Promoting informed prostate cancer screening decision-making for African American men in a community-based setting.

PURPOSE: Current screening guidelines for prostate cancer (PCa) encourage men to make individual screening decisions after consulting with their primary care provider to weigh the risks and benefits of undergoing prostate specific antigen (PSA) testing, but many men at high risk of PCa diagnosis (notably African American men) are more likely to be uninsured and lack a primary care provider. An academic-community partnership redesigned its community-based screening program to ensure access to services for African American men, incorporating a session with a trained clinical educator in community settings, designed to increase knowledge and promote informed decision-making regarding PSA testing. This study evaluated effects of the intervention on decision-making outcomes. METHODS: To evaluate program efficacy, 88 men completed pre- and post-test surveys assessing outcomes of interest. RESULTS: Participants' knowledge, beliefs, attitudes, anxiety levels, and self-efficacy all improved from pre- to post-test at a statistically significant level. Most notably participants' awareness that PCa is often not life-threatening, and watchful waiting is a reasonable treatment option increased after the encounter. More than half of the study sample felt they had received enough knowledge to make an informed decision about whether the PSA test was right for them. CONCLUSION: Our findings show the program had positive effects on men's ability to make informed decisions about PCa screening and demonstrate that educational outreach programs with an emphasis on informed decision-making can effectively balance screening guidelines with the needs of underserved populations in community settings to improve outcomes.

Examining peer support and survivorship for African American women with breast cancer.

OBJECTIVE: More than 3.5 million female breast cancer (BrCa) survivors live in the United States, and the number continues to grow. Health status and quality of life among survivors are variable, and African American (AA) survivors suffer disproportionately from BrCa morbidity and mortality. Emerging evidence suggests that peer support is an effective strategy to promote positive survivorship outcomes for AA BrCa survivors. This study aimed to explore the role of peer support in the BrCa experiences of AA survivors. METHODS: Working collaboratively with The Breakfast Club, Inc. (BCI), a community-based BrCa peer support organization, we conducted a quasiexperiment to compare the BrCa experiences of AA survivors. We conducted in-depth interviews with two survivor groups (N = 12 per group), categorized according to receiving peer support during their BrCa experiences. RESULTS: Survivors who received peer support reported greater access to and utilization of alternative support sources, more capacity to process BrCa-related stress, and improved quality of life and adjustment to life as BrCa survivors compared with those who did not receive peer support. CONCLUSIONS: Peer relationships provide consistent, quality social support. Consistent peer support helps survivors cope with the continued stress of BrCa, with implications for psychosocial health and quality of life. Findings expand our current understanding of peer support and may enable public health and clinical practitioners to better recognize and intervene with those for whom additional support services are needed.

Enhancing organizational health literacy in a rural Missouri clinic: a qualitative case study.

PURPOSE: The purpose of this paper is to evaluate a collaborative effort between a health care organization and academic institution to strengthen organizational health literacy. DESIGN/METHODOLOGY/APPROACH: The intervention took place at a rural, federally qualified health clinic in Missouri between May 2009 and April 2011. Qualitative interviews of key informants were conducted before (n=35) and after (n=23) the intervention to examine program implementation and success in effecting organizational change. FINDINGS: Intervention activities helped establish a comprehensive understanding of health literacy. The project achieved moderate, fundamental and sustainable organizational change. The program successfully integrated health literacy practices into clinic systems and garnered leadership and organizational commitment, helped the workforce improve interpersonal communication and embedded practices making health education materials more accessible. ORIGINALITY/VALUE: The study points to programmatic, conceptual and methodological challenges that must be addressed for organizations to improve health literacy practices, and suggests change management strategies to advance organizational health literacy.

Perceptions of Urologists About the Conversational Elements Leading to Treatment Decision-Making Among Newly Diagnosed Prostate Cancer Patients.

Widespread adoption and use of the practice of shared decision-making among health-care providers, especially urologists, has been limited. This study explores urologists' perceptions about their conversational practices leading to decision-making by newly diagnosed prostate cancer patients facing treatment. Semi-structured, in-depth interviews were conducted with 12 community and academic urologists practicing in the St. Louis, MO, region. Data were analyzed using a consensus coding approach. Urologists reported spending 30-60 min with newly diagnosed prostate cancer patients when discussing treatment options. They frequently encouraged family members' involvement in discussions about treatment, especially patients' spouses and children. Participants perceived these conversations to be difficult given the emotional burden associated with a cancer diagnosis, and encouraged patients to postpone their decisions or to get a second opinion before finalizing their treatment of choice. Initial discussions included a presentation of treatment options relevant to the patient's condition, side effects, outcome probabilities, and next steps. Urologists seldom used statistics while talking about treatment outcome probabilities and preferred to explain outcomes in terms of the patient's practical, emotional, and social experiences. Their styles to elicit the patient's preferences ranged from explicitly asking questions to making assumptions based on clinical experience and subtle patient cues. In conclusion, urologists' routine conversations included most elements of shared decision-making. However, shared decision-making required urologists to have nuanced discussions and be skilled in elicitation methods and risk discussions which requires further training. Further research is required to explore roles of family and clinical staff as participants in this process.

Systematic Review of Decision Aids for Newly Diagnosed Patients with Prostate Cancer Making Treatment Decisions.

PURPOSE: Despite established evidence for using patient decision aids, use with newly diagnosed patients with prostate cancer remains limited partly due to variability in aid characteristics. We systematically reviewed decision aids for newly diagnosed patients with prostate cancer. MATERIALS AND METHODS: Published peer reviewed journal articles, unpublished literature on the Internet and the Ottawa decision aids web repository were searched to identify decision aids designed for patients with prostate cancer facing treatment decisions. A total of 14 aids were included in study. Supplementary materials on aid development and published studies evaluating the aids were also included. We studied aids designed to help patients make specific choices among options and outcomes relevant to health status that were specific to prostate cancer treatment and in English only. Aids were reviewed for IPDAS (International Patient Decision Aid Standards) and additional standards deemed relevant to prostate cancer treatment decisions. They were also reviewed for novel criteria on the potential for implementation. Acceptable interrater reliability was achieved at Krippendorff α = 0.82. RESULTS: Eight of the 14 decision aids (57.1%) were developed in the United States, 6 (42.8%) were print based, 5 (35.7%) were web or print based and only 4 (28.5%) had been updated since 2013. Ten aids (71.4%) were targeted to prostate cancer stage. All discussed radiation and surgery, 10 (71.4%) discussed active surveillance and/or watchful waiting and 8 (57.1%) discussed hormonal therapy. Of the aids 64.2% presented balanced perspectives on treatment benefits and risks, and/or outcome probabilities associated with each option. Ten aids (71.4%) presented value clarification prompts for patients and steps to make treatment decisions. No aid was tested with physicians and only 4 (28.6%) were tested with patients. Nine aids (64.2%) provided details on data appraisal and 4 (28.6%) commented on the quality of evidence used. Seven of the 8 web or computer based aids (87.5%) provided patients with the opportunity to interact with the aid. All except 1 aid scored above the 9th grade reading level. No evidence on aid implementation in routine practice was available. CONCLUSIONS: As physicians look to adopt decision aids in practice, they may base the choice of aid on characteristics that correlate with patient socioeconomic and educational status, personal practice style and practice setting.

Effects of patient health literacy, patient engagement and a system-level health literacy attribute on patient-reported outcomes: a representative statewide survey.

BACKGROUND: The effects of health literacy are thought to be based on interactions between patients' skill levels and health care system demands. Little health literacy research has focused on attributes of health care organizations. We examined whether the attribute of individuals' experiences with front desk staff, patient engagement through bringing questions to a doctor visit, and health literacy skills were related to two patient-reported outcomes. METHODS: We administered a telephone survey with two sampling frames (i.e., household landline, cell phone numbers) to a randomly selected statewide sample of 3358 English-speaking adult residents of Missouri. We examined two patient-reported outcomes - whether or not respondents reported knowing more about their health and made better choices about their health following their last doctor visit. Multivariable logistic regression models were used to examine the independent contributions of predictor variables (i.e., front desk staff, bringing questions to a doctor visit, health literacy skills). RESULTS: Controlling for self-reported health, having a personal doctor, time since last visit, number of chronic conditions, health insurance, and sociodemographic characteristics, respondents who had a good front desk experience were 2.65 times as likely (95% confidence interval [CI]: 2.13, 3.30) and those who brought questions were 1.73 times as likely (95% CI: 1.32, 2.27) to report knowing more about their health after seeing a doctor. In a second model, respondents who had a good front desk experience were 1.57 times as likely (95% CI: 1.26, 1.95) and those who brought questions were 1.66 times as likely (95% CI: 1.29, 2.14) to report making better choices about their health after seeing a doctor. Patients' health literacy skills were not associated with either outcome. CONCLUSIONS: Results from this representative statewide survey may indicate that one attribute of a health care organization (i.e., having a respectful workforce) and patient engagement through question asking may be more important to patient knowledge and health behaviors than patients' health literacy skills. Findings support focused research to examine the effects of organizational attributes on patient health outcomes and system-level interventions that might enhance patient health.

Prostate cancer survivors as community health educators: implications for informed decision making and cancer communication.

Recent evidence questioning the effectiveness of prostate-specific antigen testing leave community-based prostate cancer (CaP) outreach programs with a dilemma between promoting screening and highlighting screening risks. CaP survivors are uniquely positioned to address this problem by drawing upon real-life experiences to share nuanced information and perspectives. While CaP survivors have historically been incorporated into outreach programs, little is known about their impact on psychosocial outcomes and their effectiveness compared to professional health educators. This study addressed these gaps through a quasi-experimental design where African American men attended a CaP screening session conducted by a health educator (HE) or survivor educator (SV). The presentation included prostate cancer statistics, CaP information, and descriptions of CaP screening tests. SV were encouraged to bolster their presentations with personal stories whereas HE maintained fidelity to the curriculum content. All participants completed pre- and post-test questionnaires. Our sample comprised a total of 63 participants (HE group = 32; SV group = 31) with an age range of 40-70 years. Decision self-efficacy increased significantly in the SV group (p = 0.01) whereas perceived screening risks reduced significantly in the HE group (p < 0.001). No significant changes were found in knowledge, subjective norms, outcome expectancies, and screening benefits. Survivor educators were found to have significantly greater appeal (p = 0.03), identification with audience (p = 0.01), and liking (p = 0.03). Training CaP survivors as health educators might be a viable strategy for community-based cancer communication efforts confronted by the CaP screening controversy. We discuss conceptual and programmatic implications of our findings and present directions for future research.

Young adults' perceptions about established and emerging tobacco products: results from eight focus groups.

INTRODUCTION: In order to sustain their market, tobacco producers target young adults through novel product design and marketing strategies. Public health professionals need to understand young adults' risks perceptions about and use of new tobacco products to best inform tobacco control interventions. METHODS: In 2009, researchers conducted 8 focus groups with 67 young adults stratified by self-reported tobacco use and nonuse, residence in rural and urban areas, and living in a state with or without a statewide smoking restriction policy. Participants provided feedback about their knowledge and risk perceptions about and use of tobacco products and marketing. RESULTS: Participants reported a high level of familiarity with a wide range of novel tobacco products. A great deal of confusion and disagreement appeared with regard to absolute and relative risk of different tobacco products. Participants readily discussed using smokeless tobacco products as alternatives to smoking when smoking is prohibited. Fewer differences in tobacco-related knowledge risk perceptions and use were found between urban and rural participants and those in smoke-free policy and nonpolicy states than between user and nonuser groups. Both users and nonusers were familiar with and skeptical about tobacco marketing and prevention efforts. CONCLUSIONS: Young adults are familiar with many tobacco products, but they convey little understanding of relative risks of new or trendy tobacco products, such as snus or hookah. Mindful of industry innovation, tobacco control advocates must continuously update prevention efforts, seeking new strategies to limit promotion, marketing, and use of new and conventional products.

Advancing organizational health literacy in health care organizations serving high-needs populations: a case study.

Health care organizations, well positioned to address health literacy, are beginning to shift their systems and policies to support health literacy efforts. Organizations can identify barriers, emphasize and leverage their strengths, and initiate activities that promote health literacy-related practices. The current project employed an open-ended approach to conduct a needs assessment of rural federally qualified health center clinics. Using customized assessment tools, the collaborators were then able to determine priorities for changing organizational structures and policies in order to support continued health literacy efforts. Six domains of organizational health literacy were measured with three methods: environmental assessments, patient interviews, and key informant interviews with staff and providers. Subsequent strategic planning was conducted by collaborators from the academic and clinic teams and resulted in a focused, context-appropriate action plan. The needs assessment revealed several gaps in organizational health literacy practices, such as low awareness of health literacy within the organization and variation in perceived values of protocols, interstaff communication, and patient communication. Facilitators included high employee morale and patient satisfaction. The resulting targeted action plan considered the organization's culture as revealed in the interviews, informing a collaborative process well suited to improving organizational structures and systems to support health literacy best practices. The customized needs assessment contributed to an ongoing collaborative process to implement organizational changes that aided in addressing health literacy needs.

Effects of a campus-wide tobacco-free policy on tobacco attitudes, norms and behaviors among students, staff and faculty.

Objective: In 2016 a private Missouri university implemented a campus-wide tobacco-free policy to change social norms and prevent tobacco use among students, staff and faculty. This study assesses impact on tobacco and policy-related perceptions and behaviors. Methods: Before the policy went into effect and again one year later, all university students, staff and faculty were invited to participate in an online survey. Missouri Assessment of College Health Behaviors survey findings supplement results for students. Results: Policy support and norms disapproving tobacco use on campus increased, and self-reported use of any tobacco decreased after the ban was enacted. Conclusions: Our results suggest that the policy led to an increase in the proportion of university community members who agree that smoking on campus is unacceptable, which contributed in turn to a decline in tobacco use on campus, consistent with our theory of effects.

Changing the conversation about prostate cancer among African Americans: results of formative research.

OBJECTIVES: To understand obstacles to and opportunities for improving prostate cancer communication to and within African American communities. DESIGN: Researchers conducted interviews with 19 community leaders and five focus groups with healthy men and survivors. The team also conducted process evaluations of two outreach projects in which survivors spoke to African American men about prostate cancer and screening. RESULTS: Three levels of obstacles to prostate cancer screening and treatment were identified. Individual-level obstacles included limited knowledge about the condition, about prevention and treatment, and fear of cancer. Socio-cultural barriers included distrust of the medical system, lack of a provider for routine and preventive care, reluctance to talk about cancer, and aversion to aspects of screening. Institutional deficits included the scarcity of educational efforts targeting prostate cancer. Outreach project evaluations suggested that survivors can be effective in building prostate cancer knowledge, promoting positive attitudes toward screening, and fostering conversations about prostate cancer. Educational efforts included little information about screening risks and decision-making however. CONCLUSIONS: The findings suggest that most potent interventions may combine survivor-led education with mass media and institution-based outreach. Such comprehensive programs could shift social norms that inhibit conversation and foster fear, leading in turn to more informed decisions and better treatment outcomes.

Communicating with the public about emerging health threats: lessons from the Pre-Event Message Development Project.

OBJECTIVES: We sought to better understand the challenges of communicating with the public about emerging health threats, particularly threats involving toxic chemicals, biological agents, and radioactive materials. METHODS: At the request of the Centers for Disease Control and Prevention, we formed an interdisciplinary consortium of investigative teams from 4 schools of public health. Over 2 years, the investigative teams conducted 79 focus group interviews with 884 participants and individual cognitive response interviews with 129 respondents, for a total sample of 1013 individuals. The investigative teams systematically compared their results with other published research in public health, risk communication, and emergency preparedness. RESULTS: We found limited public understanding of emerging biological, chemical, and radioactive materials threats and of the differences between them; demand for concrete, accurate, and consistent information about actions needed for protection of self and family; active information seeking from media, local authorities, and selected national sources; and areas in which current emergency messaging can be improved. CONCLUSIONS: The public will respond to a threat situation by seeking protective information and taking self-protective action, underlining the critical role of effective communication in public health emergencies.

Bridging research and practice through competency-based public health education.

Reducing the gap between research and practice is gaining much needed attention. Schools of public health can play a role by ensuring that students are taught the necessary knowledge and skills to translate research into practice and to effectively disseminate research and other public health information. Competency-based education is one mechanism by which this can occur. In this article, we introduce a set of competencies specific to translation and dissemination. We describe the process used to develop the set as well as the ways in which we have begun to use these competencies for curriculum review and development. In this way, other schools and training programs in public health can begin to design curricula that will prepare their students to reduce the gap between research and practice. Graduate students will thus be effectively prepared to respond to the changing demands of the field of public health.

Becoming a health literate organization: Formative research results from healthcare organizations providing care for undeserved communities.

Background Integrating health literacy into primary care institutional policy and practice is critical to effective, patient centered health care. While attributes of health literate organizations have been proposed, approaches for strengthening them in healthcare systems with limited resources have not been fully detailed. Methods We conducted key informant interviews with individuals from 11 low resourced health care organizations serving uninsured, underinsured, and government-insured patients across Missouri. The qualitative inquiry explored concepts of impetus to transform, leadership commitment, engaging staff, alignment to organization wide goals, and integration of health literacy with current practices. Findings Several health care organizations reported carrying out health literacy related activities including implementing patient portals, selecting easy to read patient materials, offering community education and outreach programs, and improving discharge and medication distribution processes. The need for change presented itself through data or anecdotal staff experience. For any change to be undertaken, administrators and medical directors had to be supportive; most often a champion facilitated these changes in the organization. Staff and providers were often resistant to change and worried they would be saddled with additional work. Lack of time and funding were the most common barriers reported for integration and sustainability. To overcome these barriers, managers supported changes by working one on one with staff, seeking external funding, utilizing existing resources, planning for stepwise implementation, including members from all staff levels and clear communication. Conclusion Even though barriers exist, resource scarce clinical settings can successfully plan, implement, and sustain organizational changes to support health literacy.

Comparing State Legislative Aides' Perspectives on Tobacco Policymaking in States With Strong and Weak Policies: A Qualitative Study.

PURPOSE: The study compared perceptions of state legislative aides about tobacco policymaking in states with strong and weak tobacco control policies. APPROACH: Qualitative in-depth interviews carried out in 2009. SETTING: The US states were ranked on a combination of tobacco prevention funding, taxes, and presence of smoke-free policies. States at the top and bottom of the rankings were chosen. PARTICIPANTS: Interviews were conducted with 10 legislative aides in 5 states with strong tobacco control policies and 10 aides in 7 states with weak policies. METHOD: Twenty semistructured interviews were conducted, coded, and analyzed using a consensus coding process. RESULTS: Tobacco control was a lower priority in states with weak policies, and respondents from these states listed more barriers to tobacco control policymaking than those from states with strong policies. Successful arguments for tobacco control emphasized operational applications, for example, enhanced revenue from tobacco taxes or safety of children and employees. CONCLUSION: Our findings support propositions posited in the Advocacy Coalition Framework. They point to the preeminence of contextual factors, notably political leanings and economic climate on success of policy change efforts. Lessons learned from participants from states with strong policy nonetheless show promise for success in states with weak policy.

Understanding the decisions of cancer clinical trial participants to enter research studies: factors associated with informed consent, patient satisfaction, and decisional regret.

OBJECTIVE: To understand the psychosocial outcomes related to decision-making processes of individuals eligible for participation in clinical trials. METHODS: Individuals eligible to participate in selected clinical trials were contacted to complete two surveys; one shortly after participants were identified, and the second 6 weeks after the first survey was completed (N=50). Measures included subjective informed consent; satisfaction with decision-making; decisional regret; and timing of consent (early versus late signers). ANOVA and correlation coefficients were used to test the relationships between variables. RESULTS: Early signers reported themselves to be less informed about the details of their particular clinical trials than later signers (M=81.9 versus 91.2; F=5.5; p=.02). There was a non-significant trend for early signers to be less satisfied with their decisions than late signers. Satisfaction with decision-making and subjective informed consent were both strongly associated with later decisional regret (r=-.32 and -.30, respectively). However, there was no relationship between timing of consent and decisional regret. CONCLUSION: Participants who enroll in clinical trials quickly may not believe they fully understand the implications of trial participation. In general, participants who do not believe they fully understand the implications of trial participation, or who are less satisfied with their decision to enroll in the trial may ultimately feel regret about their decision to participate. PRACTICE IMPLICATIONS: More effort is needed to ensure that clinical trial participants fully understand the risks and benefits of participation and are satisfied with their decision to enroll in a trial prior to signing consent forms.

Perceptions of Adolescents with Overweight and Obesity for the Development of User-Centered Design Self-Management Tools within the Context of the Chronic Care Model: A Qualitative Study.

BACKGROUND: The Chronic Care Model (CCM) is helpful to illustrate multiple levels of influence in the management of chronic disease, such as overweight and obesity in adolescents. Unfortunately, various constraints create gaps in the management process activities performed within the CCM. Consumer health technologies (CHT) may serve as a linkage between adolescents with overweight or obesity, their parents, and their pediatricians. OBJECTIVE: To conduct formative research to qualitatively identify views of adolescents with overweight and obesity on use of consumer health technologies to manage weight loss across chronic care management settings. DESIGN: As part of a multi-perspective qualitative study, 10 focus groups were conducted with adolescents with overweight and obesity. PARTICIPANTS/SETTING: Forty-eight adolescents (15 male, 33 female) aged 12 to 17 years who were current participants of an intensive lifestyle change camp in the summer of 2012 participated in focus groups. All adolescents were classified as overweight (21%) or obese (79%) according to body mass index (BMI) for age charts published by the Centers for Disease Control and Prevention. ANALYSIS: All focus groups were recorded, transcribed verbatim, and checked for accuracy. Predefined and open coding were used to analyze transcripts for emerging themes. RESULTS: Adolescents perceive CHT, with its functional requirements of assistance with restaurant food selection, teaching cooking skills, and providing encouragement and motivation, to be helpful with overweight and obesity self-management. Desired features to carry out these functional requirements included avatars, self-monitoring capabilities, social networking, and rewards. CONCLUSION: Our findings largely agree with previously reported parental perceptions of the benefit of CHT for adolescent overweight and obesity self-management and strengthen support for the design and implementation of CHT within the CCM.

A community-wide media campaign to promote walking in a Missouri town.

INTRODUCTION: Engaging in moderate physical activity for 30 minutes five or more times per week substantially reduces the risk of coronary heart disease, stroke, colon cancer, diabetes, high blood pressure, and obesity, and walking is an easy and accessible way to achieve this goal. A theory-based mass media campaign promoted walking and local community-sponsored wellness initiatives through four types of media (billboard, newspaper, radio, and poster advertisements) in St Joseph, Mo, over 5 months during the summer of 2003. METHODS: The Walk Missouri campaign was conducted in four phases: 1) formative research, 2) program design and pretesting, 3) implementation, and 4) impact assessment. Using a postcampaign-only, cross-sectional design, a telephone survey (N = 297) was conducted in St Joseph to assess campaign impact. Study outcomes were pro-walking beliefs and behaviors. RESULTS: One in three survey respondents reported seeing or hearing campaign messages on one or more types of media. Reported exposure to the campaign was significantly associated with two of four pro-walking belief scales (social and pleasure benefits) and with one of three community-sponsored activities (participation in a community-sponsored walk) controlling for demographic, health status, and environmental factors. Exposure was also significantly associated with one of three general walking behaviors (number of days per week walking) when controlling for age and health status but not when beliefs were introduced into the model, consistent with an a priori theoretical mechanism: the mediating effect of pro-walking beliefs on the exposure-walking association. CONCLUSION: These results suggest that a media campaign can enhance the success of community-based efforts to promote pro-walking beliefs and behaviors.

How do African American men rate their health care? An analysis of the consumer assessment of health plans 2003-2006.

African American (AA) men remain one of the most disconnected groups from health care. This study examines the association between AA men's rating of health care and rating of their personal physician. The sample included 12,074 AA men aged 18 years or older from the 2003 to 2006 waves of the Consumer Assessment of Healthcare Providers and Systems Adult Commercial Health Plan Survey. Multilevel models were used to obtain adjusted means rating of health care systems and personal physician, and the relationship of ratings with the rating of personal physician. The adjusted means were 80 (on a 100-point scale) for most health ratings and composite health care scores: personal physician (83.9), specialist (83.66), health care (82.34), getting needed care (89.57), physician communication (83.17), medical staff courtesy (86.58), and customer service helpfulness (88.37). Physician communication was the strongest predictor for physician rating. AA men's health is understudied, and additional research is warranted to improve how they interface with the health care system.

What does the public want to know in the event of a terrorist attack using plague?

We used formative research to assess the information needs and information-seeking strategies with general public audience segments in response to a hypothetical attack using plague, and we pretested informational materials about plague. Twelve focus groups were conducted across the country, with 129 individuals being purposively sampled by ethnicity and place of residence. Across groups, participants wanted to understand: the nature of the threat of plague, how to protect themselves from transmission, how to detect exposure and symptoms, how to treat infection, and progress in apprehending perpetrators. Participants reported that they would seek information from both the news media and local authorities. Based on the findings and the challenges posed by a terrorist attack using plague, the authors recommend that message materials answer key questions, provide clear action steps, be clear and easily understood, include sources for credibility, and reflect full government disclosure. A dissemination plan is required to ensure that critical information will be available when people need it and where they look.