Cancer Detection and Prevention 30 (2006) 432–438 www.elsevier.

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Effects of pictures and textual arguments in sun protection public service announcements
Henk Boer PhD*, Ellen Ter Huurne MA, Erik Taal PhD
Department of Communication Studies, Faculty of Behavioral Sciences, University of Twente, P.O. Box 217, 7500 AE Enschede, The Netherlands Accepted 22 June 2006

Abstract Background: The effect of public service announcements aimed at promoting primary prevention of skin cancer may be limited by superficial cognitive processing. The use of both pictures and textual arguments in sun protection public service announcements were evaluated for their potentially beneficial effects on judgment, cognitive processing and persuasiveness. Methods: In a 2 Â 2 factorial experimental design individuals were shown public service announcements that advocated the advantages of sun protection measures in different versions in which a picture was present or not present and a textual argument was present or not present. The 159 participants were randomly assigned to one of four conditions. In each condition, participants were shown 12 different public service announcements designed according to the condition. Participants judged each public service announcement on attractiveness, credibility, clarity of communication and the required amount of reflection. After the judgment task, they completed a questionnaire to assess knowledge, perceived advantages and disadvantages of sun protection and intended use of sun protection measures. Results: Pictures enhanced attractiveness, but diminished comprehension. Textual arguments enhanced attractiveness, credibility and comprehension. Pictures as well as textual arguments increased knowledge of sun protection measures. Conclusion: Pictures and textual arguments in public service announcements positively influence the individual’s perception of the advantages of sun protection methods and the advantages of their adoption. # 2006 International Society for Preventive Oncology. Published by Elsevier Ltd. All rights reserved.
Keywords: Skin cancer; Primary prevention; Communication; Experimental design

1. Introduction Overexposure to ultraviolet radiation leads to photo aging [1], and is a major factor in the etiology of skin cancer [2–4]. It is estimated that 90% of non-melanoma skin cancers and two-thirds of melanomas can be attributed to excessive exposure to the sun [5]. Sun protection methods like staying out of the midday sun, wearing protective clothing, and applying sun screen reduce the risk of skin cancer [6]. Furthermore, wearing sun glasses reduces the risk of lens opacities like cataracts. However, the proper use of these methods among the general public is limited [7,8]. To promote sun protective behavior, mass media campaigns usually employ television and printed
* Corresponding author. Tel.: +31 53 489 3291; fax: +31 53 489 4259. E-mail address: h.boer@utwente.nl (H. Boer).

public service announcements together with additional media, like billboards [9]. In general, sun protection messages consist of behavioral advice (like ‘wear sun protective clothing’), supported by arguments indicating the importance of the behavior addressed (like ‘excessive sun exposure enhances wrinkling’). For textual arguments to be effective, individuals should reflect the message’s content and subsequently consider the arguments presented in the message to reach a conclusion [10–12]. Limited reflection about the textual arguments leads to ineffective messages [13]. A promising approach to enhance the effectiveness of sun protection public service announcements is the appropriate use of pictures to evoke the use of mental imagery [14]. Research has shown that pictures may improve attention, comprehension, recall and adherence to health advice [14–16]. Positively evaluated pictures may

0361-090X/$30.00 # 2006 International Society for Preventive Oncology. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.cdp.2006.06.001

gained knowledge. After presentation of each public service announcement the participants answered a few questions on its judgment. Different pictures were used in each of these public service announcements related to the different possible outcomes of unprotected sun tanning behavior: three pictures related to 2. in which subjects were confronted with public service announcements that contained a slogan (‘Practice safe sun tanning’) together with a concrete sun protection advice (e.g. with four conditions with different combinations of pictures and textual arguments. Therefore. containing twelve different public service announcements aimed at promoting sun protective behavior—three for each of the four sun protection measures. The public service announcements were presented in a fixed random order within each condition.e. using sun screen. It took about 15 min for respondents to complete the judgement task and 5 min to complete the questionnaire. In their review of pictures’ effects in health communication. this study aims at providing insight into both pictures’ and textual arguments’ beneficial contribution to judgment. and perceived advantages of sun protection measures in public service announcements. Therefore. as shown in Fig. sun protection public service announcements succeeding in changing these attitudes will be more effective. and wearing sunglasses with UV-protection while in the sun). when you are in the sun’). little is known about the interactive effects of textual arguments and pictures in health communication. Methods 2. [16] concluded that in general. Public service announcements. and 3:00 p. the subjects completed a questionnaire. wearing protective clothing.3. ‘Always use sun screen on uncovered skin. attitudes are related to the perceived advantages and disadvantages of sun protection measures’ use. However.2.. can be helpful of clarifying and illustrating these advantages. four different versions of each public service announcement were created. the Netherlands. 2 represents an example of the four different executions as just described. The 2 Â 2 factorial between subjects design of the study.g. An individual’s attitude towards different modes of sun protection is postulated as a major psychological determinant in predicting actual sun protection behavior [18–20]. pictures provide significant benefits.m. i. Pictures possibly might evoke more reflection about the message. Participants and procedure Participants (N = 159) were recruited from the University of Twente and a college.. a logo. In the study described here. The basic format of the public service announcements was similar across all conditions. both located in Enschede.. Fig. consisting of a yellow sun with sunrays supported by a slogan (‘Practice safe sun tanning’) combined with one of the four sun protection advices (using sun screen. if targeted at transposing misperceptions about the advantages of sun protection measures. After judging all of the public service announcements. Houts et al. even without the presence of textual arguments. Fig. 1. The presence or absence of textual arguments and pictures supporting the given behavioral advice differed across the experimental conditions.1. The advice was supported by different combinations of pictures and textual arguments on the basis of a 2 Â 2 factorial between subjects design of the factor picture (present–not present) and the factor textual argument (present–not present). Respondents were randomly allocated to one of the four experimental conditions according to a random list. 1. / Cancer Detection and Prevention 30 (2006) 432–438 433 produce a higher level of public service announcements’ attractiveness and lead to more favorable attitudes towards the content of the message [17]. resulting in acceptance of the sun protection advice. Boer et al. Design This study involved four experimental conditions. In condition A (argument present and picture present). wearing covering clothes. 2.m. Materials The public service announcements employed in this study were designed by using professional photo editing software. sun protection advice was accompanied with one of the three arguments that explain the possible outcomes of that behavior (e. The experiment was presented as a study on the execution of public service announcements about sun protection methods. However. ‘‘Overexposure to sunlight during a longer period of time causes premature skin aging’’). Respondents received a booklet . because of the studies’ inconsistent results [16].. On the basis of the 2 Â 2 factorial design with the factor textual argument (present or not present) and the factor pictures (present or not present). staying out of the midday sun. avoiding the sun between 12:00 p. Attitudes refer to favorable or unfavorable feelings with respect to a given object or behavior. 2. it remains hard to predict people’s responses to pictures in health communication.H. and wearing sun glasses.

. gender and existing sun protection behavior in the past summer (using sun screen. 2. pictures. and three pictures related to damage of the eye (e. slogan. To obtain sufficient variety in all conditions. Both pictures and textual arguments were absent. Demographic characteristics and current sun protection behavior We assessed age. condition (D): neither textual argument nor picture). Measures 2. wearing sunglasses) on a five-point scale with extremes never (1) .. Boer et al. In this condition. wearing protecting clothes. three pictures related to wrinkles (e. always (5). 2. three pictures related to skin cancer (e. A diagram with examples of the four types of public service announcements used in the experiment (condition (A): textual argument and picture. condition (B): no textual argument and picture. The items formed an internally consistent scale (Cronbach’s a = 0. .1. especially in condition D. red sun burn faces).. each advice was accompanied simply by a picture related to the possible negative outcomes.g.4. faces with wrinkles).72). a Braille alphabet). The behavioral advice in this condition was simply accompanied by a textual argument.g. Condition B (argument not present and picture present) resembled the format of condition A. and condition. In condition D (argument not present and picture not present) the public service announcements consisted of the logo.434 H. A pretest among ten subjects was executed to assure comprehensibility of all public service announcements within all conditions. . . melanomas). the public service announcements were printed on three different colors of paper that varied systematically among behavioral advice and conditions.4.. and behavioral advice. however differing from that condition by absence of a textual argument. condition (C): textual argument and no picture. avoiding the fierce midday sun. Condition C (argument present and picture not present) differed from A in the sense that pictures were absent. By applying this method. / Cancer Detection and Prevention 30 (2006) 432–438 Fig. we controlled for an equally distributed frequency of color use with arguments.g.g. sunburn (e.

6. No significant differences between the conditions with respect to mean age (F (3. pictures in public service announcements affected reflection significantly in a positive direction. Univariate analyses of variance were performed to test the effects of pictures and textual arguments on these dependent variables. The presence of pictures enhanced attractiveness significantly.7.2.05.89). Pictures and textual arguments had significant interactive effects on attractiveness of and reflection about the public service announcements. Data analysis intended to determine both main and interactive effects of textual arguments and pictures in public service announcements on judgments.63).4. credibility (‘I think the public service announcement is credible’).5. like preventing sun burn. 2.58). amount of reflection.5 years.93 (wearing sun glasses). 155) = 1. Inspection of the mean scores showed substantially lower scores for attractiveness and reflection for public service announcements with no pictures and no textual arguments. and level of previous sun protection behaviors (F (3. 2.m. unpleasant smell. and 3:00 p.85 (wearing skin covering clothes).m.5. and wearing sun glasses (causes white edges around the eyes. = 3. textual arguments evoked significantly more reflection. wearing skin covering clothes (tan less quickly. Good levels of internal consistency were found for attractiveness (a = 0.80 (sun screen use).f.84) and required amount of reflection (a = 0.4. gender (x2 = 2. d.4. keeps me from enjoying the sun.4. Participants responded on a fivepoint Likert scale ranging from ‘strongly disagree’ (1) to ‘strongly agree’ (5). Each of the particular sun protection behaviors was assessed by three items representing the behavior in three different settings (i. a = 0. sunglasses do not suit me. / Cancer Detection and Prevention 30 (2006) 432–438 435 2. Perceived disadvantages of sun protection methods Perceived disadvantages of sun protection were measured separately with three-item scales for using sun screen (tan less quickly. Knowledge To assess knowledge. on the beach. were assessed separately for using sun screen (a = 0. credibility (a = 0. The presence of textual arguments led to significantly higher levels of attractiveness. wearing skin covering clothes (a = 0.. Furthermore.72). skin becomes greasy. Mean scores were computed for all scales. The advantages of wearing sun glasses were assessed by two items on the prevention of damage to the eyes and prevention of sight loss (r = 0. and comprehensibility. Univariate analysis of variance was performed to test equal distribution of the subjects among the four conditions for age and level of previous sun protection behavior.1. sunglasses are inconvenient. avoiding the fierce sun between 12:00 p. a = 0. Respondents indicated their level of agreement with the statements on a five-point Likert scale ranging from ‘strongly disagree’ (1) to ‘strongly agree’ (5).63) and avoiding the fierce sun between 12:00 p. Furthermore. wrinkles and skin cancer. but led to significantly lower levels of comprehensibility. comprehensibility (‘I think the public service announcement is easy to understand’) and the required amount of cognitive processing (‘The public service announcement has given me food for thought’) on five-point Likert scales (‘strongly disagree’ (1) to ’strongly agree’ (5)). 2.4. comprehensibility (a = 0. 155) = 1.e. Results The sample (n = 159) consisted of 103 males (65%) and 56 females (35%). A x2-test was employed to test equal gender distribution across experimental conditions. 2.86). knowledge. Statistical significance was assumed with a p-value of 0.3. The total number of correctly mentioned negative consequences (0–4) and the total number of correctly mentioned sun protection advice (0–4) was scored. too hot. Statistical analysis Data were analyzed using the Statistical Package for the Social Sciences 12 (SPSS). Judgement of the public service announcements Participants judged each public service announcement on attractiveness (‘I think the public service announcement is attractive’).3. sweating.H. Public service announcements with pictures or textual arguments lead to significantly more knowledge about sun exposure consequences than did public service . Internal consistency was computed across the twelve public service announcements to indicate the scales’ reliability. a = 0. 2. Boer et al. a = 0. ranging in age from 17 to 27 years old with a mean age of 21. Intended sun protection Intended sun protection behavior was assessed separately for each of the four sun protection behaviors stressed in this study by a five-point Likert scale with extremes ‘strongly disagree (1) to strongly agree (5)’. during outdoor activities).86). (a = 0.m.84 (avoiding the midday sun).69). keeps me from doing what I like outside. and 3:00 p. credibility. a = 0. ns).57).75). ns) were found. and perceived advantages and disadvantages of sun protection behaviors.4. (tan less quickly. ns).91).4.m. The scales showed good internal consistencies. Table 1 shows the significant effects of both pictures and textual arguments on the judgment of public service announcements. 3. Perceived advantages of sun protection Perceived advantages of sun protection. around the house. a = 0. a = 0. and a = 0. respondents were asked to recall as many negative consequences of excessive sun exposure as well as sun protection advices as they could.

9 * 25.5) (0.7 3.1* 6.4 7.4 ** 4.6 * Main effect pictures.0 5.9 (0.4 1. avoiding the fierce sun. Using either pictures or textual arguments in public service announcements did not affect the intention to employ techniques for sun protection.6) (0.6 (0. as shown in Table 1.0) 2.6) Yesb 2.8 (0.4*** 1. * p < 0. Mean scores indicated that intention to wear sun glasses was significantly lower among participants exposed to announcements without pictures or text arguments.6 3.6) Yesd 2.8) 3. dn = 39.8) 2. Neither pictures nor textual arguments in public service announcements affected the perceived disadvantages of sun protection measures significantly. textual arguments led to higher levels of perceived advantages regarding the behavioral advice to avoid the fierce midday sun.8) 1.5) (0.8 3.1 (0.9 (0. However.0 3.4 ** 1.8 (0.9) 3. 155) Interaction.5*** 8. 150) 1.5) (0. F(1. Boer et al. 150) Interaction. wearing protective clothing. bn = 40.4 * 27. * p < 0. The presence of textual arguments in public service announcements did not result in significantly higher levels of perceived advantages of the following sun protection measures: using sun screen. Knowledge of sun protection advice was not significantly influenced by the presence of only pictures or textual arguments. avoiding fierce midday sun and. ** p < 0.5) (0.7) 3. as shown in Table 2. No significant main effects of pictures on the perceived advantages of sun protection measures were found.6) (0.6) (0. In an Table 2 Mean scores (standard deviations) in the four experimental conditions on perceived advantages of sun protection measures Textual argument present Pictorial argument Not present Noa Sun screen use Protective clothing Avoiding fierce sun Wearing sun glasses 3.436 H.6 3.8) Present Noc 4.6) (0.1 3.1 (0.3 3.6 2.5) (0. F(1. bn = 40.6) (0. 155) Main effect textual argument.8* 5.9 4. wearing protective clothing.8 3.7 <1 <1 <1 <1 3.6) 41.05. The interactive effect was not significant either.6) (0.1 (1.9) 3.7) Yesb 3. we also analyzed whether they influenced perceptions about the disadvantages of sun protection measures and intentions of their use.6) (0.7) Present Noc 2.001.6 (0. F(1.9) Note: an = 40.5) (0.8) Yesd 3. 150) Main effect textual argument.9) 3.0 4.9 3. Although the public service announcements were designed to positively affect the perceived advantages of four sun protection behaviors. Mean scores were substantially higher than among subjects confronted with announcements lacking either pictures or textual arguments.8 3. *** p < 0.7 2.4 (0.8 (0.0 4.3 3.6) (0.3*** 4.5) (0. cn = 40.01.0 (0. F(1.8 3.8 2.5) (0. dn = 39.7 * 2.05.5 3.3 (0.6) (0. as well as wearing sun glasses.9 (0.9 ** 26. The public service announcements used in this study were designed to positively influence the perceived advantages of four sun protection measures: using sun screen.1 ** 16.4 <1 4. Discussion This study explored the effects of pictures and textual arguments in public service announcements to promote the perceived advantages of sun protection measures. cn = 40.7) (0.8) (0.4* Main effect pictures. The interactive effect of pictures and textual arguments appeared to be significant on knowledge about the negative outcomes of overexposure to the sun. wearing UV-protective sun glasses.7) (0.6) (0.6 4.6) (0.7*** <1 9. 4. F(1.2 (0. 155) Note: an = 40. F(1.8 3. Inspection of the mean scores revealed substantially less knowledge in the condition without both pictures and textual arguments.8 3.5) (0. announcements without pictures or textual arguments.6*** 20.6) (0. as shown in Table 3.4 2. and wearing sun glasses. The presence of both pictures and textual arguments in the announcements had significant interactive effects on the perceived advantages of protective clothing.1 (0.2 2. / Cancer Detection and Prevention 30 (2006) 432–438 Table 1 Mean scores (standard deviations) in the four experimental conditions on the judgments of the public service announcements and knowledge assessed after the judgment task Textual argument present Pictures Not present Noa Judgment of PSA’s Attractiveness Credibility Comprehensibility PSA reflection Knowledge Sun exposure consequences Sun protection advice 1.1*** <1 7. .8 3.

6 <1 <1 <1 2.8) (0. / Cancer Detection and Prevention 30 (2006) 432–438 437 Table 3 Mean scores (standard deviations) in the four experimental conditions on disadvantages of sun protection measures and intended sun protection behavior Textual argument present Pictorial argument Not present Noa Disadvantages of sun protection Sun screen use 2.9) (0. The more elaborate processing of public service announcements with pictures and textual arguments was also reflected in the recall of the content of the public service announcements.7 3.0) (0.g.9) (0. in accordance with the elaboration likelihood model.0 2.8) (1.6 2.2 (0. experimental setting participants were exposed to public service announcements.9) (0. These results indicate that the persuasiveness of public service announcements is limited.0 <1 3.8 Protective clothing 3.0 2.8) (1. even among highly educated students. .9) (1.9) (0.2 3.’s finding that pictures in health communication enhance recall [16]. Pictures as well as textual arguments had significant interactive effects on the perception of the advantages of wearing protective clothes.5 <1 <1 9. F(1.7 (0.9 2. comprehensible and credible than public service announcements without text arguments.9 2.0 2.2 Wearing sun glasses 2.9) (1. the use of more difficult pictures negatively affects comprehensibility.15].6 1.2 2. Pictures were hypothesized to underscore the advantages of the use of sun protection methods in a visual way (like a photo of a wrinkled face). A significant interactive effect of pictures and textual arguments on knowledge about negative consequences pointed out that participants who were confronted with public service announcements with neither pictures nor textual arguments performed substantially poorer in reporting negative consequences of overexposure to the sun than the other participants.6 2.3 3. This finding is in accordance with the expectation that pictures will allure subjects into more elaborate cognitive processing of the argument from the public service announcements [14.1 1. No effects on perceived disadvantages and sun protection intentions were found.2) (1. Results of this study showed that pictures in public service announcements had a significant positive effect on attractiveness.2 3. textual arguments to underscore the advantages of sun protection advice by representing the possibly positive outcomes of the sun protection method addressed. Textual arguments only enhanced the perceived advantages of avoiding the fierce midday sun.9 2.6 3. subjects will make an effort to reach a conclusion on the basis of processing these arguments [12]. although varying regarding presence or absence of both pictures and textual arguments.6 3.0 * Main effect pictures. Participants confronted with public service announcements with pictures or textual arguments were able to report a significantly higher number of negative consequences of overexposure to the sun than participants confronted with public service announcements without pictures or textual arguments.8) (1.8) (0.2 3.0) Yesb 2.8) (0. concluded that pictures in health communication can improve comprehension. cn = 40. dn = 39.0) (0.8) (0.0) Yesd 2. Houts et al.9 3.6 3. F(1. 158) Note: an = 40. as some of these pictures were a bit puzzling to attract attention and promote reflection (e. The finding that pictures improve knowledge is in line with Houts et al.4 <1 <1 <1 1. 158) Main effect textual argument. with each containing similar advice on sun protection methods. * p < 0. Those presenting textual arguments were judged to be significantly more attractive. Boer et al.9) (0.4 1.4 (0. Inspection of mean scores indicated that these interaction effects were caused by substantially lower perceived advantages of these sun protection behaviors among participants who were confronted with public service announcements lacking both pictures and textual arguments.0) 1.8) (0.7 2.8) (0. This effect might be due to the fact that the pictures used in the study required a higher level of attention and reflection. In general.9 (0.8) (0.0 <1 <1 2.4 2.5 3.2 2.0 2.7 3.6 2. This indicates that the provision of either a picture or a textual argument in a sun protection public service announcement substantially improves the knowledge of the negative consequences of overexposure to the sun. Pictures in public service announcements led to significantly higher levels of reflection. a picture of a Braille alphabet in combination with the argument that overexposure to the sun can damage the eyes).9) (0. bn = 40. Public service announcements with text arguments also lead to more reflection. public service announcements with pictures or textual arguments did not have a main effect on the perceived advantages of sun protection methods.H. that assumes that with the presence of arguments in the message.05. 158) Interaction. F(1.8) (0. but a negative effect on comprehensibility.6 Intended behavior Sun screen use Protective clothing Avoiding fierce sun Wearing sun glasses 2. because as this study shows.5 Avoiding fierce sun 3.7) (0.8) (0.2 3.3 3.0) (1.8) (1. especially among people with low literacy skills [16].2) Present Noc 2.9) (0.2 2. avoiding the fierce sun and wearing sun glasses.8) (0. We agree with their advice to use simple and realistic pictures.

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