Health-Risk Communication

Alicia Sokol

April 2003

 

Key Objectives

 

After completing this chapter, the reader should be able to:

  1. Define principle methods of effectively communicating news of public health risk.
  2. Understand three health-education models and how they relate to health-risk communications.
  3. List potential audiences affected by a public health risk.
  4. Discuss how various risk-perception factors affect an individual’s response to health-risk communications.
  5. Identify appropriate channels of communication for reaching specific audiences.
  6. Determine appropriate methods for working with the news media in disseminating health-risk information.
  7. Identify program evaluation methods, models and design characteristics.

 

Introduction

 

This chapter is intended to inform and prepare those responsible for communicating topics of health concern, including government officials, health-care providers, public health workers, agencies and associations committed to maintaining public health, to those who may be vulnerable. It is important to note that this chapter provides merely a basic framework, and that individual situations should be assessed based on the specific needs and priorities of those at risk.

 

What is health-risk communication?

Health-risk communication, when effective, prevents or mitigates adverse human health outcomes related to 1) hazardous substance exposure (ATSDR, 2001), such as occupational and environmental exposures to toxic chemicals; 2) health-risk behaviors,  or 3) product safety and consumer protection (Allen). Communications may include information about community health concerns, possible health outcomes, demographics, resource availability and environmental factors. Gathering this information quickly often requires a collaborative effort by health-care providers, state and local government representatives, citizens’ groups and community residents. Active involvement and quick turnaround by all parties involved are essential to collecting necessary facts and creating an effective plan to disseminate information to critical audiences.  

 

Health-risk communication is a burgeoning area of focus. The public has become increasingly aware of possible threats to public health caused by chemical and physical agents. Plans for communicating relevant and timely information are needed to ease public panic and allow for quick action in the event of an imminent health risk.

 

A Word on Credibility

credibility (noun) – the quality of being believable or trustworthy.

In communicating messages to any group of individuals, credibility is first and foremost. Without it, even the most clear, concise, well-delivered message will be completely dismissed by the audience. Once lost, credibility is difficult to regain. Therefore, it is critical for a communicator to gain and maintain the trust of his audience.  Hence, credibility is tantamount to the success of any risk-communications plan.

Generating and maintaining credibility is not an exact science, but there are a few simple points to consider. Honesty is obligatory. The fastest way to destroy credibility is dishonesty. Second, actions are as important, if not more so, than words. The target audience, especially if skeptical, will keep a close watch on body language and emotional tone. Audience members will look for caring and compassion, and will know when these sentiments are feigned. Third, follow through with promises. Do not make claims that cannot be honored. This will destroy the audience’s confidence in future claims.

 

Health-Education Concepts

 

The health-education concepts described below are helpful in understanding the basis for effective health-risk communications strategies.

 

The Health-Belief Model

Perhaps the most important health behavior model for understanding effective risk communication strategies, the health belief model is based on an individual’s belief in his own susceptibilities to a disease or condition, its severity, the effectiveness of prevention and treatment techniques, and his own capacities for making use of those techniques (Rosenstock & Cullen, 1994). The health belief model is built upon the idea that an individual will protect his health and actively screen for and treat disease if certain characteristics apply. The individual must believe he is personally susceptible to the disease, that the disease will have serious effects on his health, that his actions can limit the ill-effects associated with the disease, and that the benefits of taking action to control the disease will outweigh the costs. Many outside factors influence each of these beliefs. Some believe that sociodemographic factors, such as education level, have a strong bearing on these individual beliefs.

 

The health belief model was developed in the 1950s and has since been extended and refined. One notable addition to the model is Bandura’s concept of self-efficacy, which relates to an individual’s belief that he can effectively take action to protect his health. For instance, one who is at risk for exposure to a harmful agent may take action to prevent exposure. He must believe that taking action will protect him and that he can successfully carry out the particular strategy (i.e. receiving a vaccine).

 

This model clarifies the role of effective health-risk communication. According to the model, a successful communications strategy must not only provide information about the hazard but must also outline preventive actions and stress self-efficacy. The model is built such that audience-specific concerns can be addressed in creating an effective communications plan. For instance, in communicating the risk of exposure to influenza in a community of elderly individuals, the model stresses the importance of clearly defining the severity of the flu virus to an elderly individual as well as the effectiveness of receiving a flu vaccination. If effective, the community would be convinced of the flu’s potential harm, aware of actions to prevent infection, and if there is a belief in the effectiveness of the prevention mechanism, likely to take steps for protection.

 

Social Learning Theory

Social learning theory relies on an individual’s interactions with those around him and the values he places on behaviors and corresponding outcomes. The theory also relies on environmental factors that influence an individual’s behavior. Social learning theory is built on the concept of observational learning, meaning that an individual can learn by watching others and noting the benefits or costs of the actions chosen. One of the theory’s most critical constructs in determining behavior is behavioral capacity, which distinguishes between knowledge and skill (Rosenstock & Cullen, 1994). This concept implies that a person must be able to identify a behavior as well as know how to perform it. Social learning theory provides a valuable theoretical framework for creating multilevel interventions that simultaneously address individual action and environmental action.

 

Diffusion Theory

Diffusion theory centers on the process by which information is communicated among members of a social system. Key components of the diffusion theory are the resource system, comprised of the “experts” creating ideas and innovations, and the user system, comprised of those receiving these ideas. The theory specifies certain attributes that ultimately lead to success or failure. Ideas or concepts likely to be diffused successfully or adopted should be easy to understand, flexible, cost-effective, low-risk, reversible and compatible with the community’s value system.

 

Early diffusion theory models involved a straightforward approach to disseminating information to the appropriate parties and making necessary changes. Recent models of diffusion theory are more complex, involving additional steps to ensure and maintain changes in behavior to reach a desired outcome.  A multistep diffusion process is identified as follows (Rogers): 1) recognition of a problem or need; 2) basic and applied research; 3) development, in which an innovation is given a form intended to meet the needs of a particular population; 4) production, marketing and distribution; 5) diffusion and adoption; and 6) consequences (Rosenstock & Cullen, 1994).

 

The diffusion theory is useful in planning health-risk communications because it presents a framework for communicating new research findings or innovations to a community. In addition, the diffusion theory provides a way to use proven techniques in creating effective health-risk communications programs.

 

Identifying Relevant Audiences

 

The first step in creating an effective health-risk communications plan is to identify target audiences and their concerns. Identifying specific characteristics of the audience allows special consideration to be made in choosing messages and communication channels. It is also meaningful to learn how the community gathers information (via television, newspaper, local officials, other residents, etc.), whom they trust for information, and their perception of risk. Additionally, it is helpful to understand attitudes, opinions, education levels, topical knowledge levels and community involvement.  For example, when planning communications channels, knowing that a target audience spoke and read only Spanish would be useful. This information assists in choosing appropriate communications materials – in this case, brochures and pamphlets in English would not be well-suited to the audience.

 

Pertinent audiences may include employees, community residents, health-care providers, government officials, media and regulatory agencies. Identifying groups or individuals who may show opposition to the communication, or provide challenges in delivering the information, is helpful in determining how to navigate potential road blocks.  

 

Risk Perception

 

A variety of factors affect an individual’s perception of the severity of risk. Statistical data and scientific facts are a strong influence, but people also are affected by factors specific to the risk itself.

 

Health risks are generally most worrisome if perceived as:

(Adapted from Bennett)

 

Risk perception plays a central role in risk communication because it takes into account the attitudes and fears of the audience receiving the message. Sensitivity to these attitudes not only allows those delivering the message to show an extra measure of compassion and support, but allows an opportunity to build credibility by understanding and responding to these perceptions.

 

Message Development

 

Messages must be clear, concise and consistent. The process of creating and updating messages is ongoing in a health-risk communication setting as information evolves. Nevertheless, baseline ideas and objectives should be clearly outlined and should remain stable throughout the communications process.

 

Education is part of the message development process in many health-risk communication efforts. Scientists, physicians or public health workers need to start the communications process by allowing the audience to understand the concerns from a medical or scientific standpoint. This information may include specifics on the particular agent involved, basic toxicological information, how adults and/or children might be affected, entry pathways and treatment options for exposed individuals. These messages should be specifically tailored for easy understanding by the target audience. For example, a group of at-risk health care workers would have a different level of concern and understanding than a community of at-risk migrant farm workers.  In either case, language should be clear and understandable to those at risk.

 

When creating messages, the following questions should be considered. What harmful element or elements exist? How have these elements become a hazard? Who is at risk for exposure? How can exposure be avoided or the risk of exposure minimized? What is being done to protect those at risk? What treatment options are available to those exposed? What short- and long-term effects can be expected in those exposed? What organizations or agencies are responding to the crisis? Who is available to address questions of concerned individuals and how can they be reached? What are possible solutions and alternatives? What costs are associated with each alternative or solution? Who is responsible for decision-making? Are there legal issues involved? What additional information sources are available?

 

Once basic messages have been crafted, communicators should be trained to deliver the messages in a variety of situations. For example, spokespersons should be designated and prepared to address the concerns of community residents, government officials and media. An effective communicator is able to anticipate anger and difficult questions and prepare answers to sticky issues. The spokesperson should be prepared to allow the audience to share input and express worries. This eases alarm and allows audience members to feel like they are a part of addressing the problem and delivering the solution. This approach also minimizes the possibility of escalated conflict and unbalanced focus on secondary issues.     

 

Channels of Communication

 

As mentioned previously, achieving effective health-risk communication requires knowledge of the habits and preferences of the target audience. For instance, it would be pointless to use the print media to deliver a message to a largely illiterate community. Similarly, it would be ineffective to deliver an urgent health-risk message via e-mail to employees who do not have regular access to computers. One must understand how to best communicate with the target audience, including who audience members trust, and how and where they get their information.

 

Following is a list of potential audiences with corresponding communication channels. Each specific situation is unique, so the following list is meant as a general guideline

 

Community Residents – Rural

Community Residents – Urban

Employees

Government officials

Media*

 

*Media is, in and of itself, a channel of communication or medium. In this case, it is used as an audience because of its power to broadly communicate public health messages to a wide array of audiences.

 

Effective Question & Answer

 

Inevitably, questions arise when health risks are present. Key messages are valuable when handling questions. They should be reiterated whenever possible. It is helpful to anticipate likely questions from various audiences and formulate answers ahead of time. Practice answering a variety of questions to become more comfortable in delivering clear, succinct answers. This technique is especially useful in dealing with difficult questions that lack easy answers. Preparation is critical in handling these questions smoothly.

 

The first rule of effective question and answer is to be prepared to listen. Show the audience that its questions are important and that each question will be given care and consideration. When fielding questions in person, make eye contact, be attentive and become engaged in the dialogue. Avoid interrupting the speaker before he is finished asking the question.

 

Answers to questions should be concise, on-point and thought through carefully. Do not stray from the point or to cover unrelated topics when addressing a specific question. Be sure the question is understood, and if it is not, ask to have it clarified or repeated. Do not answer “no comment.” This response is suspicious and hints that there is something to hide. If the answer to a question is not known, it is better to tell the truth and get back to the question later. Never, under any circumstances, lie or guess at an answer when uncertain. It is acceptable to say, “We do not know at this time.” Be sure to follow up and provide an accurate answer when one is available.

 

Every question, even the tricky ones, present an opportunity to drive home a key message. Use the following phrases to make a smooth transition or weave in messages when appropriate:

 

“What is important to remember is…”

“What I think you are really asking is…”

“What I can tell you about our recommendation is…”

“What I’d really like to emphasize is…”

“Let me put this in perspective…”

(Nelson, 2002)

 

Finally, the sensitivities surrounding health risk naturally lend themselves to emotions. If emotions become heated, resist the temptation to become defensive or argumentative, and remain calm. It is never productive or professional to engage in a heated shouting match. This type of behavior can destroy credibility and create distrust.    

 

Working with the Media

 

The media, or “the press,” refer to individuals working in various capacities to deliver news to the public. The media can play an important and unique role in communicating health-risk information to the public because of their broad reach. An estimated 100 million households in the United States watch television several hours every day (A.C. Nielsen) and tens of millions of Americans listen to the radio or read a newspaper daily (Nelson). In addition to bringing news to various audiences, the media play a major role in determining which people, issues and events are newsworthy.

 

All reputable journalists share the same overall mission – to report news in a factual, impartial fashion. Media outlets can be broken down into two main categories – print and broadcast. The print media includes primarily newspapers, magazines, newsletters, and trade publications. Print media are produced by reporters and editors, who work together to bring news stories to life on paper. Broadcast media refer to television and radio. Bringing television and radio broadcasts to viewers and listeners requires the work of reporters, news directors, production staff and technical staff.

 

What is news?

How do the media decide what is newsworthy? In general, reporters are interested in information that appeals to and affects the interest of the mass public. Often this includes information pertaining to public health, lifestyle and recreation, human interest stories, people’s perspectives, public policy and “bad news” (i.e. crimes). Risks to public health are more likely to gain media attention if there are questions of blame, alleged secrets, attempted “cover-ups,” links to existing high-profile issues or personalities, risk of mass exposure, strong visual impact and links to crime (Bennett). Be mindful of these “media triggers.” While it may not be possible to deter negative media attention, carefully crafted, consistent messages play a key role in diffusing it.

 

It is necessary to develop and maintain relationships with key media. In some cases, it is helpful to build media relationships on both local and national levels. Establishing these relationships early and actively maintaining them is especially helpful in the event of crisis communications. Knowing which reporters to call and how they work takes much of the guesswork out of broadly disseminating news in an expedient fashion. Good relationships also increase the chances of balanced, accurate coverage (Lundgren & Makin, 1998).

 

Communicating with the Media

In working with the media, one must be prepared to handle reactive communications as well as proactive communications. Reactive communications are required when a journalist shows interest in a particular topic and requests help in reporting that topic. Most often, reporters have very tight deadlines. They need to research a story, interview spokespeople and write or produce a finished piece in a number of hours. For this reason, it is important to respond to requests immediately. Even if unable to assist a reporter, it is critical to the relationship to respond in a timely manner. Proactive communications involve taking a story idea to a reporter in hopes of interesting him or her in writing or producing a story. Offering a story in this fashion is called a “pitch.” Story pitching can be tricky if the topic does not involve breaking news or an urgent threat to public health. Careful execution when pitching is critical to the success of future pitches. For example, failure to determine what is newsworthy can lead to inappropriate and unnecessary proactive communications (Nelson). Reporters are less likely to consider future pitches from a source if they do not believe there is legitimate news. Finally, it is helpful to think through all elements of a story before making contact with the targeted reporter. For instance, what are the issues? Who is affected? What expert sources are available for the reporter to interview? Are there compelling visuals to the story (critical for television)?   

 

Reporters can be reached in a variety of ways. The best approach varies dependent on the nature of the news. News involving an immediate threat to a community (i.e. a rash of tuberculosis cases) would be handled very differently than a more long-term risk (i.e. a high rate of childhood lead poisoning). If the news potentially could incite fear or anger, it is best to try to contact the media proactively rather than wait for the phone to ring. Journalists do not like to be taken by surprise or caught off-guard. In addition, a reporter has a better chance of delivering an accurate report if given more time and sources. A press conference is an efficient way to reach many reporters simultaneously. In most cases, press conferences allow for questions and answers. Press conferences can be used in conjunction with press releases and other written materials (fact sheets, brochures). If possible, press conferences should be held early in the day to allow newspapers time to place the story in the following day’s edition.   

 

Levels of Media Involvement

Media involvement varies in accordance to the type of risk communication. For example, when a crisis presents immediate danger to a community, the media will begin reporting details quickly, often without complete information. The priority of the media in this situation is to alert the public to the danger and provide information to allow people to protect themselves and their families. As more information develops, reporters will continue to deliver new developments to keep the public abreast of the latest information. Once the public is out of immediate danger, the press may launch an investigative report to determine what led to the emergency, potentially offering solutions.

 

Another style of media coverage and involvement occurs when an outlet chooses to report on a specific issue or long-term health risk to the community. This type of reporting allows for more thorough, in-depth research and more balanced reporting than in the case of a crisis. A reporter may provide background information on the problem, detail the negative consequences associated with the risk, and offer ways for individuals to reduce risk to themselves and their families. To gather important factual information, the reporter obtains background information from a variety of sources and interviews a handful of experts to include in the news report.    

 

Finally, a media outlet may become very involved in a particular issue and take an advocacy role. Key decision makers at the outlet, such as editors or senior producers, may meet with elected officials or opinion leaders to discuss the nature of the risk, its alternatives, consequences, benefits and possible solutions. They may use editorials or other opinion commentary, such as op-ed pieces, to support their position. Editorial boards, a collection of media representatives, may work with key stakeholders to describe the nature and consequences of a risk and its potential solutions (Lundren & Makin, 1998).

 

Errors and “Bad Press”

Unfortunately, the media do not always report desirable stories and occasionally, inaccuracies occur. As media contact increases, so does the likelihood of being misquoted or having information taken out of context (Nelson). In most situations it is best to ignore minor errors. If an error is particularly egregious, it is possible to ask the outlet for a correction. The publication may or may not decide to grant the request. Another option is to write a letter to the editor or submit an op-ed piece that addresses the issue. However, the publication may choose not to print such pieces. Finally, relations with the media should be kept on a professional level at all times. When “bad press” occurs, keep in mind the importance of maintaining working relationships with media for the benefit of future issues – both positive and negative. 

 

Measuring Effectiveness

 

As mentioned earlier, health-risk communications programs are used to address a variety of issues, from behavioral health risks such as smoking and substance abuse, to the importance of immunizations, to environmental exposure to toxic chemicals. In the context of risk communication, evaluation refers to any purposeful efforts to determine and measure the effectiveness of risk-communication programs (Fisher, Pavlova & Covello, 1991). Program evaluation is necessary to ensure that health-risk messages are disseminated in an efficacious fashion, reaching the targeted audience through appropriate channels. Evaluation techniques vary depending on the stated goal. Common goals include raising awareness, changing behaviors and educating people to make informed decisions.

 

Program evaluation provides useful information for planning and program execution, and can indicate the need for modifications. In addition, evaluation highlights program accomplishments and can justify program budget expenditures in a quantifiable way. Programs that show success in achieving stated objectives are likely to receive funds to continue their work, and possibly additional funding for program expansion.

 

In the planning phase, evaluation efforts assist in designing critical program elements. A variety of tools, including focus groups, surveys and questionnaires, can be used to identify relevant audiences, obtain initial audience opinions and attitudes, identify important problems perceived by the audience, uncover issues and events people are aware of and determine how people react to different sources of information. Pilot testing can be used to predict efficacy and feasibility of alternative communication activities, determine the kinds of information needed by target audiences to understand risk communication materials, examine how people process and interpret risk communication information, and obtain feedback on draft materials (Fisher, Pavlova & Covello, 1991).

 

No matter how basic the health-risk communication, careful planning and goal-setting are necessary to meaningfully evaluate the program’s success, or lack thereof.

 

Types of Evaluation

Following are four major types of evaluations that can lead to more effective health-risk communication when used appropriately: formative, process, outcome and impact (NCI, 1992).

 

  1. Formative evaluation assesses program materials and campaign strategies prior to implementation. This type of evaluation creates an opportunity to make necessary changes in concepts, materials, strategy and communications channels before initiating program activity. Pretesting and pilot testing are methods of formative evaluation.
  2. Process evaluation identifies and measures a program’s administrative and organizational strengths and weaknesses. It gives the program implementers the ability to modify processes and procedures along the way to ensure that the right messages are reaching the right people through the right channels.
  3. Outcome evaluation is used to identify short-term results and descriptive data, such as the immediate impact of the risk communication program on the intended audience. This type of evaluation is the first step in determining whether the program achieved its goals, measuring both quantitative (how many people called a hotline number following a television news report) and qualitative data (changes to audience knowledge, perceptions and attitudes).
  4. Impact evaluation, the most broad and comprehensive of the evaluation types, identifies long-term results as measured by changes in audience behavior (increase in enrollment of smoking-cessation programs) or improvement in health status (lower rate of childhood lead poisoning). Although impact evaluations can produce valuable information, they are often very expensive and require a generous commitment of time and effort. In addition, it is often hard to isolate results attributable specifically to a risk-communication program because of the influence of other strategies.

 

Elements of Evaluation Design

There are eight basic elements required of formal evaluation design regardless of evaluation type.

 

  1. Statement of Communication Objectives

Clear, defined goals must be stated in order for evaluators to measure program effects.

  1. Definition of Data to be Collected

This determines what is to be measured with respect to the stated program goals.

  1. Methodology

Study design must be formulated to permit valid, reliable measurement of data.

  1. Instrumentation

Instruments used in data collection must be designed and pretested. Such instruments can range some simple tally sheets to elaborate surveys and questionnaires.

  1. Data Collection

This involves the physical process of gathering information.

  1. Data Processing

This includes converting the collected data into a usable format for analysis

  1. Data Analysis

This allows discovery of significant relationships through the application of statistical techniques.

  1. Reporting

This involves compiling and recording evaluation results. From reported results, changes to the existing program can be made. In addition, new programs can be planned using reported results as a guide and benchmark.

 

(NCI, 1992)

 

Difficulties in Evaluation   

A variety of barriers exist in evaluating health-risk communications programs. Awareness of these difficulties assists in anticipating possible roadblocks. Resources are a key constraint to optimal program evaluation. Limitations on funds, staffing, time, equipment and tools can interfere with evaluation. Additionally, when working with a variety of groups or agencies, it may be difficult to agree on program objectives and goals. A lack of clearly defined objectives leads to trouble in creating suitable measures for evaluating a program. Finally, it may be difficult to separate specific program influences when evaluating long-term effects because of the intended audience’s exposure to outside factors (ATSDR).

 

Conclusions

 

Effective health-risk communication is crucial to health promotion and disease prevention. The role of risk communication is becoming increasingly important as new threats surface. Recently, public concern about health risks has become heightened because of bioterrorism threats, West Nile virus, SARS, anthrax, dietary supplements, pesticides, mercury in childhood vaccines, and radiation from nuclear weapons testing, to name a few. As a result, health practitioners must learn and exercise effective methods for educating the public, calming fears that may lead to irrational behavior, responding to inquiries, offering resources and using various channels to communicate new information quickly and efficiently.

 

The following rules provide a brief summary of some topics discussed in the chapter. This list, developed by Covello and Allen (1988), acts as a set of “commandments” for health-risk communications, and neatly summarizes several general rules of thumb.

 

Seven Cardinal Rules of Risk Communication

  1. Accept and involve the public as a partner.

Work to produce an informed public, not defuse public concerns or replace actions.

  1. Plan carefully and evaluate your efforts.

Different goals, audiences, and media require different actions.

  1. Listen to the public’s specific concerns.

People often care more about trust, credibility, competence, fairness, and empathy than about statistics and details.

  1. Be honest, frank and open.

Trust and credibility are difficult to obtain; once lost, they are almost impossible to regain.

  1. Work with other credible sources.

Conflict and disagreements among organization make communication with the public much more difficult.

  1. Meet the needs of the media.

The media are usually more interested in politics than risk, simplicity than complexity, danger than safety.

  1. Speak clearly and with compassion.

Never let your efforts prevent your acknowledging the tragedy of an illness, injury or death. People can understand risk information, but they still may not agree with you; some people will not be satisfied.


References

 

A.C. Nielsen. http://www.acneilsen.com. Accessed July 12, 2001. In: Nelson DE, Brownson RC, Remington PL, Parvanta C eds. Communicating Public Health Information Effectively: A Guide for Practitioners. Washington, DC: American Public Health Association; 2002.

 

Agency for Toxic Substances and Disease Registry (ATSDR). A Primer for Evaluating Health Risk Communication. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service. http://www.atsdr.dcd.gov/HEC/evalp1.html

 

Agency for Toxic Substances and Disease Registry (ATSDR). 2001. A Primer on Health Risk Communication Principles and Practices. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service.

 

Allen FW. The government as a lighthouse: a summary of federal risk communication programs. In: Covello V, McCallum D, Pavlova M eds. Effective Risk Communication: The Role and Responsibility of Government and Nongovernment Organizations. New York: Plenum Press; 1989.

 

Bennett P. Communicating About Risks to Public Health: Pointers to Good Practice. EOR Division, Department of Health. United Kingdom.

 

Covello V, Allen F. 1988. Seven Cardinal Rules of Risk Communication. U.S. Environmental Protection Agency, Office of Policy Analysis, Washington, DC. In: Agency for Toxic Substances and Disease Registry (ATSDR). 2001. A Primer on Health Risk Communication Principles and Practices. Atlanta, GA: U.S. Department of Health and Human Services, Public Health Service.

 

Covello V, McCallum D, Pavlova M eds. Effective Risk Communication: The Role and Responsibility of Government and Nongovernment Organizations. New York: Plenum Press; 1989.

 

Fisher A, Pavlova M, Covello V. interagency Task Force on Environmental Cancer and Heart and Lung Disease, Committee on Public Education and Communication, January 1991, pp. xvi-xvii   http://www.health.gove/environment/Casestudies/csapp3.htm

 

Glanz K, Rimer B, Lewis FM. 2002. Health Behavior and Health Education: Theory, Research, and Practice. Third Edition. San Francisco: Jossey-Bass.

 

Lundgren R, Makin AM. 1998. Risk Communication: A Handbook for Communicating Environmental, Safety and Health Risks. Second Edition. Ohio: Battelle Press.

 

National Cancer Institute (NCI). 1992. Making Health Communication Programs Work: A Planner’s Guide. U.S. Department of Health and Human Services. Public Health Service, National Institutes of Health, Office of Cancer Communications, NIH Publication No. 921493.

 

Nelson DE, Brownson RC, Remington PL, Parvanta C eds. Communicating Public Health Information Effectively: A Guide for Practitioners. Washington, DC: American Public Health Association; 2002.

 

Rosenstock L, Cullen MR. 1994. Textbook of Clinical Occupational and Environmental Medicine, Philadelphia: Saunders; 68.