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Risk Perception and Communication in Addressing Exposure Concerns. Susan L. Santos, Ph.D., M.S. War Related Illness & Injury Study Center VA NJ Healthcare System East Orange, NJ. Overview. Veterans’ exposure concerns Principles and implications of risk communication

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risk perception and communication in addressing exposure concerns

Risk Perception and Communication in Addressing Exposure Concerns

Susan L. Santos, Ph.D., M.S.

War Related Illness & Injury Study Center

VA NJ Healthcare System

East Orange, NJ

  • Veterans’ exposure concerns
  • Principles and implications of risk communication
  • Understanding risk perception
  • Do’s and Don’ts of provider-Veteran communication
top ten environmental exposures gulf war
Top Ten Environmental Exposures: Gulf War
  • Protective gear/alarms (82.5 %)
  • Diesel, kerosene & other petrochemicals (80.6%)
  • Oil well fire smoke (66.9%)
  • Ate local food (64.5%)
  • Insect bites (63.7%)
  • Harsh weather (62.5%)


  • Smoke from burning trash/feces (61.4%)
  • Within 1 mile of missile warfare (59.9%)
  • Repellants & Pesticides (47.5%)
  • 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
Data from Risk Perception Pilot Survey and Focus Groups

Primarily Gulf War Veterans

Substances mentioned as having the most exposure:


  • Air Pollution 28.6% 54.3%
  • Petrochemicals 25.7% 45.7%
  • Vaccines 11.6% 68.8%
  • Pesticides 28.6% 22.9%

Most unsure of being exposed was:

  • Depleted Uranium 37.1%
data from risk perception pilot survey and focus groups1
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
top ten environmental exposures of concern oef oif
Top Ten Environmental Exposures of concern: OEF/OIF
  • Smoke from burning trash or feces (44.6%)
  • Sand and dust storms (41.5%)
  • Gasoline, Jet Fuel, Diesel Fuel (21.1%)
  • Depleted Uranium (19.0%)
  • Paint, solvents, other petrochems (15.2%)
  • Oil well fire smoke (14.9%)
  • Contaminated food and water (14.4%)
  • Anthrax Vaccine (14.2%)
  • Multiple Vaccinations (13.9%)
  • Vehicular Exhaust (10.3%)
what is risk communication
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
Why Risk Communication?
  • High concern
  • Low trust
  • Differential relationships of power
  • Communicating complex information
  • High uncertainty or expert disagreement
principles of effective risk communication
Principles of Effective Risk Communication
  • Know why you are communicating
  • Identify and understand your patient’s concerns, beliefs and perceptions
  • 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 your audience
Know Your Audience
  • Effective communication requires knowing your patient as a person – and enables you to understand the patient’s problems and concerns from their perspective
  • Understand their perceptions as valid and rational…not “misconceptions”
  • Understand the patient’s theories, beliefs, and prognosis of illness/symptoms as part of exposure assessment
there are two languages communicating health risk

Assessment of Risk



Acceptable Risk

Changing Knowledge

Comparative Risk

Population Averages

A death is a death


Assessment of Risk




Is it or isn’t it?

Discrete Events

Personal Consequences

It matters how we die

There are Two Languages Communicating Health Risk
importance of risk perceptions
Importance Of Risk Perceptions
  • Risk perceptions are related to health behavior, medical-decision making, and the processing of health information
  • Lay risk perception is influenced by a wide variety of cognitive, motivational, and affective factors
  • These psychological processes often lead to errors in risk perception among laypeople and the media
  • Information does not cure “wrong” perceptions
understanding risk perception
Less Risky


Individual Control


Low Dread

Affects Everybody

Naturally Occurring

Little Media Attention


High Trust

Consequences Limited/Known

Benefits Understood

Alternatives Available

More Risky


Controlled by Others


High Dread

Affects Children

Human Origin

High Media Attention

Not Understood

Low Trust

Catastrophic Consequences

Benefits Unclear

No Alternatives

Understanding Risk Perception

What Makes A Source Credible

Assessed in First

30 Seconds

Empathy and/or Caring










who the public perceives as credible
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



Establishing Trust & Credibility

  • Third party endorsements from credible sources
  • Demonstrating supporting characteristics
    • Caring
    • Honesty
    • Competence
    • Dedication
  • Organizational credibility
    • Consistency
    • Accessibility
    • Track Record
risk perception and uncertainty
Risk Perception and Uncertainty
  • Scientists/physicians recognize uncertainty exists and information will change over time
  • Lay persons view changing or incomplete information as a sign of uncertainty and lack of knowledge
  • High uncertainty increases perception of risk
  • People see uncertainty as greater if unfavorable information is presented last
risk perception symptom reporting
Risk Perception & Symptom Reporting
  • Perceptions of illness associated with chemical, biologic, etc. exposure can result from psychological processes individuals apply to understanding and interpreting physical experiences and events
  • Symptoms are experienced within a psychosocial context which gives meaning to the symptomology and a framework for causal explanations
risk perception model

Risk Perception

Mental Models Expectations

Somatic Change

Illness Perception



Emotion and Stress



sensory cues

Risk Perception Model

Fig. 1. Model of the relationship between risk perception, stress, somatic change, and illness perception

5 stage model for responding in situations of high concern and or low trust
5 Stage Model for Responding in Situations of High Concern and/or Low Trust
  • Active listening and emphatic responses
  • Provide short clear statements of findings -- your main point
  • Provide 1-2 facts to support main point
  • Repeat the statement/main point
  • Next steps/follow-up by provider and patient
physician veteran communication
Physician-Veteran Communication
  • Listen and restate the Veteran’s concern
  • Discuss important concepts in assessing exposure
    • Route and duration of exposure
    • Concept of dose-response
  • Determine Veteran’s exposure profile
  • Discuss risk of long-term health effects in relation to type of exposure
physician veteran communication1
Physician-Veteran Communication
  • Explain exposure and relationship with symptoms of concern/health problems
  • Address risk perception issues including uncertainty
  • Involve the Veteran in examining the research
  • Acknowledge “errors” as needed
  • Discuss provider’s basis for conclusions
  • Check back on Veteran’s understanding
physician veteran communication2
Physician-Veteran Communication
  • Manage expectations – Veterans and providers
  • Acknowledge perceptions about beliefs
    • e.g. Low trust, frustration about classified information, changing science, etc.
  • Avoid debate or being confrontational
  • Listening opens channels of communication
  • Provide objective scientific information and have a dialogue
differences between gulf war and prior veterans
Differences between Gulf War and Prior Veterans
  • Prior Veterans have health problems or symptoms they relate to past exposures
  • Current Veterans have questions and concerns, not necessarily 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
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 ts1
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 ts2
Do’s and Don’ts
  • Treat 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
  • 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