health risk communication programs outomes evaluation primer - atsdr usa - 2004

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ATSDR Evaluation Primer on Health Risk Communication Programs, TOC

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Agency for Toxic Substances and Disease Registry

Evaluation Primer on Health Risk Communication ProgramsPrograms and Outcomes

Environmental Health Policy CommitteeSubcommittee on Risk Communication and Education

ote: While the original publication dates on some of ATSDR's documents may not appear to be current, theormation in the documents is valid and may still provide relevant information.

ontents

q Preface q About the Primer q Overview of Principles and Techniques for Evaluating Health Risk Communication Activities

r Why Evaluate Risk Communication Programs? r Types of Evaluation r Elements of an Evaluation Design r Risk Communication Objectives as a Measure of Effectiveness r Barriers to Risk Communication Evaluation

q What Do We Want to Say? The Role of Formative Evaluation and Researchr Designing and Testing the Message r Whom To Include in Review and Pretesting r Guidelines for Selecting Pretest Methods r

Pretest Methods for Print Materials r Sample Survey for Assessing Risk Communication Needs r Sample Focus Group Case Study r Guidelines for Analyzing Pretest Results r Guidelines for Using Pretest Results r Evaluating Communications To Special Populations r Evaluation Tool: Risk Message Checklist

q Did It Work? Tips for Evaluating Communication Outcomes and Impacts

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ATSDR Evaluation Primer on Health Risk Communication Programs, TOC

r Risk Communication Program Assessment Questions r Evaluation Options Based on Available Resources r Factors To Consider in Midcourse Reviews r Have We Succeeded? r Evaluation Case Example r Evaluation Action Plan r

Attributes of an Effective Risk Communication Program q Selected References

Primer Content Prepared by:

Tim L. Tinker, Dr.P.H., M.P.H.Agency for Toxic Substances and Disease Registry

Paula G. Silberberg, M.Ed.U.S. Food and Drug Administration

May 1997

US DEPARTMENT OF HEALTH AND HUMAN SERVICESPublic Health Service

This page last updated on May 28, 2002

Contact Name: Wilma Lpez/ [email protected]

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ATSDR - Evaluation Primer, Section 1


Preface

mong agencies of the federal government, the U.S. Department of Health and Human Services DHHS) and the U. S. Environmental Protection Agency (EPA) share the broadest set of sponsibilities for determining and communicating health risks to the public. Risk assessment and

ommunications activities have spanned a very broad range over recent years, as illustrated by the work f the National Cancer Institute (NCI) to determine behavioral risk factors for cardiovascularsease and cancer and public outreach efforts of the Centers for Disease Control and Prevention

CDC) to inform the public about the adverse human health effects of environmental tobacco

moke (ETS).

growing emphasis within the U.S. Public Health Service (PHS) and other federal agencies onetermining the value and utility of public health information has created an increasing need fornovative and cost-effective evaluation strategies. As with other health education efforts, health risk

ommunication programs must be evaluated to understand which strategies are helpful and which areot. Health risk communication messages enter our lives in many forms (e.g., advertisements,olicitations, health campaigns, medical care requirements, and word of mouth). This suggests manyompounding factors, many problems, many challenges, and complexities of beliefs, values, andehaviors.

he Environmental Health Policy Committee (EHPC) is a standing DHHS committee. It is chaired bye Assistant Secretary for Health and has representation from the PHS agencies EPA, U.S. Departmen

f Energy , U.S. Department of Agriculture , and U.S. Department of Defense .

1993, PHS undertook an analysis of health risk communication policies and practices across itsgencies with the goal of developing recommendations to improve health risk communication. EHPCharged its subcommittee on risk communication with the analysis. Member agencies of theubcommittee submitted examples of health risk communication activities or decisions they perceived toe effective and examples of activities they thought had been less effective. These examples and findingse contained in the Subcommittee's report "Recommendations to Improve Health Risk Communication:Report on Case Studies in Health Risk Communication." A major finding of the analysis was that

valuation was the least understood of the communication components. Collecting process and anecdotalformation was the preferred method of evaluation, with relatively little or no emphasis on outcome and

mpact evaluation.

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he Subcommittee on Risk Communication and Education developed A Primer for Evaluating Healthisk Communication to assist federal health risk communication practitioners and decisionmakers to help

mprove their effectiveness in evaluating health risk messages and campaigns. The primer encompassesvaluation principles and practices as a central means for ensuring appropriate goals, content, andutcome of our health risk communication programs.

o address the perceived evaluation needs of various PHS agencies, the subcommittee recommended

at each PHS agency consider developing a set of generally accepted practices and guidelines forfective evaluation of communication activities and programs. This primer presents key principles andchniques to assist federal decisionmakers and health risk communicators to improve their overallfectiveness in evaluating health risk messages and materials.

Table of Contents ]

About the Primer

arget Audience

he principles and techniques provided in the evaluation primer are designed to improve the capacity of sk communication practitioners and decisionmakers in PHS and non-PHS agencies to evaluate theficiency and effectiveness of health risk communication messages, materials, and campaigns.

urpose

se of the primer can facilitate planning evaluations for health risk communication programs in severaley areas.

q Informs decisionmakers about what should be communicated, in what form, to whom, and withwhat expected outcome.

q Identifies performance indicators used in assessing or measuring communication goals. Forexample, the Seven Cardinal Rules of Risk Communication, as identified by EPA , are

1. accept and involve the public as a legitimate partner2. plan carefully and evaluate your efforts3. listen to the public's specific concerns4. be honest, frank, and open5. coordinate and collaborate with other credible sources6. meet the needs of the media

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7. speak clearly and with compassion.

q Provides guidance on how to most effectively use target audience ideas and opinions to shape therisk communication message.

rganization

he primer excerpts from the research of leading risk communication experts, including (1) issues anduiding principles to consider in evaluating health risk communication activities, and (2) case examplesustrating proven evaluation methods and tools.

Table of Contents ]

Why Evaluate Risk Communication Programs?(Regan and Desvousges 1990)

valuation is a purposeful effort to determine effectiveness. It is essential to communication because itovides feedback about whether risk messages are received, understood, and internalized by those forhom they are intended. Without evaluation, it is impossible for communicators to chose those messages

nd channels that use limited resources more effectively. Instead, communicators are left to their ownubjective interpretations about what works and what does not. A lack of evaluation, therefore, affects

oth quality of the specific risk communication effort and the primary goalimproving public health.

he ideal way to apply evaluation findings is to improve ongoing risk communication activities. Inddition, evaluation is valuable for other uses.

q To provide evidence of need for additional funds or other resourcesq To increase institutional understanding of and support for risk communication activitiesq To encourage ongoing cooperative ventures with other organizationsq To avoid making the same mistakes in future risk communication efforts

Table of Contents ]

Types of Evaluation

(NCI 1992)

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he following types of evaluation have been adapted to serve the goals of evaluating risk communicationograms.

ormative. Evaluation during the formative stages of a risk communication effort assesses the strengthsnd weaknesses of materials or campaign strategies before implementation. It permits necessaryvisions before the full effort goes forward. Among other things, materials can be tested for the

llowing characteristics:

q clarityq toneq comprehensivenessq anticipated reactions.

rocess. Process evaluation examines the procedures and tasks involved in implementing an activity.his type of evaluation also can collect the following information about the administrative and

ganizational aspects of the overall effort:

q number of staff working on the projectq schedule of activitiesq number of materials distributedq attendance at meetingsq number of calls to a hotlineq number of public inquiries received as a result of a public serviceq announcementq articles printed.

utcome. Outcome evaluation is used to collect and present information needed for judgements aboute effort and its effectiveness in achieving its objectives. Not all risk communication efforts are suitabler outcome evaluation. Outcome evaluation is most suitable when the program has clear and measurable

oals and consistent replicable materials, organization, and activities. Outcome evaluation can obtainescriptive data on a project and document the immediate effects of the project on the target audience (e., percent of the target audience showing increased awareness of the subject).

n outcome evaluation can collect the following information about the program:

q changes in knowledge and attitudesq expressed intentions of the target audienceq changes in behavior.

mpact. Impact evaluation focuses on the long-range results of the program and changes ormprovements in health status as a result. It is designed to identify whether and to what extent a programontributed to accomplishing its stated goals (more global than outcome evaluation). In a "real world"



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nvironment, there are many factors that influence an individual's health behavior, including peerupport and approval, self-esteem and other individual characteristics, advertising and mass mediaoverage of health, and community and institutional factors (such as availability of services). It is usuallyxtremely difficult to separate the impact of a health risk communication program from the effects of her confounding variables on an individual's behavior. Thus, the results of an impact evaluation often

annot be directly related to the effects of an activity or program because of the other (external)fluences on the target audience which occur over time. Impact evaluations are rarely possible because

ey are frequently costly, involve extended commitment, and may depend upon other strategies inddition to communication. Information obtained from an impact study may include the following:

q changes in morbidity and mortalityq changes in absenteeism from work q long-term maintenance of desired behaviorq rates of recidivism.

Table of Contents ]

Elements of an Evaluation Design

(NCI 1992)

very formal designwhether formative, process, outcome, impact, or a combinationmust contain

ght basic elements.

A Statement of Communication Objectivesnless there is an adequate definition of desired achievements, evaluation cannot measure them.valuators need clear and definite objectives in order to measure program effects.

Definition of Data To Be Collectedhis is the determination of what is to be measured in relation to the objectives.

Methodologystudy design is formulated to permit measurement in a valid and reliable manner.

Instrumentationata collection instruments are designed and pretested. These instruments range from simple tally sheetsr counting public inquiries to complex survey and interview forms.

Data Collectionhe actual process of gathering information.

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Data Processingutting the information into a usable form for analysis.

Data Analysishe application of statistical techniques to the information to discover significant relationships.

Reportingompiling and recording evaluation results. These results rarely pronounce a program a complete

uccess or failure. To some extent, all programs have good elements and bad. It is important toppreciate that lessons can be learned from both if results are properly analyzed. These lessons should bepplied to altering the existing program or as a guide to planning new efforts.

Table of Contents ]

Risk Communication Objectives as aMeasure of Effectiveness

(Covello, Slovic, and von Winterfeldt 1987)

rogram planning of any sort should begin with an explicit statement of objectives and how they will bevaluated. The following are the four major types of risk communication programs, categorizedccording to their primary objectives.

YPE 1: Information and Education

q Informing and educating people about risks and risk assessment in general.

EXAMPLE: Using statistical comparisons of risks from different energy production technologies.

YPE 2: Behavior Change and Protective Action

q Encouraging personal risk-reduction behavior.

EXAMPLE: Using advertisements to encourage people to wear seat belts.

YPE 3: Disaster Warnings and Emergency Information

q Providing direction and behavioral guidance in disasters and emergencies.



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EXAMPLE: Using sirens to indicate an accidental release of toxic gas from a chemical plant.

YPE 4: Joint Problem Solving and Conflict Resolution

q Involving the public in risk management decisionmaking and in resolving health, safety, andenvironmental controversies.

EXAMPLE: Using public meetings to inform citizens about a possible hazardous waste site.

Table of Contents ]

Barriers to Risk Communication Evaluation

(Arkin 1991)

very program manager faces constraints to undertaking optimal evaluation tasks, just as there areonstraints to designing other aspects of a risk communication program.

hese constraints may include the following:

q limited fundsq limited staff time and capabilitiesq length of time allotted to the programq limited access to computer facilitiesq agency restrictions to hiring consultants or contractorsq policies limiting the ability to gather information from the publicq management perceptions regarding the value of evaluationq levels of management support for well designed evaluation activitiesq difficulties in defining (or establishing) agency consensus regarding the objectives of the programq difficulties in designing appropriate measures for risk communication programsq difficulties in separating the effects of program influences from other influences on the target

audience in "real world" situations.

Table of Contents ]

Designing and Testing the Message

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(AED, JHU, and PN 1993)

crucial step in creating and assessing the effectiveness of health risk communication activities isetermining what message ideas or concepts have the best chance of "connecting" with the targetudience and influencing them to change behavior if behavior change is the stated objective. Thisocess begins with using formative research and evaluation, a combination of techniques designed to

elp develop effective messages.

iterature reviews, in-depth interviews, and focus groups are examples of formative research tools thatan be used to help determine if one concept is more salient to an audience segment than another, andhich concepts should eventually be developed into specific messages. The general approach toetesting concepts is to share them with members of the target audience and gauge their reactions.

retesting is conducted while materials are in draft form, to allow changes to be made without greatxpense if testing reveals ways to improve the messages or materials. Methods of pretesting includetercept interviews with members of the target audience and focus groups. Pretesting helps determinehether the messages and formats are appropriate, understandable, clear, attention-getting, credible,levant, and have the desired effect (e.g., to raise awareness about an issue).

Table of Contents ]

Whom To Include in Review and Pretesting(AED, JHU, and PN 1993)

here are four groups to consider for pretesting and review.

1. Target Audience

r To identify current knowledge, attitudes, and behavior related to the subject to identifywhether and what kind of new information is needed

r To identify myths and misconceptions about the topicr To assure appeal, appropriateness, understanding, clarity, and personal relevance of

materialsr To check for comprehension and cultural appropriateness

2. External Experts



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r To verify appropriateness of materials based on proven models and theories of communication

r To verify accuracy and appropriateness of information in the materials

3. Gatekeepers (e.g., print and broadcast media, religious leaders, political and legal groups,legislators, and other key policy- and decisionmakers)

r To assure that they will support, not block, use of materialsr To increase "ownership" of the materialsr To identify problems based on gatekeepers' experiences with the target audience. If any

problems are identified, they should be verified through pretesting directly with the targetaudience

4. Clearance officials

r To obtain approvals prior to printing

Table of Contents ]

Guidelines for Selecting Pretest Methods


ou must choose the method that works best. The following are points to consider in determining theest method.

q The material's format and complexity (e.g., longer and more complex materials may requirehaving an interviewer to ensure the participants complete the pretest)

q The material's degree of sensitivity (e.g., youth may be more comfortable with a self-administeredquestionnaire on topics such as sex and AIDS)

q Target audience characteristics (e.g., interest and willingness to respond, lack of reading skills or

other limitations)q Where materials can be accessed (e.g., clinic, school, home)q Purpose of the pretest (e.g., is more in-depth information about target audience perceptions of the

topic desired?)q Resources available for pretesting (e.g., using trained interviewers and companies to recruit for

and conduct focus groups are more expensive options; self-administered pretests can be moreinexpensive)

q Consider using a combination of methods to meet pretest purpose and budget (e.g., use a largernumber of self-tests, followed by a limited number of individual interviews to clarify findings or



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explore problematic areas)

Table of Contents ]

Pretest Methods for Print Materials(AED, JHU, and PN 1993)

Self-administered Surveys (mailed or personally delivered)

urpose: To obtain individual reactions to draft materials

pplication: Print or audiovisual materials

umber of: Enough to see a pattern of response

espondents: (Minimum 20; ideal 100-200)

esources Required: List of respondents; draft materials; questionnaire; postage (if mailed)

ros: Inexpensive. Does not require staff's time to interact with respondents if mailed; can benonymous for respondents; can reach homebound, rural, or other difficult to reach groups; easy andsually) quick for respondents

ons: Response rate may be low if mailed; may require followup; may take long time to receiveufficient responses; respondents self-select (potential bias); exposure to materials isn't controlled; mayot be appropriate if audience has limited writing skills

Sample Survey for Assessing Risk Communication Needs

(Chess and Hance 1992)

1. Approximately what percentage of your on-the-job time, on average, do you spend interactingwith the public?_____

2. What are the different publics you communicate with? (check all that apply)[ ] community members [ ] local government officials [ ] state government officials [ ] reporters[ ] environmental groups [ ] health professionals [ ] other, pleasespecify_____________________________

3. What do you think will most help you improve your communication with the public?



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4. What do you think will most help your organization improve its communication with the public?5. What kind of assistance in dealing with the public would you most like to have?6. If your organization provides training on communicating with the public, what should it be sure

to include?7. What should it be sure to avoid?8. Any other comments?

Individual Interviews (telephone or in person)

urpose: Can answer questions similar to self-administered questionnaires; probe for individual'ssponses, and beliefs; discuss range of issues

pplication: Develop hypotheses, messages, potentially motivating strategies; discuss sensitive issues complex draft materials

umber of Respondants: Dependent on variables of issue urgency and complexity, time, and money.or a ballpark figure, get 10 opinions.

esources Required: List of respondents; discussion guide/questionnaire; trained interviewer, telephone quiet room, tape recorder (optional)

ros: In-depth responses may differ from first response; can test sensitive or emotional materials; canst more complex/longer materials; can learn more about "hard-to-reach" audiences; can be used withdividuals who have limited reading and writing skills

ons: Time consuming to conduct/analyze; expensive; may yield to firmer conclusions or consensus

Focus Group Interviews

urpose: To obtain insight into the target audience's perceptions, opinions, beliefs, and attitudes aboutaft materials. Readability and understandability of print materials can also be addressed.

pplication: Testing broad concepts, issues, audiovisual or print materials, and logos or other artwork.

umber of Respondants: 8-10 group. Usually, the number of groups is dependent on program needsnd resources. Minimum 2 groups per type of respondent. When target audience perceptions areomparable, additional focus group sessions are not necessary.

esources Required: Participants representative of the target audience, recruitment screeningstrument, moderator's guide, trained moderator, focus group facility with one-way mirror and audio-

nd videotape capability (optional).



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ros: Capture of real-life data in a social environment where the moderator can interact directly withspondents; group interaction and length of discussion can stimulate more in-depth responses thandividual interviews; can discuss concepts prior to materials development; can gather more opinions at

nce than individual interviews; can cover multiple topics; flexibility and ability to probe for moreformation; high face validity and an easily understood technique compared to sophisticated surveysearch employing complex statistical analyses; provision of data more quickly than individualterviews; and richness of data as the group participants react and build upon the responses of others in

n open format.

ons: Too few responses for consensus or decisionmaking; no individual responses (group influence)nless combined with other methods; can be expensive; respondents choose to attend and may not bepical of the target population; less control of the responses by the moderator than in individualterviews; difficult analysis of data (e.g, summarization, interpretation); special skills are required of oderators and moderator bias may occur; troublesome differences between groups (e.g., oppositesponses); difficulty in recruiting participants; can be expensive; and logistical problems (e.g., arrangingcation, dates, and times, incentive payments, and refreshments).

Table of Contents ]


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Sample Focus Group Case Study:Four Focus Groups Among Women on Their Reactions to Two

Contraceptive Efficacy Tables for Uniform ContraceptiveLabeling

ackground

n keeping with the goal of the U.S. Food and Drug Administration (FDA) to develop uniform

ontraceptive labeling, focus groups were conducted to determine a presentation format most useful tohe consumer for contraceptive pregnancy rates. The focus group study obtained consumer reactions toeveral model contraceptive efficacy tables and graphs. Using findings from the study, the Center for

Devices and Radiological Health developed for further testing two prototype, composite tableswith the characteristics the focus group participants favored for uniform contraceptive labeling.

tudy Purpose

o utilize focus groups to garner reactions (perceptions, opinions, beliefs, and attitudes) and preferences

rom women about the format and content of the two different model contraceptive efficacy tables.

articipant Characteristics

he single and married premenopausal women participating in the study were currently using oronsidering using a birth control method; had not earned a bachelor's degree or above; had no more thanwo health science or mathematics classes beyond the high school level; and had not participated in aocus group in the past 12 months.

Recruitment Method

Women who had previously expressed interest in participating in focus groups were recruited by phone.

ample Questions from the Moderator's Guide

1) What do you know about pregnancy rates?

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2) Where have you seen (or heard) information telling about pregnancy rates for various birth controlmethods?

3) Has this information about pregnancy rates been useful to you in deciding on a particular birthontrol method?

4) After showing each table:

q (a) What does this table tell you?q (b) How easy to understand is this table?q (c) What information here is new to you?q (d) What did you especially like about this table?q (e) What did you dislike about this table?q (f) How useful is this information to you?q (g) What might you change, delete, or add to this table?

5) How would you describe how well these tables help you understand how effective your birth controlmethod is compared to other birth control methods?

6) Is there any other format you would suggest?

7) Is there any other information you would like to see in these tables?

8) Is there anything else you want to say about the tables you've seen today?

Major Findings

articipants were equally divided between their preference for each of the two tables. Although they didot clearly demonstrate an overwhelming preference for one table over the other, most participants foundhat the tables met the goal of helping them to understand how effective their birth control method was inomparison to other methods.

Table of Contents ]

Guidelines for Analyzing Pretest Results


Remember these guidelines as you first plan, and then consider the meaning of the pretest findings.



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q Write a clear statement of purpose prior to the pretest.r Make sure that the questions asked relate to the purpose.r Then use the purpose statement to analyze the findings.

q Consider what was found and what was not foundsometimes what is not stated by participantsis very important.

q If the answers to some questions are unclear, consider more or different types of pretesting.

Table of Contents ]

Guidelines for Using Pretest Results

Qualitative research can be predictive, but it is not precise. Interpreting and applying the results of retesting and materials review will require certain actions.

q Give more weight to target audience and reviewers' responses that are within the context of theirroles regarding the materials.

q Temper their responses with your own professional judgment, while considering the lay public asrespected equals with a right to the information.

q Do not feel obligated to respond to every individual's every comment or complaint.q Remember that gatekeepers can block target audience access to print materials, so their opinions

are important too.

Table of Contents ]

Evaluating Communications To Special Populations

ormative research findings may reveal special communications needs of the audiences you're trying toeach with prevention information and education. For example, it may be important to tailor content,ayout, and use of visuals to the needs of a reader with poor reading and communication skills. Whatoes this mean in concrete terms? Low-literacy experts have identified key principles for developingffective materials for this audience. These principles are summarized in the checklist below. You canse this list as you are developing a new publication and doublechecking product drafts.

hecklist: Key Principles of Effective Low-Literacy Print MaterialsGatson and Daniels 1988)

ontent/Style



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__ The material is interactive and allows for audience involvement.__ The material presents "how-to" information.__ Peer language is used whenever appropriate to increase personal identification and improveeadability.__ Words are familiar to the reader. Any new words are defined clearly.__ Sentences are simple, specific, direct, and written in the active voice.__ Each idea is clear and logically sequenced (according to audience logic).

__ The number of concepts is limited per piece.__ The material uses concrete examples rather than abstract concepts.__ The text highlights and summarizes important points.

ayout

__ The material uses advance organizers and headers.__ Headers use simple and close to text.__ Layout balances white space with words and illustrations.

__ Text uses upper and lower case letters.__ Underlining or bolding rather than caps give emphasis.__ Type style and size of print are easy-to-read; type is at least 12 point.

Visuals

__ Visuals are relevant to text, meaningful to the audience, and appropriately located.__ Illustrations and photographs are simple and free from clutter and distraction.__ Visuals use adult rather than childlike images.

__ Illustrations show familiar images that reflect cultural context.__ Visuals have captions. Each visual illustrates and is directly related to one message.__ Different illustration styles, such as photographs, shaded line drawings, and simple line drawings,re pretested with the audience to determine which is understood best.__ Cues, such as circles or arrows, point out key information.__ Colors used are appealing to the audience (as determined by pretesting).

Readability

__ Readability analysis is done to determine reading level.

Table of Contents ]

Evaluation Tool: Risk Message Checklist

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(National Research Council 1989)

nformation About the Nature of Risks

1. What are the hazards of concern?2. What is the probability of exposure to each hazard?3. What is the distribution of exposure?4. What is the probability of each type of harm from a given exposure to each hazard?5. What are the sensitivities of different populations to each hazard?6. How do exposures interact with exposures to other hazards?7. What are the qualities of the hazard?8. What is the total population at risk?

nformation About the Nature of Benefits

1. What are the benefits associated with the hazard?

2. What is the probability that the projected benefit will actually follow the activity in question?3. What are the qualities of the benefits?4. Who benefits and in what ways?5. How many people benefit and how long do benefits last?6. Which groups get a disproportionate share of the benefits?7. What is the total benefit?

nformation on Alternatives

1. What are the alternatives to the hazard in question?2. What is the effectiveness of each alternative?3. What are the risks and benefits of alternative actions and of not acting?4. What are the costs and benefits of each alternative and how are they distributed?

Uncertainties in Knowledge About Risks

1. What are the weaknesses of available data?2. What are the assumptions on which estimates are used?

3. How sensitive are the estimates to changes in assumptions?4. How sensitive is the decision to changes in the estimate?5. What other risk and risk control assessments have been made, and why are they different from

those being offered?

nformation Management

1. Who is responsible for the decision?2. What issues have legal importance?

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3. What constrains the decision?4. What resources are available?

Table of Contents ]

Risk Communication Program Assessment Questions

(Arkin 1991)

How many people were reached? (process evaluation)

q Amount of time on radio and television and estimated audience for those timesq Print coverage and estimated readershipq Number of educational materials distributedq Number of speeches and presentations and size of audienceq Number of other organizational and personal contacts

Did they respond? (process evaluation)

q Number of in-person, telephone, and mail inquiries (location of person inquiring, where inquirerheard of the program, and what was asked)

q Number of new organizations, businesses, and media outlets participating in the programq Response from presentations (e.g., filled-out evaluation forms)

Who responded? (outcome evaluation)

q Demographics of responders (e.g., gender, education, income, and geographic residence)

Was there change? (outcome evaluation)

q Changes in knowledge and attitudesq Changes in intentions (e.g., intentions to modify diet)q Actions taken (e.g., increased enrollment in smoking cessation clinics)q Policies initiated or other institutional changes made

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Evaluation Options Based on Available Resources

(NCI 1992)

ote: The following chart uses an additive matrix from left to right (i.e., each ascending programvel could be expected to include the evaluation technique described at lower levels in addition to

ose described at the higher level).

Program Levels

pes of Minimal Modestbstantialaluation Resources Resources

sources

rmative Readability test Central locationcus groups

Intercept interviewsdividual indepth interviews

ocess Recordkeeping Program checklistanagement audit

(e.g., monitoring (e.g., review of adherenceg., external management

activity timetables) to programs plans)view of activities)

utcome Activity assessments Progress in attainingsessment of target

(e.g., numbers of objectives monitoreddience for knowledge

health screenings (e.g., periodic calculationin (e.g., pretest and

and outcomes or of percentage of aware,sttest of change in

program attendance referred, participating)owledge)

and audience response)

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pact Print media review Public surveysudies of public

(e.g., monitoring of (e.g., telephonehavior/health

content of articles surveys of self-ange (e.g., data on

appearing in reported behavior)

ysician visits or changes newspapers)public's health status)

able of Contents ]

Factors To Consider in Midcourse Reviews

(Lum 1991)

n designing and implementing a midcourse review for risk communication program activities, severalactors should be considered.

q Is the process of implementation formal or informal?q Is control centralized or decentralized?q

Is management authoritarian or participatory?q Is the program structure hierarchical or egalitarian?q Is the community divisive or cohesive?q Is the program isolated or community oriented?q Are the methods of communication standardized or individualized?q Is response and interaction controlled or expressive?q Are strategies partitioned or integrated?

Table of Contents ]

Have We Succeeded?

(Chess and Hance 1992)

o help make adjustments, duplicate successes, and avoid repeating failures, you should plan for

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eedback and evaluation of your communication. This might include taking the following actions:

q pretesting of materials before they are printed or distributedq handing out evaluation forms to get feedback after meetingsq debriefing agency staff after meetings or other interactionsq tracking news coverageq asking for feedback from key people outside the agency on writtenq materials, meeting agendas, and communication plansq documenting communication efforts through up-to-date files and summariesq summarizing lessons learned from communication effortsq conducting rigorous evaluations on large-scale efforts.

Table of Contents ]

Evaluation Case Example:Communicating the NCI Mammography Screening Guidelines:

The Practicing Physician's Perspective

(NCI 1994)

ackground

efore announcing its decision to drop the mammography guideline for women under age 50, the Officef Cancer Communications (OCC) at the National Cancer Institute (NCI) conducted a series of even focus groups with obstetrician/gynecologists (ob/gyns) and primary care physicians. The purposef the study was to (1) assess the likely impact of a change in the NCI mammography screeninguidelines on physician decision making with regard to mammogram referrals, and (2) explore ways that

NCI can best support physicians in their use of the new guidelines and in their communications withatients. Obtaining a better understanding of the environment in which physicians practice, includingheir attitudes and concerns about the new guidelines, was considered a prerequisite for developingffective communication materials.

valuation Approach

o achieve diversity in the seven focus groups, physicians were recruited based on a number of differentariables: their practice setting (i.e., managed care and fee-for-service), length of time in practiceminimum of 5 years), patient base (minorities, low income, etc.) and sex. Physicians who had

mammography equipment in their offices were excluded from participation in the study. Three of theroups were composed of full-time practicing ob/gyns or gyns; four groups were composed of primary

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are physicians who were either family physicians or internists. Fifty-five physicians participated;pproximately one-fourth were members of a minority group.

he focus groups were convened in four locations: Baltimore, Maryland; Chicago, Illinois; Omaha,Nebraska; and Newark (Wyckoff), New Jersey. Overall, these sites were selected for their geographic,thnic, racial, and socioeconomic diversity. During the focus groups, participants were asked to react to aumber of sample print materials designed to support the introduction of the revised guidelines.

indings and Lessons Learned

q Physicians have a strong sense of responsibility with regard to screening patients for breastcancer. This reflects the high level of concern they see in their patients; in part, it reflects theirconcerns about liability. However, their own commitment to fighting a deadly disease hastouched them professionally and in some cases personally.

q Physicians firmly believe that mammography is the only effective means of detecting breastcancer at its earliest possible stage. Moreover, physicians are convinced that early detection is the

single greatest factor influencing survival.q Physicians prefer to take a conservative approach with respect to mammography. They follow the

most stringent guidelines in screening low-risk patients. For high-risk patients, they ordermammograms earlier and more frequently than the guidelines specify, as is evident from theirdesire for more explicit recommendations for high-risk women. Physicians do not like operating"in the gray zone" where they must rely primarily on self-judgement.

q NCI's guidelines are largely unknown to physicians, compared with those of the American CancSociety (ACS) and the American College of Obstetricians and Gynecologists (ACOG) . Lack of knowledge and familiarity with NCI may be responsible in part for

physicians' questioning whether the guideline change is politically or scientifically motivated.q Most physicians are highly resistant to decreasing their use of mammography, particularly in

women under 50 years old. They indicate they would need strong, compelling evidence thatmammography is either useless or harmful before they would change the way they currentlypractice. The scientific evidence, as presented to them, is seen as inconclusive; it does notconvince them that a change in the guidelines is warranted at this time.

q It is important to physicians that their professional organizations endorse any change that takesplace in the recommendations for mammography screening. Ob/gyns in particular are unlikely tosupport a change unless ACOG endorses it.

q Overall, the findings from the study suggest that a majority of physicians will simply ignore thenew NCI guidelines and continue to practice as usual. As some physicians have realized, they canfollow their current practices and still be in compliance with the new guidelines.

q Given that the communications environment is characterized by skepticism and resistance, it islikely that any communications program designed to introduce and support the guidelines willface stiff challenges. The sample materials presented in this study were largely unsuccessfulbecause they could not overcome physicians' objections to the revised recommendation. Newstrategies based on what was learned about physicians as consumers in this study are now beingdeveloped.

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Table of Contents ]

Evaluation Action Plan

urpose

he purpose of an evaluation action plan is to assist you in identifying specific evaluation strategies forssessing how well your messages, materials, and activities were implemented and received by the targetudiences.

nstructions

deas for Actions. Write down ideas and strategies that you might want to try in evaluating your ownealth risk communication program.

Action Plan. Choose two or three of your evaluation ideas and develop specific actions to implementhem. Write these ideas on an action plan form. When developing your action plan, ask yourself theollowing questions:

lanning

q Is the action specific (Are action verbs used)?q How much time will it take?q Is it written so that I or someone else will know when the action occurs?

Resources

q Are the skills and resources for carrying out the action available?q Who will do it?q Are special materials or equipment necessary?q Is continual monitoring or followup required?

mplementation

q Do I have the authority to implement the action? If not, who does?q How can I go about getting approval?q What is the degree of support for my idea?q Besides my supervisor, who will I need to sell my idea to?q What in my organization environment might interfere with doing this?

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valuation

q Whom will this action affect?q How will it affect them?q How will I measure the effects? (evaluation plan)

Table of Contents ]

Attributes of an Effective Risk Communication Program

(Covello, Slovic, and von Winterfeldt 1987)

When designing and evaluating communication programs' effectiveness, the following maxims may beelpful.

q The communication should be clear, understandable, informative, accurate, and concrete.q The source of the communication should be perceived as credible and reliable.q When the target population is not homogeneous, the message should be presented in several

ways, each specifically designed for one segment of the target population.q Whenever possible, the target population or representatives of it should be closely involved in the

planning and implementation of the program. The earlier the involvement, the better. This adviceparticularly refers to occupational hazards, where the involvement of unions is consideredessential.

q Multimode presentation is considered to be more effective than single mode presentation. Thisapplies both to mass-media programs and to programs designed for smaller target populations. Inthe latter situation, face-to-face, two-way communication is also advocated.

q Feedback about the behavior change and its consequences in lowering risk is highly effective, andshould be used whenever possible.

q Incentives or rewards are thought to be effective in inducing change.q Repetitions of the message are desirable to a point; too many repetitions are ineffective or even

deleterious. The optimal number of repetitions is not known.q Certainly the message should be interesting; vividness has been shown to aid learning. But how

arousing should the material be? Research results are mixed concerning the effectiveness of feararousal.

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Selected References

rkin E. 1991. Evaluation for risk communicators. In: Ann Fisher, Maria Pavolva, and Vincentovello, editors. Evaluation and effective risk communications workshop proceedings. Washington,C: U.S. Environmental Protection Agency, Pub. no. EPA/600/9-90/054, pgs. 17-18.

rkin E. 1992. Health communications for consumers: the role of the federal government. Testimonyefore the Subcommittee on Housing and Consumer Interests, House Select Committee on Aging.

Washington, DC, August 5, 1992.

enters for Disease Control and Prevention (CDC). 1993. Health communication at CDCCDC'sealth communication wheel. Atlanta: U.S. Department of Health and Human Services, Public Healthervice.

cademy for Educational Development; Johns Hopkins University; Porter/Novelli (for National AIDSformation and Education Program, Centers for Disease Control and Prevention). 1993. A workshop in

eveloping effective educational print materials, April 1993. Washington, DC: Academy forducational Development; John Hopkins University; Porter/Novelli.

hess C and Hance BJ. 1992. Communicating with the public: ten questions environmental mangershould ask. New Jersey: Center for Environmental Communication, Rutgers University.

hess C and McCallum DB. 1992. Needs assessment for ATSDR risk communication focus groups.tlanta: U.S. Department of Health and Human Services, Public Health Service.

ovello VT, McCallum DB, and Pavolva MT. 1989. Principles and guidelines for improving risk ommunication. In: Effective risk communication: the role and responsibility of government and

ongovernment organizations. New York: Plenum Press.

ovello VT, Slovic P, and von Winterfeldt D. 1987. Risk communication: a review of the literature.raft, pgs. 5, 58-9.

atson N and Daniels P. 1988. Guidelines: writing for adults with limited reading skills. Washington,C: U.S. Department of Agriculture, Food and Nutrition Service.

um M. 1991. Benefits to conducting midcourse reviews. In: Ann Fisher, Maria Pavolva, and Vincent

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ovello, editors. Evaluation and effective risk communications workshop proceedings. Washington,C: U.S. Environmental Protection Agency, Pub. no. EPA/600/9-90/054, pg. 97.

ational Cancer Institute. 1992. Making health communication programs work: a planner's guide.Washington, DC: National Cancer Institute, NIH Publication no. 92-1493, pgs. 64-65.

ational Cancer Institute. 1994. Communicating the NCI mammography screening guidelines: theacticing physician's perspective. In: Tim Tinker, editor. Case studies of applied evaluation for healthsk communication (workshop proceedings). Washington, DC: U.S. Department of Health and Humanervices, Public Health Service, pgs. 21-22.

ational Research Council. 1989. Improving risk communication. National Academy Press,Washington, DC, pg. 175.

egan MJ and Desvousges WH. 1990. Communicating environmental risks: a guide to practicalvaluations. Washington, DC: U.S. Environmental Protection Agency, Pub. no. 230-01-91-001, pgs. 2-

.S. Department of Health and Human Services (DHHS). 1986. Determining risks to health: federalolicy and practice. Dover, Massachusetts: Auburn House Publishing Company.

Table of Contents ]


Privacy Policy | External Links Disclaimer | Accessibility U.S. Department of Health and Human Services

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ATSDR - Glossary of Terms


CONTENTS

En Espaol

General TermsA B C D E F G H I J K L M N O P Q R S T U V W X Y Z

ATSDR Glossary of Terms

The Agency for Toxic Substances and Disease Registry (ATSDR) is a federalpublic health agency with headquarters in Atlanta, Georgia, and 10 regionaloffices in the United States. ATSDR's mission is to serve the public by using thebest science, taking responsive public health actions, and providing trusted healthinformation to prevent harmful exposures and diseases related to toxicsubstances. ATSDR is not a regulatory agency, unlike the U.S. EnvironmentalProtection Agency (EPA), which is the federal agency that develops and enforcesenvironmental laws to protect the environment and human health.

This glossary defines words used by ATSDR in communications with the public.It is not a complete dictionary of environmental health terms. If you havequestions or comments, call ATSDR's toll-free telephone number,1-888-422-8737.

General Terms

Absorption The process of taking in. For a person or an animal, absorption is the process of asubstance getting into the body through the eyes, skin, stomach, intestines, or

lungs.

Acute Occurring over a short time [compare with chronic ].

Acute exposure Contact with a substance that occurs once or for only a short time (up to 14 days)[compare with intermediate duration exposure and chronic exposure ].

Additive effect A biologic response to exposure to multiple substances that equals the sum of responses of all the individual substances added together [compare withantagonistic effect and synergistic effect ].

Adverse health effect A change in body function or cell structure that might lead to disease or healthproblems

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Aerobic Requiring oxygen [compare with anaerobic ].

Ambient Surrounding (for example, ambient air).

Anaerobic

Requiring the absence of oxygen [compare with aerobic ].

Analyte A substance measured in the laboratory. A chemical for which a sample (such aswater, air, or blood) is tested in a laboratory. For example, if the analyte ismercury, the laboratory test will determine the amount of mercury in the sample.

Analytic epidemiologic study A study that evaluates the association between exposure to hazardous substancesand disease by testing scientific hypotheses.

Antagonistic effect A biologic response to exposure to multiple substances that is less than wouldexpected if the known effects of the individual substances were added together[compare with additive effect and synergistic effect ].

Background level An average or expected amount of a substance or radioactive material in aspecific environment, or typical amounts of substances that occur naturally in an

environment.

Biodegradation Decomposition or breakdown of a substance through the action of microorganisms (such as bacteria or fungi) or other natural physical processes(such as sunlight).

Biologic indicators of exposure study A study that uses (a) biomedical testing or (b) the measurement of a substance[an analyte ], its metabolite , or another marker of exposure in human body fluidsor tissues to confirm human exposure to a hazardous substance [also seeexposure investigation ].

Biologic monitoring Measuring hazardous substances in biologic materials (such as blood, hair, urine,or breath) to determine whether exposure has occurred. A blood test for lead isan example of biologic monitoring.

Biologic uptake



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The transfer of substances from the environment to plants, animals, and humans.

Biomedical testing Testing of persons to find out whether a change in a body function might haveoccurred because of exposure to a hazardous substance.

Biota

Plants and animals in an environment. Some of these plants and animals might besources of food, clothing, or medicines for people.

Body burden The total amount of a substance in the body. Some substances build up in thebody because they are stored in fat or bone or because they leave the body veryslowly.

CAP [see Community Assistance Panel .]

Cancer Any one of a group of diseases that occur when cells in the body becomeabnormal and grow or multiply out of control.

Cancer risk A theoretical risk for getting cancer if exposed to a substance every day for 70years (a lifetime exposure). The true risk might be lower.

Carcinogen

A substance that causes cancer.

Case study A medical or epidemiologic evaluation of one person or a small group of peopleto gather information about specific health conditions and past exposures.

Case-control study A study that compares exposures of people who have a disease or condition(cases) with people who do not have the disease or condition (controls).Exposures that are more common among the cases may be considered as possiblerisk factors for the disease.

CAS registry number A unique number assigned to a substance or mixture by the American ChemicaSociety Abstracts Service .

Central nervous system The part of the nervous system that consists of the brain and the spinal cord.

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CERCLA [see Comprehensive Environmental Response, Compensation, andLiability Act of 1980 ]

Chronic Occurring over a long time [compare with acute ].

Chronic exposure

Contact with a substance that occurs over a long time (more than 1 year)[compare with acute exposure and intermediate duration exposure ]

Cluster investigationA review of an unusual number, real or perceived, of health events (for example,reports of cancer) grouped together in time and location. Cluster investigationsare designed to confirm case reports; determine whether they represent anunusual disease occurrence; and, if possible, explore possible causes andcontributing environmental factors.

Community Assistance Panel (CAP) A group of people from a community and from health and environmentalagencies who work with ATSDR to resolve issues and problems related tohazardous substances in the community. CAP members work with ATSDR togather and review community health concerns, provide information on howpeople might have been or might now be exposed to hazardous substances, andinform ATSDR on ways to involve the community in its activities.

Comparison value (CV)

Calculated concentration of a substance in air, water, food, or soil that is unlikelyto cause harmful (adverse) health effects in exposed people. The CV is used as ascreening level during the public health assessment process. Substances found inamounts greater than their CVs might be selected for further evaluation in thepublic health assessment process.

Completed exposure pathway [see exposure pathway ].

Comprehensive Environmental Response, Compensation, and Liability Actof 1980 (CERCLA) CERCLA, also known as Superfund, is the federal law that concerns the removalor cleanup of hazardous substances in the environment and at hazardous wastesites. ATSDR, which was created by CERCLA, is responsible for assessinghealth issues and supporting public health activities related to hazardous wastesites or other environmental releases of hazardous substances. This law was lateramended by the Superfund Amendments and Reauthorization Act (SARA) .

Concentration The amount of a substance present in a certain amount of soil, water, air, food,



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blood, hair, urine, breath, or any other media.

Contaminant A substance that is either present in an environment where it does not belong oris present at levels that might cause harmful (adverse) health effects.

Delayed health effect A disease or an injury that happens as a result of exposures that might haveoccurred in the past.

Dermal Referring to the skin. For example, dermal absorption means passing through theskin.

Dermal contact Contact with (touching) the skin [see route of exposure ].

Descriptive epidemiology The study of the amount and distribution of a disease in a specified population byperson, place, and time.

Detection limit The lowest concentration of a chemical that can reliably be distinguished from azero concentration.

Disease prevention

Measures used to prevent a disease or reduce its severity.

Disease registry A system of ongoing registration of all cases of a particular disease or healthcondition in a defined population.

DOD United States Department of Defense.

DOE United States Department of Energy.

Dose (for chemicals that are not radioactive) The amount of a substance to which a person is exposed over some time period.Dose is a measurement of exposure. Dose is often expressed as milligram(amount) per kilogram (a measure of body weight) per day (a measure of time)when people eat or drink contaminated water, food, or soil. In general, thegreater the dose, the greater the likelihood of an effect. An "exposure dose" ishow much of a substance is encountered in the environment. An "absorbed dose"



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is the amount of a substance that actually got into the body through the eyes,skin, stomach, intestines, or lungs.

Dose (for radioactive chemicals) The radiation dose is the amount of energy from radiation that is actuallyabsorbed by the body. This is not the same as measurements of the amount of radiation in the environment.

Dose-response relationship The relationship between the amount of exposure [ dose ] to a substance and theresulting changes in body function or health (response).

Environmental media Soil, water, air, biota (plants and animals), or any other parts of the environmentthat can contain contaminants.

Environmental media and transport mechanism Environmental media include water, air, soil, and biota (plants and animals).Transport mechanisms move contaminants from the source to points wherehuman exposure can occur. The environmental media and transport mechanismis the second part of an exposure pathway .

EPA United States Environmental Protection Agency.

Epidemiologic surveillance [see Public health surveillance ].

Epidemiology The study of the distribution and determinants of disease or health status in apopulation; the study of the occurrence and causes of health effects in humans.

Exposure Contact with a substance by swallowing, breathing, or touching the skin or eyes.Exposure may be short-term [ acute exposure ], of intermediate duration, or long-term [ chronic exposure ].

Exposure assessment The process of finding out how people come into contact with a hazardoussubstance, how often and for how long they are in contact with the substance,and how much of the substance they are in contact with.

Exposure-dose reconstruction A method of estimating the amount of people's past exposure to hazardoussubstances. Computer and approximation methods are used when pastinformation is limited, not available, or missing.



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Exposure investigation The collection and analysis of site-specific information and biologic tests (whenappropriate) to determine whether people have been exposed to hazardoussubstances.

Exposure pathway

The route a substance takes from its source (where it began) to its end point(where it ends), and how people can come into contact with (or get exposed to)it. An exposure pathway has five parts: a source of contamination (such as anabandoned business); an environmental media and transport mechanism (suchmovement through groundwater); a point of exposure (such as a private well); aroute of exposure (eating, drinking, breathing, or touching), and a receptor population (people potentially or actually exposed). When all five parts arepresent, the exposure pathway is termed a completed exposure pathway.

Exposure registry A system of ongoing followup of people who have had documentedenvironmental exposures.

Feasibility study A study by EPA to determine the best way to clean up environmentalcontamination. A number of factors are considered, including health risk, costs,and what methods will work well.

Geographic information system (GIS)

A mapping system that uses computers to collect, store, manipulate, analyze, anddisplay data. For example, GIS can show the concentration of a contaminantwithin a community in relation to points of reference such as streets and homes.

Grand rounds Training sessions for physicians and other health care providers about healthtopics.

Groundwater Water beneath the earth's surface in the spaces between soil particles andbetween rock surfaces [compare with surface water ].

Half-life (t ) The time it takes for half the original amount of a substance to disappear. In theenvironment, the half-life is the time it takes for half the original amount of asubstance to disappear when it is changed to another chemical by bacteria, fungi,sunlight, or other chemical processes. In the human body, the half-life is the timeit takes for half the original amount of the substance to disappear, either by beingchanged to another substance or by leaving the body. In the case of radioactive



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material, the half life is the amount of time necessary for one half the initialnumber of radioactive atoms to change or transform into another atom (that isnormally not radioactive). After two half lives, 25% of the original number of radioactive atoms remain.

Hazard A source of potential harm from past, current, or future exposures.

Hazardous Substance Release and Health Effects Database (HazDat) The scientific and administrative database system developed by ATSDR tomanage data collection, retrieval, and analysis of site-specific information onhazardous substances, community health concerns, and public health activities.

Hazardous waste Potentially harmful substances that have been released or discarded into theenvironment.

Health consultation A review of available information or collection of new data to respond to aspecific health question or request for information about a potentialenvironmental hazard. Health consultations are focused on a specific exposureissue. Health consultations are therefore more limited than a public healthassessment, which reviews the exposure potential of each pathway and chemical[compare with public health assessment ].

Health education Programs designed with a community to help it know about health risks and howto reduce these risks.

Health investigation The collection and evaluation of information about the health of communityresidents. This information is used to describe or count the occurrence of adisease, symptom, or clinical measure and to evaluate the possible associationbetween the occurrence and exposure to hazardous substances.

Health promotion

The process of enabling people to increase control over, and to improve, theirhealth.

Health statistics review The analysis of existing health information (i.e., from death certificates, birthdefects registries, and cancer registries) to determine if there is excess disease ina specific population, geographic area, and time period. A health statistics reviewis a descriptive epidemiologic study.



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Indeterminate public health hazard The category used in ATSDR's public health assessment documents when aprofessional judgment about the level of health hazard cannot be made becauseinformation critical to such a decision is lacking.

Incidence The number of new cases of disease in a defined population over a specific timeperiod [contrast with prevalence ].

Ingestion The act of swallowing something through eating, drinking, or mouthing objects.A hazardous substance can enter the body this way [see route of exposure ].

Inhalation The act of breathing. A hazardous substance can enter the body this way [seeroute of exposure ].

Intermediate duration exposure Contact with a substance that occurs for more than 14 days and less than a year[compare with acute exposure and chronic exposure ].

In vitro In an artificial environment outside a living organism or body. For example,some toxicity testing is done on cell cultures or slices of tissue grown in thelaboratory, rather than on a living animal [compare with in vivo ].

In vivo Within a living organism or body. For example, some toxicity testing is done onwhole animals, such as rats or mice [compare with in vitro ].

Lowest-observed-adverse-effect level (LOAEL) The lowest tested dose of a substance that has been reported to cause harmful(adverse) health effects in people or animals.

Medical monitoring

A set of medical tests and physical exams specifically designed to evaluatewhether an individual's exposure could negatively affect that person's health.

Metabolism The conversion or breakdown of a substance from one form to another by aliving organism.

Metabolite Any product of metabolism .



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mg/kg Milligram per kilogram.

mg/cm 2 Milligram per square centimeter (of a surface).

mg/m 3

Milligram per cubic meter; a measure of the concentration of a chemical in aknown volume (a cubic meter) of air, soil, or water.

Migration Moving from one location to another.

Minimal risk level (MRL) An ATSDR estimate of daily human exposure to a hazardous substance at orbelow which that substance is unlikely to pose a measurable risk of harmful(adverse), noncancerous effects. MRLs are calculated for a route of exposure(inhalation or oral) over a specified time period (acute, intermediate, or chronic).MRLs should not be used as predictors of harmful (adverse) health effects [seereference dose ].

Morbidity State of being ill or diseased. Morbidity is the occurrence of a disease orcondition that alters health and quality of life.

Mortality

Death. Usually the cause (a specific disease, a condition, or an injury) is stated.

Mutagen A substance that causes mutations (genetic damage).

Mutation A change (damage) to the DNA, genes, or chromosomes of living organisms.

National Priorities List for Uncontrolled Hazardous Waste Sites (National

Priorities List or NPL) EPA's list of the most serious uncontrolled or abandoned hazardous waste sites inthe United States. The NPL is updated on a regular basis.

National Toxicology Program (NTP)Part of the Department of Health and Human Services. NTP develops and carriesout tests to predict whether a chemical will cause harm to humans.

No apparent public health hazard A category used in ATSDR's public health assessments for sites where human



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exposure to contaminated media might be occurring, might have occurred in thepast, or might occur in the future, but where the exposure is not expected tocause any harmful health effects.

No-observed-adverse-effect level (NOAEL) The highest tested dose of a substance that has been reported to have no harmful(adverse) health effects on people or animals.

No public health hazard A category used in ATSDR's public health assessment documents for sites wherepeople have never and will never come into contact with harmful amounts of site-related substances.

NPL [see National Priorities List for Uncontrolled Hazardous Waste Sites ]

Physiologically based pharmacokinetic model (PBPK model) A computer model that describes what happens to a chemical in the body. Thismodel describes how the chemical gets into the body, where it goes in the body,how it is changed by the body, and how it leaves the body.

Pica A craving to eat nonfood items, such as dirt, paint chips, and clay. Some childrenexhibit pica-related behavior.

Plume A volume of a substance that moves from its source to places farther away from

the source. Plumes can be described by the volume of air or water they occupyand the direction they move. For example, a plume can be a column of smokefrom a chimney or a substance moving with groundwater.

Point of exposure The place where someone can come into contact with a substance present in theenvironment [see exposure pathway ].

Population A group or number of people living within a specified area or sharing similarcharacteristics (such as occupation or age).

Potentially responsible party (PRP) A company, government, or person legally responsible for cleaning up thepollution at a hazardous waste site under Superfund. There may be more than onePRP for a particular site.

ppb Parts per billion.



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ppm Parts per million.

Prevalence The number of existing disease cases in a defined population during a specifictime period [contrast with incidence ].

Prevalence survey The measure of the current level of disease(s) or symptoms and exposuresthrough a questionnaire that collects self-reported information from a definedpopulation.

Prevention Actions that reduce exposure or other risks, keep people from getting sick, orkeep disease from getting worse.

Public availability session An informal, drop-by meeting at which community members can meet one-on-one with ATSDR staff members to discuss health and site-related concerns.

Public comment period An opportunity for the public to comment on agency findings or proposedactivities contained in draft reports or documents. The public comment period isa limited time period during which comments will be accepted.

Public health action A list of steps to protect public health.

Public health advisory A statement made by ATSDR to EPA or a state regulatory agency that a releaseof hazardous substances poses an immediate threat to human health. Theadvisory includes recommended measures to reduce exposure and reduce thethreat to human health.

Public health assessment (PHA)

An ATSDR document that examines hazardous substances, health outcomes, andcommunity concerns at a hazardous waste site to determine whether people couldbe harmed from coming into contact with those substances. The PHA also listsactions that need to be taken to protect public health [compare with health consultation ].

Public health hazard A category used in ATSDR's public health assessments for sites that pose apublic health hazard because of long-term exposures (greater than 1 year) to

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