Risk Communication in Health Promotion S. Thavaraj Pengarah R&D Malaysian Health Promotion Board (MySihat)

Health Promotion Health promotion is the process of enabling people to increase control over, and to improve their health (Ottawa Charter for Health Promotion. WHO, Geneva,1986). The Ottawa Charter for Health Promotion identifies basic prerequisites for health (e.g. education, shelter, etc) and outlines priority action areas (e.g. building healthy public policy). The Ottawa Charter follows a structural approach to promoting health, driven by the core values of social justice and equity (Raphael, 2003; in Hofrichter Health and Social

Health Promotion Health promotion represents a comprehensive social and political process It not only embraces actions directed at strengthening the skills and capabilities of individuals, but also action directed towards changing social, environmental and economic conditions so as to alleviate their impact on public and individual health.

Health Promotion Health promotion is the process of enabling people to increase control over the determinants of health and thereby improve their health. Participation is essential to sustain health promotion action (World Health Organization Health Glossary 1988).

Health Promotion In 1984 the World Health Organization (WHO) Regional Office for Europe defined health promotion as "the process of enabling people to increase control over, and to improve, their health”.

Health Promotion: WHO In addition to methods to change lifestyles, the WHO Regional Office advocated "legislation, fiscal measures, organisational change, community development and spontaneous local activities against health hazards" as health promotion methods.

Health Promotion and Behavior Risk Factors (relevance to Risk Communication) There is a tendency among public health officials and governments—and this is especially the case in liberal nations such as Canada and the USA—to reduce health promotion to health education and social marketing focused on changing behavioral risk factors.

Health Communication Health communication can be defined as "where health promotion and communication meet" (Hershfield & Rootman, 1996). Health communication involves the dissemination of health information through the media via the use of various communication techniques (Nutbeam, 1998). It aims to improve the health status of both individuals and populations by informing, influencing, and motivating the public about important health issues, as well as ensuring that key health concerns are on the public agenda (Nutbeam, 1998).

Risk Communication Risk Communication is defined as an interactive process of exchange of information and opinion among individuals, groups and institutions It expresses messages about risk, concerns, opinions or reactions. Risk communication is helping people understand the nature and seriousness of a risk so that they can make an informed decision about how to deal with the risk.

Risk Communication Ideally, risk communication is “an interactive process of exchange of information and opinion among individuals, groups, and institutions” . The goal of risk communication could also be defined as the need to align risk perceptions of the public with that of the risk experts and to reduce fear of risk related technology.

Risk Communication and Health Promotion With respect to public health, risk can be separated into two main perspectives. First risk as a health danger to individuals as a result from environmental hazards (i.e. pollution, nuclear waste and toxic chemical residues). Specifically, risk is "a health threat that is regarded as a hazard which is external, over which the individual has little control“ .

RC and HP The second view conceptualizes risk as a consequence of "lifestyle" choices that individuals make, thus placing the emphasis upon self-control (i.e. the individuals ability to manage the self )(Lupton, 1995).

Risk as a Consequennce of Lifestyle Choices: Behavior Risk factors The vast majority of NCD risk factors are environmental or lifestyle-related, thus NCDs are largely preventable. Greater than 30% of cancer is preventable via avoiding risk factors including: tobacco (6 million die a year), being overweight or obesity, low fruit and vegetable intake, physical inactivity, alcohol, sexually transmitted infections, and air pollution. (WHO)

Behaviour Risk Factors A trend has emerged, particularly in the early 2000s, in which numerous studies have revealed a link between fast food and an increase in heart disease. Many major fast food chains, particularly McDonald's, have protested the methods used in these studies and have responded with “healthier menu” options. Consumers continue to patronise

Behaviour Risk Factors Diabetes mellitus is an NCD which is largely preventable and manageable but difficult to cure. Patient education, understanding, and participation is vital since the complications of diabetes are far less common and less severe in people who have well-managed blood sugar levels. Wider health problems may accelerate the deleterious effects of diabetes. These include smoking, elevated cholesterol levels, obesity, high blood pressure, and lack of regular exercise.

Behavior Risk factors Chronic Kidney Diseases, diabetes and cardiovascular disease are closely associated conditions that often coexist; share common risk factors and treatments; and would benefit from a coordinated global approach to prevention and control.

Others Risk Factors Thus, CKD, diabetes and cardiovascular disease are closely associated conditions that often coexist; share common risk factors and treatments; and would benefit from a coordinated global approach to prevention and control.

Communicating the Risk to High Risk Individuals to Manage their Risk When there is risk it is important to communicate with the high risk group or vulnerable group (Haze, Melamin, Nitrofuran, Dioxin, SARS, Avian Flu, Recycled cooking oil ) as we have a Duty of Care. Communicating risk to the general public is often challenging due to a variety of issues including: increased emotion, limited access, availability of facts, clutter, distorted facts, speculation, assumptions, translating technical information into something understandable and sometimes incomplete knowledge.

Communicating Risk The manner in which information is communicated must be genuine and attempt to address both perceived ( may not be real) and real risk concerns

Incorporating Risk Communication in Health Promotion Integrate with health promotion components of the existing programs of the MOH Risk Communication has already been incorporated in our existing programs It need not stand on its own Nevertheless they are certain prerequisites

Prerequisites: The Risk Communication Process Epidemiological assessment of Risk Identifying the Risk Group Behaviour risk factor surveillance along the lines of the Morbidity Survey Educational Assessment Setting Risk Communication Objectives Formulating Strategies Executing Strategies Developing Risk Communication Messages Disseminating the messages through the effective Channels Impact Evaluation

Risk Communication Settings Clinic Hospital Workplace School Community

Strategies Planned Media Activities Electronic Print Social Face to Face

Strategies Planned Community Intervention, NGOs. Brief Intervention; Incidental Unplanned Community Health Promotion Centre Lobbying Environmental Support Social Support

Evaluation Evaluating the strategies : Formative Evaluation Evaluating the Objectives/ Goals : Impact Evaluation Evaluating Messages conveying Risk and Risk Reduction Educational Efforts as to Risk : Knowledge and Attitude on Risk Behaviour Changes as to Risk Reduction Morbidity Mortality Statistics as a result of Risk Reduction Policy Changes Environmental and Social changes

Behaviour Change Theories: Common 1. Yale Attitude Change Approach 2. Developmental Theory 3. Group Dynamics Approach 4. Perception Theory 5. Motivation Theory 6. Learning Theory 7. Force Field Theory 8. Group Dynamics 7. Cognitive Dissonance Theory 8. Attribution Theory 9. Social Learning Theory 10. Social Cognitive Theory 11. Health Belief Model 12. Theory of Reasoned Action 13. Diffusion of Innovation Theory 14. Precede-Proceed Model 15. Kelman

Health Belief Model The 7 major beliefs that influence the likelihood of taking action that is relevant to a given disease or condition are Perceived susceptibility to disease Perceived severity of disease Perceived threat of disease Perceived benefits of action Perceived barriers to action Cues to action Self efficacy

RC in Malaysia Action plans eg Pandemic Flu, Emergency Response Simulation Exercises Training Modules and Training Key Personnel Research Centre Research: FGDs ASEAN and Local Strategic Plan of Action

Example: Obesity Risk Communication : Prerequisites Epidemiology of Obesity Behaviour Factors contributing to Obesity: Walking less common now Knowledge and Attitude towards Eating Socio Cultural factors contributing to Obesity Availability and convenience of cheap calorie densed food Existing Policies and Regulations

Obesity Risk Communication: Who are the Main and Major Players? Risk Assessment (Epidemiological Assessment): NCD Behaviour Risk Factor Surveillance, and Educational Assessment: IPTK Developing the Strategies HECC/IPTK/NCD Developing Messages: HECC/ IPTK Dissemination of Messages: HECC/NCD/MySihat Impact Evaluation: HECC/IPTK/MySihat Policies/Regulations/Enforcement: Program Managers

High Risk Group: From Epidemiological Assessment and Behaviour Risk Factor Surveillance Family history/Family Lifestyle Sedentary Smokers who quit Pregnant mothers Age: Middle to Old Medical cases Identify risk groups within various categories

Risk Factors for Obesity Genetic predisposition. Inactivity. Unhealthy diet and eating habits. Family lifestyle. Quitting smoking. Pregnancy. Lack of sleep. Certain medications. Age. Social and economic issues. Medical problems. You can counteract most risk factors through diet, physical activity and exercise, and behavior changes.

Formulating Objectives of Risk Communication Need to know Knowledge Gap of the Risk Existing Attitude and Perception to the Risk Current lifestyle

Formulating Objectives for Risk Communication for the Obese Increase in Awareness and Knowledge of the Risk involved ie. to narrow the gap Instill changes in Perception to the Risk Susceptibility Severity Threat Benefits Engineer changes in Behaviour Eg. Sedentary to active lifestyle.

Strategies for NGOs: Providing the cues to effect changes in Behaviour Community Intervention through NGOs (Profesional and non Profesional) Empowering them by doing Risk Appraisal through Screening: Opportunities for Brief Intervention Normal, Risk Group, Cases Experiential learning, personal and situational Cases will be referred and messages on complication and quality of life Risk Group (overweight and obese): Planned activities to reduce K gap, changes to perception and above all to reduce weight Normal weight same as above for maintenance of weight

Strategies for NGOs: Strengthening Skills and Capabilities of the Community Providing them the technological know how through: Jointly Developing Risk Communication Modules Jointly conducting training for Community leaders and appointed Trainers Conduct Training for the Members

NGO

NGO

Screening

NGO activity

NGO: Persatuan Pesara Kerajaan Malaysia

Aktiviti

NGO: on Obesity

Exercise

Persatuan Ibu Tunggal

Kelab Sukan &Kebajikan Jinjang

Persatuan Ibu Tunggal

Holos Centre

Holos Centre

Empowering NGOs

Empowering NGOs

Empowering NGOs

Capacity Building

Capacity Buiding

Capacity Building

Meeting the Community Leaders in Putrajaya

Strategy for Policy Makers:Lobbying Communicating Risks to Law Makers/ Legislators by Lobbying Creating Policies at various settings Regulations Enforcements

No Smoking Zone

Strategy : Risk Communication Messages through the Media Conveying messages on Healthy Lifestyle (Normal) Conveying messages on Risk Factors and how to reduce Risk (Risk Group) Messages on complications and lifestyle changes (cases) Overcoming obstacles to Healthy Lifestyle Avoiding conflicting messages Information Management: Who is the authority? Lobbying the risk to Policy makers to create a supporting environment

Outdoor Ads

Banners

Media Channels and Vehicles Existing Channels and Networks Perhaps utilising the ever growing social media to a greater extent Incidental learning/Piggy riding Face to Face intervention

Evaluating the Risk Communication Efforts Knowledge and Perception changes Behaviour change: Life style changes Reduction in weight Mental Appraisal

Overseas Examples: Environmental Support The walkability of neighbourhoods and access to recreational facilities in and around neighbourhoods may also assist in promoting healthy weights (John Spence from the U of A's Faculty of Physical Activity) (In Malaysia we are creating pathways, (KLCC-Bt Bintang Walkway, Bintang Walkway) and many others in cities and towns) but inadequate, with gaps, poorly maintained and above all often unsafe in terms manhole covers removed and cement slaps missing, reckless motorists who drive on the walkways and park their cars and snatch thieves who prowl and their likes).

Examples Education and Recreation. "Conversely, factors such as urban sprawl, lack of physical and recreational facilities favour sedentary behaviour and lower physical activity levels and promote obesity.” (University of Alberta 2008 Urban Planning a Factor in Rising Obesity Rates, in Science wise, 18th March 2008.)

Examples: Policy to reduce Obesity In Wales Large-scale policies ranging from urban development to transport policy. For instance the Welsh Assembly Government has launched a four-year blueprint to get more people to walk and cycle as part of their daily lives. The Walking and Cycling Action Plan identifies a number of actions, including: Prioritizing walking and cycling in public transport investments Ensuring that local authorities provide and maintain high quality routes and facilities for cyclists Increasing provision of safe traffic free walking routes to schools and workplaces through continuation of the “Assembly Government’s Safe Routes in Communities Programme”

cont: In Wales Opening an all Wales Coast Path, including provision for bikes in appropriate places, which will be completed in time for the 2012 Olympics Implementation of Rights of Way Improvement Plans by all local authorities Introduction of the Sustainable Travel Town project in Wales. In the same vein the BBC reported on radical proposals to boost children’s health by creating car-free housing developments in Wales.

Policy on Obesity: In The UK Authority needs to be shared among many public, private and non-for-profit bodies in the UK. The Foresight report has promoted the view that obesity is a societal challenge, therefore calling for active and structural policies. As with other large-scale efforts (e.g. climate change) the UK strategy for tackling obesity entails the building of partnerships between government, science, business and civil society. This approach has underpinned the development of a UK-wide campaign, called Change4Life.

UK The strategy, sponsored by the Department of Health and involving the co-branding of a large array of initiatives relies on “grassroots involvement from local supporters who will encourage at-risk families in their community to trial and adopt the desired behavior The UK Change4life initiative has sought the active involvement of neutral third parties, for example:

Change for Life Initiative UK Prominent scientists Three NGOs who have produced a major communication campaign in support of Change4life, local voluntary and community organisations (over 20,000 of whom have signed up as Change4life partners and are using the Change4life resources) GPs and other health professionals who have endorsed and channel messages (nearly 4 million items for communication have been ordered by health care professionals) Schools, who have been active distributor of the How Are The Kids (HATKs) questionnaires. Head teachers have written to parents and planned Change4life assemblies. ur”. Change4Life focussed on prevention, and developed messages about lifestyle changes. Communication on treatment of individuals in a clinical setting (e.g. drugs and surgery) has been developed by the NHS (e.g. under NHS Choices).

UK This approach could help to address the challenge of a coherent and acceptable message. Opinion leaders, NGOs and independent scientists, when they are trusted sources of expertise, may contribute to build trust and change behaviour. Provided they are good communicators, they may also develop narratives that speak to people. To make an impact scientists and opinion leaders would need to spread simple messages about healthier lifestyles. Their communication may be supported by the simple framing of the Change4life key messages, “eat well”, “move more”, “live longer”. An evaluation of the impact made on the public by the messages released could help to adapt future communications.  (Löfstedt, R.E. 2005. Risk Management in Post-Trust Societies, Basingstoke: Palgrave.)

UK One major advantage of involving companies is that it avoids exposing the government to a top-down presentation of the risks of obesity. In modern “post-trust” societies, one-way communication from the Government down to the people is unlikely to deliver the desired behavioural change. For example, poor messages from government sources have contributed to amplify the MMR scare controversy. On the other hand, the format of the communication developed by commercial companies should also take account the level of trust vested in them. In this case the Department of Health assumed that they would be seen as credible sources of information: Bouder, F. 2006. ‘A Contribution to Transnational risk analysis: comparative analysis of risk perception related to human health issues’, in Richter, I.K., Sabine Berking, S. and Müller-Schmid, R. (Eds.) Risk Society and the Culture of Precaution, Basingstoke: Palgrave Macmillan.

Comparing Anti Smoking to Obesity “Using tobacco as a model is an interesting (and maybe not optimal) choice, since so much of the action in reducing smoking has come from making cigarettes expensive and making smoking inconvenient (e.g., through bans in different locations). Only a little traction was gained by raising awareness of the risks, and in some ways smoking behaviour is easier to understand since the goal (zero cigarettes) is clear. With eating and exercise, having a conscious goal means that people are doing some sort of calculus about how many calories they are consuming and expending every single day, an unreasonable expectation in general”. 

Smoking and Obesity Slovic has also shown that cigarette smoking is very high in perceived risk and very low in perceived benefits, which helps achieve behavioural change. It is unlikely that food intake could be treated the same way. Even restricted to the stigmatised category of “junk food” individual risk-benefit assessment is likely to be much more positive. Using tobacco as a model is a problematic choice, since so much of the action in reducing smoking has come from making cigarettes expensive and making smoking inconvenient (e.g. through bans in different locations).

Govt. Efforts V Non. Govt. Govt. Campaigns may also backfire, especially when levels of trust for the government are declining. Critical media reporting has already suggested that health authorities’ plans for an ‘obesity tour’ may not be seen positively: The tours were aimed to “help people understand labelling in a familiar environment”. Critiques saw it as a waste of money and a prime example of the government acting as a ‘nanny state’. Martin, D. (2009), Health Chief’s ‘Obesity Tour’ of supermarkets backfires – as no one turns up to take part, The Daily Mail, 19th February

Key Messages for Policy Makers on Risk Communication for Obesity Reflect on the risk itself, including perceptions. Define obesity risk communication on the basis of the evidence and perceptions directly related to the issue. Close parallels with other public health issues, like smoking, are likely to be misleading Continue to ensure that, despite the complexity of the issue, evidence-based messages are presented and discussed. This implies a responsible approach to avoid spreading quack or biased theories and at the same time over simplification (e.g. ‘junk food is the cause of obesity’)

Key Messages for Policy Makers on Risk Communication for Obesity When developing public campaigns always keep in mind that trust is a critical factor of acceptance. Make sure that regular evaluations take place looking at how well key actors are trusted, including government and private sponsors. Loud messages from distrusted actors may breed cynicism and are counter-productive.

Key Messages to Policy Makers Ensure that the financing of government’s campaign is well understood, especially when it involves commercial sponsors. Ensure that neutral third parties (opinion leaders, scientists etc.) are invited to express their views as often as possible. Ensure that their involvement also targets those most affected and not only the general population.

Key Messages to Policy Makers Obesity is multi-factorial and is likely to result in many policy interventions involving various parts of government. Co-ordination of the risk communication should focus on avoiding conflicting messages. A first step could be to develop a holistic evaluation of the totality of prevention and weigh control mechanisms e.g. Change4Life, Why Your Weight Matters, the NCMP letters, the NHS Choices content on weight etc.

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