Office of Public Health &Environmental Hazards

Speaking with Veterans about Exposure Concerns: Risk Communication

Implications Susan L. Santos, PhD, M.S.

Assistant Director, Risk Communication & Education

War Related Illness & Injury Study CenterVA NJ Healthcare System

East Orange, NJ

Disclaimer The views expressed in this presentation

are those of the author and do not necessarily represent the position of the Department of Veterans Affairs or the United States Government

I have no known conflicts of interest other than that I work for the Department of Veterans Affairs

Presentation Overview Understanding Veterans’ exposure

concerns What is Risk Communication and when

needed Key principles of risk communication Understanding risk perception and the

importance of trust and credibility Developing messages Do’s and Don’ts of provider-Veteran

communication

Top Ten Environmental Exposures of Concern: OEF/OIF1. Smoke from burning trash or feces (44.6%)2. Sand and dust storms (41.5%)3. Gasoline, Jet Fuel, Diesel Fuel (21.1%)4. Depleted Uranium (19.0%)5. Paint, solvents, other petrochems (15.2%)6. Oil well fire smoke (14.9%)7. Contaminated food and water (14.4%)8. Anthrax Vaccine (14.2%)9. Multiple Vaccinations (13.9%) 10.Vehicular Exhaust (10.3%)

Top Ten Environmental Exposures: Gulf War

1. Protective gear/alarms (82.5 %)2. Diesel, kerosene & other

petrochemicals (80.6%)3. Oil well fire smoke (66.9%)4. Ate local food (64.5%)5. Insect bites (63.7%)6. Harsh weather (62.5%)

N=651

7. Smoke from burning trash/feces (61.4%)

8. Within 1 mile of missile warfare (59.9%)

9. Repellants & Pesticides (47.5%)

10. Paint/solvents & petrochemicals (36.5%)

Schneiderman AI, et al. American Public Health Association, 133rd Annual Meeting, Philadelphia, PA, December 14, 2005.

Data from Risk Perception Pilot Survey and Focus Groups Sensory cues are viewed as evidence

of exposure Protective measures (alarms, suits)

are seen as evidence of exposure vs limiting the potential for exposure

Dread, uncertainty and lack of trust exacerbate health concerns

Veterans aware of media coverage of exposure concerns

Having information on exposure potential is important

What is Risk Communication?

“… an interactive process of exchange of information and opinions among individuals, groups, and institutions.”

“It involves multiple messages about the nature of risk and other messages… that express concerns, opinions or reactions to risk messages… as well as information on what to do to control/manage the (health) risk.” -National Research Council, 1989

Why Risk Communication? High concern Low trust Differential

relationships of power Communicating

complex information High uncertainty or

expert disagreement

Principles of Effective Risk Communication

Know why you are communicating - Have clear goals

Identify and understand Veteran’s concerns, beliefs, perceptions, and prior knowledge

Recognize that trust and credibility are key Structure provider-Veteran communication to

respond to Veteran’s concerns and provide information to facilitate collaborative decision- making

Good risk communication is two-way - listening not risk speak

Know the Veteran Important principle of risk communication is to

know with whom you are communicating Ongoing research suggests we need to take into

account the Veteran’s overall social network and experiences – not just exposures and symptoms

Be careful about assumptions – e.g. why a Veteran associates exposures with health concerns

Importance Of Risk Perceptions

Related to health behavior, medical-decision making, and the processing of health information

Influenced by a wide variety of cognitive, motivational, and affective factors

Often lead to errors in risk perception among laypeople (including Veterans), media, “non experts”

Information does not cure “wrong” perceptions

Understanding Risk Perception

Less Risky Voluntary Individual Control Familiar Low Dread Affects Everybody Naturally Occurring Little Media Attention Understood High Trust Consequences Limited/Known Benefits Understood Alternatives Available

More Risky Involuntary Controlled by Others Unfamiliar High Dread Affects Children Human Origin High Media Attention Not Understood Low Trust Catastrophic Consequences Benefits Unclear No Alternatives

What Makes a Source Credible

Empathy and/or Caring

Competenceand

Expertise Honesty

andOpenness

Commitmentand

Dedication

Assessed in First30-45 Seconds

Institutional Trust and Perceived Risk

In addition to individual trust need to look at “Institutional trust” (trust in authorities)

Institutional trust domains include: openness, honesty, reliability, fairness, caring and integrity-Metlay 1999

Two primary factors: affective is most important (caring, openness, reliability, honesty, credibility and caring); 2nd factor-competence

Institutional Trust and Perceived Risk

Numerous studies indicate that as institutional trust increases –perceived risk decreases -Flynn et. al., 1992; Siegrist et. al.,2000,2002; Allum, 2007

Magnitude of effect depends on population and hazard

Perceived Risk

Institutional trust

Who The Public PerceivesAs Credible

Local citizens perceived as neutral, respected, informed about the issue

Health/safety professionals (nurses, physicians, firefighters) Professors/educators (especially from respected local institutions) Clergy Non-profit organizations Media Environmental/advocacy groups Federal government State/local government Industry “For profit” consultants

MOST CREDIBLE

LEAST CREDIBLE

Establishing Trust & Credibility Third party endorsements from credible sources Demonstrating supporting characteristics

Caring Honesty Competence Dedication

Organizational credibility Consistency Accessibility Track Record

5 Stage Model for Responding in Situations of

High Concern and/or Low Trust

1. Active listening and emphatic responses

2. Provide short clear statements of findings -- your main point

3. Provide 1-2 facts to support main point

4. Repeat the statement/main point

5. Next steps/follow-up by provider and patient

Designing Your Message

What your patient/Veteran want to know

What you think is critical

What they are likely to misunderstand, if you don’t address

Sensitivity to emotions, concerns, values, etc.

Messages should include:

What Do You Think?“It wasn’t our accident, but we are absolutely responsible for the oil, for cleaning it up and that’s what we intend to do.”

“What has failed here is the ultimate safety of the drilling rig…There are many barriers of protection that you have to go to before you get to this. It isn’t designed to not fail.”

“There is limited or suggestive evidence of no association between deployment to the Gulf and lung disease… “

Example:

Operation Enduring Freedom Veteran

24 year old healthy Veteran Deployed to Afghanistan for 1 year He was given 1 dose of anthrax

vaccination prior to temporary suspension of the vaccine

He has concern about why this occurred Vaccine safety Quality control/approval of the vaccine Involuntary

Risk Communication Approach

Listen to Veteran’s concern about vaccine safety Explain the risk and benefits of vaccine Explain vaccine safety with appropriate

language Acknowledge any “errors” Understand concern about voluntary vs.

involuntary risk Check back on Veteran’s understanding

Differences Between Gulf War 1 & OEF/OIF Veterans GW1 Veterans have health problems or

symptoms they often relate to past exposures OEF/OIF Veterans have questions and

concerns, not necessarily linked to health problems or symptoms

Different communication goals Inform/educate OEF/OIF Veterans Understand perceptions and shift behaviors of prior

Veterans

Do’s and Don’ts Listen: Risk communication is two-way

Veteran has much information to offer Recognize empathy and trust are

extremely important Convey caring before information/science

Explain concepts of exposure Explain how exposure is determined

Translate dose-response Assist with knowledge gap (belief that any

level of exposure may cause harm)

Do’s and Don’ts Explain uncertainty

Provider/Veteran perception of uncertainty likely differs “We have no data to suggest that…”; “It doesn’t appear that…” Important to “bound it” with explanation

Reflect Back The Veteran’s understanding of what you find and do not find

Be collaborative Goal is to increase Veteran participation in decision-making “Let’s work on this together”

Do’s and Don’tsTreat Veterans with dignity

and respect• Their worldview/perception

is valid, not misperception

Don’t rely on your position of authority

• Not a substitute for good communication

• Don’t try to convince them you have more knowledge: Instead, explain why you believe

• Don’t use medical short-cuts

Summary Risk communication is an important part of

addressing Veterans’ exposure concerns There are things you can do to improve

communication Recognize our goal is to assist the Veteran

in making the best decisions to support their health and well-being