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HEALTH RISK PERCEPTION IN CANADA I : RATING HAZARDS,
SOURCES OF INFORMATION AND RESPONSIBILITY FOR HEALTH PROTECTION
Daniel Krewski, Ph.D., M.H.A. -1'2, Paul Slovic, Ph.D. ,
Sheryl Bartlett, Ph.D.1, James Flynn, Ph.D.3, C.K. Mertz .
Health Canada, Ottawa, Canada .
Carleton University, Ottawa, Canada
Decision Research, Washington, U.S.A.
Correspondence: Daniel: Krewski,,
Room 109
Environmental Health Centre
Tunney's Pasture
Ottawa, Ontario
K1A 0L2
I. Introduction
Public perception of risk is recognized as an important factor
in risk management decision making (1,2). Vertinsky and Wehrung
(3) argue that perceived risk can influence public policy, market
processes, individual behaviour, evaluation of new risk evidence,
as well as integrity and trust. Moreover researchers agree that
public perception of risks often play an important role in
influencing their response to risks and in particular health risks.
Slovic et al. (4.) suggest that an in-depth understanding of public
perception of risk is essential for effective risk communication
(5). Understanding the public's perception of risks is important
in formulating risk communication strategies (6,7). Kraus et al.
(8) conducted a unique study of the perception chemical risks in
which the views of experts (members of the U.S. Society of
Toxicology) were directly compared with those of the lay public.
Although this investigation represents an important milestone in
the analysis of perceived risk, the findings warrant confirmation
in other study populations. The purpose of this article and a
companion paper (9) is to report on the results of a national
survey of risk perception in Canada, patterned after the study by
Kraus et al. (8). This paper will focus on the ratings of
perceived risk for specific health issues, sources of information
on health risks and responsibility for RBK Mangement. The
companion paper (9) reports on attitudes and opinions about risk.
The results of a comparative survey of experts (members of the
Canadian Society-of Toxicology) will be reported separately (10).
II. Methods
Survey Content
The present survey was designed to assess many different
aspects of health-risk perception. Respondents were asked to
indicate the degree of health risk they associated with each of 33
hazards. Each of these items was rated in terms of the health risk
posed "to the Canadian public as a whole." The possible responses
were "almost no health risk," "slight health risk," "moderate
health risk," and "high health risk." In addition, for ten of the
items thought to pose risks to respondents and their families that
might be quite different from the risks to the general public
(e.g., street drugs), ratings were also obtained for "the health
risk to you and your family." Five additional items (breast
implants, medical X-rays, contraceptives, contact lenses, and heart
pacemakers), representing medical devices or treatments were rated
on perceived health risk under the assumption that "you or some
member of your family were considering using the following medical
devices or treatments."
Respondents were asked to indicate the amount of information
about health risks that they received from various sources and the
degree of confidence they had in each source. Respondants were
also asked about the degree of responsibility those same
individuals or groups were perceived to hold for protecting people
against health risks, and about how good a job each was doing in
fulfilling their responsibilities for protecting people against
health risks.
5The middle segment of the survey contained approximately 40
items designed to elicit the respondents' attitudes and opinions to
a variety of health-risk perception issues. The survey contained a
small number of statements designed to measure the following
worldviews (11, 12, 13): fatalism, hierarchy, individualism,
egalitarianism, and technological enthusiasm. Finally, the survey
elicited information on demographic variables, health status and
lifestyle, voluntary risk taking, occupational exposure to risk,
and political and environmental activism. These will be reported on
in the companion paper (9).
Survey Design and Implementation
A representative sample of the Canadian adult population was
interviewed by telephone. The interviewing was conducted in either
English or French during the period between February 14 and
February 24, 1992. A stratified random sampling procedure produced
2765 contacts from which 1506 completed interviews were obtained,
for a response rate of 54.5%. Weighting of the data was performed
to produce a final sample of 1500 individuals, matched to the 1992
Canadian population in terms of household size, community size,
age, and gender. A survey of this type has an overall statistical
reliability of ±2.6%, nineteen times out of twenty. The
statistical reliability of the weighted proportions in various
subpopulations ranged from 4.3% to 9.0% for the individual region
and 3.5% for females and males, respectively.
III. Results
Perception of Risk
Risk to the Canadian public. The perceived risk of thirty-
three environmental hazards (Figure la) to the Canadian public as
a whole and of five medical devices and treatments to individuals
and their families (Figure 6) ranged from high to low levels.
Using the percentage of responses in the "high risk" category as an
indicator of perceived risk, cigarette smoking was perceived as
presenting the highest risk; bottled water and contact lenses were
perceived as the lowest risk. Ozone depletion and the related risk
from suntanning stood out as quite high in perceived risk, perhaps
reflecting the degree to which recent media coverage has
effectively brought this issue to the public's attention. A
substantial amount of media attention was directed towards breast
implants, also perceived to be a high risk, immediately before and
during the time the survey was done. Stress was assigned a
relatively high level of risk, close to street drugs and higher
than crime and violence, AIDS, traffic accidents, and nuclear power
risks. In contrast, other hazards that experts might see as
relatively serious, such as bacterial contamination of food and
indoor air quality, were rated as lower risks to health by the
Canadian public.
Chemical risks from ozone, street drugs, chemical pollution,
PCBs or Dioxin, pesticides, food additives, and alcohol were rated
high in risk, although as prescription drugs were perceived as
7relatively low in risk. Radiation hazards associated with industry
(nuclear power and nuclear waste) were seen as more risky than
radiation hazards associated with medicine (x-rays). The
relatively low perceived risks associated with medical uses of
chemicals and radiation replicates earlier findings in Canada (14)
and elsewhere (15) and may reflect the influence on risk
perceptions of perceived benefit, familiarity, and trust in medical
treatments and the medical establishment.
Perceived risks due to climate change were seen as moderate in
magnitude, smaller than risks from ozone depletion. Nuclear waste
was seen as a more serious risk than nuclear power (another
replication of previous findings). Drinking alcoholic beverages
during pregnancy was seen as more risky for the public as a whole
than was drinking alcoholic beverages overall. The higher
perception of risk associated with alcohol and pregnancy may
reflect the conjunction fallacy (16), whereby a combination of
events sometimes seems more frequent or probable than the
individual events themselves. This result may also indicate that
perceived risk in this context reflects the probability of harm to
the unborn child if its mother engages in the specified behavior
(i.e., drinking alcohol if pregnant is perceived as more risky than
drinking alcohol if not pregnant).
Risk to respondents and their families. Comparing the
percentage of "high risk" responses when respondents were
considering the health risk "to you and your family" with the
percentage for the "Canadian public as a whole" for each of 10
8items. In every instance, there were more high-risk judgments in
reference to the Canadian public for every item (Figure 2). For
some items, such as street drugs and AIDS, the difference between
personal and societal risk perception was quite large. Note that
nuclear waste and nuclear power received more "high risk"
evaluations than any other items when the reference was to personal
or family risk.
Subgroup analyses: Gender. Perceived risk for all thirty-
eight health hazards was examined for subgroups of respondents
differing according to gender, age, education, and region of
residence. Sizable differences were observed as a function of each
of these demographic variables. Women were more likely to rate a
hazard as a "high risk" for every item but one-heart pacemakers
(Figure 3). In many instances, the differences between men and
women were quite large-up to 22.8%, for example, for suntanning.
Other items exhibiting more than a 15% difference in percentage of
high-risk responses were crime and violence, AIDS, motor vehicle
accidents, stress, ozone depletion, malnutrition, nuclear power
plants, drinking alcohol, chemical pollution, and waste
incinerators. Items for which women had relatively less excess
concern (when compared to men) included asbestos, nuclear waste,
and genetically engineered bacteria.
Subgroup analyses: Age. Respondents of age 55 or more were
more likely than respondents age 30 or less to rate a health risk
as high (Figure 4) . This tendency was particularly evident for
street drugs, breast implants, crime and violence, suntanning,
9alcohol and pregnancy, asbestos, video display terminals, and
cigarette smoking. The younger respondents displayed slightly
higher perceived risk than did the older group for heart pacemakers
and chemical pollution.
Subgroup analyses: Gender differences by age. In each of
three age categories, women were more likely than men to rate a
risk as high. However, the "gender gap" was not always uniform
across age groups. Younger women were relatively more concerned
about AIDS as compared to younger men. Middle-aged men were
relatively less likely to see stress as a high risk and older women
stand out in having relatively more concern about malnutrition than
do older men.
Subgroup analyses: Education. College-educated respondents
were consistently less likely than respondents with high-school
educations to rate a risk as "high" (Figure 5). People with less
formal education were relatively more concerned about chemical
pollution, street drugs, nuclear waste, AIDS, malnutrition, and
high-voltage power lines. In general, these differences were
smaller than the gender differences described earlier. The maximum
difference in the "high-risk" response associated with education
was 17.5%, for street drugs.
Subgroup analyses: Region of residence. Regional differences
for the 10 items rated with respect to both individual and family
risk were small in most instances, with one exception (Figure 6).
Residents of Quebec were more likely to rate certain risks as high
than were residents of other regions. This tendency was
10
particularly marked for perceived individual and family risks from
street drugs, nuclear waste, AIDS, alcohol and pregnancy, and
nuclear power plants.
Out of the 38 hazard items, residents of Quebec produced the
highest proportion of "high risk" responses for 29 of the items.
Differences among the other regions were relatively small in
comparison with the differences between Quebec and the rest.
Residents of Quebec were particularly high in perceived risk for
street drugs, stress, chemical pollution, crime and violence,
suntanning, nuclear waste, PCBs or dioxin, food additives, nuclear
power plants, nonprescription medicines, malnutrition, and bacteria
and molds in food. Residents of Quebec expressed considerably
lower perceptions of risk for implants and moderately lower
perceptions of risk from asbestos.
In a previous survey conducted in Canada in February, 1989
(17) , residents of Quebec were not particularly exceptional in
their perceptions of risk. However, their perceptions of the
benefits of prescription drugs were consistently lower than benefit
perceptions in four other regions (Atlantic, Ontario, Prairies,
British Columbia). However, they were more concerned about the
risks from prescription drugs than were other Canadians and rated
the benefits lower.
11
Sources of Information
The source of information about health issues and risks relied
upon most heavily was the news media (Figure 7). Private industry
and municipal government were relied upon least often. Differences
among the remaining sources were relatively small. The degree of
confidence that respondents had in those information sources
roughly paralleled degree of reliance on that source (Figure 8).
However, medical doctors were trusted substantially more than other
sources. Health and Welfare Canada and Environment Canada received
high evaluations. Private industry received the lowest ratings on
confidence. The news media, the most heavily relied upon source,
was outranked on confidence by a number of the other sources.
Responsibility for Health Risk Protection
Medical doctors and Health and Welfare Canada were seen to be
most responsible for protecting people against health risks (Figure
9) . These two groups were also to be perceived to be doing the
best job of fulfilling those responsibilities (Figure 10) . Private
industry was judged to be doing the poorest job in meeting this
responsibility.
IV. Summary and Discussion
The present study represents one of the most comprehensive
national surveys of health-risk perception conducted in Canada to
date. The main findings with respect to ratings of perceived risk,
12
sources of information on risk, and responsiblity for health
protection may be summarized as follows.
1. The Canadian public reported a high degree of perceived
risk for many hazards. Contrary to the view of many observers that
the public is overconcerned about small risks and underconcerned
about serious risks, the present study found that people are quite
sensitive to individually chosen lifestyle risks that are judged
serious by health and risk professionals (e.g., cigarette smoking,
street drugs, alcohol, AIDS, suntanning). There was also a great
deal of concern expressed regarding health risks associated with
industrial pollution (e.g., ozone depletion, chemical pollution,
nuclear waste) and risks from certain medical devices (e.g., breast
implants).
2. Perceptions of risk between pairs of hazards tended to be
positively correlated. That is, persons concerned about one hazard
were more likely to be concerned about other hazards as well.
Those unconcerned about one hazard were more likely to be
unconcerned about others.
3. There were sizable effects of gender, age, education, and
region of residence that need to be better understood. Women
generally rated health risks as higher than did men, and less
educated persons had generally higher perceptions of risk than did
people with more education. Residents of Quebec stood out from
other respondents in their attitudes and perceptions.
Many studies have found women to be more concerned than men
about risks from nuclear power and chemicals (4,11,12, 13). The
13
differences between men and women observed in the present study
appear to be larger than differences observed previously. The
present results also indicate that gender differences exist even
for perceptions of nonchemical and non-nuclear hazards (e.g.,
stress, crime, motor vehicle accidents). These results also
demonstrate that the magnitude of gender differences in risk
perception varies considerably across hazards. There have been
relatively few studies attempting to explain the origin of gender
differences in risk perception. The sizable differences observed
in the present study call attention to the need for a better
understanding of these differences.
The observed regional differences also need to be much better
understood. Why, for example, do residents of Quebec perceive more
risk from nuclear power and nuclear waste than do residents of
Ontario when only one of the country's 22 reactors are located in
Quebec and 20 are located in Ontario? Is this another example of
the finding by Lindell and Earle (18) that persons closest to
hazardous facilities are least concerned about them? Or do persons
living in Quebec feel vulnerable to the reactors in Ontario? Why,
also, do respondents from Quebec appear to perceive less risk from
breast implants and asbestos than do persons living elsewhere?
4. Other specific findings of interest:
14
a. Although younger people were slightly more likely than
older people to rate cigarette smoking as a high risk,
a higher percentage of younger persons smoked.
b. Health and Welfare Canada was viewed relatively
favorably as a useful and credible source of
information about health risks and as an agency that
was doing a good job in fulfilling its responsibility
for protecting people against health risks.
While these results are broadly similar to results from
other studies in Canada and elsewhere, many of the findings are new
and point to the need for more extensive studies of specific
issues. Many of the hazards currently of concern to Canadians,
such as ozone depletion, breast implants, suntanning, AIDS, and
climate change, would not have been considered serious only a few
years ago. Perceptions of risk are constantly in flux and surveys
such as the present study, if repeated periodically, can track the
ebb and flow of public opinion in light of new discoveries in the
world of hazards, educational campaigns, and risk-management
policies.
15
Acknowledgements
Guidance for this study was provided by members of a Health
Protection Branch Steering Committee: Sheryl Bartlett, Janice
Hopkins, George Jarvis, Diane Kirkpatrick, Daniel Krewski, Ray
MacDougal, Christina Mills, Suzanne Ouellette, Maura Rickets, and
Peter Toft. The Steering Committee worked with Paul Slovic and
James Flynn at Decision Research to develop the questionnaire for
the study. Douglas Hurley and Sudha Mehta of Goldfarb Consultants
also provided input into the design of the questionnaire. Goldfarb
Consultants administered the survey under contract to the
Department of National Health and Welfare. We are grateful to
Leisha Mullican of Decision Research for help in reporting on the
results of the study. The conclusions presented in this paper do
not necessarily represent the views of the Government of Canada.
Earlier versions of this article were presented at the Annual
Meeting of the Statistical Society of Canada, (Wolfville, Nova
Scotia, June, 1993) and at the National Workshops on the
Charaterization of Risks to Humans at the Environment (Ottawa, June
23, 1993).
16
References
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17
15. 'Slovic P. Perception of risk from radiation, In W.K.
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Analysis 1983: 245-254.
, .
18
List of Figures
Figure la. Perceived Risk of Thirty-Three Environmental Hazards
to Canadian Public.
Figure lb. Perceived Risk of Five Medical Devices and Treatments
to Individuals.
Figure 2. Perceived Health Risk to Individuals and to the
Canadian Public for Selected Hazards.
Figure 3. Perceived Health Risks to Canadian Public by Gender.
Figure 4. Perceived Health Risk to Canadian Public by Age.
Figure 5. Perceived Health Risks to Canadian Public by
Education.
Figure 6. Perceived Health Risks by Region: Individual and
Family Risks.
Figure 7. Sources of Information about Health Issues and Risks.
Figure 8. Confidence in Organization as Information Source.
Figure 9. Perceived Degree of Responsibility for Protecting the
Public Against Health Risks.
Figure 10. Perceived Fulfillment of Responsibility for Protecting
the Public Against Health Risk.
Figure1a.PerceivedRiskofThirty-Three
EnvironmentalHazardstotheCanadianPublic
CigaretteSmoking
OzoneDepletion
StreetDrugs
Stress
ChemicalPollution
CrimeandViolence
Suntanning
AIDS
MotorVehicleAccidents
NuclearWaste
AlcoholandPregnancy
PCB'sorDioxin
PesticidesinFood
FoodAdditives
DrinkingAlcohol
NuclearPowerPlants
ClimateChange
NonprescriptionMedicines
Asbestos
WasteIncinerators
Malnutrition
HighVoltagePowerLines
FoodIrradiation
PrescriptionDrugs
GenetEngrBacteria
OutdoorAirQuality
BacteriainFood
MoldsinFood
MercuryinFillings
TapWater
IndoorAirQuality
VideoDisplayTerminals
BottledWater
0%20%40%60%
PercentResponse
80%100%
IHigh•Moderate•SlightE3AlmostNone•Don'tKnow
19.
Figure 1b: Perceived Risk of Five Medical
Devices and Treatments to Individuals
Breast Implants
Medical X-rays
Contraceptives
Heart Pacemakers
Contact Lenses
0% 20% 40% 60%
Percent Response
80% 100%
IHigh IZlModerate •Slight EUAImost None CIDon'tKnow I
20
2)
Figure 2. Perceived Health Risk to Individuals
and to the Canadian Public for Selected Hazards
Nuclear Waste
Nuclear Power Plants
Street Drugs
Alcohol and Pregnancy
AIDS
High Voltage Power Lines
Waste Incinerators
Malnutrition
Mercury in Filings
Video Display Terminals
0%
IIndividual
20% 40%
' Percent High Risk
•Public
60%
ZI
Figure 3. Perceived Health Risks to the Canadian
Public by Gender
Cigarette Smoking
Street Drugs
Breast Implants
Ozone Depletion
Chemical Pollution
Stress
Crime and violence
Nuclear Waste
Suntanning
AIDS
Motor Vehicle Accidents
Alcohol and Pregnancy
PCB's or Diarin
Food Additives
Pesticides in Food
Drinking Alcohol
Asbestos
Nuclear Power Rants
Climate Change
Nonprescription Medicines
Food Irradiation
Waste Incinerators
High Voltage Power Lines
Genet Engr Bacteria
Malnutrition
Outdoor Air Quality
Bacteria in Food
Prescription Drugs
Molds in Food
Mercury in Fillings
Medical X-rays
Tap Water
Indoor Air Quality
Video Display Terminals
Heart Pacemakers
Contraceptives
Bottled Water
Contact Lenses
0% 10% 20% 30% 40% 50% 60% 70%
Percent High Risk
♦Males
-S-Females
2o
Figure 4. Perceived Health Risks to the Canadian
Public by Age
Ozone Depletion
Cigarette Smoking
Chemical Pollution
Stress
AIDS
Street Drugs
Motor Vehicle Accidents
Breast Implants
Crime and Violence
Nuclear Waste
Suntanning
PCB's or Dioxin
Pesticides in Food
Alcohol and Pregnancy
DrinkingAlcohol
Food Additives
Nuclear Power Rants
Climate Change
Waste Incinerators
Nonprescription Medicines
Asbestos
Malnutrition
•=igh Voltage Power Lines
Prescription Drugs
Food Irradiation
Outdoor Air Quality
Molds in Food
Bacteria in Food
Genet Engr Bacteria
Tap Water
Heart Pacemakers
Mercury in Filings
Medical X-rays
Indoor Air Quality
Contraceptives
Video Display Terminals
Bottled Water
Contact Lenses '
0%
Percent High Risk
-•• Under 30 Years of Age -9-55 Years of Age and Over ~[
Figure5.PerceivedHealthRiskstoCanadian
PublicbyEducation
BreastImplants
OzoneDepletion
CigaretteSmoking
Stress
Suntanning
ChemicalPollution
StreetDrugs
CrimeandViolence
MotorVehicleAccidents
NuclearWaste
AIDS
AlcoholandPregnancy
PesticidesinFood
PCB'sorDioxin
FoodAdditives
DrinkingAlcohol
ClimateChange
NuclearPowerRants
Asbestos
NonprescriptionMedicines
WasteIncinerators
FoodIrradiation
PrescriptionDrugs
Malnutrition
OutdoorAirQuality
GenetEngrBacteria
HighVoltagePowerLines
BacteriainFood
MoldsinFood
IndoorAirQuality
MedicalX-rays
MercuryinFillings
TapWater
VideoDisplayTerminals
Contraceptives
HeartPacemakers
BottledWater
ContactLenses
••-College
PercentHighRisk
-s-HighSchool
ZI
24
Figure 6. Perceived Health Risks By Region:
Individual and Family Risks
Nuclear Waste
Nuclear Power Rants
Street Drugs
Alcohol and Pregnancy
AIDS
High Volt Power Lines
Waste Incinerators
Malnutrition
Mercury in Fillings
Video Display Terminals
0% 10% 20% 30% 40% 50% 60% 70%
Percent High Risk
IQuebec aAtlantic •Ontario •Prairies •British Columbia
Figure7.SourcesofInformationaboutHealth
IssuesandRisks
NewsMedia
MedicalDoctors
Public/EnvironmentalGroups
Health&WelfareCanada
EnvironmentCanada
FriendsandRelatives
UniversityScientists
AgricultureCanada
ProvincialGovernment
MunicipalGovernment
PrivateIndustry
20%40%60%80%100%
PercentResponse
lAlot•Fair•Little^NonenDonlknow
lo
Figure 8. Confidence in Organization as
Information Source
News Media
Medical Doctors
Public/Environmental Groups
Health & Welfare Canada
Environment Canada
Friends and Relatives
University Scientists
Agriculture Canada
Provincial Government
Municipal Government
Private Industry
0% 20% 40% 60%
Percent Response
80% 100%
IA Lot •Fair •Little CDNone •Don't Know
Figure9.PerceivedDegreeofResponsibility
forProtectingthePublicAgainstHealthRisks
MedicalDoctors
Hearth&WelfareCanada
EnvironmentCanada
IndividualCitizens
OtherHealthProfessionals
AgricultureCanada
LocalGovernment
PrivateIndustry
Public/EnvironmentalGroups
20%o40%60%
PercentResponse
80%100%
•MajorOModerateISomeSNone•Don'tKnow|
25
Figure10.PerceivedFulfillmentof
ResponsibilityforProtectingthePublicAgainst
HealthRisks
MedicalDoctors
Health&WelfareCanada
EnvironmentCanada
IndividualCitizens
OtherHealthPros
AgricultureCanada
LocalGovernment
PrivateIndustry
Public/EnvironmentalGroups
20%40%60%
PercentResponse
80%100%
ExcellentDGood•AdequateePoornDon'tKnow
2g.