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Risk Communication in Health Promotion


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Title: Risk Communication in Health Promotion

Risk Communication in Health Promotion
  • S. Thavaraj
  • Pengarah RD
  • 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
  • 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 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

Health Promotion and Behavior Risk Factors
(relevance to Risk Communication)
  • There is a tendency among public health officials
    and governmentsand this is especially the case
    in liberal nations such as Canada and the USAto
    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,
  • 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
  • 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

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

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
  • 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

Incorporating Risk Communication in Health
  • 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
  • Impact Evaluation

Risk Communication Settings
  • Clinic
  • Hospital
  • Workplace
  • School
  • Community

  • Planned Media Activities
  • Electronic
  • Print
  • Social
  • Face to Face

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

  • Evaluating the strategies Formative Evaluation
  • Evaluating the Objectives/ Goals Impact
  • Evaluating Messages conveying Risk and Risk
  • 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
  • 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)
  • 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

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

NGO activity
NGO Persatuan Pesara Kerajaan Malaysia
NGO on Obesity
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 MakersLobbying
  • 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
  • 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
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).

  • 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
  • Increasing provision of safe traffic free walking
    routes to schools and workplaces through
    continuation of the Assembly Governments 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 childrens 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.

  • 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

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

  • 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
  •  (Löfstedt, R.E. 2005. Risk Management in
    Post-Trust Societies, Basingstoke Palgrave.)

  • 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

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

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

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 Chiefs 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

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 governments
    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.

Operations Room Bilik Gerakan
  • Soft Skills
  • What should one know
  • What should one do
  • Counter Rumours
  • SOP
  • Health Education materials
  • Circulars and Guidelines
  • Frequently Asked Questions

  • Thank You
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