By Victoria Woof and David French, Manchester Centre for Health Psychology, University of Manchester, UK

Traditionally in medicine and health psychology, healthcare professionals have provided patients with their personalised disease risks with the aim of preventing disease. Where risk communication facilitates changes to health behaviour, it can potentially reduce the development of disease and find diseases at treatable stages. For instance communicating the risk of cardiovascular disease to promote the uptake of physical exercise and improved diet to reduce risk. However, there are other possible aims and outcomes to consider when delivering information about disease risk. Further, the goals of healthcare professionals and patients or members of the public may not always be aligned. Several related goals of risk communication have been identified, including facilitating informed choices and producing appropriate affective responses, as well as motivating behaviour change.

Current risk communication practices and implications

To facilitate understanding of numerical information and improve risk communication, various approaches have been considered, such as using visual representations of risk, for example icon arrays (icons representing the number of people at risk). Yet, recipients continue to experience difficulties in understanding numerical figures and their implications. In particular, providing risk information of this kind in isolation does not appear to have any large or long lasting effects on behaviour change. One likely explanation for this lack of impact is that changing recipients’ susceptibility beliefs via numerical risk information alone is a comparatively weak intervention, with beliefs about self-efficacy and coping (i.e. how much an individual believes they have the capacity to carry out a behaviour) potentially having more positive implications for changing behaviour.

Nonetheless as previously mentioned, there are other aims for risk communication to consider. In the cancer risk literature, it has been found that individuals understand and are able to recall their risk estimates. However, these individuals do not always believe the risk estimate reflects their perceived risk despite clear explanation, with the majority over-estimating their risk. It would appear here that individuals have pre-existing perceptions of their risk which remain unchanged when a numerical clinical estimate is provided. So, what might be causing this?

Risk communication and personal risk appraisals

Personal experiences of familial disease, congruence between personal expectations and clinical estimates and personal ideas of causes all have an effect on how a clinical breast cancer risk estimate in particular is perceived and internalised. Although the provision of a clinical risk estimate has little impact on emotional outcomes, pre-existing emotions (assessed before risk is communicated) are a strong predictor of how risk estimates are perceived and reacted to. Without acknowledgement of these types of issues, the risk communication techniques we employ will only go so far in supporting informed decisions and accurate risk appraisals.

We have recently highlighted in a systematic review of qualitative studies that the severity of familial breast cancer affects women’s engagement in preventative behaviours. Should breast cancer not be the main priority compared to other diseases, engagement in preventative action may be neglected, as other diseases in the family are more worrisome. Similarly, when prior expectations of risk do not match with a clinical risk estimate, women may react with dubiety and shock, with trust in the estimate undermined. If the clinical estimate does not fit with these pre-existing views and expectations, suggested changes to diet or uptake of preventative medication may not be acted upon.

Toward a more personal approach to risk communication

Those receiving a personalised disease risk estimate are not passive recipients of this information. Instead these individuals use their social contexts, personal biases, values and experiences to make sense of information regarding their risk, which may not always align with the goal of the communicator or the numerical risk provided.

An open dialogue with the recipients of a disease risk is beneficial, covering more than the numerical estimate in order for goals and knowledge to converge. For effective risk communication healthcare professionals need to establish in the first instance, what knowledge and understanding individuals already possess about a given disease risk. By doing so professionals would provide themselves and the recipient with the opportunity to discuss shared understanding and work through misperceptions to align their goals. More time spent providing individualised and tailored feedback would likely improve how recipients think about their risk and also increase both parties’ confidence in shared informed decision making, as well as facilitating sustained changes to health behaviours.

Practical recommendations:

• What are the goals of your risk communication – before providing a disease risk it is important to first establish what you are trying to achieve, e.g., behaviour change, informed choices. Once goals are established, professionals should also consider the goals of the recipient and work together to find common ground.
• Open up a dialogue with the recipient – provide a space for the recipient to communicate their thoughts in order to assess the different ways in which they view their risk and whether they possess the necessary knowledge to make informed choices and help guide them in their choice, whatever that may be.
• Respectfully challenge misunderstandings – work with the recipient to discuss incorrect ideas and work through knowledge gaps. This will set the foundations for more informed decision making, if this is the goal of the communication.
• Tailor your communication – think about the needs of the recipient and establish ways of transferring knowledge in order to engage in a meaningful discussion. This may be done by layering information by providing brief or ‘gist’ information which is then backed-up by more detailed material, if requested.