Risk – reality, perception and communication
Article Outline
Perhaps this is a good time to recall Geoffrey Rose's strategy for preventive medicine – the dilemma between investing in targeted interventions for those most at risk and mass population interventions.1 Both probably have their place even if evidence is scanty, although it seems that the former has greater currency at present in many jurisdictions, perhaps because it sits more comfortably alongside a political agenda of personal choice. This month's issue has examples of the impact of both targeted interventions, such as an exercise referral scheme in Suffolk2 and population policy, such as the legislation controlling exposure to tobacco smoke in the workplace.3
Of great topical interest is the issue of immunisation among care home staff: this autumn, front line health and social care staff are finding themselves under varying degrees of pressure to accept influenza immunisation, in the context of pandemic flu. So the findings of a study4 in Nottinghamshire, England, that a high proportion of care home staff do not receive standard seasonal influenza immunisation provides a fascinating and challenging backdrop to this year's scenario. Nations are making plans for immunisation of high risk patients and also of front line health and social care workers. Already, just in the UK, several professional trade unions have expressed concerns for the welfare of their members of exposure to the new vaccine and some have advised members to decline to be immunised. The interplay between an understanding of risk, risk management and risk communication on one hand and ethics on the other, leads to a need to consider some complex issues.5 At what point is the estimated risk to the individual trumped by the interests of the people for whom s/he cares? As we write, the two major manufacturers are conducting pre-marketing tests on their vaccines, in the expectation that the products released will be as safe as is reasonable to expect. How safe is that? Since no drug is universally safe, so it is with vaccines. But asking someone to have a drug, in this case a vaccine, primarily for the benefit others, is not always easy to accomplish.
Think back to the introduction of universal MMR in the UK – prior to the infamous MMR debacle, the major obstacle was not the fear about safety per se, but a concern by parents of boys that, since the rubella vaccine was only of benefit to girls (sic) their male offspring should be exempt. The epidemiological argument that favoured the achievement of herd immunity, which, of course, knows no gender boundaries, won the day and universal immunisation became the norm. In the context of influenza, health and social care workers stand to benefit personally by avoiding the impact of the disease on themselves and by retaining themselves in the workforce, as well as by protecting the vulnerable with whom they come into contact, while others continue to be exposed to the risk of contracting the virus and so suffering the illness.
Whether health and social care professionals who decline immunisation without documented medical reasons can be criticised or even penalised for so doing remains a matter for employers. The decisions of individuals with regard to immunisation are likely to be based on a relatively poorly informed assessment of personal risk combined with a subjective opinion about the value of preventive interventions. Even where the risk has been clearly set out and widely accepted, as in the case of tobacco, we are reminded6 that individuals continue to make their own decisions to use tobacco, often with a scientifically irrational justification.
What is urgently needed is a clearly stated, independent, evidence-based public health analysis of risk to inform the decisions of normal rational individuals. So where is it?
This month a number of papers consider the evidence – and its weaknesses – gleaned from self-reported health measurement. Whilst attractive at first glance, these tools need careful interpretation and an appreciation of their limitations: who amongst us could possibly claim to have perfect, entirely objective recall about ourselves, whether about health or any other aspect of our lives? Nonetheless, such papers offer valuable insight into an infinite variety of topics, and in this issue, seasonal variation in self-perceived health and health behaviour, self-reported health associated with exposure to tobacco smoke, and the association between health and physical activity. Smoking continues to be a massive topic for publications, reflecting its continuing position as a chart-topping global determinant of poor health: ‘smoking’ papers this month consider the impact of tobacco control policies, including legislation restricting purchasing age and exposure to secondhand smoke.
And please don't forget this month's book – Geoffrey Rose's great book with a commentary by two contemporary epidemiological ‘giants’: doesn't that give you the urge to buy yourself – or a friend or your library – a non-seasonal gift?
References
- Harvey I. Book review: Rose's Strategy of Preventative Medicine, G. Rose (with commentary by K. T. Khaw and M. Marmot). Oxford University Press, Oxford (2008). Public Health 2009;123(10):699.
- . An evaluation of the effectiveness of ‘Active for Life’: an exercise referral scheme in West Suffolk. Public Health. 2009;123(10):670–672
- . Active cigarette smoking, secondhand smoke exposure at work and home, and self-rated health. Public Health. 2009;123(10):650–656
- Influenza vaccine uptake among staff in care homes in Nottinghamshire: a random cluster sample survey. Public Health. 2009;123(10):645–649
- . Risk communication and management in public health crises. Public Health. 2009;123(10):643–644
- . Secular trends in adult male smoking from 1992 to 2006 in South Korea: age-specific changes with evolving tobacco-control policies. Public Health. 2009;123(10):657–664
PII: S0033-3506(09)00283-2
doi:10.1016/j.puhe.2009.10.002
© 2009 The Royal Society for Public Health. Published by Elsevier Inc. All rights reserved.
