Methodology and
Organization
Case
Study Profiles
Health
Risk Communication Description and Overview
Through development work and
literature reviews, the Subcommittee found that, with the
possible exception of the National Cancer Institute (NCI)
of the National Institutes of Health (NIH), most PHS
agencies do not systematically apply agency-specific
principles and standards in practicing effective health
risk communications. NCI, in 1989, made a significant
contribution to the study and practice of health
communications by developing a six-stage approach to
health communication, commonly referred to as the
"health communication wheel." The major steps
in the NCI wheel are designed to integrate assessments of
target audience needs and perceptions at critical points
in program development and implementation. A slightly
modified version of the NCI wheel (Appendix 2) has been incorporated into the
Subcommittee's recommendation for recognizing proven
methods in health risk communications.
Further assessment revealed that most PHS agencies either
were familiar with or had applied in varying degrees the
model standards of risk communication developed by EPA.
The Seven Cardinal Rules of Risk Communication, as
identified by EPA, are as follows:
- Accept and involve the public
as a legitimate partner.
- Plan carefully and evaluate
your efforts.
- Listen to the public's
specific concerns.
- Be honest, frank, and open.
- Coordinate and collaborate
with other credible sources.
- Meet the needs of the media.
- Speak clearly and with
compassion.
Some PHS agencies indicated that although they agreed
with the basic assumptions and principles contained in
the Seven Cardinal Rules of Risk Communication, they had
difficulty actually applying them to daily health
communication activities and decisions. Although many of
the EPA rules seem obvious, they are continually and
consistently violated in communicating with the public
about health and environmental risks.
It was clear from the preliminary assessment that further
investigation was needed to identify some of the specific
factors that contributed to a health risk communication
message or activity's effectiveness. The Subcommittee
proposed that a formal study be conducted to determine
more precisely how PHS agencies were communicating
information about risk, how effective these
communications were, and what specific principles,
strategies, and practices best promote more effective
health risk communication outcomes. The study was to be
planned and conducted by members of the Subcommittee on
Risk Communication and Education, who also were to
prepare the final report.
Because a case study approach was planned, the
Subcommittee circulated a memorandum in January 1992,
requesting that all Subcommittee member agencies submit
examples of health risk communication activities or
decisions they perceived to be effective or less
effective. Of the 10 case studies received, 7 were
submitted as examples of effective health risk
communication and 3 as examples of less effective health
risk communication. The 10 case studies are each
organized into 4 sections:
- Case description provides
background information on the events or actions
that preceded and occurred during the health risk
communication process;
- Characterization of risk identifies the
specific health risk issue or problem, the scope
of the problem, and levels of public concern;
- Health risk communication procedures
discusses the specific methods and strategies for
communicating information about health risks; and
- Outcomes and benefits examines the results
and the overall effectiveness of risk
communication efforts.
Information contained in the case
studies describing the agencies' health risk
communication strategies and practices was compared with
EPA's Seven Cardinal Rules of Risk Communication.
Frequency counts of EPA's Cardinal Rule critical elements
were tabulated on both a cross-case and individual-case
basis (Appendix
1) . The relationship of
the tabulations was further examined by calculating
second-order numbers such as means and percentage
distributions.
Case
Study Profiles
The first case study discussed in this report is from the
National Cancer Institute (NCI), National Institutes of
Health (NIH). It reveals how a multimedia approach, along
with improved diagnostic procedures for malignant
melanoma, directly affected disease incidence rates and
resulted in significant cost savings.
Like NCI, the National Library of Medicine (NLM), NIH,
relied on mass media, in this case, a national online
information network, to inform health professionals about
recent clinical trial findings and studies of medications
and new procedures. Immediate access and the relative
speed with which information could be disseminated were
perceived advantages over other forms of communication
such as press conferences and direct mailing.
The third case history was contributed by the National
Center for Environmental Health (NCEH) of the Centers for
Disease Control and Prevention (CDC). Faced with the
difficult task of communicating to the public the
findings of a study to estimate radiation doses to the
community, CDC made use of multiple media to explain the
project and build public trust.
The fourth case study, which comes from the National
Institute of Environmental Health Sciences (NIEHS), NIH,
shows how the effective use of timing, message clarity,
and organizational commitment can help to balance the
perceptions and interests of competing audiences (in this
example, public advocacy groups and commercial
enterprise) in the fluoridation of public water supplies.
In the fifth case study, the National Institute of Mental
Health (NIMH), NIH, discusses the role of an intervention
program in reducing risky sexual behaviors among runaway
youths in New York City who are at high risk for
contracting HIV. Intervention activities specific to the
communication of HIV health risks—counseling sessions,
training in coping skills, and video and art workshops—showed
significant increases in HIV knowledge and
positive attitudes toward the prevention of HIV
infection.
The sixth case study illustrates the role of information
and education in increasing the knowledge and
understanding of health professionals about the health
risks of hazardous substances in the environment. Case
Studies in Environmental Medicine, developed by the
Agency for Toxic Substances and Disease Registry (ATSDR),
are designed to: (1) enhance the knowledge of health
professionals about the recognition, treatment, and
prevention of illness or injury of persons exposed to
hazardous substances and; (2) improve the ability of
health professionals to communicate health information
concerning hazardous substances to their patients and the
concerned public. Feedback from health care professionals
indicates that communication between physician and
patient about the health effects of exposure to hazardous
substances has improved.
In case study seven, a manufacturer of heart valves
informed the Food and Drug Administration (FDA) of its
intent to organize an extensive media outreach and letter
notification program to identify, locate, and notify
patients whose implanted heart valves were defective.
Statistical data had shown a higher-than-normal incidence
of valve fractures, generally resulting in death. Once
contacted, patients were advised to discuss with their
physicians the risks and emergency procedures to follow
in the event of valve fracture and to join an implant
registry for any future notifications. FDA reviewed
several versions of the patient notification letter to
clarify the risk communication message. Activities such
as hospital record searches, media outreach, and
enrollment incentives resulted in 16,000 out of a
possible 23,000 patients being notified.
The eighth case study shows how competing interests can
affect a health communication campaign. The efforts of a
manufacturer of analgesic drugs (acetaminophen) taking
issue with an NIEHS study that linked acetaminophen use
to kidney disease point to the need for PHS agencies to
be aware of the ability of private commercial interests
to influence public concern and sentiment.
In the ninth case study, ATSDR's attempts to improve
public trust and credibility in a community concerned
about a hazardous waste site are described. The case
involves a rural site that was included on EPA's National
Priorities List (NPL) in 1986 because of public health
concerns due to on-site chemical contamination. Through
community organization techniques, interpersonal contact,
and a variety of media strategies, ATSDR has attempted to
improve its working relationship with local residents in
the community. The success of the community intervention
remains indeterminate.
In the tenth case study, a manufacturer of a
temporomandibular jaw (TMJ) implant was ordered by FDA to
conduct a patient notification program. Patient
notification was necessary after clinical studies showed
a higher-than-normal incidence of device failure with
serious consequences. The manufacturer subsequently
declared bankruptcy, forcing FDA to assume responsibility
for conducting the notification effort. Media outreach
and letter notification activities were aimed at
identifying, locating, and notifying patients. Those
contacted were advised to take appropriate protective
actions: having a professional evaluation by a physician;
having implants removed, if warranted; and joining an
implant registry established to facilitate future
notifications.
Health
Risk Communication Description and Overview
The communications input-outcome process
is shown in Table
1 . The communications
attributes and practices of PHS agencies are organized in
the matrix according to the five major components
(source, message, channel, receiver, and outcome) in the
communication-feedback process. The
communication-feedback transaction is a form of
communication designed to transfer information from the
source (agency) to the receiver (audience). Every
communication event consists of a message, a channel for
sending the message, a receiver, and an outcome. The
message is the information that the audience is to
receive. The channel for sending the message may be mass
media, face-to-face communication, or some other channel
form. The receiver is the target audience.
Once implementation has occurred, the final step is to
evaluate the efficiency and effectiveness of the
communication strategy. A useful distinction can be made
between process and outcome and impact evaluation.
Whereas the purpose of process evaluation is to measure
how well communication messages, materials, and services
were implemented and received by intended audiences, the
goal of outcome and impact evaluation is to measure the effects
(e.g., changes in awareness, knowledge, attitudes, or
behavior) of the communication activity on the target
audience. The communication outcomes are evaluated for
the feedback needed to improve the health risk
communications process.
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