Health Education and Risk Communication Strategies

Steps for Communication Planning

Materials development should not occur without knowing the concerns and needs of the people to whom they are directed.

Development of materials is too often the first step in agency communication, although to be effective it needs to be part of a larger communication strategy that takes into account, at minimum, audience concerns and questions, as well as communication strategies. Without appreciating the information that affected individuals want, communications planners are unlikely to develop materials that will respond to their concerns, leaving readers frustrated, potentially reducing agency credibility, and ultimately draining agency resources through calls from confused community residents.

There are many guides for communication planning. Here are some basic questions that should be addressed (adapted from Chess and Hance, 1994):

1. What are your communication goals?

Goals will differ at various times and places. Some basic goals are

• Empowering those affected to make decisions about the actions they wish to take. Effectiveness depends not only on government actions but on the actions of affected parties such as homeowners and managers of restaurants and day care centers. Reporting potential exposures, reducing those exposures, and developing alternative means of pest control will depend on affected individuals. They need to make critical decisions about how they want to deal with potential exposures. Agencies can recommend actions but, ultimately, potentially affected parties must make critical decisions about potential remediation.

• Providing appropriate information and conducting sufficient dialogue to accomplish the preceding goal.

• Reducing the spread of application of MP and other illegal pesticides.

• Identifying exposed individuals.

• Involving formal and informal organizations at the community level in many functions. For example, federal agencies cannot effectively monitor illegal pesticide applicators nor develop command and control options that will end all such operations.

• Maintaining agency credibility.

2. Who are your audiences?

When asked whom to reach, agency personnel are often tempted to say "everyone," particularly because many individuals have the potential to use illegal applicators. However, even Pepsi Cola, with far more resources that agencies will ever have to devote to MP communication, segments its audiences to target its messages to particular markets. In essence, agencies are now involved in a form of social marketing, purveying information and advice rather than commercial products (Rice).

We see three key audiences for agencies to consider, each of which have specific subaudiences:

Those who have been identified as exposed.

Those who are exposed but do not yet know it.

Those who should be alerted about the risk of illegal applicators.

The following discussion focuses largely on the audience of immediate concern for agencies, according to agency representatives involved in the expert panel: those who have been identified as exposed. A later section outlines strategies for communication with those who are exposed but do not yet know it. Agencies should outline communication plans for each of these broad audiences, before implementation, the plans should be integrated in such a way that they build on each other and maximize resources. For example, although different audiences may need different information, ideally some materials can be developed that serve all three.

3. What do audiences want to know?

At first contact, people want to hear answers to their questions, not just what agencies think is important. Social and cultural backgrounds may influence what people see as important. To find out what people want to know and how they might be involved, a variety of approaches can be used. One involves maximizing the time agency personnel spend with individuals by ensuring that personnel keep track of questions asked. The key questions can be incorporated into routine agency communication.

For example, a standard intake questionnaire might ask individuals what questions they have regarding MP. Those questions can be not only be answered, but quickly compiled to serve as the basis for the development of materials. Other potential approaches to finding out audience concerns quickly and efficiently are consulting local community leaders, reviewing news clippings, and receiving routine input from a local advisory committee. However, these approaches are short cuts that should be complemented with formal research (see later section).

Three affected residents (all with Level 1 homes) who were available to the expert panel for consultation indicated they would like more clarity on health information, including both short-term and long-term potential implications. Equally important was information on the process that the agency would be using to deal with their families and homes. They each wanted an outline, with a timeline, of basic steps in the process (e.g., testing, conveying of results, relocation and remediation). They also wanted detailed information about each step. Some of the affected individuals had questions that were specific to their situation but also were likely to have broader interest. The questions concerned the impact of exposure on children; referrals to doctors with specialized expertise (this was particularly important to one family where children were raised from birth in a contaminated environment and had severe respiratory problems that continued after removal from their home); and appreciation of the appraisal process.

The individuals we spoke with felt they did not have adequate access to information on these issues and others. They also did not have an open means of communication with the agencies and were typically referred from place to place when calling for information. Thus, even if agencies are devoting considerable resources to communication, there may be significant communication gaps that need to be identified and addressed.

People may also want more information than agencies think it is wise for them to know at initial stages. That is, some people, even before they know the level of contamination of their home, may want fairly detailed information on the potential health effects of MP, even though the information may not ultimately be relevant to them (e.g., they have a level 4 home). However, a rule of thumb is that agencies should provide people with as much information as they ask for, while providing appropriate caveats (e.g., symptoms are unlikely to occur in people who live in level 4 homes).

4. How will you communicate with audiences?

Identify local capacity and leaders.

There are established methods for identifying local capacity and conducting local needs assessments (including Superfund guidance that will have some applicability although the time frames, dispersed geographical distribution of affected homes, etc. undoubtedly will require some different protocols). We recommend that a flexible protocol be developed to help agencies quickly assess the social infrastructure and identify the most useful organizations with which to collaborate. The collaborations can vary in duration, scope, and extensiveness. Collaborations can involve one-time activities or ongoing relationships that maximize existing channels of communication.

It is beyond the scope of our work to specify all potential channels of information. However, we strongly recommend that a list of potential organizations that might be useful should be developed and that agencies use different forms of partnerships in dealing with them. For example:

• Agencies need to partner with local organizations that have established channels of communication that may be used effectively. To do so, agencies need to develop an understanding of the local capacity, which is likely to vary. In some areas, a poison control center may serve as a key conduit of initial information and advice but in other areas this role might be more appropriately served by another organization. This initial information service can help agencies deal with the considerable load of requests from concerned people. Poison control centers and other such organizations have trained personnel on staff who can be trained quickly and easily to provide information on MP to the public.

• It may be effective for agencies to distribute information for community groups to include in their newsletters, which have a readership federal agencies might not otherwise reach easily. Agricultural extension services have ongoing efforts with farmers that may be an effective way to reduce the selling of methyl parathion or other agricultural chemicals. Piggybacking on local efforts can be done with minimal effort in some cases, rather than asking local agencies to add to their already heavy loads. For example, extension agents talk to farmers daily about a range of issues. They might be able to distribute material and alert farmers to the dangers of indoor use as part of their daily schedule of meetings with individual farmers and groups. Similarly, 4H clubs are another potential route for reaching potentially exposed individuals or reducing the use of illegal pesticides. 4H is also a potential route to begin discussion of issues related to integrated pest management (IPM).

• Existing health services have also been tapped for assistance. Some may play major roles; others, which already have programs for chronic illnesses such as diabetes or hypertension, may be able to distribute materials and ask clients about pesticide spraying as part of their routine contact with clients.

• Many community organizations such as churches and civic organizations are already overburdened and underfunded. However, if alerting people to the possibility of exposure to MP (and other illegal pesticides) can be easily incorporated into their routine duties, it is more likely to occur than if they are asked to take on major functions without major funding.

• Finally, and most importantly, consider using affected individuals as participants in outreach efforts. Those affected individuals who came to the expert workshop were interested in being involved in constructive ways, such as providing emotional support to other affected individuals, serving as speakers to local community groups and churches, speaking with friends and neighbor and leading support groups. Agencies lack the resources (and maybe the credibility) to conduct such outreach. Agencies can develop a short training program for interested individuals and then encourage them to train others. We recommend that such innovations be tried on a pilot basis, perhaps involving one or more of the three participants in the expert workshop in leadership roles.

5. What message do you want to get across?

Messages should be created based on answers to the following questions:

What do people want to know?

What do agencies think people should know?

What are people likely to misunderstand if not explained?

A short-term strategy (within a week) for specific message and materials development might include the following steps:

1. Identify participant concerns by convening a focus group or calling people who are exposed for guidance. Determine their questions and concerns.

2. Determine what messages the agencies think are critical.

3. Consider what your audiences are likely to misunderstand if you don't spell it out.

4. Draft materials based on the answers to the three questions above.

5. Pretest. Have members of the intended audience read the material and comment. There are various means of pretesting, and health education experts can implement a quick-and-dirty plan. A health educator can accomplish the above in a week or so with input of technical staff throughout the process so that technical review does not take additional weeks.

Using an iterative approach

Such materials should be used for a limited time while health educators/community relations staff implement a more methodologically stringent approach to materials development. Because of the need to revise materials for a variety of reasons, including the development of new information, agency materials should not be elaborately formatted or printed. In this way, materials can be adapted easily.

Materials might be developed on the national level in collaboration with local agencies and representatives of affected people. Development of specific national materials should be delegated to state and local agencies. Materials for national use should leave space for local contact information. Local or regional agencies can also adapt the materials to suit their particular needs or develop different information. However, decentralized adaptation should be far more resource- effective than development of similar materials by many agencies.

Select key audiences to be told of changes in agency protocol

The three affected people who came to the expert workshop had little or no understanding of agency timelines, processes, or decision-making criteria. It should not be assumed that transmitting changes in the protocol is a major issue for all affected people. Agencies need to know who has said what to whom--what promises have already been made? What do people understand those promises to be? It may be wise for agency staff to conduct one-on-one sessions with those who might be affected by changes in protocol. The agency might consider, for credibility purposes, maintaining promises to those to whom clear promises have already been made. Agencies might also conduct follow-up confirmatory biomonitoring to ensure that affected residents are truly not eligible under the new protocol. Although needs assessments should be conducted at local levels to determine awareness of past protocols and number of people affected by changes, etc., we are concerned that major announcements of changes in protocol may cause greater confusion than they resolve.

Regardless of approach, agencies should be careful to avoid the perception that information is being withheld. Local announcements of changes in protocol might be placed in the context of agencies' continuing efforts to improve scientific understanding of MP and the most effective ways to reduce contamination. A strategy will need to be developed for local levels that ensures that no parties are blindsided and that, if at all possible, affected residents hear of changes firsthand, rather than from media sources.

6. What milestones need to be planned for?

Some of the milestones, as we understand them, are the following:

a. Initial point of contact

Affected parties are likely to want not only to report information but to receive it.

Even callers who do not know the extent of their exposures may want information about health concerns: What are potential health effects? Short-term/long-term adverse health impacts? What is the process they should expect to be involved in and timeline for it? When is testing appropriate? What does testing include? What are stages after that?

Possible approaches:

• Personnel dealing with callers at initial point of contact need training to respond to very basic questions. This can be delegated to another agency such as the poison control centers, after appropriate training of personnel.

• More technically qualified workers need to be available to respond to more detailed questions. Detailed questions require technical expertise that can not be developed through routine training. An agency might consider a national referral center or regional contacts (poison control centers) to which callers can be referred.

• Criteria for decision for such a technical service should consider the possibility for 24-hour service for 7-day- week operation; existing infrastructure (phone lines, trained personnel; etc); credibility with existing track record; standard operating procedures that can be modified to meet agencies' needs; experience in counseling and dialogue, not merely providing information; and the ability to develop program without close agency supervision (although coordination will be essential). Under no conditions should this function be taken on by an organization that is not already routinely supplying information on, at minimum, health-related questions from individuals who are concerned about toxic exposure. Thus, services that deal largely with concerns about application, agriculture, or regulations are unlikely to be good candidates for such a service.

• Materials: When possible, these should be mailed or otherwise transmitted to people before their homes are tested. At minimum, the materials must outline agency process for testing and follow-up. Materials should be based on information related to the three questions above. Although mailing costs could be saved by distributing brochures through various public facilities, affected parties should have the easiest access possible.

• We suggest that a pilot program be implemented to develop support groups for exposed people, who could be referred to the support group at point of contact. The individuals we spoke with felt varying degrees of isolation, fear, and confusion. Agencies often lack the resources to deal as extensively with these issues as they might like. The affected individuals at the expert panel meeting commented how much they learned from each other and remarked on the comfort of dealing with others in like situations. A pilot might be developed in an area for support group meetings led by community leaders or affected individuals, for which agencies would serve as resources. Those who initially contact the agencies could be told, for example, that there is a meeting at a certain location on a weekly basis.

b. Home and urine testing

• Personnel who are charged with collecting specimens should bring other materials to participants and go over wipe process and collection procedures. The discussion should include information such as timelines and next steps. The materials distributed at this time must include phone number for more detailed questions.

• Pilot options: Training community people to do testing. If possible, training could provide local employment, reduce burden on government, and build local capacity.

Giving homeowners materials with instructions for conducting their own testing; can be followed by confirmatory testing for those levels that seem potentially problematic. (This model was used with some success in the New Jersey Radon program.)

c. Communication of test results

• Delivering test results by mail can be problematic, and one-on-one counseling is advisable if resources are available. If this is not possible, phone contacts for detailed information are essential, as would be weekly availability sessions that affected people could attend. The support group concept mentioned previously may be particularly helpful in this area. It is also important that test results be given to the affected individuals in a timely manner so that critical family decisions can be made and anxiety doesn't build further while families wait long periods for the test results.

d. Follow-up steps:

For each step in the timeline, information needs and strategies need to be considered, which is beyond the scope of this report. One possible approach is discussed below:

Potential case management approach

For working with families who have been found to be exposed to high levels of MP (either through environmental assessment or biomonitoring), it is not sufficient for the agencies to recommend relocation without keeping families informed of agency progress. One way agencies may be able to better work with the relocated families is to use a team approach to case management that is increasingly used by social service agencies. This approach increases accountability and responsiveness to the information needs of the affected community residents. This is necessary to reduce the likelihood that affected residents will be referred from office to office when they call to obtain information of the status of their cases.

We recommend consideration of piloting a program in which team of agency officials is assigned to manage and keep track of a specific number of families to whom relocation has been recommended. Each member of the team would be responsible for a specific number of cases, each of whom can call this team member for information on the status of their case and next steps. The team members will have a clear idea of the protocol to be followed, which would be standard for all affected community residents once guidelines are in place. Residents who choose relocation need to have someone specific to call in the agencies for information regarding their progression through the protocol, from test results, relocation, medical monitoring, and remediation.

Responsible individuals in the agencies may also consider training key community residents who have gone through the process to be able to take some of the workload of the agency team members. Community residents who have been particularly active and have a strong relationship with the agency representatives may become invaluable extensions of agency officials. They may be trained to distribute information to the community regarding the procedures that affected residents can expect to go through when their homes have been identified as potentially contaminated.

7. How can the media be used effectively?

This could be the topic of a separate report. Given limited time to consider this issue, we focused on innovative approaches that agencies might use to incorporate local resources. For example, although good news is often not as salient a news peg as bad news, agencies can focus on the development of feature and human interest stories that promote how families have coped successfully with the process of dealing with MP contamination. Call-in talk shows often reach large audiences and, rather than using agency personnel, talk shows might involve affected individuals who can provide constructive firsthand experiences as well as technical experts. Some of the most effective media outreach might include that of affected residents and community leaders who can send letters to the editor (for years one of the most-read sections in newspapers).

8. How can constructive participation be encouraged?

We cannot emphasize strongly enough that local level solutions will need involvement of affected individuals and local leaders in many phases. We reiterate here some of the approaches we have mentioned:

• the need for a local steering committee to give ongoing input into agency plans and to develop local outreach efforts

• piloting the use of affected parties as peer counselors and outreach workers

• piloting the training of residents to participate in case management teams

• piloting the engagement of affected parties as peer counselors

• involving local leadership on a national task force to develop communication planning

• listening to affected parties to guide materials development; those who write columns in weekly newsletters should also be encouraged to tackle the subject.

9. How can feedback be gathered for program improvement?

The MP program will be evolving overtime. The key to program improvement is soliciting feedback from participants including affected individuals, agency staff, and local partners. Because staff are already overburdened, we suggest the following:

• Collect feedback routinely by building this task into daily operations. This could take many forms including meeting evaluation forms, sending questionnaires to random callers, and asking them to provide feedback on their contacts.
• Document lessons learned by keeping routine records The kind of documents that were produced from the Loraine experience, which summarized key problems and successes, are essential to progress. They might be developed through routine debriefing of agency staff in the field.
• Formal evaluation research is needed. We strongly recommend formative research, aimed not at providing a final "grade," but rather at providing incremental feedback for mid-course corrections.
• Pilot efforts should not be started without a strategy to provide feedback on their success. The stringency of the methodology should depend on the nature and scope of the pilot.