risk communication and communicating with patients

Office of Public Health and Environmental Hazards

Part Two of the 2011 WRIISC Webinar SeriesMarch 16, 2011

Risk Communication and Communicating with Patients


Presented By:Susan L. Santos, PhD, MSAssistant Director, Risk Communication and EducationWar Related Illness & Injury Study CenterVA NJ Health Care SystemEast Orange, [email protected]


WRIISC Webinar Series Pulmonary Effects of Combat Theater

Exposures Presented by Ron Teichman, MD, MPH, FACP, FACOEM Tuesday 5/24 @ 1:00pm EST

TBI and PTSD in Post-Deployment Veterans Presented by Steven Chao, MD, PhD and colleagues Monday, 6/27, 1:00pm EST

Information available at www.warrelatedillness.va.gov (973)-676-1000 x1177 or [email protected]

A special Thank You to Employee Education System (EES) for their support and assistance


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War Related Illness & Injury Study Center (WRIISC) WRIISC (pronounced “risk”) is a National Program in

three locations (CA, DC, and NJ) Expert “second opinion” resource on issues regarding

post-deployment health Four areas: Research, Clinical, Education, and Risk

Communication We provide clinical evaluations for Veterans with

difficult to diagnose conditions and/or deployment related exposure concerns

This Webinar series is part of our efforts to educate the VA Provider community


What We’ll Cover What is Risk

Communication and why is it important?

Principles of risk communication

Understanding risk perception and how it effects communication

Importance of trust & credibility

Do’s and Don’ts of provider-Veteran communication


The Role of Risk Communication in Communicating with Veterans“Risk Communication after a deployment is a crucial component of the appropriate care and support for the service member upon his or her return”Persian Gulf Veterans Coordinating Board (1999)“Efforts at risk communication must be part of an overall effort to see that returning service members are treated with gratitude and provided with medical care and support services to ease their readjustment” IOM (1999)


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)


When Is Risk Communication Needed? High concern Low trust Communicating

complex information

High uncertainty or expert disagreement

Differential relationships of power


Principles of Effective Risk Communication

Risk communication needs to be a dialogue (“two-way”) it means listening not just risk speak

Know why you are communicating – Have clear goals

Set a shared agenda with the Veteran – share “control”

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


Principles Of Effective Communication Tailor communication/messages to address

Veteran perceptions, concerns and your needs

Ensure consistency or explain discrepancies Structure communication to respond to

concerns and provide information to facilitate collaborative decision-making

Check back on understanding The person communicating must be

perceived as trustworthy and credible


Increase awareness

Inform and educate

Change behavior

Promote problem-solving and collaborative decision making

Know Your Communication Goals


Set a Shared Agenda Often, time for provider-Veteran visits

are limited Listen to the Veteran’s top concerns and

reasons for the visit Setting an agreed to agenda for the visit

up front is important Be sure you are addressing the Veteran’s

top questions/concerns – not just your own agenda

Set a collaborative tone


Know the VeteranImportant principle of risk communication is to know with whom you are communicatingThis means knowing the Veteran as a person as well as a “patient”Identify current concerns, beliefs, knowledge levels, who they trust for information, etc.Be careful about assumptions – e.g. why a Veteran associates exposures with health concerns


Perception = RealityWhat is

perceived as real is real in its

consequences

Perceptions form quickly; beliefs

more slowly

Effective risk communication requires

knowledge and understanding of your

patient’s/Veterans’ perceptions


Importance Of Risk Perceptions In Communicating About Risks Related to health behavior, the processing

of health information, and medical-decision making

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


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 which heightened concerns

Having information on exposure potential is important


What The Research Tells Us Public/Veterans tend to equate any

degree of exposure with harm Physicians use more of a “lay” mental

model when evaluating certain health risks

Public/Veterans rely on other mental “cues” for processing risk information

Public/Veterans weigh risk and benefit differently than physicians or scientists


Top Ten Environmental Exposures of Concern: OEF/OIF

44.6%

41.5%

21.1%19%15.2%

14.9%

14.4%

14.2% 13.9%10.3% Smoke from burning trash

or feces Sand and dust storms Gasoline, Jet Fuel, Diesel Fuel Depleted Uranium Paint, solvents, other petrochemicals Oil well fire smoke Contaminated food and water Anthrax Vaccine Multiple Vaccinations Vehicular Exhaust


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


Concern Over Burn Pits


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


Concerns About H1N1 Vaccine Safety


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 casual explanations


Risk Perception Model

Somatic Change

TriggersSensory Cues

Emotion and Stress

Risk PerceptionMental Models Expectations

Illness Perception and Interpretation

Illness


Trust and Credibility of the Communicator is Key

Empathy and/or Caring

Competenceand

Expertise Honesty

andOpenness

Commitmentand

Dedication

Assessed at start of

communication


Institutional Trust and Perceived Risk

Veterans may trust their individual provider but also 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


Institutional Trust


Who The Public PerceivesAs Credible

MOST CREDIBLELocal citizens perceived as neutral, respected, informed

about the issueHealth/safety professionals (nurses, physicians,

firefighters)Professors/educators (especially from respected local

institutions)ClergyNon-profit organizationsMediaEnvironmental/advocacy groupsFederal governmentState/local government Industry “For profit” consultantsLEAST CREDIBLE


Estabilishing 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

Scientists/physicians recognize uncertainty exists and information will change over time

Veterans/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


BP Workers Safety Concern


Communicating Uncertainty Be upfront and clear about uncertainties

but take care not to overwhelm the patient/Veteran with them

Say what has/will/can be done to reduce the uncertainty further

Describe ongoing monitoring efforts (“watchful waiting”), ongoing studies, etc

Describe steps the individual can take


Putting it all Together for Effective Communication

Experience/Express Concern/Empathy

Achieve/Convey Understanding

Provide InformationExplore/

Articulate Implications

Follow Up Actions


5 Stage Model for Responding in Situations of High Concern and/or Low Trust

1. Active listening and emphatic responses2. 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


Effective Communication Requires Listening…

It’s human nature to not listen

Ways of not listening vary: Common alternatives to listening:

Answering (assert, refute, argue or defend?)

Perfunctory acknowledgment (“I appreciate what you’re saying,

but...”) Conspicuous ways of not

listening: Reprimanding Laying down the law Non-Verbal Cues


Elements of Active Listening Acknowledging you hear Encouraging the other person to say

more Actively exploring his or her perspective Testing the meaning to the other person Paraphrase by repeating back without

inserting your own point of view


Responses That Help Communication

Paraphrasing “So you’re thinking that...” “Sounds like you are

concerned that...” “You feel... because...” “I’m hearing that...” “Let me see if I understand

what you are saying...”


Active Listening:It’s More Than Words Paraphrasing Body Language Voice Tone Feeling Words Word Emphasis Emotions Behind the Words


Non Verbals Matter


Using “Negatives” Confounds Communication

“It wasn’t our accident, we are not responsible 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… “


Delivering Your MessageMessages should include: What your patient/Veteran want to know

(i.e. address their top concerns first!) What you think is critical What they are likely to misunderstand, if

you don’t address Sensitivity to emotions, concerns,

values, etc.


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


Provider/Veteran Communication

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 key concepts Explain how exposure is determined Explain what a “syndrome is”

Translate dose-response Assist with knowledge gap (e.g. that any

level of exposure may cause harm)


Provider/Veteran Communication

•Provider/Veteran perception of uncertainty likely differs•“We have no data to suggest that…”; “It doesn’t appear that…”•Try to “bound” the uncertainty

Explain uncertainty

•The Veteran’s understanding of what you have found and not found Reflect Back

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

Be collaborative


Provider/Veteran Communication Not having the answer - is ok! You don’t

have to but… Be sure to follow up - where else can they get

information/ who else can help; concept of watchful waiting

Avoid negative responses “I don’t have time to answer your concerns.” “I agree with you but I can’t say that…” “I don’t think I can help you.” “You wouldn’t feel so badly if you would just lose

weigh and stop smoking.”


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 what you do•Don’t use medical short-cuts


Summary•Dealing with exposure concerns•Dealing with medically unexplained symptoms•Dealing with high uncertainty

Risk communication is an important part of

Provider/Veteran communication

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


Resources and References The Perception of Risk, Slovic, P. (ed.) (pp.80-103) Earthscan Publications Ltd,

London 2000. Scammell, M., Senier, L., Darrah-Okike, J., Brown, P., Santos, S.L. “Tangible

evidence, trust and power: Public perceptions of community environmental health studies” Social Science & Medicine Vol 68, issue 1, January 2009, 143-153.

Santos, S.L. “Risk Communication”. In Environmental Health Risk Assessment. M. Robson & W. Toscano eds.(pp.463-486) Association of Schools of Public Health (Sponsor) Josey-Bass, San Francisco, CA 2007.

Lundgren, R.E., McMakin, A.H., Risk Communication: A Handbook for Communicating Environmental, Safety, and Health Risks, 4th edition, John Wiley & Sons, Inc, Hoboken, NJ, 2009

Santos, S.L. and McCallum, David B., “Communicating to the Public: Using Risk Comparisons”, Human and Ecological Risk Assessment Journal, CRC Press, Vol. 3, No 6, December 1997


War Related Illness & Injury Study Center (WRIISC) WRIISC is a National Program in three locations (CA,

DC, and NJ) Expert “second opinion” resource on issues regarding

post-deployment health Four areas: Research, Clinical, Education, and Risk

Communication We provide clinical evaluations for Veterans with

difficult to diagnose conditions and/or deployment related exposure concerns

What’s next: Upcoming Webinars in May and June. Upcoming WRIISC conferences on March 30-31 Caring for Veterans with Post Deployment Concerns: Past, Present and Future, Seattle Washington; and Caring for Veterans: Moving Forward in Providing Quality Care, August 9-10, Washington DC.


WRIISC Referrals WRIISC National Referral Program

Second opinion evaluations for Veterans Please visit our website for referral

information: http://www.warrelatedillness.va.gov/referral.asp Complete WRIISC Assessment Form in CPRS Fax Pre-Screen Application and DD-214


For More Information Visit our National Web site:

www.warrelatedillness.va.gov Or call one of our three centers:

East Orange, NJ– 800-248-8005 Palo Alto, CA– 888-482-4376 Washington, DC– 800-722-8340

risk communication and communicating with patients

Documents

health risk

risk messages

nature of risk

risk speakknow

environmental hazards5what

environmental hazards8when

environmental hazards7what

veterans concerns