Acknowledgements We offer special thanks to Nancy Ostrove, recently retired from her position as Director, Risk Communication Staff, Office of Planning of the US Food and Drug Administration (FDA), and Lee Zwanziger, Designated Federal Official for FDA’s Risk Communication Advisory Committee. Without them, this guide, like so many of FDA’s initiatives, would not have happened. We also thank Nancy Derr and Elena Ketelhut for their thoughtful and patient help in seeing the guide through the production process. Finally, we thank the guide’s authors and reviewers. Each has either served on the Committee or supported its work. Each has also had a role in creating the field of risk communication, producing its research foundations or making communications work in ways that are faithful to the science being communicated and to the needs of those whom it serves. We also thank the following publishers for kind permission to reuse figures: Elsevier (Chapter 4, figure 1 and Chapter 8, figure 2), John Wiley and Sons (Chapter 4, figure 2 and Chapter 8, figure 1), Nature Publishing Group (Chapter 4, figure 3), Lawrence Erlbaum Associates (Chapter 15), and University of California Press (print) and Lisa M. Schwartz (electronic) (Chapter 6, figure 1). Other figures were obtained from open sources such as governmental publications, created by the authors for this volume, or were owned by the authors for purposes of reuse in their own works. Published by the Food and Drug Administration (FDA), US Department of Health and Human Services, August 2011. Contributors to this compilation are past or current members or consultants of the FDA’s Risk Communication Advisory Committee. For more information on the committee, see http://www.fda.gov/AdvisoryCommittees/CommitteesMeetingMaterials/ RiskCommunicationAdvisoryCommittee/default.htm FDA Disclaimer: The findings and conclusions in this compilation are those of the individual authors and do not necessarily represent the views of the Food and Drug Administration. There is no copyright in U.S. government work (per 17 U.S.C. 105), and the work provided here is considered U.S. government work. Communicating Risks and Benefits: An Evidence-Based User’s Guide is available on FDA’s Web site at http://www.fda.gov/ScienceResearch/SpecialTopics/RiskCommunication/ default.htm US Department of Health and Human Services, Food and Drug Administration 10903 New Hampshire Ave, Silver Spring, MD 20993 Cover photo: Nancy M. Ostrove, Rock formation, Valley of Fire State Park, 2009 Cover design: Erica Munoz, 2011 Communicating Risks and Benefits: An Evidence-Based User’s Guide Table of Contents Introduction to Evidence-Based Communication Page Chapter 1: Introduction - (Editors) ...................................................................................... 1 Chapter 2: Goals - Noel Brewer ........................................................................................... 3 Chapter 3: Evaluation - Julie Downs .................................................................................. 11 Chapter 4: Duty to Inform - Baruch Fischhoff ................................................................... 19 Chapter 5: Language - Musa Mayer .................................................................................. 31 Evidence-Based Best Guesses at Best Practices Basic Processes Chapter 6: Definitions - Baruch Fischhoff ......................................................................... 41 Chapter 7: Quantitative Information - Angie Fagerlin, Ellen Peters .................................. 53 Chapter 8: Qualitative Information - Julie Downs, Baruch Fischhoff ................................ 65 Chapter 9: Health Literacy - Michael Wolf ........................................................................ 77 Chapter 10: Affect and Emotion - Ellen Peters .................................................................. 89 Chapter 11: Information and Persuasion - Mary Brown, Christine Bruhn ...................... 101 Chapter 12: Across the Life Span - Valerie Reyna ........................................................... 111 Chapter 13: Health Care Professionals - Betsy Sleath, Michael Goldstein ...................... 121 Communication Design Chapter 14: Readability, Comprehension, and Usability - Linda Neuhauser, Kala Paul .... 129 Chapter 15: Warnings and Disclosures - J. Craig Andrews.............................................. 149 Chapter 16: Human Factors - Gavin Huntley-Fenner ...................................................... 163 Chapter 17: Shared Decision Making - Nananda Col ...................................................... 173 Chapter 18: News Coverage - Gary Schwitzer ................................................................ 185 Chapter 19: Inside the Organization - Caron Chess ........................................................ 195 Implementing Evidence-Based Communication Chapter 20: Practitioner Perspectives - Lee Zwanziger .................................................. 205 Chapter 21: An Agency Perspective - Nancy Ostrove ..................................................... 215 Chapter 22: Strategic Planning - (Editors) ....................................................................... 223 Communicating Risks and Benefits: An Evidence-Based User’s Guide | 1 Chapter 1: Introduction Baruch Fischhoff, PhD - Carnegie Mellon University Noel T. Brewer, PhD - University of North Carolina Julie S. Downs, PhD - Carnegie Mellon University Organizations bear economic, legal, and ethical obligations to provide useful information about the risks and benefits of their products, policies, and services. Failure to fulfill those obligations can be costly, as seen with Three Mile Island, Hurricane Katrina, Vioxx, and other cases when people believe that they have been denied vital information. Less dramatic versions of these problems arise with poorly handled produce recalls, badly labeled appliances, and confusing medication instructions. Financial analysts estimate that 70% of a typical private firm’s assets are intangibles, like goodwill, that can be lost when communications fail. Public institutions’ reputations often depend on their ability to communicate. Risk communication is the term of art used for situations when people need good information to make sound choices. It is distinguished from public affairs (or public relations) communication by its commitment to accuracy and its avoidance of spin. Having been spun adds insult to injury for people who have been hurt because they were inadequately informed. Risk communications must deal with the benefits that risk decisions can produce (e.g., profits from investments, better health from medical procedures), as well as the risks — making the term something of a misnomer, although less clumsy than a more inclusive one. The risk communication research literature is large and diverse, including results from many contributing disciplines (e.g., psychology, decision science, sociology, communications) and a wide range of applications. Unfortunately, the norms of academic research make it inaccessible to outsiders, filling it with jargon and technical details. Moreover, academic researchers’ theoretical interests often lead to studying communication processes in isolation, leaving gaps as to how research results apply to complex, real-world situations. Unable to access the research literature, practitioners rely on their intuition, unproven best practices, and popular accounts of psychological research. This guide seeks to fill that gap, making evidence-based communication possible. The chapters that follow cover key topics in risk communication, 2 | Chapter 1: Introduction focusing on three questions: (1) What does the science say about that aspect of human behavior? (2) What are the practical implications of those scientific results? (3) How can one evaluate communications based on that science? These questions assume that sound communications must be evidence- based in two related ways. One is that communications should be consistent with the science — and not do things known not to work nor ignore known problems. The second is communications should be evaluated — because even the best science cannot guarantee results. Rather, the best science produces the best-informed best guesses about how well communications will work. However, even these best guesses can miss the mark, meaning that they must be evaluated to determine how good they are and how they can be improved. Each chapter in the guide is self-contained, so that its issues can be studied on their own. Each is written as simply as possible, consistent with fidelity to the science it reports. Each includes both the references documenting its claims and an annotated list of further readings. They offer evaluation methods suited to practitioners with no budget, a small budget, and a budget worthy of the stakes riding on the communication — so that evaluation can become part of every application. Some chapters deal with the audience (e.g., how people interpret quantitative information, how emotions — and age — affect risk perceptions), others with communications (e.g., decision aids, mass media). Introductory chapters consider the goals of risk communications (Chapter 2), methods for evaluating them (Chapter 3), standards for assessing their adequacy (Chapter 4), and the language that they use (Chapter 5). The first of three concluding chapters reports the perspectives of the committee’s practitioner members (Chapter 20). The second concluding chapter