9UNP0110SD_Delores_Severtson_WordPress

>> I'm going to move fairly quickly. 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 public health communication. So if we look at the ten essential public health services, informing and educating the public is listed as number three. And the findings that I'll be sharing with you today pertain to a design of that information. And these are objectives of this public health service. So the design of the information, making that information accessible and recognizing that much of the public health information that's provided to people comes from partnerships. The cohort that I have studied has been that of private well owners. They make a particularly good group to study, because they are responsible for managing the safety and quality of their water. And we hope they will use information to guide their actions. And we have a variety of Wisconsin agencies that provide this information and participate in educational programming, with this goal of informing their decisions. 

The topic that I have studied the most is that of arsenic in well water. So an outline for the talk today is that I'll start out with a brief introduction on well water. 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 fairly recently, just enforced last year. And this revision was based 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, and have multiple causes. Arsenic is also a co-carcinogen because it interferes 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. It also can replace calcium and iron. So it's broadly implicated in many metabolic processes. This shows you where arsenic is found across the state. I will caution you that the blank spots on this map don't necessarily mean that there's not arsenic there. Because one of the things that state agencies are looking to do is to build their database to understand where arsenic occurs, and those factors that might be related to that occurrence. We do, however, see this hot spot of arsenic that falls across these two counties. These are Winnebago and Outagamie Counties, which you can see blown up here. 

This was designated as an arsenic advisory area in the early 1990s. These tan spots on the map that you see running right down the middle, show you where this arsenic occurs. Arsenic is occurring as mineralized deposits. So it tends to be, the arsenic we find in well water in the state, and also across the country, most of our contaminated water comes from these naturally occurring mineralized deposits of arsenic that are really fairly broadly spread across the United States. In this case, the arsenic is associated with a layer called the St. Peter Sandstone. And the tan spots show you where these minerals are close enough to the surface of the earth so that when they drill wells, they're likely to transect this arsenic-rich layer. So five miles on either side was designated as that arsenic advisory area. You'll also note that these are two fairly large cities here, lots of suburban development. In Wisconsin, suburban development often needs a private well and a private septic system, which may be an issue in terms of thinking about how water quality is related to land use issues. 

In this area, about a quarter of the wells are estimated to be over the drinking water standard for arsenic. They're used by a fairly large number of people. So this shows you a cross section of these wells drilled into the aquifer. Here you see the St. Peter Sandstone. 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. The shallow aquifer is not encouraged for use, because it's easily contaminated by surface contamination. The deeper aquifer tends to be used by municipalities, but it's fairly expensive to construct wells into that aquifer. 

So, this is the aquifer of choice for private well owners. The other issue here, you see the green arrow points to the upper table, upper layer of the water table, so that surface, that water table. And due to the development in this area, that water table has been dropping at the rate of about one to three feet per year. There's really more water being taken out than is being replenished. These are related to each other. 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, triggers an oxidation process that exacerbates the release of arsenic in this area. I talked to one gentleman who had 30 ppb. Five years later, he had 500 ppb. It was a substantial increase in his particular well. This isn't occurring in all of the wells. 

But that situation is really dependent on the configuration of the well, the water table, and that arsenic-rich layer. But it causes a lot of concern among residents in this area, because even if they have a safe amount of arsenic now, 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, they were only testing for arsenic. And these public health departments contracted with a private lab to do the testing for a reduced fee. But it was really town officials that did the work. They advertised the program. 

People would have to pick up a water bottle and then drop it off at a local location. And then the test results were dispensed at a town meeting, where people would go and pick up their results. But then there would be an educational program. This program would be with people from various local and state agencies that provide this information to the public. So here you have these various agencies coming into play, because they each have different elements of expertise that is important to these homeowners. This information was to mitigate arsenic at two levels. One is at that level of personal threat. So constructing a new well, installing a filter, drinking bottled water, were all things people could do at a household or personal level. At an environmental level, I would say that the strongest message that was provided at these meetings was that people needed to engage in community-wide water conservation as a strategy to slow down this pressure on the amount of water in the aquifer. The other environmental thing that was being suggested was that we might need to rethink this idea of having every house have a private well. 

So are there strategies like houses sharing a deeper well that might be good solutions to this. 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 that was in the well. So my interest in this was in understanding how this information was working. So we have a situation. We have a number of people at risk. We have numerous occurrences in this area. We have a program that's put into place to provide this information to the public. But there's a lot to understand about how this information might be working, or how it might not be working. So my goal is to really do what I what I would call theory-based applied research that can build our knowledge in terms of adding to the literature or the academic understanding of how information works, but that can also support evidence-based practice. So really, generating practice-based evidence that we hope might be adopted by practice. 

So some of the questions that I've asked, and that I've explored in my research have been simply looking at this 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 the mechanism by which this information might be working. With a goal of understanding that information is particularly effective and powerful by looking at the content and the format. So I've done two, what I would think of as program evaluation 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. The second has to do with taking appropriate action after they've tested it. And that was explored with my dissertation research, which was done in 2003. I'll be sharing results from both of these studies and then a couple of additional ones. 

So the first study, the 2007 study, was conducted in 27 towns across nine counties. About a 72% response rate was fairly decent. I used a targeted sampling. I had specific questions I wanted to answer in specific areas. And the question we're going to look at right here is looking at rates of arsenic testing in that arsenic advisory area across three different towns that were selected purposefully. This is seven years after the program, so we're not looking at it as it happens. We're looking at seven years later. One of these towns offered regular testing. 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 program testing, we can 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 are bringing people to test who might not test otherwise on their own. I think this shows you a benefit of these programs in reaching people that we might not reach, who might not test privately. If we look at the difference between these people in terms of demographics, we can see that those people who test through a program tend to be older and they've lived longer in the community. It seems to me that a lot of the private testers are people who might've moved to the community to take on a job. They live there professionally, but they might not have as strong of a community identity. 

If we look at those people who don't test, the only demographic that really separated them was that of education. 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. And this separated, actually, each of the groups. It's interesting to think about, is this a variable that if we can manipulate this, would this increase testing. If we can come up with ideas that might help you know more people that test, would that have an effect. I'm not sure if it's a 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, that was a study conducted 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 question of how this information might be working. If you look across these towns, 19 out of 20 towns offered the town-based testing, which I think is pretty successful. If we take all those residents in those 19 towns, and look at how many of them tested through the program, on average it was about 24%. This varied from town to town. I have a variety of hypotheses for why. But advertising 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. So we have this program set up to provide people with information. And most people are not fully participating. So one of my questions was what other sources of information were they using. I had about 15 sources of information. But in terms of that information that is used most often, it's that information that is mailed with the test results. Not too surprising. 

When we asked them about the information that is most useful, for those who test in a program, it's talking to somebody who has expertise. For those people who test privately, it's still those people who test through a program. We need to know and be aware of the fact that throughout the state, most people test privately because these programs aren't offered in many towns. And even when they are offered, more 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. In terms of the no test group, this suggests ways that we might use them. 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 need to talk to somebody if we want to change their behavior. So I think it's interesting to think about those ways, the content and the format of that information that we might be able to employ to make that information that people read more successful, especially in the area of public health where we have limited resources to allow people to actually interact with people to help them solve their problems. So in terms of summarizing this access to information issue, more people are testing privately. 

And when we ask people why they weren't testing, some people didn't really think 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 groundwater quality. In terms of access to information after people have tested, there's really very little information provided by private testing labs. I did a telephone survey to all the labs in the state that are certified to test for arsenic, private labs. And the amount of information people got varied very widely, with some labs not even providing a drinking water standard when people test their wells. It would be pretty hard to understand the meaning of your test result if you don't get a drinking water standard. A few labs provide information, but I would say that the lab that provides the most information is also a lab that sells water filters, and so we might question the motivation of that lab in terms of the information they provide. So people need information to help them understand that result and what they can do. 

We have a lack of easy access here 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, there's a design, a research design called theory-based program evaluation. In this, you identify a theory that might explain why your program is effective and how it works. 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 too remarkable here. But then also understanding how that might shape their behavior. Notice that we're measuring this relationship at a couple of different points. 

What we really want to see is this chain of causation to tell us that our theory is explaining this mechanism by which this information is working. So we could have failure at several points. 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. It can help you locate where it's not working. But if it is working, it can suggest to you how, and those things that might be more powerful. One of the things I was particularly interested in was understanding the differential influence of different types of information, with a goal of understanding that information that might be more powerful. 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. 

Most of the work he did to develop this model was done while he was here at UW-Madison. Several of the nursing professors at the School of Nursing worked with him. He was interested in 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 very broadly. It says our behavior is determined by our mental model of an issue. And that when we give people information, they come to that with information they already have stored in memory, with information they get from experience. So you can imagine for illnesses, it was people's symptoms, their aches and pains they might feel. In terms of environmental symptoms, we can smell, taste and see certain environmental hazards. Then in terms of external sources, that was obviously the program information or other sources they might use. 

People process this information by these inter-related cognitive and affective processes. What I really liked about this model was it fit very well with some of the risk communication research that is 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 communication research. Some of the studies they're doing are quite interesting. They're having people solve problems while measuring their brain activity to understand that role of affect in people's decisions and behavior. That's an aside. But what this model did, was allow me to help my study be, I would say, be salient in terms of the current research that's being done. This information then shapes our beliefs and that there's an emotional component to those beliefs that then shapes our behavior. 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 was that test result, which we knew was important, and a score of total information use. The experience was whether they thought they had any arsenic-related health symptoms. And also, perceived water quality, which is a proxy for smell, taste and appearance. We know that those are the primary factors that influence people's beliefs about water quality. After I did this study, I did another study that kind of verified that. That definitely is the case. Those would shape people's beliefs. The common sense model says our beliefs are structured in terms of these dimensions. And these were the outcomes that I measured. 

So in addition to protective behavior, I looked at their policy opinions about things, policies at an environmental level and also their safety judgment. So basically, looking at 45 variables. I looked at the relationships among these variables using structural equation modeling. This is a nice way to look at cross sectional data. That's a caveat of this study. It allows us to propose 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 how that information is working. This shows you the results of the model. I'd rather that you don't look at the specific numbers, but to notice that right here you can see that our information has a lot of, it looks like, activity in terms of influencing people's beliefs, and that these beliefs are having an effect on protective behavior, especially if we take into account this safety judgment. 

I'll pull out a couple things that are interesting to look at here. The first has to do with these policy opinions. I was quite interested in this topic, because this was a topic 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. Only about 11% said that they were conserving water. If we look at that based on their arsenic level, more people were conserving water when they have something to personally gain from preventing their arsenic levels to increase to a point where they'd be over 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. If we look at those variables related to water conservation, it was their causal beliefs. So do you think that those two things are related to each other, decreasing groundwater and increasing arsenic. 

And efficacy beliefs, which is fairly common, that efficacy is related to people's health behavior. 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 information variables were related to people's protective behavior. 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 behavior. This is significant, because if you look at the literature, one of the things that there is a concern about is that providing people with information doesn't really do much, it doesn't really have much of an effect. But this shows that yes, in fact, you can see that it's having an effect. But you'll also see that the environmental symptoms are also having a strong effect. We're getting into a part of the talk where it's a little complicated. 

I know that this is the time in the talk where people are getting kind of overloaded with all the information that's put up on the screen. So if we could focus for about five minutes, then things 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 arsenic drinking water standard. So I asked them to tell me how much arsenic do you think would be safe, the highest amount you think would be safe. And so you can see that clearly, people did appear to be adopting this lower-- Whoops, let's go back. Were adopting this lower standard, although we see another bump of people who were sticking with the 50 ppb. But we also see that people have their own ideas about what they think is safe. There's a fair number of people reaching even lower. 

If we look at this as it relates to their arsenic level, people who have more arsenic pick a higher safety standard. What this means is that they can conclude their water is safe because they picked a safety threshold that allows them to do that. We see this positive relationship here between arsenic and their safety threshold. We also see that how much arsenic they have is somewhat related to their ideas about whether their water is good or bad, but certainly not a perfect relationship. We see that there is a different influence here. If you have bad water, you pick a lower safety threshold. If you have more arsenic, you pick a higher. There's a differential influence. 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, that arsenic test result confirms your beliefs that you have a problem. However, if you think your water is good, or excellent, and many people are rather attached to their well water. 

They think it's the best water in the world. If somebody tells you that you have arsenic, you might try to defend that belief that you have good water. It's that mechanism of defensive biases is fairly widespread in literature. If you look at people who have tested their blood for cholesterol, you'll find some of these same issues going on. For example, 20% of these people recall having less arsenic than they actually had. 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, across a variety of threats. If we want to understand that information that is most powerful, it seems that this environmental symptoms is especially powerful. But that a test result compared to a safety standard gives us concrete evidence of an unseen risk. I think that's one of the important things about understanding laboratory test information, is the fact that it's often telling us something that we could not otherwise sense. 

We need to think about how that information can be made clear to people. The other factor going on here is that people's beliefs about control were related to their protective behavior. If we look at this hierarchical influence of information, certainly experience plays a strong role. But this test result compared to a safety standard is important. I was interested in how this information could be made more concrete, especially because 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 understand what this means." A couple people sent me their test results and asked if I could tell them what it means. I had questions written on the back saying that laboratories could do a better job of explaining their test results. This, to me, seemed like a really interesting question to work on in terms of 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 information technology can do is it can take data and it can turn it into a graphical display. I was interested in developing a graphic display. When I went to look at the literature, I wanted to look at the evidence. We knew that vertical distance communicates incremental risk. Pictorial icons improve comprehension and recall. Color is an important way to communicate risk. We probably all know a little too much about that if you go through the airport. 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 to convey quantity. 

Then finally, if we want to label our graphs, and we want to label those to promote appropriate action, we might want to use action messages rather than another kind of label. All of these pieces of evidence were integrated into a visual image of a test result. I was interested in understanding what the impact of that would be. Could I compare that image versus the standard test result. I created another version of the image that used-- And it doesn't come out very well here. These are incrementally darker shades of red to communicate that incremental risk message. People tend to treat safety standards as a threshold. I wanted to see if I could strengthen the incremental risk message. This was done as a study among undergraduate students. The results of the study, in a nutshell, is that females viewed both of these images as a stronger message than males. 

But only males viewed this image as a stronger message. I did not expect to see an interaction effect based on gender from the reading I had done to locate the evidence. I replicated this study as a mailed survey, which is a lot more work, among private well owners. I was pretty happy with it. I was looking for an even split between males and females. In this case, both genders were understanding these to be a stronger message. I did not see that interaction effect. That didn't help me. One of the things I wanted to do was to actually pick one of those images. My studies still weren't telling me which image would be better to pick. 

This shows you the results. The females are the dark red and pink. These people had more arsenic, less arsenic. I randomized people to get more or less arsenic. The blue are the males. Again, you'd expect them to have stronger beliefs that they have more arsenic. But what I saw, and among the students, the red was more consistently understood. And among the well owners, I did not see that significant drop off. I did, however, see this attenuation of this graded image being a less strong message. What concerned me was that this was occurring among those people assigned to have more arsenic. 

Actually, they weren't assigned to have arsenic. I created a fictitious substance so that they wouldn't be in this lab. But nevertheless, there seemed to be this attenuation effect occurring here. I decided that this red image would be the most appropriate. Another thing that was interesting to me, and I think it's worth sharing here. In this area of risk communication, the way that oftentimes messages are developed are by using 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. When I talked to people, the feedback I got from people in terms of these messages was that they really like this image with the graded red shading. They said it gave them more information. 

I even got feedback from a graphic artist who has read everything. You know, he said that this is definitely the right way to go, and including other people, as well. What was surprising to me was that my study results meant that I was picking an image other than I thought would be more effective. Quite certainly, I think these interviews and focus groups are important and they can give us good data, and they can give us a different kind of understanding than we can through doing a quantitative study. I think that quantitative studies help us understand things we can't understand in any other way. So if we look, then, at a convergence here, we have this test result as being an especially powerful piece of information, especially when it's an image. And then we recall that the information that is most used is that information that comes with the test results. But there are some issues in terms of how to make this information accessible. So in the 2007 study, I asked people where they would first look for information. Actually, I was surprised to see that both the Internet and local public health departments came in first. 

They were almost even. But those definitely came in as the first places people would go to look for information. The second two, and these were also very close, were the water testing laboratory and the state health department. 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 to this information. We can think in terms of a technology enhanced practice to make this information more accessible. We can design it for users. With Web-based information, we can meet a variety of information needs, because people can pick and choose how much information they get. We also have to think about how this information can support this partnership that we have. I think that's a challenge, because we really have a number of partners who produce this information. 

We also need to provide information at those points in time, so helping them test and also understand their test results. So I created an experimental Web site and I used the visual image. But the way that the information was structured was really from the perspective of the user. 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 with this purpose of providing user-friendly information to the public, for some very good reasons, actually. Because they have many jobs that they're doing as part of their agency mission. It may be important to think about how we can harmonize 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 in this area of groundwater quality. And helping them, as residents 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 to think about ways that we can get residents to share their data with us. We certainly know that a lot more people are testing privately than through these educational programs where we might get that data to help us build surveillance. One of the questions I asked on my 2007 study was would you share your test results with the DNR, and 85% said that they would share their test results for the purpose of surveillance, to help build groundwater quality data. 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 for these public health services I think it's important to think about building capacity to expand the partnerships that engage in public health communication. I think private laboratories are a very important piece of that equation. We need to think about how we can think of them as partners. I think they're quite interested in meeting the information needs of residents. And how we can collaborate with these partners to make this information easily accessible and design that information to be both user-centered and evidence-based. 

In terms of the work that I'm currently doing, one is a longitudinal study. As I showed you earlier, those were cross sectional studies. So this is a much stronger design if we understand how test results shape people's beliefs and their sensory perceptions. Then the work I'm looking to do, or the work I'm starting to do pilot work in is looking at maps as risk information. We're certainly using map information much more broadly, as a way to convey information to the public. People really specified on the surveys that they wanted a map of what the water problems are in their area. I think we need to understand that they will interpret their household results within that context of their community results. That's one of the questions I'm interested in looking at, as how those two interact with each other. Finally, I'm a partner on a proposal that was just submitted that would fund collaborative planning of user-centered Web-based resources. So to bring in these various agency partners along with some non-public health partners to plan potential resources, to make this information more accessible. 

I would like to thank you very much for coming today. I need to acknowledge all the sources of support that I've had, both pre-doc and post-doc, and the funding support. And then open up for questions or comments. (applause)