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Issue: Health Education and Risk Communication Strategies

Given the apparently widespread indoor use of methyl parathion and the limited understanding of associated public health implications, is the current strategy of health professional education, community health education, and the national health alert the most appropriate and effective methodology?

See Public Health Practice Workgroup report following this section.

Overarching Issues

Although many of the issues posed to the panel deal with approaches to past MP misapplications, the panel strongly recommends that efforts directed toward primary prevention (i.e., preventing future misapplications) be continued. In addition to the voluntary actions taken by the manufacturer and enforcement actions taken by the appropriate agencies, we recommend continued emphasis on health education to alert the public to the hazards of pesticide misapplications.
Resources must be devoted to evaluating the effectiveness of alternative, cost-effective control strategies.
More coherent planning is needed to effectively respond to these environmental health emergencies. Moreover, the planning for health education needs to be integrated with risk management.
Members of affected households will be faced with difficult decisions regarding the risks of MP exposure and costs and benefits of alternative interventions. Risk communication and health education are critical to assist these people in making informed choices.
The panel suggests that the steering committee explore the feasibility of using sentinel animal populations (e.g., household pets) as biomonitors for residential MP contamination.
The panel has identified critical data gaps that must be urgently addressed so that scientifically based risk management decisions can be made. These gaps have been identified throughout this report but are again summarized here:
Field Survey of MP Environmental Degradation Products
The EPA should design and implement an environmental sampling study to determine the environmental degradation products of MP in indoor settings, especially PNP. The study should include a sufficient sample of representative homes (by region, time of application, type of application, etc.) to allow inference to other homes in the region.
7-day Study with Daily A.M. and P.M. Urinary PNP
The agencies should conduct a minimum 7-day pilot study of minimum daily a.m. and p.m. urinary PNPs in households currently undergoing environmental sampling. Individual environmental exposure questionnaires such be administered before each sample collection. In addition to urinary PNP, urinary creatinine should be measured on all samples to allow for creatinine adjustment. The study should be performed in a sufficient number of residences to make these observations under varying exposure conditions. The results of this study will help to determine the variability of spot urine samples, the usefulness of individual exposure questionnaire data in selecting optimal sampling times, and the value of adjustment for urinary creatinine. NB: The public health protection of households participating in this more intensive monitoring overrides research issues: if on-site inspections demonstrate an imminent hazard situation or if urinary PNP results indicate overexposure in the course of data collection, the usual relocation interventions must be put into effect, regardless of the impact on the study.
Dermal Absorption Studies
Humans: The work group feels that it is critical to conduct a dermal absorption mass balance study correlating MP dermal dose with urine PNP excretion pattern in human volunteers. Such a study should be contracted to recognized experts in human dermal exposure studies and must be approved by the institution's Institutional Review Board.
Animals: The effects of combined dermal exposures to MP and PNP, as well as combined exposure to MP and other pesticides identified in the field, should be investigated in a relevant animal model (pig, monkey, hairless guinea pig).
Subchronic Toxicity Study in Animals To Determine Dermal RfD
A subchronic toxicity study in rats to determine a dermal RfD for MP would be very useful for risk assessment in this situation. EPA and ATSDR should review available databases to determine if such data are currently available. If not, agencies should consider initiating such a study.
Pilot Study of Urinary PNP and RBC Cholinesterase
Data from occupationally exposed agricultural workers indicates that depression of RBC cholinesterase is unlikely at urinary PNP levels less than 1,000 g/L. The assumption that chronic low-level MP exposure will not depress RBC cholinesterase levels should be confirmed. A representative sample of people should be offered both urinary PNP and blood RBC cholinesterase monitoring. These may be individuals who are referred or self-referred to AOEC clinics for evaluation. If the sample is not random, sample should be compared with the target population in terms of levels of environmental exposure, urinary PNP, demographics, etc., to assess the possibility of selection bias. The RBC cholinesterase assays should ideally be performed by a single reference laboratory with demonstrated quality assurance for this assay. Before a single laboratory is identified, however, the issue of sample preservation needs to be addressed to determine if shipping samples to a central location is technically and logistically feasible.
Cohort Study of Neurobehavioral Effects in Children Exposed to MP in Utero and Postnatally
The panel recognizes the need for and importance of a cohort study to assess the relationship between in utero and postnatal exposure to MP and neurobehavioral effects in these populations. This epidemiologic study should be designed to address key risk management questions: What is the dose-response relationship between indoor exposure to MP and neurobehavioral effects in the highest risk groups? The study should be able to determine the exposure levels that produce no observable adverse effects on central nervous system function in these populations and would be very useful in setting future relocation criteria. This study is likely to be complex and expensive; nevertheless, it is a reasonable expenditure given the huge amount of resources devoted to current interventions. ATSDR should enlist the assistance of an expert peer review committee to assist in reviewing and providing guidance in the design of this study. There is a small window of opportunity to implement this study, especially if reversible effects are considered an important outcome.

PUBLIC HEALTH PRACTICE WORKGROUP

CHARGE TO THE WORKGROUP

Good communication is as important as good science for protecting public health. ATSDR and EPA should be commended for including an emphasis on communication in this expert panel workshop. The federal, state, and local agencies, despite tremendous time and resource constraints, have also stressed communicating with affected populations.

Clearly, there is a commitment to public health education and a recognition that communication is essential to coping with the methyl parathion situation. A suggestion or recommendation in this document does not imply that agencies have failed to take such action. In fact, given agency expertise and commitment, we would be surprised if many of our suggestions have not been acted upon in some way. Finally, our mission is not to critique current agency programs, nor do we have the information to do so. Thus, any examples of communication problems, unless otherwise stated, are derived from research or experience with issues other than MP.

Although agencies need guidance on step-by-step processes, this document does not attempt to serve as a manual. We cannot emphasize strongly enough that we see the following guidance as a beginning of agency consideration of communication issues, not a communication plan.

The efforts of the public health practice work group would not have been possible without the input of affected people from three states, and the personnel from ATSDR, EPA, and state agencies who provided information, reality checks, and invaluable ideas.

Finally, in this section of the expert panel report we have not examined the larger policy decisions about the most appropriate public interventions. We have not looked at whether agencies should be conducting mitigation or pursuing other strategies, nor have we examined where responsibility should lie. We assume such strategies have already been examined not only from technical perspectives but also from social ones.

Why is communication important?

Communication should be oriented toward helping affected people make decisions and empowering them to implement those decisions. Affected participants, agencies at all levels of government, and local organizations should be involved in communication planning.

General Recommendations

Coherent communication planning is needed for short-term, mid-term, and long-term communication.

Agencies are devoting considerable effort to ensure that good science underpins their intervention strategy on methyl parathion (MP). Agencies avoid sampling or monitoring without at least a short-term plan. To do otherwise would lead to poor risk management. Similarly, communication without a plan is equally unwise. It can lead to confusion that is hard to overcome, as agencies have often discovered after faulty news reports on any number of environmental issues. Distrust, once created, is very difficult to dispel (Slovic, 1993).

Communication without planning can also be a great drain on agency energy and resources. For example, brochures made public before considering the content and method of distribution may languish unused; coordination failures may lead to inundations of phone calls for which staff are unprepared; misinformation of the community can be more difficult to remedy than lack of information.

Getting over the "there's not enough time" syndrome

Insufficient time is the most common reason for skipping planning. One result is that agencies spend much time fighting communication fires rather than planning for them or avoiding them. In fact, ad hoc communication efforts often take far more time than carefully planned ones. Just as a poor sampling plan can slow down assessment because of the need to rethink and resample, it is ultimately more time-consuming to develop a brochure or fact sheet without thinking through how it will further your communication goals.

If the "there's not enough time" syndrome is affecting efforts to communicate about methyl parathion, consider the following potential options:

Planning to be proactive rather than reactive. Avoid firefighting by knowing where the flashpoints may occur.
Integrating communication and technical planning. If technical planning goes on for months and communication is thought of afterwards, it is impossible for communication to be timely or effective.
Developing basic outlines of long-term plans, so short-term implementation can occur. You can't get anywhere without a map, but tracing the major highways can be sufficient to get you to the right area--where you can develop the more detailed street map for immediate use.

Too often agencies do not have well-thought out protocols for communication emergencies that can be general but flexible to the situation. Because, unfortunately, MP situations are now being found in other areas, federal agencies should have generic standard operating procedures (with sufficient flexibility to modify for local conditions) about how to handle newly found outbreaks.

Standard Operating Procedures should include

Identification of affected community members who can be consulted for advice on the design and dissemination of information materials. Representatives of affected community residents should be consulted at the earliest possible junction in the decision-making process.
Immediate coordination with local authorities such as the local and regional departments of health, department of environmental protection, agricultural extension service. These officials may provide expert advice on specific features of the target communities and may also already have other programs that can provide a basic infrastructure for the implementation of the emergency MP program. The efforts of the local and federal agencies must be coordinated from the start so that potential conflicts can be resolved and division of labor can be accomplished smoothly.
Pretesting of information materials before their release, to avoid misinforming the community. Because of agency time pressures during the MP crisis, it is understandable that pretesting was not done. However, a misinformed community can extremely time-consuming to manage. We recommend that in cases of emergencies such as MP exposures, a limited pretesting protocol can be implemented in which key community representatives are asked to review the materials for no more than a week. This protocol would help agencies avoid costly mistakes.
Consultation with communication specialists, if not on staff. Specialists should be consulted at the earliest stages of the crisis, before any communication actions have been implemented. These specialists will help design a communication strategy and reduce the burden on the agencies responding to the emergency.

Integrated scientific, management, and communication planning

Effective communication cannot be added after scientific and technical decision making are completed. Such an approach ensures that there will never be enough time for communication planning. In addition, given that "people problems" can be the stumbling block of risk management strategies, social science and communication input are needed to develop effective risk management strategies. To maximize resources, risk management and communication strategies must be complementary.

Planning requires thinking through the appropriateness of risk management strategies, given the social dynamics that may be quite different from remediations at Superfund sites. Similarly, communication strategies should be developed mindful of considerations such as field constraints and the state of the science. Optimally, planning of technical and communication efforts will be collaborative, particularly in MP intervention, where individual behavior is integral to risk reduction. To conserve resources, it will be useful consider of how to complement communication and risk management strategies at each phase of helping a family through the MP process.

Policy decision making should include input from risk management and communication experts, although representation need not be equal. Thus, major policy decisions on assessment protocols and remediation should include representation from senior communication managers who have significant experience in health education or community relations. Public information or press office experience is rarely sufficient for planning communication programs such as those for MP, which require dialogue and involvement of affected parties (Grunig et al.).
Technical personnel must also be part of communication planning, so that the strategies can be coordinated. If technical personnel are not involved in communication planning and implementation, the planning is unlikely to succeed. This is because communication planning involves the design of a method to deliver a risk information and health promotion message. Technical personnel must decide what that message should be in conjunction with the communication experts.
Communication strategies, such as those needed for MP intervention, cannot be developed without personnel experienced in community relations, public involvement, or health education They have specialized expertise and, just as toxicologists have more authority when dealing with toxicological issues, these experts' opinions should carry more weight when developing communication strategies.
We do not know enough about present institutional structures for MP planning to advise whether and how they might be modified. Planning mechanisms should allow for diverse input on long-term plans, yet recognize that detailed plans cannot be developed by large groups. One structure might include use of larger, more representative forums for communication planning. These forums should be mechanisms for soliciting ideas and feedback on "straw outlines." Smaller task forces can develop the more detailed plans. Although some interaction will be needed among larger groups and smaller task forces, the timelines of MP crises do not allow for consensus on all issues. The goal should be coordination and planning that allows for a great deal of local flexibility.

Limitations of Information Dissemination Strategies

Communication can take many forms. Agencies are familiar with traditional information dissemination conducted by public information or press offices. This type of information dissemination tends to be one-way (National Research Council, 1989, 1996). Information release has other limitations:

There is limited data about the relationship between information, attitude, and behavior. Mounting evidence shows that the links between information and behavior are tenuous and ill-defined (Johnson, 1993). Thus, traditional public information plans that rely on information dissemination may not be sufficient.
Affected parties need to make complex decisions that have emotional as well as cognitive dimensions.
The trade-offs that affected parties need to make are potentially difficult and multidimensional. For example, are the health benefits of relocation worth the potential stress of relocation? How should coping with pesticide exposures figure into the priorities of their lives? Information alone is only one component of this type of problem-solving conducted by public information or press offices.
If affected individuals do not feel a sense of efficacy, a feeling that they can make some impact on their circumstances, agencies are condemning themselves to shouldering the entire burden of solving the myriad problems tied to methyl parathion and related pesticide applications. Just as important, when people feel that they cannot change their circumstances, the loss of control over their lives can increase stress, which can have adverse health consequences. Information is only one input to developing efficacy (Rile and Dunlap).

Therefore, communication strategies should promote effective problem solving, which requires

dialogue and exchange of information among affected institutions, agencies, and other community organizations
collaborative efforts that maximize resources and expertise
integration of affected individuals as resources and participants rather than as merely passive victims for whom agencies must take responsibility. These principles have been formulated as part two major reports: Understanding risk: Making decisions in a democratic society (National Research Council, 1996) and Presidential/Congressional Commission on Risk Management of 1997.

We strongly suggest the development of local advisory committees that include not only local civic leaders but also affected individuals who have the energy and commitment to serve as leaders on this issue.

Steps for Communication Planning

Materials development should not occur without knowing the concerns and needs of the people to whom they are directed.

Development of materials is too often the first step in agency communication, although to be effective it needs to be part of a larger communication strategy that takes into account, at minimum, audience concerns and questions, as well as communication strategies. Without appreciating the information that affected individuals want, communications planners are unlikely to develop materials that will respond to their concerns, leaving readers frustrated, potentially reducing agency credibility, and ultimately draining agency resources through calls from confused community residents.

There are many guides for communication planning. Here are some basic questions that should be addressed (adapted from Chess and Hance, 1994):

1. What are your communication goals?

Goals will differ at various times and places. Some basic goals are

Empowering those affected to make decisions about the actions they wish to take. Effectiveness depends not only on government actions but on the actions of affected parties such as homeowners and managers of restaurants and day care centers. Reporting potential exposures, reducing those exposures, and developing alternative means of pest control will depend on affected individuals. They need to make critical decisions about how they want to deal with potential exposures. Agencies can recommend actions but, ultimately, potentially affected parties must make critical decisions about potential remediation.
Providing appropriate information and conducting sufficient dialogue to accomplish the preceding goal.
Reducing the spread of application of MP and other illegal pesticides.
Identifying exposed individuals.
Involving formal and informal organizations at the community level in many functions. For example, federal agencies cannot effectively monitor illegal pesticide applicators nor develop command and control options that will end all such operations.
Maintaining agency credibility.

2. Who are your audiences?

When asked whom to reach, agency personnel are often tempted to say "everyone," particularly because many individuals have the potential to use illegal applicators. However, even Pepsi Cola, with far more resources that agencies will ever have to devote to MP communication, segments its audiences to target its messages to particular markets. In essence, agencies are now involved in a form of social marketing, purveying information and advice rather than commercial products (Rice).

We see three key audiences for agencies to consider, each of which have specific subaudiences:

Those who have been identified as exposed.

Those who are exposed but do not yet know it.

Those who should be alerted about the risk of illegal applicators.

The following discussion focuses largely on the audience of immediate concern for agencies, according to agency representatives involved in the expert panel: those who have been identified as exposed. A later section outlines strategies for communication with those who are exposed but do not yet know it. Agencies should outline communication plans for each of these broad audiences, before implementation, the plans should be integrated in such a way that they build on each other and maximize resources. For example, although different audiences may need different information, ideally some materials can be developed that serve all three.

3. What do audiences want to know?

At first contact, people want to hear answers to their questions, not just what agencies think is important. Social and cultural backgrounds may influence what people see as important. To find out what people want to know and how they might be involved, a variety of approaches can be used. One involves maximizing the time agency personnel spend with individuals by ensuring that personnel keep track of questions asked. The key questions can be incorporated into routine agency communication.

For example, a standard intake questionnaire might ask individuals what questions they have regarding MP. Those questions can be not only be answered, but quickly compiled to serve as the basis for the development of materials. Other potential approaches to finding out audience concerns quickly and efficiently are consulting local community leaders, reviewing news clippings, and receiving routine input from a local advisory committee. However, these approaches are short cuts that should be complemented with formal research (see later section).

Three affected residents (all with Level 1 homes) who were available to the expert panel for consultation indicated they would like more clarity on health information, including both short-term and long-term potential implications. Equally important was information on the process that the agency would be using to deal with their families and homes. They each wanted an outline, with a timeline, of basic steps in the process (e.g., testing, conveying of results, relocation and remediation). They also wanted detailed information about each step. Some of the affected individuals had questions that were specific to their situation but also were likely to have broader interest. The questions concerned the impact of exposure on children; referrals to doctors with specialized expertise (this was particularly important to one family where children were raised from birth in a contaminated environment and had severe respiratory problems that continued after removal from their home); and appreciation of the appraisal process.

The individuals we spoke with felt they did not have adequate access to information on these issues and others. They also did not have an open means of communication with the agencies and were typically referred from place to place when calling for information. Thus, even if agencies are devoting considerable resources to communication, there may be significant communication gaps that need to be identified and addressed.

People may also want more information than agencies think it is wise for them to know at initial stages. That is, some people, even before they know the level of contamination of their home, may want fairly detailed information on the potential health effects of MP, even though the information may not ultimately be relevant to them (e.g., they have a level 4 home). However, a rule of thumb is that agencies should provide people with as much information as they ask for, while providing appropriate caveats (e.g., symptoms are unlikely to occur in people who live in level 4 homes).

4. How will you communicate with audiences?

Identify local capacity and leaders.

There are established methods for identifying local capacity and conducting local needs assessments (including Superfund guidance that will have some applicability although the time frames, dispersed geographical distribution of affected homes, etc. undoubtedly will require some different protocols). We recommend that a flexible protocol be developed to help agencies quickly assess the social infrastructure and identify the most useful organizations with which to collaborate. The collaborations can vary in duration, scope, and extensiveness. Collaborations can involve one-time activities or ongoing relationships that maximize existing channels of communication.

It is beyond the scope of our work to specify all potential channels of information. However, we strongly recommend that a list of potential organizations that might be useful should be developed and that agencies use different forms of partnerships in dealing with them. For example:

Agencies need to partner with local organizations that have established channels of communication that may be used effectively. To do so, agencies need to develop an understanding of the local capacity, which is likely to vary. In some areas, a poison control center may serve as a key conduit of initial information and advice but in other areas this role might be more appropriately served by another organization. This initial information service can help agencies deal with the considerable load of requests from concerned people. Poison control centers and other such organizations have trained personnel on staff who can be trained quickly and easily to provide information on MP to the public.
It may be effective for agencies to distribute information for community groups to include in their newsletters, which have a readership federal agencies might not otherwise reach easily. Agricultural extension services have ongoing efforts with farmers that may be an effective way to reduce the selling of methyl parathion or other agricultural chemicals. Piggybacking on local efforts can be done with minimal effort in some cases, rather than asking local agencies to add to their already heavy loads. For example, extension agents talk to farmers daily about a range of issues. They might be able to distribute material and alert farmers to the dangers of indoor use as part of their daily schedule of meetings with individual farmers and groups. Similarly, 4H clubs are another potential route for reaching potentially exposed individuals or reducing the use of illegal pesticides. 4H is also a potential route to begin discussion of issues related to integrated pest management (IPM).
Existing health services have also been tapped for assistance. Some may play major roles; others, which already have programs for chronic illnesses such as diabetes or hypertension, may be able to distribute materials and ask clients about pesticide spraying as part of their routine contact with clients.
Many community organizations such as churches and civic organizations are already overburdened and underfunded. However, if alerting people to the possibility of exposure to MP (and other illegal pesticides) can be easily incorporated into their routine duties, it is more likely to occur than if they are asked to take on major functions without major funding.
Finally, and most importantly, consider using affected individuals as participants in outreach efforts. Those affected individuals who came to the expert workshop were interested in being involved in constructive ways, such as providing emotional support to other affected individuals, serving as speakers to local community groups and churches, speaking with friends and neighbor and leading support groups. Agencies lack the resources (and maybe the credibility) to conduct such outreach. Agencies can develop a short training program for interested individuals and then encourage them to train others. We recommend that such innovations be tried on a pilot basis, perhaps involving one or more of the three participants in the expert workshop in leadership roles.

5. What message do you want to get across?

Messages should be created based on answers to the following questions:

What do people want to know?
What do agencies think people should know?
What are people likely to misunderstand if not explained?

A short-term strategy (within a week) for specific message and materials development might include the following steps:

Identify participant concerns by convening a focus group or calling people who are exposed for guidance. Determine their questions and concerns.
Determine what messages the agencies think are critical.
Consider what your audiences are likely to misunderstand if you don't spell it out.
Draft materials based on the answers to the three questions above.
Pretest. Have members of the intended audience read the material and comment. There are various means of pretesting, and health education experts can implement a quick-and-dirty plan. A health educator can accomplish the above in a week or so with input of technical staff throughout the process so that technical review does not take additional weeks.

Using an iterative approach

Such materials should be used for a limited time while health educators/community relations staff implement a more methodologically stringent approach to materials development. Because of the need to revise materials for a variety of reasons, including the development of new information, agency materials should not be elaborately formatted or printed. In this way, materials can be adapted easily.

Materials might be developed on the national level in collaboration with local agencies and representatives of affected people. Development of specific national materials should be delegated to state and local agencies. Materials for national use should leave space for local contact information. Local or regional agencies can also adapt the materials to suit their particular needs or develop different information. However, decentralized adaptation should be far more resource- effective than development of similar materials by many agencies.

Select key audiences to be told of changes in agency protocol

The three affected people who came to the expert workshop had little or no understanding of agency timelines, processes, or decision-making criteria. It should not be assumed that transmitting changes in the protocol is a major issue for all affected people. Agencies need to know who has said what to whom--what promises have already been made? What do people understand those promises to be? It may be wise for agency staff to conduct one-on-one sessions with those who might be affected by changes in protocol. The agency might consider, for credibility purposes, maintaining promises to those to whom clear promises have already been made. Agencies might also conduct follow-up confirmatory biomonitoring to ensure that affected residents are truly not eligible under the new protocol. Although needs assessments should be conducted at local levels to determine awareness of past protocols and number of people affected by changes, etc., we are concerned that major announcements of changes in protocol may cause greater confusion than they resolve.

Regardless of approach, agencies should be careful to avoid the perception that information is being withheld. Local announcements of changes in protocol might be placed in the context of agencies' continuing efforts to improve scientific understanding of MP and the most effective ways to reduce contamination. A strategy will need to be developed for local levels that ensures that no parties are blindsided and that, if at all possible, affected residents hear of changes firsthand, rather than from media sources.

6. What milestones need to be planned for?

Some of the milestones, as we understand them, are the following:

a. Initial point of contact

Affected parties are likely to want not only to report information but to receive it.

Even callers who do not know the extent of their exposures may want information about health concerns: What are potential health effects? Short-term/long-term adverse health impacts? What is the process they should expect to be involved in and timeline for it? When is testing appropriate? What does testing include? What are stages after that?

Possible approaches:

Personnel dealing with callers at initial point of contact need training to respond to very basic questions. This can be delegated to another agency such as the poison control centers, after appropriate training of personnel.
More technically qualified workers need to be available to respond to more detailed questions. Detailed questions require technical expertise that can not be developed through routine training. An agency might consider a national referral center or regional contacts (poison control centers) to which callers can be referred.
Criteria for decision for such a technical service should consider the possibility for 24-hour service for 7-day- week operation; existing infrastructure (phone lines, trained personnel; etc); credibility with existing track record; standard operating procedures that can be modified to meet agencies' needs; experience in counseling and dialogue, not merely providing information; and the ability to develop program without close agency supervision (although coordination will be essential). Under no conditions should this function be taken on by an organization that is not already routinely supplying information on, at minimum, health-related questions from individuals who are concerned about toxic exposure. Thus, services that deal largely with concerns about application, agriculture, or regulations are unlikely to be good candidates for such a service.
Materials: When possible, these should be mailed or otherwise transmitted to people before their homes are tested. At minimum, the materials must outline agency process for testing and follow-up. Materials should be based on information related to the three questions above. Although mailing costs could be saved by distributing brochures through various public facilities, affected parties should have the easiest access possible.
We suggest that a pilot program be implemented to develop support groups for exposed people, who could be referred to the support group at point of contact. The individuals we spoke with felt varying degrees of isolation, fear, and confusion. Agencies often lack the resources to deal as extensively with these issues as they might like. The affected individuals at the expert panel meeting commented how much they learned from each other and remarked on the comfort of dealing with others in like situations. A pilot might be developed in an area for support group meetings led by community leaders or affected individuals, for which agencies would serve as resources. Those who initially contact the agencies could be told, for example, that there is a meeting at a certain location on a weekly basis.

b. Home and urine testing

Personnel who are charged with collecting specimens should bring other materials to participants and go over wipe process and collection procedures. The discussion should include information such as timelines and next steps. The materials distributed at this time must include phone number for more detailed questions.
Pilot options: Training community people to do testing. If possible, training could provide local employment, reduce burden on government, and build local capacity.

Giving homeowners materials with instructions for conducting their own testing; can be followed by confirmatory testing for those levels that seem potentially problematic. (This model was used with some success in the New Jersey Radon program.)

c. Communication of test results

Delivering test results by mail can be problematic, and one-on-one counseling is advisable if resources are available. If this is not possible, phone contacts for detailed information are essential, as would be weekly availability sessions that affected people could attend. The support group concept mentioned previously may be particularly helpful in this area. It is also important that test results be given to the affected individuals in a timely manner so that critical family decisions can be made and anxiety doesn't build further while families wait long periods for the test results.

d. Follow-up steps:

For each step in the timeline, information needs and strategies need to be considered, which is beyond the scope of this report. One possible approach is discussed below:

Potential case management approach

For working with families who have been found to be exposed to high levels of MP (either through environmental assessment or biomonitoring), it is not sufficient for the agencies to recommend relocation without keeping families informed of agency progress. One way agencies may be able to better work with the relocated families is to use a team approach to case management that is increasingly used by social service agencies. This approach increases accountability and responsiveness to the information needs of the affected community residents. This is necessary to reduce the likelihood that affected residents will be referred from office to office when they call to obtain information of the status of their cases.

We recommend consideration of piloting a program in which team of agency officials is assigned to manage and keep track of a specific number of families to whom relocation has been recommended. Each member of the team would be responsible for a specific number of cases, each of whom can call this team member for information on the status of their case and next steps. The team members will have a clear idea of the protocol to be followed, which would be standard for all affected community residents once guidelines are in place. Residents who choose relocation need to have someone specific to call in the agencies for information regarding their progression through the protocol, from test results, relocation, medical monitoring, and remediation.

Responsible individuals in the agencies may also consider training key community residents who have gone through the process to be able to take some of the workload of the agency team members. Community residents who have been particularly active and have a strong relationship with the agency representatives may become invaluable extensions of agency officials. They may be trained to distribute information to the community regarding the procedures that affected residents can expect to go through when their homes have been identified as potentially contaminated.

7. How can the media be used effectively?

This could be the topic of a separate report. Given limited time to consider this issue, we focused on innovative approaches that agencies might use to incorporate local resources. For example, although good news is often not as salient a news peg as bad news, agencies can focus on the development of feature and human interest stories that promote how families have coped successfully with the process of dealing with MP contamination. Call-in talk shows often reach large audiences and, rather than using agency personnel, talk shows might involve affected individuals who can provide constructive firsthand experiences as well as technical experts. Some of the most effective media outreach might include that of affected residents and community leaders who can send letters to the editor (for years one of the most-read sections in newspapers).

8. How can constructive participation be encouraged?

We cannot emphasize strongly enough that local level solutions will need involvement of affected individuals and local leaders in many phases. We reiterate here some of the approaches we have mentioned:

the need for a local steering committee to give ongoing input into agency plans and to develop local outreach efforts
piloting the use of affected parties as peer counselors and outreach workers
piloting the training of residents to participate in case management teams
piloting the engagement of affected parties as peer counselors
involving local leadership on a national task force to develop communication planning
listening to affected parties to guide materials development; those who write columns in weekly newsletters should also be encouraged to tackle the subject.

9. How can feedback be gathered for program improvement?

The MP program will be evolving overtime. The key to program improvement is soliciting feedback from participants including affected individuals, agency staff, and local partners. Because staff are already overburdened, we suggest the following:

Collect feedback routinely by building this task into daily operations. This could take many forms including meeting evaluation forms, sending questionnaires to random callers, and asking them to provide feedback on their contacts.
Document lessons learned by keeping routine records The kind of documents that were produced from the Loraine experience, which summarized key problems and successes, are essential to progress. They might be developed through routine debriefing of agency staff in the field.
Formal evaluation research is needed. We strongly recommend formative research, aimed not at providing a final "grade," but rather at providing incremental feedback for mid-course corrections.
Pilot efforts should not be started without a strategy to provide feedback on their success. The stringency of the methodology should depend on the nature and scope of the pilot.

Identifying Exposed Populations

Similar questions to the nine posed above should shape the strategy for identifying exposed populations.

The agency representatives who provided information to this panel have expressed a concern that the cases identified are merely the "tip of the iceberg." This possibility should not deter the agencies involved from continuing or expanding efforts to identify other populations that have been exposed. We believe that before these identification efforts, agencies need to devise a standard protocol to deal with newly exposed individuals and new areas of contamination. This protocol should then be communicated effectively to the newly identified populations so that follow-up expectations from the community can be met.

Impact of media campaigns: It is not known whether the media campaign used thus far has reached the populations at risk or what message they have received and understood. Therefore, there is a need to assess what the people who have been reached from the campaign already implemented have understood from the information, what they expect will be done in their cases, and what other general expectations they have regarding the agency's responsibilities. To address these questions within the exposed population that have already been identified, it is recommended that the agencies take an individualized approach to case management. (See section on communicating with exposed populations.)

Impact on rural populations: There is a concern that rural populations are not being reached by the bulletins being issued for the identification of possibly exposed individuals. There is a need to assess whether the populations at risk are being reached effectively. This can be done by direct sampling (such as telephone interviews) of the target populations to assess awareness of the campaign.

Preventing New Exposures

Development of strategies for this population should also be based on the nine questions above.

We recommend piloting potential prevention strategies at the local level that can be implemented as models for action at the national level. These approaches are based on models that have worked with other health risks, and these models may be available for modification and application to the current situation on MP. (For example, research on community-based approaches to reducing lead contamination may be of use.) Because we realized that the agencies will be planning major strategies, and we did not have time to develop a step-by-step planning outline, we focused on innovative approaches that might be overlooked.

Manufacturer's recall program of MP that does not have "stenching" agent. Local farmers may exchange unused MP at their local providers and distribution centers. There should be incentives provided for them to do so.
It may be possible for the manufacturer to backtrack from distribution lists to target individuals such as farmers. This approach does not necessarily represent an immense additional burden for the agencies involved. On the contrary, we believe that this may help curtail the spread of the problem in a cost-effective manner by targeting information to those who may be distributing the pesticide illegally to consumers. It is also possible to utilize existing channels of contact to farmers that already exist through the Department of Agriculture. Other agencies might issue a short, half-page brochure that includes information about the availability of new and safer batches of MP (with the stenching additive) that they must use as soon as possible. The pamphlet would also include information on the outbreak and effects of indoor use and the consequences of not following these recommendations, such as prosecution. This approach to the sources of MP can be complemented with the amnesty and recall strategies.
Amnesty program for illegal applicators for returning the MP they have in exchange for immunity from prosecution. This amnesty program would be implemented at local levels during a finite period of time. Consider requiring applicators to bring client list without fear of prosecution for a limited time during the amnesty. This would serve two purposes: (a) to reduce the amount of MP that is now stockpiled and does not meet the new requirements for making it impossible for use indoors; and (b) to help identify other potentially exposed populations.
Potential incentives to encourage the recall may be the understanding that people who do not come forward during the allotted time of the amnesty WILL be prosecuted. This can be conveyed by using the examples of people who have already been prosecuted, jailed, and fined. The recall could also serve to reduce the risk of illegal dumping of the MP materials. Although the agency contacts we spoke with implied that such an amnesty program is impossible, gun recall efforts and tax amnesties should be explored as potential options.
Certified applicators have a vested interest in informing the public about the possible consequences of using illegal applicators for their pest control needs. Agencies may want to consider exploring the following ideas with commercial applicators through trade associations: (a) commercial applicators developing advertisements that build on the theme that not only do they get rid of bugs, they do so safely; (b) development of a joint media campaign between agencies and commercial applicators that recommends the use of certified exterminators because they can be safer than illegal applicators; (c) discussion of possibility of commercial applicators employing those who come forward in amnesty program and training them for certification and employment (in some areas there are shortages of applicators and this may be feasible); (d) encouragement of applicators to consider public housing contracts; (e) discussion of ways to encourage the trust in commercial applicators that people have invested in illegal applicators who are friends, ministers, tradespeople who have been relied on for years.
Agencies such as the Better Business Bureau can be used to inform consumers about legitimate commercial applicators who have proper certification.
Resident managers at public housing areas and landlords can be provided with lists of recommended applicators whom they may contact for their pest control needs. The incentive for landlords to get involved is to reduce the likelihood of use of illegal applicators who may cause contamination.
Real estate agencies may inform home buyers that utilizing MP will reduce the value of their homes. This approach may use the radon model of enlisting Realtors to disseminate agency information. Informal practices of Realtors have been useful in the past (e.g., encouraging buyers to put in clauses regarding radon on prepurchase agreements caused homeowners to take radon seriously).
Affected community residents can address existing community-based organizations to inform others about the potential risks of using MP indoors. By using a train-the-trainer approach, agencies have the potential to reach a large number of people who may not be aware of the risks involved in using MP. For this approach to work, the expertise gained by the community members who have gone through this process must be validated. They may share their experiences in the format of a testimonial at the local churches, parent-teacher association meetings, and other venues where community members meet.
Outreach to local schools can be used to encourage integrated pest management in the homes. This outreach can build on the successes of recycling programs and the Open Airways for Schools asthma management curriculum from the American Lung Association, where integrated pest management becomes part of the science curriculum as a homework project that students take to their homes.
Creative approaches to national media. Agencies should recognize that one letter in Dear Abby or an appearance on Oprah or 20/20 can reach more people than any pamphlet or news broadcast. Although agencies may not be able to use such strategies, affected individuals can do so in effective ways--not merely to talk about victimization but to discuss the need for people to take responsibility on this issue.
Use of punishment of applicators as news peg. In some areas applicators are let off with a slap on the wrist, but in one region an applicator received 25 years in prison and a substantial fine. This type of example highlights the salience of problems with illegal pesticide use.
Chicago story. As unfortunate as this incident is, it will also be able to generate media coverage in ways that small southern towns cannot.
Research Needs
Although "quick and dirty" assessments of the sort encouraged in this report are essential to expedite immediate communication, efforts of this magnitude require research, just as scientific research is needed to develop effective risk management strategies. We suggest convening a small team of researchers, agency representatives, and others to consider a meaningful, manageable research agenda. (The risk communication research agenda proposed in 1995 as a result of a national symposium could serve as a generic guide to consideration of priority needs.) We strongly recommend that social science research include input from practitioners and affected people in the initial conceptualization of research so that it ultimately is as on target as possible. The following questions describe some research that may be useful, but is not meant as inclusive:
1. What mental models do individuals hold of insects and pesticides? Before determining whether and how to integrate IPM messages into prevention, it is essential to appreciate cognitive and emotional components of individual perception. A literature review, particularly of the environmental education literature, is an essential first step. Without an appreciation of how people think and feel about these issues, it will be difficult to construct effective messages.
2. What variables determine the difficulty or ease of community interventions? There is a substantial social psychology literature that speaks to why some communities are more difficult to mobilize than others. This research might serve as the basis for defining a study to guide agency intervention efforts.
3. What evaluation tools will be most useful to provide feedback on agency interventions and community-level initiatives? There has been considerable discussion of the development of useful methodologies to evaluate such efforts and a variety of models have been developed. Ideally, various evaluative efforts would be put in place. The most useful evaluative designs may piggyback on existing agency data collection to reduce the need for substantial additional resources. Although agencies have a tendency to favor quantitative research, ethnography should also be considered to develop meaningful case studies from which lessons learned can be derived.
4. What organizational factors and coordination facilitate effective intervention? One of the most difficult aspects of multi-agency interventions is coordination among agencies. Ways to improve such efforts have been studied by organizational researchers, largely in the corporate sector. As more such multi-agency efforts become essential, organizational insights might become increasingly useful.
The above topics are merely some initial thoughts. We strongly recommend that agencies fund meaningful research that will provide useful insights, using researchers with extensive background in the issues.
Conclusions
In less than 2 days, it is impossible for us to consider many other aspects of communication regarding MP exposure. However, we hope the above provides further fodder for agency thinking and action. The following are our key recommendations:
1. Plan for proactive communication.
2. Do not design materials without knowing audience concerns firsthand.
3. Integrate planning for risk management and communication.
4. Involve community organizations and affected individuals from the beginning.
5. Planning needs to be targeted to three audiences: those identified as affected, those who are exposed but do not yet know it, and those who might expose themselves to contamination in the future.
6. To accomplish the above will require research.
7. The agencies will need to conduct follow-up forums and develop institutional coordination to plan communication.
8. Consult communication specialists before implementing a communication strategy.
9. Integrate communication efforts within the technical assessment of the risk management program.
10. Pretest materials developed to the extent possible.
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