Patients’ Perceptions of Cholesterol, Cardiovascular Disease Risk, and Risk Communication Strategies

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