Developing new hazard category language for the agency for toxic substances and disease registry's public health assessment products.
The Agency for Toxic Substances and Disease Registry (ATSDR) determines public health implications associated with hazardous waste sites and other environmental releases. Since its inception, ATSDR has continued to improve its approach to evaluating public health hazards in light of evolving science. For example, in response to concerns about the clarity, meaning, and understandability of the five conclusion categories outlined in its Public Health Assessment Guidance Manual (www.atsdr.cdc. gov/HAC/PHAmanual/index.html), ATSDR established an ad hoc work group to evaluate and recommend changes to the categories based on health and risk communication science.
All site-specific public health assessment reports must include a statement that assigns a hazard conclusion category to the site, a time period for exposure (e.g., past, current, or future), or an exposure pathway, as appropriate. This statement reflects one of the following: that the site does not pose a public health hazard, that the site poses a public health hazard, or that data are insufficient to determine whether any public health hazard exists. The language used to convey these categories, however, was difficult for community members and lay audiences to understand because it was not written clearly.
After initial input from partners and stakeholders, the work group modified the language to include more comprehensive, descriptive statements within each category and initiated a three-part review process to test and refine the messages. First, the language was reviewed by an expert panel of risk communication scholars and practitioners and by internal and external stakeholders. Next, by using this input, the work group revised the language and tested it in two focus groups with members of the public. Finally, the language was revised another time and tested again with members of the public.
Expert Panel and Stakeholder Review
Four nationally recognized risk communication experts were asked to provide feedback on the modified hazard category language to ensure that it reflected risk communication science, theory, and practice. The expert panel was first briefed on the public health assessment process and then asked to review the language and rate each message on 1) consistency with communication theory, 2) message clarity, and 3) readability.
Panel members also provided recommendations for modifying the language because they suggested that the revised messages still needed improvement. For example, panelists noted that the differences among several of the hazard categories were slight and that the proposed messages did not accurately convey these differences. Also, messages needed clearer, more understandable language with specific information about the nature of the risk and what people should do to avert or reduce exposure to it. In addition, the panel discouraged the use of subjective wording to avoid confusing the readers. The panel also recommended that the work group pay particular attention to the emotional responses the messages might cause and make the messages more empathetic. Lastly, the panel recommended that the work group use a standardized methodology to convey messages, such as message mapping (Covello, 2006), to ensure consistency, accuracy, and receptivity across ATSDR messages.
ATSDR provided the modified language to state cooperative agreement and federal government technical partners for review and comment. These partners provided comments similar to those received from the expert panel.
Given this feedback, the work group modified the language to clarify the intent of the public health assessment category, to focus the language on actions that needed to be taken, and to use words that were meaningful to a nontechnical audience.
Testing the Language in Focus Groups
The work group then tested the language with the lay public. Two focus groups were held in Atlanta, Georgia, in November 2006 in a professional focus group facility and lasted between 1.5 and 2 hours. Participants were recruited from the facility's database and received $75 for their time. The focus group sessions were audio taped and video recorded. Seventeen individuals participated across the two racially diverse groups, and approximately half the participants were male. Participants were aged 18-45 years and had at least a high school diploma but not more than a four-year college degree.
Each focus group answered a separate set of questions. Key questions tested whether the modified language had improved the hazard conclusion category messages. Participants were told that they might read or hear these messages if a piece of land or property in their community had been found to be contaminated. The participants were not told that these messages would be part of a formal site investigation nor were they told what agency sponsored the investigation.
Participants preferred short, concise sentences, yet they preferred to have too much information rather than too little. Participants did not like word choices that implied that they would not be harmed in the future if they were exposed to a chemical or hazardous substance. Participants had difficulty understanding in the revised language if an exposure had occurred, was occurring, or may occur in the future. Based on the findings from these focus groups, the work group recommended revising the hazard category language to a reading level between sixth and eighth grade, using short sentences that included all the necessary facts, and clarifying who was to take action to address the hazard.
Cognitive Response Testing of Revised Language
In August 2008, a final round of testing was conducted with the lay public to ensure that the revised language met its intended objectives of empathy, clarity, and understandability. The testing focused on ensuring that the proposed hazard category language conveyed the intended meaning and had limited unintended emotional effects on readers. Cognitive response testing was conducted with two groups at a professional focus group facility in Atlanta, Georgia. The first group consisted of participants who were not living near a hazardous waste site and who were not seeking information about environmental exposures. The second group consisted of participants who lived near a hazardous waste site or were concerned about chemicals in the environment. Participants ranged in age from 24-55 years and were ethnically diverse.
Participants read the proposed messages and rated their emotional responses to the statements. They then participated in a facilitated discussion about their reactions to the statements. Results suggested that the proposed language conveyed the intended meaning and elicited the appropriate emotional response given the degree of hazard stated in the message. Slight changes to the language were required, including the need for more specific information about the time period for exposure (e.g., use "less than a year" rather than "a short period of time").
New Hazard Category Language
Based on this input, the work group proposed that hazard category statements in ATSDR's public health assessments explicitly state 1) that ATSDR is the agency offering the conclusion;
2) the substance and pathway of exposure in lay terms (e.g., drinking, breathing, eating);
3) the specific time period for exposure (e.g., more or less than a certain number of days, weeks, or years);
4) location of the exposure; and
5) whether the exposure could, is not expected to, or will not harm people's health.
Table 1 compares the language from the old hazard categories with the new template for these messages.
The work group recommended that information mapping (Horn, Nicol, Kleinman, & Grace, 1969; Information Mapping, Inc., 1999), which is a method of structuring information to increase comprehension by organizing it into labeled blocks, be used to deliver messages in the summary sections of public health assessments and public health consultations. ATSDR recommends that summaries be structured with the following information blocks: 1) Introduction, 2) Conclusion (using the overarching hazard conclusion category statements described in Table 1), 3) Basis for Decision, 4) Next Steps, and 5) For More Information. ATSDR also advocates that public health assessment and public health consultation reports use plain language (www.plainlanguage.gov), a writing technique that aims to have readers understand the meaning the first time the message is heard or read. ATSDR recommends that plain language be used for the overarching statements in these reports.
The work group recognized the relationship between risk perception and trustworthiness of the communicator (Covello, 2005). A key aspect to developing and maintaining trust is empathy. Empathy statements are an important aspect of risk communication as they add to the speaker's credibility and assist in building rapport and positive relationships with community members. For these reasons, ATSDR suggests that its documents include empathy statements. Typically, empathy statements contain two parts: labeling of feelings and linking to a situation. These statements allow the speaker to recognize the other persons' wants, needs, and desires and to engender feelings that the other persons have been heard; in turn, the statements help make the other persons more receptive to hearing negative information (Bedell & Lennox, 1996).
Table 2 shows a hypothetical example of how a hazard conclusion Category 4 statement would appear by using plain language, information mapping, and empathy statements.
Drawing on communication science and input from experts, stakeholders, and the lay public, ATSDR's revised hazard conclusion categories represent clearer, more easily understood health messages about environmental exposures. ATSDR's use of the new language and format in its public health assessments and public health consultations should result in communities better understanding the basis for public health decisions and what those decisions mean to their public health.
Bedell, J.R., & Lennox, S.S. (1996). Handbook for communication and problem-solving skills training: A cognitive-behavioral approach. New York: John Wiley and Sons.
Covello, V.T. (2005). Risk communication. In H. Frumkin (Ed.), Environmental health: From global to local (pp. 988-1009). San Francisco: Josey-Bass.
Covello, V.T. (2006). Risk communication and message mapping: A new tool for communicating effectively in public health emergencies and disasters. Journal of Emergency Management, 4(3), 25-40.
Horn, R.E., Nicol, E., Kleinman, J., & Grace, M. (1969). Information mapping for learning and reference (A.F Systems Command Report ESD-TR-69-296). Cambridge, MA: I.R.I.
Information Mapping, Inc. (1999). The Information Mapping[R] method: 30 years of research-- research paper and notes. Retrieved May 26, 2009, from http://www. infomap.com/documents/IMI%20history%20and%20results.pdf
Corresponding Author: Sylvia Allen-Lewis, Lead, Community Involvement Team, Agency for Toxic Substances and Disease Registry, 1600 Clifton Road, NE, Mail Stop F-59, Atlanta, GA 30333. E-mail: SAllen-Lewis@cdc.gov.
Gregory Ulirsch, PhD
Ken Orloff, PhD
Dan Alexanian, MS
Sylvia Allen-Lewis, Ma
Jerald Fagliano, MPH, PhD
Danielle M. Langmann, MS
Karen Larson, PhD
Donald Miles, MS
Jana Telfer, MA
Susan Robinson, MS
Monique Mitchell Turner, PhD
Judy Berkowitz, PhD
TABLE 1 Previous and Recommended Hazard Category Statements Previous Hazard Category New Overarching Hazard Category Statements Category 1: Category 1: Short-term exposure, Chemical hazard: ATSDR concludes that acute hazard [SUBSTANCE/PATHWAY. Describe the pathway--drinking, breathing, eating, etc.] Urgent public for [TIME PERIOD. List the time period--for health hazard example, less than a year, less than two weeks, or two weeks or less] at/in [PLACE] could harm people's health. "This is an urgent public health hazard." Physical hazard: ATSDR concludes that [PHYSICAL HAZARD. Describe the physical hazard] at/in [PLACE] could harm people's health. This is an urgent public health hazard. Category 2: Category 2: Long-term exposure, Chemical hazard: ATSDR concludes that chronic hazard [SUBSTANCE/PATHWAY. Describe the pathway--drinking, breathing, eating, etc.] for Public health hazard [TIME PERIOD. List the time period--for example, a year or longer] at/in [PLACE] could harm people's health. Optional statement for this category: "This is a public health hazard." Physical hazard: ATSDR concludes that [PHYSICAL HAZARD. Describe the physical hazard] at/in [PLACE] could harm people's health. The following optional statement may be added for this category: "This physical hazard is a public health hazard." Category 3: Category 3: Lack of data or ATSDR cannot currently conclude whether information [SUBSTANCE/PATHWAY. Describe the pathway--drinking, breathing, eating, etc.] Indeterminate public at/in [PLACE] could harm people's health. The health hazard following optional statements may be added for this category: (1) "The reason for this is [add information why data will never be available]" or (2) "The information we need to make a decision is not available. We are working with [specify agencies] to gather the needed information." Category 4: Category 4: Exposure, no harm ATSDR concludes that [SUBSTANCE/PATHWAY. expected Describe the pathway--drinking, breathing, eating, etc.] at/in [PLACE] is not expected to No apparent public harm people's health. The following optional health hazard phrase may be added to the end of the sentence for this category: "because [state reason]." Or, the following optional statement may be added for this category: "The reason for this is [state reason]." Note: Category 4 has two options: exposure with further action or without further action. Category 5: Category 5: No exposure, no ATSDR concludes that the [SUBSTANCE/PATHWAY] harm expected will not harm people's health. The following optional phrase may be added to the end of the No public health sentence for this category: "because people hazard have not been [describe the pathway--drinking, breathing, eating, etc.]." Or, the following optional statement may be added for this category: "The reason for this is that people have not been [describe the pathway--drinking, breathing, eating, etc.]." TABLE 2 Example of How the New Hazard Category Language and Approach Would Be applied to category 4 * Information Block Description Introduction In the Yakliske community, the Agency for Toxic Substances and Disease Registry (ATSDR)'s purpose is to serve the public by using the best science, taking responsive public health actions, and providing trusted health information to prevent people from coming into contact with harmful toxic substances. Conclusion ATSDR concludes that touching, breathing, or accidentally eating zinc found in soil and dust at the XYZ site is not expected to harm people's health because zinc levels in soil are below levels of health concern. Basis for decision Zinc is an essential nutrient. Although zinc is needed by the body for immune function and normal growth and development, too much zinc can be harmful. Children may be exposed to zinc in soil by putting their soiled fingers or toys ir their mouths. In addition, residents may be exposed to zinc by unintentionally eating soil or breathing dust during recreational activities. The amount of zinc that could enter the bodies of adults or children when they visit or trespass on the XYZ site is below a level that would harm their health. Next steps No public health actions are needed related to the XYZ site surface soil. For more information If you have concerns about your health, you should contact your health care provider. You may also contact ATSDR at 1-800-CDC-INFO and ask for information on the XYZ site. * Category 4 refers to exposure that is not an apparent public health hazard and requires no further public health action.
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|Title Annotation:||GUEST COMMENTARY|
|Author:||Ulirsch, Gregory; Orloff, Ken; Alexanian, Dan; Allen-Lewis, Sylvia; Fagliano, Jerald; Langmann, Dani|
|Publication:||Journal of Environmental Health|
|Date:||Dec 24, 2010|
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