I'm going to move fairly
What I've done is I'm providing findings from a variety of
studies that I've done that I think make a strong case for
the importance of evidence-based
So if we look at the ten public health communication.
services, informing and educating the public is listed
as number three.
sharing with you today And the findings that I'll be
of that information. pertain to a design
of this public health service. And these are objectives
information, making that So the design of the
recognizing that much of the information accessible and
that's provided to people pcomes from partnerships.
The cohort that I have studied
well owners. has been that of private
group to study, because they They make a particularly good
the safety and quality are responsible for managing
And we hope they will use information to guide
their actions.
Wisconsin agencies that provide this information and participate
in educational programming, with this goal of informing
their decisions.
the most is that of arsenic The topiin well water.studied
So an outline for the talk today
with a brief introduction is ton well water. out
I'll share these selected findings about how these
public health information programs work.
And I hope to demonstrate how research can both inform
practice and build knowledge. So in terms of a health issue.
The drinking water standard for arsenic was revised from
50 to 10 parts per billion
just enforced last year. fairly recently,
on the calculated cancer risk of lung and bladder cancer.
However, arsenic has been associated with a variety of
cancers and these very common chronic diseases that are widely
distributed in the population,
Arsenic is also a co-carcinogen anbecause it interferess.
with cellular repair. And in terms of toxicology,
well, it's complicated. They're doing, actually, a lot
of research in terms of the toxicology of arsenic.
Most of this is at a molecule and gene level
to understand this. But one of the things arsenic
does is it replaces phosphorous.
and iron. ISo it's broadly implicated
in many metabolic processes.
is found across the state. This shows you where arsenic
the blank spots on this map Idon't necessarily mean
that there's not arsenic there. Because one of the things that
state agencies are looking to do
understand where arsenic occurs, is to build their database to
related to that occurrence. and We do, however, see this be
hot spot of arsenic that
These are Winnebago fand Outagamie Counties, whichs.
you can see blown up here.
as an arsenic advisory area in the early 1990s.
These tan spots on the map
the middle, show you where that you see running right down
Arsenic is occurring this arsenic occurs.
So it tends to be, the arsenic as mineralized deposits.
in the state, and also across the country, most of our
contaminated water comes
mineralized deposits of arsenic that are really fairly broadly
spread across the United States.
is associated with a layer In this case, the arsenic
And the tan spots show you where called the St. Peter Sandstone.
to the surface of the earth tso that when they drill wells,
they're likely to transect
So five miles on either side this arsenic-rich layer.
arsenic advisory area. was designated as that
two fairly large cities here, Ylots of suburban development.e
In Wisconsin, suburban
a private well and a private development often needs
an issue in terms of thinking seabout how water qualitybe
is related to land use issues.
of the wells are estimated In this area, about a quarter
standard for arsenic. to They're used by a fairlyer
large number of people. So this shows you a
cross section of these wells
Here you see drilled into the aquifer.
The arsenic-rich layer. There are arsenic deposits
distributed throughout, but it's really concentrated
at this interface here. We have three aquifers
in this area of the state.
encouraged for use, because Tit's easily contaminatedt
by surface contamination. The deeper aquifer tends
to be used by municipalities, but it's fairly expensive
to construct wells into that
So, this is the aquifer of aquifer.
The other issue here, you see chothe green arrow points tors.
the upper table, upper layer
surface, that water table. of the water table, so that
this area, that water table has been dropping at the rate
of about one
There's really more water being taken out than is being
replenished.
The arsenic and this dropping water table are related in this.
area, such that when this water table drops, it exposes
the mineralized deposits to air,
that exacerbates the release triggers an oxidation process
I talked to one gentleman of awho had 30 ppb.area.
Five years later, he had 500 ppb.
It was a substantial increase in his particular well.
This isn't occurring
But that situation is really in all of the wells.
of the well, the water table, dand that arsenic-rich layer.n
But it causes a lot of concern
because even if they have a safe among residents in this area,
they're not sure how that might change in the coming years.
And it's an interesting example of this relationship between
resource use and a health risk. To address this public
health risk, they initiated a town-based well testing program
in this area. And this was for a program
that was initiated by the local public health departments there.
The town-based testing is adapted from a program
that Extension uses throughout the state.
But in this particular area,
arsenic. they were only testing for
departments contracted with Ana private lab to doth
the testing for a reduced fee.
officials that did the work. But it was really town
People would have to pick up They advertised the program.
off at a local location. a water bottle and then drop it
dispensed at a town meeting, And then the test results were
and pick up their results. where people would go
educational program. But then there would be an
people from various local and state agencies that provide
this information to the public. So here you have these various
agencies coming into play,
elements of expertise that is bimportant to these homeowners.t
This information was to mitigate arsenic at two levels.
One is at that level
So constructing a new well, installing a filter, drinking
bottled water, were all things
or personal level. people could do at a household
I would say that the strongest At an environmental level,
these meetings was that people message that was provided at
community-wide water needed to engage in
to slow down this pressure conservation as a strategy
in the aquifer. The other environmental thing
that was being suggested was
this idea of having every house that have a private well.hink
So are there strategies like
that might be good solutions houses sharing a deeper well
And then the final one was that the DNR ended up, first of all
suggesting, and then later on mandating, specific well
construction methods that would seal off those arsenic deposits
from the water
So my interest in this that was in the well.
this information was working. So we have a situation.w
We have a number of people
We have numerous occurrences at risk.
We have a program that's in this area.
information to the public. put into place to provide this
about how this information But there's a lot to understand
it might not be working. might be working, or how
what I what I would call So my goal is to really do
that can build our knowledge theory-based applied research
literature or the academic in terms of adding to the
works, but that can also support understanding of how information
So really, generating practice-based evidence that
we hope might be adopted
So some of the questions by practice.
explored in my research have that I've asked, and that I've
impact of these programs, understanding the information
that people use and what their needs might be.
And then I would say in terms of theory, it's pertained to
really understanding
information might be working. With a goal of understanding
that information is particularly
by looking at the content effand the format.rful
So I've done two, what I would
research studies. And if we look at the sequence
here with the arrows, there's two things that need to occur.
One is people need to test their water.
So, I explored well water testing in a study that
was just done this spring.
taking appropriate action Tafter they've tested it.
And that was explored with
which was done in 2003. I'll be sharing results from
both of these studies and then
So the first study, the 2007 a couple of additional ones.
across nine counties. stuAbout a 72% response rateowns
was fairly decent.
I had specific questions I used a targeted sampling.
in specific areas. I wanted to answer
look at right here is looking at And the question we're going to
arsenic advisory area raacross three different townsat
that were selected purposefully.
program, so we're not Tlooking at it as it happens.
We're looking at
One of these towns seven years later.
This is a rare thing. This doesn't happen very often
across the state. This other one offered
the program one time in 2001. And there was only one town
in this area that had not offered the program.
They were an interesting town to be able to bring in.
If we look at the rates of
definitely see a bump that came from the regular program.
But what is interesting is that private testing is fairly steady
across these three towns. And if we look at the total,
we can see that these programs
who might not test otherwise are bringing people to test
I think this shows you a benefit on their own.
people that we might not reach, who might not test privately.
If we look at the difference
of demographics, we can see that between these people in terms
a program tend to be older those people who test through
longer in the community. and they've lived
private testers are people who It seems to me that a lot of the
to take on a job. They live there professionally,
but they might not have as
If we look at those people who strong of a community identity.
that really separated them don't test, the only demographic
But then there was this other variable that I thought was
fairly interesting. And that is who else do you know
that has tested their water.
each of the groups. It's interesting to think about,
is this a variable that if we can manipulate this,
would this increase testing.
that might help you know more If wepeople that test, ideas
would that have an effect.
cause and effect variable here. So that's from the 2007 study.
That will come up again a few other times.
Now let's take a look at the 2003 study.
That's looking at, first of all,
in this area. A better response rate, because
most of these people have participated in town testing.
So I think they were a little more motivated.
We'll look at the information sources they used and
then get at this interesting
might be working. If you look across these towns,n
19 out of 20 towns offered
I think is pretty successful. If we take all those residents
in those 19 towns, and look at
through the program, how many of them tested
This varied from town to town. on average it was about 24%.
for why. I have a variety of hypotheses
could be one of them. Some towns are very cohesive.
Some towns are less cohesive. There are a few possibilities.
But if you look at the number of people who attended that
educational program, this 20% to 50% was what they told
me of how many people attended. We can see that in these towns,
only about 8% of people are getting what we would think of
as a full dose of information.
to provide people So we with information. set up
And most people are not fully participating.
So one of my questions was
information were they using. what other sources of
of information. But in terms of that information
that is used most often,
mailed with the test results. it's Not too surprising.at is
When we asked them about the
for those who test in a program, information that is most useful,
who has expertise. it's talking to somebody
privately, it's still those Fpeople who test throught
a program.
the fact that throughout We need to know and be aware of
privately because these programs the state, most people test
And even when they are offered, armore people test privately.
than through the program. The dominant form of getting
this information throughout the state is that information
that's mailed with the test.
this suggests ways In terms of the no test group,
I think in terms of the strength of information
to change behavior, mailed information tended to be
thought of as a fairly weak intervention.
We tend to think that people
want to change their behavior. need to talk to somebody if we
to think about those ways, the So I think it's interesting
information that we might be content and the format of that
information that people read able to employ to make that
the area of public health where we have limited resources
to allow people to actually interact with people to help
them solve their problems.
access to information issue, So in terms of summarizing this
privately. more people are testing
weren't testing, some people And when we ask people why they
they needed to. But one of the things that
people needed was information to help them understand how
to test and what to test for. They really didn't know where to
go to get that information. They were also very interested
in information about local
In terms of access to information after people have
tested, there's really very little information provided
by private testing labs.
all the labs in the state Ithat are certified to test
for arsenic, private labs.
people got varied very widely, And the amount of information
providing a drinking water with some labs not even
test their wells. It would be pretty hard to
understand the meaning of your
a drinking water standard. test result if you don't get
but I would say that the lab A few labs provide information,
information is also a lab that that provides the most
might question the motivation sof that lab in terms of thewe
information they provide. So people need information to
help them understand that result
We have a lack of easy access ahere to information.
The next question we'll look at pertains to how this information
is working. This is really getting more at
this theoretical information, or this theory piece.
If we take a look,
design called theory-based there's a design, a research
In this, you identify a theory program evaluation.
your program is effective thand how it works.why
In this case, I was looking at information.
I thought it would change people's beliefs and opinions,
which is pretty typically how we think of information.
This is not anything
But then also understanding toohow that mightre.
shape their behavior. Notice that we're measuring
this relationship at a couple of different points.
What we really want to see
to tell us that our theory is this chain of causation
by which this information is explais working.mechanism
So we could have failure
And the value of a theory-based evaluation is that if this
fails, you can understand where it's failing.
You can understand if the information isn't working,
or if you have the wrong theory.
where it's not working. But if it is working, it can
suggest to you how, and those things that might be
more powerful.
particularly interested in was One of the things I was
influence of different types understanding the differential
understanding that information of information, with a goal of
Because we're challenged when we're giving people printed.
information to make information more powerful.
The theoretical framework that I use is called
a common sense model. It was developed by Howard
Leventhal while he was here.
to develop this model was done Most of the work he did
Several of the nursing while he was here at UW-Madison.
of Nursing worked with him. prHe was interested inol
understanding people's behavior in response to a health threat.
And I was interested in translating this model
to an environmental threat. I like it because it
conceptualizes information
It says our behavior is determined by our mental model
of an issue.
information, they come to that And that when we give people
have stored in memory, with information they already
they get from experience. So you can imagine for
illnesses, it was people's
they might feel. symptoms, their aches and pains
symptoms, we can smell, taste and see certain environmental
hazards.
sources, that was obviously the program information or other
sources they might use. People process this information
by these inter-related cognitive
What I really liked about this and affective processes.
some of the risk model was it fit very well with
currently a very hot topic. So the role of affect right now
is pretty big in terms of decision making research
and in terms of risk
Some of the studies they're doing are quite interesting.
They're having people solve problems while measuring their
brain activity to understand
decisions and behavior. that rolThat's an aside.eople's
But what this model did,
be, I would say, be salient in terms of the current research
that's being done.
beliefs and that there's an Themotional component to thoseur
beliefs that then shapes
We have to remember there's always this emotional piece
that intra-related with that. We'll appraise whether that's
effective, and that's information that's fed back in.
I've never looked at appraisal, but maybe some day I think it
would be interesting. In terms of a study framework
then, the external information
knew was important, and a score waof total information use. we
The experience was whether
arsenic-related health symptoms. they thought they had any
quality, which is a proxy for smell, taste and appearance.
We know that those are the
people's beliefs primary factors that influence
After I did this study, I did another study.
that kind of verified that. That definitely is the case.
Those would shape people's
The common sense model says our beliefs are structured
in terms of these dimensions. And these were the outcomes
that I measured.
behavior, I looked at their policy opinions about things,
policies at an environmental
judgment. level aSo basically, safety
looking at 45 variables.
among these variables using structural equation modeling.
This is a nice way to look
That's a caveat of this study. at cross sectional data.
cause and effect relationships, and to test whether our model
fits that data. So you get an assessment
of model fit. You also get a chance to look at
these direct and indirect relationships, these potential
mediators that might explain
This shows you the results how that information is working.
I'd rather that you don't look of the model.
but to notice that right here you can see that our information
has a lot of, it looks like,
people's beliefs, and that activity in terms of influencing
effect on protective behavior, these beliefs are having an
account this safety judgment. I'll pull out a couple things
that are interesting
The first has to do with these policy opinions.
I was quite interested in this
where people were being encouraged to act at two levels.
At this personal exposure level and at this community-wide,
let's all conserve water level. I asked people, how many of you
are conserving water or doing something else to mitigate
this at a community level.
were conserving water. Only about 11% said that they
their arsenic level, more people If we look at that based on
have something to personally were conserving water when they
arsenic levels to increase gain from preventing their
that old safety standard of 50. We can see that it seems fairly
clear that people's action at a community level were driven
by their concern to protect their household levels
from increasing.
related to water conservation, If we look at those variables
So do you think that those it was their causal beliefs.
other, decreasing groundwater twoand increasing arsenic.each
And efficacy beliefs, which is
is related to people's health fairly cobehavior.t efficacy
It gives us a sense of the content.
Now we'll go back to the safety issues and behavior issues.
Look at how these four
were related to people's information variables
If we total all those sources of information, their direct and
indirect effects, what we see is that information coming
from that program is having an effect.
It is influencing people's
This is significant, because behavior.
one of the things that there is if a concern about is thature,
providing people with information doesn't really
do much, it doesn't really have much of an effect.
But this shows that yes,
that it's having an effect. But you'll also see that the
environmental symptoms are
We're getting into a part alsof the talk where it'sct.
a little complicated. I know that this is the time
in the talk where people are
with all the information getting kind of overloaded
So if we could focus for about that's put up on the screen.
will kind of slow down again. I think this is kind of an
interesting variable. It's an interesting finding
here. One of the questions that I
asked, I wanted to find out the degree to which people were
adopting this new and this lower
So I asked them to tell me how arsenic drinking water standard.
be safe, the highest amount you much athink would be safe.would
And so you can see that clearly, people did appear
to be adopting this lower-- Whoops, let's go back.
Were adopting this lower
another bump of people who standard, although we see
But we also see that people were have their own ideas ppb.
about what they think is safe.
reaching even lower. There's a fair number of people
relates to their arsenic level, people who have more arsenic
pick a higher safety standard.
can conclude their water is safe What this means is that they
threshold that allows them because they picked a safety
We see this positive to do that.
arsenic and their safety relationship here between
We also see that how much arsenic they have is somewhat
related to their ideas about
or bad, but certainly not wha perfect relationship.od
We see that there is
If you have bad water, you pick aa lower safety threshold..
If you have more arsenic, you pick a higher.
There's a differential
If you think from a psychological standpoint,
if you think your water is bad, you test your water and
you find out you have arsenic,
confirms your beliefs that you have a problem.
However, if you think your water
people are rather attached to is goodtheir well water.nd many
They think it's the best water
If somebody tells you that you in the world.
to defend that belief hthat you have good water.y
It's that mechanism of defensive
in literature. biases is fairly widespread
have tested their blood for cholesterol, you'll find some
of these same issues going on.
recall having less arsenic For example, 20% of these people
This is about the same number of people who recalled having
lower cholesterol test results. This mechanism seems to operate
kind of across the population,
If we want to understand across a variety of threats.
powerful, it seems that this that information that is most
is especially powerful. But that a test result
compared to a safety standard gives us concrete evidence
of an unseen risk.
important things about I think that's one of the
information, is the fact that it's often telling us something
that we could not otherwise sense.
We need to think about how
clear to people. that information can be made
is that people's beliefs The other factor going on here
to their protective behavior. If we look at this hierarchical
influence of information, certainly experience
plays a strong role.
a safety standard is important. BuI was interested in how thisto
information could be made more
I knew a lot of people were having trouble understanding
their test results. I got written comments back on
my survey saying, "I don't quite
A couple people sent me their test results and asked if I"
could tell them what it means.
back saying that laboratories I hcould do a better job ofthe
explaining their test results.
really interesting question Thto work on in terms of a
thinking about different ways to present this information.
I was interested in the power of using visual images.
This is about the point in time I was stepping into my post-doc,
so I was thinking about informatic strategies.
One of the things that
it can take data and it can turn information technology can do is
I was interested in developing it into a graphical display.
When I went to look at a graphic display.
to look at the evidence. the literature, I wanted
communicates incremental risk. We knew that vertical distance
comprehension and recall. Color is an important way
to communicate risk.
too much about that if you go We prthrough the airport.ttle
However, this is done among the industrial ergonomics
literature, where they're creating warning literatures
for people in the workplace and finding that these colors are
very consistently understood. In the area of cartography,
color gradients are used
Then finally, if we want to label our graphs, and we want
to label those to promote appropriate action,
we might want to use
another kind of label. action messages rather than
were integrated into a visual All image of a test result.ence
I was interested in understanding what the impact
of that would be. Could I compare that image
versus the standard test result.
of the image that used-- I created another version
very well here. These are incrementally darker
shades of red to communicate
People tend to treat safety thstandards as a threshold.ge.
I wanted to see if I could
message. strengthen the incremental risk
undergraduate students. ThThe results of the study,ong
in a nutshell, is that females
a stronger message than males. viewed both of these images as
as a stronger message. But only males viewed this image
an interaction effect based on gender from the reading I
had done to locate the evidence.
as a mailed survey, which is a lot more work,
among private well owners.
I was looking for an even split Ibetween males and females.
In this case, both genders
to be a stronger message. were I did not see these
that interaction effect.
One of the things I wanted to do That didn't help me.
one of those images. was to actually pick
telling me which image My studies still weren't
This shows you the results. would The femaleso pick.
are the dark red and pink.
less arsenic. TheseI randomized peoplesenic,
to get more or less arsenic.
Again, you'd expect them The blue are the males.
that they have more arsenic. to have stronger beliefs
the students, the red was more consistently understood.
And among the well owners,
that significant drop off. I did not see
attenuation of this graded image I did, however, see this
What concerned me was that this was occurring among those people
assigned to have more arsenic.
assigned to have arsenic. I created a fictitious substance
so that they wouldn't be
But nevertheless, there seemed in this lab.
occurring here. I decided that this red image
would be the most appropriate.
interesting to me, and I think Another thing that was
In this area of risk it's worth sharing here.
that oftentimes messages communication, the way
interview and focus group data. It's pretty typical in terms
of advertising. If we want to develop
an advertising message, we go out and we do a focus group
where we talk to people.
the feedback I got from people When I talked to people,
that they really like this image in terms of these messages was
They said it gave them with the graded red shading.
I even got feedback from more information.
who has read everything. a graphic artist
definitely the right way to go, Yand including other people,is
as well.
was that my study results meant that I was picking an image
other than I thought
Quite certainly, I think these would be more effective.
important and they can give us interviews and focus groups are
give us a different kind good data, and they can
than we can through doing a quantitative study.
I think that quantitative studies help us understand
things we can't understand
So if we look, then, in any other way.
we have this test result as being an especially powerful
piece of information, especially
And then we recall that the information that is most used
is that information that comes
But there are some issues in terms of how to make
this information accessible.
people where they would Sfirst look for information.d
Actually, I was surprised to see
local public health departments that bcame in first.et and
They were almost even.
as the first places people would But those definitely came in
The second two, and these were also very close, were the
water testing laboratory and
75% of these participants had access to the Internet at home.
So I think it tells us that information technology has this
potential to increase access
We can think in terms of a to this information.
to make this information technology enhanced practice
We can design it for users. With Web-based information,
we can meet a variety of information needs, because
people can pick and choose
We also have to think about how this information can support
this partnership that we have.
because we really have a number of partners who produce this
information.
information at those points in time, so helping them test
and also understand their test results.
So I created an experimental
the visual image. But the way that the information
was structured was really from
What I find when I go to most Web sites created by agencies
is that by necessity, those are really structured based on
the mission that agency has to achieve.
It's not really structured
user-friendly information witto the public, for someding
very good reasons, actually.
that they're doing as part Because they have many jobs
It may be important to think of their agency mission.
information that comes from these various agencies into
a message that's designed for users, that also lets them
understand better how these various agencies across the
state work with each other
quality. in this area of groundwater
of the state know what they can do to participate.
Certainly, this information needs to include links to
testing recommendations and laboratory information.
They want access to local groundwater quality data.
But as you noted earlier, we need more data.
I think it's interesting
that we can get residents to share their data with us.
We certainly know that a lot
privately than through these more people are testing
might get that data to help us build surveillance.
One of the questions I asked
share your test results with on my 2007 study was would you
would share their test results the DNR, and 85% said that they
to help build groundwater for the pquality data.veillance,
We might be able to think about a two-way flow of information
in which we include residents of the state as public health
partners. To summarize the results here,
if we look at these objectives
I think it's important to think for about building capacityvices
to expand the partnerships
communication. that engage in public health
are a very important piece I think private laboratories
We need to think about how we can think of them as partners.
I think they're quite interested
of residents. in And how we can collaborateeds
with these partners to make this
and design that information infto be both user-centeredle
and evidence-based. In terms of the work
that I'm currently doing, one is a longitudinal study.
As I showed you earlier, those
So this is a much stronger were cross sectional studies.
results shape people's beliefs design if we understand how test
Then the work I'm looking to do, and their sensory perceptions.
pilot work in is looking at maps or the work I'm starting to do
We're certainly using map information much more broadly,
as a way to convey information
People really specified on to the public.
a map of what the water problems the surveys that they wanted
I think we need to understand that they will interpret their
household results within that context of their community
results.
I'm interested in looking at, Tas how those two interacts
with each other.
proposal that was just submitted Finally, I'm a partner on a
planning of user-centered that Web-based resources.tive
So to bring in these various
some non-public health partners to plan potential resources,
to make this information
I would like to thank you very much for coming today.
I need to acknowledge all the sources of support
that I've had,
and the funding support. both pre-doc and post-doc,
or comments. ( applause And t) tions