© 1999 by Oxford University Press
Journal of the National Cancer Institute Monographs, No. 25, 21-22,
1999
© 1999 Oxford University Press
Introduction of Section: Overarching Considerations in Risk Communications: Romancing the Message
Correspondence to: Joann E. Rodgers, M.S., Media Relations, Office of Communications and Public Affairs, The Johns Hopkins Medical Institutions, 550 N. Broadway, Suite 1100, Baltimore, MD 21205-2011 (e-mail: jrodgers{at}jhmi.edu).
If evaluation of factual information, by itself, informed the debate each of us has with ourselves about risky behaviors, this would have long ago been a nation full of nonsmoking, seat belt-wearing, lean, exercising, chemopreventing, sun-avoiding, health care-seeking men and women. That we are not such a nation also is underscored by the American experience with Alar, silicone breast implants, and screening mammography. They stand as powerful testimony not only to the influence and impact of the media on risk perception and behavior but also, most of all, perhaps, to the difficulty risk communicators face in crafting messages that individuals find meaningful (1).
Put another way, individual perception and assessment of risk is fundamentally a subjective enterprise. Groups do not decide to quit smoking. Individuals do. And emotional, temperamental, and life-history factors—along with factual information—guide the decisions we make—or do not make—about the information we seek or get. One person's adventure is another's mortal threat. She calls racing cars great fun; he calls it a mobile death wish. He cares little for annual prostate-specific antigen tests; she demands screening mammography at age 35 years. Consequently, whereas it may be popular in scientific circles, whining about "irrational" and "unscientific" public assessments of risk not only gets us nowhere, but it also threatens to turn off interest among the very people we most want to better inform about risks.
Communications and behavioral scientists have long demonstrated that the most effective way to teach, persuade, or attract attention is with one-on-one face time. Doctors talking to patients patiently, helping each one understand the risks and benefits of this or that decision. Teachers mentoring students intensively. Parents explaining something multiple times when their children are ready to listen. And, in the best of all possible worlds, and with unlimited resources, that is what we know would work best for communicating risk.
Realistically, however, in the risk communications business, one-on-one time, because it is resource intensive, must be selectively used; most of the teaching, persuading, and attracting of attention must be left to collective forms of communications and mass media. The mass communications perspective is robust but presents challenges of its own.
The good news is that mass media, especially, can be powerful and cost-effective venues for health risk messages. According to a 1997 Kaiser Family Foundation (2), three fourths of adult men and women consider magazines to be an "important" source of information on a variety of health topics, including breast cancer, pregnancy, human immunodeficiency virus or acquired immunodeficiency syndrome, and abortion. Results of a National Health Council (NHC) survey (3) reported earlier this year found that the media are the leading source for medical and health information among healthy 18- to 59-year-olds, although among those with chronic conditions, physicians are the primary source, followed by television news magazines and print news. Moreover, 53% of Americans, the NHC survey reported, say they have discussed a medical or health news story they saw or read with their doctor and that their doctors were mostly happy to do so. The survey found that 82% of the respondents believe health and medical news in mass media help them lead a healthy life and 58% report changing their behavior or having taken some type of action as a result of a medical news story (italics mine). Seventy-six percent said they took the advice offered in the story, particularly if it had to do with avoiding a certain food, increasing exercise, talking to a doctor, reducing or stopping smoking, and dieting.
The bad news is that there appears to be a disconnect between the value scientists and doctors place on the information disseminated by mass media and the value placed on it by viewers and readers. Doctors routinely label a significant portion of health and medical coverage sensationalized, incomplete, inaccurate, unbalanced, or misleading, whereas the vast majority of Americans find it highly credible. In the NHC survey, for instance, 87% of Americans consider 60 Minutes and 20/20 the most believable media sources, followed closely by television news in general (85%), daily newspapers (83%), and radio news (81%).
The worse news is that individuals come to mass media information and risk messages with an impoverished level of science literacy. A Dartmouth survey (4) of women 40-50 years old found they overestimated by 2000% their chances of dying of breast cancer within 10 years and exaggerated the relative reduction of risk by mammography screening by 600%. Also, they overestimated the absolute risk by 10 000%, according to Black et al. (4) And the still worse news: The women in the study had higher incomes and levels of formal education than the general population—91 of 145 had college or postgraduate degrees.
Other surveys have found that more than half of Americans incorrectly believe breast cancer is the leading cause of death for women, that four in 10 think spicy food causes and think Alar causes cancer, and that one third think eating sweets causes diabetes. In a landmark paper, Miller (5) reported that, in 1990, only 36% of American adults met even the most basic standards for scientific literacy as defined by a nine-item true or false quiz. On one question, for example, only 47% correctly disagreed that the earliest humans lived at the same time as dinosaurs. In a follow-up publication in 1998 in the National Science Board's Science and Engineering Indicators, Miller and Kimmel (6) reported that only 11% of Americans can define the word "molecule" and that only 20% understand what "DNA" means. Moreover, he wrote, only about one in three Americans understands the foundations of scientific inquiry—e.g., how theories are developed, how controlled experiments are designed, and how valid comparisons are made.
Additional complications and challenges emerge from both the routine and innovative activities of institutions and their public information and public relations staffs (Adams WC: personal communication). In their legitimate quest for attention, loyalty, funds, patients, and students, they do even less than the press to follow up or bring closure to previous breathless reports of "promising" advances or new discoveries that have an impact on risk perception. Does their work serve the cause of good risk communication? Or does it merely increase the noise-to-signal ratio by spewing out a constant stream of "promising solutions" to "medical problems" and risks in need of "cures" and "reductions" that involve tests, screening examinations, drugs, and expensive procedures. In press-release land, almost everything is a mortal threat.
How then to bridge this multiple credibility gap, lower the volume, clean out the confusion, and improve the process so that it works without resorting to propaganda or repeal of the First Amendment?
Sociologist Dorothy Nelkin has pointed out in numerous studies and books that the effect of messages delivered via mass media depends heavily on the social context in which the messages are received. In a 1996 article in the Lancet (7), she wrote that social context ". . . may include the readers' personal experience or prior knowledge, and the cumulative influence of previous media reports, popular representations and other sources of information . . . such as the television doctor stories." Seeking to trade on the impact of the latter, in fact, public affairs specialists at The Johns Hopkins Medical Institutions have persuaded the two top-rated "doctor shows" on television—Chicago Hope and ER—to tie in preproduced consumer health "programettes" designed to trade on the entertainment value of the shows to slip in presumably useful information. The concept behind "Living With Hope" and "Following ER" is enticing, and, in fact, it is successful, pulling in foundation grants and commercial sponsors. But whether or not this is a good use of resources, or even a credible form of public health education, is an unanswered question. Neither Johns Hopkins, nor the television producers, nor the funding agencies and sponsors have any idea why the spots might be effective, or whether anyone in the viewing audience finds the messages credible or merely another blob of "infotainment." The medium is powerful all right, but like a windmill's energy, sounds and images need a harness and a fixed channel to be useful. Some efforts are under way to evaluate the effect of "Following ER." The program's utility as a model depends heavily on sorting out what viewers are willing—or able—to bring to and take away from the experience.
Summarizing the overall focus of the panel devoted to overarching considerations in risk communications, it is helpful to mutate a phrase from recent presidential election politics: It's the context, stupid, along with the noise-to-signal ratio of risk messages. As with the economy, risk communication is a complex social science, not always amenable to exactitude and metrics. Thus, crafting and distributing messages that reach to the core of people's inner debate and grasp at behavior change remains an art as well as a science.
The experts gathered for this panel addressed some of these contextual considerations with novel insights into the process of communicating risks. Out of their remarks, it is hoped, will emerge some tips, based on their experience, to improve the process. In earlier conversations with them, all hummed a persistent leitmotif: the need to embrace the complexity of it all—to romance the message, if you will—if we wish to hit target audiences and make an impact.
In a world of limited resources, there are not enough means—even if we could figure out the ways—to reach every audience with every message. Priorities must be set, always a public policy challenge. Assuming key audiences are identified, audience attitudes, beliefs, behavior patterns, and values must be sorted out, along with what matters or does not matter to them as groups and as individuals. Cultural patterns, sex, age, class, and race must be figured into the sort, along with "influencers" that cut across all cultures, sexes, ages, classes, and races.
Fears must be not only correctly unveiled but also approached with caution. Women, for example, largely report breast cancer, or cancer in general, as their biggest health fear, although heart disease kills twice as many of them with symptoms and consequences every bit as crippling as cancer. But from a social and health policy standpoint, do risk communicators want to leave the two disease factions to duke it out with competing and conflicting risk messages or risk trivializing one risk or another?
Matthew Kreuter, an authority on health communication research at Saint Louis University, suggests that what little research there is in cancer risk communication has failed to account for how individuals with multiple and sometimes conflicting risks differ in their risk perceptions and behaviors, a failure with profound consequences for message crafters.
Elmer Huerta, a Peruvian-born physician with a long track record in using mass communication, especially radio, to inform the Hispanic community about health and health risks, and the founder of a nonprofit company that produces and distributes educational material for the Latino community in the United States, argues passionately for culture-based risk communications. In the Latino world, for example, failure to understand the particular bonds encompassed in the word "familismo" may well doom risk messages to the communications garbage heap.
Alfred Marcus, a behavioral scientist at the AMC Research Center in Denver, CO, combines an interest in communication research with practical experience in developing communication intervention messages for widespread use by managed care organizations and special populations. His remarks focus in part on identifying potential areas of research that will improve risk communications.
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REFERENCES |
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2 Treise D, Walsh-Childers K. 1997 Kaiser Family Foundation survey results. Presented at Conference for Magazine Editors and Writers sponsored by Columbia University Graduate School of Journalism and Kaiser Family Foundation; 1997 Apr 18.
3 National Health Council. 21st century housecall: the link between medicine and the media [online] [cited 1998 Feb] Available from: http://www.healthanswers.com/Sourc.../21st_century/21st_housecall-2.htm
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5 Miller J. The public understanding of science in the United States, 1990. Presented at annual meeting of the American Association for the Advancement of Science; 1991 Feb 15; DeKalb (IL): Public Opinion Laboratory.
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7 Nelkin D. An uneasy relationship: the tensions between medicine and the media. Lancet 1996;347:1600-3.[CrossRef][ISI][Medline]
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