AN EXAMINATION OF GOLF MAGAZINES FOR HEALTH BELIEF AN EXAMINATION OF GOLF MAGAZINES FOR HEALTH BELIEF MODEL APPLICATIONS AND SKIN CANCER PROTECTION ADVICE MODEL APPLICATIONS AND SKIN CANCER PROTECTION ADVICE AN EXAMINATION OF GOLF MAGAZINES FOR HEALTH BELIEF MODEL APPLICATIONS AND SKIN CANCER PROTECTION ADVICE

Skin cancer rates are elevated among men, especially men who participate in outdoor sports, such as golf. Male golfers who play regularly are particularly susceptible to skin cancers because of the length of ultraviolet radiation exposure during game time, lack of adequate skin protection, plus their cumulative lifetime exposure is higher than non-golfers. Drawing on the health belief model, the purpose of the research was to analyze golf magazines from two decades for editorial content that communicates the increased risk of skin cancer for male golfers as well as protective measures they can undertake to prevent ultraviolent solar radiation exposure, the primary cause of skin cancers. The study reviewed 20 years of content (1999-2019) for health belief model constructs and interviewed male golfers about their beliefs regarding their skin cancer risks and how they learned to protect their skin. The editorial coverage lacked explanations about why preventative measures are essential and too brief to explain the risks in depth. Photos and illustrations of golfers do not reflect golfer identities. Health interventionists can look to golf magazines as a channel for educational campaigns for men at risk for skin cancer.


LIST OF TABLES
Examples of interview questions 24 Table 4 Health belief model construct frequencies 25

INTRODUCTION
In 2014, the United States Surgeon General issued a report on skin cancer, stating that the rates continue to rise, affect more than 5 million Americans annually, cost more than $8 billion to treat, and take the lives of 9,000. Two groups identified with higher risks than average are men and athletes. Certainly, frequently participating in exercise outdoors is beneficial to health but less so when the athletes -professional and amateur alike -expose themselves excessively to UV solar radiation, the most primary cause of skin cancer.
A cancer diagnosis can bring emotional, physical, financial and psychological harm to individuals. Although medical advancements often extend survival rates and make treatments shorter and less harsh, prevention by way of avoiding carcinogens is preferable. Mass media aid medical experts in educating the public about carcinogenics and their effects on humans. Articles feature information, without medical jargon, to help readers understand the vast varieties of cancers, the known and suspected causes, surgical and oncological medical treatments, and prevention tactics. Educating people to avoid carcinogens intentionally results in more healthy, less painful lives while alleviating the burden on the medical ecosystem treating cancers.
Because of the complexity of human behavior and the influences upon it throughout a lifetime, a simple approach to persuade people to adopt healthy practices does not exist. Identifying subsets of individuals and examining their exposures to carcinogens, and then devising communications that will effectively convey information that will help them make lifestyle adjustments is a key element to prevention.
Prior research in mass media sources has focused on men's and women's magazines and national newspapers. The information may have been helpful to all readers in many demographic categories, but the broad messaging hasn't been tailored to this niche audience identified as highly susceptible to skin cancer. Researchers to date have not examined skin cancer educational material in golf magazines, a mass media specialty format with high readership among male golfers. A review of editorial content pertaining to skin cancer for the scope, frequency, and relevance of information will aid in devising messaging that addresses weaknesses and gaps.
To this end, this research will analyze editorial content in golf magazines pertaining to past messaging about skin cancer and interview male golfers about their impressions about the content, how it has affected their skin protection beliefs and behaviors; and their receptiveness to more skin cancer content in golf magazines.
Because product advertising is created by manufacturers and sales benefit their businesses, advertising messages carry bias and are not considered as credible as content curated by neutral sources, such as reporters and columnists. Therefore, the current study does not analyze advertising content in golf magazines.
I hope this research will shed light on the design of a communications campaign specifically for male golfers about their unique challenges related to skin cancer disease, and thus can help to reduce incidence among this target audience identified by data as at higher risk. Male golfers, like many Americans, consume large amounts of mass media and audience segmentation and microtargeting tailored messages to them is a common 3 campaign practice -in fundraising, elections, consumer marketing, public advocacy, and many more sectors.

LITERATURE REVIEW
When detected early and treated appropriately, persons with skin cancer have to an ill-informed public about the deleterious, long-term effects of sunburn (Dixon et al., 2014). Over the course of decades, anti-sunburn, anti-tanning and self-protection multichannel media campaigns have increased awareness of the direct evidence connecting cancer and ultraviolet exposure, but people have not changed their behaviors to adopt the inexpensive and easy measures that will protect their skin from ultraviolet solar radiation ( (Gristwood, 2011), the health belief model "looks deeper into the relationship between an individual's confidence to take action (self-efficacy) if they perceive themselves to be susceptible to a condition, the identification of the potential severity (…), and evaluation of perceived benefits versus barriers" (Gristwood, 2011 Examples of barriers are stigma, vanity, inconvenience, lack of motivation, cost, and fear. As a construct, self-efficacy explains that individuals must believe they are self-enabled to take actions needed to achieve positive results (Glanz et al., 2010;Gristwood, 2011).
The application of the health belief model can help identify health behaviors associated with golfers and the drivers needed to shift their behaviors favorable to skin cancer protection, and intervention strategies targeting them can be developed and deployed (Geller et al., 2006). In this research, the perceived susceptibility construct pertains to information that explains the risk and likelihood of contracting skin cancer as well as the factors that influence the onset of skin cancer (e.g., golfers who don't use any protection are more likely to develop cancer). Information that would increase golfers' understanding of the seriousness of skin cancer and/or ultraviolet solar exposure as well as the medical treatments and long-lasting effects on health, well-being and appearance Strategy 2A calls to "improve sun protection, especially among adult men" by emphasizing "wide-brimmed hats, protective clothing, and broad spectrum sunscreen …when outdoors for extended periods." Also mentioned in that report's strategy was a recommendation to "improve communication about when and how to use sun protection" (Office of the Surgeon General, 2014, pp.50-51).
Readers of golf magazines skew heavily male. According to Golf Digest, the most read golf magazine, 82% of its subscriber base are male. Gathering information from this and other golf magazines about their skin cancer coverage, such as how frequently they publish articles about it, how comprehensive the articles are, and that types of advice they are providing, will help improve the creation of prevention messages for male golfers that will resonate with them and motivate behavior changes. Because golf magazines are not as popular among women golfers and women golfers do not have the same incidence of skin cancer as male golfers, the research will focus on male golfers. To that end, this research examined the following questions: While the association between recall of articles and the effect of learning and adopting behaviors would be difficult to draw from a study of this size and scope, the information gathered was examined for evidence of a relationship.

CHAPTER 3 METHODOLOGY
In the course of this research, two methods were utilized. A content analysis of the most popular golfing magazines in the United States was performed to gather information about how well the topic of solar protection had been covered and for the presence of the health belief model in published content. Interviews were conducted with male golfers to gain insight about their ultraviolet solar protection practices and how they had been influenced to adopt these behaviors.

Content Analysis
Sample. The three golf magazines with the largest circulation figures in the U.S., as self-described in media sales kits, were selected for the content analysis: Golf Magazine, Golf Digest and Golf World. See Table 1 for circulation statistics and the number of relevant articles procured for the research. Qualifying content included articles, columns, editorials, opinions, letters to the editor, sidebars, health quizzes, photos, illustrations, cartoons, product reviews, and Q&A. Advertising was excluded. qualified. Article searches that produced results for products, such as sunglasses, that did not also mention sun protection, UVR protection or similar, were excluded.
Coding Scheme. A coding scheme was constructed based on a preview of the sampled 64 articles, and operationalized the health belief model constructs as they pertained to ultraviolet solar radiation protection and skin cancer avoidance and treatment topics. Details of the coding scheme can be found in Table 2. The constructs used for the content analysis were: susceptibility of developing cancer or overexposure to ultraviolet solar radiation; severity of skin cancer and concomitant treatments; barriers to adopting preventive measures to avoid ultraviolet solar radiation exposure; the benefits of engaging in skin protection; and promotion of prevention and early skin cancer detection measures that could help golfers become more self-efficacious toward their skin health.
Content was coded by subcategory within the five constructs. Table 2

Table 3 Examples of interview questions
Do you recall having read in any golf magazine about an increased risk of skin cancer among men who play golf regularly? Do you believe you are at risk? Why or why not?
Of the items you mentioned earlier that you do to protect your skin, why are you doing this?
Of the things you do to protect your skin, why are you doing this?
Would you find it helpful or not helpful to read information frequently about skin cancer health-related news in golf magazines? Why?
Please identify measures that you, as a golfer, practice on the golf course to protect skin from ultraviolet solar radiation.

Content analysis results
Text and imagery of 64 articles were examined, and only four articles in the magazines examined were comprehensive enough to cover the scope of the issue, such as long-term and persistent threats to the golfing population, how to identify suspicious moles, and the best methods to protect skin. The repetition of topic was not evident because the total number of articles over 20 years numbered 72.
The most common health belief model construct within the 64 articles and 69 images was content that promoted self-efficacious actions (n=55); followed by benefits (n=36); susceptibility (n=33); barriers (n=30); and severity (n=29) (See Table 4 for a detailed description of each construct's coding results). Susceptibility. Just over half of the articles reviewed (n=33) published content related to susceptibility. Mention of the long-term and cumulative effects of UV solar radiation garnered the most coverage (n=15), followed by statistics about how the disease affects the population or golfers more specifically (n=14). Lengthy articles were more likely to convey information about the mortality rate among golfers (n=7) than shorter articles, for which susceptibility messaging was more likely to be broad ("1 in 5 Americans will get skin cancer") (Barton, J. (2010); not correlated to golfing ("incidence of skin cancer among Americans rose 50% between 1980-1990") (Horton, 1997); or highly specific to a body part rather than overall risk ("lower lip is especially susceptible to skin cancer") (Kapriske, 2010). It was more common for the magazines to publish broad statements rather than scientifically-based statistics, such as, "Golfers face an elevated risk of developing all sorts of skin trouble" ("Dodging the Big C," 2002). When statistics were published, they tended to be about the broader population in the United States than that of golfers ("Skin cancer will affect about 1 million Americans this year (Malanka, 1996), and the susceptibility of an ill-defined set of people rather than golfers specifically. Eleven articles featured the perspective of professional golfers who had undergone skin cancer treatments, inferring that cumulative exposure and multiple sunburns like they had experienced translates to an elevated risk for the disease for other golfers.
Despite warnings that younger golfers are most at risk for melanoma (American Barriers. Social influences, i.e., the appearance one presents to the public and the force of peer pressure upon the self, were present in the magazines, usually as humor (n=15). Vanity reasons were cited in eight of the articles. Ridiculing wide-brimmed hats as unfashionable because " your wife made you wear it" ("Head Cases," 2018) and wraparound sunglasses that protect eyes from ultraviolet radiation as "looking like an extra from a low-budget sci-fi B movie" (Barton, 1995) reinforced a common barrier for golfers considering or employing these recommended protections. In a first-person narrative, a writer (Owen, 2019) stated that many golfers came of age in an era where darkening one's skin was widely practiced and a norm. Other content revealed attitudes about skin cancer held by golfers when discussing their cases.
Padraig Harrington had a 'sun spot' removed from his forehead last week according to the Irish Independent newspaper. The spot, a patch of "nonmelanoma skin cancer" was nothing serious, according to Harrington. "It was continuing to expand, so it was decided to catch it before it got any bigger," he told the paper. "It's nothing exciting. Just standard procedure." (Antonini, 2007) Masculine norms about toughness when facing with adversity could be a factor in the aforementioned story (Geller et al., 2006; Office of the Surgeon General, 2014) and the attempt by the golfer to downplay the impact of skin cancer as a sun spot, the removal of which was de rigueur.
Products perceived to interfere with the play of game were also coded as barriers.
The most common examples were sunglasses, which are believed to make it more difficult to read the greens or see golf balls, and sunblock that leaches into the eyes or is messy to apply. The inconvenience of applying and reapplying sunblock was an obstacle acknowledged (n=2).
Confusion about the efficacy of sunblocks, SPF ratings, and ignorance about the signs of skin cancer, when to see medical professionals, and the susceptibility of skin on lips and eyes were factors in seven of the articles. Seventeen articles either stressed the importance of making appointments with physicians or spotlighted advances in how skin cancer is treated, which has made it one of the most treatable of all cancers. In total, nine articles featured skin tests. Three included color photographs of irregular moles (n=1) and the ABCDE self-test for melanoma detection (n=2).
Overall, only 15% of the articles made note of the fact that male golfers have a higher risk of skin cancer, and just seven mentioned that skin cancer, particularly melanoma, is deadly. Ninety-one percent of the content presented information about prevention with either the benefits and/or promotion of self-efficacious behaviors. Eight articles presented in-depth commentary about golfer risks for skin cancer based the ultraviolet levels of solar radiation exposure, solutions to exposure, and deeper context of the threats. Over a quarter of the content analyzed (n=18) featured an image of a sunblock bottle or a pair of sunglasses with bland headlines such as "shades of protection" or "sun protection." Generally, the texts of the examined magazine articles were more descriptive and informative than their accompanying images for conveying ultraviolet solar radiation and skin cancer protection advice. Over a quarter of the content analyzed (n=18) were images of products -sunblock bottles, sunglasses, clothing, and a watch -rather than action photos of individuals applying sunblock, wearing sunglasses while playing golf, or similar. Explanations about why a reader needed sunblock or sunglasses were omitted.
Eight articles over the course of the 20-year period provided in-depth, contextual understanding of the susceptibility male golfers face in developing skin cancer; the severity of the disease to their well-being; the benefits of avoiding cancer, eye diseases, and other physiological negative effects of ultraviolet solar radiation; the barriers, myths and obstacles men face regarding protecting their skin during gameplay; and explanations of behaviors golfers can adopt to protect themselves from solar carcinogens.

Interview Results
Eleven of the respondents did not recall reading any content in golf magazines, either in paper or online, related to ultraviolet solar radiation protection. The one individual who recalled reading relevant content revealed that he was a cancer survivor and that other family members had been diagnosed with and treated for skin cancer.
Importantly, recall about the origins of read content was very difficult to accurately state.
Nine of the 12, when asked how they learned to protect their skin from cancer, stated that they learned from a medical professional. Although the subjects were not asked to reveal the type of medical professional, five responded that they had learned from a dermatologist. Friends and family members as well as print and broadcast media news outlets were mentioned as entities that taught them about skin care. Unique answers about where they learned about skin protection included coaches and public education campaigns at work. One sexagenarian golfer stated that he never received any advice nor practiced any ultraviolet solar protection measures because of his ethnicity and that his olive-colored skin does not burn.
How are the golfers protecting their skin? Eleven of the twelve reported that they seek shade, although some admitted that the shade also provided relief from the heat as well as the sun's burning rays. Getting cool rather than reducing ultraviolet solar exposure was the primary intent. Said Golfer #3, Staying in the shade, I would just get hot so I would go step into the shade…It's a mix. Sometimes (going to shade is) to cool down. Sometimes it is because I can feel myself getting burned. And usually toward the end of the course I'll try to steer closer to the shade to avoid getting more burned.
Choosing early morning or late afternoon tee times, when the ultraviolet solar rays are less intense, was not a consideration for any of the golfers interviewed. They universally agreed that they preferred tee times based on their own schedules or accepted the time slots available by the course. Many golf in late-afternoon leagues, therefore they are not deliberately avoiding the sun.
Ten of the 12 golfers said they use sunblock, which was the most popular form of skin protection touted by the golf magazines studied. The men who replied that they do not use sunblock revealed that they have dark skin due to continuous ultraviolet radiation exposure and naturally darker shades of skin. Ten revealed that they believed to be at-risk for skin cancer, and two mentioned that they had been treated for melanoma and precancerous lesions. The reasons the male golfers offered about their beliefs about their own risks for skin cancer included the paleness of the skin, lack of motivation to apply sunscreen, family history, prior sunburns, and outdoor work.
None of the golfers interviewed wear long pants, and two wear long sleeves only periodically and during cooler, spring weather. Rather than cover exposed arm and leg skin, they cited comfort as the prevailing reason for the clothing choices. One mentioned that he works indoors all day and usually plays only in the season. Wearing casual clothes to play his sport, he said, is more comfortable than his formal work clothes.
To A common thread of the golfers' replies about covering exposed skin related to fashionable clothing. They were very interested in adopting fashion endorsed by and worn by professional golfers. Said Golfer #1, Phil Mickelson's got this goofy set of glasses he wears now because someone's paying him $500 grand to wear them, and now everyone's buying them, right? So if they find out that arm sleeves are protective and pros wear them, people are going to buy them, right?
The professional golfers hold the interest of the interviewees, not only in fashion but in new equipment trends. They remarked that if new golf accoutrements included ultraviolet solar protective clothing or products such as arm sleeves, they expressed their proclivities to explore and adopt the trends. One remarked that he enjoyed reading about products that are advancements in technology and was open to hearing golf professionals' opinions about the products that were new and protective as long as golfing information was not eclipsed by health and beauty news.
Because of the golfers' revelations that they did not recall golf magazine articles about skin cancer, elevated incidences among male golfers, or skin protection advice, it suggests that the content they are reading in the golf magazines isn't powerful enough to trigger recall, or frequent enough that they know that the content is published even if they can't remember the specifics on the content. Nevertheless, none cited golf media specifically as a channel for educating themselves on ultraviolet radiation protection. It is therefore reasonable to conclude for RQ3 that the male golfers are not following advice about skin cancer protection measures that are published in golf magazines.

CHAPTER 5 DISCUSSION
The first research question asks to what extent skin cancer protection is covered by golfing magazines? For a sport with a higher than average rate of skin cancer among its participants (Matthews et al., 2018), the dearth of content related to protecting their health while playing the sport is noteworthy. Over the course of 20 years, three golfspecific magazines published 72 articles related to skin cancer and ultraviolet solar radiation protection advice. Some content was nothing more than an endorsement of a brand of sunblock and a caption about its favorable attributes (e.g., scent, sweat-proof).
Often, the text presumed that the reader understood that sunblock lotions, sunglasses, term "sun damage" were discussed frequently, but the accompanying imagery tended to be illustrations of men, the sun, or products. One photograph published together with a message about sun protection was of a blonde professional golfer in a cheesecake pose wearing a mini-dress with her bare shoulders and arms exposed. If the images of golfers are limited to older men, younger men may not connect that they are a susceptible group.
Cartoons of men in exaggerated brimmed hats, illustrations of golfer faces as roasted marshmallows, and golfers photographed from behind may hinder the questioning of susceptibility by those most at risk.
Some of the most impactful photos published were the mugshot-style ultraviolet photographs of four professional golfers, ages 53-58, next to their color photos. Sun damage to their heads was evident, and their first-person accounts of painful sunburns, surgical procedures, and impressions about their damaged pigmentation was compelling.
The golfers interviewed said they enjoyed reading about professional golfers, and this article stood out from the rest for inclusion of candid remarks and impressions. The 5,696-word article was peppered with first-hand accounts of PGA players, the impacts of too much sun exposure, skin cancer prevention and treatments, and advice from dermatologists. It also featured photos of an assortment of moles and cancer lesions to help readers learn how to identify their own skin concerns.
Golf professionals, according to the men interviewed, are seen as authorities and their opinions about golf are influential. If the pros were to speak more openly and candidly about their own skin cancer treatments, the effect on amateur sportsmen would help raise awareness of the frequency of diagnosis, the severity of the disease, and the ability to engage in self-protection to avoid similar consequences. One interviewee said he hoped that professionals would endorse items such as wide-brimmed hats so that the hats would become fashionable and sought-after, rather than ridiculed. The extent of the impact of the 64 articles evaluated is unknown but among those interviewed in this research, the editorial content had little impact. The men did not recall reading content in these three magazines about the risks of sunburning and overexposure to ultraviolent radiation, therefore messaging about their skin cancer risks did not have enough impact to influence behavior.

Limitations
The content analysis retrieving all the content dating back 20 years had limitations due to copyright issues. More content is published in other mediums, especially golfing websites, whereby the content could be more engaging, interactive, and informative. The Because the study lacks information about how much content was read in the golf magazines by the men interviewed in the study, future researchers can do an experimental study in which a sample of male golfers are provided editorial (and/or advertising) content with skin cancer information (e.g., their unique susceptibility to skin cancer, the disease's severity, purported barriers among male golfers, information about the beneficial outcomes of adopting healthy skin practices, and actions promoted to help them prevent skin cancer as well as identify signs of disease). Contrasting this group of male golfers with another group of male golfers who have not been exposed to that messaging through a follow-up survey to see if they have changed any of their sun protective behaviors about golfing can illuminate the effectiveness of the channel.

Conclusion
Opportunities exist for golf magazines to engage more frequently with readers about the skin cancer realities of the sport. Content that addresses susceptibility factors, such as statistics about skin cancer diagnoses among male golfers; melanoma fatality statistics; and the growing risk to males under age 35 is warranted. The severity of the physical and emotional pain associated with a cancer diagnosis has not been fully or frequently conveyed to readers. For future content to be effective, it will need to confront barriers, such as masculinity norms and the lack of regimented protection routines, and encourage men to adopt the behaviors that will be most efficacious for their health.
Writers and editors should not shy away from using the term "skin cancer" or "melanoma" when promoting the benefits of products such as sunblock, sunglasses, and wide-brimmed hats. Advertising by manufacturers of these products should take notice of the opportunities for increased awareness and concentration of the cancer-protective attributes of their merchandise. For designers of public education campaigns, adding the perspective of golf professionals who have experienced skin cancer with increased frequency to articles will help get traction with this high-risk audience who respect PGA celebrity players. The Office of the Surgeon General (2014) specifically recommended targeted media messages for male golfers about their unique cancer risks and how and when to use sun protection. The explicit mention of cancer as a player risk, demonstrations about how to apply sunblock, and why the ultraviolet protective measures used in tandem will offer the most protection is essential.

APPENDIX B
Sample images from golf magazines analyzed for skin cancer content in golf magazines.
Images and content that explains how to spot a mole that needs to be examined by a medical professional. This self-test is commonly referred to as the ABCD test, an acronym for asymmetry, border, color and diameter.
Professional golfer Ernie Els is pictured applying a heavy coat of sunscreen to the areas most at risk for UV solar damage: The face and the back of the neck. (Dimenna, 2005).
The caption, "I've been through my battles of having stuff burned offpre-cancerous actinic keratosis. I go twice a year and get checked" accompanied these side-by-side photographs of Senior PGA golfer Steve Flesch. (Rudy, 2019).