PHA Guidance Manual

• Table of Contents
• Foreword
• Disclaimer
• Chapter 1: Introduction
• Chapter 2: Public Health Assessment Overview
• Chapter 3: Obtaining Site Information
• Chapter 4: Involving and Communicating With the Community
• Chapter 5: Exposure Evaluation: Evaluating Environmental Contamination
• Chapter 6: Exposure Evaluation: Evaluating Exposure Pathways
• Chapter 7: Health Effects Evaluation: Screening Analysis
• Chapter 8: Health Effects Evaluation: In-depth Analysis
• Chapter 9: Determining Conclusions and Recommendations
• Appendices
• Tables
• Figures

Appendix D: Guidelines For Effective Communication

As mentioned in Section 4.2.5, two challenges for the health assessor and other site team members as they conduct public outreach and involvement activities for the site are communicating clearly and with compassion. This appendix provides guidance on how to communicate with sensitivity and respect in both your verbal and written community interactions (Section D.1) and how to update the community on the public health assessment process in clear, easy accessible ways (through the PHA, fact sheets, and other written materials) that will allow them to understand and trust your findings (Section D.2).

D.1 Communicating with Sensitivity and Respect

To build community trust, you will need to be sensitive to and respectful of community concerns throughout the public health assessment process. This aspect of communication is just as vital for building trust as clear and honest communication. Here are some guidelines for how you can be sensitive and respectful as you interact and communicate with community members:

Listen Well, then be Responsive, Direct, and Empathetic

Listen actively (see box on "Active Listening" below) with respect and without judgment and be sensitive to the needs and concerns of community members. Take all concerns seriously. Show empathy by letting the community know that you have heard, understand, and respect their concerns. Remember that for some residents, concerns are personal: they or a family member may have an illness that they are trying to cope with and understand. Recognize people's non-scientific concerns, such as their feelings and values; the psychological stress that living near a contaminated site may cause for some residents; and residents' perceptions of different risks, which can significantly affect their responses to technical information.

Active Listening Active listening is a simple but effective method that helps you listen clearly and compassionately to others, demonstrate your understanding and empathy, and diffuse emotional tension. Active listening helps you really focus on what the other person is saying because it clearly separates the process of listening from responding. There are five steps to active listening: Step 1: As the speaker talks, listen for the main ideas. Look for feelings and pay attention to the speaker’s body language. Do not interrupt the speaker. Simply listen empathically with the goal of fully understanding what the speaker is saying. Try to set aside your own feelings and opinions and put yourself in the speaker’s shoes. Accept what the speaker says as being fully legitimate from his or her point of view. Step 2: Periodically, in your own words, repeat back the main ideas the person has said. As appropriate, include an understanding of how the person feels. When paraphrasing, be sure to reflect only your understanding of the speaker’s ideas. Do not judge or comment on the speaker’s ideas at this point. Step 3: Listen and look for confirmation that you have accurately paraphrased the key ideas. Step 4: Let the speaker make any clarifications or corrections to your paraphrase. (There may not be any.) Step 5: When it is clear you have correctly understood what the speaker said, continue the conversation either by (1) going back to Step 1 and listening for the next ideas, or (2) if it is your turn to speak, by contributing your own ideas.

Avoid Comparing Different Types of Hazards

Scientists and community members often define or perceive risks differently. For example, scientists tend to define and perceive risks from a purely objective standpoint. On the other hand, community members often are influenced by subjective factors, such as intuition, belief, rumor, emotions (mistrust, fear, anger, etc.), and whether the hazard has been imposed on them rather than assumed voluntarily. In some cases, scientists may be more concerned about the hazards at a site than the public; in other cases, the public may perceive hazards as being greater than scientists judge them to be. To ensure that community members feel their concerns are being addressed, avoid comparing risks related to the site to other types of risks—for example, risks that some community members may voluntarily expose themselves to, such as smoking cigarettes or driving a car. Because these types of comparisons do not take into account subjective aspects of risk perception, they can easily lead the community to feel that you do not understand or respect their concerns.

Be Aware of and Respect Diversity

To ensure you present information sensitively, you will need to be aware of and respect the diversity of people you will interact with at each site. A community includes many different people with varying concerns, including people from different neighborhoods or towns, elected officials, environmental groups, health care providers, and others. Some people, including certain ethnic or racial groups, may be affected in unique ways by possible exposures to environmental contamination. Tribal communities, for example, may be uniquely affected because of their reliance on hunting of local game and consumption of local fish or use of plants for medicinal purposes. Certain neighborhoods in urban areas may have been exposed to a variety of contamination sources. Keep in mind that diversity also exists within any particular neighborhood, ethnic, or racial group. As discussed in Chapter 4, site team should use cultural contacts and interpreters as appropriate to ensure that communications are sensitive to the cultures and needs of different ethnic or racial groups within the community.

Avoid False Promises and Reassurances

To avoid losing credibility with the community, do not offer services, materials, or solutions that you may not be able to provide. If you do not know an answer, say so and get back to the person asking the question as soon as possible with an answer. Raising false expectations or hopes is generally worse than being able to offer nothing. Although residents may not like to hear that the agency's resources are limited, it is better to tell them the truth and try to figure out with them what might realistically be accomplished with available resources.

D.2 Communicating with Clarity and Accuracy

Following are some basic tips for communicating clearly and accurately in all of your written documents. For an example of a clearly written fact sheet that utilizes these tips to announce the findings of a public health assessment, see the attached fact sheet developed by ATSDR for a U.S. Air Force site.

Use "Plain English"

Environmental contamination, exposure, and health information are often highly complex. Your job is to boil down the science into a succinct, yet clear and accurate explanation. On the other hand, you do not want to oversimplify information. Although residents may not be familiar with regulatory jargon, they can understand complex concepts if explained adequately. Tips for conveying this information as clearly as possible to the public include:

• Avoid using scientific jargon, acronyms, and overly technical language. Use simpler terms where possible, such as "breathe" instead of "inhale," "eat" instead of "ingest," "child" or "adult" instead of "receptor," and "come in contact with" instead of "be exposed to." If you need to use technical terms, make sure you define them. For example,

  Groundwater on the island is located in several distinct aquifers (an aquifer is a layer underground that contains water). One of these aquifers is contaminated. A separate aquifer is used to supply drinking water. The contaminated aquifer is not connected to the aquifer used for drinking water, therefore, island residents are not coming in contact with contaminated groundwater.

• In your sentences, use active rather than passive voice when possible. Active voice means putting the subject (the "doer") of your sentence before the verb rather than after. For example: "ATSDR conducted a public health assessment of the site" is active. "A public health assessment of the site was conducted by ATSDR" is passive. Active voice uses fewer words and is more direct and easier to understand than passive voice.
  
  
• Use shorter rather than longer sentences. Your material will be easier to understand if you use shorter sentences with simpler construction rather than more complex compound sentences. Check your writing for longer sentences that could be divided into two or more statements. For example:

  "We do not expect that contamination in the shallow aquifer will migrate to the base water supply because a confining layer separates the shallow aquifer from the deeper aquifer, thus preventing the transfer of contaminants to the groundwater layer from which the base wells draw water."

  could be rewritten as:

  "Wells at the Army base draw their water from an aquifer deep in the ground. The contaminated aquifer is nearer to the surface and separated from the deeper aquifer by a solid layer of bedrock. This layer prevents contaminants in the shallow aquifer from moving into the aquifer used for base water. For this reason, we do expect the base water to become contaminated."

• Relate information on a personal level and use examples, stories, and analogies as appropriate to establish a common understanding. This can also be particularly helpful when communicating orally.
  
  
• Make sure the reading level is appropriate for the intended audience. As appropriate, you can ask one or more community members to read your draft material and provide feedback on how clear and understandable it is.
  
  
• Include a user-friendly glossary that defines technical terms.
  
  
• Avoid minimizing risk. As you strive to communicate as simply and clearly as possible, make sure that the information you convey remains accurate, particularly the information about health hazards. State explicitly when a hazard does or does not exist and why or why not.

Tell the "Story"

Your information will be easiest to understand if you present it in a logical, well-organized manner and avoid irrelevant information. Try to focus on "telling the story" and omitting extraneous details that do not add to the story. Often, chronology provides an effective way to organize information, particularly when writing for the public. Following are two examples showing how information can be presented chronologically to tell the "story":

Acknowledge Uncertainties

Understandably, community members will want your statements and conclusions to be as definitive and certain as possible. Typically, however, the public health assessment process is fraught with uncertainties, such as whether and to what extent residents were exposed to contaminants; to what extent exposure to small concentrations of a substance may be a health hazard; and to what extent exposure to mixtures or multiple toxins influences the toxicity of the individual toxins. In your communications, clearly delineate what is known and not known; explain where and why there are uncertainties; and explain how you have accounted for these uncertainties in your conclusions. If there are uncertainties that could be resolved, let people know what you will do to resolve these uncertainties. For example,

Be Honest and Objective

Be objective (i.e., your tone should be neutral) and make a clear distinction between facts and other information (e.g., judgments and opinions). If information is unavailable and, as a result, no conclusions can be drawn, simply state so. For example,

If, after you have released results and conclusions to the public, new data become available that cause you to revise your conclusions, then you should clearly explain how and why the new information has led to different conclusions.

Also, if you realize you have provided inaccurate or misleading information, or there has been a miscommunication that has led the community to misunderstand what you intended to communicate, then acknowledge the mistake or miscommunication and correct it as soon as possible.

Put Health Information into its Proper Context

You do not want to unnecessarily alarm the community. Make sure dose and exposure conditions drive your discussions. Avoid making general statements like, "chemical 'x' causes cancer," without discussing under what conditions such health impacts could occur. In addition, to help community members understand how technical information ultimately affects them, you will want to put available environmental and health outcome data into meaningful perspective for them, as illustrated in the example below.

Avoid Conflicting Messages

When different agencies and groups provide conflicting information to the community, it undermines the credibility of all agencies, erodes trust, and generates confusion. To avoid this, you should be sure to communicate with other agencies at the beginning of and throughout the public health assessment process, and you should coordinate, as appropriate, to ensure that all agencies are presenting consistent messages and information. If conflicting information has already been presented, then you should attempt to reconcile the messages as soon as possible, taking care not to compromise the validity of what is being said. Consistency is also important in the draft and final public health assessment documents. When preparing the documents, make sure that the document is internally consistent—for example, that the conclusions are based on the information presented in earlier sections of the document, and that the recommendations parallel the conclusions.

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¹ Although TCE is a possible human carcinogen, the important message is that no exposure is occurring. In other cases, should exposures be occurring, be sure to clearly explain whether the levels to which people are being exposed are expected to result in adverse health outcomes (or illness).