KEYNOTE ADDRESS

BARRY L. JOHNSON, Ph.D., assistant surgeon general and assistant administrator of the Agency for Toxic Substances and Disease Registry, Atlanta, Georgia.

The Role and Importance of Applied Evaluation Methods for Health Risk Communication

Health risk communication is a key element of public health strategies to promote health and prevent disease. Good communication practice is becoming increasingly important because citizens wish to be informed and to participate in all areas that affect their quality of life, personal health, and welfare. Second, a growing public concern about a variety of health risks has placed new requirements and demands on Federal health agencies for information that describes and explains the nature of health risks in clear and comprehensible terms. Most importantly, we need to know more about the outcomes of these communication initiatives.

Federal public health agencies have been at the front line of health communications for many years. Because a major proportion of morbidity and mortality is preventable through changes in health behavior, communication that is useful and effective about health risks and benefits is critical. Health risk communication campaigns have been used to address many issues, including smoking cessation, the importance of testing for radon in homes, childhood lead poisoning prevention, and overall health and fitness. Experience has shown, however, that disseminating information without reliance on communication principles can lead to less effective health messages and public health interventions.

With attention focused on a growing number of environmental health problems in recent years, Federal public health agencies have found the task of communicating health risks to be increasingly difficult. When confronted with a potential health hazard, a Federal public health agency typically responds by examining the public health implications of the environmental health assessment and then working within its legal and economic constraints to recommend and provide for the best solution for the situation and ensure its success. The assessment is often very technical in nature and is sometimes poorly received by a public that (1) wants to be certain of safety, (2) can be resistant to a "negative finding" of no adverse health effect, and (3) is particularly sensitive to health risks perceived as imposed involuntarily (e.g., exposures to hazardous substances from closed or operating hazardous waste sites in their communities).

Unfortunately, when government agencies do not understand and deal effectively with public perceptions of health risks, public alarm about the risks and hostility toward these agencies may increase. Agency credibility suffers and the public becomes skeptical or indifferent to information about health risks provided by experts. Poor health risk communication may also lead to ineffective public health interventions. Because agency assessments of health risk and public concerns may not be correctly communicated, some public health concerns go relatively unaddressed while others command a disproportionate amount of resources.

Although the evaluation of environmental health risk communication has been undertaken, only a few efforts provide substantial guidelines for practice. Notable exceptions include Effective Risk Communication (Covello and McCallum, 1989), Evaluation and Effective Risk Communication (Fisher et al., 1991), and Making Health Communication Programs Work (USDHHS, 1992). As with other health education efforts, risk communication programs must be evaluated so as to understand which strategies are helpful and which are not.

Health risk communication evaluation is about us—our beliefs, values, and behavior. Health communication messages enter our lives in many forms: advertisements, solicitations, health campaigns, medical care requirements, and word of mouth. This suggests many compounding factors, many problems, many challenges. It suggests that risk communication evaluation is fraught with difficulty because the meaning of a criterion for success, or for that matter, lack of success, will be elusive.

The Agency for Toxic Substances and Disease Registry (ATSDR) has made a strong effort to implement various communication models, theories, and practices in its planning process:

  1. ATSDR trains its staff using its own personnel to improve health communication to communities that are concerned about hazardous substances and associated health effects;
  2. ATSDR supports a lecture seminar series with local academic and Federal partners to examine health risk communication methods and models;
  3. ATSDR has implemented environmental health risk communication courses for health professionals who serve concerned citizens (more than 1,000 health professionals were trained by ATSDR staff in fiscal year 1993; this number is expected to increase in 1994); and
  4. ATSDR continues to support capacity building of health risk communication training implemented by its public health partners (National Association for County and City Health Officials [NACCHO], Association of State and Territorial Health Officials ASTHO, and the National Environmental Health Association [NEHA]).

All of these ATSDR communication programs have evaluation components, and we are always seeking to understand what is useful and what is not.

One evaluation effort that ATSDR has undertaken is directly related to the theme of this workshop.

ATSDR's Division of Health Education has recently encouraged one of its partners, the National Association of County and City Health Officials (NACCHO), to evaluate its ATSDR supported, introductory risk communication short courses for its membership. Overall, the evaluation suggests that the NACCHO Risk Communication program has been successful in meeting its original objectives and in improving awareness and understanding of risk communication principles. More importantly, the data indicate that the course encouraged positive risk communication behavior because respondents attributed numerous oral and procedural changes to knowledge gained by attending the NACCHO risk communication short course.

In conclusion, evaluation provides a central means for ensuring appropriate goals, content, and outcome of our health risk communication programs. Most importantly, evaluation must be viewed as cost effective and taken seriously as a central part of good public health practice communication programs, and not merely as an activity to conduct if sufficient funds are left when the program is completed.

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