Introduction of section: overarching considerations in risk communications: romancing the message.

If evaluation of factual information, by itself, informed the debate each of us has with ourselves about risky behaviors, this would have long ago been a nation full of nonsmoking, seat belt-wearing, lean, exercising, chemopreventing, sun-avoiding, health care-seeking men and women. That we are not such a nation also is underscored by the American experience with Alar, silicone breast implants, and screening mammography. They stand as powerful testimony not only to the influence and impact of the media on risk perception and behavior but also, most of all, perhaps, to the difficulty risk communicators face in crafting messages that individuals find meaningful (1). Put another way, individual perception and assessment of risk is fundamentally a subjective enterprise. Groups do not decide to quit smoking. Individuals do. And emotional, temperamental, and life-history factors—along with factual information—guide the decisions we make—or do not make—about the information we seek or get. One person’s adventure is another’s mortal threat. She calls racing cars great fun; he calls it a mobile death wish. He cares little for annual prostate-specific antigen tests; she demands screening mammography at age 35 years. Consequently, whereas it may be popular in scientific circles, whining about “irrational” and “unscientific” public assessments of risk not only gets us nowhere, but it also threatens to turn off interest among the very people we most want to better inform about risks. Communications and behavioral scientists have long demonstrated that the most effective way to teach, persuade, or attract attention is with one-on-one face time. Doctors talking to patients patiently, helping each one understand the risks and benefits of this or that decision. Teachers mentoring students intensively. Parents explaining something multiple times when their children are ready to listen. And, in the best of all possible worlds, and with unlimited resources, that is what we know would work best for communicating risk. Realistically, however, in the risk communications business, one-on-one time, because it is resource intensive, must be selectively used; most of the teaching, persuading, and attracting of attention must be left to collective forms of communications and mass media. The mass communications perspective is robust but presents challenges of its own. The good news is that mass media, especially, can be powerful and cost-effective venues for health risk messages. According to a 1997 Kaiser Family Foundation (2), three fourths of adult men and women consider magazines to be an “important” source of information on a variety of health topics, including breast cancer, pregnancy, human immunodeficiency virus or acquired immunodeficiency syndrome, and abortion. Results of a National Health Council (NHC) survey (3) reported earlier this year found that the media are the leading source for medical and health information among healthy 18to 59-year-olds, although among those with chronic conditions, physicians are the primary source, followed by television news magazines and print news. Moreover, 53% of Americans, the NHC survey reported, say they have discussed a medical or health news story they saw or read with their doctor and that their doctors were mostly happy to do so. The survey found that 82% of the respondents believe health and medical news in mass media help them lead a healthy life and 58% report changing their behavior or having taken some type of action as a result of a medical news story (italics mine). Seventy-six percent said they took the advice offered in the story, particularly if it had to do with avoiding a certain food, increasing exercise, talking to a doctor, reducing or stopping smoking, and dieting. The bad news is that there appears to be a disconnect between the value scientists and doctors place on the information disseminated by mass media and the value placed on it by viewers and readers. Doctors routinely label a significant portion of health and medical coverage sensationalized, incomplete, inaccurate, unbalanced, or misleading, whereas the vast majority of Americans find it highly credible. In the NHC survey, for instance, 87% of Americans consider 60 Minutes and 20/20 the most believable media sources, followed closely by television news in general (85%), daily newspapers (83%), and radio news (81%). The worse news is that individuals come to mass media information and risk messages with an impoverished level of science literacy. A Dartmouth survey (4) of women 40–50 years old found they overestimated by 2000% their chances of dying of breast cancer within 10 years and exaggerated the relative reduction of risk by mammography screening by 600%. Also, they overestimated the absolute risk by 10 000%, according to Black et al. (4) And the still worse news: The women in the study had higher incomes and levels of formal education than the general population—91 of 145 had college or postgraduate degrees. Other surveys have found that more than half of Americans incorrectly believe breast cancer is the leading cause of death for women, that four in 10 think spicy food causes and think Alar causes cancer, and that one third think eating sweets causes diabetes. In a landmark paper, Miller (5) reported that, in 1990, only 36% of American adults met even the most basic standards for scientific literacy as defined by a nine-item true or false quiz. On one question, for example, only 47% correctly disagreed that the earliest humans lived at the same time as dinosaurs. In a follow-up publication in 1998 in the National Science Board’s Science and Engineering Indicators, Miller and Kimmel (6) reported that only 11% of Americans can define the word “molecule” and that only 20% understand what “DNA” means. Moreover, he wrote, only about one in three Americans understands the foundations of scientific inquiry—e.g., how theories are developed, how controlled experiments are designed, and how valid comparisons are made. Additional complications and challenges emerge from both the routine and innovative activities of institutions and their