## Communications Approach

**Contents:** This chapter outlines the many steps and challenges that
may be associated with a public awareness and education effort conveying
the results of a detailed study of the health consequences of nuclear
weapons testing. The informational needs as defined by various
stakeholder groups are identified and current work being conducted by
the NCI on its ^131^I/NTS Communications Project is discussed.

### Introduction

Effective health communication and education efforts increase the
awareness and knowledge of a potential health risk. Often, such efforts
are launched with hopes to motivate people to seek more information and
possibly seek individual care and examination from a health care
provider. This is not a simple task, and communicating effectively with
multiple audiences about their exposures and the potential health
consequences resulting from nuclear weapons tests conducted 4--5 decades
ago is particularly challenging. A comprehensive effort to communicate
the results of an in-depth scientific assessment of dose and risk, and
to address the numerous issues that have been raised by stakeholders
regarding fallout, would likely be an extremely complex and
resource-intensive public awareness and education effort. This is not
only because of the technical nature of the science used to develop the
exposure estimates and potential health risks, but also because of the
breadth of information that must be included. A study of the health
consequences of nuclear weapons testing encompasses exposures to
multiple radionuclides present in radioactive fallout and estimates of
the likelihood of a number of health consequences resulting from these
exposures. In addition, because exposure occurred across the country,
information must be designed with sensitivity to educational, cultural,
and other differences in population groups. It is clear that the
development, implementation and evaluation of any communications plan
will require extensive collaboration with state and local health
departments, health professional organizations, advocacy groups, and
community organizations, as well as the use of multiple channels to
disseminate the information once developed.

Given the historical, social justice, and political contexts enveloping
testing programs (for example, the United States tests at the NTS and
the Marshall Islands), a public awareness and education campaign could
engender additional public mistrust of government and possibly intensify
demands for Federal government policy and legislative changes. It will
be a formidable task to communicate information in a way that is
perceived as believable as well as understandable by those concerned
about the consequences of the testing program. Nevertheless, one of the
most important public health implications of performing a detailed
dosimetric and risk analysis study in the future will be the need to
clearly communicate the results of this more detailed study to the
American public and health care providers.

This chapter provides general information about the discipline of risk
communication and focuses on the many steps and challenges that may be
associated with a public awareness and education effort to convey the
results of a detailed study of the health consequences of nuclear
weapons testing. The informational needs, as defined by various
stakeholder groups, have been identified through work conducted by NCI
to communicate the results of its report on *Estimated Exposures and
Thyroid Doses Received by the American People from Iodine-131 (^131^I)
In Fallout Following Nevada Atmospheric Nuclear Bomb Tests* (NCI 1997)
(hereafter referred to as ^131^I/NTS Communications Project). While this
chapter deals specifically with communicating the results of a more
in-depth study of the health consequences of fallout exposures to the
American public, a number of the issues and strategies discussed would
be applicable to communicating the results of this feasibility report.

### Components of a Proposed Communications Plan

There are multiple components of a communications plan. However, it is
clear that, to be effective, any communications effort must target both
the public and health care providers.

#### Public Communication and Education

The objectives of a nationally coordinated public awareness and
education effort toward informing the American public of their potential
exposure from fallout from United States and global nuclear weapons
testing are:

-   **To Satisfy the Public's 'Right to Know'**

    Specifically, to alert Americans alive in the 1950s and the early
    1960s that they were exposed to fallout from tests conducted at the
    NTS and from other global testing events, the potential health
    consequences of such exposure, and what, if any, steps concerned
    individuals may take to get answers to questions related to
    potential health effects from global fallout. This could include
    educational information on the history and conduct of nuclear
    testing programs within the United States and globally (for
    atmospheric testing ending in 1962). This information could also
    provide the public with the information it needs to enter into a
    public debate regarding issues of Federal responsibility with regard
    to the potential health outcomes associated with the United States
    and global nuclear weapons programs. Additionally, this could be
    structured to provide a central information repository for
    educational materials regarding these issues.

-   **To Enable the American Public to Understand the Level of Exposure
    from Fallout and the Potential Risk of Disease Associated with that
    Exposure Level**

    Specifically, to educate the American public about factors that may
    have increased their chances of exposure or their risk of disease so
    that they can self-identify whether or not they may be in a
    high-exposure and/or high-risk group. Additionally, to provide
    information on the potential health consequences of radioactive
    fallout so that people have the knowledge they need to make informed
    decisions about their health and are motivated to act on recommended
    follow-up activities (i.e., seeing their health care provider).
    Emphasis would be on reaching those population groups estimated to
    have received the greatest exposure and having the greatest
    likelihood of resultant health risks.

-   **To Address Special Information Needs Including Access to Health
    Care and Ability-to-Pay Issues**

    Specifically, to address the special information needs of those who
    are potentially at high risk and/or who are concerned, but do not
    have a source for medical care.

#### Health Care Provider Education

The nation's health care providers will likely have the greatest impact
on improving the health status of persons who may have been adversely
affected by radioactive fallout. This health care provider group
includes local health care providers; national, state, and local medical
associations; academic medical centers; medical schools; and schools of
public health. The objectives of this component of a communications
program would be to:

-   **Inform Physicians/Health Care Providers about the Radionuclides of
    Concern and Potential Health Consequences**

    Specifically, to target health care professionals in the geographic
    regions that received high doses and those practicing near former
    United States nuclear weapons program sites. Information should also
    include current recommendations by professional organizations and
    others regarding screening, diagnostic, and treatment options.

-   **Build Expertise**

    This could entail educating health care providers about radiation
    fallout-related disease and potential high-risk populations in their
    area and building skills through the use of training programs and
    short courses for health care professionals that guide them through
    the screening, diagnosis, treatment, and surveillance of specific
    illnesses.

### Using NCI's ^131^I/NTS Communications Project as a Model

In its review of NCI's 1997 report, the IOM (IOM 1999) recommended that
the Department of Health and Human Services (DHHS) take additional steps
to develop and implement a communication plan to fully explain the
potential health implications of ^131^I exposure to the American public
from nuclear weapons testing at the Nevada Test Site (NTS). In response
to the IOM recommendations (IOM 1999), NCI began collaborating with CDC
to develop and disseminate accurate, yet understandable, information
regarding the potential risks of thyroid cancer and thyroid disease
associated with exposure to ^131^I released during nuclear bomb testing
in the 1950s and early 1960s at the NTS. In January, 2000 NCI and CDC
sponsored a communications workshop entitled "^131^I Fallout from NTS:
Informing the Public." Subsequent to this workshop, NCI, in consultation
with a group of citizens, scientists, physicians, communication experts,
and representatives of the advocacy community and state public health
departments, developed its ^131^I/NTS Communications Plan (see
**Appendix I.1**).

Because a great deal of work has already been accomplished by NCI to
structure its ^131^I/NTS Communications Project to ensure ongoing public
involvement in the development and implementation, it would seem
appropriate to use a similar approach for future communication planning
efforts associated with a detailed study of the health consequences of
nuclear weapons testing by the United States and other countries. In
planning for this future work, the specific recommendations made by the
IOM in its review of NCI's 1997 report concerning communicating with
health care providers and the public (IOM 1999) should also be
considered.

#### The January 2000 ^131^I Communications Workshop

In January 2000, NCI (along with a working group consisting of CDC,
citizen, advocacy group, state health department, and the Advisory
Committee on Energy Related Epidemiologic Research \[ACERER\]
representatives and a health educator) planned and convened a Workshop
to begin the process of designing and implementing the ^131^I/NTS
Communications Project. The Workshop, entitled *"^131^I Fallout from
NTS: Informing the Public,"* was held January 19-21, 2000, in Rockville,
Maryland (see Workshop Agenda and Summary in **Appendices I.2 and
I.3**). This multi-day Workshop was structured with expert panels that
explored relevant issues and public health communications
recommendations. Through the Workshop, NCI sought input from affected
and concerned citizens, health and environmental nonprofit
organizations, health care providers, public health and other local
government officials, experts in radiation sciences, and experts in
health and risk communications on how to best plan and implement the
^131^I/NTS Communications Project.

Over 70 participants and presenters were directly involved throughout
the Workshop (see **Appendix I.3** for the participant list). Workshop
participants discussed the need for a more comprehensive ongoing
information campaign.

At the end of the Workshop, participants agreed that NCI should proceed
with plans to communicate to the American public what is known about
^131^I/NTS exposures and the potential health consequences. Participants
understood that CDC and NCI would be providing Congress with a
feasibility study regarding potential doses and health risks from
exposures from United States and global testing, and that any
communications effort associated with a more in-depth study would be
resource-dependent. They agreed that the ^131^I/NTS Communications
Project should be structured such that it could be broadened as more is
learned from continuing work on exposures to global fallout and other
radionuclides from the NTS. Thus, DHHS would be able to utilize the
model developed for the ^131^I/NTS Communications Project in planning
for future communications efforts.

The Workshop ended with recommendations for further action and for
creation of a citizen review group that would be involved in the
planning phases of the ^131^I/NTS Communications Project. NCI
incorporated these recommendations as it developed the plan for its
^131^I/NTS Communications Project.

Keeping in contact with workshop participants

To meet Workshop participant expectations, NCI and CDC have made a
commitment to communicate frequently and fully with the community about
their timetable and progress toward meeting milestones. One of those
milestones was to provide participants with a copy of the feasibility
report to review and to inform them of Congressional response to this
report. NCI and CDC have developed a process for ongoing communication
with Workshop participants to keep them informed about the progress in
implementing the ^131^I/NTS Communications Plan, any new efforts
initiated (for example, if Congress decides to appropriate funds to
carry out the work detailed in this report) or the reasons for any
delays. This process included:

-   Progress reports sent out via an electronic mailing list --
    utilizing the National Institutes of Health (NIH) LISTSERV facility.
    Workshop participants (and any other interested individuals) who
    subscribed to this service received updates on NCI's progress
    implementing the plan for the ^131^I/NTS Communications Project.
    This process was also used to disseminate draft documents and to
    collect review comments. Workshop participants also "discussed"
    topics via group e-mail exchanges. (Note: The listserv was
    discontinued in April 2003 with the launch of the print and
    Web-based outreach campaign.)

-   Mailings (for those Workshop participants who did not have Internet
    access, those who preferred mailings, or those who were not
    subscribed to the Listserv).

-   Other avenues of communication such as postings on NCI's or CDC's
    Web sites.

#### The ^131^I/NTS Communications Development Group

During the ^131^I/NTS Communications Workshop, participants determined
that a structure was needed for continued public participation in the
communication planning process. Workshop participants decided that NCI
should form a working group of concerned citizens and health
professionals to provide guidance to NCI as it developed the plan for
the ^131^I/NTS Communications Project. NCI used the feedback received
during the Workshop to solicit and select eight people to comprise the
Communications Development Group. These individuals represented
activists, Native American groups, minority citizens, local and state
public health departments, physicians and health care providers, and
health educators. This eight-member group provided input and feedback
into the development of the ^131^I/NTS Communications Plan.
Specifically, the group assisted in efforts to:

-   Identify all potential target audiences;

-   Identify the cultural sensitivities of those audiences;

-   Choose appropriate strategies to reach the intended audiences;

-   Develop project message concepts;

-   Identify appropriate delivery channels (e.g., face-to-face, group,
    organizational, community, and media);

-   Identify appropriate information sources (credible persons to
    deliver the information); and

-   Identify appropriate materials to use.

#### ^131^I/NTS Communications Project Outreach and Dissemination 

In December 2002, the NCI released communication materials for the
Project, developed with extensive input from advocacy groups, community
representatives, and health officials, as well as extensive focus group
testing. Materials included:

-   **Get the Facts About Exposure to I-131 Radiation\--**This general
    information brochure provides information about the Nevada tests and
    identifies individuals at particular risk.

-   **Making Choices: Screening for Thyroid Disease\--**This
    decision-aid workbook/brochure is for individuals concerned about
    their exposure to ^131^I from fallout (based on decision support
    format of the Ottawa Health Decision Center at the University of
    Ottawa and Ottawa Health Research Institute, Ontario, Canada).

-   **Radioactive Iodine (I-131) and Thyroid Cancer\--**This flip chart,
    designed for use in small groups of up to 10 people, addresses
    concerns specific to Native Americans.

-   I-131 Web site ([www.cancer.gov/i131](http://www.cancer.gov/i131)),
    including tools for partners.

#### The campaign implementation is discussed fully in Appendix I. 

#### Assessing the Effectiveness of the ^131^I/NTS Communications Project

Because there will be a significant time lapse between the
implementation of the ^131^I/NTS Communications Plan and the completion
of in-depth research on exposure to radionuclides from global fallout
and radionuclides other than ^131^I from NTS fallout, sufficient time
exists to evaluate the effectiveness of the ^131^I/NTS Communications
Project. Such an evaluation is necessary to determine if the ^131^I/NTS
Communications Project could actually be used as a model for
communicating the results of other fallout-related scientific research.

A process evaluation should focus on determining the public reaction to
the ^131^I/NTS Communications Project and the degree to which the
original objectives (i.e., determining changes in public awareness, the
"reach" of the project, and the effectiveness of the communication
channels, etc.) were met. Additionally, an outcome evaluation should
assess the appropriateness of any changes in public perceptions and
actions. Any changes discovered from an assessment would be relevant to
the development of a communications plan based on possible future
research described in this report. The structure and content of a
communications plan would also need to take into account the publication
of new research that could potentially change what is known about the
relation between radiation exposure and a health risk or new policies
and programs that change how the risk affects the public. The final
evaluation design and implementation is discussed in Appendix I.

### Audience Profiling and Message Development

Health communication is the crafting and delivery of messages and
strategies, based on consumer research, to promote the health of
individuals and communities. Characteristics of a successful national
public health communication and education effort include (Arkin 1999):

-   Careful planning;

-   Sufficient funding and staffing;

-   Long-term legislative and public support;

-   In-depth audience identification, focus, and involvement;

-   Clearly identified changes and challenges;

-   Multiple dissemination channels, activities, and strategies;

-   Trustworthy spokespersons and credible information sources;

-   Multiple partners; multiple types of evaluation;

-   Evaluation; and

-   Flexibility to be modified as changes are identified.

#### Determining the public's awareness

Before the implementation of any communication effort, the level of
public awareness must be examined and considered. Prior to the January
2000 Communications Workshop, NCI conducted limited research to measure
the level of public awareness, concern, and familiarity with the United
States' nuclear weapons atmospheric tests conducted during the 1950s and
early 1960s at the Nevada Test Site. (See Appendices I.4 and I.5 for a
copy of the reports on the key findings from this market research). This
market research, along with knowledge gained from the implementation of
the ^131^I/NTS Communications Project, will be extremely useful to DHHS
in developing future communication plans to address fallout issues. What
follows is a brief description of the type of research conducted by NCI
and a discussion of the main areas where DHHS would need to conduct
supplemental research.

##### In-depth Interviews with Subject Experts

In the Fall/Winter of 1999, NCI conducted 19 in-depth interviews with
individuals who were identified by agency and public representatives as
having expertise in areas related to the issue of nuclear fallout (see
**Appendix I.4**). The main objective of these qualitative interviews
was to provide NCI with useful and detailed insights into the
perceptions and views of different organizations and experts involved in
the ^131^I fallout issue and, as such, they were not intended to
represent the views of all such groups or persons (NCI 2000a). The
interviews yielded results that have helped NCI determine the direction
and scope of further research for the ^131^I/NTS Communications Project.

##### Public and Physician Focus Groups

In December 1999, NCI conducted six focus groups with three audience
segments, referred to as the "higher-exposure public," the
"lower-exposure public," and "physicians" (see **Appendix I.5**). The
higher-exposure and lower-exposure definitions were extracted from NCI's
1997 report, *Estimated Exposures and Thyroid Doses Received by the
American People from Iodine-131 In Fallout Following Nevada Atmospheric
Nuclear Bomb Tests* (NCI 1997), which outlined the key risk factors for
health effects from ^131^I exposure.

Conducting research with both the higher- and lower-exposed public was
done to obtain an approximate sense of how exposure status might affect
one's awareness, knowledge, and concerns about the NTS and potential
health effects from ^131^I exposure. Physicians were defined as general
practitioners, family physicians, or general internists who had been
practicing medicine for at least 3 years in a high-exposure state (NCI,
2000b).

##### Focus Group Research

NCI conducted twelve additional focus groups consisting of four groups
in each of the following regions: Chicago, Illinois; Tulsa, Oklahoma;
and Denver, Colorado. These locations were selected based on geographic
diversity and the ability to recruit lower-exposed as well as
higher-exposed individuals. NCI conducted the groups with lower-exposed
and higher-exposed African-Americans, Caucasians, Hispanics, and Native
Americans. Determination of higher-exposure was based on age (birth-15)
and state of residency during the testing years. These additional focus
groups were conducted to test messages and concepts for the development
of educational materials about ^131^I exposure from NTS. NCI is
currently summarizing the focus group findings in a report that will
help identify which messages and concepts resonate with the public.

#### Additional Research Needed for Expanded Communication Efforts

Development and testing would also be necessary for the expanded
communication efforts outlined in this feasibility report --
specifically, communicating dose and risk information for radionuclides
from global testing and from radionuclides other than ^131^I in fallout
from the NTS. This research should help identify the outstanding issues
the public may have as they begin to absorb and understand "the big
picture" of the potential health consequences associated with
atmospheric nuclear weapons testing.

Qualitative and quantitative research would need to be conducted to
collect information about the concepts, messages, channels, activities,
materials, and strategies appropriate for a far-reaching and large-scale
communications and education campaign on the health consequences of
fallout from nuclear testing (see **Appendix I.6** for a description of
the types of "tools of research" that could be used). Research methods
should be selected to augment research collected by NCI for the
^131^I/NTS Communications Project. The following section discusses the
main areas where further formative research should be conducted.

#### Defining Target Audiences

There is no uniform "general public," but rather numerous smaller,
sometimes intersecting groups of individuals sharing common concerns,
interests, perspectives, or demographic characteristics (Arkin 1999).
The consumer research NCI has conducted for its ^131^I/NTS
Communications Project provides a good sense of the target population
groups for ^131^I dose and risk information related to nuclear weapons
testing at the NTS. However, as the list of radionuclides and potential
health consequences expands, more research would need to be conducted in
this area to segment the target population groups into main audiences,
then select and profile these target audiences (see Figure 5.1). These
audience profiles would be used to help frame messages -- providing DHHS
with the information to address audience-specific needs and issues.

![](media/image1.wmf){width="3.6819444444444445in"
height="1.5277777777777777in"}

Figure 5.1 Selecting Target Audiences.

It would also be necessary to profile and link with the proposed
communications campaign's secondary audience(s). Secondary audience
refers specifically to the audience(s) that can also benefit the
campaign by reaching and influencing primary target audiences (e.g.,
health care providers, grassroots organizations, etc.) (CDC 1998).

In the ^131^I/NTS Communications Project, exposure information on ^131^I
fallout from the NTS was utilized from NCI's 1997 report. Specifically,
it was used to define potentially higher- and lower-exposed populations
based on geographic residence and age. With this information in hand,
NCI has designed educational messages that address both higher and lower
^131^I/NTS exposed populations based on the focus group findings.

Because dose and risk information on radionuclides from global testing
sources and other radionuclides from NTS are not yet fully quantified,
work to further identify audiences cannot yet occur. The dose and risk
estimates, with accompanying uncertainty, that would result from more
in-depth research than has occurred in this feasibility study, would
more clearly identify the subgroups of the general population that may
have received higher exposures and be most at risk. When available,
these results would help the Federal government explain to subgroups of
the American public how the potential public health impact of ^131^I
fallout from the NTS and from global fallout compares with that of the
other biologically significant radionuclides in fallout as well as other
health threats.

To date, the broad target population groups already defined through
research and stakeholder input include:

-   The United States population;

-   Native American populations;

-   People at higher risk -- those who meet research-identified factors
    for higher exposure and risk (e.g., lived in high-fallout areas
    during testing years, were children during time of testing, drank or
    ate certain foods, etc.);

-   People at lower risk -- those who meet research-identified factors
    for lower exposure and risk (e.g., born after cessation of testing;
    did not eat or drink foods of concern, etc.);

-   People who worked at, lived adjacent to, or currently live adjacent
    to the NTS or a United States nuclear weapons production facility;

-   People who are concerned about potential risk from multiple
    radiation sources;

-   Mobile populations (e.g., migrants and farm workers);

-   Family and friends of those potentially at high risk;

-   Health care providers in areas determined to have had high fallout;

-   Health care providers in areas determined to have had low fallout;

-   State and local health departments;

-   Public health and medical organizations;

-   State and local elected officials;

-   Environmental health advocates and professional and citizen-based
    associations/organizations;

-   Other federal agencies; and

-   Media.

As stated, the target population groups listed here represent a broad
sweep of the work conducted to date for the ^131^I/NTS Communications
Project. Table 5.1 illustrates some broad assumptions made by
participants of the ^131^I/NTS Communications Workshop regarding target
population groups, the potential information needs and perceptions of
those groups, and potential communications channels and activities.
These general assumptions could be used as starting points to define and
select target audiences and their subgroups.

#### Developing Messages

Work on the ^131^I/NTS Communications Project has revealed broad and
basic assumptions and information about the target population groups
already identified (see Table 5.1, second column). These broad
assumptions could serve as a rudimentary guide in developing messages
for work relating to global fallout and other radionuclides contained in
NTS fallout. In addition, the following discussion highlights some of
the challenges and issues to consider when developing messages for a
fallout-related communications and education campaign.

Table 5.1. Broad Target Population Groups, Assumptions and Potential
Communications Channels and Activities

+------------------+---+---+---------------------------------+---+---+-----------------+
| **Target         | * |   |                                 | * |   |                 |
| Population       | * |   |                                 | * |   |                 |
| Groups \***      | B |   |                                 | P |   |                 |
|                  | r |   |                                 | o |   |                 |
|                  | o |   |                                 | t |   |                 |
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|                  | i |   |                                 | m |   |                 |
|                  | o |   |                                 | u |   |                 |
|                  | n |   |                                 | n |   |                 |
|                  | s |   |                                 | i |   |                 |
|                  | * |   |                                 | c |   |                 |
|                  | * |   |                                 | a |   |                 |
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|                  |   |   |                                 | v |   |                 |
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|                  |   |   |                                 | s |   |                 |
|                  |   |   |                                 | * |   |                 |
|                  |   |   |                                 | * |   |                 |
+==================+===+===+=================================+===+===+=================+
| The United       | ( |   |                                 | N |   |                 |
| States           | L |   |                                 | a |   |                 |
| Population       | a |   |                                 | t |   |                 |
|                  | r |   |                                 | i |   |                 |
| (National plan   | g |   |                                 | o |   |                 |
| to educate       | e |   |                                 | n |   |                 |
| American public  | p |   |                                 | a |   |                 |
| on history of    | o |   |                                 | l |   |                 |
| the United       | r |   |                                 | m |   |                 |
| States nuclear   | t |   |                                 | a |   |                 |
| weapons program, | i |   |                                 | s |   |                 |
| global testing   | o |   |                                 | s |   |                 |
| and current      | n |   |                                 | m |   |                 |
| knowledge about  | o |   |                                 | e |   |                 |
| the potential    | f |   |                                 | d |   |                 |
| health           | p |   |                                 | i |   |                 |
| consequences of  | o |   |                                 | a |   |                 |
| this legacy, and | p |   |                                 | • |   |                 |
| to increase      | u |   |                                 | T |   |                 |
| overall national | l |   |                                 | a |   |                 |
| "awareness" of   | a |   |                                 | r |   |                 |
| current issues)  | t |   |                                 | g |   |                 |
|                  | i |   |                                 | e |   |                 |
|                  | o |   |                                 | t |   |                 |
|                  | n |   |                                 | e |   |                 |
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|                  | m |   |                                 |   |   |                 |
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|                  | n |   |                                 |   |   |                 |
|                  | t |   |                                 |   |   |                 |
|                  | • |   |                                 |   |   |                 |
|                  | I |   |                                 |   |   |                 |
|                  | n |   |                                 |   |   |                 |
|                  | f |   |                                 |   |   |                 |
|                  | o |   |                                 |   |   |                 |
|                  | r |   |                                 |   |   |                 |
|                  | m |   |                                 |   |   |                 |
|                  | a |   |                                 |   |   |                 |
|                  | t |   |                                 |   |   |                 |
|                  | i |   |                                 |   |   |                 |
|                  | o |   |                                 |   |   |                 |
|                  | n |   |                                 |   |   |                 |
|                  | o |   |                                 |   |   |                 |
|                  | n |   |                                 |   |   |                 |
|                  | o |   |                                 |   |   |                 |
|                  | n |   |                                 |   |   |                 |
|                  | g |   |                                 |   |   |                 |
|                  | o |   |                                 |   |   |                 |
|                  | i |   |                                 |   |   |                 |
|                  | n |   |                                 |   |   |                 |
|                  | g |   |                                 |   |   |                 |
|                  | w |   |                                 |   |   |                 |
|                  | o |   |                                 |   |   |                 |
|                  | r |   |                                 |   |   |                 |
|                  | k |   |                                 |   |   |                 |
|                  | t |   |                                 |   |   |                 |
|                  | o |   |                                 |   |   |                 |
|                  | a |   |                                 |   |   |                 |
|                  | d |   |                                 |   |   |                 |
|                  | d |   |                                 |   |   |                 |
|                  | r |   |                                 |   |   |                 |
|                  | e |   |                                 |   |   |                 |
|                  | s |   |                                 |   |   |                 |
|                  | s |   |                                 |   |   |                 |
|                  | o |   |                                 |   |   |                 |
|                  | u |   |                                 |   |   |                 |
|                  | t |   |                                 |   |   |                 |
|                  | s |   |                                 |   |   |                 |
|                  | t |   |                                 |   |   |                 |
|                  | a |   |                                 |   |   |                 |
|                  | n |   |                                 |   |   |                 |
|                  | d |   |                                 |   |   |                 |
|                  | i |   |                                 |   |   |                 |
|                  | n |   |                                 |   |   |                 |
|                  | g |   |                                 |   |   |                 |
|                  | p |   |                                 |   |   |                 |
|                  | u |   |                                 |   |   |                 |
|                  | b |   |                                 |   |   |                 |
|                  | l |   |                                 |   |   |                 |
|                  | i |   |                                 |   |   |                 |
|                  | c |   |                                 |   |   |                 |
|                  | c |   |                                 |   |   |                 |
|                  | o |   |                                 |   |   |                 |
|                  | n |   |                                 |   |   |                 |
|                  | c |   |                                 |   |   |                 |
|                  | e |   |                                 |   |   |                 |
|                  | r |   |                                 |   |   |                 |
|                  | n |   |                                 |   |   |                 |
|                  | s |   |                                 |   |   |                 |
|                  | a |   |                                 |   |   |                 |
|                  | n |   |                                 |   |   |                 |
|                  | d |   |                                 |   |   |                 |
|                  | i |   |                                 |   |   |                 |
|                  | s |   |                                 |   |   |                 |
|                  | s |   |                                 |   |   |                 |
|                  | u |   |                                 |   |   |                 |
|                  | e |   |                                 |   |   |                 |
|                  | s |   |                                 |   |   |                 |
|                  | • |   |                                 |   |   |                 |
|                  | C |   |                                 |   |   |                 |
|                  | a |   |                                 |   |   |                 |
|                  | m |   |                                 |   |   |                 |
|                  | p |   |                                 |   |   |                 |
|                  | a |   |                                 |   |   |                 |
|                  | i |   |                                 |   |   |                 |
|                  | g |   |                                 |   |   |                 |
|                  | n |   |                                 |   |   |                 |
|                  | k |   |                                 |   |   |                 |
|                  | i |   |                                 |   |   |                 |
|                  | c |   |                                 |   |   |                 |
|                  | k |   |                                 |   |   |                 |
|                  | o |   |                                 |   |   |                 |
|                  | f |   |                                 |   |   |                 |
|                  | f |   |                                 |   |   |                 |
|                  | m |   |                                 |   |   |                 |
|                  | e |   |                                 |   |   |                 |
|                  | s |   |                                 |   |   |                 |
|                  | s |   |                                 |   |   |                 |
|                  | a |   |                                 |   |   |                 |
|                  | g |   |                                 |   |   |                 |
|                  | e |   |                                 |   |   |                 |
|                  | s |   |                                 |   |   |                 |
|                  | a |   |                                 |   |   |                 |
|                  | n |   |                                 |   |   |                 |
|                  | d |   |                                 |   |   |                 |
|                  | m |   |                                 |   |   |                 |
|                  | a |   |                                 |   |   |                 |
|                  | t |   |                                 |   |   |                 |
|                  | e |   |                                 |   |   |                 |
|                  | r |   |                                 |   |   |                 |
|                  | i |   |                                 |   |   |                 |
|                  | a |   |                                 |   |   |                 |
|                  | l |   |                                 |   |   |                 |
|                  | s |   |                                 |   |   |                 |
|                  | s |   |                                 |   |   |                 |
|                  | h |   |                                 |   |   |                 |
|                  | o |   |                                 |   |   |                 |
|                  | u |   |                                 |   |   |                 |
|                  | l |   |                                 |   |   |                 |
|                  | d |   |                                 |   |   |                 |
|                  | b |   |                                 |   |   |                 |
|                  | e |   |                                 |   |   |                 |
|                  | p |   |                                 |   |   |                 |
|                  | r |   |                                 |   |   |                 |
|                  | o |   |                                 |   |   |                 |
|                  | v |   |                                 |   |   |                 |
|                  | i |   |                                 |   |   |                 |
|                  | d |   |                                 |   |   |                 |
|                  | e |   |                                 |   |   |                 |
|                  | d |   |                                 |   |   |                 |
|                  | a |   |                                 |   |   |                 |
|                  | t |   |                                 |   |   |                 |
|                  | l |   |                                 |   |   |                 |
|                  | e |   |                                 |   |   |                 |
|                  | a |   |                                 |   |   |                 |
|                  | s |   |                                 |   |   |                 |
|                  | t |   |                                 |   |   |                 |
|                  | i |   |                                 |   |   |                 |
|                  | n |   |                                 |   |   |                 |
|                  | o |   |                                 |   |   |                 |
|                  | n |   |                                 |   |   |                 |
|                  | e |   |                                 |   |   |                 |
|                  | o |   |                                 |   |   |                 |
|                  | t |   |                                 |   |   |                 |
|                  | h |   |                                 |   |   |                 |
|                  | e |   |                                 |   |   |                 |
|                  | r |   |                                 |   |   |                 |
|                  | l |   |                                 |   |   |                 |
|                  | a |   |                                 |   |   |                 |
|                  | n |   |                                 |   |   |                 |
|                  | g |   |                                 |   |   |                 |
|                  | u |   |                                 |   |   |                 |
|                  | a |   |                                 |   |   |                 |
|                  | g |   |                                 |   |   |                 |
|                  | e |   |                                 |   |   |                 |
|                  | a |   |                                 |   |   |                 |
|                  | n |   |                                 |   |   |                 |
|                  | d |   |                                 |   |   |                 |
|                  | f |   |                                 |   |   |                 |
|                  | o |   |                                 |   |   |                 |
|                  | r |   |                                 |   |   |                 |
|                  | l |   |                                 |   |   |                 |
|                  | o |   |                                 |   |   |                 |
|                  | w |   |                                 |   |   |                 |
|                  | - |   |                                 |   |   |                 |
|                  | l |   |                                 |   |   |                 |
|                  | i |   |                                 |   |   |                 |
|                  | t |   |                                 |   |   |                 |
|                  | e |   |                                 |   |   |                 |
|                  | r |   |                                 |   |   |                 |
|                  | a |   |                                 |   |   |                 |
|                  | c |   |                                 |   |   |                 |
|                  | y |   |                                 |   |   |                 |
|                  | a |   |                                 |   |   |                 |
|                  | u |   |                                 |   |   |                 |
|                  | d |   |                                 |   |   |                 |
|                  | i |   |                                 |   |   |                 |
|                  | e |   |                                 |   |   |                 |
|                  | n |   |                                 |   |   |                 |
|                  | c |   |                                 |   |   |                 |
|                  | e |   |                                 |   |   |                 |
|                  | s |   |                                 |   |   |                 |
+------------------+---+---+---------------------------------+---+---+-----------------+
| Native-American  | ( |   |                                 | M |   |                 |
| Tribes           | W |   |                                 | a |   |                 |
|                  | o |   |                                 | s |   |                 |
|                  | u |   |                                 | s |   |                 |
|                  | l |   |                                 | m |   |                 |
|                  | d |   |                                 | e |   |                 |
|                  | b |   |                                 | d |   |                 |
|                  | e |   |                                 | i |   |                 |
|                  | t |   |                                 | a |   |                 |
|                  | a |   |                                 | i |   |                 |
|                  | r |   |                                 | s |   |                 |
|                  | g |   |                                 | n |   |                 |
|                  | e |   |                                 | o |   |                 |
|                  | t |   |                                 | t |   |                 |
|                  | e |   |                                 | p |   |                 |
|                  | d |   |                                 | r |   |                 |
|                  | s |   |                                 | i |   |                 |
|                  | i |   |                                 | m |   |                 |
|                  | m |   |                                 | a |   |                 |
|                  | u |   |                                 | r |   |                 |
|                  | l |   |                                 | y |   |                 |
|                  | t |   |                                 | c |   |                 |
|                  | a |   |                                 | o |   |                 |
|                  | n |   |                                 | m |   |                 |
|                  | e |   |                                 | m |   |                 |
|                  | o |   |                                 | u |   |                 |
|                  | u |   |                                 | n |   |                 |
|                  | s |   |                                 | i |   |                 |
|                  | l |   |                                 | c |   |                 |
|                  | y |   |                                 | a |   |                 |
|                  | o |   |                                 | t |   |                 |
|                  | r |   |                                 | i |   |                 |
|                  | s |   |                                 | o |   |                 |
|                  | o |   |                                 | n |   |                 |
|                  | o |   |                                 | c |   |                 |
|                  | n |   |                                 | h |   |                 |
|                  | a |   |                                 | a |   |                 |
|                  | f |   |                                 | n |   |                 |
|                  | t |   |                                 | n |   |                 |
|                  | e |   |                                 | e |   |                 |
|                  | r |   |                                 | l |   |                 |
|                  | m |   |                                 | , |   |                 |
|                  | a |   |                                 | i |   |                 |
|                  | i |   |                                 | n |   |                 |
|                  | n |   |                                 | t |   |                 |
|                  | c |   |                                 | r |   |                 |
|                  | a |   |                                 | a |   |                 |
|                  | m |   |                                 | / |   |                 |
|                  | p |   |                                 | i |   |                 |
|                  | a |   |                                 | n |   |                 |
|                  | i |   |                                 | t |   |                 |
|                  | g |   |                                 | e |   |                 |
|                  | n |   |                                 | r |   |                 |
|                  | k |   |                                 | t |   |                 |
|                  | i |   |                                 | r |   |                 |
|                  | c |   |                                 | i |   |                 |
|                  | k |   |                                 | b |   |                 |
|                  | o |   |                                 | a |   |                 |
|                  | f |   |                                 | l |   |                 |
|                  | f |   |                                 | i |   |                 |
|                  | ) |   |                                 | s |   |                 |
|                  |   |   |                                 | b |   |                 |
|                  | S |   |                                 | e |   |                 |
|                  | a |   |                                 | s |   |                 |
|                  | m |   |                                 | t |   |                 |
|                  | e |   |                                 | • |   |                 |
|                  | a |   |                                 | A |   |                 |
|                  | s |   |                                 | s |   |                 |
|                  | " |   |                                 | s |   |                 |
|                  | U |   |                                 | o |   |                 |
|                  | n |   |                                 | v |   |                 |
|                  | i |   |                                 | e |   |                 |
|                  | t |   |                                 | r |   |                 |
|                  | e |   |                                 | e |   |                 |
|                  | d |   |                                 | i |   |                 |
|                  | S |   |                                 | g |   |                 |
|                  | t |   |                                 | n |   |                 |
|                  | a |   |                                 | n |   |                 |
|                  | t |   |                                 | a |   |                 |
|                  | e |   |                                 | t |   |                 |
|                  | s |   |                                 | i |   |                 |
|                  | P |   |                                 | o |   |                 |
|                  | o |   |                                 | n |   |                 |
|                  | p |   |                                 | s |   |                 |
|                  | u |   |                                 | , |   |                 |
|                  | l |   |                                 | w |   |                 |
|                  | a |   |                                 | a |   |                 |
|                  | t |   |                                 | n |   |                 |
|                  | i |   |                                 | t |   |                 |
|                  | o |   |                                 | c |   |                 |
|                  | n |   |                                 | o |   |                 |
|                  | " |   |                                 | n |   |                 |
|                  |   |   |                                 | t |   |                 |
|                  | P |   |                                 | r |   |                 |
|                  | l |   |                                 | o |   |                 |
|                  | u |   |                                 | l |   |                 |
|                  | s |   |                                 | o |   |                 |
|                  | : |   |                                 | f |   |                 |
|                  | F |   |                                 | i |   |                 |
|                  | e |   |                                 | n |   |                 |
|                  | e |   |                                 | f |   |                 |
|                  | l |   |                                 | o |   |                 |
|                  | g |   |                                 | r |   |                 |
|                  | o |   |                                 | m |   |                 |
|                  | v |   |                                 | a |   |                 |
|                  | e |   |                                 | t |   |                 |
|                  | r |   |                                 | i |   |                 |
|                  | n |   |                                 | o |   |                 |
|                  | m |   |                                 | n |   |                 |
|                  | e |   |                                 | d |   |                 |
|                  | n |   |                                 | i |   |                 |
|                  | t |   |                                 | s |   |                 |
|                  | i |   |                                 | s |   |                 |
|                  | s |   |                                 | e |   |                 |
|                  | n |   |                                 | m |   |                 |
|                  | o |   |                                 | i |   |                 |
|                  | t |   |                                 | n |   |                 |
|                  | m |   |                                 | a |   |                 |
|                  | e |   |                                 | t |   |                 |
|                  | e |   |                                 | i |   |                 |
|                  | t |   |                                 | o |   |                 |
|                  | i |   |                                 | n |   |                 |
|                  | n |   |                                 | a |   |                 |
|                  | g |   |                                 | n |   |                 |
|                  | a |   |                                 | d |   |                 |
|                  | l |   |                                 | o |   |                 |
|                  | l |   |                                 | u |   |                 |
|                  | d |   |                                 | t |   |                 |
|                  | e |   |                                 | r |   |                 |
|                  | s |   |                                 | e |   |                 |
|                  | i |   |                                 | a |   |                 |
|                  | r |   |                                 | c |   |                 |
|                  | e |   |                                 | h |   |                 |
|                  | s |   |                                 | • |   |                 |
|                  | / |   |                                 | N |   |                 |
|                  | g |   |                                 | o |   |                 |
|                  | o |   |                                 | n |   |                 |
|                  | v |   |                                 | t |   |                 |
|                  | e |   |                                 | r |   |                 |
|                  | r |   |                                 | a |   |                 |
|                  | n |   |                                 | d |   |                 |
|                  | m |   |                                 | i |   |                 |
|                  | e |   |                                 | t |   |                 |
|                  | n |   |                                 | i |   |                 |
|                  | t |   |                                 | o |   |                 |
|                  | e |   |                                 | n |   |                 |
|                  | f |   |                                 | a |   |                 |
|                  | f |   |                                 | l |   |                 |
|                  | o |   |                                 | m |   |                 |
|                  | r |   |                                 | e |   |                 |
|                  | t |   |                                 | d |   |                 |
|                  | s |   |                                 | i |   |                 |
|                  | a |   |                                 | a |   |                 |
|                  | r |   |                                 | a |   |                 |
|                  | e |   |                                 | n |   |                 |
|                  | l |   |                                 | d |   |                 |
|                  | i |   |                                 | i |   |                 |
|                  | k |   |                                 | n |   |                 |
|                  | e |   |                                 | t |   |                 |
|                  | l |   |                                 | e |   |                 |
|                  | y |   |                                 | r |   |                 |
|                  | t |   |                                 | p |   |                 |
|                  | o |   |                                 | e |   |                 |
|                  | d |   |                                 | r |   |                 |
|                  | i |   |                                 | s |   |                 |
|                  | s |   |                                 | o |   |                 |
|                  | a |   |                                 | n |   |                 |
|                  | p |   |                                 | a |   |                 |
|                  | p |   |                                 | l |   |                 |
|                  | o |   |                                 | c |   |                 |
|                  | i |   |                                 | o |   |                 |
|                  | n |   |                                 | m |   |                 |
|                  | t |   |                                 | m |   |                 |
|                  | • |   |                                 | u |   |                 |
|                  | B |   |                                 | n |   |                 |
|                  | e |   |                                 | i |   |                 |
|                  | l |   |                                 | c |   |                 |
|                  | i |   |                                 | a |   |                 |
|                  | e |   |                                 | t |   |                 |
|                  | v |   |                                 | i |   |                 |
|                  | e |   |                                 | o |   |                 |
|                  | t |   |                                 | n |   |                 |
|                  | h |   |                                 | s |   |                 |
|                  | a |   |                                 | • |   |                 |
|                  | t |   |                                 | U |   |                 |
|                  | c |   |                                 | s |   |                 |
|                  | u |   |                                 | e |   |                 |
|                  | l |   |                                 | t |   |                 |
|                  | t |   |                                 | r |   |                 |
|                  | u |   |                                 | i |   |                 |
|                  | r |   |                                 | b |   |                 |
|                  | a |   |                                 | a |   |                 |
|                  | l |   |                                 | l |   |                 |
|                  | d |   |                                 | l |   |                 |
|                  | i |   |                                 | e |   |                 |
|                  | f |   |                                 | a |   |                 |
|                  | f |   |                                 | d |   |                 |
|                  | e |   |                                 | e |   |                 |
|                  | r |   |                                 | r |   |                 |
|                  | e |   |                                 | s |   |                 |
|                  | n |   |                                 | a |   |                 |
|                  | c |   |                                 | n |   |                 |
|                  | e |   |                                 | d |   |                 |
|                  | s |   |                                 | e |   |                 |
|                  | n |   |                                 | x |   |                 |
|                  | e |   |                                 | i |   |                 |
|                  | v |   |                                 | s |   |                 |
|                  | e |   |                                 | t |   |                 |
|                  | r |   |                                 | i |   |                 |
|                  | a |   |                                 | n |   |                 |
|                  | c |   |                                 | g |   |                 |
|                  | c |   |                                 | n |   |                 |
|                  | o |   |                                 | e |   |                 |
|                  | u |   |                                 | t |   |                 |
|                  | n |   |                                 | w |   |                 |
|                  | t |   |                                 | o |   |                 |
|                  | e |   |                                 | r |   |                 |
|                  | d |   |                                 | k |   |                 |
|                  | f |   |                                 | s |   |                 |
|                  | o |   |                                 | , |   |                 |
|                  | r |   |                                 | s |   |                 |
|                  | i |   |                                 | u |   |                 |
|                  | n |   |                                 | c |   |                 |
|                  | f |   |                                 | h |   |                 |
|                  | o |   |                                 | a |   |                 |
|                  | r |   |                                 | s |   |                 |
|                  | m |   |                                 | t |   |                 |
|                  | u |   |                                 | r |   |                 |
|                  | l |   |                                 | i |   |                 |
|                  | a |   |                                 | b |   |                 |
|                  | s |   |                                 | a |   |                 |
|                  | ( |   |                                 | l |   |                 |
|                  | s |   |                                 | a |   |                 |
|                  | c |   |                                 | d |   |                 |
|                  | i |   |                                 | v |   |                 |
|                  | e |   |                                 | o |   |                 |
|                  | n |   |                                 | c |   |                 |
|                  | t |   |                                 | a |   |                 |
|                  | i |   |                                 | c |   |                 |
|                  | f |   |                                 | y |   |                 |
|                  | i |   |                                 | a |   |                 |
|                  | c |   |                                 | n |   |                 |
|                  | , |   |                                 | d |   |                 |
|                  | c |   |                                 | g |   |                 |
|                  | o |   |                                 | r |   |                 |
|                  | m |   |                                 | a |   |                 |
|                  | m |   |                                 | s |   |                 |
|                  | u |   |                                 | s |   |                 |
|                  | n |   |                                 | r |   |                 |
|                  | i |   |                                 | o |   |                 |
|                  | c |   |                                 | o |   |                 |
|                  | a |   |                                 | t |   |                 |
|                  | t |   |                                 | s |   |                 |
|                  | i |   |                                 | e |   |                 |
|                  | o |   |                                 | n |   |                 |
|                  | n |   |                                 | v |   |                 |
|                  | , |   |                                 | i |   |                 |
|                  | e |   |                                 | r |   |                 |
|                  | t |   |                                 | o |   |                 |
|                  | c |   |                                 | n |   |                 |
|                  | . |   |                                 | m |   |                 |
|                  | ) |   |                                 | e |   |                 |
|                  | • |   |                                 | n |   |                 |
|                  | M |   |                                 | t |   |                 |
|                  | a |   |                                 | a |   |                 |
|                  | y |   |                                 | l |   |                 |
|                  | w |   |                                 | o |   |                 |
|                  | a |   |                                 | r |   |                 |
|                  | n |   |                                 | g |   |                 |
|                  | t |   |                                 | a |   |                 |
|                  | d |   |                                 | n |   |                 |
|                  | o |   |                                 | i |   |                 |
|                  | s |   |                                 | z |   |                 |
|                  | e |   |                                 | a |   |                 |
|                  | i |   |                                 | t |   |                 |
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|                  | s |   |                                 |   |   |                 |
+------------------+---+---+---------------------------------+---+---+-----------------+
| People at high   |   |   | (Would be targeted              |   |   | \[Still         |
| risk             |   |   | simultaneously or after         |   |   | geographically  |
|                  |   |   | campaign kickoff -- many would  |   |   | widespread\]    |
| Those            |   |   | "self-identify" through         |   |   |                 |
| characterized by |   |   | education on risk factors for   |   |   | Targeted and    |
| **factors that   |   |   | disease learned through         |   |   | strategic local |
| increased their  |   |   | campaign kickoff messages and   |   |   | media • State   |
| likelihood of    |   |   | materials)                      |   |   | and local       |
| exposure and     |   |   |                                 |   |   | health          |
| subsequent       |   |   | Potentially could need:         |   |   | departments •   |
| disease risk**,  |   |   | Detailed information on risk    |   |   | Regional and    |
| such as;         |   |   | factors for disease for         |   |   | local health    |
| geographic       |   |   | exposure to each radionuclide   |   |   | care providers  |
| location, age    |   |   | of concern • Information to     |   |   | • State and     |
| and diet during  |   |   | answer questions related to     |   |   | local medical   |
| testing period.  |   |   | potential multiple exposures •  |   |   | institutions    |
|                  |   |   | Assurances that health care     |   |   | and health      |
|                  |   |   | providers are getting same      |   |   | clinics •       |
|                  |   |   | information • Information on    |   |   | Internet •      |
|                  |   |   | what to do next, including what |   |   | State and local |
|                  |   |   | to do if health care is not     |   |   | advocacy groups |
|                  |   |   | available • May want more than  |   |   | and grassroots  |
|                  |   |   | studies can deliver (i.e.,      |   |   | organizations • |
|                  |   |   | comprehensive care, long-term   |   |   | Library         |
|                  |   |   | support, compensation) •        |   |   | resource        |
|                  |   |   | Government efforts are likely   |   |   | centers •       |
|                  |   |   | to disappoint • Information     |   |   | Industry trade  |
|                  |   |   | that addresses multiple         |   |   | associations •  |
|                  |   |   | literacy levels, languages,     |   |   | Veterans        |
|                  |   |   | etc. • Many would be outraged   |   |   | associations •  |
|                  |   |   | at past perceived government    |   |   | Toll-free       |
|                  |   |   | secrecy and actions • Need      |   |   | telephone       |
|                  |   |   | government acknowledgement of   |   |   | systems •       |
|                  |   |   | involuntary risk • Concerned    |   |   | Internet •      |
|                  |   |   | with physical impact of         |   |   | Community and   |
|                  |   |   | exposure and psychological      |   |   | business health |
|                  |   |   | stress from exposure •          |   |   | fairs           |
|                  |   |   | Information on national,        |   |   |                 |
|                  |   |   | regional, state and local       |   |   |                 |
|                  |   |   | support networks • Some         |   |   |                 |
|                  |   |   | percentage of population would  |   |   |                 |
|                  |   |   | be outraged at expenditure of   |   |   |                 |
|                  |   |   | Federal public health funds     |   |   |                 |
+------------------+---+---+---------------------------------+---+---+-----------------+
| People at LOW    |   | ( |                                 |   | M |                 |
| RISK             |   | M |                                 |   | a |                 |
|                  |   | a |                                 |   | i |                 |
| Those who are    |   | n |                                 |   | n |                 |
| NOT              |   | y |                                 |   | m |                 |
| characterized by |   | w |                                 |   | e |                 |
| factors that     |   | o |                                 |   | s |                 |
| **increased**    |   | u |                                 |   | s |                 |
| their likelihood |   | l |                                 |   | a |                 |
| of exposure and  |   | d |                                 |   | g |                 |
| subsequent       |   | " |                                 |   | e |                 |
| disease risk,    |   | s |                                 |   | s |                 |
| such as          |   | e |                                 |   | r |                 |
| geographic       |   | l |                                 |   | e |                 |
| location, age,   |   | f |                                 |   | c |                 |
| and diet during  |   | - |                                 |   | e |                 |
| testing period.  |   | i |                                 |   | i |                 |
|                  |   | d |                                 |   | v |                 |
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|                  |   | r |                                 |   |   |                 |
|                  |   | n |                                 |   |   |                 |
|                  |   | m |                                 |   |   |                 |
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|                  |   | n |                                 |   |   |                 |
|                  |   | t |                                 |   |   |                 |
|                  |   | s |                                 |   |   |                 |
|                  |   | e |                                 |   |   |                 |
|                  |   | c |                                 |   |   |                 |
|                  |   | r |                                 |   |   |                 |
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|                  |   | c |                                 |   |   |                 |
|                  |   | y |                                 |   |   |                 |
|                  |   | a |                                 |   |   |                 |
|                  |   | n |                                 |   |   |                 |
|                  |   | d |                                 |   |   |                 |
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|                  |   | o |                                 |   |   |                 |
|                  |   | n |                                 |   |   |                 |
|                  |   | s |                                 |   |   |                 |
+------------------+---+---+---------------------------------+---+---+-----------------+
| People who       |   | S |                                 |   | S |                 |
| worked at, lived |   | a |                                 |   | a |                 |
| adjacent to, or  |   | m |                                 |   | m |                 |
| currently live   |   | e |                                 |   | e |                 |
| adjacent to the  |   | a |                                 |   | a |                 |
| NTS or a United  |   | s |                                 |   | s |                 |
| States nuclear   |   | " |                                 |   | " |                 |
| weapons          |   | P |                                 |   | P |                 |
| production       |   | e |                                 |   | e |                 |
| facility         |   | o |                                 |   | o |                 |
|                  |   | p |                                 |   | p |                 |
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|                  |   | o |                                 |   |   |                 |
|                  |   | g |                                 |   |   |                 |
|                  |   | r |                                 |   |   |                 |
|                  |   | a |                                 |   |   |                 |
|                  |   | m |                                 |   |   |                 |
|                  |   | s |                                 |   |   |                 |
|                  |   | , |                                 |   |   |                 |
|                  |   | w |                                 |   |   |                 |
|                  |   | h |                                 |   |   |                 |
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|                  |   | r |                                 |   |   |                 |
|                  |   | e |                                 |   |   |                 |
|                  |   | a |                                 |   |   |                 |
|                  |   | p |                                 |   |   |                 |
|                  |   | p |                                 |   |   |                 |
|                  |   | l |                                 |   |   |                 |
|                  |   | i |                                 |   |   |                 |
|                  |   | c |                                 |   |   |                 |
|                  |   | a |                                 |   |   |                 |
|                  |   | b |                                 |   |   |                 |
|                  |   | l |                                 |   |   |                 |
|                  |   | e |                                 |   |   |                 |
+------------------+---+---+---------------------------------+---+---+-----------------+
| People who are   |   | S |                                 |   | S |                 |
| concerned about  |   | a |                                 |   | a |                 |
| potential risk   |   | m |                                 |   | m |                 |
| from multiple    |   | e |                                 |   | e |                 |
| radiation        |   | a |                                 |   | a |                 |
| sources          |   | s |                                 |   | s |                 |
|                  |   | " |                                 |   | " |                 |
|                  |   | P |                                 |   | P |                 |
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|                  |   | t |                                 |   | t |                 |
|                  |   | H |                                 |   | H |                 |
|                  |   | i |                                 |   | i |                 |
|                  |   | g |                                 |   | g |                 |
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|                  |   | R |                                 |   | R |                 |
|                  |   | i |                                 |   | i |                 |
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|                  |   | k |                                 |   | k |                 |
|                  |   | " |                                 |   | " |                 |
|                  |   |   |                                 |   |   |                 |
|                  |   | P |                                 |   | P |                 |
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|                  |   | s |                                 |   | s |                 |
|                  |   | : |                                 |   | : |                 |
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|                  |   | n |                                 |   |   |                 |
+------------------+---+---+---------------------------------+---+---+-----------------+
| Family and       |   | S |                                 |   | S |                 |
| friends of those |   | a |                                 |   | a |                 |
| potentially at   |   | m |                                 |   | m |                 |
| high risk        |   | e |                                 |   | e |                 |
|                  |   | a |                                 |   | a |                 |
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|                  |   | : |                                 |   |   |                 |
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|                  |   | t |                                 |   |   |                 |
|                  |   | w |                                 |   |   |                 |
|                  |   | o |                                 |   |   |                 |
|                  |   | r |                                 |   |   |                 |
|                  |   | k |                                 |   |   |                 |
|                  |   | s |                                 |   |   |                 |
+------------------+---+---+---------------------------------+---+---+-----------------+
| Mobile           |   |   | Same as "United States          |   |   | Non-traditional |
| populations      |   |   | Population"                     |   |   | media and       |
|                  |   |   |                                 |   |   | interpersonal   |
| *(e.g., migrants |   |   | Plus: Information tailored for  |   |   | communications  |
| and farm         |   |   | multiple literacy and language  |   |   | • Member        |
| workers)*        |   |   | needs                           |   |   | organizations • |
|                  |   |   |                                 |   |   | Unions and      |
|                  |   |   |                                 |   |   | worker          |
|                  |   |   |                                 |   |   | associations •  |
|                  |   |   |                                 |   |   | Religious       |
|                  |   |   |                                 |   |   | leaders • Small |
|                  |   |   |                                 |   |   | group and       |
|                  |   |   |                                 |   |   | community       |
|                  |   |   |                                 |   |   | channels •      |
|                  |   |   |                                 |   |   | Internet        |
+------------------+---+---+---------------------------------+---+---+-----------------+
| Health care      |   |   | (Would likely be targeted       |   |   | Professional    |
| providers in     |   |   | before and simultaneous to      |   |   | journals •      |
| areas determined |   |   | information delivered in        |   |   | Professional    |
| to have had high |   |   | national campaign -- geared     |   |   | associations •  |
| fallout          |   |   | toward primary care physicians, |   |   | State health    |
|                  |   |   | including those in family       |   |   | personnel,      |
|                  |   |   | practice, general medicine,     |   |   | training        |
|                  |   |   | internal medicine, and other    |   |   | courses and     |
|                  |   |   | health care providers, such as  |   |   | publications •  |
|                  |   |   | nurses, physician assistants,   |   |   | CDC-produced    |
|                  |   |   | and internists with specialties |   |   | CME sessions    |
|                  |   |   | in those areas related to       |   |   | (e.g., Grand    |
|                  |   |   | identified health outcomes.)    |   |   | Rounds) •       |
|                  |   |   |                                 |   |   | Satellite       |
|                  |   |   | (Most under-informed)           |   |   | information     |
|                  |   |   | Information on exposures, risk  |   |   | conferences •   |
|                  |   |   | factors for disease in their    |   |   | CDC/ATSDR "case |
|                  |   |   | areas • Information on fallout  |   |   | studies" • MMWR |
|                  |   |   | pattern, why their area is      |   |   | • "Dear         |
|                  |   |   | estimated to have had high      |   |   | Colleague"      |
|                  |   |   | fallout • If applicable,        |   |   | letters •       |
|                  |   |   | patient decision aids •         |   |   | Medic           |
|                  |   |   | Training and credentials (e.g., |   |   | al/professional |
|                  |   |   | CMEs) to evaluate potential     |   |   | conferences •   |
|                  |   |   | patients • Would be primary     |   |   | Internet •      |
|                  |   |   | information source sought by    |   |   | Pharmaceutical  |
|                  |   |   | concerned public/potential      |   |   | representatives |
|                  |   |   | patient • Information and       |   |   | • Managed       |
|                  |   |   | referral resource list(s) •     |   |   | health care     |
|                  |   |   | Receive volumes of educational  |   |   | organizations   |
|                  |   |   | information daily • Information |   |   |                 |
|                  |   |   | on national, regional, state or |   |   |                 |
|                  |   |   | local support networks          |   |   |                 |
+------------------+---+---+---------------------------------+---+---+-----------------+
| Health care      |   |   | (Would likely be targeted same  |   |   | Same as health  |
| providers in     |   |   | as above)                       |   |   | care providers  |
| areas determined |   |   |                                 |   |   | in              |
| to have had low  |   |   | Same as health care providers   |   |   | "high-fallout   |
| fallout          |   |   | in "high fallout areas"         |   |   | areas" • More   |
|                  |   |   |                                 |   |   | passive         |
|                  |   |   | Plus: Specific information      |   |   | communication   |
|                  |   |   | materials designed for people   |   |   | channels        |
|                  |   |   | at low risk and those living in |   |   | (s              |
|                  |   |   | "low-fallout areas"             |   |   | elf-motivating) |
+------------------+---+---+---------------------------------+---+---+-----------------+
| State and Local  |   |   | Have a vested interest in       |   |   | One-on-one      |
| Health           |   |   | activities • Concerned that     |   |   | meetings •      |
| Departments      |   |   | past issue(s) not affect        |   |   | Satellite       |
|                  |   |   | present perceptions • Some      |   |   | and/or          |
|                  |   |   | states may prefer to be         |   |   | telephone       |
|                  |   |   | "project lead" • May want to be |   |   | conferences •   |
|                  |   |   | involved with communications    |   |   | Printed         |
|                  |   |   | strategies • States would       |   |   | materials •     |
|                  |   |   | communicate with local health   |   |   | Internet •      |
|                  |   |   | officials • Would want to use   |   |   | ASTHO, NACCHO,  |
|                  |   |   | their own information           |   |   | NPHIC, ASTE and |
|                  |   |   | dissemination networks • Would  |   |   | other affiliate |
|                  |   |   | want specific information tools |   |   | organizations   |
|                  |   |   | for public health clinics       |   |   |                 |
|                  |   |   | (specific for multiple literacy |   |   |                 |
|                  |   |   | and language needs) • Would     |   |   |                 |
|                  |   |   | want information for those      |   |   |                 |
|                  |   |   | underinsured                    |   |   |                 |
+------------------+---+---+---------------------------------+---+---+-----------------+
| Public health    |   |   | Same as "Health Care Providers" |   |   | Same as "Health |
| and medical      |   |   |                                 |   |   | Care Providers" |
| organizations    |   |   | Plus: Information on national,  |   |   | and             |
|                  |   |   | regional, state or local        |   |   | "Environmental  |
|                  |   |   | support networks                |   |   | and Health      |
|                  |   |   |                                 |   |   | Advocates" •    |
|                  |   |   |                                 |   |   | Professional    |
|                  |   |   |                                 |   |   | conferences •   |
|                  |   |   |                                 |   |   | Professional    |
|                  |   |   |                                 |   |   | organization    |
|                  |   |   |                                 |   |   | newsletters •   |
|                  |   |   |                                 |   |   | Mailings to     |
|                  |   |   |                                 |   |   | organization    |
|                  |   |   |                                 |   |   | memberships     |
+------------------+---+---+---------------------------------+---+---+-----------------+
| State and Local  |   |   | Would want advance notice of    |   |   | Status reports  |
| Governments and  |   |   | campaign kickoff • Would want   |   |   | •               |
| Congressional    |   |   | confirmation that their health  |   |   | Correspondence  |
| Staff Members    |   |   | departments have been engaged • |   |   | • One-on-one    |
|                  |   |   | Have a vested interest in all   |   |   | meetings •      |
|                  |   |   | activities                      |   |   | Satellite or    |
|                  |   |   |                                 |   |   | telephone       |
|                  |   |   |                                 |   |   | conferences •   |
|                  |   |   |                                 |   |   | Printed         |
|                  |   |   |                                 |   |   | materials •     |
|                  |   |   |                                 |   |   | Internet        |
+------------------+---+---+---------------------------------+---+---+-----------------+
| Other Federal    |   |   | Have a vested interest in all   |   |   | Headquarters    |
| Agencies         |   |   | activities • Would want to be   |   |   | and regional    |
|                  |   |   | informed of activities/issues   |   |   | office          |
|                  |   |   | that potentially concern their  |   |   | correspondence  |
|                  |   |   | agency • May be interested in   |   |   | • E-mail •      |
|                  |   |   | partnering with CDC/NCI         |   |   | Internet •      |
|                  |   |   |                                 |   |   | Satellite       |
|                  |   |   |                                 |   |   | and/or          |
|                  |   |   |                                 |   |   | telephone       |
|                  |   |   |                                 |   |   | conferences •   |
|                  |   |   |                                 |   |   | One-on-one      |
|                  |   |   |                                 |   |   | meetings •      |
|                  |   |   |                                 |   |   | Internet        |
+------------------+---+---+---------------------------------+---+---+-----------------+
| Environmental    |   |   | Many have disparate viewpoints  |   |   | Professional    |
| and Health       |   |   | • Same information as "People   |   |   | journals •      |
| Advocates        |   |   | at High Risk" and "Health Care  |   |   | Direct mail     |
|                  |   |   | Providers" • Need training and  |   |   | with key        |
| Professional     |   |   | education materials • Regular,  |   |   | information and |
|                  |   |   | consistent messages/information |   |   | camera-ready    |
| and              |   |   | • Have questions about          |   |   | newsletter      |
| Citizen-based    |   |   | government public health        |   |   | articles, fact  |
| Associatio       |   |   | agenda(s) • Many would be       |   |   | sheets, etc. •  |
| ns/Organizations |   |   | viewed as more credible         |   |   | Follow-up phone |
|                  |   |   | information sources to some     |   |   | calls •         |
|                  |   |   | target audiences • Some would   |   |   | Localized       |
|                  |   |   | like more service than study •  |   |   | information •   |
|                  |   |   | Some may never be satisfied by  |   |   | Pro-active      |
|                  |   |   | actions taken • Want to provide |   |   | approaches •    |
|                  |   |   | input on material development • |   |   | National        |
|                  |   |   | Desire innovative communication |   |   | organization    |
|                  |   |   | approaches                      |   |   | partnerships •  |
|                  |   |   |                                 |   |   | Direct contact  |
|                  |   |   |                                 |   |   | • Focus groups  |
|                  |   |   |                                 |   |   | • Localized     |
|                  |   |   |                                 |   |   | infor           |
|                  |   |   |                                 |   |   | mation/coverage |
|                  |   |   |                                 |   |   | • National,     |
|                  |   |   |                                 |   |   | state and local |
|                  |   |   |                                 |   |   | media •         |
|                  |   |   |                                 |   |   | Internet •      |
|                  |   |   |                                 |   |   | Professional    |
|                  |   |   |                                 |   |   | conferences •   |
|                  |   |   |                                 |   |   | Professional    |
|                  |   |   |                                 |   |   | organization    |
|                  |   |   |                                 |   |   | newsletters •   |
|                  |   |   |                                 |   |   | Mailings to     |
|                  |   |   |                                 |   |   | organization    |
|                  |   |   |                                 |   |   | memberships     |
+------------------+---+---+---------------------------------+---+---+-----------------+
| Media            |   |   | Same as "United States          |   |   | Editorial board |
|                  |   |   | Population"                     |   |   | meetings •      |
|                  |   |   |                                 |   |   | Pre-written     |
|                  |   |   | Plus: Need timely, clear,       |   |   | articles (for   |
|                  |   |   | concise, interesting            |   |   | outreach        |
|                  |   |   | information • Simplified,       |   |   | activities) to  |
|                  |   |   | clarified science to            |   |   | local media     |
|                  |   |   | communicate to audiences •      |   |   | outlets •       |
|                  |   |   | Probably would still make       |   |   | Testimonia      |
|                  |   |   | mistakes/misinform public and   |   |   | ls/first-person |
|                  |   |   | communicate errors • They would |   |   | information     |
|                  |   |   | seek other scientific           |   |   | (Areal people@) |
|                  |   |   | information and viewpoints •    |   |   | • AMass@        |
|                  |   |   | Would need information on the   |   |   | conference call |
|                  |   |   | "process of science" as well as |   |   | link (e.g.,     |
|                  |   |   | the end results • Information   |   |   | telephone press |
|                  |   |   | and education on uncertainty    |   |   | conference,     |
|                  |   |   | involved in estimating doses    |   |   | video           |
|                  |   |   | and risk • Information on       |   |   | conference) •   |
|                  |   |   | context with other causes of    |   |   | Radio talk-show |
|                  |   |   | morbidity and mortality • Need  |   |   | host who is     |
|                  |   |   | to educate on difference        |   |   | Aopinion        |
|                  |   |   | between absolute and relative   |   |   | leader@ • Info  |
|                  |   |   | risk; individual and population |   |   | to community    |
|                  |   |   | risk• Information on what       |   |   | channels        |
|                  |   |   | people can do about risk/what   |   |   | (cable, radio   |
|                  |   |   | government is doing             |   |   | stations) •     |
|                  |   |   |                                 |   |   | Celebrity       |
|                  |   |   |                                 |   |   | spokesperson    |
|                  |   |   |                                 |   |   | (media-related  |
|                  |   |   |                                 |   |   | and/or star) •  |
|                  |   |   |                                 |   |   | Environmental   |
|                  |   |   |                                 |   |   | and health      |
|                  |   |   |                                 |   |   | advocates •     |
|                  |   |   |                                 |   |   | Grassroots      |
|                  |   |   |                                 |   |   | organizations • |
|                  |   |   |                                 |   |   | Internet        |
+------------------+---+---+---------------------------------+---+---+-----------------+

-   Would require further segmentation into main audiences, then
    selection and profiling of those target audiences

##### Understanding the social, political, and cultural context

Understanding the social, cultural, and political context associated
with the perceptions of the target population groups will be the most
important consideration in developing messages for this proposed public
awareness and education plan. Over the past 50 years, Government
secrecy, mass media reports, and stories about radioactive contamination
have influenced how people think and feel about nuclear issues and
activities. Messages would need to be framed with consideration of
societal and cultural perspectives that are dominated by nuclear and
radioactive stigmatization. Therefore, to understand specific
populations, communities, and regions that are targeted for risk
messages, appropriate conceptual theories developed in behavioral
science research on perceptions of risk, the social amplification of
risk, and others would have to be utilized (Kasperson et al. 1988; Weart
1988; Slovic et al. 1991; Kasperson 1992; Gregory et al. 1995; Flynn et
al. 1998; Flynn 1999).

Legacy of mistrust

Success in this communications endeavor will depend on the sensitivity
of DHHS to the American public's views about the United States and
global weapons programs. Given the legacy of mistrust that has developed
over the past half-century, this is a formidable social and political
context within which to communicate (Flynn 2000). For such an effort to
succeed, messages should acknowledge the Government's responsibility for
past actions in the history of its nuclear weapons program.

Meeting racial/ethnic and/or cultural needs

Understanding ethnic differences can make or break a successful
communication campaign (Huerta and Macario 1999). It is possible that
the only broad public messages developed in this proposed campaign would
be those constructed to provide historical context to the communications
campaign -- providing the American public with the facts and issues
surrounding the United States and global nuclear weapons testing legacy.
Otherwise, messages would need to be tailored so that they are
meaningful and appropriate for target audiences and their subgroups. To
do this, a two-pronged approach is recommended. This would include: 1)
conducting research to determine the racial/ethnic and/or cultural
subgroups in each identified target audience, and 2) working with a
community group (such as the Communications Development Group formed to
assist NCI in the development of the ^131^I/NTS Communications Plan) to
form partnerships with identified racial/ethnic and/or cultural groups
to assist in the planning stages of the communications project. From
that point, further research would then be conducted into the cultural
sensitivities, diversity, and culture-specific risk perceptions for each
subgroup, resulting in unique project planning strategies for each.

Tribal Nations

Because many of the populations affected by the nuclear weapons program
throughout the years of the Cold War were Native American populations,
any communication efforts should include careful planning with Native
American tribal leaders, tribal health care providers, tribal
organizations, and the Indian Health Service. Risk communication
research shows that the interactive process of receiving and processing
messages involves values, social-cultural perspectives, and emotional
responses as well as knowledge (Peters and Slovic 2000; Peters and
Slovic 1996; Gregory and Keeney 1994; Damasio 1994). Tribal governments
interact and deliberate differently; this must be understood and
protocols must be followed, as done with other sovereign nations. The
challenge in this regard is daunting and will require careful planning,
extensive resources and specific expertise. One possible approach would
be to establish a separate Native American caucus where research,
audience profiling, message testing, and other communications planning
tasks can be designed and conducted in partnership with a consultative
panel of Native Americans. This panel could objectively review the
communication and education plan for sensitivity to language, moral and
religious structures, and cultural perspectives that are distinct to
Native American nations.

##### The Challenge of Communicating Estimated Doses and Risks

Estimating the risk of exposure to radiation released from weapons tests
involves reconstructing radiation doses from tests that took place 40 to
50 years ago, identifying estimated exposures to populations, and
estimating the subsequent potential health effects. The only way this
research is possible is to rely on limited data, complex mathematical
models, and expert judgments and assumptions. The results of such
complex processes are not usually convincing to the average layperson,
especially when such results are presented with the appropriate range of
uncertainty and are routinely subject to contradicting interpretations,
even among scientists. Nor can such results be easily explained to the
public in defense of their reliability or accuracy (Purchase, et al.
1999; Slovic 1999; Flynn 2000). In this dose reconstruction and risk
assessment work, scientists will not be able to make definite statements
about cause and effect and therefore may be seen as "waffling" when
asked to definitively answer the question, "Will I get sick or not?"
Thus, the very data that will serve as the basis for this public
awareness and education effort may be perceived as "poor" or
"inadequate" science.

In addition, not everyone identifies with or understands scientific
concepts. It is especially confusing when different definitions apply to
everyday words used by both scientists and the public (Flynn 2000). How
scientists define words like risk, exposure, uncertainty, screening,
etc., may differ from how lay people or even other scientists may define
those words. For example, what does risk mean? Even if risk is confined
to human mortality, there are numerous ways it can be expressed (Slovic
1998; Sandman 1987). In most situations, scientists believe that risk
should be conveyed numerically (e.g., percentages, probabilities,
ranges, etc.). However, research indicates that numerical probabilities
are often meaningless to lay people. The dilemma with verbal expressions
of probability is that while people usually feel they understand the
information better, it is difficult to get consensus on what that
information actually means (Slovic 1996; Mertz et al. 1998; MacGregor et
al. 1999; Lipkus and Hollands 1999).

The specific challenge of estimating doses and potential health risks to
the American public from exposure to NTS and global fallout adds another
layer of complexity. Dose estimates from this research will not be able
to account for all the factors that contribute to individual differences
in exposure over time for any single person. Therefore, risk estimates
developed from these estimated fallout exposures will only represent the
average risk for a population group that shares common characteristics
such as age, place of residence, dietary factors, etc. Meaningful
estimates of the actual risk to a particular individual will be
unobtainable because one cannot account for all the factors that may
influence individual risk. This means it will be exceedingly important
to develop messages that clearly emphasize that risk estimates generated
for NTS and global fallout exposures are average risks and that a
person's actual, individual risk may vary greatly from this average. One
approach to meeting this communication challenge would be to use
hypothetical exposure scenarios in both the exposure and risk
assessment. Providing hypothetical individual scenarios that have
"characteristics" people can identify with would provide some context
for understanding what exposures they may have received and how these
exposures may translate into dose and potential disease risk.

As a result, the charge to develop messages to communicate the type of
research outlined in this report will be difficult. Partners in this
approach must discover how the public, specifically each target
audience, uses and responds to risk-related messages. In addition, the
complicated issue of trust and credibility must be examined before it is
determined how each audience would process and accept risk messages.

Because the scope of fallout-related research is much broader than the
issues being addressed by the ^131^I/NTS Communications Project, the
consumer research conducted for the ^131^I/NTS Communications Project
would need to be augmented. Further research would allow DHHS to better
ascertain each audience's perceptions of risk, understanding of multiple
exposure information, and how each audience best receives, understands,
responds to, and uses risk information. Such research is vital to
develop messages for audiences that are credible and useful rather than
messages that overwhelm, confuse, cause undue anxiety, or are
misinterpreted.

##### Include Public Health Recommendations in Messages

Informing the public about a health risk without explaining what can be
done about that risk can lead to anger and frustration (Arkin 1999).
Clearly, recommended actions and other advice would need to be included
in messages. In general, these would cover:

-   Recommended actions to lessen the consequence of exposure (e.g.,
    regular physicals, early detection, lifestyle changes); and

-   Sources of additional information or assistance (e.g., toll-free
    hotline; Federal agencies or organizations; state, regional or local
    information resource centers).

Identifying discrepancies in medical recommendations and developing
consistent public health messages

Before any health communication and education project is launched, it is
important to develop consistent messages for all audiences --
specifically for messages that make recommendations concerning visits to
health care providers. This would require identifying and examining the
inconsistencies in current medical and public health recommendations
specific to any health outcomes of concern. There are many differences
in scientific and public health policy opinions surrounding what is
known (and what is not known) about the potential health consequences
from the nation's nuclear weapons legacy as well as the potential health
impacts from exposure to fallout from NTS and global nuclear weapons
testing. In addition, there are many viewpoints concerning appropriate
medical interventions to deal with any potential health impacts from
these exposures. An expert panel may need to be convened to explore and
evaluate the scientific basis of these differing opinions and
recommendations to develop consistent public health recommendations for
inclusion in messages. This panel could include relevant scientific,
medical, and public health organizations and advocates, such as the
Agency for Healthcare Research and Quality (AHRQ) and members of the
United States Preventive Services Task Force. DHHS has already begun to
address public requests and opinions regarding government-sponsored
screening opportunities for thyroid cancer as well as for other
(noncancerous) thyroid diseases in the wake of NCI's ^131^I NTS Fallout
report (NCI 1997) at a thyroid disease screening workshop sponsored by
ACERER in June 2000.

### Developing Working Partnerships

Working partnerships would need to be developed with various stakeholder
groups for both the planning and implementation phases of any proposed
communications and education plan. The NCI Communications Development
Group used to plan NCI's ^131^I/NTS Communications Project provides an
example of the utility of bringing together representatives of various
constituencies to assist in communications planning. Because of the
added breadth and scope of the potential health consequences of exposure
to global fallout and other radionuclides from NTS, partners from the
following areas would need to be included in any working partnership
that is developed:

-   Federal agencies,

-   State and local health departments,

-   Public health and environmental advocates,

-   National, regional, state, and local grass-roots organizations
    (public health and environmental),

-   Medical and public health professionals and professional
    organizations,

-   Tribal leaders and organizations,

-   Religious organizations,

-   National citizen and consumer organizations, and

-   Managed care organizations.

As with other national health communications campaigns, partners are
essential because they are the ones "in the field." The partners sought
should be those who promote collaboration, possess the ability to
problem-solve, and possess skills needed in garnering additional
resources -- volunteers, mailing lists, service networks, Web sites,
conference venues, printing, etc. (CDC 1998). These partners may be
needed to gather the necessary data to develop the communications plan,
establish and maintain access to target audiences, and/or develop and
pre-test messages and materials. Or they may be needed in the
implementation phase to participate in special events (e.g., campaign
kick-off); disseminate messages and materials, foster the credibility of
messages and the program, keep other concerned groups and organizations
up to date, and/or evaluate and revise program activities.

#### Providing Technical Assistance and Resources

For a national communications and education plan to be effective,
provisions must be made to coordinate and provide technical assistance
and resources to state and local health departments to ensure that
communication and educational programs, materials, and methodologies can
be successfully planned for and applied. During the planning phase,
federal agencies may have to provide technical assistance and/or
resources to enlist assistance from various partners to define and
access target audiences, develop and pre-test messages, and conduct
material field testing. For the implementation phase, it may be
necessary for these agencies to provide technical assistance and/or
resources to guide and train external partners' staff on how to
integrate effective public education into local programs and services.

Examples of the types of technical assistance and resource support
typically necessary for a nationwide communications and education
campaign are:

-   Disseminating research results and model educational protocols to
    state and local health agencies.

-   Developing and maintaining a clearinghouse for partners and other
    individuals, groups, and organizations to identify and retrieve
    resources and expertise currently existing in medical organizations,
    universities, archival projects, grassroots organizations,
    government agencies, and the private sector. Such an effort could
    help to better ensure consistency in all communication and
    educational materials.

-   Increasing the resources needed at the state and/or local level to
    implement the communications and education campaign as well as to
    evaluate its reach and success.

-   Providing technical assistance, resources, and training on risk
    factors for disease to public health workers at federal, state and
    local levels.

-   Providing informational materials to leading managed care providers
    to disseminate with nationwide benefit mailings.

-   Developing and providing static and interactive information
    materials (e.g., fact sheets, decision aids for primary care
    providers to promote discussion and patient education, Web sites,
    CD-ROMs, information kiosks).

### Coordinating with Other Programs

There is a growing accumulation of information on the history of the
United States nuclear weapons program and the potential health effects
from exposure to radioactive substances. As a result, it is important to
identify messages that the American public has already received through
other national, regional, or local communication and education programs
concerning potential health effects from exposure to radionuclides.

This would require coordination with other relevant public and health
care provider education efforts to ensure that messages contained in
both the ^131^I/NTS Communications Project and in the potential
communication and education plan associated with any future in-depth
assessment of global and NTS fallout are consistent and accurate. This
would probably be most applicable for messages and educational materials
containing information on the history and legacy of nuclear weapons
production and testing as well as the potential health consequences
associated with any radionuclides of concern. In all communication
efforts, partners would have to decide how to manage and address errors
in fact, discrepancies or contrasting scientific results and opinions.

Some examples of proposed, ongoing, or recently discontinued programs
that are relevant to the issues discussed in this report are provided in
the following section.

#### The Hanford Thyroid Disease Study (HTDS)

CDC and the Fred Hutchinson Cancer Research Center conducted the HTDS as
a retrospective cohort study. The primary purpose of the study was to
determine whether thyroid disease in the population surrounding Hanford
is associated with exposure to ^131^I released from Hanford between 1944
and 1957, the years when the greatest releases of ^131^I occurred. The
final report is available on the internet at
<http://www.cdc.gov/nceh/radiation>. No demonstrable excess in thyroid
cancer risk was found; this suggested that, if there was an increase in
risk at the range of thyroid dose estimated for the Hanford population,
it was too small to be detected in more than 3,000 people examined in
the study.

#### Case Study in Environmental Medicine on ^131^I

The Agency for Toxic Substances and Disease Registry in a cooperative
agreement with the American College of Medical Toxicologists (ACMT) has
developed a Case Study in Environmental Medicine (CSEM) on ^131^I. This
CSEM is a self-study guide for PHC professionals about the impact of
^131^I on the thyroid gland. It includes a review of the exposures of
the American public to ^131^I from nuclear weapons production and
testing, and also discusses pathways of exposure, who is at risk,
potential health effects, diagnosis, and management. It addresses both
cancerous and non-cancerous thyroid and parathyroid gland disease, and
provides information about prevention of health effects on the thyroid
gland in case of nuclear accidents.

This CSEM can be accessed at
<http://www/atsdr.cdc.gov/HEC/CSEM/iodine/index.html>.

#### The Hanford Individual Dose Assessment (Hanford IDA) Project

The Hanford Individual Dose Assessment (Hanford IDA) Project was a
public service to provide individual thyroid dose estimates for people
who lived or spent time in the Hanford Environmental Dose Reconstruction
(HEDR) study area between December 26, 1944 and December 31, 1957. The
individual radiation dose estimates were for ^131^I released to the air
from the Hanford facility. Along with the individual dose estimates, the
Hanford IDA Project provided information to help people understand their
thyroid dose estimates and what it might mean for their health. The
Hanford IDA Project was operated jointly by the state health agencies of
Idaho, Oregon, and Washington, and was funded by CDC. This project
closed on December 31, 2000. Copies of informational material developed
by the project are on file at CDC.

#### The Hanford Health Information Network (HHIN)**,** the Hanford Community Health Project, and the Hanford Health Information Archives

The Hanford Health Information Network (HHIN) was funded by ATSDR and
was managed by the state health agencies of Idaho, Oregon, and
Washington, and nine Pacific Northwest Indian Nations. HHIN closed on
June 30, 2000. However, over the years, individuals were able to call
toll-free to speak with a health educator and request free educational
materials on Hanford's releases between 1944 and 1972 and the potential
health effects from those releases. The Network also offered a
self-study guide for health care professionals. HHIN-generated
materials, procedures, and data will be an important source of
information to the American public for years to come. In addition, HHIN
operating procedures and management principles may serve as an excellent
framework to follow if a similar program is funded in the future.
Currently, HHIN publications are archived through the Washington
Department of Health
([www.doh.wa.gov/hanford](http://www.doh.wa.gov/hanford)).

The Hanford Community Health Project, an outreach and education
initiative sponsored by ATSDR, provides educational information and
materials about potential health risks to individuals who were exposed
as young children to past releases of ^131^I between 1944 and 1951 from
the Hanford Nuclear reservation. Information is available at
<http://www.atsdr.cdc.gov/hanford/>[.]{.underline}

The Hanford Health Information Archives collects and makes available the
personal records and health information of Hanford-exposed people who
choose to participate. It is housed at Gonzaga University in Spokane,
Washington.

#### Citizen-Based and Professional Education Programs

Numerous educational materials concerning potential health risks
associated with exposure to fallout from nuclear testing at the NTS and
from the nuclear weapons program have been developed by citizen and
professional advocacy groups (e.g., Alliance for Nuclear Accountability
\[ANA 1998\]; Physicians for Social Responsibility \[PSR 1998\]). These
materials have been disseminated on a national, state, and local level.

### Implementation

Should additional work as outlined in this feasibility report be
recommended and sufficient resources be made available, communications
should be built on the tremendous advances in health education theory,
social marketing, and communication techniques, and on grassroots
expertise. Moreover, as time progresses, ever changing and improving
communication technologies and methods may allow DHHS to consider more
direct and cost-effective communication channels. Whatever communication
strategies are selected, community members should be involved in all
phases of the communication plan to help provide information materials
and activities that are compatible with audience need.

#### Development of Education Materials

Before developing any educational materials, an information database to
promote a nationally and regionally coordinated approach to public and
health care provider education should be developed. Thus, the nature and
extent of existing educational materials regarding the history of the
United States nuclear weapons program, global testing programs,
radionuclides of concern, and information on the potential health
consequences of exposures to those radionuclides can be determined. This
will ensure:

-   Consistency in the information the public receives;

-   Prompt development and dissemination of general informational
    materials \-- eliminating time needed to "start from scratch;" and

-   Holistic review of materials to identify gaps and needs.

After existing health education materials have been collected from both
local and national resources, review and pre-tests of the materials
collected would need to be conducted to decide if they are appropriate
for use. Pre-testing methods should be used to ensure that concepts and
resulting materials are appropriate and relevant for the intended
audiences. This will help DHHS obtain insight into the perceptions,
beliefs, and languages of the intended audience(s). This approach will
ultimately save resources, but will take more time and effort initially.

#### Determining Communication Channels

Developing and implementing innovative and effective methods for
communicating with this project's defined target audiences will be
necessary. Table 5.1, shown earlier in this chapter, provides examples
of the wide range of communication channels and activities that would
have to be considered -- from interpersonal and small group to
organizational, community, and mass reach media. To be successful in
such a communications effort, these channels and activities would be
defined for each target audience and subgroup(s) as more research is
conducted. And as the focus turns to specific audience subgroups,
priority consideration should be made to identify effective
interventions (e.g., nontraditional media and interpersonal
communications) -- for those audience groups who are low-literacy,
minority, under- or uninsured, oral-culture-based, or
non-English-speaking.

To determine communication channels, the sources of health information
among targeted audiences and their various subgroups would need to be
analyzed and a broad range of communication channels and activities,
such as libraries and resource centers, the Internet, print materials,
advertising, video news releases, toll-free telephone information
services, commercial tie-ins, training classes, and community
partnerships would need to be considered. Extensive time and resources
may be needed to adapt messages, communication channels, and
communication activities to audience needs and perceptions, cultural
norms, and linguistic variations to increase the understanding and
reception of those messages.

The communications and education plan envisioned would be designed to
include an array of mass media and interpersonal communication
activities. Multiple mass media strategies can include public service
announcements (PSAs), radio and television programs, an interactive Web
site, news coverage, and perhaps even informational brochures or CD-ROMs
mailed directly to homes. Interpersonal communication activities can
include such channels as physician-patient counseling, presentations to
high-risk individuals, a speakers' bureau, and assistance of local
grassroots organizations to provide for more personal support and
message reinforcement.

For example purposes only, four mass-reach mediums that could likely be
considered for this proposed communications and education plan are
highlighted below:

##### Interactive Technology -- The Internet and Electronic Media

Today's consumers do not just rely on their doctors -- they look to the
media and the Internet for health care advice. It is estimated that 110
million adults nationwide "go online" to look for health care
information. On average, they do so three times a month, searching
mainly through portals or search engines rather than by going directly
to particular sites (Harris Interactive). The Internet brings health
information simultaneously to both the public and to health care
professionals. Interactive technology can be used to relay health
information on demand, enable informed decision-making, promote
interaction between the public and health professionals, and even allow
for peer information exchange and emotional support. Interactive
technology also allows for the presentation of more in-depth
information.

For example, both the public and health care providers would benefit
from a final study report and associated reference materials in
electronic media format and on the Internet. Users could instantly
"jump" to the report's glossary, appendices, tables and graphs,
supporting data, and references as they read. Alternatively, through an
Internet site or other electronic media, users could link to related Web
sites, other government databases, professional or grassroots
organizations, or library/resource centers.

Additionally, a Web site could be designed along similar lines as was
done by NCI for its 1997 ^131^I/NTS report. A key component of NCI's Web
site has been its dose calculator. Since NCI first launched this dose
calculator, they have received consumer feedback regarding its
usefulness and readability. As a result, they conducted usability
testing to provide insight into how best to modify the Web site design
to improve its ease of use and understandability. In 2003, the new
dose/risk calculator was released and is available at
<http://ntsi131.nci.nih.gov/>. The feedback they have received and
"lessons learned" can be incorporated into any new Web site developed if
a more detailed dose and risk study is conducted.

##### Toll-Free Information Services

As part of its communication strategy, toll-free telephone information
services could be considered. Three options in this area are to provide
the public with access to an automated toll-free voice/fax information
system, a staffed toll-free information clearinghouse and "hotline," or
a combination of the two. It would be relatively cost-friendly to
provide an automated toll-free information service if it is included as
part of an existing toll-free voice/fax information system. For example,
CDC has a system that provides CDC-supplied voice recordings and
fax-on-demand services to the public and health care or public health
workers through a toll-free telephone number. Users hear a menu of items
about which they can receive information. The system also captures
address information to facilitate on-demand mailings as well as provide
mailing lists for mass-mailing campaigns.

The automated system is less costly than a staffed "hotline," and it
does provide accurate and timely delivery of materials. However, because
of the social and political context framing the issues discussed in this
report, this communications effort may be best served by a combination
of an automated toll-free service and a staffed (at least part-time)
information clearinghouse and toll-free telephone service. In addition,
a pilot program to monitor public usage of the staffed hotline to
forecast extended need would be necessary.

##### Education for Public Health Professionals

CDC has been a central source of practice-based, job-relevant,
high-priority training for public health professionals in state and
local health departments since its beginning in 1946. For many years,
this training was primarily delivered in the classroom or laboratory.
But fundamental changes in the American health care system increased
both the number of persons who needed training and the number of content
and skill areas they needed training in, and in recent years CDC found
itself unable to meet the increased demand using traditional methods. In
June 1993, CDC launched the Public Health Training Network (PHTN) (CDC
2000). This network could be used as the main communication channel to
educate and train physicians/health care providers on the potential
health consequences of exposure to NTS and global radioactive fallout.

PHTN is a distance learning system that uses a variety of instructional
media: print-based self-instruction, interactive multimedia, videotapes,
two-way audio conferences, and interactive satellite videoconferences.
Since 1993, PHTN has delivered nearly one million training opportunities
to professionals in public health settings and, increasingly, in health
care and related settings. PHTN's success has stimulated state and
federal health agencies to produce training programs and to build their
own capacity to meet training needs through distance learning. State
health departments are expanding their own capacity, supporting field
operations, and developing new courses that address their audiences'
unique needs.

PHTN successful in the past

Evaluation studies demonstrate that PHTN programs, and distance learning
as a medium, are effective ways to update and enhance professional
competencies. In particular, CDC has successfully used PHTN to educate
health care providers about potential health effects from exposure to
ionizing radiation. CDC used the PHTN in its nationwide public health
awareness campaign to alert physicians to the potential adverse health
effects associated with past nasopharyngeal radium irradiation
treatment. This project altered the policy of the Department of
Veterans' Affairs (VA) and the Department of Defense (DOD) concerning
head and neck exams for veterans and military personnel who received the
treatment in the early 1940s and 50s. It also was the impetus behind
DOD's notification project to alert veteran service personnel to the
treatment's possible health risks.

Using PHTN technology, in 1996 CDC convened a live satellite
videoconference to address the history and potential health consequences
of nasopharyngeal radium irradiation treatments. This conference linked
CDC with more than 250 VA and DOD medical facilities throughout the
country. Its target audience was physicians, nurse practitioners, and
physician assistants in general practice, family practice, internal
medicine, otolaryngology, radiology, and nuclear medicine. The program
served as a continuing medical education program for physicians and
other health care providers about the potential adverse health effects
of this treatment, and included a demonstration of a thorough head and
neck examination. Moreover, to capture attention in the public health
community, the program offered CME, CEU, American Academy of Family
Practice elective credits and Continuing Nursing Education Credits.

Since then, CDC has provided the videotaped version to the VA for use in
more than 200 VA medical centers, to more than 50 public and private
hospitals in Connecticut and Rhode Island, to the media, and to
interested citizens. This effort, in combination with publishing
information in medical journals (e.g., CDC's *Morbidity and Mortality
Weekly Report*, the *Journal of the American Medical Association* and
*Otolaryngology -- Head and Neck Surgery*), was a successful and
far-reaching effort to educate public health care providers on this
issue.

##### Public Service Announcements (PSAs)

Within the context of a large communications program, PSAs are most
useful for creating public awareness or heightening the public\'s
sensitivity to a health problem or issue, or transmitting specific
information to the public. They are also appropriate for increasing
recognition of a health program, generating requests for health
information or recruiting volunteers (NCI 1996). The use of PSAs may or
may not be useful during the initial "launch" of a plan to create
nationwide public awareness for fallout issues. The benefits of using
PSAs would have to be further explored. However, if PSAs are developed,
they must be carefully crafted and their delivery carefully planned
before launch, so that all messages, partner support structures, and
media planning (at the federal, state and local levels) are in place to
respond to the public's health concerns and potential outrage emotional
issues.

### Additional Work Outside the Scope of this Report

A public awareness and education effort dealing with fallout would be
perceived by the public as just one part of the big picture of potential
health impacts from environmental radiation exposure from the NTS,
global, and individual emissions from nuclear weapons production
facilities. Therefore, for this communications effort to be considered
credible by the American public, all issues must be acknowledged, though
some are beyond the scope of the proposed research and communication
efforts.

With that premise in mind, any proposed communication and education plan
should contain communications strategies that speak to outstanding
public concerns and issues. The following outstanding public concerns
and issues have been raised by stakeholders:

-   Concern over multiple and cumulative exposures from all phases of
    the United States nuclear weapons program, including weapons testing
    and operational and cleanup activities related to research
    laboratories and weapons production facilities;

-   Diverse opinions from the scientific community regarding health
    consequences of radiation exposures;

-   The provision of follow-up medical services for those in high-risk
    groups and/or for those underinsured;

-   Government accountability for past actions;

-   Government acknowledgement of health impacts;

-   Government compensation;

-   The desire to receive formal promises at upper Administration levels
    that prove the U.S. Government's commitment not to harm its public
    again in the name of National Security.

-   The need for dose and risk estimates specific for Native American
    diets and migratory patterns;

-   The need for dose and risk estimates for workers and military
    participants

As some of these are policy issues, an intergovernmental task force
would be needed to address these issues.

### Conclusion

Development and implementation of a nationwide communications project
would require careful planning to provide appropriate, effective, and
credible messages and educational materials to the American public and
to the nation's health care providers about the potential health risks
associated with fallout from atmospheric nuclear weapons tests conducted
in the 1950s and early 1960s by the United States and other countries.
This public awareness and educational effort would be a necessary step
in providing United States citizens and residents with the information
they need to evaluate their potential risk from the United States and
global nuclear weapons legacy.

Because the research concerning the health consequences of radioactive
fallout from the NTS and global sources is not complete, it is too early
to provide a communications and education plan for communicating those
results to the American public. Instead, it is recommended that the
American public receive information on the potential health consequences
from nuclear test fallout in a staggered approach. The DHHS can draw on
the efforts already underway for NCI's ^131^I/NTS Communications
Project. This effort, led by NCI and advocated by CDC, began in 1999 in
response to public interest and the IOM's review of NCI's 1997 report,
*Estimated Exposures and Thyroid Doses Received by the American People
from Iodine-131 In Fallout Following Nevada Atmospheric Nuclear Bomb
Tests (NCI 1997)*. Because a great deal of work has already been
accomplished by NCI to structure its existing ^131^I/NTS Communications
Project to ensure ongoing public involvement in plan development and
implementation, it may be appropriate to use a similar approach for
future communication planning efforts associated with a more in-depth
analysis of the research discussed in this feasibility report. The
effectiveness of NCI's approach should, however, be formally evaluated
before it is adopted for this potentially much larger communications
project.

In this chapter, the numerous steps and challenges associated with
communicating information of NTS and global nuclear weapons fallout were
discussed. Also discussed were the two major components of such a
proposed national education and public awareness campaign: public
communication and education, and health care provider education. The
first component addresses "right-to-know" issues and educates the
American public on scientifically determined risk factors for disease
for each of the radionuclides of concern, so that individuals can
self-identify whether or not they are in a "high-exposure" and/or "high-
risk" group. The second component serves the premise that the nation's
health care providers will have the greatest impact on improving the
health status of persons who may have been adversely affected by
radioactive fallout. Physicians and health care providers could be
educated on risk factors for disease, risks and uncertainties of
exposure to the radionuclides of concern and their potential health
consequences, and recommended testing and screening procedures. This
will enable them to not only serve as a source of information to the
public, but also to help with the decision process for a concerned
patient.

Additionally, recruiting working partners would be extremely important
for both the planning and implementation phases of a communications and
education project. The goal in establishing these partnerships is to
ensure that the proposed communications project meets the needs of the
intended audiences, and that the materials and activities developed are
compatible with each audience's needs.

Finally, it is important to consider a broad range of communication
channels and activities, such as libraries and resource centers, the
Internet, print materials, advertising, video, news releases, toll-free
telephone information services, commercial tie-ins, training classes,
and community partnerships to meet these needs.

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