© 1999 by Oxford University Press
Journal of the National Cancer Institute Monographs, No. 25, 35-42,
1999
© 1999 Oxford University Press
New Directions for Risk Communication Research: a Discussion With Additional Suggestions
Correspondence to: Alfred C. Marcus, Ph.D., AMC Cancer Research Center, 1600 Pierce St., Denver, CO 80214 (e-mail: marcusa{at}amc.org).
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ABSTRACT |
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The papers by Huerta and Macario and Kreuter share the theme of suggesting new directions for risk communication research in cancer prevention and control. Huerta and Macario remind us once again that sociocultural factors must be considered when conducting risk communication research on underserved populations. Of special note is their recommendation to target the family, which could introduce a compelling new chapter in risk communication research in cancer prevention and control. In contrast, Kreuter challenges us to consider multiple cancer risks and risk-reducing behaviors in our research and provides a provocative framework for achieving this goal. Given this common theme and the need to position specific recommendations within the larger context of other competing research questions, this paper also highlights several additional recommendations for future research. These recommendations include the following: more research on risk presentation; establishing guidelines for measuring risk; additional research testing strategies to de-bias optimistic and pessimistic perceptions of risk and evaluating risk communication as a strategy for behavior change; more research investigating the sociology of risk communication, with a special emphasis on the family as the unit of investigation; and, finally, more research that specifically targets underserved populations in diverse community settings.
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INTRODUCTION |
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I am delighted to have this opportunity to respond to the papers by Huerta and Macario (1) and Kreuter (2). Both papers share the common theme of suggesting new directions for research in risk communication. The main thesis of Huerta and Macario is that more research is needed that specifically targets underserved and minority populations, while Kreuter proposes that future research consider the challenge of targeting multiple risk factors. Although both papers approach this general theme from different perspectives, each has substantial merit as we contemplate the future course of risk communication research in cancer prevention and control.
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"COMMUNICATING HEALTH RISK TO ETHNIC GROUPS: REACHING HISPANICS AS A CASE STUDY" — ELMER E. HUERTA AND EVERLY MACARIO |
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Huerta and Macario remind us once again that sociocultural factors must be taken into account when designing and implementing risk communication interventions for racial/ethnic minorities. This paper is especially timely, given that much of the risk communication research conducted to date has focused on the majority population. Thus, as this field of research expands to include other populations, the factors identified by Huerta and Macario will need to be given serious consideration. For example, among the more intriguing factors identified by Huerta and Macario was the distinction between "collectivistic" versus "individualistic" cultures. Individuals from a collectivistic culture may respond more favorably to messages that first provide the context for the message, building methodically, as noted by Huerta and Macario, to the main take-home message. In contrast, individuals from individualistic cultures may prefer to hear the best or strongest arguments first, as a way to generate desire or interest to hear the entire argument. Although this distinction appears noteworthy, whether it actually merits meaningful differences in message structure is a legitimate question that could, and perhaps should be, answered through research.
The complexity and challenges of designing culturally competent risk messages is further illustrated by Huerta and Macario with respect to designing health messages for Hispanics. According to Huerta and Macario, such messages should consider several core values within "Hispanic" culture, including familialism, collectivism, simpatia, personalismo, respeto, and power distance. I was especially struck by their recommendation to consider the family when designing risk communication interventions, which is a recommendation that would seem to transcend cultural boundaries. This recommendation reminds all of us that preventive health behaviors are nurtured and sustained within the context of one's larger social environment. Although this recommendation to target the family is appealing, it also presents at least two fundamental challenges.
Broadly speaking, the first challenge is one of conceptualization. What types of information should be collected from families and from whom? Does a family focus simply translate into collecting health risk information from individual family members? I suspect not. For some risk-reducing behaviors (e.g., diet and nutrition), the preferred unit of intervention may in fact be the family, while others will require a focus on the individual (e.g., cancer screening behavior). However, even in those situations where the individual remains as the unit of intervention, the larger context of the family can play a vital role in risk communication, especially with respect to setting priorities for health behavior and sustaining these behaviors over time. It would seem, for example, that framing messages in terms of reducing family risk from cancer would be beneficial in promoting behavior change, especially among populations where protection of the family is emphasized (e.g., eating more fruits and vegetables may help protect your family from cancer). Similarly, risk messages that target specific family members may take on added significance if they can be framed in terms of protecting family functioning (e.g., if you are screened for colorectal cancer on a regular basis, it may help you prevent colorectal cancer from developing and thus protect your family from the consequences of this disease). It might even be possible, under certain circumstances (e.g., with appropriate informed consent), to share individual risk information with other family members, which might then mobilize the protective function of the family.
There are undoubtedly other ways to conceptualize risk messages within the context of the family. However, the three examples cited above serve to illustrate the potential value of this key recommendation. Families are more than the sum of their individual members. If we can harness the sociology of the family in our risk communication interventions, a new and exciting chapter in risk communication research could emerge.
In addition to the above, patterns of family communication and decision making, both of which have a definitive sociocultural context, should be of great interest to those who embrace the family orientation recommended by Huerta and Macario. Indeed, one could argue that before we can effectively target the family, we first need to improve our basic understanding of how the family might impact risk communication. To what extent will individual risk information be filtered through the prism of family dynamics? How will such information be reinforced, distorted, or otherwise modified by other family members? Under what conditions should risk communication programs explicitly take these family dynamics into account?
Precisely the opposite question should also attract our attention in risk communication research. Thus, in addition to asking what impact the family might have on individual risk communication, we could also ask what impact this information will have on the family. As noted recently by Bottorff et al. (3) in their discussion of genetic testing for inherited cancers, "Communication of cancer risk can also have serious implications for family relationships... however, nearly all of the empirical literature concerning the impact of testing solely addresses the individual (pg. 73)." This potential impact on the family might be expected for risk factors that are either inherited or result from common exposures. Unfortunately, the diffusion and interpretation of risk information within the family will not always be tempered by scientific judgment and thus could extend to other situations as well. This possibility accentuates the need to consider these potential consequences on the family as a whole, including unwarranted perceptions of risk that might cascade to other family members. Perhaps the greatest sin would be to ignore these potential consequences altogether, which highlights the need for more research to document and assess the diffusion of individual risk information and its potential impact within the family.
A second major challenge attending a focus on the family involves logistical issues. As noted above, one key decision is whom to target in the family for collecting health risk information. Another key logistical question is how to gain access and collect such information from families. For some risk behaviors, individuals might be targeted, others may require targeting the male or female head of household as a spokesperson for the family, while still others may require targeting the family unit rather than individual family members. If the risk behaviors have a normative component, confidentiality of data must be considered, especially if risk profiles are being collected from adolescents (e.g., exposure to tobacco). Issues of confidentiality become even more pronounced when operationalizing procedures for individualized feedback to families and individual family members.
Taken together, these conceptual and logistical challenges highlight the need to assemble multidisciplinary research teams that have expertise not only in risk communication, tailored message technology, behavioral science, and health education but also in medical anthropology and the sociology of the family. It also seems self-evident that we need more minority investigators involved in the research agenda suggested by Huerta and Macario. My own sense is that the focus on the family represents exceptionally fertile ground for future research. However, so little is known in this regard that a substantial amount of pilot research will be needed, perhaps funded by the National Cancer Institute (NCI) by the use of program announcements or request for applications (RFAs) that specifically encourage phase I and phase II research.
Also highlighted in the paper by Huerta and Macario was the importance of considering appropriate channels for conveying risk information to subjects. There is a wide variety of such channels to choose from, including electronic media, print material, telephone counseling, lay health advisor interventions, and other interpersonal education and counseling interventions. Their description of the use of radio was especially intriguing and could serve as a model for other investigators who face the challenge of reaching underserved populations. In addition, I would like to briefly comment on the use of computer systems to tailor risk information and behavioral recommendations to subjects (4-7).
This new technology clearly has great potential to make risk communication "self relevant" to subjects and perhaps more efficacious in promoting behavior change. However, much of the research conducted to date has tested this new technology within the context of the traditional health care system (4,5,8-17). Although such research needs to receive continual support, other venues should also be explored, especially as a vehicle for reaching the populations emphasized by Huerta and Macario. For example, tailored message interventions delivered in a hospital or clinic setting may not reach populations that underutilize the traditional health care system. Moreover, placing computers in waiting rooms can be expensive, especially in public-supported hospitals and clinics, patient flow may not allow all patients to utilize this technology even if it were made available, and computer phobia could be a deterrent to their utilization. At the very least, computer-tailored interventions will need to be made available in other locations in the community by use of kiosks and other venues (6).
One promising avenue for future research would involve integrating this new technology within existing models of lay health advisor (LHA) interventions (18,19). Thus far, such interventions have relied mainly on personal encounters to convey health-education messages to clients. However, these personal encounters could also be used to generate tailored follow-up print material, including tailored risk communication (20-22). This marriage between LHA interventions and computer-tailored risk communication would seem to represent another profitable direction for future research and may be especially attractive to the emphasis on families suggested by Huerta and Macario.
Another example of moving this technology beyond the health care setting is illustrated by the research we are conducting in partnership with the NCI-funded Cancer Information Service (CIS) (23). Thus, at the end of usual service, a brief baseline telephone assessment is conducted of CIS callers related to fruit and vegetable consumption, colorectal screening, or smoking cessation. This baseline assessment will then be used to generate follow-up tailored print communication, including tailored risk communication.
This same strategy could be applied to an almost infinite variety of community programs and agencies. What would be required is a commitment from program administrators to extend client services to include risk assessment, to provide appropriate time during client encounters to allow for these assessments to occur, and to facilitate feedback of tailored risk information to clients. Obvious candidates for such programs include worksite wellness programs, schools, nutrition programs, churches, etc. (20-22,24-28). Clearly, this focus on integrating computerized risk assessments and tailored risk communication within existing community-based organizations should be given high priority in future research and would represent, at least in my view, a worthwhile concept for phase III-IV research funded by the NCI through program announcements or the RFA mechanism.
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"DEALING WITH COMPETING AND CONFLICTING RISKS IN CANCER COMMUNICATION"— MATTHEW W. KREUTER |
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Kreuter addresses a critically important and largely unexplored issue in risk communication: how to deal with competing and conflicting risks in cancer communication. This is a daunting task, given that we are still struggling with de-biasing optimistic perceptions of risk with respect to a single precautionary or risk-reducing behavior (29). Nonetheless, Kreuter makes a convincing case for addressing this issue in future research by introducing four key assumptions:
Assumption 1: Many individuals lack a clear understanding of cancer risks in general, and more specifically, about their own personal cancer risks.
Assumption 2: By better understanding their own cancer risks, individuals will be better able to make informed decisions about screening and about adopting risk-reducing lifestyle changes.
Assumption 3: Many individuals have multiple cancer risk factors, or are nonadherent for multiple types of cancer screening.
Assumption 4: Health communication addressing multiple competing risks requires different considerations or approaches than communication about a single risk.
Kreuter provides substantial evidence supporting the first three assumptions, all of which lead logically to the fourth assumption, which provides the context for Kreuter's main thesis. As risk communicators and behavioral scientists in cancer prevention and control, we need to move our discipline forward by designing, implementing, and evaluating interventions that will provide information on competing risks, prioritize these competing risks, and, by extension, prioritize risk-reducing behaviors for individuals. Thus, Kreuter recommends that we compare competing risks for subjects based on statistical risk probabilities, probabilities of gains/losses (perhaps using a balance sheet to present this information), perceived controllability of competing risks, familiarity with risk and its consequences, voluntary versus involuntary nature of the risk exposure, and actual risk levels. Ultimately, as suggested by Kreuter, "Risk communications and other intervention materials should prioritize among competing risks when multiple risk factors exist," based on such factors as epidemiologic risk, readiness to change, self-efficacy, objective difficulty of behavioral change, and selected "gateways" to behavior change.
This agenda for designing and testing a competing risk intervention is both visionary and, it seems to me, enormously challenging. Two potential obstacles that might limit our ability to implement Kreuter's research agenda are briefly highlighted below.
1) Will the underlying science in cancer prevention and control, at this point in time, support the model proposed by Kreuter? This model assumes sufficient precision to differentiate among individual risk factors, and, by extension, specific risk-reducing behaviors, especially in terms of their relative contribution in reducing the individual's overall risk from cancer. However, if there is one defining challenge in risk communication, it involves communicating risk under conditions of uncertainty. This is a profound and pervasive challenge encompassing virtually all behavioral risk factors in cancer control, exclusive perhaps of cigarette smoking, which should be at the top of everyone's list. For example, how much risk is associated with a poor diet, and what elements of a poor diet should be given the highest priority? How much reduction in risk is associated by increasing fruit and vegetable intake from three servings per day to five or from two servings per day to five? Where do we rank sun protection or clinical examinations for skin cancer relative to other precautionary behaviors in cancer prevention and control? With respect to specific cancer screening tests, which of several different guidelines will be used to establish priorities for reducing cancer risk (e.g., ACS, NCI, U.S. Preventive Services Task Force, the subject's managed care organization)? When providing individualized feedback to subjects regarding priorities for risk reduction, how does one modulate specific recommendations based on age, family history, self-efficacy, readiness to change, etc.? How does one determine "objective difficulty" in making specific recommendations for behavior change? Again, the overriding concern is that the underlying science is not sufficiently developed to answer these or a myriad of related questions that would appear to be fundamental to the model proposed by Kreuter.
2) How exportable is the approach recommended by Kreuter? At a minimum, this approach would involve assessing multiple cancer risks and risk-reducing behaviors, providing information to subjects regarding these competing risks and recommending priorities for risk-reducing behaviors. However, it would also seem advisable to convey to subjects the underlying rationale for the specific, individualized set of priorities that are being recommended, which, according to Kreuter's model, would involve some combination of additional factors, including self-efficacy, readiness to change, objective difficulty in making changes to specific behaviors, etc. Moreover, once these priorities are established and their rationale is explained to the subjects, it would seem prudent to introduce selected behavior change strategies to promote the high priority behaviors that are being recommended. From a program implementation and management perspective, this approach would appear to be quite challenging, especially if the goal is to implement a low-intensity public health intervention to reduce cancer risk within defined populations.
Another related concern has to do with the potential for information overload, and the ability of the subjects to process and interpret both the magnitude and complexity of information that could be provided pursuant to Kreuter's model. As a case in point, consider the challenge of conveying risk information to subjects regarding a single risk factor. One recommendation found in the literature is to convey such information to subjects in quantitative terms, preferably in the form of absolute risk by use of age intervals appropriate to the individual (30-32). However, even this relatively straightforward recommendation regarding a single risk factor can present risk communicators with a significant challenge. Previous research has shown, for example, that when risk information is conveyed quantitatively, individuals tend to construct their interpretations in everyday life by use of qualitative categories, choosing to describe their risk, for instance, as being either high or low (3). Reconciling this tendency of individuals to simplify their interpretations of risk with the sheer volume and complexity of information that might be conveyed by use of Kreuter's model is not a trivial issue, which will only be compounded if other factors (in addition to competing risks) are also introduced to subjects.
Despite the two concerns noted above, Kreuter has elevated our ongoing discussions regarding future directions for risk communication research. Thus, while Kreuter proposes several possible criteria for establishing priorities for risk reduction (e.g., epidemiologic risk, readiness to change, self-efficacy, objective difficulty in making specific behavior changes), exactly how these criteria might be combined most effectively for different populations is a legitimate and compelling question for future research. A related question is the extent to which priorities for risk reduction should be explicitly recommended versus allowing individuals to make these decisions themselves. There may even be a middle ground in which the goal of the intervention is to negotiate decisions with subjects regarding their priorities for behavior change. Taken together, these various options for involving subjects in the decision-making process, combined with the relative emphasis placed on the different prioritizing factors proposed by Kreuter, present an intriguing and provocative agenda for future research. However, while this agenda is both compelling and visionary, it should nonetheless be tempered by the state of the science and potential concerns regarding exportability, including the ability of individuals to process and interpret this information effectively. Given these concerns, one might conclude that Kreuter's research agenda exceeds what is feasible at the present time, especially within the context of large-scale phase III randomized trials in cancer prevention and control. If this is indeed true, it can hardly be viewed as a criticism, since all visions of the future should push the envelope of possibility beyond the reach of where we are today.
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SELECTEDRECOMMENDATIONS FOR FUTURE RESEARCH |
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Ultimately, informed discussions regarding future directions for risk communication research must position specific recommendations within the larger context of other competing research questions. This must occur, given that there are finite resources available to support risk communication research in cancer prevention and control. Thus, by way of conclusion, listed below in no particular order are several suggestions in this regard.
More Research on the Presentation of Risk Information to Subjects
The field of risk communication would clearly benefit from more research on how best to convey risk information to specific target audiences, using both visual and text formats. The organizers of this conference are keenly aware of this issue, as evidenced by the paper by Lipkus (33). In another conference paper, Rothman and Kiviniemi (34) have argued that risk information should be presented within the larger informational context of the antecedents and consequences of the targeted health problem. An additional issue that has caught my attention has to do with the recommendation to present quantitative descriptions of risk (3,31,32,35), perhaps to the exclusion of qualitative presentations of risk (30,36). However, as noted above, previous research has also shown that when risk information is conveyed in quantitative terms, individuals tend to construct their interpretations using ordinal or qualitative categories of risk (3). If individuals are indeed prone to impose qualitative interpretations on quantitative risk information, perhaps we should acknowledge this fact and help individuals navigate through this process as part of our risk communication interventions. Thus, others have suggested that both quantitative and qualitative descriptions of risk should be presented to subjects (37), using empirically based guidelines for translating quantitative risk into qualitative categories (38,39). It would seem that more research is needed to identify optimal strategies for integrating both quantitative and qualitative presentations of risk into our risk communication interventions.
Establishing Guidelines for Measuring Risk
Even a superficial review of the literature reveals a fundamental lack of standardization with respect to measuring risk. Common formats include a wide variety of fixed-response categorical questions that may or may not provide a specific referent for comparative judgments by subjects, and various numerical scales that utilize a wide range of metrics for positioning subjects on a continuum of perceived risk. This lack of standardization clearly inhibits our ability to make comparisons of risk across studies and populations, and across time. It would seem worthwhile for the NCI to convene a consensus workshop to make recommendations for standardization in this field of study, in a manner similar to the consensus workshops that have been convened for dietary assessments (40). This recommendation would seem to be especially timely, given that measures of perceived risk are being used extensively as intermediate outcomes, for end point assessments, and as key variables in our tailoring algorithms. However, it should be emphasized that what is not being suggested is that all future studies move forward in lock-step fashion using only those items that reflect standardization. Nonetheless, there would be benefit to establishing guidelines for a core set of risk assessment questions and formats that would be recommended across studies.
More Research Testing Interventions to De-Bias Optimistic and Pessimistic Perceptions of Risk
Various theories of behavior change highlight perceived risk as a major causal factor, including the Health Belief Model (41), Precaution Adoption Model (42,43), and Protection Motivation Theory (44). Thus, one major challenge in risk communication arises from the observation that many people tend to underestimate their personal risk (12,42,45-50), which, according to theory, should lower the probability of adopting precautionary or risk-reducing behaviors. This key premise provides the underlying rationale for targeting these optimistic perceptions of risk in our risk communication interventions.
Investigators have achieved varying levels of success with respect to de-biasing optimistic perceptions of risk (12,29,34,51). One promising line of research invokes social comparison theory to de-bias optimistic perceptions of risk. Thus, instead of providing risk information (for social comparison purposes) that is either general in nature or linked to "typical others," one might use "similar, individuated, physically present others as comparison targets" (51). As noted by Klein and Weinstein (51), such comparison targets could include similar peers who have a healthier lifestyle than the subject (and hence a lower risk), or they may include comparison targets at high risk and otherwise similar to the subject.
Although social comparison theory offers significant promise in de-biasing optimistic perceptions of risk, more research is needed. In particular, socioeconomic and cultural influences on the social comparison imperative need to be explored, as well as other maintenance strategies used by subjects to protect and sustain their risk perceptions. Other promising lines of research, some of which may directly or indirectly benefit attempts to de-bias optimistic perceptions of risk, include message framing (52,53), targeting the attributions of risk (42,54), and presenting risk information within a larger informational context that highlights both the antecedents and consequences of a potential health problem (34). In addition, coping styles with respect to information preferences (e.g., information monitors versus blunters) might also help tailor the level and type of information provided to subjects (55-58). These promising lines of inquiry, while not exhaustive of all possible opportunities for future research, nonetheless illustrate the dynamic nature of the state-of-the-science, and the potential to improve our ability to convey risk information to subjects.
Although receiving less attention in the research literature, efforts to de-bias pessimistic perceptions of risk should also be included in our agenda for future research. It is instructive to note in this regard that for some cancers (most notably breast cancer), a sizable percentage of individuals may overestimate their perceptions of risk (59-63). If these pessimistic perceptions of risk result in a greater likelihood of adopting precautionary behaviors, then efforts to de-bias these pessimistic perceptions of risk may become less compelling and might even be viewed as counter-productive. This implicit dilemma is, perhaps, best illustrated with the following two questions. First, to what extent should we tolerate and accept pessimistic perceptions of risk, especially if they increase the probability of adopting precautionary behaviors in cancer prevention and control? And second, will pessimistic perceptions of risk, if taken to the extreme, impede behavior change by triggering denial and avoidance behavior? As will be noted below, the answers to these two questions should affect how we design and implement future risk communication programs.
More Research Examining Risk Communication as a Strategy for Behavior Change
Although various theories of behavior change highlight perceived risk as a major causal factor, what is not clearly understood is the relative efficacy of this theoretical construct in promoting behavior change, especially in comparison to other theoretical constructs in our models of health behavior. Under what conditions will manipulations of perceived risk, or more precisely, efforts to de-bias optimistic perceptions of risk yield the greatest impact in promoting behavior change? How does the relative efficacy of this theoretical construct differ by population subgroup or across different risk-reducing behaviors? The answers to these and similar questions have yet to be provided, which underscores the enormous challenges that lie ahead as we plot the future course of risk communication research in cancer prevention and control.
Of special note in this regard is the tendency for researchers to test interventions that simultaneously manipulate several theoretical constructs, thereby complicating efforts to disentangle and identify the specific theoretical mechanisms responsible for behavior change. The NCI is acutely aware of this problem, and thus has advocated that researchers devote more attention to specifying these mechanisms in their research (64). This call to action will require appropriate modifications to our research designs, including differential manipulations of various theoretical constructs within our phase III trials. Although such studies may place a premium on the size of our samples, they are nonetheless needed if we are to advance the science of cancer prevention and control, and, more specifically, enhance our understanding of risk communication as a strategy for promoting cancer-protective behaviors nationwide.
As mentioned above, a related concern involves specifying the conditions under which risk information might impede behavior change. As noted at this conference, the available evidence would seem to support the hypothesis of a positive linear function between perceived risk and risk-reducing behaviors, at least for cancer screening (65). Implicit in this empirical relationship is the notion that pessimistic perceptions of risk may facilitate the adoption of precautionary behaviors. Nonetheless, it is important to remember that this "best-fitting model" may not apply to specific individuals. Another model found in the literature suggests a curvilinear relationship between perceived risk and behavior (66). According to this perspective, extreme perceptions of risk may exacerbate feelings of distress, and perhaps trigger denial and avoidance behavior, thereby producing a curvilinear relationship between perceived risk and risk-reducing behaviors. This latter model takes on added significance, given that there is evidence suggesting that extreme perceptions of risk and/or elevated levels of cancer-specific distress may impede the adoption of precautionary behaviors in cancer prevention and control (67-69).
For example, in a recent review of the literature, McCaul et al. (70) found that perceptions of breast cancer risk were predictive of breast cancer screening behavior in a positive linear fashion. However, virtually all of the studies included in this review involved samples drawn from the general population. It is conceivable that the hypothesized curvilinear relationship (described above) remains undetected in studies of the general population, given that extreme perceptions of risk may be relatively rare in such populations (thus truncating the distribution of perceived risk). In contrast, in samples of higher-than-average-risk populations, where concerns about a specific risk may be especially acute, risk perceptions may predict precautionary behaviors in a curvilinear fashion, especially if the behavior in question triggers anxiety or fear because of its potential to confirm these perceptions of risk, as in the case of breast cancer screening among populations at high risk for breast cancer.
Given the above, it would seem prudent in our research to identify at baseline those subjects who embrace extreme pessimistic biases of risk and elevated levels of cancer-specific distress. This cautionary note is being introduced for three main reasons. First, our risk messages should be appropriately tailored to this situation (e.g., instead of focusing on reducing optimistic perceptions of risk, our efforts should be directed in precisely the opposite direction). Second, and perhaps more importantly, we would not want to promote further denial or avoidance behavior or inflict additional distress by exacerbating extreme perceptions of risk. And finally, as suggested recently by Lerman et al. (71), if cancer-specific distress is substantially elevated, efforts to counsel subjects about their risk may first need to address these psychosocial sequela.
Our colleagues in the field of genetic testing are keenly sensitive to the issue of psychosocial distress and thus have established various guidelines and procedures for minimizing serious psychosocial sequela attending disclosure of positive test results (3,72,73). I would argue that we should be no less vigilant in other areas of risk communication involving groups at higher-than-average risk. Thus, we might consider assessing cancer-specific distress in all populations at higher-than-average risk, especially if elevated levels of distress are suspected, and we are attempting, as part of our intervention, to manipulate perceptions of risk. By routinely making these assessments at baseline and follow-up, we could also begin to assemble evidence regarding the prevalence of this potential problem in our research of high risk populations.
Finally, it seems apparent that the interrelationships between risk perceptions (especially extreme perceptions of risk), cancer-specific distress, and the adoption of precautionary behaviors need to be further clarified. For example, future research might conclude that extreme perceptions of risk is not what impedes behavior change or triggers denial and avoidance behavior, but rather its corollary, cancer-specific distress. This hypothesis suggests the need to model these factors in a multivariate environment, which again underscores the value of measuring both risk perceptions and cancer-specific distress in our studies of risk communication.
More Research Investigating the Sociology of Risk Communication
It would seem that risk communication research in cancer prevention and control is currently preoccupied with a focus on the individual. This preoccupation may be a logical outgrowth of many of our theories of behavioral change, which tend to emphasize, as first-order causal factors, the knowledge base of individuals, their attitude and belief structures, and their perceptions of self-competency and various other facilitators and barriers to behavior change. When the role of one's larger social environment is acknowledged in our theories of health behavior, it is usually within the context of operating through these more proximal causal pathways. However, regardless of where these sociological influences are positioned in the causal chain, they need to be studied. More specifically, what is not fully understood is the role of sociocultural norms, and by extension, various significant others (and especially the family) in modifying or mediating risk communication on individual health behavior. However, such influences from one's larger social environment are undoubtedly present, perhaps quite compelling, and clearly in need of more research. Similarly, we lack a basic understanding of how individual risk information might impact the family, including familial relationships and the risk perceptions of other family members.
More Research That Specifically Targets Minority and Underserved Populations
In virtually all areas of inquiry in behavioral science, the first generation of research tends to focus on populations that are the most accessible, which typically translates into studies that focus on the majority (White/Anglo) population. However, as suggested by Huerta and Macario, the time has arrived for risk communication research to embrace underserved and minority populations. Given the NCI's commitment to promote research on underserved populations, this emphasis should be of high priority, perhaps facilitated with program announcements or RFAs that would specifically encourage such research.
More Research Testing Tailored Message Interventions, Including Risk Communication Interventions Within Diverse Community Settings
One of the most significant developments in recent years has been the introduction of computerized tailoring algorithms and interventions to promote behavior change in cancer prevention and control (4-6,74). The capability of this technology to enhance the "self-relevance" of educational messages and print material could conceivably revolutionize the field of health education. As noted previously, more research is needed that tests this technology for risk communication within existing community settings. The NCI has been at the forefront in supporting such research, which needs to receive continued funding. Such research might be further encouraged through program announcements and RFAs that would specifically encourage partnerships with existing community intermediaries beyond the traditional health care system, especially as a strategy for reaching underserved populations.
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SUMMARY |
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TopAbstractIntroduction"Communicating Health Risk to..."Dealing With Competing and...SelectedRecommendations for...SummaryReferences |
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The paper by Huerta and Macario reminds us of the need to consider sociocultural factors when designing risk communication interventions for minority and underserved populations. Their paper also reminds us that the time has arrived to focus more of our research efforts in risk communication on these special populations. In contrast, Dr. Kreuter challenges us to consider multiple and competing risks in cancer prevention and control, and offers a provocative framework for embracing this challenge. Clearly, both of these papers, combined with other priorities for research identified herein, illustrate the rich and compelling opportunities that exist as we continue to refine and improve the science of cancer prevention and control.
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REFERENCES |
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