福島県立医科大学 学術機関リポジトリ

Title

Psychosocial support for the examinees and their families
during the secondary confirmatory examination: Analyses of
support records at first visit

Author(s)Setou, Noriko; Suzuki, Satoru; Matsuzuka, Takashi; Iwadate,
Manabu; Maeda, Masaharu; Namekata, Yuko; Yoshida, Fusae;
Oshima, Kayoko; Ohira, Tetsuya; Yasumura, Seiji; Ohto,
Hitoshi; Kamiya, Kenji; Yokoya, Susumu; Shimura, Hiroki

Citation

Fukushima Journal of Medical Science. 67(2): 53-63

Issue Date

2021

URL

http://ir.fmu.ac.jp/dspace/handle/123456789/1585

Rights© 2021 The Fukushima Society of Medical Science. This
article is licensed under a Creative Commons [AttributionNonCommercial-ShareAlike 4.0 International] license.

DOI

10.5387/fms.2021-01

Text Version publisher

This document is downloaded at: 2024-10-16T12:31:51Z

Fukushima Medical University

Fukushima J. Med. Sci.,
Vol. 67, No. 2, 2021

Psychosocial support in TUE secondary exam

53

[Original article]

Psychosocial support for the examinees and their families during
the secondary confirmatory examination :Analyses of support records at first visit
Noriko Setou1)2), Satoru Suzuki1), Takashi Matsuzuka1)3), Manabu Iwadate1)4), Masaharu Maeda1)2),
Yuko Namekata1), Fusae Yoshida1), Kayoko Oshima1), Tetsuya Ohira1), Seiji Yasumura1),
Hitoshi Ohto1), Kenji Kamiya1), Susumu Yokoya1)5) and Hiroki Shimura1)6)1)

Radiation Medical Science Center for the Fukushima Health Management Survey, Fukushima Medical
University, Fukushima, Japan, 2)Department of Disaster Psychiatry, School of Medicine, Fukushima
Medical University, Fukushima, Japan, 3)School of Health Sciences, Asahi University, 4)Department ofThyroid and Endocrinology, School of Medicine, Fukushima Medical University, Fukushima, Japan,
5)
Thyroid and Endocrine Center, Fukushima Global Medical Science Center, Fukushima Medical University, Fukushima, Japan, 6)Department of Laboratory Medicine, School of Medicine, Fukushima Medical University, Fukushima, Japan(Received January 5, 2021, accepted May 24, 2021)
Abstract
Background and Purpose
The Thyroid Ultrasound Examination (TUE) program is conducted as part of the Fukushima
Health Management Survey. Following the established criteria, examinees are called in for a secondary confirmation examination, which may induce high anxiety related to a thyroid cancer for boththe examinees and their families. Therefore, Fukushima Medical University created the Thyroid
Support Team to reduce anxiety. The purpose of this study is to analyze the psychosocial support
for examinees and their families through two types of records, and to clarify the current issues anddetermine future directions of support.
Materials and methods
We analyzed 223 records of support for the first visit of examinees who attended the secondary
confirmatory examination, conducted at Fukushima Medical University from September 2018 toMarch 2019.
Results
During the first visit, frequent topics and questions brought up by the examinees and their families were about the “Thyroid Ultrasound Examination (TUE) program” and “Examination findings”. The Thyroid Support Team members assisted them by “Responding to questions”, “Confirming the doctor’s explanation” and “Providing information”. The percentage of people with highanxiety decreased in both examinees and their family members after the examination. The level ofanxiety was lower among those who had already taken the secondary confirmatory examination. Family members’ anxiety was significantly higher than that of the examinees, and anxiety
levels were highly correlated between examinees and their families.
Conclusion
The psychosocial support for examinees and their families was important in reducing theiranxiety. Currently there are changes in social conditions and various opinions concerning the TUE.
Thus, careful explanation and the need for decision-making supports for the examinees and their
Corresponding author : Noriko Setou   E-mail : setou@fmu.ac.jp©2021 The Fukushima Society of Medical Science. This article is licensed under a Creative Commons [Attribution-NonCommercial-ShareAlike 4.0 International] license.
https://creativecommons.org/licenses/by-nc-sa/4.0/53

N. Setou et al.

54

families increased. Also, we should take into account the aging of the examinees and expanding theavailable psychosocial support.
Key words : psychosocial support, Ultrasound Thyroid Examination (TUE), the secondary confirmatory examination, Thyroid Support Team

Introduction
The Great East Japan Earthquake on March 11,2011 not only caused earthquake damage, but also
the resulting tsunami- triggered a nuclear hazard
event that dispersed radioactive substances into theenvironment. The accident at the Fukushima Daiichi Nuclear Power Station has continued to havevarious forms of influence in Fukushima even 10
years later. Approximately 185,000 residents ofFukushima Prefecture were forced to evacuate immediately after the earthquake and even today, it isestimated that more than 40,000 people remain exiled from their homes, both in and out of the prefecture. Since this accident was rated as a Major Accident (Level 7) by the International Atomic Energy
Agency (IAEA), equivalent to the 1986 Chernobyl
disaster, great concern arose about a possible increase in the number of childhood thyroid cancer
cases, one of the effects of Chernobyl. As a result,
starting in October of 2011, Fukushima Prefecture
began a large-scale Thyroid Ultrasound Examination(TUE) program for children1,2).
The TUE program is a part of the Fukushima
Health Management Survey conducted by the Radiation Medical Science Center of Fukushima Medical
University, commissioned by Fukushima Prefecture.
Approximately 385,000 children aged 0 to 18 who
were living in Fukushima Prefecture at the time ofthe earthquake are examined once every 2 years1,2).
The examinations consist of primary and confirmatory examinations. The primary examination (E1)
consists of an ultrasound examination on the thyroid.
If nodules measuring >5.0 mm and/or cysts measuring >20.0 mm in diameter are found, a secondary
confirmatory examination (E2) is scheduled. E2
includes a precise ultrasound examination, blood andurine tests, and fine-needle aspiration cytology if sonographic findings of nodule or cysts met the FNAC
criteria. The survey was divided into the Preliminary Baseline Survey and the Full - scale Survey.
The Preliminary Baseline Survey began on October
9, 2011 and was mostly completed by the end of
March, 2014 3). The first Full - scale Survey was
conducted from April, 2014 to the end of March,2016. Thereafter, all subjects have been and will

be included in further Full-scale Surveys every two
years until they reach the age of 20, and every five
years after that for the rest of their lives 4). By
March 31, 2020, the third Full - scale Survey (thefourth-round survey) was almost complete.
After the nuclear power station accident, residents in Fukushima Prefecture became extremely
anxious about the impact on their health due to radiation exposure. The exposure doses received by
the residents immediately after the disaster wereuncertain due to the lack of direct measurements5),
and the residents tended to directly correlate resultsof the thyroid examinations of their children to theeffects of radiation exposure6). Many family members had strong anxiety and blamed themselves, especially in regards to the actions that they took toprotect their children. Examples include not evacuating and staying behind right after the accident,
and unknowingly moving to higher contaminated areas. This gave a lot of people strong feelings ofanxiety and guilt. And family anxiety about thyroid
cancer was heightened by the discovery of even asmall nodule or cyst7,8).
These substantial concerns and fear of thyroid
cancer were particularly high for examinees andtheir families during E2. Since the psychologicalimpact of disasters is particularly high on motherswith children, programs and/or psychosocial support
for children and families are recommended to reduce
psychological distress and post-disaster impact andpromote adaptation 9,10). Addressing the strong
needs for improving quality of life (QOL), even if disaster effects are not life-threatening, is considered
to be one of the most important public health challenges11). In response, Fukushima Medical University established its Thyroid Support Team in November of 2013 to provide psychosocial support tothose examinees and their families.
Currently, the Thyroid Support Team consistsof 4 members (3 nurses and 1 psychologist). We
support examinees and their families twice a weekduring E2 and also on other days for those who arereferred to the departments of thyroid surgery andinternal medicine for treatment and follow-up at Fukushima Medical University Hospital.
At present, several years after the nuclear acci-

Psychosocial support in TUE secondary exam

dent, the importance of psychosocial support for examinees and their families has been emphasized12),
but there are few reports concerning related issues.
Taking into consideration that E2 tends to increase
the anxiety level of examinees and their families
compared to E1, it is important to devise appropriate
strategies for them on the basis of the current situations. Therefore, the purpose of this study is toevaluate the psychosocial support provided by the
Thyroid Support Team for examinees and their families, and to sort out future support issues.

Materials and methods
The flow of psychosocial support by the Thyroid Support Team in E2 is as follows.
An examinee usually visits at least twice during
E2. One support member will be assigned to eachexaminee. On the first visit, the examination procedure is explained prior to the actual examination.
Then the medical and sonographic examination are
conducted by medical doctors followed by blood andurine examinations. The results of the ultrasoundexamination are explained by the doctors on thesame day. At the second visit, the results of bloodand urine examinations are explained. If fine-needle aspiration cytology (FNAC) is not needed to confirm the diagnosis, that set of E2 is concluded, andinformation on taking future TUE is provided.
Support team members try to listen carefully tothe examinees and their families’ anxieties andthoughts before and after the medical doctor’s examination, to ease their tension and sufficiently
communicate with them. Additionally, before theexamination starts, we encourage the examinees
and their families to ask questions of medical doctors and staff about any issues that remain unclear.
Also, the support member always accompanies
the examinee and his/her family and listens to the
medical doctor’s explanation together. After theexamination, we take the time to talk with them toconfirm that they understood the explanation, and if
necessary, provide further supplementary explanations and information. Throughout the examination, the support member tries to encourage the examinees and their families to express their feelings
and thoughts in their own words.
As a result of the Preliminary Base-line Survey
and past Full-scale Surveys, FNAC was not required
for nodules in many participants who subsequently
underwent the confirmatory examination after the
primary examination7,8). However, the sonographic
findings of the thyroid nodules sometimes meet the55

guideline for implementation of FNAC in E29). In
such a situation, a very heavy psychological burden
can occur in examinees and their families. Therefore, in this situation, after the medical doctor explains the necessity of the examination, the support
team members take sufficient time to try to alleviate
the anxiety of the examinee and his/her family.
Sometimes, it is recommended that examinees
continue follow-up and treatment using their healthinsurance. For example, when the thyroid nodules
are diagnosed as malignant and interpreted to be unsuitable for medical follow-up, the examinee is referred to the thyroid surgery department and counseled about surgical treatment. When the treatment
is started under health insurance, we deliver theprospects for the future and information about procedures while answering questions and carefully attempting to alleviate the anxiety of the examineeand his/her family.
One support team member keeps two types ofrecords (detailed below) during and after such support.
Objects of analysis
The analysis was based on two types of support
record of examinees who had undergone E2 conducted at Fukushima Medical University during theseven-month period from September 2018 to March
2019. The number of examinees given support
during this period was 408 (236 examinees), which
consisted of 223 for the first E2 visit, 158 for thesecond visit, and 23 for additional visits (FNAC and/or its explanation). In the present study, we analyzed the support records for the 223 first visits (69males and 154 females).
The two types of records are a check-off sheetof support records (Record 1), on which support
members marked with a number at each visit, and afree detailed description of support which the support members recorded after the examination (Record 2).
Record 1 is a unique chart, as shown in Table 1,
in which we extracted items based on our experience. The thyroid support member who was incharge of the examinee on the day selected the appropriate option for each of the items, “Basic information”, “Concerns of examinees/family”, “Level ofanxiety”, and “Support”. In addition, for each item,“item definitions” and “check criteria” were created
so that would be as little bias as possible among the
support members. For the analysis, every item inRecord 1 was first tabulated. Second, in order tosee changes in “anxiety level”, in both pre - andN. Setou et al.

56

Table 1. Items of Record1
1)

Basic Examinee Information① Gender1. male 2. Female

②

Age

③

Student or other (working adult etc.)

1. sutudent 2. other④-1 Previous confirmatory examination taken

1. Yes 2. No

2 Number of confirmatory examination taken-⑤

Family history of thyroid disease2)

Contents of consultation①

Examination findings②

Program of TUE (Thyroid ultrasound examination)③

Causesnumbernumber
1. Yes 2. No

1. Radiation 2. Heredity 3. Daily life style
4. Diet 5. Others④

Health insurance treatment⑤

Examinee’s health problems⑥

Examinee’s mental and social problems⑦

Examinee’s future matters⑧

Reflections on the time of the earthquake⑨

Social support⑩

Medical subsidies and services⑪

Dietary habits and lifestyle concerns⑫

Others3)

Examinee’s and Family Members’ Anxiety Level

Anxiety Level

1. Yes 2. No

1. Very Low 2. Low
3. High 4. Very High
5. Absent 6. Unknown4) Support①

Listening to examinee’s thoughts② Listening to family’s thoughts③

Confirmation of the doctor’s explanation④ Responding to questions⑤ Feedback to medical doctors⑥ Providing information
1. Next and/or future TUE rounds
2. Treatment
3. Special telephone number for medical information
4. Subsidies

0. Not conductedor
1. Conducted

5. Supplemental explanations
6. Offering pamphlets
7. Others⑦

Daily life and dietary habits support⑧ Self health management⑨

Decision-making support for future rounds of TUE⑩

Decision-making support for FNAC and medical care⑪

Others2-2) TUE : schedule of E2 in this round of TUE and/or next round of TUE
2-5) health problems : relationship between thyroid nodule (s) and examinees current symptoms, etc2-6) mental and social problems : very shy, school truancy, etc.
2-7) future matters : going to higher education, future careers, etc2-8) Reflections on the time of earthquake : actions and feelings (guilty and anxiety etc.) at thetime of the earthquake2-11) dietary habits : thyroid-related dietary life such as intake of iodine, etc.

Psychosocial support in TUE secondary exam

post- examinations, and in examinees- and families-,a McNemar test was conducted over the degree ofthe examinee’s and their family members’ anxiety
setting Very High/High as the “high anxiety group”
and Very Low/Low as the “low anxiety group”, excluding “Absent” and “Unknown”, and calculated asignificance probability. Next, Spearman’s correlation coefficient and significance probability were calculated to evaluate the relationship to the degree of
each examinee’s and their family members’ anxiety
levels. Furthermore, we hypothesized, based on
our experience that people who underwent E2 forthe first time would have a higher level of anxiety. Thus, a t-test was conducted for each anxiety
level with and without E2 history, in order to calculate a p-value. The risk ratio of significance level
was set at <0.05 or lower.
Also, we extracted the questions from Record 2
which were asked by the examinees and their families during the support. These statements wereintercepted one by one and given code names.
Then, the similar code names were classified into
several categories, and the final category names
were generated by two analysts. One analyst is a
psychological researcher and the other a medical researcher, both with more than 20 years of experience.
This study was approved by the Research Ethics Committee of Fukushima Medical University(approval number 2019-113).

Results
General Characteristics
The basic characteristics of the 223 first-visit
examinees are shown in table 2. 217 (97.3%) werestudents and the average age was 16.0 years. The
AYA (adolescent & young adult) generation, aged 15
and older, accounted for more than 70% of the examTable 2.

57

inees. Over 90% of the examinees were residentsof the Naka-dori area, which is located in the central
part of Fukushima prefecture and where approximately one third of the target persons were living.
74 examinees (33.2%) were found to have taken E2
before ; Forty-seven were taking it for the second
time, 24 for the third time, and 3 for the fourth time.
Contents of consultation
Figure 1 shows the content of consultation fromexaminees and their families during the first visit.
The most frequently consulted context was about“Program of TUE” including its procedures, schedule and system at this- and the next- round of examination, followed by the “Examination findings” and“Health issues” of the examinees. There were 30
cases of cousultation for the “Cause” of growing
nodules including 15 inquiries concerning heredity
such as a family history of thyroid disease, and 9
about the impact of radiation on their health.
Degree of anxiety
Figures 2 and 3 show the change in the degreeof anxiety level pre- and post- examination as evaluated by the support team members. Family members are often more anxious than examinees before
the examination, and approximately half of themshowed High and Very High levels of anxiety. How­ev­er, after the examination, the percentage of highlevel anxiety decreased to about 11% for both examinees and family members.
According to the results of statistical analyses,
the degree of anxiety before and after the examination significantly decreased for both examinees andfamilies (p<0.01). Also, the percentage of families
with a high level of anxiety was higher than that of
the examinees (p<0.01), both pre- and post- exam.
Spearman’s correlation coefficient of examinee andfamily anxiety was 0.519 before the examinations(p<0.01), and 0.644 afterwards (p<0.01), both of

Basic Information of Examinees (n=223)
n (%)

FemaleAYA generation (≧15 years)
Area : Naka-dori1)
Accompanied by family
Taken confirmatory examination before
Family history of thyroid disease2)

159 (69.0%)
163 (73.1%)
201 (90.1%)
217 (97.3%)
74 (33.2%)
36 (16.1%)

1) Naka-dori is central Fukushima prefecture2) Family history of thyroid disease includes a relative’s thyroid tumor,
thyrotoxicosis such as Graves’ disease, and hypothyroidism such as
Hashimoto’s thyroiditis, etc.

N. Setou et al.

58【Figure 1】（n）
Figure 1. Contents of ConsultationΨ This figure shows how often these topics arose when support members consulted with examinees and theirfamilies during E2 support (N=223)【変更点】

項目のフォントを Figure4 と揃えました。

Figure 2. Examinee’s anxiety levels pre- and post- exams
Ψ The degree of anxiety was shown in 5 levels [Very High, High, Low, Very Low and Unknown]

which showed a high correlation. The anxiety level
was lower for both the examinees and their families
who had a previous confirmatory examination experience (examinees p<0.01, families p<0.01).

ed 209 inquiries about the dedicated-line telephoneservice to obtain medical information (see note below), 125 about next and/or future TUE, and 54 supplemental explanations.

Support provided by the support member

Note) Special number for medical information
The Thyroid Examination Section of the Radiation
Medical Science Center of Fukushima Medical University
provides a dedicated-line telephone service (telephone service for medical questions) to respond to questions about
thyroid examinations.

Figure 4 shows the content of the support provided by the thyroid support team members. Categories included “Responding to questions”, “Confirmation of explanation from the doctor”, “Providing
information”, “Listening to the examinee’s and family’s thoughts” and “Decision-making support for future rounds of TUE”. Provided Information includ-Psychosocial support in TUE secondary exam

59

Figure 3. Family member’s anxiety levels pre- and post- exams
Ψ The degree of anxiety was shown in 5 levels [Very High, High, Low, Very Low and Unknown]

Figure 4. Support provided by the Thyroid Support Team membersΨ This figure shows numbers of times these items were provided in support of examinees and their families
during E2 (N=223)

Categories of the questions asked by the examinees andtheir families
From the descriptive record (Record 2), we extracted 254 questions asked by the examinee andfamily members. 18 questions were asked by theexaminees, and 236 were asked by family members.
Specific examples of questions among examinees
and their families are shown in Table 3. They are
divided into 4 categories ; “Program of TUE”,“Findings and causes of nodules”, “Changes in nodules”, and “Thyroid cancer”.
For TUE-related questions, some felt taking E2
allowed them be more relieved, while others, especially those who had been subject to E2 multiple

times and who came to the hospital from a long distance away, felt taking these examinations was aburden.

Discussion
Analysis of the support records revealed several findings. First, the concerns of examinees andtheir families during this period were related to
TUE, followed by examination findings (Figure 1).
Also, there were many questions asked by examinees or family members about TUE, such as “Willthis examination continue?” and “Is it better for me
to undergo this examination next time?” (Table 3).
Regarding the TUE-related questions, some people

N. Setou et al.

60
Table 3.
Category

Frequent questions among examinees and their families (excerpts)
n

Question・Will this examination continue?

Program of
TUE

・Is it better for me to undergo this examination next time?
88・If I am employed outside Fukushima prefecture, which Medical institution
should I be examined at?
・Are the criteria for E2 based on size?
・Is my symptom (swelling in the neck, etc.) related to this nodule?

Findings andcauses of
nodules

86

・Has the nodule grown larger than before?
・Why was the nodule formed?
・My family has thyroid disease. Is it related to the child’s nodule?
・Will the nodule grow larger? (or Will it shrink smaller?)

Changes in
nodules45

・Can benign nodules turn into thyroid cancer?
・What symptoms will be appeared If the nodule grows larger?
・How many people have been diagnosed as malignant cases?
・Are there many malignant cases in Fukushima Prefecture?

Thyroid cancer

22・What kind of treatment is given for thyroid cancer?
・Is there anything that I need to be aware of in my daily life to avoid thyroid
cancer?

found great relief in receiving E2, while others felt aburden to undergo the examination, especially those
who had undergone E2 many times or came from far
away. Because E2 examinees already have nodules
or cysts above a certain size, they are often subjected to secondary examinations every time they undergo TUE, and they often have to adjust theirschool or work schedule. Therefore, some people
wonder what to do about future examinations.
One of the reasons for the large number of TUE
concerns and questions must take into account thatthe social environment for TUE have changed over
the years. For example, in the report from the International Agency for Research on Cancer (IARC)
in 2018, the Expert Group stated that within the
thyroid monitoring programme, there should be ashared decision-making process between individuals, families, and clinicians about whether and how
to engage in thyroid examinations16). Although thisreport is not a recommendation with regard to thecurrent TUE program in Fukushima prefecture,
more attentive explanation for the understanding of
its advantages and disadvantages on TUE is socially
recommended. On the other hand, experts in Japanare divided on whether TUE should continue under
the current system, considering the risk of over-diagnosis and the increased psychological anxiety of

examinees and their families17,18).
However, the discussion of over-diagnosis of
thyroid cancer is extremely specialized and quite difficult for the general public to understand. Therefore, the support members at E2 have tried to communicate with examinees and their families in as
neutrally as possible, helping them to understandthe background and the current status of TUE. As
Figure 4 shows, “Responding to questions”, “Confirmation of the doctor’s explanation” and “Providing
information” were provided to almost examinees
and their families. Additionally, “Decision-making
support for future rounds of TUE” was provided toabout half of examinees and families. For the process of decision-making support, we try to 1) identify what they understand about TUE, 2) answer theirquestions, 3) sort out confusing information, and 4)
provide appropriate information. In addition, we
encourage examinees and their families to think
about future examinations independently.
Following consultations about TUE, the common topics were questions about the results of theexamination, such as the findings of nodules, andtheir cause (Figure 1). And the specific questions
were categorized as “Findings and causes of nodules”, “Changes in nodules”, and “Thyroid cancer”(Table 3). All of these are directly related to the ef-

Psychosocial support in TUE secondary exam

fects of radiation exposure and the anxiety and fearof thyroid cancer.
A number of studies have found that health effects due to exposure to radiation from the nuclear
power plant accident in Fukushima prefecture areunlikely19), and rather the deterioration of the healthconditions of the affected people is pointed out to becaused due to the evacuation20). On the other hand,
there are quite a few people, especially those who
lived close to the nuclear accident, who are still worried about the effects on the next generation, evenseveral years after the disaster21). In the aftermathof the Chernobyl accident, the incidence of thyroid
cancer increased several years after the accident22),
and the health effects of continuous low-dose radiation exposure remain largely unexplained23). Therefore, there are still many people who continue tohave concerns about the radiation exposure of children in Fukushima. In this study, there were also
many questions and consultations regarding the current condition of the nodules, the causes of the nodules and future changes.
The examinees and their families often have insufficient medical knowledge about the thyroid
gland, nodules, cysts, and thyroid cancer. Therefore, the support members helped examinees andtheir families understand by repeating the doctor’s
explanations, providing supplementary explanations
and feedback to the doctor if needed (Figure 4).
For those who had high anxiety about radiation exposure, the support members also listened to theiranxieties and explained the results of the 2016 interim report24), which is based on epidemiological analysis of the first and second round of TUE and statesthat “At this point, there is no evidence of a link between thyroid cancer and radiation exposure”. Midorikawa et al. reported that holding explanatory
meetings for children and parents helped to reduce
their anxiety8). In this study, we also consider that
careful explanations to help understanding and sharing of anxious thoughts through dialogue reduced
the proportion of highly anxious examinees and theirfamilies significantly after E2 (p<0.01) (Figure 2, 3).
In addition, it has been confirmed that the anxiety levels of those who had taken E2 before, weresignificantly lower than those who had not (p<0.01).
This may have been due to the fact that those who
had experienced E2 had asked questions and received information about their concerns during previous E2, which may have contributed to their reduced anxiety. Many examinees and family members
expressed reassurance when they know that young
people often develop thyroid nodules and cysts1),

61

that not many people are diagnosed with malignancy,
even in those who undertake E21), that most thyroid
cancers, unlike other cancers, have a good prognosis25), and that most of the thyroid cancers found by
TUE are less than 20 mm in size1) and are in thevery early stages. Hino et al. reported that careful
explanation of objective facts is important when explaining TUE to affected residents, and such explanations and question-and-answer sessions, can reduce anxiety and increase subjective understanding,especially in small groups18). Particularly for support during E2, it is possible to provide face-to-facedialog and respond to questions, which may directly
help reduce the anxiety of examinees and their family members by providing sufficient explanation andinformation.
Also, families were significantly more likely tohave high anxiety than examinees (p<0.01). Examinees and their families had a high correlation coefficient in their anxiety levels, (R=0.519 before theexaminations and R=0.644 after them), according tostatistical analyses. A report of the Chernobyl disaster showed that maternal anxiety was strongly
associated with their children’s negative self-evaluation of health after the incident28). Another reportfound that mothers’ concerns about their children’s
health persisted for a long time, and undergoing a
medical examination or clinic attendance was also
associated with their health risk perceptions 29).
Following the Fukushima nuclear accident, it was reported that parental disaster-related guilt is strong6,7),
and disaster-related experiences and family stressare significantly associated with radiation-related
anxiety30). Therefore, considering the high correlation between parent-child anxiety in the present results, it was considered important to provide careful
explanations and continuous psychological education
to both examinees and families on matters related toradiation anxiety, as well as psychological support toencourage family communication.
We found three issues in term of future TUE
support. One is the aging of the examinees. Children were generally aged 0-18 at the time of the nuclear accident, but in this study, the percentage ofthe so-called AYA generation aged 15 and above exceeded 70%, and the number of the AYA generation(adolescents and young adult generation) will increase more and more in the future. In the past,
many examinees had been relatively passive about
taking the examination, based on parental recommendations or examinations in their schools. From
now on, explanations to examinees themselves inE2 should be enhanced so that they can decide

N. Setou et al.

62

whether or not to undergo TUE. In addition, psychosocial support tailored to the unique needs ofthat generation, such as employment, marriage andchildbirth31), should be taken into consideration.
The second issue is how we expand the psychosocial support by specialized trained staff and thesystem in TUE. As shown in table 2, most of thesubjects of this study live in Naka-dori, where Fukushima Medical University is located, but many of
those who live in other areas visit other facilities,
where few professional staff for psychological care
are assigned.
The third issue is to address the information
gap inside and outside the prefecture, and the strong
stigma, especially outside the prefecture. Many
young people in Fukushima prefecture also leave theprefecture to attain the next step of education or finda job. Since stigma may causes great psychologicalburden and trauma32), it is important to establish accessible counseling or support services and to educate the public to correct prejudice.
The Chernobyl Forum Report from the 20th anniversary of the Chernobyl nuclear power plant disaster and the presidential review of the health consequences of the Three Mile Island nuclear accident,
concluded that mental health effects were the mostsignificant public health consequence of the accident33,34). Thyroid Support Team members would
like to ensure that the examinees’ and their families’
wellbeing will be protected in the long term by enhancing the psychosocial support of the current andfuture TUE.

Conflict of interest disclosure
We declare that we have no competing interests.

Reference
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Study limitations and future issues
The data for this study was not obtained onstandardized scales, but was recorded by membersof the Thyroid Support Team. Another limitation isthat this study is retrospective one and in order toclarify the effects on the mental health and quality oflife among examinees, we need a cohort study basedon prospective design. Additionally, the residential
areas of the examinees did not cover the entirety ofFukushima prefecture, and the period was limited. We’d like to analyze the support data and identify the characteristics for each TUE period in orderto prepare for nuclear accidents that may occur inthe future.

8.

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Abbreviations   TUE : the Thyroid Ultrasound Examination   E1 : the primary examination   E2 : the secondary confirmatory examination