skin cancer, and to promote risk-modifying behaviour among four at-risk groups: sunbed users, young male sun lovers, over-50 male sun lovers, and parents of school-age children.
Alongside a multimedia campaign that included ‘mirror stickers’, posters, leaflets and a dedicated website, the campaign used the concept of ‘hit squads’, which had successfully been employed in previous campaigns to approach the target groups and have one-on-one discussions about detecting and preventing skin cancer.
- Increase in respondents who had seen or heard an advertisement about prevention or detection of skin cancer in the last 3 months, from 11 per cent to 22 per cent
- 28 per cent increase in respondents who know that young people who use sunbeds increase their risk of skin cancer
- Over a third (36 per cent) of those who had seen the campaign had already taken action as a result, and of these 7 per cent had stopped using sunbeds or had cut down their visits
Skin cancer develops when cells in the skin become damaged from the sun or sunbed use and the body cannot repair them. There are two types of cancer: non-melanoma skin cancer, which is very common, and malignant melanoma, which is less common but more serious. In 2007, 10,672 new cases of malignant melanoma were diagnosed in the UK.
If detected early (stage one – the tumour is thinner than 2mm or less than 1mm thick but ulcerated), malignant melanoma can be removed under local anaesthetic. The estimates of 5-year relative survival for patients diagnosed in 2001 to 2006 is 81 per cent for men and 90 per cent for women, and the survival rates are better for people diagnosed early with the thinnest tumours.
Over the last 30 years, the incidence of malignant melanoma has increased more than for any other common cancer in the UK. Although the rates of skin cancer are highest in the over-70s, there is a substantial number of cases at younger adult age. Almost a third (30 per cent) of all cases occur in people aged less than 50 years and in the age group 15 to 34 malignant melanoma is the second most common cancer.
The South East London Cancer Network (SELCN) covers Southwark, Lewisham, Lambeth, Bromley, Bexley and Greenwich. The total London registrations for malignant melanoma in 2006 was 2,188, and for the 6 boroughs of the SELCN was 1,070. The figures for the primary care trust (PCT) areas of South East London for the period 2004 to 2006 are:
- NHS Bromley – 239 cases
- Bexley Care Trust – 218 cases
- NHS Lewisham – 200 cases
- NHS Greenwich – 165 cases
- NHS Lambeth – 138 cases
- NHS Southwark – 110 cases
The SELCN was concerned about the rates of malignant melanoma in the six boroughs and was keen to tackle sunbed usage and to target those with other risk behaviours known to increase the likelihood of skin cancer.
Objectives and behavioural goals
Social marketing agency Corporate Culture was appointed in November 2008 to work with the SELCN team to develop an initiative, informed by research, which would:
- Raise awareness of risk factors associated with the development of skin cancer
- Raise awareness of early signs of skin cancer
- Promote risk-modifying behaviour
The specific behavioural goals were identified as:
- Not using or stop using sunbeds
- Wear at least factor 15 sunscreen when out in the sun
- Cover up and wear a hat when out in the sun
- Spend time in the shade between 11am and 3pm
- Check for warning signs of skin cancer and see a GP as soon as any warning signs are found
The Thames Cancer Registry data (latest figures from 2004 to 2006) was assessed to identify the incidences and mortality rates from skin cancer in each South East London PCT area. It was found that in each of the PCT areas, the highest incidences and mortality was amongst males aged over 50.
Previous campaigns targeting skin cancer were analysed, including assessments of the strengths and weaknesses of the following initiatives:
- SunSmart (Cancer Research UK)
- The SAFE campaign – Skin Awareness For Everyone (Institute of Cancer Research and Superdrug)
- B.A.D – Sun Awareness Campaign (British Association of Dermatologists)
- Australian Protect Yourself campaign
- American Protect The Skin You’re In campaign (Marc Jacobs)
- Blackpool’s Health Visitors’ Shun the Sun campaign
- Waveney District Council and Lowestoft Air Show, SunSmart
This research showed that the use of personal interventions were particularly successful for changing behaviours to avoid risks of skin cancer. The use of ‘hit squads’ had been successfully employed in a number of locations. This involves trained personnel who engage with at-risk groups using a friendly approach, gently talking about the issue of skin cancer and using supporting information.
Analysis of the national Target Group Index (TGI) consumer database was conducted to gain understanding of wider lifestyle behaviours and media habits of possible key audiences.
One-to-one clinical stakeholder interviews with members of the Network Skin Cancer Tumour Working Group (also known as the Network Site Specific Group) were conducted to gain anecdotal feedback on their views of the main risk behaviours.
Six focus groups were conducted with residents of the six PCT areas to identify attitudes, behaviours, influences, motivators and barriers to action. These focus groups, alongside the TGI analysis, identified three at-risk groups, with specific behaviours and attitudes towards skin protection in the sun.
Lifestyle and influences:
- Generally younger females
- Very body conscious
- Heavily influenced by celebrities and fashion
- Spend free time socialising and shopping
Attitudes and behaviours regarding health, skin protection and tanning:
- Only concerned with what will happen now and not what will happen in the long term
- Only worried about their health in the context of the impact it might have on the way they look
- Will never give up their tan, which is much more than an outward display – it changes the way they feel about themselves, what they can wear and how they behave
Sun lovers – young men
Lifestyle and influences:
- Chauvinistic, like to take risks and do not believe in rules
- Like to socialise, drink (often binge drink) and go out
- Body conscious
Attitudes and behaviours regarding health, skin protection and tanning:
- Like being out in the sun, but are light or non-users of sunscreen (they believe it is not hot enough in the UK to need to use sunscreen)
- Consider themselves fit and healthy
- Fatalistic about health issues
- Generally avoid seeing a doctor
- Like sunbed users, they are only concerned with the here and now
Sun lovers – males over 50
Lifestyle and influences:
- Many are retired
- Take lots of holidays
- Spend much of their time outdoors in a range of activities from walking to gardening
Attitudes and behaviours regarding health, skin protection and tanning:
- Have direct experience of health issues and it is high on their agenda
- Often check their body for warning signs of illnesses or conditions
- Have changed their behaviour and lifestyle regarding health, for instance drinking less, giving up smoking and trying to get more exercise
- Leave it to their partner to sort out sunscreen
- Generally feel it is not macho to use sunscreen, although they do when abroad
Through discussions with SELCN it was agreed that the campaign would also target parents of school-age children, to give them advice on how to protect children in the sun. While the pre-campaign research showed that parents were very aware of protecting their children, it was felt that targeting this audience on the back of the wider campaign would work well.
Subsequently, advice was obtained by local authority Personal Social and Health Education (PSHE) leads in South East London, which identified using peer-to-peer messaging and influential figures like sport teachers and professionals to disseminate messages.
- Perception that the UK sun is not strong enough to cause skin cancer
- Wanting a tan (sunbed users and young male sun lovers)
- Only care about the here and now, rather than health risks in the future (sunbed users and young male sun lovers)
- Using sunscreen perceived as not macho (young male sun lovers and male over-50 sun lovers)
- Partners ‘deal with’ sunscreen (male over-50 sun lovers)
600 street questionnaires were completed in February and March 2009 across the 6 PCT areas (100 in each) to cross-reference attitudes and behaviours demographically and by borough.
All groups believed there was not much chance of getting skin cancer in the UK. Apart from the older group, knowledge of skin cancer was fairly limited and it was considered to be a less serious skin cancer than others. The majority did not believe you could die from skin cancer, and that any treatments were simple as the disease is only ‘on top’ of the skin. Results included:
- One in five do not use sunscreen, or use only a low factor on a beach holiday
- Over half do not apply sunscreen when playing outdoor sport
- 68 per cent do not apply sunscreen when working outdoors and 42 per cent do not protect themselves when at leisure outside (like shopping, gardening or barbequing)
- Almost everyone knew that a change in shape or size of a mole could indicate the presence of skin cancer
Results by PCT area
Percentage that never checked their moles:
- Bromley – 27 per cent
- Bexley – 22 per cent
- Greenwich – 20 per cent
- Lewisham – 20 per cent
- Southwark – 8 per cent
- Lambeth – 7 per cent
Percentage that are ‘not concerned’ or ‘not really concerned’ about skin cancer:
- Lewisham – 53 per cent
- Greenwich – 43 per cent
- Bromley – 41 per cent
- Bexley – 37 per cent
- Southwark – 29 per cent
- Lambeth – 20 per cent
Pretesting messages and images
Campaign messages and images were tested through the 600 street questionnaires. Respondents stated the appearance of a mole or scarring on a face was the most effective image for making them consider changing their behaviour. This was particularly the case for sunbed users and young male sun lovers.
The street questionnaires had identified that images of cancerous moles or scarring in the facial area was deemed most effective by sunbed users and young male sun lovers. Despite being relatively controversial, SELCN agreed that this ‘shock’ approach was appropriate for the younger audience, while a more traditional approach would be employed for the older audience and parents.
A former actor from the Hollyoaks television series, who had been diagnosed with skin cancer following excessive use of sunbeds, was approached to endorse the campaign aimed at sunbed users and young male sun lovers.
After consulting with clinical professionals the team decided to use images of cancerous moles from actual patients, superimposed onto the facial area of models. Based on this imagery the brand name ‘Spot of Sun’ was developed, with modifications for each target group: ‘spot the sunbed user’ and ‘spot the sun lover’. For sun lovers (males over 50) and for parents of school-age children images of the target audience and their lifestyle (such as older males gardening and young children playing in the sun) were used instead.
SELCN or NHS branding was kept to a minimum, based on findings from previous campaigns which found that people were more likely to engage if they were not immediately aware that they were being targeted as part of a health initiative.
In addition, Cancer Research UK (CRUK) was consulted to ensure all messages were in line with national campaigns.
These images and messages were used on:
- Posters in nightclubs and bars, including mirror stickers so that reflections showed people with a cancerous mole on their face (aimed at sunbed users and young male sun lovers)
- Leaflets – Distributed at events and through 75 pharmacies within the Network
- The Spot of Sun website, outlining skin cancer awareness and prevention information and signposting to CRUK’s website
Materials were translated into the five most used languages in South East London (besides English).
Based on the success of personal interventions and hit squads in previous campaigns, these tactics were employed and tailored to the four at-risk target audiences:
- Hit squads wearing branded T-shirts approached people in key shopping areas on 18 days to discuss skin cancer awareness and prevention (over 5,000 people were approached)
- A street theatre performance highlighting the risks of sunbed use was delivered and posted on YouTube
Young male sun lovers
- Hit squad teams wearing branded T-shirts approached people in parks and eating places on 18 days to discuss skin cancer awareness and prevention and give away Sun Lover hats (over 8,000 people were approached and 2,000 ‘sun lover’ hats given away)
- Over 400 photographs of men wearing Sun Lover hats were uploaded to the Spot of Sun website
Male over-50 sun lovers
- Clinical and non-clinical staff from SELCN and the Spot of Sun hit squad team attended one major event in each of the six boroughs in 2009:
- Woolwich Great Get Together, 20 June
- Biggin Hill Air Show, 27 and 28 June
- Bexley Danson Festival, 4 and 5 July
- Lewisham Peoples Day, 11 July
- The Event, Southwark, 11 July
- Lambeth County Show, 18 and 19 July
- Branded deckchairs were laid out at the events
- Sunscreen samples and stickers were given away to children
Parents of school-age children
- Campaign packs were distributed to 395 primary schools, including free sunscreen samples, posters and leaflets for parents, stickers and CRUK SunSmart lesson plans
- Leaflets were distributed to 87 sports clubs who agreed to give ‘health briefings’ to young people, including Charlton, Crystal Palace, Millwall and Fulham Football Clubs, and The Oval and Kent County Cricket Club
- A DVD of a school performance about the dangers of sunbed use performed by Bexley Heath school was edited and sent to each secondary school in the area and uploaded onto the Spot of Sun website
The campaign was rolled out during the summer of 2009, between April and August.
While the research had shown that sunbed users in particular were influenced by celebrity, it was unclear whether the use of a celebrity added value to the campaign, since disappointingly this did not (in itself) gain extensive media coverage. It is likely that celebrity endorsement will only have an impact if the celebrity is very famous.
The use of hit squads where residents were engaged on a one-to-one basis proved to be very successful. The team’s attendance at events was particularly beneficial, because residents had time to stop and discuss issues.
The use of hit squads in town centres did have a key benefit in being flexible in terms of locations and times. The freedom to roam meant the hit squads could find the busiest places depending on the day of the week, time of day and the surrounding areas. The hit squad teams found shopping areas with tanning salons, hairdressers and similar settings particularly effective for reaching the target audiences. Planning hit squad days does however need to be as flexible as possible, since the success of this outreach activity is highly dependent on the weather.
In addition, the use of freebies (sun lover hats and sunscreen samples, and stickers for children) was a simple and effective way of attracting people’s attention and enabling non-threatening conversations to be started.
CRUK released a number of press initiatives over the campaign period, which may have detracted from the Spot of Sun campaign. While CRUK was consulted on the campaign’s messaging and the Spot of Sun website signposted visitors to the CRUK website to ensure consistency and avoid duplication, it would have been better to have coordinated with the CRUK press office, so that the Spot of Sun team could be aware of their press releases in advance.
While the YouTube posting was an interesting use of social networking media, the download rate was low for the Spot of Sun campaign videos. While such methods may have a place for health initiatives focused on young people, it did not seem to add much value to this campaign, especially with some target audiences being from older groups.
The initial 600 street questionnaires gave a benchmark of residents’ attitudes, awareness and behaviour regarding skin cancer. Following the Spot of Sun campaign a further 600 street questionnaires were conducted to measure change.
- 11 per cent of regular sunbed users had seen the campaign
- The proportion of respondents who had seen or heard an advertisement about prevention or detection of skin cancer in the last 3 months doubled, increasing from 11 per cent to 22 per cent
- 10 per cent of people aged 50 to 69 years had seen the campaign
Changes in attitudes
- Increase in respondents who know that young people who use sunbeds increase their risk of skin cancer (from 40 per cent to 68 per cent)
- Increase in respondents who now believe that skin cancer treatment can cause scarring (from 26 per cent to 54 per cent)
- Increase in respondents who know that skin cancer is the second most common cancer in young adults (from 27 per cent to 49 per cent)
- Increase in respondents who ‘strongly agree’ that using sunbeds often can cause skin cancer (from 44 per cent to 62 per cent)
- Increase in respondents who disagree that skin cancer is easy to treat and nothing to worry about (from 52 per cent to 68 per cent)
- Increase in respondents who agree that getting sunburnt as a child increases your risk of skin cancer (from 23 per cent to 38 per cent)
- Increase in respondents who ‘strongly agree’ that protecting yourself against the sun will reduce your risk of skin cancer (from 49 per cent to 63 per cent)
- Increase in respondents who disagree that ‘you can’t get skin cancer from the UK sun’ (from 75 per cent to 85 per cent)
- Over a third (36 per cent) of those who had seen the campaign had already taken action as a result (including checking their skin more often, using higher level sun protection and protecting their children more) – of these, 7 per cent had stopped using sunbeds or had cut down their visits
- Nearly a fifth (19 per cent) of those who had seen the campaign no longer ‘stay in the sun as long as possible’
- Those who had seen the campaign were more likely to use sunscreen, with 29 per cent using it all the time on their face, versus 10 per cent of those who had not seen the campaign
- The percentage of those who reapply sunscreen all the time or quite often rose from 67 per cent to 80 per cent
- Those who no longer rely on clothes alone as sun protection when playing outdoor sport rose 13 per cent
SELCN recommended that individual PCTs continue to target residents identified as at-risk over the next two to three years. Each PCT was written to with a personalised sustainability plan and recommended budget of between £2,000 and £5,000 which they should allocate to the campaign in the following year’s commissioning plans (2010 to 2011).
Many of the campaign resources are still held by SELCN, including leaflets, posters, stickers, scripts for hit squads, branded deckchairs and exhibition panels, which are available to the PCTs on request. In addition, the Spot of Sun website address is owned by SELCN and contains a simple content management system that allows web statistics to be collected.
In October 2009, SELCN was invited to the first National Cancer Action Team Skin Cancer Prevention event to showcase the Spot of Sun campaign and offer advice to other networks and PCTs about to embark on skin awareness campaigns. In addition, the Spot of Sun campaign is showcased on the Corporate Culture website.
SELCN’s Spot of Sun campaign was commended in the Best Campaign category at the 2009 National NHS Communication Awards.
Narrowing a campaign’s focus to a few key target audiences and tailoring interventions accordingly is essential for a campaign to have real impact. This campaign did well in identifying target audiences, but by choosing four rather than one at-risk group may have diluted the campaign, especially due to the limited budget. If the campaign had chosen one target audience, for instance sunbed users, it may have had a bigger impact on the behaviour of this one group, although wider campaign awareness would not have been as great.
Timeframes and planning
This campaign was rolled out on a tight timeframe, with the pre-campaign research carried out in February and March and the campaign going live in April. This at times made booking key sites for events difficult. For future initiatives more time will be allocated for planning, with at least three months from the start of the pre-campaign research before the launch of a campaign.
The use of personal interventions in the form of hit squads was very successful, but make sure that hit squad personnel are well recruited and trained – detailed ‘scripts’ are developed (to make sure that no clinical advice is given) and if possible ‘mystery shoppers’ are used to anonymously check for quality control.
It is very important to attain and maintain stakeholder engagement throughout the life of a campaign and is vital for the sustainability of campaigns through other organisations (in this case particularly individual PCTs). Ensuring good stakeholder engagement also increases the likelihood of social marketing skills being transferred to local staff, which will aid future campaigns.