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Human Biomonitoring for Environmental Chemicals 6 Communicating Results, Interpretations, and Uses of Biomonitoring Data to Nonscientists Very recent history has seen tensions aroused by monitoring of human tissues to assess exposure to environmental chemicals and the consequent importance of communication about biomonitoring. For example, concern over whether biomarker data would prompt new mothers to abandon beneficial breast-feeding for fear of contaminating their children helped to scuttle proposed biomonitoring legislation in California. Biomonitoring makes environmental exposure personal (Chapter 1), raising concerns about materials that seem out of place in the human body, such as perchlorate in breast milk and flame retardants in fetal cord blood. However, there is also great anxiety over “erroneous” use of biomonitoring data to reach premature conclusions about health effects or contaminant sources and exposure reduction. Another example of communication issues within “fractious debates” (Chapter 4) concerned the Centers for Disease Control and Prevention (CDC) release of its 2005 report on biomonitoring data. Two allegedly competing implications were trumpeted by outside groups: “The nation is awash in toxics.” “Look at the progress made in reducing exposures.” Anxiety among laypeople can be heightened by frequent reporting of biomonitoring data that are not fully explainable with current scientific knowledge. Communication is essential for proper interpretation and use of biomonitoring data. Earlier in this report, we emphasized the intricate and mutual involvement of analysis, management, and communication of environmental biomonitoring (Chapter 1); the contentious social and political context with diverse constituencies for biomonitoring information; and the need to incorporate communication-evaluation planning, consideration of
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Human Biomonitoring for Environmental Chemicals partnerships, and constituency assessment into study design (Chapter 4). This chapter focuses on issues entailed in reporting results of biomonitoring studies and in discussing their interpretation and use. If study design included partnership with one or more constituencies, continued partnership on implementation of evaluation and of reporting results is prudent. Partnerships could be undertaken even without prior partnership in the study planning, but evaluation is likely to determine that communication would have been even more effective if partnership had begun earlier. Constituency assessment should have been completed by the time results are reported, although a significant lag time since the planning stage might necessitate updating this assessment to ensure there have been no critical changes before communication of results begins. Public perceptions about uncertainty, exposure, and other biomonitoring-relevant topics discussed in this chapter might inform constituency assessment as described in Chapter 4. The remainder of Chapter 6 assumes that appropriate evaluation planning and implementation, partnership consideration and implementation, and constituency assessment have been done, and therefore this chapter focuses on reporting of results, interpretation, and use. Without effective communication in particular between biomonitoring researchers and nonscientists and among nonscientists, proper interpretation and use of biomonitoring data will occur only with difficulty, conflict, anxiety, and waste of time and money. The challenges for biomonitoring reflect those common to communication of risk assessment (not to mention risk management) as identified by the field of risk communication. There are failures by information generators to characterize interpretation of data fully and fairly, or to attend to constituent information needs or concerns; failure of information reporters to fully convey information complexities, and caveats while avoiding simple “sound bites”; and by information recipients to be prepared (for example, with knowledge and attention) to deliberate adequately on the information’s meaning for risk management. Because the literature on biomonitoring-specific communication is extremely scarce, this chapter addresses risk communication issues most relevant to biomonitoring. LIMITS OF THIS CHAPTER’S DISCUSSION First, we focus here on communication with nonscientists, partly because that is where the challenges often are the most difficult1 and partly 1 Communication among scientists (such as toxicologists, epidemiologists, and risk assessors) about biomonitoring can be fraught with problems. However, the focus of this chapter is on the communication path between scientists and nonscientists, where the nature of the problems and potential solutions is less understood.
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Human Biomonitoring for Environmental Chemicals because that is where the sketchy evidence on communication issues is centered. We also see scientists, as well as institutional policy-makers and communicators, as among the prime audiences for this chapter’s advice on communication. As noted in Chapter 4, potential discussants of environmental biomonitoring are more diverse than just “laypeople” and “experts,” and there is great diversity within each constituency cited in Chapter 4 in the nature and degree of beliefs relevant to biomonitoring. Communication is best described as at least a two-way, if not a multiple-voice all-talking-at-once, conversation in which scientists are not the sole generators of biomonitoring data (see Chapter 2), let alone the only ones able to interpret and use the data. Second, the committee does not equate nonscientists with the general public, although much of the current scientific literature on lay beliefs and attitudes relevant to biomonitoring focuses on the latter. We treat nonscientists as a broader category because that describes reality: even in universities, some biomonitoring communicators and constituents are laypeople, and that is the case even more in government agencies, business firms, foundations, activist groups, and amongst politicians, as well as “the general public.”2 The need to distinguish biomonitoring communication for informing citizens from that for informing other constituencies is unclear.3 No doubt, similarities can be taken too far such as in giving an organization a clinical consultation, or assuming that officials of an agency or firm are unreceptive to quantitative data or explicit consideration of tradeoffs between variously uncertain health benefits and similarly uncertain exposure-reduction costs. The literature on reporting scientific results to lay decision-makers in government and other institutions (e.g., Brown 1985; NRC 1989; Balch and Sutton 1995; Stern and Fineberg 1996; Andrews 1998; PCCRARM 1997; Thompson and Bloom 2000) can be useful. Potential diversity is the reason to support research on how biomonitoring-related concepts might differ among discussants. How- 2 Scientists also occur in all these groups, including politicians, activists, and the general public; presuming that a constituency’s members have no relevant expert knowledge or scientific sensibility can be a serious mistake. 3 For example, Brown (1985) on “presenting risk management information to policymakers,” PCCRARM (1997) on “risk assessment and risk management in regulatory decision-making,” and Thompson and Bloom (2000) on “communication of risk assessment information to risk managers” include topics and recommendations familiar to readers of guides on risk communication to the public. They discuss, for example, the need to consider the larger context (for example, What makes this decision important? What do various stakeholders think about it?); challenges of conveying uncertainty accurately and effectively, whether it entails qualitative or quantitative measures; how risk comparisons can be helpful or misleading; and risk differences among management options. Thompson and Bloom (2000) go so far as to suggest “using risk managers as representatives of the public to assess the effectiveness of different communication methods.”
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Human Biomonitoring for Environmental Chemicals ever, until such research is conducted, it would not be incorrect to treat biomonitoring knowledge of, and communication with, nonscientists as if there are no differences within that group other than those that a competent and early constituency assessment (Chapter 4) would take into account in determining how to design an effective biomonitoring study. We do not minimize the challenges of communicating to different constituencies, but we believe that at this stage of the art, far more is to be gained by stressing similarities among biomonitoring communication of all types. Third, the scientific literature on risk perception and communication reviewed in the rest of this chapter is based entirely on external-exposure monitoring and other nonbiomonitoring aspects of environmental issues. To the committee’s knowledge, no studies have directly explored biomonitoring beliefs or communication. We assume that the cited literature can be extrapolated to biomonitoring, but without evidence that it is a safe assumption. The risk communication literature shows that generalization from experience or other research topics can backfire if not verified with empirical testing (for example, Morgan and Lave 1990). That is why the communication-research agenda recommended by the committee is critical: it will fill a serious gap in our knowledge that has been left by the non-biomonitoring priorities of researchers and research funders—and a gap probably not fillable without explicit funding by biomonitoring sponsors. Fourth, although good communication is critical for interpretation and use of biomonitoring data, this dictum should not blind anyone to the limits of what communication about biomonitoring can accomplish, given the volatile social and political context cited in the introduction to Chapter 4. Communication will not eliminate all value conflicts, will not obscure or reduce all imbalances of power between parties contending about what constitutes good science or appropriate risk management, and will not even get everyone to agree on interpretation of “facts” even if they agree on the facts themselves. Some gaps in knowledge, responses to uncertainty, power, and values are too large to bridge simply with what one says and how one says it, rather than (for example) with what one does.4 In making these 4 It is not our mandate to discuss noncommunication means of resolving environmental-management challenges (e.g., NRC 1997; 2004), but a few examples can be useful. The joint fact-finding and analytic-deliberative processes cited in Chapter 4 can narrow factual or values disputes. Stern (1991) suggested that “learning through conflict” could be “a realistic strategy for risk communication” if bolstered by a supportive infrastructure (such as, incentives for risk analysts and communicators to resist employer and other pressures, independent evaluation of risk messages, watchdog groups, institutional debates more open to citizen participation, and wider distribution of resources for risk communication). Finally, direct risk-reduction efforts by organizations and individuals (such as, emission controls; favoring nonpersistent, nontoxic inputs to production; and avoidance of possible sources) can minimize some communication challenges if decision-makers believe that such steps are appropriate.
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Human Biomonitoring for Environmental Chemicals remarks, we do not wish to encourage the view that communication about biomonitoring would be ineffective or inefficient. On the contrary, communication and systematic evaluation of communication techniques has been given inadequate attention in environmental management (Chapter 4). Neither overenthusiasm of supporters, as reflected in unmet (and undeliverable) promises, nor cynicism or apathy should undermine implementation of biomonitoring communication. In the next section of this chapter, we discuss how “principles” of risk communication provide a good starting point, but details of a communication strategy must be case-specific and tested empirically before implementation. Examples from the literature on lay response to uncertainty and trust in risk-managing institutions demonstrate that point. Then the chapter argues that a proper balance must be achieved between communications seeking to avoid false positives (such as the inference that detection of a biomarker signals inevitable adverse health effects) and false negatives (such as the belief that nondetections or low concentrations relative to a reference range indicate no health problems). The core of the chapter discusses how different groups of biomarkers and thus different kinds and amounts of relevant information can affect interpretation and use. The chapter concludes with practical and research recommendations to enhance the infrastructure for effective communication about biomonitoring. PRINCIPLES OF RISK COMMUNICATION Our aim is to inform research and practice on environmental-biomonitoring communication, not to provide a primer on risk communication in general (a few, widely varied, examples of primers include ATSDR 2001; Hance et al. 1988; NRC 1989; Pflugh et al. 1994; Stern and Fineberg 1996). However, a brief background can both inform potential communicators who are new to this topic and put biomonitoring-relevant discussions into context. The extensive practical literature on risk communication can be drawn on for more detailed instruction as needed. Much attention has been garnered by “principles” of communication that professionals are advised to follow. Well-known examples are seven principles articulated for the Environmental Protection Agency (EPA): accept and involve the public as a legitimate partner (see our Chapter 4); plan carefully and evaluate efforts (Chapter 4); listen to the public’s specific concerns (Chapter 4); be honest, frank, and open; coordinate and collaborate with other credible sources; meet the needs of the media; and speak clearly and with compassion (Covello and Allen 1988). Those and related principles have face validity and often practical utility despite their apparent obviousness and abstractness. For example, treating your constituents as though they are ignorant, hysterical, self-interested, or ideologically
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Human Biomonitoring for Environmental Chemicals driven is no more likely to be effective than if you were treated that way by someone who wanted you to comprehend and agree with his or her message. Thus, one of the first commandments of effective communication is to never assume how any party knows or feels without empirical test. Another is to show respect for each other, regardless of what you think you know about the other’s beliefs. Such principles emerge from practitioners’ deliberation on personal experiences, complemented occasionally by systematic observation or experimentation. As with the Golden Rule and its equivalents in other cultures (“Do unto others …”), it can be surprisingly difficult to recognize shortfalls in one’s performance of principles regarding respect, honesty, clarity, and the like, let alone to modify one’s behavior to put them into practice. So repetition of such principles in communication guides and careful attention to them by would-be communicators are by no means superfluous. However, “rules for risk communication are not enough” (Rowan 1994). There are two critical notions in biomonitoring communication: the need for empirical testing of even the assumptions of the expert or experienced communicator (Morgan and Lave 1990) and attention to situational details that broad principles alone cannot provide and published principles may not even cover. For example, if your goal is to communicate biomonitoring findings to a constituency, what do you know about its members’ beliefs, attitudes, behavioral intentions, behaviors, and policy preferences with regard to this topic, in both mean responses and their variability? How are they similar to or different from other constituents on these measures, including those who will hear your conversation without being deliberately included? How do your background and current environment, and those of your institution, limit what you could say or even imagine saying? How aware are you of such personal and institutional limits? How might constituents’ or your own limits or flexibility affect communication success? Those and other contextual factors affect whether and how mutual understanding, agreement, and action on biomonitoring data occur; and people charged with such communication must learn the answers to these and related questions. The tension between “principles” and effective communication practices is illustrated in discussion of uncertainty (and variability) and trust. Uncertainty and Variability As with other data used to evaluate health risks, uncertainty will characterize interpretation and use of biomonitoring results for years to come, although little is known about how nonscientists deal with technical uncertainties. In general, in their daily lives, people avoid wherever possible
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Human Biomonitoring for Environmental Chemicals uncertainty about bad outcomes from activities that have small or uncertain benefit; control over outcomes is preferred to the lack of control that uncertainty implies (Edwards and Weary 1998). However, both citizens and policy-makers make decisions in the face of uncertainty (e.g., Lopes 1983); decisions are often rationalized, if not driven, by that uncertainty. It is common for scientists and officials to believe that they are far less uncertainty-averse with respect to environmental risks than is “the public” (Lopes 1983; Carpenter 1995; Einsiedel and Thorne 1999); for many environmental-health scientists, uncertainty is a professional “given.” Many scientists and officials apparently deem citizens unable to conceptualize risk-management uncertainties (Frewer et al. 2003)—a view not shared by this committee. In fact, what little evidence we have suggests that a globally uncertainty-averse public is a myth; responses vary widely across the population (e.g., Furnham and Ribchester 1995). Johnson and Slovic (1998) found that 35% of a college-student sample preferred to know whether a situation was safe or unsafe rather than to get a risk probability or range of risk estimates. Frewer et al. (2002) found that only 13% of their UK sample preferred no information about risk until all uncertainty had been eliminated. They also found a public demand for information on food-risk uncertainty as soon as the uncertainty was identified and a greater public acceptance of uncertainty about the science than of uncertainty due to government’s ignorance of the nature or extent of a problem. Those authors concluded that communication should focus on “what is being done to reduce the uncertainty.” Miles and Frewer (2003) speculated that communication of uncertainty in risk estimates about a hazard exposure over which people feel they have little individual control might make the hazard seem “out of control” by institutions too, but their study design did not allow a direct test of that hypothesis. Overall, most risk-communication guides urge open and transparent discussion of uncertainty (e.g., NRC 1989; Hance et al. 1988; ATSDR 2001; also see literature reviews in Johnson and Slovic 1995, 1998).5 Occasionally, the guides go into slightly more detail. For example, Hance et al. (1988) suggest “be specific about what you are doing to find the answers,” “consider involving the public in resolving the uncertainty,” “give people as much individual control as possible over an uncertain situation,” “stress the caution built into standard-setting and risk assessment,” “if people are demanding absolute certainty, pay attention to values and other concerns, not just the science,” and “acknowledge the policy disagreements that arise from uncertainty.” Despite their and others’ discussions of what this advice might mean, however, such principles carry practitioners only so far. 5 Many reports on risk assessment also stress the value of reporting uncertainty (e.g., NRC, 1994).
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Human Biomonitoring for Environmental Chemicals Sketchy but provocative suggestions are beginning to emerge from empirical studies of uncertainty in risk communication. Frewer et al. (1998) provided persuasive information about genetic engineering in food production to British citizens who had positive or negative attitudes toward the technology. Half saw a statement of uncertainty; half did not. The statement said “we are reasonably certain that there are minimal risks …, we cannot be 100 percent certain. This is true of any scientific process. However, the information provided has been derived from the best scientific information available” (Frewer et al. 1998). The admission of uncertainty increased acceptance and reduced rejection of genetic engineering of human DNA, animals, and plants. People with prior negative views were particularly likely to “find the information more informative if information about uncertainty is included” (Frewer et al. 1998). Carpenter (1995) noted that “the client/recipient” might prefer “unambiguous predictions and advice” now to candor about uncertainties, but environmental professionals’ credibility will disappear if “events … show them to be substantially wrong.” However, White and Eiser (in press) suggested that trust experiments show that if, in the face of uncertainty, professionals make a “mistake … of the right kind [such as a precautionary rather than risk-taking action on the public’s behalf, it] could actually make them seem more trustworthy to lay observers because a) it shows they are open and honest and b) people accept that even experts make mistakes sometimes.” Thus, the results of communicating about uncertainty depend on the context. That conclusion is complemented by studies (Johnson and Slovic 1995, 1998; Johnson 2003a, 2004a) that examined how people reacted to uncertainty as expressed in a range of estimates of risk (for example, from 1 in 10,000,000 to 1 in 100,000). As reported by Johnson (2003a, 2004a), the proportions of college-student and working-class industry-neighbor samples that found the producer of such a risk range to be honest and competent ranged from 23% to 49%. Ratings for dishonest and incompetent were 12-27%, honest but incompetent 9-17%, and competent but dishonest 10-20%; 7-18% did not know. The honest-competent inference clearly dominated even without any signal of what (if anything) would be done in light of the uncertainty in risk estimates, although there was no majority view. Adding a precautionary signal (such as, intent to reduce exposure) might increase the proportion that found official discussion or representation of uncertainties in biomonitoring cases to be both honest and competent, just as a clear signal of inaction might sharply increase negative responses. Systematic testing of those and other uncertainty hypotheses is needed because we do not yet know what factors (such as, perceived benefits of hazardous activities) might affect such relations. Empirical examination of principles of risk communication related to uncertainty is in its infancy.
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Human Biomonitoring for Environmental Chemicals Carpenter (1995) specified four questions that communication should try to answer: What do we know, with what accuracy, and how confident are we about our data? What don’t we know, and why are we uncertain? What could we know, if we had more time, money, and talent? What should we know to act in the face of uncertainty? The first two questions are ones that CDC uses when it reports results of site-specific biomonitoring studies (J. Pirkle, CDC, personal commun., May 16, 2005). Both are valuable, but attention should also be devoted, in communication research and practice, to the latter two questions. Communicating about variability might be less challenging than communicating about uncertainty, although equally important. Anecdotal information suggests that people tend to be aware of or to recognize quickly the concept of variability in susceptibility and exposure, so communicating about variability might be easier than discussing probability and other unfamiliar concepts. Furthermore, uncertainty can be reduced to some degree if sufficient and proper effort is devoted to that end, and failure to undertake uncertainty reduction might undermine trust, whereas variability is immutable (Chapter 4). However, no research has explored those hypotheses, and other aspects of biomonitoring variability (for example, in excretion rates) important for interpretation and use of biomarker data are probably less familiar to laypeople. Trust On its face, the topic of trust is more abstract than uncertainty in application to biomonitoring. However, experience and correlational studies suggest that trust in institutions is a critical factor in judgments of how risky something is, and it is likely, in the contentious atmosphere surrounding biomonitoring, that trust will also affect whether nonscientists see having biomarker concentrations in one’s body tissues as risky. For example, later in this chapter we point to evidence of skepticism about the protectiveness of benchmarks based on external-exposure monitoring and suggest that it might apply to biomonitoring benchmarks, too. Interpretations of experience and initial research on “trust asymmetry” in the risk literature (Slovic 1993) suggest that trust is easy to lose and hard to gain. The thrust of the “principles” literature, however, puts practitioners in a bind. They must perform flawlessly to avoid ultimate failure, so it seems, but they have no guidance on building or maintaining trust much more specific than “plan carefully” (plan what?), “listen” (how and to whom?), and the like. More recent research suggests that any asymmetry in gaining and losing trust can depend on the risk object (such as nuclear power vs pharmaceutical industries); studies differ in whether good or bad news has stronger effects on judged risk. Whether trust is
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Human Biomonitoring for Environmental Chemicals asymmetric depends on such factors as the constituency’s attitudes (for example, trusting groups resist bad news, and skeptical ones resist good news) and on whether the good or bad “news” concerns risk-management policies or concrete events (Cvetkovich et al. 2002; White et al. 2003; White and Eiser 2005). Studies also are beginning to suggest that demonstrating that one shares salient values with one’s constituencies—such as preferring to take the risk of creating false alarms (false positives) rather than misses (false negatives)—can build trust (e.g., Earle and Cvetkovich 1995; Cvetkovich and Winter 2003; Siegrist et al. 2003; White and Eiser, in press). For example, a comparison of the same risk at different times (for example, this year vs last year) was suggested to be among the best ways to put risks into context. It was shown empirically that the public ranked it first among 14 comparisons (Roth et al. 1990; Johnson 2003b). However, the message tested also included elements of risk reduction (“Despite the extremely low health risks to the community from emissions … at our plant, we are still looking for ways to lower these levels further. These are some of the plans we have under way to accomplish this….”) and information-sharing not strictly part of the temporal comparison. With those removed from the text, it dropped to a middle-to-low rank (Johnson 2004b). In other words, it was the promise to keep searching for ways to lower the risk further and to keep the concerned community informed about plant operations that fostered positive reactions, not the risk comparison itself. Those studies differ in the conditions that make value-sharing helpful. For example, some scholars argue that effective demonstration that one shares the constituency’s salient values is most important when people are unfamiliar with a hazard (often the case with environmental chemicals). Others suggest that the critical factor is how constituents judge the balance of risks and benefits to themselves; if they see few personal benefits (also commonly the case when environmental toxicants are being considered), a precautionary stance by risk managers becomes more desired. The field is not yet developed enough to provide guaranteed recipes for trust-building. Such recipes may be impossible to provide, given variability in social contexts, and might be undesirable for ethical and democratic reasons. But the studies point the way toward moving beyond general principles to more-detailed advice. Clearly, biomonitoring efforts will vary widely in both need and ability to match the full scope of suggestions for promoting trust, such as the analytic-deliberative processes discussed in Chapter 4 (Stern and Fineberg 1996). But study funders and managers would benefit from considering whether and how their efforts would be enhanced by pursuing trust-enhancing techniques and by empirically testing and expanding relevant communication principles.
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Human Biomonitoring for Environmental Chemicals TRADING OFF AVOIDANCE OF FALSE POSITIVES AND FALSE NEGATIVES IN COMMUNICATION Communication challenges are often intimately entwined with risk-management challenges (Chapter 1), and biomonitoring is no exception. Scientists use statistical and other criteria to err on the side of accepting false negatives (they reject a hypothesis that turns out to be true) because they see false positives (not rejecting a false hypothesis) as the outcome more dangerous to science’s advance and credibility.6 In a parallel sense, there is a strong emphasis in current institutional messages about biomonitoring, as well as in concerns about incautious expansion of biomonitoring, on avoiding message recipients’ false-positive interpretations (Becker 2005; Duggan 2005; Osterloh 2005; Robison 2005; Schober 2005). For example, government agencies and industry groups have argued that one should warn against inferences that health effects would come from observed biomarker concentrations when (as for most biomarkers) the effects are not certain. Similarly, messages should not imply without evidence that a specific activity is the source of observed body burdens or that particular actions will reduce exposures to environmental chemicals. The assumption in those arguments is that most claims about health effects or sources will turn out to be false positives, so officials do not want other people (such as “the general public”) to conclude prematurely that a health effect could occur or a source be responsible. Avoiding the creation of such false positives and possible large negative outcomes is a legitimate risk-management aim that biomonitoring communicators should respect. However, there are flaws in an unreflective emphasis on avoiding creation of false-positive inferences as a result of biomonitoring communications. First, it fails to discriminate between good and bad reasons for fearing that messages will evoke false-positive conclusions. Erroneous assumptions about the psychological, economic, or political fallout of declaring a biomarker concentration as evidence of a public-health threat can lead to misallocation of societal resources. For example, it is an enduring myth among many policy-makers that “panic” is the default response of “the public” to natural, social, and technological hazards, whether hurricanes, terrorism, or “pollutants” in people’s bodies. In some cases, individual or collective human responses may be inappropriate, but 6 For instance, suppose the statistical criterion for testing a null hypothesis is p < 0.05. If p < 0.05, the researcher does “not reject” the hypothesis, because to “accept” the hypothesis would be to take a greater risk of treating as true a proposition that might turn out to be false. Because scientists have been historically more averse to false positives than to false negatives, they have been willing to “reject” hypotheses rather than take the stance of “not accepting” them.
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Human Biomonitoring for Environmental Chemicals who order biomarker tests themselves or through their doctors) may have been subject to lower-quality tests or less-informed consent, which may have presented their physicians with challenges that the doctors had trouble recognizing. Third, most doctors are notoriously ignorant about environmental exposure and health issues (e.g., American College of Physicians 1990; Grupenhoff 1990; Goldman et al. 1999; Wynn et al. 2003), and increasing pressures on their time in medical school and practice offer little hope for swift resolution of this problem. Biomonitoring, because it deals with internal doses, might have a better but still small chance at gaining doctors’ attention and comprehension than other environmental-health topics. Bates et al. (2005) cite some helpful resources for physicians, such as medical toxicologists (ACMT 2006) and pediatric environmental-health specialty units (ATSDR 2005), but efforts must be made to make doctors aware of them and to use them. Fourth, communication between doctor and patient is often problematic, even without the time pressures of the current U.S. clinical visit. There is a growing literature on doctor-patient communication problems and solutions (e.g., Rimer and Glassman 1998; Schwartz et al. 1999; Alaszewski and Horlick-Jones 2003; Maynard 2003; O’Connor et al. 2003; Paling 2003), but it will take time for this literature to influence clinical practice. RECOMMENDATIONS There is no easy recipe for good biomonitoring communication, even if we were dealing with only one kind each of population, biomarker, health effect, reference range or benchmark, exposure pathway, exposure source, biomonitoring study, initial communicator, and constituency and if we had good information on each of these. Given that those conditions do not apply and given the dangers of extrapolating unduly from seemingly similar situations, we do not encourage nor have we promulgated any such recipes. Situation-specific, empirically driven understanding and testing of communication options are vital. However, implementation of several general practical and research recommendations also would enhance the practice of biomonitoring communication. These are listed in rough order of priority for practice and research, respectively. Practical Recommendations The research proposed in the next section is critical for systematic development and evaluation of improved biomonitoring communication. However, even without such research, effective implementation of the practical recommendations listed below would go a long way toward improving both the performance and the comfort level of biomonitoring communicators.
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Human Biomonitoring for Environmental Chemicals Promote Communication Funding and Good Practice. All too often in current biomedical and environmental research and practice, no attention is given by sponsors to communication issues or funding, so the proposals they receive for studies also ignore them (for example, McCallum and Santos 1996). By implication, communication is either relegated to institutional review board review of informed-consent forms or is to be performed (without funding, training, expertise, or planning) in the interstices of the technical tasks of the project. This action by omission is a recipe for bad communication. Without strong institutional support for communication planning and evaluation in individual studies and without development of communication infrastructure generally, biomonitoring communication will become at best unhelpful and at worst a barrier to effective interpretation and use of biomonitoring data. Occasional creative solutions will die for lack of support and dissemination. Biomonitoring sponsors of all kinds (agencies, corporations, foundations, activist groups, and so on) should take the lead in promoting and funding of communication. Sponsors should require explicit planning of communication (Chapter 4); study-specific evaluation of communication (Chapter 4); documentation of communication methods, messages, evaluation methods, and results; and wide distribution of communication materials and findings to the biomonitoring community (not only peer-reviewed academic publications) so that each study need not start from scratch. In a more ambitious approach to information– sharing, a sponsor or consortium of sponsors would establish a biomonitoring-communication database to be maintained and updated for the benefit of the national and international biomonitoring community. In addition to its practical use, biomonitoring-communication researchers might use it for retrospective analyses or to help to set up cooperating networks of practitioners for prospective research (for example, testing one kind of message against another). Use Consistent Terminology and Concepts. Consistency of usage is needed within and between projects (see above on varied definitions of reference populations, for example). This is a recommendation that can be implemented quickly and relatively easily. Ultimately, this should become part of a larger effort to train various constituencies on what biomonitoring can and cannot tell one about environmental chemicals in humans. Both efforts are vital if there is to be any hope of establishing a minimum of shared knowledge among constituencies so that communicators eventually will not need to recapitulate the entire spectrum of education for each new project. Expand Biomonitoring Education for Constituents. Depending on educational gaps identified in proposed research, appropriate institutional actors, such as government agencies and university staff, should provide simple, standard background information that will help people to under-
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Human Biomonitoring for Environmental Chemicals stand how to interpret biomonitoring results that might appear in the mass media and to decide whether and how to pursue informative independent biomonitoring of their own environmental-chemical body burdens. This generic effort will complement project-specific use of consistent terminology and concepts. The usual warnings about systematic development and evaluation of communication apply to these educational materials. Support Communication Training. Communication training for institutions, organizations, and professionals is particularly important, and it will become more vital once research makes such training more than drilling in communication “principles.” Personal and institutional barriers to good practice by doctors, officials, and experts need to be addressed, and training is necessary, but not sufficient, for that task. If partnerships (Chapter 4) with research subjects or other people are envisioned, all parties (including citizens) need some time to learn, both individually and collectively, “how to do it.” Practices that “work” in other contexts, such as conventional public hearings, do not help much here, and citizens are as unfamiliar with appropriate behavior in partnerships as are institutions (Renn et al. 1995). Yet training is as neglected as any other communication issue in environmental practice or funding. Anecdotal data suggest that people assume that communication is either something anyone can do without training or obtainable from press-office advice; neither is true. Document Risk-Reduction Options. Given the potential importance of exposure-reduction actions for both ethics and communication and for both citizens and officials, it is important that there be documentation and wide distribution of information about steps that individuals, communities, and private and public organizations could take to reduce external exposures that might or do contribute to observed biomarker concentrations. Good communication practices mentioned elsewhere in this chapter and in Chapter 4 are as vital to clear and credible communication of exposure reduction information as communication of any other biomonitoring topic. That information should include, whenever available, sources of each environmental chemical and their relative contribution; types of exposure-reduction actions that individuals, households, and institutions could take; and absolute and relative strengths and weaknesses of the actions, such as effectiveness for a given source, cost, and cost effectiveness. The information must be updated to account for new research, innovative technology, and social changes. CDC’s biannual reports on human exposure to environmental chemicals now include information on each chemical’s uses and sources but too generically to be much more than a start for deciding whether and how to act. Exposure-source and -reduction information is unlikely to come from biomonitoring projects themselves in most cases, so other researchers and institutions must provide information on exposure reduction that will be useful for biomonitoring-study design, communica-
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Human Biomonitoring for Environmental Chemicals tion, and ethics. The aim of the documentation is not to endorse either exposure reduction in general or specific actions but to help people to identify quickly whether and which exposure-reduction actions, collective or individual, might be appropriate in a given situation. Ideally, there will be a central clearinghouse for such exposure-reduction information because a more laissez faire approach to the distribution of relevant information might not match the need to know and could create communication and ethical problems. Study managers must adapt any general advice to their own cases, so we urge managers to include discussion of their adaptations in their documentation and distribution of communication efforts, so that future biomonitoring studies can benefit from the creativity of their predecessors. Research Recommendations All the following recommendations are expected to be valuable for the advancement of biomonitoring communication. However, the first three listed should be particularly fruitful because they should be mutually reinforcing: knowing the biomonitoring-related beliefs of communicators and constituents allows evaluation of current and development of alternative communication messages, and evaluation of current and alternative messages feeds back into understanding of what people believe and thus how to improve communication. Identify Mental Models of Exposure and Health Effects. The direct and indirect links between external dose, biomarker concentrations, and biologic effects (Figure 3-1) are the core of both exposure biomonitoring and biomonitoring-communication research. Probing for beliefs about specific subtopics (such as chemical mixtures’ effects on health, pharmacodynamics, and variability in susceptibility) pertinent to biomonitoring communication will need to be part of the effort. We need a better grasp of the mental models of the linkages held by all parties to biomonitoring communication. Studies of the views of lay, “general-public” constituents are important, but so are those of experts, institutional risk managers, and others. That expansive approach is justified by the need to know the expert consensus on causal linkages as a “gold standard” for building messages about the links; any expert disputes that will need explanation to nonexperts (and, perhaps, foster steps toward scientific resolution of the disputes); how, if at all, those who are neither experts nor the general public (such as most institutional officials interested in biomonitoring) differ in their views of causal linkages; and how communicators’ similar or different beliefs about the linkages will affect whether communication succeeds or fails. That information will inform both experts and lay people about technical and nontechnical issues related to biomonitoring, and will determine whether it
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Human Biomonitoring for Environmental Chemicals is feasible to develop and evaluate generic, rather than project-specific, communication designs. Assess Current Biomonitoring Communications. Research to identify the current nature and scope of biomonitoring-related communications by various organizations, including retrospective analyses of generic and project-specific informational materials, will be a vital complement to the prospective evaluation of new project communications recommended in Chapter 4. For example, the apparently growing phenomenon in which individuals contract with a testing laboratory to measure biomarkers in their urine or blood independently of any formal study (Chapter 2) raises communication concerns. Most people are unlikely to have the background to know what to demand of laboratories in terms of tests, quality control, or interpretation, and it cannot be expected in this for-profit, narrow-margin sector that the laboratories themselves will undertake thorough communication efforts. But without systematic analysis, we do not know whether or what deficits exist in current communication by laboratories, so we cannot work to correct them. Similarly rigorous analyses of biomonitoring-related communication by citizen activists, university scientists, industry (for both occupational and environmental issues), and environmental and public-health agencies at local, state, and federal levels of government are also needed. Despite its increasing experience, for example, even the mass-media strategies of CDC in announcing results of its national surveillance reports might be improved (and inform the work of others) if given careful study. Inconsistencies and gaps among the various organizations’ efforts can be identified as targets for remediation or explanation. Furthermore, experience shows that communication may be at odds not only with the beliefs of their intended audiences but also with the mental models of the communicators themselves. That is, the mental models of the communicator might aim at reassurance and clarification, but the actual communication materials do not exemplify reassurance, clarity, or topical relevance even to sympathetic colleagues, much less to intended constituents. Thus, comparison of such materials with the mental models of originators and recipients can be informative. Identify Reactions to and Effective Messages About Uncertainty. Some relevant topics (such as trust) will continue to be the subject of considerable research outside the biomonitoring field and might in turn be applicable to biomonitoring efforts without much adaptation or supplementation. That is unlikely to be true of the perception of and communication about uncertainty, which despite its centrality to environmental-health issues generally has attracted little researcher attention in the last few decades. Furthermore, only some aspects of biomonitoring-relevant uncertainty are shared with other health or environmental topics. If biomonitoring sponsors do not fund this critical research, it is unlikely to be sponsored by others.
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Human Biomonitoring for Environmental Chemicals Particular questions important to biomonitoring include these: Which of the myriad uncertainties in biomonitoring are of most concern or most difficult to understand? For example, are laypeople more interested in reduction of uncertainties about biomarker-effects relations or exposure-biomarker relations? How can these uncertainties best be explained—for example, with verbal vs numeric formats (PCCRARM 1997); Carpenter’s (1995) four questions? How can alternative lay explanations for uncertainties (such as incompetence or self-interest of experts) best be addressed? What are the best means to convey that exposure need not mean health effects, given existing lay beliefs about the exposure-health link? What are the best means to convey that low or typical biomarker concentrations do not rule out health effects? Can values affirmation and other techniques to reduce resistance to messages of personal relevance (such as exposure and exposure reduction) be applied in nonlaboratory situations and populations? How do comparisons with necessarily uncertain reference ranges (for example, “less than 95% of the population”) affect beliefs about exposure, or comparisons with necessarily uncertain benchmarks affect beliefs about health effects, and thus in turn affect the credibility of biomonitoring communication? Do discussions of uncertainty affect judgments of the discussant’s honesty and competence differently, depending on whether action or inaction is proposed as a consequence of the uncertainty? What are the best ways to communicate biomonitoring results when science is unable to determine any interpretation of the data (such as health effects of mixtures)? Identify Mental Models of Exposure Reduction and Risk Managers. The mental-models method was developed to identify how experts and lay constituencies conceive of causal links in the development of hazards, including the exposure-effects link that is so central to biomonitoring, and how these conceptions and differences between the linkages might affect risk communications. One of the goals for systematically identifying potential reasons for communication failures was to develop subsequent messages that would help laypeople accurately identify institutional or personal actions that would prevent such effects. The method is technically capable of identifying relevant beliefs about risk management as well, but its advocates have done little in this direction despite evidence that such beliefs could have a dominant effect on risk judgments. Although, as mentioned earlier, related trust research does not depend entirely on biomonitoring
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Human Biomonitoring for Environmental Chemicals funding, additional work will be needed to make some of it applicable to that field. For example, such research often uses abstract institutional stimuli, such as “the federal government” or “information provision,” that are not useful (Earle and Cvetkovich 1995), and biomonitoring includes actors (such as private laboratories) that are rarely included in these studies. Probing for exposure-reduction and risk-management beliefs will identify whether precautionary exposure-reduction action by institutions or exposure-reduction advice to individuals reduces or increases judged-risk magnitude, concern, or trust among the various constituencies involved. It will also identify effects of lay and expert concepts of detection limits and scope of biomonitoring surveillance on communication. Summary Given the central role of communication in the success of interpretation and use of biomonitoring data, but high uncertainty about what makes for effective biomonitoring communication, building infrastructure and research in this field must have high priority for biomonitoring funders and investigators. Without that priority, the whole field of biomonitoring could fail to advance. REFERENCES ACMT (American College of Medical Toxicology). 2006. American College of Medical Toxicology, Fairfax, VA [online]. Available: http://www.acmt.net/main [accessed April 4, 2006]. Alaszewski, A., and T. Horlick-Jones. 2003. How can doctors communicate information about risk more effectively? BMJ 327(7417):728-731. American College of Physicians. 1990. Occupational and environmental medicine: The internist’s role. Ann. Intern. Med. 113(12):974-982. Andrews, C.J. 1998. Giving expert advice. IEEE Technol. Soc. Mag.17(2):5-6. ATSDR (Agency for Toxic Substances and Disease Registry). 2001. A Primer on Health Risk Communication Principles and Practices [online]. Available: http://www.atsdr.cdc.gov/HEC/primer.html [accessed Nov. 30, 2005]. ATSDR (Agency for Toxic Substances and Disease Registry). 2005. Pediatric Environmental Health Specialty Units (PEHSU). U.S. Department of Health and Human Services, Agency for Toxic Substances and Disease Registry [online]. Available: http://www.atsdr.cdc.gov/HEC/natorg/pehsu.html [accessed April 4, 2006]. Balch, G.I., and S.M. Sutton. 1995. Putting the first audience first: Conducting useful evaluation for a risk-related government agency. Risk Anal. 15(2):163-168. Bates, M.N., J.W. Hamilton, J.S. LaKind, P. Langenberg, M. O’Malley, and W. Snodgrass. 2005. Workshop report: Biomonitoring study design, interpretation, and communication—Lessons learned and path forward. Environ. Health Perspect. 113(11):1615-1621. Becker, R.A. 2005. Trace Chemicals in the Human Body: Interpreting Biomonitoring Data in a Risk Context. Presentation at the First Meeting on Human Biomonitoring of Environmental Toxicants, March 21, 2005, Washington, DC. Brown, R.V. 1985. Presenting Risk Management Information to Policymakers: Executive Summary. Technical Report 85-4. Falls Church, VA: Decision Science Consortium, Ltd.
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Representative terms from entire chapter: