Thank you very much for the invitation.
What I would like to talk about - again I was given a title,
so I have had to fit my usual spiel around the title
– is to take radon as a health threat
and to think a bit about where there are going
to be barriers to try to instil the kind of behaviour change
that we would look for in terms of promoting health.
So if we think about radon.
It is the greatest health risk from radiation in Ireland.
Yet when we ask people about radiation threat,
it’s nuclear power plants that people think of.
We know that as a known carcinogen
it’s in the same category as tobacco smoke and asbestos.
It is the second leading cause of lung cancer following tobacco smoke.
Estimates in Ireland would indicate that about 250 people every year
have a diagnosis of lung cancer linked to radon.
So that’s about two people every three days.
Within 12 months with lung cancer
about two out of three people are dead.
It has a very low survival rate.
So radon is a threat to health. But it can be managed.
And I suppose part of what I was interested in
and the work I was commissioned to do by the EPA
was to look at, what is the effectiveness of the kind of public health campaigns
in terms of being able to produce behaviour change?
But what I want to spend most of the day talking about
is really around, well what are the kinds of psychological barriers
that basically act against the effectiveness of these messages?
So radon can be managed. We can test for it, which is akin to screening.
And if we find that there is a threat,
we can take preventative action to minimise the threat.
So this is a threat that can be managed.
It’s not a threat that’s problematic because of a lack of education.
So there’s quite often a starting point
which is if we just give people information about health threats
well then that should produce behaviour change.
But we know from numerous surveys here
and in numerous countries
there are generally quite high levels of awareness of radon,
but when you ask people more about it, they are not really that sure,
or that bothered or that concerned about long-term health consequences.
And we will come back to some of the psychological factors
that can act to kind of stop us thinking about long-term consequences.
We know that in general levels of testing for radon are quite low.
Even when you tell people that they have high radon levels in their homes
remediation rates are particularly low.
So you have been told now there is a threat, in your house,
of lung cancer coming from radon,
and maybe about one in four will actually go on to do something
to remediate against that threat.
A lot of the work that’s been done in this area, nationally and internationally,
has been based around identifying regions that have high levels of radon,
and then coming in with quite elaborate and complex
community-based programmes, with various educational strands in them.
And the idea is that if you tell people there’s a threat
that they are going to respond in a rational way.
And what that would look like is, you are told that there’s a threat there,
and therefore you should be motivated to do something to see,
does it personally affect me? So I should do something, i.e. test.
And then what I should do is if the test indicates that there’s a threat to me,
well I should do something to remediate that.
I should try to reduce that threat.
I should then probably also check to make sure
whatever it is I have done has actually been effective.
So that’s the kind of simple version of what should be happening.
But if you break it down into all of the various steps
that need to happen to get from an information delivery
to actual behaviour change that is going to be of a health benefit,
people have to be exposed to the information,
they have to attend to it.
So putting information up does not necessarily mean anyone will attend to it.
They have to be interested in it. They have to understand it.
They have to see the information as being credible.
It has to be comprehensible.
They then have to have some sense that maybe
there is a threat here and a threat requires us to think of two things.
The first is that it could affect me, so that I am susceptible,
and the second thing is, that whatever it is that’s there could be negative.
So it has to be both susceptible and severe.
I then have to think and believe that that can be assessed.
I have to know how to get the threat assessed.
I have to want to do it. And then finally I get to doing it.
Now I have to get the results, which I have to understand.
I have to then interpret them as suggesting that, yes, I am at risk.
I then have to want to reduce that risk.
I have to know how to reduce it.
I then have to act and do something.
And then I have to confirm. That’s a lot of steps.
And at each of those steps we have a ‘get out of jail card’
where we basically just lose interest and don’t follow through
and proceed to the next step.
What this is trying to highlight is this is quite a complex process.
It’s a mixture of knowledge, beliefs, feelings, motivations and behaviour.
One of the defining characteristics
that comes through from the literature is, despite high levels of awareness,
by and large people’s response to this threat is apathy.
If you offer people radon tests for free just above one in three will actually avail of it.
If you give people the free test and tell them you have a high level,
therefore you and the people living in your home
are at increased risk of developing lung cancer,
maybe one in three will plan some action.
That’s not do anything, that’s plan to do something, at some point.
So what is it about radon that means we can hear about a threat
but basically not really respond in an immediate way.
OK, well it fits a number of features of threats
that we know from the psychological literature
are just really hard to get people motivated to do something about.
It’s quite a low objective level of risk.
So when you tell people about levels of risk
if that’s such a lowish level that we know people
struggle with understanding probabilities,
particularly probabilities in relation to things that are very low.
So it’s easy to dismiss. There’s no sensory cues.
So again we know that where people have clear immediate sensory cues to action,
like smells, like tastes, like things that are visible,
then they can act and respond to it.
But in essence radon is silent, tasteless, odourless.
Therefore we have no cue to tell us there is a threat here.
It’s a natural risk.
And we know from decades of research
people get far more upset about man-made threats than natural threats.
Because things that are natural we somehow seem to
automatically associate with being good for us.
So there will be more outrage over a radiation threat
associated with a power plant, because that’s man-made,
or with power pylons, because that’s man-made,
than something that’s naturally occurring.
It’s a relatively benign risk.
And what I mean by that is, that
basically people can live with this risk for decades.
There’s no side effects when they are living in the house.
There’s no real symptoms on a day-to-day level.
So you can live with it. You can tolerate the risk.
The effect is far removed from initial exposure.
So again lung cancer developed decades later.
There’s no early symptoms, which means you can keep on delaying action.
People have quite interesting perceptions of control
in so far as people fully believe that they can undo damage
in the future that they are doing today.
So I can do something in the future that reduces my risk,
but I don’t have to do anything now.
The deaths are relatively undramatic.
So we don’t get Six One news saying that somebody died from radon today.
And again we won’t get a level of threat perception about that,
because it’s not part of discourse and it’s not dramatic.
It’s inequitable. And we really don’t like this.
We don’t like the idea that due to chance as to where I’m living
I’m at threat of something bad happening,
radon, and you are not, even though you live across the road.
We struggle with those types of risks and therefore don’t act.
There is an emotional identification with our homes.
So again we think about our home,
which is our place of physical and psychological safety,
the idea that this is a threat to our health
and is causing lung cancer does not fit with our perceptions
about what our home should be.
And rather than act to basically make our home safer
we basically just do nothing.
So radon really ties into a lot of the core issues
that have been present in the psychological literature
on risk perception since the 70s.
Risk perception is not just a simple actuarial model.
It’s a complex psychological process of meaning making.
We have to perceive the threat as being credible.
And again I like the idea that if radon is being described
as a health threat it should always be described in the health area.
Because once people put it in the environmental space
it’s no longer a health threat, it’s something else,
and therefore can be discounted.
We know that there are numerous biases
that we have in how we process information
that will basically impact on how we come to act from it.
So we can’t really recall people dying from radon,
so it can’t be that much of a thing for us to worry about.
Radiation comes from nuclear power plants not from our home.
People generally are unrealistically optimist.
What that means is that, by and large
we think bad things are more likely to happen to other people.
Because that’s kind of worrying if they are likely to happen to us,
so other people will experience bad things in life, not us.
So all of these biases will exist to minimise our sense of risk.
But the other thing that’s important about risk perception
is that too often we leave it in the head of the individual.
Risk perception and threat perception happens in a social context.
So a simple example is, if the fire alarm goes off here,
what are people likely to do?
Well if you are like most people what you will tend to do is
stay still and look to your left and look to your right.
Now if you were doing that out of a concern for other people’s wellbeing that would be great.
But you are probably not.
You are probably looking around to see, well what are they doing?
And it’s the same with other health threats and in particular radon.
So what are my neighbours doing?
What are other people in the community doing?
Because if they are doing nothing, well then I’m not going to do anything.
So how threats are presented to us routinely on a daily basis,
on a weekly basis, we get exposed to more and more things that are bad for us,
that are threats to our health, and we end up just discounting them,
because there’s just too many of them.
But we respond to them in two ways.
We think about the information, but we also have an emotional response.
And what people tend to do when presented with information
that is upsetting is to respond defensively to it.
And what that means is, we can suddenly start doing things like,
questioning the accuracy of the information.
So if you tell people radon is this colourless,
odourless gas that can cause lung cancer,
the first half of that sentence they won’t question.
The second half they will start questioning.
Suddenly they will become epidemiologists.
What do you mean by evidence that this is going to cause lung cancer?
What was that study based on?
What were the data like?
People will start questioning bits of the message that they don’t like.
And they will bring a very sceptical view to it.
By and large we are characterised by a way of looking at information
and being exposed to health threats that has a bias in it.
And the bias in it is, allow us carry on doing what we have always done.
We are creatures of habit.
So things that we have been doing, that give value in our life,
that give meaning in our life, that give pleasure in our life,
we won’t give up, in the face of evidence.
Or in the face of information that may force us to change what we will do is,
we will start processing that information
in a way that basically protects ourselves and our sense of self.
And our sense of self is far more valuable to us
than any abstracted notion that we might develop
something decades down the line.
So when we think about informing people about threats,
we need to be aware that there are these biases
in how people process health information.
So when we look at programmes that have been set up
to try to enhance screening and remediation,
again they are quite good at helping improve people’s
levels of knowledge and getting people to say
that they intend to change behaviour.
But we know that intentions aren’t that good.
Every new year people make lots of intentions.
How many people actually go to the gym as often as they said they will?
How many people a few weeks later are following that new diet
that they swore they were going to do?
So getting as far as intentions is good,
but when you look at actual behaviour change, there’s quite a big gap.
So very little evidence of these programmes having an effect
on actual testing rates or remediation rates.
Even those who actually get a kit to screen
very rarely actually go on and do anything about remediating their house.
Now within the literature there are problems,
so a lot of the studies aren’t very well designed.
We don’t really have routine objective assessment of actual remediation rates.
So that is problematic.
But the general trend is pretty consistent across the literature.
Programmes work to help people feel they know more about radon,
but they generally still don’t do anything.
If we look at the Irish context that have been delivered by the EPA over the decades,
broadly we are finding that how they are delivered,
what happens in them, the process of delivery is comparable
to what goes on in the international literature.
It’s in line with what the WHO recommends for risk communication.
But by and large the level of impact is pretty similar, i.e. minimal.
So in thinking about radon, we need to look at,
well what should we expect from health intervention programmes?
Because I think sometimes we can get caught up
in damning ourselves with the ineffectiveness of interventions.
But sometimes it’s useful to benchmark
– well how effective are other things?
So if we think about what radon awareness programmes
have tried to do, they have tried to get people to test,
and they have tried to get people to remediate.
OK, so that’s akin to screening and prevention.
OK, so do people always go for screening for health threats?
Quite often they don’t because people
don’t want to hear the bad news,
because that might have an impact for a negative sense of self.
When we look at health threats that are more familiar to us,
for example, cervical cancer or breast cancer screening,
when you go into large scale communities
and you present these types of broad based education programmes
you might get behaviour change in about 4% of the population.
That’s with a known risk, cervical cancer.
And radon risk, people aren’t too sure what it is.
If we think about promotion campaigns
to try to encourage preventative behaviours,
again using similar multimedia, well-funded,
well-resourced, well-developed, well-delivered programmes,
you probably get behaviour change of about 5%-15%.
So I think we need to be very clear.
Bottom line on this is, behaviour change is hard.
Education campaigns in and of themselves
will have some effect but they are not going to have massive effects.
So we need to think about how we deliver these programmes
to try to overcome the biases that people have in perceiving risk.
So when risks threaten there are emotional and cognitive mechanisms
that will push people towards action,
but there will be more that will pull them towards inaction.
And that’s that relative balance that we have to strike.
The threat from radon is too easily downplayed.
Again we can keep on justifying inaction. It’s distal.
It happens sometime in the future.
It’s only every now and then in the public discourse.
And we can always think that we can act in the future to undo damage.
Indeed, we know from studies in the US,
this is what people will actually say to you.
They will say, I know I have got a high level now,
but sure I can do something in a few years’ time.
Every day they are in that house exposing themselves to a carcinogen.
So what we know from decades of health psychology research,
is that even well-designed, well-delivered information programmes
are seldom adequate to bring about appropriate protective behaviours.
So it’s not that we are doing something wrong in our education campaigns,
we are doing them about as well as we can do.
We may just need to be more realistic about what level of behaviour change
is actually achievable in terms of population or community health interventions.
Doyle and colleagues back in the early 90s
talked about any radon programme
that relies only on information awareness
and voluntary testing is likely to fail.
At the very least any credible mitigation
resulting from the programme has been so small
as to suggest that some programmes may be very expensive ways
for society to achieve mitigation.
So what this suggests is that we may need to think about the balance
of where we are putting on the individual versus the state.
That governmental regulation may actually be preferable.
And again the WHO acknowledges this,
that says convincing policy-makers to take action
to regulatory means may be more effective
than risk communication messages targeted at general public.
So this does raise I suppose issues about
where the state’s role is and where the individual’s responsibility lies.
And again there are a number of options
that could be taken from a state legislation perspective,
for example, we could look at testing as being part of the house selling process,
and it may well be that you have to have a test prior to sale,
or you have to test remediation prior to sale.
So there’s a number of options here.
But really what all of these are trying to do
is to try to shift the onus of behaviour out of the individual
from a voluntary perspective and putting it more under a regulatory focus.
One other possibility we might want to think about for radon
is to think about the visibility of the threat and the visibility of the remediation.
It’s an invisible threat and therefore, like air pollution, can just be negated.
How do we make the threat more salient?
Well monitors in houses that can give readings
and can have flashing red lights possibly combined with beeping red noises
might tell people that there’s a threat here now.
And we know from some of the literature
that when people have visual or auditory aids
that can change behaviour that might otherwise be forgotten.
So again it’s about trying to do something that gets us out of our routine habit.
We can also put visible markers on houses that will indicate
that when houses have been tested for example,
to basically send a signal to the community
that actually we have tested and therefore we have done the right thing.
And what we can sometime hope for
is that maybe over time the more and more people that are testing,
the more deviant it is now to not test.
So the more that testing is the norm,
then non-testing becomes the deviant thing to do,
so you are the one who is the bad person,
because you are putting yourself and your family at risk
because you are not testing.
This idea draws upon a lot of work that happens in behavioural economics,
talking about social competition and social herding
to change behaviour and not just it being about at an individual level.
The final issue that can sometimes work is to think about
rather than looking at people all at the same stage
around the threat, is to think about people being at different points
in the decision to change, so thinking about message segmentation.
There may be some people who have never thought about testing
and how do you facilitate getting them to a point of testing,
where there may be others who have thought about testing,
but aren’t quite sure what to do next.
And we know from some of Weinstein’s work,
particularly in the 80s in the US,
that you can develop interventions that meet people at their point.
So you can get interventions that match
where the person is in relation to thinking about the threat and threat management.
What I have hoped to have given you a sense of in the context of radon
is that when we look at health information campaigns
is that it’s not just about providing information.
We need to think about in essence the message recipient
and the kinds of ways in which they are going to process
the messages we give out.
Because without trying to understand the message recipient
and that may be at an anthropology level,
I would probably argue at a psychological level as well,
we are going to get stuck in terms of
how effective our interventions can be.
So what this suggests is that,
for some health threats it may well be that
we are putting too much responsibility on the individual
and it may well be that the state
may need to get more involved in this process.
There may well be a requirement to think about
increased governmental regulation,
whilst at the same time providing some information campaigns
that are there to help inform people.
But if we want to change behaviour relying purely on individuals
to do this is a tough ask,
in light of a threat like radon that can be easily discounted,
and which I think is like many of the threats that
have been mentioned so far from environmental health threats.
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Prof. David Hevey, Director of the Research Centre for Psychological Health, School of Psychology, Trinity College Dublin
Radon: A Behavioural as well as a Technical & Health Challenge