Public Health 123 (2009) e6e10

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Guidelines for the development of social marketing programmes for sun protection among adolescents and young adults
K.M. Johnson a, *, S.C. Jones a, D. Iverson b
a b

Centre for Health Initiatives, University of Wollongong, Northelds Avenue, Wollongong, NSW 2522, Australia Health and Behavioural Sciences, University of Wollongong, Wollongong, NSW 2522, Australia

a r t i c l e i n f o
Article history: Received 24 October 2008 Received in revised form 9 June 2009 Accepted 29 June 2009 Available online 13 September 2009 Keywords: Social marketing Sun protection Guideline process Delphi process

s u m m a r y
Objectives: To formulate best practice guidelines for social marketing programmes for adolescents and young adults sun protection. Study design: A Delphi consensus process. Methods: Eleven experts in sun protection and social marketing participated in a Delphi consensus process, where they were asked to provide up to 10 key points, based on their knowledge and practical experience, which they felt were most important in developing social marketing interventions for the primary prevention of skin cancer among adolescents and young adults. After reaching consensus, the evidence base for each guideline was determined and graded via the Scottish Intercollegiate Guideline Network grading system. Participants were then asked to indicate how strongly they rated the nalized 15 recommendations based on all aspects relating to their knowledge and practical opinion, as well as the research evidence, on a visual analogue scale. Results: The resultant 15 guidelines offer general principles for sun protection interventions utilizing a social marketing approach. Conclusions: This method of guideline development brought the expertise of practitioners to the forefront of guideline development, whilst still utilizing established methods of evidence conrmation. It thus offers a useful method for guideline development in a public health context. 2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.

Introduction There is increasing recognition of the importance of practice guidelines to assist decision making in health areas.1 However, while the development of guidelines has been largely standardized within a clinical context, a number of debates arise when transferring clinically originated methods into a public health arena. These debates centre on the low rating of much of the evidence, due to the difculty in evaluating public health interventions with randomized controlled trials; the use of systematic reviews in public health, whereby the context within which public health interventions are developed and implemented is removed; and how best to incorporate one of the major sources of information that inuence programme decisions that of peer and colleague opinion into traditional, hierarchical grading systems. This paper outlines a process to formulate best practice guidelines for social marketing programmes for adolescents and

young adults sun protection. This method of guideline development aimed to bring the expertise of sun protection and social marketing practitioners and academics to the forefront, whilst still utilizing established methods of evidence conrmation to establish relevant, evidence-based guidelines in the most usable form to aid decision making by practitioners. Sun protection among adolescents and young adults Adolescence and young adulthood is a time of risk behaviour with regards to sun protection. Rates of sun protection among adolescents are generally the lowest for any age group, and while the sun protection behaviours of young adults improve on adolescent gures, they continue to be poor in comparison with older groups.2,3 In a systematic review of sun protection interventions in all populations, Saraiya et al. (2004)4 concluded that there was insufcient evidence to determine the effectiveness of sun protection interventions in secondary schools and colleges. This lack of evidence for effectiveness is indicative of relatively few interventions in these settings over the past 25 years, especially in the case of secondary schools, but is also due to the lack of

* Corresponding author. Tel.: 61 2 4221 5811; fax: 61 2 4221 3370. E-mail address: kmj93@uow.edu.au (K.M. Johnson).

0033-3506/$ see front matter 2009 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.puhe.2009.06.018

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interventions with control or comparison groups. This leaves many programmes unsuitable for use in quantitative analysis. Thus, there has been limited guidance for practitioners on the most effective ways to develop programmes for this demographic. The current study aimed to ll this knowledge gap by utilizing a Delphi consensus process and systematic review to provide guidelines that could bridge the divide between evidence and experience. Good practice for social marketing While social marketing has had limited use within skin cancer primary prevention, it has had much wider use in public health areas of smoking cessation, healthy eating, drug use and physical activity promotion.5,6 In the main, these interventions are characterized by the use of communication campaigns targeted at large audiences; this has led many people to see social marketing as predominantly concerned with promotional and advertising strategies.7 However, a communication campaign is only one component of the marketing mix. To increase the understanding of social marketings core principles and provide a framework for the development and evaluation of social marketing interventions, the UKs National Social Marketing Centre (NSMC) has expanded on previous criteria developed by Andreason (2002)8 to create eight benchmark criteria which they consider to be essential elements of a social marketing process. These core elements are: (1) a customer orientation; (2) a clear focus on behaviour; (3) the use of behavioural theory to inform and guide development; (4) a focus on understanding and insight into what moves and motivates the customer; (5) the incorporation of an exchange analysis which analyses the cost to the consumer in achieving the proposed benet; (6) the consideration of internal and external competition; (7) the use of segmentation; and (8) the use of an appropriate methods mix.9 While the authors of these guidelines state that they should not be used as a guide to the how to of process in social marketing, they do suggest the criteria as a framework for good practice. The guidelines from the Delphi process are, therefore, discussed in terms of this framework. Attempts to help practitioners to develop sound social marketing initiatives have been developed by other countries, such as Canada.10 Methods Eleven experts identied from the elds of social marketing and sun protection participated in a Delphi consensus process, as outlined by Roddy et al. (2006),11 with the aim of developing evidenceand expert-based guidelines for the development of social marketing sun protection programmes for adolescents and young adults. This method can be dened as a group facilitation technique that seeks to obtain consensus on the opinions of experts through a series of structured questionnaires.12 Delphi consensus process Participants were initially asked to provide up to 10 propositions, based on their knowledge and practical opinion, which they felt were most important in developing social marketing interventions for the primary prevention of skin cancer among adolescents and young adults. Responses were collated and grouped according to similar themes via content analysis, but were not edited. Additional recommendations were developed from combined responses, and were identied as such to participants. Rounds 25 were conducted with the researcher analysing recommendations to show the percentage of agreement for each recommendation. From Round 4, those recommendations with less

than 25% agreement were rejected, with those over this percentage returned to participants. Round 5 concluded with 15 guidelines with over 50% consensus support. The rst author determined the evidence base to support each recommendation, utilizing a previously conducted systematic review (Johnson, unpublished work). This evidence came from 23 identied primary prevention interventions targeting sun protection in adolescent or young adult populations that contained some quantitative measure of effect size on one or more of seven behavioural outcome measures, such as the use of sunscreen, hat wearing or incidence of sunburn. The review included study designs rated as lower on the evidence hierarchical table, such as pre and post test, and post test with control group, as well as randomized and non-randomized control group designs. The evidence was graded using the Scottish Intercollegiate Guideline Network grading system.13 Two additional research papers were included for strength of recommendation (SOR) as they provided mediational analyses on interventions already included in the systematic review, and were used to provide extrapolated evidence to support a specic guideline. Supplementary literature provided the context for recommendations but was not included in SOR. Participants were asked to indicate how strongly they rated the nalized 15 recommendations based on all aspects relating to their knowledge, opinion and practical experience, as well as the research evidence. This was recorded using a 10-point visual analogue scale (VAS) anchored with two descriptors labelled not recommended at 0 and fully recommended at 10. The mean VAS and standard deviation were calculated for each recommendation, and presented via a table with groupings according to a traditional SOR, mean VAS and 95% condence interval. The list of recommendations was sent to participants with available evidence and traditional SOR grading provided. Finalizing the guidelines The Cancer Council of New South Wales (TCCN) sun protection staff were involved in early development of the Delphi process, and consulted before nalization of the guidelines in order to format the end product into the most usable form for practitioner use. This resulted in a document providing each guideline with background information and the reference to the initial Delphi analysis relating to each guideline, in addition to the SOR and VAS scores. The TCCN sun protection team reasoned that the enhanced background information would allow more informed decision making around the framework provided by the established guidelines. As this study was part of a larger project with the ultimate aim of conducting a social marketing sun protection intervention for an adolescent market, this guideline document is currently being used by TCCN in the development of this intervention. Results Table 1 shows the nalized recommendations in order of decreasing VAS score, which indicates the Delphi panels rating of each recommendation. As shown in Table 1, the guidelines cover recommendations on general structure (Guideline 9), settings (Guideline 11) and timing of interventions (Guidelines 13 and 15), the importance of formative research (Guideline 1) and segmentation (Guideline 6), and the need for strategies to target: (1) the competition to sun protection that comes from the social norms surrounding tanning and sun protection (Guidelines 3 and 7); (2) perceived self-efcacy (Guideline 2); and (3) skin damage concerns in addition to skin cancer (Guideline 4). Additional recommendations stated the need for policy (Guideline 8) and environmental (Guideline 10) strategies, the use of a broad range of communication

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Table 1 Guidelines for the development of sun protection interventions for adolescents and young adults. Recommendation Category of evidence (14) Strength of recommendation D Strength of recommendation (VAS) Mean (CI) 9.16 (8.349.99)

Guideline 1. Formative research is essential early in programme development in order to gain a deeper understanding of the self-interests of the target market, and the motivators and barriers to sun protective behaviour. This allows strategies and messages to be developed from the target audiences perspective; similarly, pretesting of resource material is also critical to conrm its acceptability to the target audience. Guideline 2. Sun protection programmes for this target group need to promote their perceived self-efcacy for sun protection by showing how sun protection can t into current lifestyle and fashion choices, and offering specic strategies to incorporate sun protection into their daily lives. Guideline 3. Sun protection programmes for this demographic need to have a deep understanding of the competition to sun protective behaviours that comes from the social norms and attitudes surrounding tanned skin, and consider strategies and messages to counter this competition. Guideline 4. Programmes should emphasize more direct outcomes such as skin damage (wrinkles, aging) and sunburn, rather than the indirect outcomes of skin cancer for this demographic; however, reference should still be made to skin cancer outcomes as fear is still a strong motivator for behaviour change. Guideline 5. Utilize a broad range of communication channels incorporating paid and unpaid components in order to strengthen message dissemination. While television is still the most powerful motivator, people in this demographic are also frequent users of new media. Guideline 6. Segmentation of the target market is necessary in order to tailor messages and strategies. Age segmentation is essential, but programme developers should also consider segmentation based on gender, attitudes and behaviour, perceived benets and barriers, and/or risk. Guideline 7. The changing of social norms regarding the desirability of a tanned appearance is essential for achieving whole-of-life sun protection behaviour. Such messages/strategies need to be directed both within and outside the adolescent/young adult target groups. Within the target group, possible strategies include the targeting of group norms where changing the behaviour of a few individuals might ultimately inuence the behaviour of many. Groups might be dened based on sports teams, clubs or simply groups of friends. Guideline 8. Programmes should pursue policy change and regulation where possible. This includes public policy, e.g. no sales tax on sun protective clothing or solarium regulation; and organizational policy, e.g. the scheduling of school sport during low ultra-violet periods. Guideline 9. Sun protection programmes for this demographic should take a holistic approach with long-term commitment. This necessitates multicomponent, multi-setting approaches inclusive of the wider community. Guideline 10. Sun protection programmes for this target group need to look at environmental strategies such as the provision of shade and provision of sunscreen at settings that pose a risk to this group. However, these must be provided in a manner that optimizes their usage; that is, the provision of shade will not optimize sun protection without attention to the social amenity within shaded space. Guideline 11. Programmes should target their audience at various settings that pose a sun exposure risk for this demographic. As much sunburn is incidental, this should include non-beach/pool situations. Guideline 12. Relationships with stakeholders and potential allies need to be developed to potentiate message dissemination; this can include parents, teachers, sports coaches, media/celebrity gures etc. Think imaginatively in terms of potential partnerships; possible relationships could come from the cosmetics/sunscreen or fashion industries. However, care needs to be taken not to compromise message and strategy direction. Guideline 13. Sun protection programmes should be implemented at various stages throughout adolescence, especially at developmental transitions such as the move from primary (middle) school to high school, or the move from high school to university, as these are times of decreasing parental inuence and changing peer and media inuences, which can result in increased risk behaviour. Guideline 14. To achieve behavioural change, the new behaviour being marketed needs to be easy, fun and/or fashionable; e.g. easy application of sun cream, hats considered fashionable. This necessitates focused, ongoing attention to the products (sunscreen, hats and clothing) necessary for sun protection. Guideline 15. As a large proportion of sunburn occurs because people forget to apply or re-apply sunscreen, or to take a hat or umbrella, or forget how long they have been in the sun, much of the communication strategy should be reminder communication utilizing avenues such as Friday afternoon radio and weekend media. VAS, visual analogue scale; CI, condence interval.

Expert opinion

Extrapolated evidence from two studies22,23 Expert opinion

C/D

8.75 (8.239.28)

8.72 (8.199.26)

Systematic review1421

8.44 (7.629.25)

Expert opinion

8.25 (7.059.44)

Expert opinion

8.09 (7.478.71)

Extrapolated evidence from one study22; expert opinion

8.03 (7.118.94)

Expert opinion

7.84 (6.938.76)

Expert opinion

7.84 (6.409.28)

Expert opinion

7.71 (6.838.59)

Expert opinion

7.68 (6.628.74)

Expert opinion

7.36 (6.448.29)

Expert opinion

7.22 (5.948.52)

Expert opinion

6.96 (6.027.91)

Expert opinion

6.34 (5.257.42)

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channels (Guideline 5), and focused ongoing attention on the products necessary for sun protection (Guideline 14). Discussion Social marketing is an iterative process. Its planning framework encourages development and constant adaptation of interventions based on ongoing research. Guidelines emerging from the project, therefore, represent general principles for social marketers targeting the sun protection behaviours of adolescents and young adults, and should be utilized as such. As for all social marketing, specic strategies and messages should be developed based on formative research and rigorous pretesting of materials to tailor interventions to specic contexts and audiences. While many of the guidelines are not specic to a social marketing approach, they indirectly acknowledge social marketings emphasis on customer orientation and focus on behaviour change, as well as exchange theory and the use of the marketing mix. Other core social marketing elements are represented specifically, such as: insight in the use of formative research to devise, monitor and revise campaigns (Guideline 1); the use of market segmentation (Guideline 6); and an emphasis on competition (Guideline 3). At a macro level, the guidelines stress the need for sun protection strategies to show how sun protection can t within this target markets lifestyle, as well as recognizing the strong competition to sun protection which comes from the social discouragement of social norms surrounding tans, and competition from apathy which manifests in laziness or forgetfulness to protect against the sun (Guidelines 2, 3, 7, 11, 14 and 15).24 They also include recommendations to target policy and environments, and thus take a holistic approach; recommendations more recognisably aligned with health promotion (Guidelines 8, 9 and 10). In essence, they integrate the advantages of a social marketing approach more wholly within its public health context. While it is beyond the scope of this paper to go into detail on the application of each of these recommendations in practice, two issues pertinent to the use of the guidelines are discussed briey; the use of behavioural theory and of exchange theory. Use of behavioural theory One noticeable omission in the Delphi developed guidelines when compared with the NSMC benchmark criteria is the lack of comment on behavioural theory. Interestingly, only two comments on theory were in the original recommendations put forward by Delphi participants. The rst recommended that established behavioural principles/models (e.g. including incentives, minimizing barriers) should be a part of any programme seeking to achieve behaviour change, whilst the second recommended that developmental theory/evidence should be incorporated when segmenting on age. These recommendations did not make it through the consensus process, and thus were not included in the nal guidelines. Rather than reecting a disregard for theory, it is likely that this reects the current state of debate in the literature regarding the most appropriate theory for sun protection evidence, and the limited published research on the utilization of different theories and models to this behaviour. The systematic review noted previously found eight different behavioural theories or models used as a basis for the development of sun protection interventions, either singly or in combination with other theories, by 16 out of 23 interventions (Johnson, unpublished). Of these, the most commonly used were social cognitive theory, the theory of reasoned action/planned behaviour, the health belief model, protection motivation theory and the transtheoretical model. The lack of comment on behavioural theory should, therefore, not be

interpreted as implying that social marketing should be developed in an atheoretical manner. Rather, it is the authors belief that it implies that the experts assume an eclectic approach to use of behavioural theory as they develop their initiatives, using those theories that are most relevant to the initiatives goals and the target population. The use of exchange theory Exchange theory is also considered to be a core criterion of social marketing, with the NSMC benchmark criteria recommending that an exchange analysis of the perceived and actual costs of achieving the proposed behaviour change, compared with the perceived and actual benets, should be conducted when developing a social marketing intervention.10 This criterion is indirectly expressed in the guidelines presented in the need to gain a deeper understanding of the self-interests of the target market, and the motivators and barriers to sun protective behaviour, and the need to have a deep understanding of the competition to sun protective behaviours that comes from the social norms and attitudes surrounding tanned skin. However, also inherent in exchange theory is the realization that people must be offered benets that they really value.7 This is addressed specically in the recommendation to focus on more direct outcomes such as skin damage (wrinkles, aging) and sunburn as these appearance-based issues are potentially more salient to this demographic as they offer the target audience benets that can be realized in the shorter term rather than the longer term. Appearance-based strategies can include the use of dermascans or ultra-violet photographs that show individuals the damage they have already sustained through poor sun protection behaviour, or the provision of information on skin damage. On systematic review, the use of appearance-based strategies was found to be a common element in sun protection interventions that were successful in changing sun protection behaviour. Efcacy of process The project was conducted with a pragmatic view of reducing the time and energy commitment of participants, within the connes of a process that included ve consensus rounds and one grading round. This led to a streamlined method for consensus development where participants chose 15 recommendations from the initial list of 129, with percentages given based on the number of participants choosing each recommendation. Feedback was also encouraged and presented anonymously to all participants. Holey et al. (2007)25 suggested a more involved method of consensus, showing the level of agreement for each statement with withinsubject weighted kappa statistics, and importance rankings with mean and standard deviation for each statement. Holey et al. stated that this would reduce subjectivity and ensure maximum validity of results in a Delphi process. While this may improve the consensus process by allowing more detailed feedback to participants and demonstrating when consensus is achieved to those conducting the Delphi process, this would also increase the response burden for each round. When relying on participants goodwill to be involved in such a process, this heightened commitment is likely to decrease initial and ongoing response rates and, potentially, the attention given to each statement. For this Delphi process, with an initial listing of 129 statements, the benets of this more complex method could have been outweighed by the potential loss in involvement. As expected, the traditional evidence base for most of the guidelines was of the lowest category; expert opinion. This, however, had little correlation with the VAS gradings for the guidelines based on the panels knowledge and experience

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(rs0.45, P 0.10). An example of this is seen in Guideline 1 stating the importance of formative research and pretesting of materials. This received the highest VAS grading of 9.16, yet its traditional SOR was Level D. The nature of this recommendation means that it would be difcult to establish through systematic review alone, yet it is recognized by experts as being essential when developing interventions for this demographic. This highlights the utility of a grading system based on experience as well as traditional hierarchical methods. Limitations One of the major limitations with a consensus approach is the broadening of content to accommodate all views. This, inevitably, loses more focused recommendations for recommendations which gain the acceptance of the majority but potentially lessen innovation. The number of recommendations chosen by participants in each round was increased from 10 to 15 for this reason. As the guidelines provide general principles for social marketers, their broader focus does not lessen their utility, but rather suggests the need to develop interventions specic to the context, relationships and environments present in each community. Conclusions This method offers an efcient, pragmatic approach to guideline development within a public health context, placing a stronger emphasis on expert opinion, while utilizing traditional grading methods for SOR. The resultant guidelines incorporate the major elements of social marketing theory within the established knowledge base of sun protection experience. Acknowledgements The authors would like to thank the Delphi panel for their participation in this project: Professor David Buller, Professor Robert Donovan, Professor Gerard Hastings, Dr Sara Hiom, Dr Kristina Jackson, Dr Chris Paul, Dr Sue Peattie, Dr Andrew Penman, Professor Michael Rothschild, Craig Sinclair and Professor Melanie Wakeeld.

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Ethical approval None sought.

Funding This project was part of an Australian Research Council (ARC) linkage project between the Centre for Health Initiatives, University of Wollongong and the Cancer Council of New South Wales. Competing interests None declared.