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Electronic letters published:
![[Read Comment]](/icons/misc/sectionDOWN.gif){kind=icon}
More understanding and planning needed
Understanding and relevance as keys to effective risk communication
Response to Gary Kreps' letter
One Size Does Not Fit All: Adapting Communication to the Needs and Literacy Levels of Individuals
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Kiran deep Toor, USA Resident, UCSF Fresno
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This is reference to commendable work by goldman et al.The ultimate outcome of such a study would be to enhance patient understanding and outcomes. There is no clear data associating behaviour changes with understanding complexity of pathophysiology. Some of the questions addressed in study design gave an impression of better motivation with more knowledge , while the converse may be true.By nature patients who try to know more , understand more , are more likely to be open to change. Also many clinical tools are designed to be used by physicians to better risk stratify and treat patients. The same tools given in patients hands have not been validated for outcome purposes . The role of changing physician practices as more clinical data becomes available are not to be underestimated either.More media coverage adds to the equation as well. In one study Post MI Only 7.7% of patients used statins after an MI during the study period between 1990 and 1995[1] Another study showed Post MI (50.3%) were taking statins during an average follow-up of 3.7 years (3.1% in 1993 and 62.9% in 2001)[2].Presuming nothing drastic changed in patients' life , most of improved drug usage came from physician knowledge and conviction. Like the authors suggest "although patients often desire more information than they are getting from their clinicians, their wish is not for raw data, complicated medical explanations, or population estimates"[3]. Coming up with guidelines and criteria is one thigh , getting the potential benefit is another. More such studies and understanding is needed to apply a population based strategy for 'better lifestyle' motivation. [1] Heart 2002;88:229-233 [2] BMJ 2005;330:821 [3]Annals Fam Med 4:205-212 2006 Competing interests: None declared |
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Matthew W. Kreuter, St. Louis, MO Director, Health Communication Research Laboratory, School of Public Health, Saint Louis University
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Goldman et al.’s focus group findings reinforce two important points about effectively communicating health information and disease risk: (1) the public’s level of understanding basic health concepts and disease processes varies widely; and, (2) communication strategies that make information personally relevant to recipients are often better received and more effective. To the latter point, the use of epidemiological data to generate quantitative risk messages for individuals has been the basis of health risk appraisals (HRA) for decades. The “HeartAge” metric evaluated in this study is closely akin to “Risk Age,” a representation of all-cause mortality risk used in previous HRAs. While the ability to calculate and present risk information for specific individuals has clearly been an advance in health communication and patient education, such information alone is seldom sufficient to move people into risk-reducing action. The behaviors that can help prevent or manage cardiovascular disease (CVD) are often deeply ingrained and repetitive in nature. As Becker and Janz (1987) recognized two decades ago, such behaviors require skills and confidence to change, and there is no theoretical basis for expecting that typical HRA-type feedback could accomplish these outcomes.[1] Goldman, et al. understand this, and suggest that providing patients with personalized risk information like HeartAge may be an important first step towards behavior change by capturing patients’ attention, engaging them in thinking about personal risk, stimulating patient-provider discussion, and providing some level of motivation. What’s the next step? Studies in adult family practice settings have shown that when patients receive personal risk information accompanied by tailored messages that also address specific theory-based antecedents of their behavior, rates of cholesterol screening (and other CVD prevention behaviors) are more likely to increase than when patients receive personal risk information alone.[2] Building the capacity to provide not only personal risk information but also tailored behavioral interventions into e-health applications for primary care settings could enhance patient activation efforts. Finally, the challenge of communicating risk information should not be viewed as having a singular solution. Individuals vary in reading and numeracy skills, health-related knowledge and cultural background, all factors that influence or provide context for understanding health information.[3] Findings from Goldman et al. are consistent with this expectation: although most participants preferred risk information in the form of HeartAge, others expressed serious concerns about it. Recognizing that no single approach will work best for all people, future health communication research must focus on learning for whom and under what conditions different approaches are most effective. References 1. Becker, M. and N. Janz (1987). On the effectiveness and utility of health hazard/health risk appraisal in clinical and nonclinical settings: Behavioral science perspectives on health hazard/health risk appraisal. Health Services Research 22 (4): 537-551. 2. Kreuter, M. and V. Strecher (1996). Do tailored behavior change messages enhance the effectiveness of health risk appraisals? Results from a randomized trial. Health Education Research 11 (1): 97-105. 3. Institute of Medicine (2004). Health Literacy: A Prescription to End Confusion. Washington, DC: The National Academies Press. Competing interests: None declared |
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Roberta E Goldman, Providence, RI, USA Medical Anthropologist, Cl. Assoc. Prof. of Family Medicine, Brown Medical School
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We appreciate the thoughtful comments Gary Kreps provided about our article, and the issues involved in choosing risk communication strategies, particularly those that involve metaphors or analogies. Indeed we are in agreement that use of an analogy is one step in the communication process, albeit an extremely critical step in that it is at this initial point that one engages the patient with the concept of his/her cholesterol-associated CVD risk. As we note at the close of the article, we anticipate that the Heart Age cardiovascular risk-adjusted age calculator will be used to motivate the patient to take an interest in working with his/her physician to identify his/her cholesterol-related risk and appropriate goals for cholesterol levels. Once engaged with the concepts of cholesterol and CVD risk in a way that has personal relevance, the patient may be more prepared to focus on the complex details of the traditional medical explanation. We also agree that this age calculator may not work for everyone. However we used familiar concepts (the heart and one's age) that may be considered personally meaningful to a broad range of patients, and therefore likely to engage patients who are unlikely to remember or take interest in their cholesterol numbers. We took seriously focus group participants' warnings that some people may find the message frightening, and may therefore be even less interested in engaging the issue of their CVD risk. In response to these findings, we developed language to explain that there are ways to reduce one's CVD risk and to improve their heart age, and we included this on the heart age results page of the calculator, along with encouragement for patients to speak to their doctors about what they can do to reduce their risk. The calculator can be viewed at www.heartage.com. Competing interests: None declared |
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Gary L. Kreps, Gaithersburg, USA Professor of Communication, George Mason University
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I commend Goldman and her colleagues for their important research report in the Annals of Family Medicine examining public misunderstanding about cholesterol levels and personal risks for cardiac disease, as well as their evaluation of effective communication strategies for educating consumers about cholesterol and cardiac risk. I appreciate the audience- analytic focus of their study in examining the personal perspectives of consumers to guide health communication interventions for promoting accurate health risk assessments. Too often health education programs are based upon good intentions but very little audience-analysis data about the communication orientations, expectations, and capacities of the consumers who are the targets for health education efforts. Because of this lack of good audience-analysis research the resulting health education interventions often miss their mark and have limited positive influences on consumers’ health beliefs and behaviors. Sometimes, as in the early days of the flawed National Youth Anti-Drug Abuse Media campaign, health education efforts that do not take great care to match message strategies to the communication orientations of at-risk consumers can elicit boomerang effects that actually increase the health risks of the target audiences they were intended to help! I am not surprised that most consumers studied in this research project were confused by statistical probabilities of cardiac risk based upon cholesterol level, and generally preferred being presented with a cardiac risk calculator that uses an age-adjusted scheme to illustrate the impact of cholesterol on their health. There is a large body of evidence about widespread public misunderstanding of statistical examples and mistrust of numerical data, the numeracy effect, that often limits the effectiveness of much health and risk communication. Most people prefer explanations of difficult topics that use analogies, such as the age calculator used in the study, to help them understand complex health topics. However, I urge caution with the use of analogies, such as the calculator, alone to communicate health risks to consumers. Scientific analogies do not often provide a very full picture of health risks and the best ways to respond to these risks. Due to cultural differences, there can be a lot of variance in the ways that different groups of people interpret analogies. Care must be taken to use the right analogies with specific audiences. What is more, the use of good analogies generally need to be supplemented with additional relevant explanatory health information to flesh out understanding about the broader health issues the analogy generally only points to. To go back to now infamous anti-drug abuse campaign errors, fear appeals were often used as communication strategies for alerting at-risk youth to the dangers of illegal drug use. Television commercials were aired that compared a sizzling hot pan of eggs that were cooking over a fire to the brain on drugs. This was a vivid analogy that should have encouraged caution in most people. However, the audience that was most at -risk for drug abuse that this campaign was targeting was a group of young adults who were high-risk takers, sometimes referred to as high sensation seekers. These individuals look for danger and personal challenges don’t frighten them, they excite them. The fear appeal analogies used in the anti-drug abuse campaign did not dissuade these high risk takers, but actually challenged them to use illegal drugs. While the sizzling eggs anti-drug abuse analogy probably worked very well at alerting most parents to the dangers of drug abuse, they did not work well with many of the youth who were at greatest risk for abusing drugs. Similarly, it is important to assess the potential influences of communication tools, such as the use of the age calculator analogy, on the way at-risk consumers may perceive and respond to the health education messages about the dangers of cholesterol. The age calculator analogy may trigger a sense of fatalism among consumers who don't feel a great sense of self-efficacy in directing their health behaviors. It may elicit fear that could lead some consumers to avoid thinking about and acting upon their cardiac health. Evidence suggests that fear appeals are best used when consumers feel a strong sense of personal health efficacy and are informed about the best strategies they can pursue for reducing health risks. I urge caution in designing a one-size fits all health communication strategy for educating the public about cholesterol and cardiac health. Message testing research should be conducted to determine which audiences are likely to respond most favorably to different strategic communication messages. Audiences for health education efforts need to be segmented so that the most appropriate message strategies can be used with the groups of individuals who are most likely to respond favorably to these messages. Furthermore, care must be taken to provide adequate supplemental health information to audiences to build upon the emerging risk awareness the age -calculator (or other analogies) might initiate so the consumers who begin to recognize their cardiac health risks can also learn about the best strategies for responding to these risks and improving their health. Health education is an evolving process where effective communication strategies are designed and refined over time to provide consumers with relevant health information they can understand and the support they need to live healthy lives. The research report by Goldman and her colleagues provides a nice first step toward understanding the best ways to communicate health risk information about cholesterol and cardiac health to the public, but it is only a first step in the health education process that needs to be implemented strategically and supplemented with additional appropriate health messages. Competing interests: None declared |
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