Risk Communication and Communicating with Patients

Risk Communication and Communicating with Patients

Risk Communication and Communicating with Patients Part Two of the 2011 WRIISC Webinar Series March 16, 2011 Office of Public Health and Environmental Hazards Presented By:L. Santos, PhD, Susan MS Assistant Director, Risk Communication and Education War Related Illness & Injury Study Center VA NJ Health Care System East Orange, NJ [email protected] Office of Public Health and

mcast.net Environmental Hazards WRIISC Webinar Series Pulmonary Effects of Combat Theater Exposures TBI and PTSD in Post-Deployment Veterans Presented by Ron Teichman, MD, MPH, FACP, FACOEM Tuesday 5/24 @ 1:00pm EST

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 Officesupport of Public Health and assistance System (EES) for their and Environmental Hazards Some Reminders Please place your phones on mute. Please place the microphone on LiveMeeting to mute. For the audio portion of this presentation, call VANTS at: 800-767-1750, Code: 14821# Q&A Please submit your questions anytime

during the presentation by using the Q&A button at the top of your Live Meeting screen. Questions will be addressed at the end of the presentation. Office of Public Health and Environmental Hazards 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 Office of Public Health and Environmental Hazards What Well 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 Dos and Donts of Office of Public Health and Environmental Hazards 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 Efforts (1999) 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) Office of Public Health and Environmental Hazards 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 Office of Public Health and (health) risk. Environmental Hazards (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 Office of Public Health and Environmental Hazards 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 Veterans concerns, beliefs, perceptions, and prior knowledge Office of Public Health and Environmental Hazards 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 Office of Public Health and Environmental Hazards Know Your Communication Goals Increase awareness Inform and educate Change behavior Promote problem-solving and collaborative

decision making Office of Public Health and Environmental Hazards Set a Shared Agenda Often, time for provider-Veteran visits are limited Listen to the Veterans 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 Veterans

top questions/concerns not just your own agenda Office of Public Health and Set a collaborative Environmental tone Hazards Know the Veteran Important principle of risk communication is to know with whom you are communicating This 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 Office of Public Health and Environmental Hazards Perception = Reality What is perceived as real is real in its consequences

Perceptions form quickly; beliefs more slowly Effective risk communication requires knowledge and understanding of your patients/Veterans perceptions Office of Public Health and Environmental Hazards Importance Of Risk Perceptions In Communicating About Risks

Related to health behavior, the processing of health information, and medicaldecision 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 Office of Public Health and Environmental Hazards 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 Office of Public Health and Environmental Hazards 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 Office of Public Health and Environmental Hazards Top Ten Environmental Exposures of Concern: OEF/OIF 6.65% 4.93% 21.33% 6.79% 6.89%

7.13% 19.85% 7.27% 9.09% 10.09% 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 Office of Public Health and Environmental Hazards

Top Ten Environmental Exposures: Gulf War 1. 2. Protective gear/alarms (82.5 %) Diesel, kerosene & other petrochemicals (80.6%) 7. 8. Smoke from burning trash/feces (61.4%) Within 1 mile of missile warfare (59.9%) 3.

Oil well fire smoke (66.9%) 4. Ate local food (64.5%) 5. Insect bites (63.7%) 6. Harsh weatherA,(62.5%) Schneiderman et al. American Public Health Association, 133rd Annual Meeting, 9. 10. Repellants & Pesticides (47.5%)

Paint/solvents & petrochemicals (36.5%) N=651 Philadelphia, PA, December 14, 2005. Office of Public Health and Environmental Hazards Concern Over Burn Pits Office of Public Health and Environmental Hazards 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 Office of Public Health and Environmental Hazards

Concerns About H1N1 Vaccine Safety Office of Public Health and Environmental Hazards 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 Office of Public Health and Environmental Hazards

Risk Perception Model Risk Perception Mental Models Expectations Emotion and Stress Triggers Sensory Cues Illness Perception and Interpretati on Soma tic Chan ge Office of Public Health and

Environmental Hazards Illness Trust and Credibility of the Communicator is Key Empathy and/or Caring Competence and Expertise Assessed Assessed at at start start of of communicatio communicatio n n

Commitment and Dedication Honesty and Openness Office of Public Health and Environmental Hazards 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 Office of Public Health and Environmental Hazards Institutional Trust and Perceived Risk Perceived Risk Numerous studies indicate that as institutional trust increases perceived risk

decreases -Flynn et. al., 1992; Siegrist et. al.,2000,2002; Allum, 2007 Institutio nal trust Magnitude of effect on Office depends of Public Health and Environmental Hazards population and Institutional Trust Office of Public Health and Environmental Hazards Who The Public Perceives As Credible

MOST 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 LEAST CREDIBLE Office of Public Health and Environmental Hazards

Estabilishing Trust & Credibility Third party endorsements from credible sources Demonstrating supporting characteristics Caring Honesty

Competence Dedication Organizational credibility Consistency Accessibility Track Record Office of Public Health and Environmental Hazards

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 Office of Public Health and Environmental Hazards BP Workers Safety Concern Office of Public Health and Environmental Hazards 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 Office of Public Health and Environmental Hazards Putting it all Together for Effective Communication Experience/ Express Concern/ Empathy Achieve/Convey Understanding Provide Explore/ Articulate

Implications Information Follow Up Actions Office of Public Health and Environmental Hazards 5 Stage Model for Responding in Situations of High Concern and/or Low Trust 1. Active listening and emphatic responses 2. 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 Office of Public Health and Environmental Hazards Effective Communication Requires Listening

Its 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 youre saying, but...)

Conspicuous ways of not listening: Reprimanding Laying down the law Non-Verbal Cues Office of Public Health and Environmental Hazards 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 Office of Public Health and Environmental Hazards Responses That Help Communication Paraphrasing So youre thinking that... Sounds like you are concerned that... You feel... because... Im hearing that... Let me see if I understand what you are saying... Office of Public Health and

Environmental Hazards Active Listening: Its More Than Words Paraphrasing Body Language Voice Tone Feeling Words Word Emphasis Emotions Behind the Words Office of Public Health and Environmental Hazards Non Verbals Matter

Office of Public Health and Environmental Hazards Using Negatives Confounds Communication It wasnt our accident, we are not responsible but we are absolutely responsible for the oil, for cleaning it up and thats what we intend to do. What has failed here is the ultimate safety of the drilling rigThere are many barriers of protection that you have to go to before you get to this. It isnt designed to not fail. There is limited or suggestive evidence of no association between deployment to the Gulf and lung disease Office of Public Health and Environmental Hazards Delivering Your Message Messages 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 dont address Sensitivity to emotions, concerns, values, etc. Office of Public Health and Environmental Hazards 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 Office of Public Health and Involuntary Environmental Hazards Risk Communication Approach

Listen to Veterans 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 Veterans understanding Office of Public Health and Environmental Hazards Provider/Veteran Communication Listen: Risk communication is twoway

Recognize empathy and trust are extremely important Convey caring before information/science Explain key concepts Veteran has much information to offer Explain how exposure is determined Explain what a syndrome is Translate dose-response

Assist with knowledge gap (e.g. that any Office of Public Health and level of exposure may cause harm) Environmental Hazards Provider/Veteran Communication Explain uncertaint y Reflect Back Be collaborati ve Provider/Veteran perception of uncertainty likely differs We have no data to suggest that; It doesnt appear that

Try to bound the uncertainty The Veterans understanding of what you have found and not found Goal is to increase Veteran participation in decision-making Lets work on this together! Office of Public Health and Environmental Hazards Provider/Veteran Communication Not having the answer - is ok! You dont 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 dont have time to answer your concerns. I agree with you but I cant say that I dont think I can help you. You wouldnt feel so badly if you would just lose weigh and stop smoking. Office of Public Health and Environmental Hazards Dos and Donts Treat Veterans with dignity and respect Their worldview/perception is valid, not misperception

Dont rely on your position of authority Not a substitute for good communication Dont try to convince them you have more knowledge: Instead, explain why you believe what you do Dont use medical shortcuts Office of Public Health and Environmental Hazards Summary Risk Dealing with exposure concerns communication is Dealing with medically unexplained an important part symptoms of Provider/Veteran Dealing with high uncertainty 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 Office of Public Health and Environmental Hazards 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 Office of Public Health and Environmental Hazards 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 Whats next: Upcoming Webinars in May and June. Upcoming WRIISC conferences on March 30-31 Caring for Veterans with Post Deployment Concerns: Past,

Office of Public Health and Present and Future, Seattle Washington; Environmental Hazards and Caring for Veterans: Moving Forward in Providing Quality 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

Office of Public Health and Environmental Hazards 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

Office of Public Health and Environmental Hazards

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