Health-Risk
Communication
Alicia Sokol
April 2003
Key Objectives
After
completing this chapter, the reader should be able to:
Introduction
This
chapter is intended to inform and prepare those responsible for communicating
topics of health concern, including government officials, health-care
providers, public health workers, agencies and associations committed to
maintaining public health, to those who may be vulnerable. It is important to
note that this chapter provides merely a basic framework, and that individual
situations should be assessed based on the specific needs and priorities of
those at risk.
What is health-risk communication?
Health-risk
communication, when effective, prevents or mitigates adverse human health
outcomes related to 1) hazardous substance exposure (ATSDR, 2001), such as
occupational and environmental exposures to toxic chemicals; 2) health-risk
behaviors, or 3) product safety and
consumer protection (Allen). Communications may include information about
community health concerns, possible health outcomes, demographics, resource
availability and environmental factors. Gathering this information quickly
often requires a collaborative effort by health-care providers, state and local
government representatives, citizens’ groups and community residents. Active
involvement and quick turnaround by all parties involved are essential to
collecting necessary facts and creating an effective plan to disseminate
information to critical audiences.
Health-risk
communication is a burgeoning area of focus. The public has become increasingly
aware of possible threats to public health caused by chemical and physical
agents. Plans for communicating relevant and timely information are needed to
ease public panic and allow for quick action in the event of an imminent health
risk.
A Word on Credibility
credibility (noun) – the
quality of being believable or trustworthy.
In communicating messages to any group of individuals,
credibility is first and foremost. Without it, even the most clear, concise,
well-delivered message will be completely dismissed by the audience. Once lost,
credibility is difficult to regain. Therefore, it is critical for a
communicator to gain and maintain the trust of his audience. Hence, credibility is tantamount to the
success of any risk-communications plan.
Generating and maintaining credibility is not an exact
science, but there are a few simple points to consider. Honesty is obligatory.
The fastest way to destroy credibility is dishonesty. Second, actions are as
important, if not more so, than words. The target audience, especially if
skeptical, will keep a close watch on body language and emotional tone.
Audience members will look for caring and compassion, and will know when these
sentiments are feigned. Third, follow through with promises. Do not make claims
that cannot be honored. This will destroy the audience’s confidence in future
claims.
Health-Education
Concepts
The health-education
concepts described below are helpful in understanding the basis for effective
health-risk communications strategies.
The Health-Belief Model
Perhaps the
most important health behavior model for understanding effective risk
communication strategies, the health belief model is based on an individual’s
belief in his own susceptibilities to a disease or condition, its severity, the
effectiveness of prevention and treatment techniques, and his own capacities
for making use of those techniques (Rosenstock & Cullen, 1994). The health
belief model is built upon the idea that an individual will protect his health and
actively screen for and treat disease if certain characteristics apply. The
individual must believe he is personally susceptible to the disease, that the
disease will have serious effects on his health, that his actions can limit the
ill-effects associated with the disease, and that the benefits of taking action
to control the disease will outweigh the costs. Many outside factors influence
each of these beliefs. Some believe that sociodemographic factors, such as
education level, have a strong bearing on these individual beliefs.
The health
belief model was developed in the 1950s and has since been extended and
refined. One notable addition to the model is Bandura’s concept of
self-efficacy, which relates to an individual’s belief that he can effectively
take action to protect his health. For instance, one who is at risk for
exposure to a harmful agent may take action to prevent exposure. He must believe
that taking action will protect him and that he can successfully carry out the
particular strategy (i.e. receiving a vaccine).
This model
clarifies the role of effective health-risk communication. According to the
model, a successful communications strategy must not only provide information
about the hazard but must also outline preventive actions and stress
self-efficacy. The model is built such that audience-specific concerns can be
addressed in creating an effective communications plan. For instance, in
communicating the risk of exposure to influenza in a community of elderly
individuals, the model stresses the importance of clearly defining the severity
of the flu virus to an elderly individual as well as the effectiveness of
receiving a flu vaccination. If effective, the community would be convinced of
the flu’s potential harm, aware of actions to prevent infection, and if there
is a belief in the effectiveness of the prevention mechanism, likely to take
steps for protection.
Social Learning Theory
Social
learning theory relies on an individual’s interactions with those around him
and the values he places on behaviors and corresponding outcomes. The theory
also relies on environmental factors that influence an individual’s behavior.
Social learning theory is built on the concept of observational learning,
meaning that an individual can learn by watching others and noting the benefits
or costs of the actions chosen. One of the theory’s most critical constructs in
determining behavior is behavioral capacity, which distinguishes between
knowledge and skill (Rosenstock & Cullen, 1994). This concept implies that
a person must be able to identify a behavior as well as know how to perform it.
Social learning theory provides a valuable theoretical framework for creating
multilevel interventions that simultaneously address individual action and
environmental action.
Diffusion Theory
Diffusion
theory centers on the process by which information is communicated among
members of a social system. Key components of the diffusion theory are the
resource system, comprised of the “experts” creating ideas and innovations, and
the user system, comprised of those receiving these ideas. The theory specifies
certain attributes that ultimately lead to success or failure. Ideas or
concepts likely to be diffused successfully or adopted should be easy to
understand, flexible, cost-effective, low-risk, reversible and compatible with
the community’s value system.
Early
diffusion theory models involved a straightforward approach to disseminating
information to the appropriate parties and making necessary changes. Recent
models of diffusion theory are more complex, involving additional steps to
ensure and maintain changes in behavior to reach a desired outcome. A multistep diffusion process is identified
as follows (Rogers): 1) recognition of a problem or need; 2) basic and applied
research; 3) development, in which an innovation is given a form intended to
meet the needs of a particular population; 4) production, marketing and
distribution; 5) diffusion and adoption; and 6) consequences (Rosenstock &
Cullen, 1994).
The
diffusion theory is useful in planning health-risk communications because it
presents a framework for communicating new research findings or innovations to
a community. In addition, the diffusion theory provides a way to use proven
techniques in creating effective health-risk communications programs.
Identifying Relevant
Audiences
The first
step in creating an effective health-risk communications plan is to identify
target audiences and their concerns. Identifying specific characteristics of
the audience allows special consideration to be made in choosing messages and
communication channels. It is also meaningful to learn how the community
gathers information (via television, newspaper, local officials, other
residents, etc.), whom they trust for information, and their perception of
risk. Additionally, it is helpful to understand attitudes, opinions, education
levels, topical knowledge levels and community involvement. For example, when planning communications
channels, knowing that a target audience spoke and read only Spanish would be
useful. This information assists in choosing appropriate communications
materials – in this case, brochures and pamphlets in English would not be well-suited
to the audience.
Pertinent audiences
may include employees, community residents, health-care providers, government
officials, media and regulatory agencies. Identifying groups or individuals who
may show opposition to the communication, or provide challenges in delivering
the information, is helpful in determining how to navigate potential road
blocks.
Risk Perception
A variety
of factors affect an individual’s perception of the severity of risk.
Statistical data and scientific facts are a strong influence, but people also
are affected by factors specific to the risk itself.
Health
risks are generally most worrisome if perceived as:
(Adapted
from Bennett)
Risk
perception plays a central role in risk communication because it takes into
account the attitudes and fears of the audience receiving the message.
Sensitivity to these attitudes not only allows those delivering the message to
show an extra measure of compassion and support, but allows an opportunity to
build credibility by understanding and responding to these perceptions.
Message Development
Messages
must be clear, concise and consistent. The process of creating and updating
messages is ongoing in a health-risk communication setting as information
evolves. Nevertheless, baseline ideas and objectives should be clearly outlined
and should remain stable throughout the communications process.
Education
is part of the message development process in many health-risk communication efforts.
Scientists, physicians or public health workers need to start the
communications process by allowing the audience to understand the concerns from
a medical or scientific standpoint. This information may include specifics on
the particular agent involved, basic toxicological information, how adults
and/or children might be affected, entry pathways and treatment options for
exposed individuals. These messages should be specifically tailored for easy
understanding by the target audience. For example, a group of at-risk health
care workers would have a different level of concern and understanding than a
community of at-risk migrant farm workers. In either case, language should be clear and understandable to
those at risk.
When
creating messages, the following questions should be considered. What harmful
element or elements exist? How have these elements become a hazard? Who is at
risk for exposure? How can exposure be avoided or the risk of exposure
minimized? What is being done to protect those at risk? What treatment options
are available to those exposed? What short- and long-term effects can be
expected in those exposed? What organizations or agencies are responding to the
crisis? Who is available to address questions of concerned individuals and how
can they be reached? What are possible solutions and alternatives? What costs
are associated with each alternative or solution? Who is responsible for
decision-making? Are there legal issues involved? What additional information
sources are available?
Once basic
messages have been crafted, communicators should be trained to deliver the
messages in a variety of situations. For example, spokespersons should be designated
and prepared to address the concerns of community residents, government
officials and media. An effective communicator is able to anticipate anger and difficult
questions and prepare answers to sticky issues. The spokesperson should be
prepared to allow the audience to share input and express worries. This eases
alarm and allows audience members to feel like they are a part of addressing
the problem and delivering the solution. This approach also minimizes the
possibility of escalated conflict and unbalanced focus on secondary issues.
Channels of
Communication
As mentioned
previously, achieving effective health-risk communication requires knowledge of
the habits and preferences of the target audience. For instance, it would be
pointless to use the print media to deliver a message to a largely illiterate community.
Similarly, it would be ineffective to deliver an urgent health-risk message via
e-mail to employees who do not have regular access to computers. One must
understand how to best communicate with the target audience, including who
audience members trust, and how and where they get their information.
Following
is a list of potential audiences with corresponding communication channels.
Each specific situation is unique, so the following list is meant as a general guideline
Community Residents – Rural
Community Residents – Urban
Employees
Government officials
Media*
*Media is,
in and of itself, a channel of communication or medium. In this case, it is
used as an audience because of its power to broadly communicate public health
messages to a wide array of audiences.
Effective Question
& Answer
Inevitably,
questions arise when health risks are present. Key messages are valuable when
handling questions. They should be reiterated whenever possible. It is helpful
to anticipate likely questions from various audiences and formulate answers
ahead of time. Practice answering a variety of questions to become more
comfortable in delivering clear, succinct answers. This technique is especially
useful in dealing with difficult questions that lack easy answers. Preparation
is critical in handling these questions smoothly.
The first
rule of effective question and answer is to be prepared to listen. Show the
audience that its questions are important and that each question will be given
care and consideration. When fielding questions in person, make eye contact, be
attentive and become engaged in the dialogue. Avoid interrupting the speaker
before he is finished asking the question.
Answers to
questions should be concise, on-point and thought through carefully. Do not
stray from the point or to cover unrelated topics when addressing a specific
question. Be sure the question is understood, and if it is not, ask to have it
clarified or repeated. Do not answer “no comment.” This response is suspicious
and hints that there is something to hide. If the answer to a question is not
known, it is better to tell the truth and get back to the question later.
Never, under any circumstances, lie or guess at an answer when uncertain. It is
acceptable to say, “We do not know at this time.” Be sure to follow up and provide
an accurate answer when one is available.
Every
question, even the tricky ones, present an opportunity to drive home a key
message. Use the following phrases to make a smooth transition or weave in
messages when appropriate:
“What is
important to remember is…”
“What I
think you are really asking is…”
“What I can
tell you about our recommendation is…”
“What I’d
really like to emphasize is…”
“Let me put
this in perspective…”
(Nelson,
2002)
Finally,
the sensitivities surrounding health risk naturally lend themselves to
emotions. If emotions become heated, resist the temptation to become defensive
or argumentative, and remain calm. It is never productive or professional to
engage in a heated shouting match. This type of behavior can destroy
credibility and create distrust.
Working with the Media
The media,
or “the press,” refer to individuals working in various capacities to deliver
news to the public. The media can play an important and unique role in
communicating health-risk information to the public because of their broad
reach. An estimated 100 million households in the United States watch
television several hours every day (A.C. Nielsen) and tens of millions of Americans
listen to the radio or read a newspaper daily (Nelson). In addition to bringing
news to various audiences, the media play a major role in determining which
people, issues and events are newsworthy.
All reputable
journalists share the same overall mission – to report news in a factual,
impartial fashion. Media outlets can be broken down into two main categories –
print and broadcast. The print media includes primarily newspapers, magazines,
newsletters, and trade publications. Print media are produced by reporters and
editors, who work together to bring news stories to life on paper. Broadcast
media refer to television and radio. Bringing television and radio broadcasts
to viewers and listeners requires the work of reporters, news directors,
production staff and technical staff.
What is news?
How do the
media decide what is newsworthy? In general, reporters are interested in information
that appeals to and affects the interest of the mass public. Often this
includes information pertaining to public health, lifestyle and recreation,
human interest stories, people’s perspectives, public policy and “bad news”
(i.e. crimes). Risks to public health are more likely to gain media attention if
there are questions of blame, alleged secrets, attempted “cover-ups,” links to
existing high-profile issues or personalities, risk of mass exposure, strong visual
impact and links to crime (Bennett). Be mindful of these “media triggers.” While
it may not be possible to deter negative media attention, carefully crafted,
consistent messages play a key role in diffusing it.
It is
necessary to develop and maintain relationships with key media. In some cases,
it is helpful to build media relationships on both local and national levels.
Establishing these relationships early and actively maintaining them is
especially helpful in the event of crisis communications. Knowing which
reporters to call and how they work takes much of the guesswork out of broadly
disseminating news in an expedient fashion. Good relationships also increase
the chances of balanced, accurate coverage (Lundgren & Makin, 1998).
Communicating with the Media
In working
with the media, one must be prepared to handle reactive communications as well
as proactive communications. Reactive communications are required when a journalist
shows interest in a particular topic and requests help in reporting that topic.
Most often, reporters have very tight deadlines. They need to research a story,
interview spokespeople and write or produce a finished piece in a number of
hours. For this reason, it is important to respond to requests immediately.
Even if unable to assist a reporter, it is critical to the relationship to
respond in a timely manner. Proactive communications involve taking a story
idea to a reporter in hopes of interesting him or her in writing or producing a
story. Offering a story in this fashion is called a “pitch.” Story pitching can
be tricky if the topic does not involve breaking news or an urgent threat to
public health. Careful execution when pitching is critical to the success of
future pitches. For example, failure to determine what is newsworthy can lead
to inappropriate and unnecessary proactive communications (Nelson). Reporters
are less likely to consider future pitches from a source if they do not believe
there is legitimate news. Finally, it is helpful to think through all elements
of a story before making contact with the targeted reporter. For
instance, what are the issues? Who is affected? What expert sources are available
for the reporter to interview? Are there compelling visuals to the story
(critical for television)?
Reporters
can be reached in a variety of ways. The best approach varies dependent on the
nature of the news. News involving an immediate threat to a community (i.e. a
rash of tuberculosis cases) would be handled very differently than a more
long-term risk (i.e. a high rate of childhood lead poisoning). If the news potentially
could incite fear or anger, it is best to try to contact the media proactively
rather than wait for the phone to ring. Journalists do not like to be taken by
surprise or caught off-guard. In addition, a reporter has a better chance of
delivering an accurate report if given more time and sources. A press
conference is an efficient way to reach many reporters simultaneously. In most
cases, press conferences allow for questions and answers. Press conferences can
be used in conjunction with press releases and other written materials (fact
sheets, brochures). If possible, press conferences should be held early in the
day to allow newspapers time to place the story in the following day’s edition.
Levels of Media Involvement
Media
involvement varies in accordance to the type of risk communication. For
example, when a crisis presents immediate danger to a community, the media will
begin reporting details quickly, often without complete information. The
priority of the media in this situation is to alert the public to the danger
and provide information to allow people to protect themselves and their
families. As more information develops, reporters will continue to deliver new
developments to keep the public abreast of the latest information. Once the
public is out of immediate danger, the press may launch an investigative report
to determine what led to the emergency, potentially offering solutions.
Another
style of media coverage and involvement occurs when an outlet chooses to report
on a specific issue or long-term health risk to the community. This type of
reporting allows for more thorough, in-depth research and more balanced
reporting than in the case of a crisis. A reporter may provide background
information on the problem, detail the negative consequences associated with
the risk, and offer ways for individuals to reduce risk to themselves and their
families. To gather important factual information, the reporter obtains
background information from a variety of sources and interviews a handful of
experts to include in the news report.
Finally, a
media outlet may become very involved in a particular issue and take an
advocacy role. Key decision makers at the outlet, such as editors or senior
producers, may meet with elected officials or opinion leaders to discuss the
nature of the risk, its alternatives, consequences, benefits and possible
solutions. They may use editorials or other opinion commentary, such as op-ed
pieces, to support their position. Editorial boards, a collection of media
representatives, may work with key stakeholders to describe the nature and
consequences of a risk and its potential solutions (Lundren & Makin, 1998).
Errors and “Bad Press”
Unfortunately,
the media do not always report desirable stories and occasionally, inaccuracies
occur. As media contact increases, so does the likelihood of being misquoted or
having information taken out of context (Nelson). In most situations it is best
to ignore minor errors. If an error is particularly egregious, it is possible
to ask the outlet for a correction. The publication may or may not decide to
grant the request. Another option is to write a letter to the editor or submit
an op-ed piece that addresses the issue. However, the publication may choose
not to print such pieces. Finally, relations with the media should be kept on a
professional level at all times. When “bad press” occurs, keep in mind the
importance of maintaining working relationships with media for the benefit of
future issues – both positive and negative.
Measuring Effectiveness
As
mentioned earlier, health-risk communications programs are used to address a
variety of issues, from behavioral health risks such as smoking and substance
abuse, to the importance of immunizations, to environmental exposure to toxic
chemicals. In the context of risk communication, evaluation refers to any
purposeful efforts to determine and measure the effectiveness of risk-communication
programs (Fisher, Pavlova & Covello, 1991). Program evaluation is necessary
to ensure that health-risk messages are disseminated in an efficacious fashion,
reaching the targeted audience through appropriate channels. Evaluation
techniques vary depending on the stated goal. Common goals include raising
awareness, changing behaviors and educating people to make informed decisions.
Program
evaluation provides useful information for planning and program execution, and
can indicate the need for modifications. In addition, evaluation highlights
program accomplishments and can justify program budget expenditures in a
quantifiable way. Programs that show success in achieving stated objectives are
likely to receive funds to continue their work, and possibly additional funding
for program expansion.
In the
planning phase, evaluation efforts assist in designing critical program
elements. A variety of tools, including focus groups, surveys and questionnaires,
can be used to identify relevant audiences, obtain initial audience opinions
and attitudes, identify important problems perceived by the audience, uncover
issues and events people are aware of and determine how people react to
different sources of information. Pilot testing can be used to predict efficacy
and feasibility of alternative communication activities, determine the kinds of
information needed by target audiences to understand risk communication
materials, examine how people process and interpret risk communication
information, and obtain feedback on draft materials (Fisher, Pavlova &
Covello, 1991).
No matter
how basic the health-risk communication, careful planning and goal-setting are
necessary to meaningfully evaluate the program’s success, or lack thereof.
Types of Evaluation
Following
are four major types of evaluations that can lead to more effective health-risk
communication when used appropriately: formative, process, outcome and impact
(NCI, 1992).
Elements of Evaluation Design
There are
eight basic elements required of formal evaluation design regardless of
evaluation type.
Clear, defined goals must be stated in order for evaluators
to measure program effects.
This determines what is to be measured with respect to the
stated program goals.
Study design must be formulated to permit valid, reliable
measurement of data.
Instruments used in data collection must be designed and
pretested. Such instruments can range some simple tally sheets to elaborate
surveys and questionnaires.
This involves the physical process of gathering information.
This includes converting the collected data into a usable
format for analysis
This allows discovery of significant relationships through
the application of statistical techniques.
This involves compiling and recording evaluation results.
From reported results, changes to the existing program can be made. In
addition, new programs can be planned using reported results as a guide and
benchmark.
(NCI, 1992)
Difficulties in Evaluation
A variety
of barriers exist in evaluating health-risk communications programs. Awareness
of these difficulties assists in anticipating possible roadblocks. Resources
are a key constraint to optimal program evaluation. Limitations on funds,
staffing, time, equipment and tools can interfere with evaluation.
Additionally, when working with a variety of groups or agencies, it may be
difficult to agree on program objectives and goals. A lack of clearly defined
objectives leads to trouble in creating suitable measures for evaluating a
program. Finally, it may be difficult to separate specific program influences
when evaluating long-term effects because of the intended audience’s exposure
to outside factors (ATSDR).
Conclusions
Effective
health-risk communication is crucial to health promotion and disease
prevention. The role of risk communication is becoming increasingly important
as new threats surface. Recently, public concern about health risks has become
heightened because of bioterrorism threats, West Nile virus, SARS, anthrax,
dietary supplements, pesticides, mercury in childhood vaccines, and radiation
from nuclear weapons testing, to name a few. As a result, health practitioners
must learn and exercise effective methods for educating the public, calming
fears that may lead to irrational behavior, responding to inquiries, offering
resources and using various channels to communicate new information quickly and
efficiently.
The
following rules provide a brief summary of some topics discussed in the
chapter. This list, developed by Covello and Allen (1988), acts as a set of
“commandments” for health-risk communications, and neatly summarizes several
general rules of thumb.
Seven Cardinal Rules of Risk
Communication
Work to produce an informed public, not defuse public
concerns or replace actions.
Different goals, audiences, and media require different
actions.
People often care more about trust, credibility, competence,
fairness, and empathy than about statistics and details.
Trust and credibility are difficult to obtain; once lost,
they are almost impossible to regain.
Conflict and disagreements among organization make
communication with the public much more difficult.
The media are usually more interested in politics than risk,
simplicity than complexity, danger than safety.
Never let your efforts prevent your acknowledging the
tragedy of an illness, injury or death. People can understand risk information,
but they still may not agree with you; some people will not be satisfied.
References
A.C. Nielsen. http://www.acneilsen.com. Accessed July
12, 2001. In: Nelson DE, Brownson RC, Remington PL, Parvanta C eds. Communicating Public Health Information Effectively: A Guide for Practitioners. Washington,
DC: American Public Health Association; 2002.
Agency for Toxic Substances and Disease Registry (ATSDR). A
Primer for Evaluating Health Risk Communication. Atlanta,
GA: U.S. Department of Health and Human Services, Public Health Service. http://www.atsdr.dcd.gov/HEC/evalp1.html
Agency for Toxic Substances and Disease Registry (ATSDR).
2001. A Primer on Health Risk Communication Principles and Practices. Atlanta, GA: U.S. Department of Health and Human Services,
Public Health Service.
Allen FW. The government as a lighthouse: a summary of
federal risk communication programs. In: Covello V, McCallum D, Pavlova M eds. Effective Risk Communication: The Role and
Responsibility of Government and Nongovernment Organizations. New York:
Plenum Press; 1989.
Bennett P. Communicating About Risks to Public Health:
Pointers to Good Practice. EOR Division, Department of Health. United
Kingdom.
Covello
V, Allen F. 1988. Seven Cardinal Rules of
Risk Communication. U.S. Environmental Protection Agency, Office of Policy
Analysis, Washington, DC. In: Agency for Toxic Substances and Disease Registry (ATSDR). 2001. A Primer
on Health Risk Communication Principles and Practices. Atlanta, GA: U.S. Department of Health and Human Services,
Public Health Service.
Covello V, McCallum D, Pavlova M eds. Effective Risk Communication: The Role and Responsibility of Government
and Nongovernment Organizations. New York: Plenum Press; 1989.
Fisher A, Pavlova M,
Covello V. interagency Task Force on
Environmental Cancer and Heart and Lung Disease, Committee on Public
Education and Communication, January 1991, pp. xvi-xvii http://www.health.gove/environment/Casestudies/csapp3.htm
Glanz K, Rimer B,
Lewis FM. 2002. Health Behavior and
Health Education: Theory, Research, and Practice. Third Edition. San
Francisco: Jossey-Bass.
Lundgren R, Makin AM. 1998. Risk Communication: A Handbook for Communicating Environmental, Safety
and Health Risks. Second Edition. Ohio: Battelle Press.
National Cancer
Institute (NCI). 1992. Making Health
Communication Programs Work: A Planner’s Guide. U.S. Department of Health
and Human Services. Public Health Service, National Institutes of Health,
Office of Cancer Communications, NIH Publication No. 921493.
Nelson DE, Brownson
RC, Remington PL, Parvanta C eds. Communicating
Public Health Information Effectively:
A Guide for Practitioners. Washington, DC: American Public Health
Association; 2002.
Rosenstock L, Cullen MR. 1994. Textbook of Clinical Occupational and Environmental Medicine,
Philadelphia: Saunders; 68.