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Geography, Department of
Theses and Dissertations-Geography

Texas State University Year 2007
Communicating Risk of the Bioterrorism

Threat: A Case Study in Houston, Texas
of Heathcare Professionals and the
General Public
Mark Jeffrey Cook
Texas State University-San Marcos, Dept. of Geography,
jeffathome1@yahoo.com
This paper is posted at eCommons@Texas State University.

http://ecommons.txstate.edu/geogtad/4
COMMUNICATING RISK OF THE BIOTERRORISM THREAT: A
CASE STUDY IN HOUSTON, TEXAS OF HEALTHCARE
PROFESSIONALS AND THE GENERAL PUBLIC
DISSERTATION
Presented to the Graduate Council

of Texas State University-San Marcos
in Partial Fulfillment
of the Requirements
for the Degree
Doctor of PHILOSOPHY
by
M. Jeffrey Cook, B. S., M. A. G.
San Marcos, Texas

December 2006
(Signature Page)
COPYRIGHT
by
Mark Jeffrey Cook
December 2006
ACKNOWLEDGEMENTS
It is impossible to mention specifically all of the people and actions that
contributed to the completion of this dissertation. So, I will list a few people who were
particularly motivating and supportive along the way. My most sincere thanks and
appreciation to: Denise Blanchard-Boehm, Bill and Mary Cook, Susan Macey, Rob
Dubbelde, Wendy Benedict-Schneider, Robert Atmar, Johnnie Stein, Jean Brender,
Yongmei Lu, Forrest Wilkerson and Ginger Schmid, Jamie Kraft, Doris Kraft, Stacey
Hardy, Nancy Middlebrook, Renatta Yuzda Grainger, Allison Glass, Barbara Koller, and
Angelika Wahl.
This manuscript was submitted on December 21, 2006.
iv
TABLE OF CONTENTS
PAGE
ACKNOWLEDGEMENTS............................................................................................. iv
LIST OF TABLES........................................................................................................... ix
LIST OF FIGURES ....................................................................................................... xiv
ABSTRACT.....................................................................................................................xv
CHAPTER ONE INTRODUCTION..............................................................................1
PURPOSE OF THE STUDY.......................................................................................3

RATIONALE AND THEORETICAL FRAMEWORK .............................................4
SCOPE OF THE STUDY............................................................................................6
STUDY QUESTIONS .................................................................................................7
DESCRIPTION OF THE STUDY ..............................................................................7
IMPORTANCE AND CONTRIBUTION OF THE STUDY......................................8
LIMITATIONS OF STUDY DATA .........................................................................10
BACKGROUND AND CONTENT OF THE STUDY.............................................10
CHAPTER SUMMARY............................................................................................12
CHAPTER TWO BIOTERRORISM RISK COMMUNICATION

CHALLENGES FOR HEALTHCARE PROFESSIONALS ......................................14
BACKGROUND .......................................................................................................14
CHALLENGES OF DETECTING BIOTERRORISM .............................................16
PUBLIC HEALTH SURVEILLANCE .....................................................................19
PUBLIC HEALTH SURVEILLANCE RESEARCH ...............................................22
CLINICAL JUDGMENT AND IDENTIFICATION OF
BIOTERRORISM..................................................................................................29
VIGILANCE IN THE HEALTHCARE ENVIRONMENT......................................37
CHAPTER SUMMARY AND DISCUSSION .........................................................39
CHAPTER THREE RISK COMMUNICATION THEORY AND

APPLICATION ...........................................................................................................42
DEFINITIONS AND CONCEPTS............................................................................43

HAZARDS RESEARCH WITHIN GEOGRAPHY .................................................45
PERSUASION THEORY AND THE YALE MODEL ............................................49
v
EVOLUTION OF THE RISK COMMUNICATION MODEL ................................51
THE GENERAL MODEL OF HAZARDS RISK
COMMUNICATION.............................................................................................54
RECEIVER CHARACTERISTICS ..........................................................................56
MESSAGE CHARACTERISTICS ...........................................................................69
EDUCATION AND PERCEPTIONS OF VULNERABILITY................................76
CHAPTER FOUR THEORETICAL FRAMEWORK .................................................82
THE GMHRC BEHAVIORAL STAGES .................................................................84

INFLUENCES ON THE GMHRC BEHAVIORAL STAGES.................................89
CHAPTER FIVE METHODS AND INSTRUMENTATION .....................................92
STUDY SITE.............................................................................................................92
THE QUESTIONNAIRE...........................................................................................95
THE SAMPLE GROUPS ..........................................................................................96
DATA COLLECTION PROCESS ............................................................................99
HYPOTHESES AND THE GMHRC PROCESS....................................................106
STATISTICAL METHODS....................................................................................109
CHAPTER SUMMARY AND DISCUSSION .......................................................110
CHAPTER SIX DESCRIPTION OF SAMPLE DATA.............................................112
RECEIVER CHARACTERISTICS ........................................................................112

MESSAGE CHARACTERISTICS .........................................................................136
STATISTICAL PROCESSING...............................................................................150
CHAPTER SEVEN THE BEHAVIORAL STAGE OF HEARING..........................168
SAMPLE GROUP DIFFERENCES IN HEARING................................................170

DERIVATION OF THE HEARING DEPENDENT VARIABLE .........................173
IDENTIFICATION OF INDEPENDENT VARIABLES .......................................174
MULTIVARIATE MODELING OF HEARING....................................................177
CHAPTER EIGHT THE BEHAVIORAL STAGE OF

UNDERSTANDING .................................................................................................185
DERIVATION OF UNDERSTANDING................................................................186
MULTIVARIATE MODELING OF UNDERSTANDING....................................189
vi
CHAPTER NINE THE BEHAVIORAL STAGE OF BELIEVING..........................198
DERIVATION OF THE BELIEVING DEPENDENT VARIABLE......................198

MULTIVARIATE MODELING OF BELIEVING.................................................204
CHAPTER TEN THE BEHAVIORAL STAGE OF CONFIRMING .......................216
DERIVATION OF THE CONFIRMING DEPENDENT VARIABLE..................217

MULTIVARIATE MODELING OF CONFIRMING.............................................223
CHAPTER ELEVEN THE BEHAVIORAL STAGE OF

RESPONDING ..........................................................................................................236
DERIVATION OF THE RESPONDING DEPENDENT VARIABLE..................237

MULTIVARIATE MODELING OF RESPONDING.............................................243
CHAPTER TWELVE CONCLUSIONS....................................................................256
THE BEHAVIORAL STAGE OF HEARING........................................................257

THE BEHAVIORAL STAGE OF UNDERSTANDING........................................261
THE BEHAVIORAL STAGE OF BELIEVING ....................................................265
THE BEHAVIORAL STAGE OF CONFIRMING ................................................267
THE BEHAVIORAL STAGE OF RESPONDING ................................................268
CLINICAL SAMPLE GROUPS SUMMARY........................................................273
COMPARISON OF FINDINGS .............................................................................277
CONCLUSIONS......................................................................................................279
RECOMMENDATIONS.........................................................................................282
APPENDIX
ONE SURVEY INSTRUMENTS AND VARIABLE CROSSWALKS………….287

A. Bioterrorism Questionnaire for Medical Staff
B. Bioterrorism Survey Questionnaire
C. Biotterorism Questionnaire for the Public
D. TSICP Attendees Questionnaire Crosswalk
E. Public Questionnaire Crosswalk
TWO SUPPORTING DOCUMENTATION………………………………………313

A. Texas State University Institutional Review Board Approval
B. Baylor College of Medicine Institutional Review Board Approval
vii
C. Ben Taub Hospital Institutional Review Board Approval
D. Lyndon B. Johnson Hospital Institutional Review Board Approval
E. Cover Letter to Medical Staff
F. Information for Respondents
REFERENCE LIST .......................................................................................................321
viii
LIST OF TABLES
PAGE
2.1 Summary of Possible Bioterrorism Identification Scenarios..................................... 29
3.1 Definition Latitude of Risk Communication ............................................................. 44
3.2 Important Factors of Risk Perception and Evaluation ............................................... 61
5.1 Completed Questionnaires by Group....................................................................... 103
6.1 Formal Training Levels............................................................................................ 113
6.2 Percentage of Informal Sources of Information....................................................... 114
6.3 Percentage of Previous Disaster Experience............................................................ 115
6.4 Percentage Damage Amounts from Most Recent Disaster...................................... 116
6.5 Percentage Damage Amounts from Other Disasters ............................................... 117
6.6 Impacts from Previous Disasters by Percentage...................................................... 117
6.7 Experience with False Alarms for Bioterrorism ...................................................... 118
6.8 Feelings about Future Threats Generated by False Alarms ..................................... 119
6.9 Mean Years of Education........................................................................................ 120
6.10 Length of Employment at Current Occupation....................................................... 121
6.11 Respondent Ethnicity by Percentage ...................................................................... 122
6.12 Respondent Age in Years........................................................................................ 122
6.13 Receiver Characteristics (Experiential, Occupational, and Demographic) ............ 124
6.14 Beliefs About Bioterrorism Readiness.................................................................... 126
6.15 Beliefs About Usage of Potential Biological Agents by Percentage. ..................... 128
ix
6.16 Beliefs Regarding Geographic Targets of a Bioterrorist Attack............................. 129
6.17 Beliefs Regarding Facility Targets of a Bioterrorist Attack ................................... 130
6.18 Beliefs Regarding Agency Preparedness for an Attack within One Year .............. 131
6.19 Preparedness Beliefs Regarding an Attack within One Year ................................. 132
6.20 Perceived Vulnerability to Future Bioterrorism Pre and Post 9-11-01................... 134
6.21 Receiver Characteristics (Beliefs and Perceptions) ................................................ 135
6.22 Formal Bioterrorism Training Frequency............................................................... 137
6.23 Reported Training Sources Among Trained Respondents...................................... 140
6.24 Informal Sources of Information (1)....................................................................... 142
6.25 Usage of Informal Sources of Information (2) ....................................................... 144
6.26 Perceived Credibility of Formal Training............................................................... 145
6.27 Reliability of Informal Sources of Information by Percentage (1). ........................ 146
6.28 Reliability of Informal Sources of Information by Percentage (2). ........................ 147
6.29 Message Characteristics (1) .................................................................................... 148
6.30 Message Characteristics (2) .................................................................................... 149
6.31 Collapsed Training Source Categories.................................................................... 151
6.32 Collapsed Ethnicity Categories............................................................................... 151
6.33 Dichotomized Percentage Credibility of Informal Sources (1) .............................. 152
6.34 Dichotomized Percentage Credibility of Informal Sources (2) .............................. 153
6.35 Associated Receiver Characteristics (Experiential, Occupational, and

Demographic) ......................................................................................................... 155
6.36 Associated Receiver Characteristics (Beliefs and Perceptions).............................. 156
6.37 Associated Message Characteristics (1).................................................................. 158
6.38 Associated Message Characteristics (2).................................................................. 159
x
7.1 Formal Training ....................................................................................................... 172
7.2 Informal Information ............................................................................................... 173
7.3 Hearing Dependent Variable Summary. .................................................................. 175
7.4 Independent Variables Retained for Regression of Hearing.................................... 178
7.5 Logistic Regression for Hearing: TSICP Attendees ................................................ 179
7.6 Logistic Regression for Hearing: Ben Taub MDs ................................................... 179
7.7 Logistic Regression for Hearing: Public.................................................................. 180
8.1 Understanding Dependent Variable Summary ........................................................ 187
8.2 Independent Variables Retained for Regression of Understanding......................... 190
8.3 Logistic Regression for Understanding: TSICP Attendees ..................................... 191
8.4 Logistic Regression for Understanding: Ben Taub RNs.......................................... 192
8.5 Logistic Regression for Understanding: LBJ RNs................................................... 193
8.6 Logistic Regression for Understanding: Public ....................................................... 194
9.1 Believing Dependent Variable Summary ................................................................ 200
9.2 Independent Variables Retained for Regression of Believing................................. 203
9.3 Logistic Regression for Believing: TSICP Attendees ............................................. 204
9.4 Logistic Regression for Believing: Ben Taub MDs................................................. 205
9.5 Logistic Regression for Believing: Ben Taub RNs.................................................. 206
9.6 Logistic Regression for Believing: LBJ RNs........................................................... 207
9.7 Logistic Regression for Believing: Public ............................................................... 208
9.8 Behavioral Stage Simple Correlation to Believing.................................................. 209
9.9 Logistic Regression for Believing: TSICP Attendees ............................................. 210
9.10 Logistic Regression for Believing: Ben Taub RNs ................................................ 211
xi
10.1 Confirming Dependent Variable Summary ........................................................... 219
10.2 Independent Variables Retained for Regression of Confirming............................ 224
10.3 Logistic Regression for Confirming: TSICP Attendees ........................................ 225
10.4 Logistic Regression for Confirming: Ben Taub MDs............................................ 226
10.5 Logistic Regression for Confirming: Ben Taub RNs ............................................ 227
10.6 Logistic Regression for Confirming: LBJ RNs ..................................................... 228
10.7 Logistic Regression for Confirming: Public .......................................................... 229
10.8 Behavioral Stage Simple Correlation to Confirming............................................. 230
10.9 Logistic Regression for Confirming: Public .......................................................... 232
11.1 Responding Dependent Variable Summary........................................................... 239
11.2 Independent Variables Retained for Regression of Responding ........................... 242
11.3 Logistic Regression for Responding: TSICP Attendees........................................ 243
11.4 Logistic Regression for Responding: Ben Taub MDs ........................................... 244
11.5 Logistic Regression for Responding: Ben Taub RNs ............................................ 245
11.6 Logistic Regression for Responding: LBJ RNs ..................................................... 246
11.7 Logistic Regression for Responding: Public.......................................................... 247
11.8 Behavioral Stage Simple Correlation to Responding ............................................ 248
11.9 Logistic Regression for Responding: TSICP Attendees........................................ 249
11.10 Logistic Regression for Responding: Ben Taub MDs .......................................... 250
11.11 Logistic Regression for Responding: Ben Taub RNs ........................................... 251
11.12 Logistic Regression for Responding: LBJ RNs .................................................... 252
12.1 Levels of Formal Training and Informal Information for all Sample Groups....... 259
12.2 Findings for the Behavioral Stage of Hearing ....................................................... 261
xii
12.3 Findings for the Behavioral Stage of Understanding............................................. 264
12.4 Findings for the Behavioral Stage of Believing..................................................... 266
12.5 Findings for the Behavioral Stage of Confirming.................................................. 269
12.6 Findings for the Behavioral Stage of Responding ................................................. 272
xiii
LIST OF FIGURES
PAGE
1 Syndromic Surveillance and Bioterrorism-related Epidemics..................................... 18
2 Surveillance Data Flowchart for Patient Encounters ................................................... 21
3 Timeline Milestones (in Days) for Outbreak Detection .............................................. 21
4 Timeline to Presumptive Anthrax Diagnosis During Post 9-11 Attacks ..................... 28
5 Factors Affecting Index of Suspicion of Vigilant Clinicians....................................... 32
6 Minnesota Department of Health's "Recognizing the Zebra"...................................... 35
7 The General Model of Hazards Risk Communication................................................. 83
8 Locations of Ben Taub and LBJ General Hospitals within Harris County, Texas ...... 94
9 Geographic Distribution of TSICP Attendees ............................................................. 98
xiv
ABSTRACT
COMMUNICATING RISK OF THE BIOTERRORISM THREAT: A
CASE STUDY IN HOUSTON, TEXAS OF HEALTHCARE
PROFESSIONALS AND THE GENERAL PUBLIC
by
M. Jeffrey Cook, B. S., M. A. G.
Texas State University-San Marcos, Texas
December 2006
SUPERVISING PROFESSOR: DENISE BLANCHARD-BOEHM
The primary goals of this research are to assess and model the process of risk
communication among healthcare workers towards the threat of bioterrorist agents and to
identify factors that contribute to responsive clinicians, thereby providing a strategy for
designing more effective education programs among healthcare providers who are the
population with the most likely opportunities to identify a bioterrorist event.
xv
CHAPTER ONE
INTRODUCTION
Suicide bombers and planes flying into buildings are likely recognizable as
intentional acts of terrorism upon onset. However, terrorism through the release of a
biological terrorism agent, a purposefully introduced biologic substance intended to cause
illness and death, may have an unclear or unnoticed onset period (Lillibridge 1999; Gallo
and Campbell 2000; Centers for Disease Control 2001; Joint Commission Resources
2002; Lazarus et al. 2002; Buehler et al. 2003, 2004). Terrorists are not likely to
announce that a biological agent has been released (Stern 2003). Response and recovery
may not be initiated until the event is identified or recognized. In the absence of an
announced or witnessed biological agent release, identification of onset requires a
diagnosis from a medical provider. Even worse, from an infection control standpoint,
certain biological agents are contagious. While the event goes unrecognized, these agents
have the potential to spread and wreak havoc locally, nationally, and in some cases,
globally.
Similar to other hazards, bioterrorism is to some degree unexpected, generates
morbidity and mortality, disrupts society, and is costly to the economic system.
Depending upon the scale of the event, the disruption and negative consequences might
1
2
range from minor and local to catastrophic and global. Rotz and colleagues (2002, 5)
stated that small scale bioterrorism events would perhaps be more likely due to fewer
degrees of complexity, but that large scale events are possible and potentially
catastrophic. Bioterrorist attacks are potentially as deadly as widespread thermonuclear
attacks (Stern 2003). However, different from a thermonuclear attack, evidence of a
biological agent release would be difficult to discern.
The primary hope for identifying a bioterrorism occurrence lies in public health
surveillance which typically provides information on health and natural disease trends
within a particular population. Surveillance data, it is thought might also provide a
signal of disease trends resulting from a biological agent release (Centers for Disease
Control 2001; Buehler et al. 2003, 2004). The process required to investigate and
identify an unusual disease trend first identified by public health surveillance may be
time consuming and usually relies on limited amounts of data (Lazarus et al. 2002). An
in depth discussion of the challenges of identifying potential bioterrorism occurrences
occurs in Chapter Two.
Vigilant clinicians act as society’s first line of defense in providing an alternative
pathway for identification of a bioterrorist’s attack through public health surveillance.
Clinicians have opportunities to notice unusual characteristics and trends within their
patients that are separate from public health surveillance. Clinicians who actively
monitor for the subtle early clues of what might prove to be a bioterrorist attack
demonstrate vigilance for potential bioterrorist attacks. An improved understanding of
how healthcare workers might best receive bioterrorism information and education would
3
help to maximize clinical vigilance for the subtle early clues of intentionally released
biological agents.
Following the events of September 11, 2001, the nation has been faced with the
reality of domestic terrorism. Subsequently, households have been bombarded with news
coverage, books, reports, images, and discussions about the threat of conventional
terrorism as well as terrorism through intentionally released biological agents. The
abundance of informal means of information gathering about bioterrorism from the
broadcast and print media, as well as formal training mandated by healthcare regulatory
and accreditation organizations, provide the best opportunity for assessing the extent to
which healthcare workers learn of and then respond to long term, low-key warning
messages of the threat from bioterrorist agents.
Purpose of the Study
The primary goals of this research were threefold: (1) to investigate the extent to
which awareness levels, perceptions of vulnerability, and behavioral responses of five
different groups of respondents as reflected in the theoretical relationships defined by the
General Model of Hazards Risk Communication (the GMHRC); (2) to identify
statistically significant associations in each of the five groups in order to understand how
and why bioterrorism risk communication, does or does not occur for each specific
group; and, (3) to offer recommendations on how best to tailor low-key, long term
bioterrorism risk communications that include readiness and onset identification
information.
4
Of the five groups of respondents, four emanated from the healthcare profession,
and included infection control practitioners, registered nurses, and medical doctors; with
different occupational interests and levels of engagement in risk communication for
potential bioterrorist occurrences. The fifth group was a sample of the general public that
provided a measure of the extent to which risk information regarding the bioterrorist
hazard reached a relatively uninvolved, yet at-risk, sector. This research identified
factors specific to each group that will contribute to a more effective response with a
particular focus on nurses and doctors. The findings of this research provided information
for designing more effective risk communication programs among healthcare providers
who are the population with the most likely opportunities to identify a bioterrorist event.
Rationale and Theoretical Framework
The theoretical basis for this study was found within the subfield of hazards risk
communication which comprises more than 30 years of previous research. The majority
of risk communication model based research follows the framework generally outlined
by Mileti, Fitzpatrick, and Farhar (1990) which conceptualizes risk communication as a
process of behavioral stages influenced by individuals personal characteristics, personal
experiences, and personal histories. The risk communication model behavioral stages
consist of a process of “hearing,” “understanding,” “believing,” “confirming,” and
“responding” to risk information (Mileti, Fitzpatrick, and Farhar, 1990; Mileti and
Fitzpatrick, 1992, 1993; Blanchard-Boehm 1992, 1998).
From the accumulated body of risk communication knowledge, a behavioral stage
process oriented approach to communicating risk has evolved and is known as the
5
General Model of Hazards Risk Communication (GMHRC) (Blanchard-Boehm 1992,
1998). The GMHRC evolved from the work of previous risk communication researchers
as discussed in greater detail in Chapter Three. This application of the GMHRC in this
research adds another layer of adaptations and refinements to risk communication model
based research.
To assess the degree to which the behaviors of healthcare workers follow the
precepts of the GMHRC, it was necessary to gather data via a survey questionnaire from
several groups of healthcare workers engaged in various levels of monitoring and early
detection of disease and illness. These groups included: (1) members of the Texas
Society for Infection Control Practitioners (TSICP); (2) Ben Taub General Hospital
Medical Doctors; (3) Ben Taub Hospital Registered Nurses; (4) Lyndon Baines Johnson
General Hospital Registered Nurses; and (5) the general public. The respondents most
likely to potentially observe a bioterrorist case were the Harris County Hospital District
(HCHD) clinicians who were comprised of three different groups of primary care medical
providers.
Members of the TSICP sample consisted primarily of infection control
practitioners (ICPs) and were expected to have had more opportunities for receiving both
formal and informal bioterrorism education than other groups. The general public sample
consisted of randomly selected members of the general public within Harris County,
Texas, and provided a comparison group of those employed mostly outside of healthcare.
The public sample provided insight into baseline levels of pre-emergency bioterrorism
information received largely through informal sources such as print and broadcast media.
6
The data collected from these sample groups allowed the testing of the research
hypotheses in comparison with the research literature on hazards risk communication.
Scope of the Study
This study provided an opportunity to enhance understanding of bioterrorism risk
communication by investigating the primary group of concern, the clinicians, and
comparing them to the two other groups with different job roles and varying levels of
exposure to bioterrorism training and information. Because they might have
opportunities to diagnose illnesses in their patients resulting from a biological agent,
clinicians were the primary focus of this research. The comparison between the five
groups served to highlight differences that might arise from occupational roles and the
opportunities for obtaining bioterrorism readiness information.
The scope of this study included investigation of factors related to both formal
and informal sources of information. The preferred outcome of the bioterrorism risk
communication consisted of vigilance to the threat of bioterrorism as measured through
perception of vulnerability to future bioterrorist events. Increased levels of perceived
personal vulnerability increase the likelihood that clinicians maintain vigilance for the
possibility of biological agent-induced illnesses within the spectrum of potential
diagnosis. This outcome relies on effective risk communication training and education.
The GMHRC framed the investigation of pre-emergency bioterrorism risk
communication within the clinical healthcare environment.

7
Study Questions
Six study questions framed this investigation of low-key, long term pre-
emergency bioterrorism risk communication within healthcare. The study questions
reflected the five behavioral stages of the GMHRC process which are “hearing,”
“understanding,” “believing,” “confirming,” and “responding” to bioterrorism risk
messages. The investigation focused on all five behavioral stages to determine what
factors contributed to each particular stage of the model process. The study questions are
stated as follows:
#1. What receiver and message characteristics explained the degree to which
the sample groups heard (or learned of) low-key, long term bioterrorism
risk messages, and to what extent did the sample groups differ?
the sample groups understood low-key, long term bioterrorism risk
messages, and to what extent did the sample groups differ?
the sample groups believed low-key, long term bioterrorism risk messages,
and to what extent did the sample groups differ?
#4. What message and receiver characteristics explained the degree to which
the sample groups confirmed low-key, long term bioterrorism risk
#5. What message and receiver characteristics explained the degree to which
the sample groups responded to low-key, long term bioterrorism risk
#6. How does the process of bioterrorism risk communication differ among the
clinical groups?
Description of the Study
Data collection for this project was completed in April, 2006. Data from HCHD
clinicians were collected over a three month period ending in April, 2006. HCHD
8
clinicians provided 426 completed surveys. Data from the TSICP attendees were
collected over a three year period during 2004, 2005, and 2006 and consisted of 218
completed questionnaires. Data from the public were collected during February, March,
and April, 2006 and consisted of 265 completed questionnaires. A detailed account of
data collection and methodology are included in Chapter Five.
Data were collected through a questionnaire developed by Blanchard-Boehm in
2003 to investigate bioterrorism risk communication among TSICP members across the
State of Texas. The questionnaire (Appendix One-A) evaluated and quantified the
bioterrorism risk communication process and provided measures through which to derive
the model behavioral stages of hearing, understanding, believing, confirming, and
responding. The questionnaire also established message and receiver characteristics that
influence the individual behavioral stages of the GMHRC process.
Importance and Contribution of the Study
Despite limitations, inherent in all research, the findings from this research have
both theoretical and practical goals. From the theoretical perspective, it contributed
knowledge and insight to the pre-emergency bioterrorism risk communication process
and tested the applicability of the GMHRC framework within the healthcare
environment. Results also provided feedback on the risk communication process specific
to bioterrorism.
From the practical perspective, understanding the bioterrorism risk
communication process within healthcare provides the opportunity to create improved
readiness and preparedness training programs. Bioterrorism readiness and preparedness

9
training within healthcare is often mandatory. Investigating effectiveness of risk
messages received in a mandatory (somewhat controlled) environment provided a unique
opportunity to assess receiver and message characteristics that influence the risk
communication process. Identification of factors that contributed to the behavioral stages
of the risk communication process provided feedback and knowledge about the
bioterrorism risk communication process that were previously unidentified. The findings
might help to create better and more tailored training programs for healthcare workers.
Several researchers have noted the dearth of empirical research regarding pre-
emergency risk communication. Even fewer empirical studies have investigated
biological threats. Burton, Kates, and White (1993) warned that biological natural
hazards, such as emerging diseases, have long been neglected within hazards research.
The intentional nature of a biological agent release does not necessarily impact human
populations in the same way as a naturally emerging disease, but there are many
similarities. One important similarity is that both must be identified by healthcare
providers. Another similarity between emerging diseases and bioterrorism is that
response and recovery activities are primarily functions of the medical community.
An extensive review of geographic, hazards, and medical literature yielded few
studies of healthcare providers and bioterrorism risk communication. This research
provides one of the first case studies of bioterrorism risk communication among
clinicians in an occupational role thought to be the most likely potential identifiers of a
bioterrorist event.
10
Limitations of Study Data
The data collected for this dissertation consisted of five sample groups from three
general populations. The sample groups and the data collection process varied between
the three general populations (see Chapter Five). The generalization of the inferred
results to the larger populations might be limited due to the process of data collection as
described in Chapter Five (p. 105). As in most research, the data collection process for
this dissertation presented unique challenges and less than ideal conditions which might
influence comparability. These limitations should be considered when viewing and
interpreting the results.
Background and Content of the Study
Following the events of September 11, 2001, the nation has been faced with the
reality of domestic terrorism and subsequently bombarded with news coverage, books,
reports, news-articles, images, and information about the threat of both conventional
terrorism and from the intentional release of a biological agent. The newly recognized
and heightened risk, along with the abundance of information about bioterrorism in the
broadcast and print media, created the opportunity to assess the role of multiple sources
and multiple exposures to bioterrorism information. This dissertation sought to better
understand the pre-emergency bioterrorism risk communication process within the
healthcare environment during a critical time of increased perceived risk.
The commonly relied upon methods of identifying bioterrorism events through
public health surveillance does not provide a direct indication of onset. Rather, a
11
bioterrorism occurrence would result from an investigation of an unusual disease trend
that was first noticed through surveillance. Further, public health surveillance may
require long periods of time to signal unusual trend activity. In addition, the early
evidence of a bioterrorism occurrence may be obscured by incubation periods and non-
specific symptoms following incubation. However, vigilant clinicians provide a hopeful
alternative route to identification of onset through surveillance.
Due to their unique roles in both identifying and managing a bioterrorism
occurrence, vigilant medical doctors and nurses are critical determiners of readiness and
preparedness for future bioterrorism events (Shadel et al. 2003, 282). Unlike many other
hazards, bioterrorism must be identified by and responded to largely through the actions
of healthcare providers (Lillibridge 1999; Buehler et al. 2003; Filoromo 2003).
Clinicians with higher levels of perceived personal vulnerability to bioterrorism are
considered on-alert or vigilant for bioterrorism (see Chapter Three and Four). Lower
levels of perceived vulnerability indicate possible complacency and an increased
likelihood of missing an opportunity to identify an occurrence of bioterrorism early.
Bioterrorism risk communication to healthcare providers remains especially
challenging due to the likelihood that the onset period will be difficult to identify in most
circumstances. The lack of ability to quickly identify the release of a biological agent
prohibits the issuance of risk messages to clinicians that contain specific temporal and
geographic references to the risk. The expected lack of ability to issue warning messages
during an event emphasizes the importance of bioterrorism readiness risk
communications at the pre-emergency level.

12
Chapter Summary
Previous studies of risk communication and public response to hazards compare
the “hearing” of the message to “learning” of factors of risk (Blanchard-Boehm 1992,
47). The complex bioterrorism training information imparted to healthcare providers
requires long term comprehension, which entails more than the simple receipt of the
message. Effective bioterrorism risk communication messages augment vigilance to the
possible evidence of biological agents causing illnesses within their patients. Vigilance
derives from perceiving personal vulnerability to future bioterrorism occurrences.
According to the GMHRC, responding behaviors are formed through the model process
behaviors of receiving, understanding, believing, and possibly confirming the risk
information. Clinical vigilance to bioterrorism is the preferred GMHRC responding
outcome for pre-emergency bioterrorism risk communications.
Clinicians are in a singular position to recognize an unusual syndrome trend in the
critical early stages (Lillibridge 1999, 643). Vigilant clinicians have the potential to
investigate patients with unusual characteristics before syndrome surveillance systems
indicate the need to do so. Clinical vigilance may represent the greatest opportunity for
providing early identification of onset during a bioterrorism event as discussed in more
detail in Chapter Two.
This study provided a unique opportunity to understand the bioterrorism risk
communication process by comparing five distinct groups. Each of the five groups had
different characteristics that created varying formal and informal circumstances for
exposure to bioterrorism training, education, and information. The sample of TSICP
attendees provided insight into bioterrorism risk communication among infection control
13
practitioners who are primarily concerned with bioterrorism from a planning and
readiness perspective. These specialists were expected to have had multiple formal and
informal exposures to bioterrorism information and education. The sample of clinicians
provided detailed information on the risk communication process among clinicians who
were considered to be the most likely candidates for noticing or identifying future
occurrences of intentionally released biological illnesses within their patients. The public
sample provided insight into baseline levels of information largely from informal sources
of information. Findings from this study highlighted methods for improving employee
vigilance through better training programs.

CHAPTER TWO
BIOTERRORISM RISK COMMUNICATION CHALLENGES FOR HEALTHCARE

PROFESSIONALS
Background
Following the terror attacks of 2001, the nation was reminded that many years of
under-funding and neglect had greatly compromised the nation’s public health and
disaster response infrastructure. Low levels of funding and cumulative lack of attention
by politicians and policy makers over the years has created a public health system that
remains ill-prepared to respond to or even detect an occurrence of bioterrorism. In their
2002 yearly review, the editors of HealthLeaders Magazine cited hopeful examples of a
turnaround in under funding for healthcare readiness improvements including
(HealthLeaders Magazine 2002):
• The announcement of plans by the U.S. Health and Human Services agency
(USHHS) to release approximately $2.9 billion in fiscal 2002 to combat
bioterrorism and related threats--a tenfold increase over the $296 million
appropriated in 2001;
• a supplement of $918 million to the Centers for Disease Control to bolster lab
capacity and communication;
• significant new federal and state money began flowing to hospitals and other
healthcare services organizations nationwide; and,
• a large increase in training of physicians regarding the characteristics of the
various biological agents within patients and to facilitate diagnosis and treatment
during an occurrence (p. 2).
14
15
The same issue of HealthLeaders quoted Tara O'Toole, M.D., Director of the Center for
Civilian Bio-defense Strategies at Johns Hopkins University, as stating “The federal
government is just beginning to come to grips with this new threat and has not yet
appropriately dealt with it. We still don't have a full-fledged national strategy for coping
with bioterrorism (2002, 2).” Thus, progress is being made in preparedness, but many
professionals in the healthcare industry believe the nation remains largely unprepared for
a bioterrorism attack (Stern 2002, 98).
A branch of the U.S. Department of Health and Human Services known as the
Health Resources and Services Administration's (HRSA) aims to improve and expand
access to quality health care nationwide. HRSA distributes grant based bioterrorism
funds to healthcare organizations throughout the nation. In response to the newly
accepted and acknowledged terrorist threats resulting from the events of September 11,
2001 and the subsequent anthrax attacks, HRSA sought to improve bioterrorism readiness
and response through increased funding. The 2002 HRSA budget earmarked $275 million
dollars for counter-terrorist activities (Health Resources and Services Administration
2002), and the year 2003 heralded a hospital preparedness budget of $589 million dollars,
with $267 million earmarked specifically for bioterrorism readiness activities (Health
Resources and Services Administration 2003). In 2004, the federal fiscal year budget
totaled $515 million for hospital preparedness and included funding to improve
infrastructure related to hospital surge capacity meant to better prepare hospitals for
bioterrorist incidents. The 2005 fiscal year funding dropped to $480,739,021 in funds
earmarked for hospital preparedness (Health Resources and Services Administration
2004). Slightly less money for hospital preparedness was earmarked for 2006, with funds
16
totaling close to $470 million. Another decrease in funding is expected for 2007, when
allocated funding is expected to be near $466 million (Health Resources and Services
Administration 2006).
Healthcare organizations must have access to funding sources if they are to
increase readiness and preparedness programs; however, it is commonly accepted within
the healthcare industry that available government funds are small in proportion to actual
needs. Despite the fact that bioterrorism was an identified threat before the events of
September 11, 2001, few healthcare organizations had incorporated bioterrorism planning
into their disaster plans and few have the funding to do so now (Filoromo et al. 2003).
The authors noted that following the terrorist attacks of 2001, perceptions of vulnerability
toward future terrorism-related attacks had increased, and the perceived need for
readiness and preparedness activities was beginning to increase.
Challenges of Detecting Bioterrorism
Public health professionals monitor syndrome trends within public health data to
identify early manifestations of disease activity that might potentially be related to
bioterrorism (Buehler et al. 2003). Public health surveillance monitors disease activity,
or syndrome trends, which allows for the discovery of either naturally occurring disease
trends or something more sinister (Shadel et al. 2003). Health professionals rely on
surveillance data to indicate suspicious trends because readily identifiable symptoms
from biological agents may not be obvious for many days following an agent release due
to incubation periods of the biologic agents (Gallo and Campbell 2000; Center for
17
Disease Control 2001; Buehler et al. 2004). Further, after the symptom-free incubation
period ends, many biological agents mimic ordinary illnesses for several additional days.
Even before the terrorist attacks of 2001, the serious challenges posed by clinical
recognition of a bioterrorism occurrence generated concern. Gallo and Campbell (2000)
published a study that highlights the difficulties faced by healthcare organizations and
government officials regarding identification of a bioterrorist incident. Many biologic
agents produce non-specific symptoms in the early stages of the disease, masking the
onset of an attack behind what appears to be an ordinary illness. Unlike chemical or
radiological-based terror weapons, no electronic devices currently exist that have the
ability to detect biologic agents (Bevelacqua and Stilp 2002, 74). Furthermore, experts
agree that a bioterrorist attack is difficult to distinguish from naturally occurring disease
outbreaks through public health surveillance and vigilant clinicians (Lillibridge 1999;
Gallo and Campbell 2000; Lazarus et al. 2002; Stern 2003)
Buehler and colleagues (2003) highlighted two different pathways for
identification of bioterrorism onset. The first pathway (Figure 1-upper diagram)
represents the typical public health surveillance approach which requires health
surveillance data from large numbers of patients prior to identifying an unusual disease
trend. Once identified, the trend must be investigated and understood prior to any type of
response. The second pathway (Figure 1-lower diagram) represents the identification of
onset through vigilant clinicians. Both pathways might possibly provide identification of
a bioterrorism event. However, the clinical route offers the best opportunity for true early
detection and does not always require greater numbers of patients.

18
Figure 1 Syndromic Surveillance and Bioterrorism-related Epidemics.

Source: Buehler (2003, 1199)
Nierengarten, Lutwick, and Lutwick (2003) authored a bioterrorism training
program designed for clinicians that provided training and education regarding
19
bioterrorism detection strategies. Like Buehler and colleagues (2003), they list two
separate pathways for identification of bioterrorism:
1. The route that primarily relies on data generated by clinical care

(such as emergency room syndromes defined by ICD-9 codes) and
individual behavior (such as pharmacy sales, ambulance calls,
school absenteeism, and over the counter medication sales) to track
possible disease outbreaks; and
2. The route that primarily relies on clinical judgment to recognize
disease syndromes found on patient presentation and that raises the
index of suspicion of a bioterrorist–instigated or other emerging
infectious disease outbreak (p. 5).
The first pathway represents the typical public health surveillance approach which relies
on identification of bioterrorism occurrences through collection and analysis of health
data. The second pathway represents the alternate route of clinical identification of
potential bioterrorism illnesses within their patients. Public health surveillance, as a
method for identifying potential bioterrorism activity, is explored in the following
section.
Public Health Surveillance
Gordis (2004) states that surveillance for disease within target populations is a
fundamental role of public health; further, surveillance is conducted to determine disease
frequency, changes in said frequency, and to monitor changes in prevalence of risk
factors (p. 42). What we know about morbidity and mortality from disease largely comes
from these programs of systematic disease surveillance. Surveillance provides health
and disease information as well as intervention feedback to public health officials.
Lazarus and colleagues (2002) caution that timely identification of unusual trends for
20
illnesses in the general population still proves to be a fundamental challenge of public
health surveillance due to incomplete data collection, analysis, and interpretation.
Lazarus and his research team (2002, 754) defined syndrome surveillance as rapid
identification of unusual clusters of acute illness in the general population. Buehler and
colleagues (2004, 4) defined health surveillance as ongoing and systematic indicator-data
collection, analysis, and interpretation. The final stage of surveillance consists of
dissemination of findings with the intent of reducing morbidity and mortality (Figure 2).
Surveillance systems collect syndrome data and subsequent analysis portrays clinical
manifestations of disease outbreaks within the patient population. Some governmental
and health-related organizations currently have health surveillance systems, or are
developing systems, to monitor for unusual disease trends including bioterrorism events.
Syndrome surveillance systems perform most effectively when large quantities of
and solid baseline data are both available. Lazarus and colleagues (2002) stated that
surveillance data must be timely, accurate, and inexpensive (p. 754). In addition, the
sample population must be sufficiently large to provide an accurate representation of the
general population in order to detect significant events (Buehler et al. 2003).
Buehler and his research team (2004, 4) provided a timeline for identification of unusual
disease trends through public health surveillance (Figure 3). Surveillance provides non-
diagnostic identification of aberrant trends that might possibly include a bioterrorist event
(Buehler et al. 2004). Public health surveillance does not specifically identify
bioterrorism activity; rather it indicates an unusual trend requiring further investigation.
Buehler and his team of researchers (2004, 4) cautioned that surveillance systems would
not detect a single case of bioterrorism because threshold numbers of cases must be
21
surpassed before unusual trends may be detected. In addition to requiring large numbers
of cases, another shortcoming of public health surveillance stems from the delay of
several days required to indicate and then investigate unusual trend activity (Lazarus et
al. 2002; Buehler et al. 2004).
Figure 2 Surveillance Data Flowchart for Patient Encounters.

Source: Buehler et al. (2004, 4)
Figure 3 Timeline Milestones (in Days) for Outbreak Detection.

22
Public Health Surveillance Research
The Lazarus research team (2002) partnered in a collaborative project with the
Centers for Disease Control (CDC) and evaluated a public health surveillance system.
Their study sample represented 10 percent of the regional population of eastern
Massachusetts. Syndrome data collected from ambulatory care visits and nurse
telephone ‘hot’ lines were monitored for unusual trends and disease clusters. This system
had a unique temporal benefit that differentiated itself from other approaches as it had the
potential to provide limited trend analysis every 24 hours in the form of a surveillance
summary.
Of particular note was the methodology employed by Lazarus et al. (2002), who
utilized a Geographic Information System (GIS) to address match patients to further
improve syndrome surveillance through identification of geographic clusters. Typical
public health surveillance data identified only temporal disease clusters and lacked any
spatial analysis. In the event of bioterrorism, the spatial component becomes critical for
establishing location of agent dissemination and for identifying those possibly exposed.
The GIS methodology might aid in defining the regions of potential exposure from
person-to-person contact during future bioterrorism events. Thus, identification of
geographic regions of potential exposures would enable a more efficient and targeted
response.
Proxy Sources of Health Surveillance Data
The CDC (2001) advised that multiple sources of proxy data for potential
bioterrorism events exists. Laboratories within healthcare facilities offer a variety of

23
proxy indicators of unusual disease trends. For example, an unusually large number of
samples, especially samples from the same medium, may alert lab personnel that an
unusual trend is underway. Likewise central laboratories receiving specimens from
multiple sources should be alert to increases in demand or unusual requests for culturing
which also may indicate departure from normal trends (Center for Disease Control 2001;
Buehler et al. 2004).
Rodman, Frost and Jakuboski (1998) investigated the usage of nurse hot lines as
proxy indicators of health surveillance data. People who did not believe they were sick
enough to visit the emergency room often used nurse telephone lines to obtain advice or
assistance with their medical condition. Thus, these hotlines provided data that were
categorized and quantified by symptoms into broad syndromic categories. Analysis of
data provided insight into syndrome trends and disease activity. Rodman and colleagues
(1998) hypothesized that during the early stages of a bioterrorism occurrence, nurse hot
lines would experience a surge in number of calls within a particular syndrome category
when symptoms were non-specific and non-critical, and this surge might alert public
health practitioners of the need to launch an epidemiologic investigation.
Sterling and colleagues (2005) investigated the ability of data from occupational
healthcare providers to serve as early indicators of increased disease activity. Their
findings indicated occupational healthcare providers would likely experience
opportunities to identify emerging disease or biological agent generated disease activity
within their patients. However, the fact that only a limited number of citizens across the
nation were employed at workplaces with occupational health care providers, limited the
effectiveness of this method for identifying unusual disease trends. This approach,
24
however, might augment public health surveillance especially when considering the
incomplete national coverage of surveillance.
Lazarus and his research team (2002) noted that the anthrax attacks provided an
impetus to develop and implement surveillance systems which serve to identify both
naturally occurring disease clusters and bioterrorism. They cautioned that early
recognition remains critical to successfully responding to both intentionally released
biological agents and natural disease outbreaks. In a study of plague as a bioterrorist
agent, Inglesby and colleagues (2000) discussed the complications of early identification
of intentionally released plague. The authors noted that in the first 1 to 6 days following
dissemination, plague would be indistinguishable from common respiratory illnesses in
the absence of specific diagnostics testing (p. 2287). To further complicate matters,
many regions, such as the southwest United States still have endemic plague. The
authors stated, however, that intentionally released plague would most likely transmit via
aerosol inhalation. Naturally occurring plague tends to enter the body through insect
bites and the disease progresses differently than inhalation plague. Plague as a terrorist
agent would masquerade as common illnesses until syndrome surveillance systems or
vigilant clinicians noticed an unusual trend that warranted more investigation.
Different from intentionally released biological agents, naturally occurring
emerging diseases sometimes have proxy indicators that health professionals monitor for
impending potential outbreaks within human populations. The West Nile virus, for
example, is found in a variety of natural reservoirs. Hubalek and Halouzka (1999)
reported that surveillance methods for the West Nile virus require surveying of principal
vectors. They suggested monitoring of vector population densities as well as routine

25
diagnostics for the virus in human populations of affected areas. Monitoring population
size and conditions of vectors provides insight into numbers of potential human patients.
Bioterrorism surveillance remains much less certain and straightforward as naturally
occurring vectors to monitor for intentionally released biological agents do not exist.
In a 2002 study, Goldenberg and colleagues proposed that public health
surveillance systems were ineffective as early identifiers of an anthrax attack because
prior to seeking medical care many people would first seek ‘over the counter’ (OTC)
drug treatment believing they had a common cold or respiratory illness. The goal of their
study was to test data from OTC drug sales against known facts of the anthrax attacks to
determine if OTC drug sales served as a valid proxy indicator of a bioterrorism
occurrence by highlighting regional clusters of increased OTC sales. Like many
bioterrorism agents, early anthrax symptoms are non-specific. Goldenberg and
colleagues (2002) proposed a model for monitoring OTC drug sales purchased to treat
non-specific anthrax symptoms during the early onset period when symptoms are easily
misdiagnosed as a common respiratory illness. They utilized data from both accidental
and terrorist releases of anthrax into human populations and found that patients do,
indeed, self-treat using OTC medicines prior to seeking medical treatment. They warned,
however, that even if OTC drug sales identified an unusual trend, the problem still
existed of a several day delay required to track patients and perform confirmatory
diagnostic tests. Similar to other forms of monitoring health trends and disease activity,
OTC drug sales may alert epidemiologists to an unusual trend, but are not definitive
bioterrorism identifiers.
26
In addition to OTC drug sales, data collected regarding work and school absences
also has usefulness as a proxy variable for surveillance (Buehler et al. 2004). Lazarus
and colleagues (2002) noted that the anthrax attacks provided an impetus for developing
greater coverage of and participation in public health surveillance systems. They
cautioned that early recognition is critical to successfully responding to bioterrorist
events and to natural disease outbreaks.
Surveillance During the Anthrax Attacks
The anthrax attacks, following the events of September 11, 2001, provided a
unique opportunity to obtain feedback regarding our current abilities to both identify and
respond to bioterrorism occurrences. Like many potential bioterrorism agents, anthrax
produces prodromal symptoms that are indistinguishable from common illnesses in the
early stages and only later--as the disease progresses—would symptoms appear serious
enough to warrant extensive diagnostic tests.
The anthrax attacks that followed the events of September 11, 2001 highlighted
some of the critical shortcomings of syndrome surveillance (Figure 4). Buehler and
colleagues (2003, 1200) stated that the anthrax attacks of Fall 2001 were too small and
geographically diffused to be noticed by syndrome surveillance. They reported that 6 of
the patients had identified exposure dates. The duration of time between exposure and
non-specific symptom onset ranged from 4 to 6 days in these patients. The median time
between onset of early symptoms and initial healthcare visit was 3 days with a range of 1
to 7 days. Hospitalization occurred within 3 to 7 days following exposure with a median
of 4 days. The temporal diagnostic history of these anthrax patients highlights the time
27
constraints inherent within public health surveillance. Rural locations typically lack
public health surveillance coverage; had these attacks taken place outside of urban areas,
the temporal delays would have been much worse.
Two anthrax victims were sent home from emergency rooms with a non-specific
syndrome diagnosis. As symptoms worsened, the patients returned to the hospital and
were readmitted. Another patient was recalled for treatment following release from the
hospital when a blood culture obtained during an emergency room visit was later
determined to be positive for gram-positive bacilli which is one of the indicators of
anthrax as well as numerous other bacterial infections. Following more diagnostic tests,
the culture was specifically identified as Bacillus anthracis. Two of the 11 victims were
evaluated by their primary care physician and sent home with non-specific diagnosis of
viral syndrome or bronchitis. Within 2 or 3 days of their return home, symptoms
worsened and they were eventually admitted to a hospital. Life saving antibiotic therapy
was delayed due to misdiagnosis. If these patients had suffered from a contagious
biological agent, the incorrect initial diagnoses might have been more disastrous.
Seven additional cases were successfully diagnosed by vigilant clinicians. These
7 patients were admitted to the hospital upon initial presentation and were diagnosed
within 24 hours. Vigilant clinicians monitored patients for characteristics that raised or
lowered their index of suspicion for bioterrorism and performed exploratory diagnostic
tests. Clinical opportunities to identify bioterrorism occurred during the anthrax attacks
despite the small numbers of affected patients.
Buehler and colleagues (2003) noted that the goal of public health surveillance
systems is to enable early detection of epidemics and to provide a more rapid public
28
health response within hours or even days prior to when diseases are diagnosed by
clinicians, or at least prior to the time at which reportable diseases are diagnosed and
reported to authorities. Early detection of a bioterrorism occurrence through public
health surveillance systems remains unproven and may not be achievable (Centers for
Disease Control 2002; Buehler et al. 2003, 1197; Reingold 2003). In the future,
syndrome surveillance systems may improve and better provide early identification of a
bioterrorism event, but currently they remain a crude tool that only signals the need to
look at trends more closely.
Figure 4 Timeline to Presumptive Anthrax Diagnosis During Post 9-11 Attacks.

29
Clinical Judgment and Identification of Bioterrorism
The previous sections explored problems and shortcomings generated by reliance
on public health surveillance to identify bioterrorism. The characteristics of different
methods for identifying a bioterrorism occurrence are summarized in Table 2.1.
Announced bioterrorism events are thought to be unlikely. Identification of onset
through the noticing of agent disbursal would be unreliable and unlikely. Under normal
conditions, financial resources limit the performance of diagnostic tests on most patients
thought to have an ordinary illness. For these reasons, identification of onset through
vigilant clinicians may be the best hope for rapid and effective identification of
bioterrorism onset.
Table 2.1 Summary of Possible Bioterrorism Identification Scenarios.
IDENTIFICATION
BY HEALTHCARE EARLY
IDENTIFICATION SOURCE LIKELIHOOD PROVIDERS OR PUBLIC IDENTIFICATION
HEALTH OFFICIALS
Announced event Not Likely No Possible, but not likely
Noticed event during

Not likely No Possible, but not likely
agent dispersion
Routine diagnostic tests (in the

Not likely Yes Possible, but not likely
absence of suspicion)
Syndrome surveillance with a small

Likely Yes Possible, but not likely
number of initial cases
Syndrome surveillance with a large

Likely Yes Possible
number of initial cases
Vigilant clinicians with small

Likely Yes Possible
number of cases
Vigilant clinicians with large

Likely Yes Possible
number of cases
30
Many bioterrorism agents--in the early or prodromal stages of the disease--
present non-specific symptoms similar to common illnesses, and therefore, may be
incorrectly diagnosed as a common illness (Buehler et al. 2003, 2004; Filoromo et al.
2003). Non specific symptoms of illnesses include general flu-like complaints, mild
respiratory problems, change in mental status, gastro-intestinal disorders, and
unexplained rashes with fever. A period of time ranging from several hours to many days
must pass following the onset of non-specific symptoms before many bioterrorism agents
produce more readily identifiable severe symptoms (Buehler et al. 2003). The high cost
of specific diagnostic tests, combined with scarce financial resources, reduces the usage
of expensive diagnostic tests to confirm diagnosis for those thought to have an ordinary
illness.
When healthcare providers are trained in diagnosing problems, they are often told
an old medical school truism: "When you hear hooves behind you, and you then turn to
look you should expect to see horses, not zebras." This phrase exemplifies one of the
problems regarding identification of a bioterrorism occurrence, in the absence of
warnings or other cues, the non-specific prodrome encourages incorrect diagnoses.
When an absence of suspicion for bioterrorism exists, the patient diagnosis would be the
ordinary illness that causes the primary patient complaint. Vigilant clinicians might be
able to notice subtle trends and indicators within their patients that call for a deeper
investigation of cause.
One of the first efforts to enhance clinical vigilance following the events of
September 11, 2001, originated from the CDC. The CDC issued a much anticipated
report via the Journal of the American Medical Association that offered basic guidance to
31
healthcare providers for monitoring unusual syndromes and disease trends arising from
bioterrorist attacks (Centers for Disease Control 2001). The CDC noted three main
points to facilitate clinical identification of unusual trends requiring further investigation:
1. An unusual temporal or geographic clustering of illness (for example, persons

who attended the same public gathering) or patients presenting with clinical
signs and symptoms that suggest an infectious disease outbreak (such as 2 or
more patients presenting with an unexplained febrile illness associated with
sepsis, pneumonia, respiratory failure, or flaccid muscle paralysis, especially if
occurring in otherwise healthy persons);
2. An unusual age distribution for common diseases (for example, an increase in
what appears to be a chickenpox-like illness among adult patients, but which
might be smallpox); and
3. A large number of cases of acute flaccid paralysis with prominent bulbar
palsies, suggestive of a release of botulinum toxin (p. 2088).
The report also provided biologic agent specific diagnostic information intended for
clinicians, ICPs, and lab personnel (Center for Disease Control 2001). The report noted
the difficulties posed by identification of a bioterrorism occurrence and recommended
clinical vigilance for unusual trends as well as monitoring of health data trends through
public health surveillance (Center for Disease Control 2001).
Until detected by healthcare workers, response and recovery activities may not
begin and contagious agents have an opportunity to spread sickness, death, and misery.
Initial detection of a biological agent outbreak will rely on the skill of nurses, physicians,
and hospital lab technicians (Filoromo et al. 2003). Vigilant clinicians may use their
education, knowledge, and experience to sense or notice subtle clues in individual
patients and may then take action to confirm or disprove their suspicions (Figure 5).
32
Alert Clinicians and Their Index of

Suspicion for Bioterrorism
Contextual Factors Situational Factors

Affecting Index of Suspicion Affecting Index of Suspicion
-Patient attended high profile -Other patients with similar ‘out of the
event ordinary' characteristics
-Unusual symptoms/syndrome -Terror threat levels and political unrest
-Symptoms differ from seasonal -Patient originates from or visited likely
expectations target region
-Desensitized by false alarms -Non-ordinary patient demographics
Confirmatory Cues
- Other clinicians reporting patients with similar
‘out of the ordinary’ characteristics.
-Diagnostic tests to preclude ordinary explanation
Index of Suspicion Levels, Control

Action by Clinician:
1. Low Levels: defers to ordinary
diagnosis
2. Moderate Levels: seeks more
information
3. Higher Levels: notifies authorities
who activate disaster response
plans.
Figure 5 Factors Affecting Index of Suspicion of Vigilant Clinicians.

Source: Filoromo et al. 2003. (p. 513)
33
Vigilant clinicians may be thought of as a “first line of defense” for bioterrorism.
They literally and figuratively have their “fingers on the pulse of the public.” Vigilant
clinicians utilize previous training and education while they receive cues from their
patients which influence their index of suspicion for bioterrorism. Identification of
unusual characteristics within patients may initiate an investigation to either verify or
disprove their suspicion of bioterrorism. Lazarus’s research team (2002) stated that
recognition of individual cases of bioterrorism such as anthrax requires astute and
vigilant clinicians, (p. 758). On alert or vigilant clinicians have the ability to notice
unusual trends in the early stages, and therefore, play one of the most critical roles in
bioterrorism response and recovery (Lazarus et al. 2002).
Clinicians are in a unique sentinel position with regards to bioterrorism. It will
most likely be healthcare workers who initially notice bioterrorism, and it will largely be
healthcare workers who respond to bioterrorism (Lillibridge 1999). The more effective
and rapidly the healthcare worker identifies bioterrorism, the greater the chances of
controlling and containing an outbreak (Buehler et al. 2004). Greater amounts of
bioterrorism readiness and preparedness knowledge among healthcare providers,
increases the chance of more quickly recognizing the signs of a biological agent induced
illness within their patients (Buehler et al. 2003).
Smallpox: An Example of a Bioterrorism Worst Case Scenario
Henderson’s research team (1999) reported that the usage of small pox as a
biological weapon would be among the worst types of potential bioterrorism scenarios. A
smallpox release today might be more lethal on a percentage basis than during historic
34
outbreaks, as the vast majority of the world does not have natural (from experience with
the disease) or artificial (recently enhanced through vaccination) immunity. Most
naturally occurring cases of smallpox ceased in the 1950s and worldwide vaccination
programs ended in the early 1970s. With the advent of eradication, the perceived need to
enhance population immunity by vaccination ended. Those vaccinated previously might
exhibit some immunity but are not fully protected from the disease. A largely non-
immune population has created a vulnerable global population (Henderson et al. 1999).
Like other biological agents, identification of a smallpox attack presents various
difficulties and challenges. The incubation period and non-specific symptom periods for
smallpox and other biological agents are listed in Figure 6. With a large number of
people exposed, patients with prodromal smallpox might generate a disease trend that
might be noticed through public health surveillance. Though, the aberrant trend would
appear as a common flu-like illness, it would alert epidemiologists that further
investigation of the trend might be needed. However, if the initial number of patients
were few in number, then public health surveillance would most likely not indicate an
aberrant trend. In this scenario identification of a bioterrorism occurrence through a
vigilant clinician would be one of the only remaining methods for identifying onset and
then initiating appropriate response and recovery.

35
Recognizing the Zebra:

Syndromes or Findings that May Signal Bioterrorism
1. Influenza like illness in summer months

2. Pneumonia death in otherwise healthy young adult
3. Critical illness in otherwise healthy young adult
4. Widened mediastinum on thoracic radiograph
5. Centrifugal rash
6. Viral hemorrhagic fever syndrome
7. Cluster of unusual, severe or unexplained illnesses
Inhalation Anthrax
1. Incubation: 1-6 days
2. P.E.: Non-specific; fever, malaise, fatigue, cough, mild chest discomfort followed by
severe respiratory distress
3. Diagnosis: Thoracic radiograph: widened mediastinum
Brucellosis
1. Incubation 5-60 days
2. P.E.: nonspecific, irregular fever, headache, weakness, fatigue
Pneumonic Plague
2. P.E: Non-specific, high fever, dyspnea, bloody sputum
3. Diagnosis: sputum gram stain may reveal gram negative bipolar staining rod with
safety pin-like” appearance
Smallpox
2. Rash illness that resembles chicken pox but with distinct differences:
Smallpox Chicken pox
a. Synchronous lesion development Non-synchrounous lesion development
b. Centrifugal lesion development Centripetal lesion development
Typhoidal or Pneumonic Tularemia

1. Incubation:1-21 days (avg. 3-5)
2. P.E.: nonspecific, pneumonia, substernal discomfort, non productive cough
Figure 6 Minnesota Department of Health's "Recognizing the Zebra".

Source: American Medical Association. 2002
36
Prior to identification and investigation of an unusual trend, most patients
presenting to healthcare providers with flu-like symptoms would be assumed to have
influenza or a similar ordinary illness. Patients exhibiting these symptoms would likely
be sent home, told to take ibuprofen, drink large quantities of fluids, and receive plenty of
rest. Sending home a patient with prodromal smallpox without a correct diagnosis is an
extremely tragic missed opportunity. By the time the patient had readily recognizable
pox pustules, other people would have likely been exposed to this patient and their
contagious airborne virus. The smallpox example illustrates some of the critical issues of
bioterrorism readiness.
Vigilant clinicians might notice that prodromal smallpox patients exhibit subtle
temporal or geographic clues and then investigate the situation further. Investigation of
subtle clues would require diagnostic tests and possibly epidemiological analysis.
Clinical investigation of unusual patients might avoid some of the identification delays
posed by public health surveillance. Perceiving personal vulnerability to bioterrorist
events combined with familiarity with the potential biological agents increases the
likelihood that clinicians will notice these subtle clues in their patients. If diagnosed
correctly during prodrome, the patient would be placed in isolation and the appropriate
infection control procedures would begin. The risk communication literature (see
Chapter Three) provides insight into how to improve bioterrorism readiness and
preparedness through improved risk communication.

37
Vigilance in the Healthcare Environment
Pre-emergency risk messages consist of broad ranging risk communications that
by their vague nature, sometimes tend to reinforce initial disbelief. The most effective
bioterrorist would not announce the biological agent release relying on the element of
surprise to create the most terror, injury, and death. Bioterrorism risk information given
to clinicians during the pre-emergency period lacks geographic and temporal specificity
which tends to diminish the credibility and effectiveness of the risk message. Healthcare
organizations experience numerous ordinary problems and economic strains that often
over-ride concerns over a seemingly rare event like bioterrorism. This bias towards
concern about normal conditions is reinforced by the fact that pre-emergency risk
messages lack specific temporal or geographic referents.
Palm and Hodgson (1992, 10) emphasized salience of a hazard in relation to
ordinary problems and challenges as a key factor that influences individual response to
hazards. They said that individuals would attend to particular hazards only when they
appeared more important than other problems. Seemingly pressing occupational duties
might detract from appropriate attention to unfolding hazards. Attention to new risk
messages may also be decreased by previously held attitudes and beliefs about work
priorities (Mileti 1999). This normalcy bias probably holds true in the frenetic healthcare
environment where under funding, understaffing and patient crowding are pervasive.
These common conditions within healthcare systems are not conducive environments for
noticing subtle clues from bioterrorism when faced with numerous patient care duties.
38
One of the unique characteristics of the hazard of bioterrorism is its purposeful
nature which does not typically provide sensory cues that help to override normalcy bias.
An effective bioterrorist event would be obscured providing a lack of sensory cues.
Instead of sensory cues individuals may look to the actions of others within their
occupational or social network to provide information to assess the reliability of risk
information (Turner et al. 1981; Perry and Greene 1982; Perry and Lindell 1986). If other
clinicians are experiencing an unexplained rise in certain syndromes, or a flux of patients
originating from the same geographic region, then discussions with peers may provide
cues that raise their clinical index of suspicion for bioterrorism. If clinicians are seeing
atypical patterns of seemingly normal diseases, they may themselves identify the need for
further investigation. Communication and collaboration with other clinicians may be one
of the most powerful tools for enabling early identification of an occurrence of
bioterrorism.
False Alarms for Bioterrorism
Awareness levels regarding bioterrorism are rarely based on actual experience
with bioterrorism, due to the rarity of the event to date. Few healthcare workers have
been directly affected by actual occurrences of bioterrorism; thus few have had
experiences that directly reinforce vigilance or ‘on alert’ status. Many healthcare
organizations reported multiple bioterrorism related false alarms. False alarms might
either reinforce awareness or might reinforce existing doubts on likelihood of
bioterrorism occurrence. A reasonable probability threshold for bioterrorism would be
beneficial to the health care system in order to avoid false alarms. Once early signs of
39
aberration are identified among syndromic trends, some type of confirmatory cues should
be present before launching full-scale biologic disaster response activities. Waiting for
confirmatory cues would be beneficial as it would tend to diminish false alarms which
waste scarce resources and take clinicians away from patient care duties. Conversely,
waiting too long to respond delays patient care and might delay containing the disease
which further compromises the health of patients, staff, and the functionality of the
facility.
Heightened risk for bioterrorism in times of increased political unrest combined
with the extremely high value of early detection creates the need for sensitive detection
systems with reasonable thresholds for investigation (Buehler et al. 2003, 2004). Low
thresholds for false alarms encourage too frequent staff, resource, and time intensive
investigations of the false alarms (Breznitz 1984; Porfiriev 1993). However, thresholds
set too high might miss early signals and delay detection and intervention. Surveillance
systems must be able to balance risk of an outbreak, the crucial importance of early
intervention, and the finite resources of healthcare organizations when determining
threshold levels for investigations launched by indications of aberrant trends (Buehler et
al. 2004).
Chapter Summary and Discussion
Though incomplete and piecemeal throughout most of the United States, public
health surveillance monitors health and disease activity among the general population.
This monitoring, it is hoped, will provide notice of disease activity that includes detection
of a bioterrorism occurrence. Surveillance requires large numbers of patients with a

40
particular symptom that must be registered by a clinician and then entered into the
surveillance data management system prior to an alert of an unusual trend. Only once
this trend is identified, and noticed, would it be investigated to determine cause.
Epidemiological and diagnostics tests to determine cause also require a period of hours to
days before answers are provided. In addition to public health surveillance, clinicians
have opportunities to notice unusual characteristics and trends within their patients.
Therefore, clinicians are critical to bioterrorism readiness as they provide an alternate
pathway to detection through public health surveillance.
Identification of a biological agent induced illness within the population must
originate from a medical diagnosis regardless of whether the diagnostic investigation
followed a public health surveillance signal or a vigilant clinician’s investigation. It is
the healthcare worker that will, most likely, initially identify whether a patient suffers
from a malady caused by an intentionally released biological agent or a natural
phenomenon (Lillibridge 1999, 643). As increasing numbers of victims seek treatment, a
growing body of evidence becomes available to healthcare workers resulting in more
cues and opportunities to discern a disease trend that might be either a naturally occurring
trend or a bioterrorism occurrence.
Of the numerous biological agents, early identification of smallpox stands out as
perhaps the most critical. Early detection must occur in order to minimize disease spread
and to prevent an epidemic or a pandemic. Early detection provides global long term
benefit to society by saving lives, decreasing human suffering, and by possibly
preventing the disease from rejoining the biosphere. In the case of non-contagious
41
bioterrorism, early detection remains critical as it enables earlier lifesaving treatment and
initiates response and recovery activities.
Clinicians that have internalized bioterrorism education, training, and risk may be
classified as ‘on alert’ or vigilant for potential bioterrorism events. Vigilance indicates
they are actively engaged in monitoring for subtle clues in patient characteristics and
medical status. Context, situational factors, patient history, medical status, and numerous
personal characteristics of the clinician affect the clinician’s index of suspicion for
bioterrorism. Factors pointing away from bioterrorism lower the index of suspicion and
indicate a lack of need for further investigation. Conversely, unusual trends in patients
might raise the index of suspicion which indicates a need for further diagnostic tests and
investigation. Clinicians that do not perceive themselves or their community to be at risk
from bioterrorism are more likely to dismiss subtle clues and diagnose their patient with
the common and ordinary explanation. Thus, individual characteristics of clinicians might
determine successful early recognition of bioterrorism.
This dissertation utilized the GMHRC to investigate factors that influence clinical
vigilance for potential bioterrorist events. Bioterrorism readiness education provided to
clinicians, if persuasive and convincing, may serve as a tool to ensure consideration of
bioterrorism agent generated illness among the spectrum of potential diagnoses.
Effective risk communication might, therefore, enhance bioterrorism vigilance. Thus, a
study based on the components of the GMHRC as a framework for modeling and
understanding the bioterrorism risk communication process among healthcare workers
was both appropriate and necessary. The genesis and evolution of risk communication
model based methodologies such as the GMHRC are explored in the following chapter.
CHAPTER THREE
RISK COMMUNICATION THEORY AND APPLICATION
The GMHRC, which represents the theoretical basis for this research was based
on a series of risk communication behavioral stages through which individuals progress,
as well as receiver and message characteristics that contributed to the stages in response
to risk messages (Mileti, Fitzpatrick, and Farhar 1990; Mileti and Fitzpatrick 1993;
Blanchard-Boehm 1992, 1998). The sub-field of hazards risk communication developed
over time based on the realization that the decision making process for an individual
faced with risk is more complex than a sequential protective response following receipt
of risk information (Blanchard-Boehm 1998, 254). Myriad conceptions and theories of
how risk might be communicated arose from recognition of this complexity of the
process.
Effective communication of risk serves as an evolutionary advantageous trait that
promotes tribal success and survival. Communication of risk through language is thought
to be one of the traits that gave humans a distinct evolutionary advantage over other
animals. The informal history of risk communication probably goes as far back as that of
the earliest language and the earliest primitive societies. People communicate risk to
interpret threatening events and to share this interpretation with others.
42
43
The body of research discussed in this chapter represents work from various
disciplines that have contributed to the study of risk communication and begins with a
presentation of the various definitions of risk communication, followed by an exploration
of hazards research in the discipline of geography. Next a discussion of the Yale Model
of Mass Communication is presented from the work of Hovland and colleagues (1953)
from Yale University’s School of Mass Communication. Later sections synthesize
findings from previous hazards researchers.
Definitions and Concepts
Risk communication is a broad topic with wide ranging applications, definitions
and interpretations. Early definitions were based simply on the assumed provision of
knowledge or causal approach in which the receipt of the risk message was followed by
the desired change in behavior. However, concepts and definitions evolved in complexity
over time as understanding and appreciation for the entire risk communication process
had increased.
An early example of the evolving understanding of complexity are provided by
Sims and Baumann (1972, 1391) who noted that individuals were more likely to respond
in a causal sequence to risk information if they exhibited personal locus of control.
Covello (1983) defined risk communication as a purposeful exchange of scientific
information between interested parties regarding levels of risk, the significance of the
risk, and mitigation strategies (p. 288). Sims and Baumann (1983) discussed evolution of
previous definitions of risk communication that posited a linear approach to risk
communication that began with provision of information and ended with protective
44
action. Provision of risk information, they said, may occasionally lead to rational
protective action in a direct causal link, but this happens only under highly encouraging
circumstances within target populations (p. 167).
Krimsky and Plough (1988, 5) stated that the conventional definitions were
restrictive in a definition of risk communication, as they focused on the phenomenon of
the event without regard to the importance of cultural motivators or symbolic meanings.
In general, risk communications may refer to any public or private communication that
delivers information regarding the existence, nature, form or severity of a particular risk.
Krimsky and Plough (1987, 6) offered five components for defining the latitude of
interpretation for risk communication as listed in Table 3.1.
Table 3.1 Definition Latitude of Risk Communication.
COMPONENT BROAD NARROW
Intentionality Risk communication goal unnecessary Intentional and directed; outcome

expectations about the risk message
Content Any form of individual or social risk Health and environmental risks
Audience Directed Targeted audience not necessary Targeted audience
Source of Information Any source Scientists and technical experts
Flow of Message From any source to any recipient through From experts to non-experts through
any channel designated channel.
Source: Krimsky, Sheldon, and Alonzo Plough. 1987. p. 6
Covello, Sandman, and Slovic (1988) defined risk communication as a purposeful
exchange of information between interested parties regarding levels and significance of
health and environmental risk, and the range of protective action and policies to manage
these risks (p. 172). Sandman, Weinstein, and Klatz (1987) preferred a persuasive goal
45
oriented definition of risk communication. To persuade the receiver to take action
through provision of clear and personally relevant information is once again the goal. To
ascertain effectiveness of the communication, they recommended assessment of the
actual facts learned by the receiver (p. 94). Many researchers agree that the risk
communication process was more complex than simple interpretation of meaning from
the words alone. Inferred meanings and understanding arose from communications with
others that depend upon social and demographic factors (Littlejohn 1992). Lundgren
(1994) defined risk communication similarly, but, added an interactive component to the
process. She stated that effective risk communication involved an interactive exchange
of both information and opinions between the source and the receivers (p. 12).
Risk communication strives to impart knowledge of risk, to persuade, and then
encourage protective action. The desired outcome of effective risk communication
involves an at risk individual taking protective action to prepare and mitigate. Following
review of the risk communication literature, three general goals of risk communication
are evident. First and foremost risk communication should provide information that
enables reduction of impacts on humans and society with particular emphasis on the
reduction of mortality. Morbidity reduction is the second goal of risk communication.
Reducing economic losses is the third main goal. Adequately designed and delivered risk
messages may help to reduce all three types of losses.
Hazards Research within Geography
The behavioral stages of the General Model of Hazards Risk Communication
(GMHRC) set forth by Blanchard-Boehm (1998, 254) served as the theoretical

46
framework for this research and provided the structure through which to assess the
bioterrorism risk communication process. Though, grounded in the discipline of
geography, the research record reveals that hazards risk communication is
interdisciplinary. In geography, the study of risk communication is subsumed within the
“Human Ecology Model” of hazards as developed by White, Kates, and Burton (1978).
The human ecology perspective as a path to geographic synthesis was touted in the
literature in the 1920s (Barrows 1923). Geographers adhering to the human ecological
viewpoint characterize relations between humans and the environment as a series of
interactive adjustments between humanity, social systems, and earth systems (White,
Burton, and Kates 1978, 1993; Palm 1990; Mileti 1999). Adherents believe that society
is not directly controlled by the environmental constraints because adjustment and
response behaviors may help to maintain a less adversarial relationship with nature
(Kates 1971, 442; Mileti 1999, 19).
Following World War II, Gilbert F. White advanced the human ecological
approach within geographic hazards research. His early work investigated human
habitation within floodplains. White’s conceptual mode of the flood plain hazard
consisted of the interaction between human use, extreme events, and adjustments. His
work investigated land usage that coincided with the local as well as the larger regional
context of the flood hazard to promote the best usage of the land (White, 1945). Local
adjustments to flood hazards might provide a false sense of security to flood plain
residents.
Kates (1971) characterized an early hazards and adjustment conceptual model as
the interactions between human and natural systems. The interaction between human
47
systems and natural forces that occasionally generate an extreme event was modified and
controlled by adjustments from the human system in response to the natural events
system. He stated that adjustments to hazards that generate less conflict within human
systems were a noteworthy source of information regarding the interactions of the
environment, nature, society, and technology (p. 439).
As researchers expanded upon the ideas of White, two significant fields of
interpretation developed (Hewitt 1983; Palm 1990; Burton, Kates, and White 1993). One
field of early interpretation espoused an emphasis on the extreme physical hazardous
event. This emphasis, they said, served as a distraction from the human ecologic
perspective and therefore overlooked contributing ecological factors of location,
livelihood, and social groups. The complex human ecology of daily life controlled
aspects of human habitation on the planet as well as the interaction of hazards and
humanity. Studies of only the extreme hazardous physical events represented simplistic
environmental determinism. Burton, Kates, and White (1993) warned that collectivities
of all types of hazards threatened human existence and that the importance and relevance
of any one particular hazard changes over time. They advised that vulnerabilities of
human populations germinate from the precariousness of routine existence as well as
from rare and extreme physical events.
The second field of interpretation within early hazards research found the
literature insensitive to social and economic constraints that had limited the range of
choices available to individuals and governments. Researchers noted that adjustments to
hazards were not made in isolation. Response choices were complex decisions bearing
the full weight of societal and cultural constraints that bound and constrained the
48
individual during the decision process (Hewitt 1983; Palm 1990; Burton, Kates, and
White 1993).
Hazardous agents only became hazards when people, or things that people assign
value to, became negatively influenced. Hazardous events consisted of a clash between
physical events and human systems, and the ensuing damage, morbidity and mortality
creates costs and problems to society (Burton, Kates, and White 1993). Therefore, the
accurate study of hazards must be greater than the simple understanding of the physical
event. The physical portion represents only one component of the hazard system that
must be considered when understanding hazardous agents and encouraging adjustment to
hazards. Disasters occur when components of the physical environment (hazardous
events), the built environment (infrastructure) and the social environment (human
geography, demographics) clash and collide (Mileti 1999, 210). The ecologic interface
zone between humans, society, and earth systems was realized as the zone in which
hazards exist, and this nexus is the appropriate realm for investigating hazards and for
mitigating losses through risk communication strategies.
Potential bioterrorists utilize biologic agents that originate from natural systems to
create or artificially enhance a disease process. Terrorists are essentially weaponizing the
morbidity and mortality of natural disease systems. Like other hazards, the hazard of
bioterrorism exists in the interface zone between the physical environment, the built
environment and the social environment; however; the release of biological agents stems
from an intentional act with the desire to injure, kill, and terrorize. Acts of terrorism
often are influenced by social, economic, or cultural conflicts between different groups.
Biological agents are part of a complex system of dual usages within society as lawful
49
and necessary medicinal and research usages exist for all of the currently recognized
biological agents (Stern 2003). Further, most if not all potential biological agents, may
be isolated directly from natural systems. The combination of natural, societal, cultural,
and human systems places bioterrorism in the realm of environmental geography.
The GMHRC stems from a thirty year research evolution that took place within
the sub-field of risk communication, which is encompassed by geographic hazards
research. Risk communication theory is rooted in and developed from the theoretical
background of the Yale Model of persuasion theory.
Persuasion Theory and the Yale Model
In the 1950s social-psychologists began to research the theoretical framework
behind the process of persuasion. Persuasion based research exhibits similarity to classic
marketing research and both take place through similar processes (Littlejohn 1983;
Blanchard 1992). The Yale Model (Smith 1982, 236) was the first information
processing theory of persuasion. The Yale Model, espoused by Carl Hovland and
associates, provided the theoretical underpinnings to the nascent risk communication
model (Mileti, Fitzpatrick, and Farhar 1990; Blanchard-Boehm 1992). Hovland, a
psychologist known for his research in persuasion and attitude change, asserted that
exposure to new information consisted of a learning experience contingent upon
appropriate rewards (Hovland, Janis, and Kelley 1953). To increase persuasion and
attitude change, they stated, incentives must be created as learning was contingent on
rewards for action (p.11).

50
Persuasion research sought to obtain a desired behavioral outcome arising from
receipt of new risk information (Blanchard-Boehm 1992). Grounded in cognitive
learning theory, the Yale approach seeks to both persuade and encourage attitude change.
Littlejohn (1989) stated that the Yale approach utilized the experimental method to assess
the probability that change of some type results from certain methods of portraying risk
information and the message contains supporting facts of the risk. The Yale Model, as
summarized by Smith (1982, 214) and Blanchard-Boehm (1992, 19) argued that
successful persuasion depends upon the following chain of learning responses:
1. attention to the persuasive message;

2. comprehension of its contents;
3. acceptance of, or yielding to what is comprehended;
4. retention of message for some time after attending to and
comprehending it; and
5. action in accordance with the retained argument, that is the specific
behavioral change or action requested in the message.
Hovland, Janis, and Kelly (1953, 4-10) stated the factors referenced above, yet they
focused their attention on the motivational factors affecting acceptance of information
(Smith 1982; Blanchard-Boehm 1992).
The Yale Model of persuasion provided the earliest identification of the
persuasive value of internal factors or receiver characteristics and external factors or
message characteristics (Hovland, Janis, and Kelly 1953, 13; Smith, 1982, 219). The
Yale Model research paradigm provided the framework that served as the underpinning
of the GMHRC. The behavioral stages of risk communication were built upon the chain
of learning responses as identified by the Yale approach to persuasion theory. The risk
communication model evolution is discussed in the following section.

51
Evolution of the Risk Communication Model
The chain of learning responses first identified by Hovland and colleagues (1953)
served as the general structure of the behavioral stages of the GMHRC. The evolution of
the risk communication process occurred over more than 30 years and continues today.
By the late 1960’s the science behind individual decision making and persuasion began to
show promise in predicting individual response to risk. Until the 1970 and 1980’s, risk
communication was thought to be a simple process of providing risk information and that
protective action would simply come from knowledge of the risk. The collapse of this
early causal model of risk communication was documented in several studies (Mileti
1975; Saarinen 1979; Blanchard-Boehm 1992, 1998). This collapse resulted from
recognition of the complexity behind the risk communication process and enabled
improved research on risk communication.
The risk communication model was formally proposed in scientific literature in
the 1980s, but humankind has a long history of communicating risk (Blanchard-Boehm
1992; Mileti 1999). Risk communications have the specific goal of sharing risk
information, but simply having received the message does not directly result in
appropriate protective action (Lundgren 1994, 11). Researchers have shown the
relationship between risk information and protective action to be more complicated than
simple message absorption. Perspectives, opinions, ideas, and definitions on the exact
nature of risk communication vary within the research community.
Mileti, Fitzpatrick, and Farhar (1990) published a study titled Risk
Communication and Public Response to the Parkfield Earthquake Prediction Experiment
which was one of the first in a series of major research undertakings that sought to
52
explain response through the risk communication model. This model considered both
message and receiver characteristics as important contributors to the risk communication
process. The authors wanted to identify the process through which individuals first
receive risk information, are convinced the threat is real, and what factors lead to the
taking of protective action. Message characteristics such as consistency, certainty,
specificity, and multiple sources were found to be important in predicting response
(Mileti, Fitzpatrick, and Farhar 1990; Blanchard-Boehm 1992, 1998).
Based on a comprehensive review of risk communication literature Mileti,
Fitzpatrick, and Farhar (1990) defined the risk communication model based on five
interacting behavioral stages within a communication process. Though the theory implies
sequential steps, the risk communication process differs among individuals and at each
conceptual stage (Mileti, Fitzpatrick, and Farhar 1990, 19). The five general behavioral
stages are:
1. hearing;
2. confirming;
3. understanding;
4. believing-personalizing; and
5. responding.
Continuing research provided an improved understanding of the complex nature of
communicating risk which enabled model refinements.
Various researchers have identified alternative behavioral stages within the risk
communication process. For example, Penning and Roswell (1990) proposed a five step
risk communication process that focused on message characteristics. Their five steps are
as follows:
1. risk awareness and evaluation by authorities;

2. risk communication design;
3. message characteristics;
53
4. target audience; and

5. attitude and behavior change.
Penning and Roswell focused on the actions and influences of the persuaders—those who
have a message to convey—and how these facilitate attitude and behavior change.
Subsequent to the work of Penning and Roswell, Renn (1992) specified seven
steps that comprised the risk communication process. Their steps are as follows:
1. passing of attention filters;

2. decoding of signals;
3. drawing personal inferences;
4. comparing among decoded messages;
5. evaluating messages;
6. forming specific beliefs; and
7. propensity to take corresponding action (p.180).
Different from Penning and Roswell’s (1990) approach, Renn (1992) emphasized the
importance of receiver characteristics following message receipt and subsequent
processing, decoding, and internalization by the receiver which eventually leads to a
response of some type.
Mileti (1999, 137) later expanded upon some of his earlier work and stated that
individuals are imperfect decision makers and often do not know or realize the full range
of alternative actions available. Further, they often do not use their information and
education to fully understand the situation and consequences for action or inaction.
Dissemination of risk information presumably alters personal beliefs about the risk of a
hazard, and in turn leads to the adoption of appropriate protective action. This
assumption, he said, oversimplifies the risk communication process by ignoring
variations within the message or receiver characteristics as well as personal information
processing errors, competing demands for attention, utilization of cognitive heuristics,

54
and conflicts with existing beliefs (Mileti 1999, 141). Mileti (1999) suggested a seven
step risk communication process. The seven steps are:
1. hearing the warning;

2. believing that the warning is credible;
3. confirming that the threat does exist;
4. personalizing the warning and confirming that others do also;
5. determining whether protective action is needed;
6. determining whether protective action is feasible; and
7. determining what protective action to take and taking it (p.141).
These seven steps represent the general theoretical refinements by Mileti during the
1990’s and contributed to the knowledge of the risk communication process.
The GMHRC also consists of refinements to the original risk communication
model behavioral stages as outlined by Blanchard-Boehm (1992, 157; 1998, 252)
whereby individuals progress through a behavioral stage risk communication process of:
hearing, understanding, believing, confirming, and responding to risk messages.
The General Model of Hazards Risk Communication
The body of literature reviewed in the previous sections explored various aspects
of hazards risk communication research and provided the theoretical background to the
framework that guided this dissertation. This dissertation utilized the GMHRC
framework set forth by Blanchard-Boehm (1992, 1998) as it is one of the most recent
attempts to analyze the process of risk communication from a long term, educational
standpoint. Blanchard-Boehm encouraged application of the model to real world
situations to test the spectrum of applicability to the varying types of hazards education
programs about risk and vulnerability to future threats.

55
Blanchard-Boehm adapted previous research that dealt with short term, urgent
warnings where the behavioral stages in those models identified a behavioral process of
hearing, confirming, understanding, believing, and responding to risk messages (Mileti,
Farhar, and Fitzpatrick, 1990, 11; Mileti, Fitzpatrick, and Farhar 1990, 23; Blanchard-
Boehm 1992, 29; Mileti and Fitzpatrick, 1992, 1993). The GMHRC behavioral stages
reflect the refined order of the behavioral stages of hearing, understanding, believing,
confirming and responding as described by Blanchard-Boehm (1998, 252). These
refined behavioral stages comprised the theoretical framework of the GMHRC.
Waugh (2004) explained that despite the many differences regarding the physical
characteristics of various hazards, enough common preparedness, response, and readiness
characteristics exist to make bioterrorism readiness and planning cohesive and connected
to general disaster readiness. This concept is referred to as the All Hazards Model.
Quarantelli (1994) found evidence for important similarities in individual disaster
response procedures despite differences among type of hazard. He said that challenges in
eliciting response, human problems, and organizational problems exist regardless of type
of hazard and the same general activities are undertaken to respond and recover. He also
stated that the process of warning the potentially affected population is similar across the
spectrum of hazards regardless of type of agent.
As identified in Chapter One, the dissertation study questions are based upon the
GMHRC behavioral stages which framed the analysis and investigations in the chapters
to follow. Risk communication model based research as refined over time by several
generations of researchers provided a framework with a demonstrated ability to predict
individual response to hazard and risk information. Following the all hazards logic, the
56
GMHRC provided an appropriate framework from which to investigate bioterrorism risk
communication. The nascent threat of bioterrorism today is unique in many ways and
remains largely unstudied.
The levels of bioterrorism risk information that healthcare providers typically
receive and the differences in the processing of the information by different types of
healthcare workers are largely unknown. To better understand the bioterrorism risk
communication process, the GMHRC defines two main types of influences on the model
behavioral stages. Mileti, Fitzpatrick, and Farhar (1990, 18) stated that responses to a
risk communication are influenced by two general categories: Characteristics unique to
the risk message, known as message characteristics, and characteristics unique to the
receiver, known as receiver characteristics (Mileti, Fitzpatrick, and Farhar 1990; Mileti
1999; Blanchard-Boehm 1998, 252; Mileti 1999, 142).
Receiver Characteristics
Mileti and Sorenson (1990, 94) stated that individual risk message receivers’ have
their own predispositions of fact, context, and circumstance that predispose them to
certain responses. Differing receiver characteristics among individual receivers explains
much of the disparity in response between individuals. Receiver and message
characteristics have emerged within the risk communication literatures as significant
contributors to individual response to risk messages. Receiver characteristics consist of
factors unique to individual receivers that filter, frame, and influence risk messages.
Message characteristics consist of factors unique to the actual risk message that influence
perception of risk messages.

57
A variety of receiver characteristics have been identified as influential to risk
communication process behaviors (Mileti, Fitzpatrick, and Farhar 1990; Blanchard-
Boehm 1998; Mileti 1999). The different receiver characteristics include perceptions of
vulnerability, previous experience with disasters, social and environmental influences on
individual response, normalcy bias, and demographic factors. Previous experience with
hazards has also been found by hazards researchers to be a contributing factor to risk
communication response for certain hazards and certain populations. Beliefs held by the
receiver concerning the hazard in question may serve to constrain or enhance response
behavior (Littlejohn 1989; Blanchard-Boehm 1992). Some of the receiver characteristics
that have been found to influence the risk communication process are explored in the
following sections.
Perceptions of Vulnerability
This dissertation investigates bioterrorism risk communication within healthcare
at the pre-emergency level, prior to notice of event onset. Different from research that
quantified responding to risk messages among the public (Chapter Two), one of the
primary goals of bioterrorism risk communication consists of maintaining clinical
vigilance. Vigilant clinicians are broadly defined as having high levels of perceived
vulnerability to future bioterrorism occurrences so that consideration of the potential
biological agent induced illnesses remains present. Prior to further discussion about
perceptions of vulnerability, a brief discussion regarding the concept of vulnerability is
provided to frame the concept.

58
Following the work of White and colleagues, researchers began to appreciate the
importance of the conflicts that have been generated between human and Earth systems
(Burton, Kates, and White 1993). Systemic conflicts may generate morbidity, mortality,
and economic losses. Depending upon the impact and scale of these systemic conflicts,
these conflicts may generate enough negative consequence to become disasters.
Particular characteristics that create vulnerability are now recognized as one of the most
critical factors to whether a hazard produces an actual disaster. Cutter, Michael, and
Scott (2000) investigated spatial variability of vulnerability and methods for its reduction.
They broadly defined vulnerability as the potential for loss of property or life from
hazards. Blaikie and colleagues (1994) defined vulnerability as either personal or group
characteristics that influence their capacity to anticipate, respond to, resist and recover
from impacts of hazards. Similarly, Mileti (1999) defined vulnerability to hazards in
terms of ability to resist damage and losses. Rodriguez, Wachtendorf, and Russell (2004)
stated that vulnerability to hazards within individuals, groups, or communities equates to
susceptibility to damage from hazards as well as the extent from which they may recover.
Vulnerability is a broad concept with wide ranging applicability from the
individual to the global level. Individual vulnerability refers to the individual or a
relevant structure and is often examined through health or engineering factors. Cutter,
Michael, and Scott (2000) mentioned that vulnerability from the social and biophysical
perspective largely refers to social groups and landscapes that may be susceptible to
damage from hazards. They asserted that vulnerability is geographical in nature, due to
spatial location in reference to the hazardous agents to spatial variability of vulnerability.
Spatial distance from the hazard influences impact as increased distance from the event
59
tends to minimize impact. However, some components of vulnerability such as political
and socio-economic factors may not be proximate to the location of the initiating
hazardous event and therefore social vulnerability may vary independently from the
location of impact. Vulnerability of place is formed by biophysical and social factors in
addition to the population’s utilities, transportation, health, government, and political
infrastructures (Cutter, Michael, and Scott 2000).
Perceptions of vulnerability are the degree to which an individual or organization
perceives or recognizes their own personal vulnerability. Receiver perceptions of
vulnerability for a particular risk influence their range of response behaviors and
protective actions (Mileti, Farhar, and Fitzptrick 1990; Palm et al. 1995; Blanchard-
Boehm 1998). Several hazards researchers have found that those who perceive personal
vulnerability to a particular hazard tend to take mitigative or preparatory action.
Perceptions of vulnerability to hazards arise from a complex process involving a
variety of personal, societal, and cultural factors. The general perception of risk
vulnerability within an individual or organization influences mitigation, preparedness,
and response behavior (Rodriguez, Wachtendorf, and Russell 2004). An individual must
perceive personal vulnerability to a hazard before they become likely to take protective
action. Nigg (1993, 227) stated that unless risk message receivers perceive personal risk
and danger, it is likely that their bias towards normal expectations will continue.
Perception of vulnerability—whether personal vulnerability towards future events
or personal risk regarding disasters unfolding—largely explains why people do, or do not,
engage in protective action and behavior (Palm 1995). She identified five factors that
60
influenced both the extent to which individuals perceive a given hazard as a personal
threat, as well as their willingness to act on this belief:
• Individuals vary to the extent to which they give credence to expert advice;
• Individuals vary regarding their perceived likelihood of an occurrence, as well as
by their beliefs about preparation and mitigation;
• Individuals vary in the ways that they balance costs and benefits;
• Individuals vary in their beliefs and expectations regarding who should accept
risks and responsibilities for a disaster; and
• Individuals vary in the relative importance that they ascribe to the hazard as
opposed to other competing information in their daily lives (p. 45).
Palm’s findings caution that individuals behave differently in response to threat and risk
information due to a variety of reasons, but that their perceptions of vulnerability indicate
their personal concern regarding the risk. Individual response to risk information
depends on the receiver’s perceptions of vulnerability which depends on: (1) differences
in personal traits and characteristics; (2) proximity to and previous experience with the
hazard; and (3) a suite of socioeconomic and demographic characteristics (Palm et al.
1990a, 1990b; Blanchard-Boehm 1992; Palm and Hodgson 1992; Palm 1995; Blanchard-
Boehm and Cook 2004).
Covello, Sandman, and Slovic (1988, 55) identified factors important to
formulation of risk perception and ensuing evaluation of action (Table 3.2). They found
that large consequence occurrences that are unfamiliar to the receiver may be associated
with increased public concern. Conversely, increased trust in the abilities of the primary
response organization tends to decrease concern for the event.

61
Table 3.2 Important Factors of Risk Perception and Evaluation.
CONDITIONS ASSOCIATED WITH CONDITIONS ASSOCIATED WITH

FACTOR INCREASED PUBLIC CONCERN DECREASED PUBLIC CONCERN
C a t a s t ro p h i c Fat al iti es and Injuri es G roup e d in T i me Fat al iti es and I n juri es S ca tt er ed and
Poten ti al and Spa ce Random
Fa mi li arit y Unfa mi li ar Fa mi li ar
U n d e rst a n d i n g Me c h a n i s ms o r P ro c e s s N o t Un d e rs t o o d Me c h a n i s ms o r P ro c e s s U n d e r s t o o d
Risks Scientifically Unknown or

Un c er ta in t y R is k s Kn o wn t o S ci en c e
Un c er ta in
Contro ll abil it y
U n c o n t ro l l a b le C o n t ro l l a b l e
(P e r s o n a l )
V o l u n t a ri n e s s o f
In v o l u n t a r y Voluntary
Exposu re
Ef f ec t s o n
Child ren Sp ec i f ica ll y at R isk Child ren Not S p ecif ic all y a t Risk
Child ren
Ef f ec t s
De la y ed Ef f ec t s I mme d ia te Ef f e cts
Man if e s ta t i o n
Ef f ec t s o n Fu t u re
Risk to Futu re Gen erat ions No Risk to Fu t u re Gen erat ion s
G e n er a t i o n s
Vi cti m I d en tit y Iden tif i able Vi cti ms Sta tis ti cal Vi ct i ms
Dr ead Ef f ec ts D re ade d Ef f ec ts No t D r ead ed
T ru s t in
La c k o f Tru st i n R e s p o n s i b l e In s t i t u t io n s T ru s t i n R es p o n s i b l e In s t i t u t i o n s
Inst itut ions
Med ia Att ent io n Much Med ia A tten tion Li ttl e M edi a A tten tion
A c c i d en t H i s t o r y Ma j o r a n d S o met i me s Min o r A c c i d en t s N o M a j o r o r M i n o r A c c i d e n ts
In e q u it a b l e D i s trib u t i o n o f R i s k s a n d Eq u i t a b l e D i s t r i b u t i o n o f R is k s a n d
Eq u i t y
Benefits Benefits
B en ef i t s Un c l e ar B en ef i t s C l e ar B en ef i t s
R ev e rs i b i l i t y Ef f ec t s I r rev er s i b l e Ef f ec t s R ev e rsi b l e
Origin Caus ed b y Hu ma n Ac tions o r F ailu r e s C a u s e d b y A c t s o f N a t u re o r G o d
Source: Covello, Sandman and Slovic. 1988. (p.55).

62
Other hazards researchers defined the importance of perceptions of vulnerability
in complimentary, yet different ways. Tobin and Montz (1997, 281) defined two broad
categories that influence individual perceptions. Situational and cognitive factors
influence how an individual perceives risk which guides their response behavior in a non-
deterministic manner. The first category, known as situational factors, included factors
associated with the socioeconomic environment such as demographics, culture, and prior
experiences, as well as those associated with the physical component of the hazard such
as magnitude, duration, and frequency. The second category, known as cognitive factors,
included locus of control, denial, fatalism, and ‘gambler’s fallacy’ as well as attitudinal
factors that arose from psychological and situational factors. Gambler’s fallacy refers to
the erroneous belief held by some individuals that because an event happened in a
particular year, that less of a chance of recurrence exists the following year (Slovic,
Fischhoff, and Lichtenstein 1976). In the case of a bioterrorism occurrence, the event
would be neither natural nor random. An occurrence of bioterrorism arising from
political unrest might signal an even higher risk of recurrence, rendering gambler’s
fallacy even more incorrect.
Perceptions of vulnerability held by individual receivers have been identified as
critical indicators of response to risk information by numerous researchers. Slovic (1987,
282) stated that formulation of perceptions of vulnerability result from a somewhat
intuitive process, controlled by personal perceptions regarding the likelihood,
controllability, and information available about the particular hazard. Slovic (1987) used
factor analysis to identify the main factors that influenced perceived vulnerability and
risk. He found that: (1) dread risk, involving evaluations of control, catastrophic
63
potential, fatal consequences, and cost-benefit ratio of action/inaction; and (2) unknown
factors of risk, such as whether the outcome of concern is new and observable, and if its
effects are immediate (p. 282). Cross (1990) performed a longitudinal study to track
hurricane awareness among residents of the lower Florida Keys. He found that over a
twelve year period, residents had increased their understanding of potential damage from
storms, but that they still tended to underestimate their personal vulnerability to their
homes from wave and wind damage.
Fischoff, Bostrom, and Quadrel (1993) warned that in matters of public health
education, underestimation of risk often results in reduced levels of preparedness among
the population which decreases their ability to handle a health threat. They warned,
however, that overestimation of risk may enhance behaviors that create public panic,
increase distrust of authority, and increase the adoption of counterproductive behavior.
Previous Experience with Disasters
Another receiver characteristic, previous experience with disasters, repeatedly
emerged in the hazards literature as a contributor to response. As early as the 1970s,
researchers found links between previous experience with hazards and the desire to take
protective action. People who were directly affected by environmental hazards have
occasionally been found to be more responsive to future risk information and also tended
to prepare and mitigate more than those who were never affected by disaster (Mileti,
Drabek, and Haas 1975; Hutton 1976; Perry, Lindell, and Greene 1981; Mileti,
Fitzpatrick, and Farhar 1990; Nigg 1992; Palm and Hodgson 1992; Mileti 1999;
Blanchard-Boehm and Cook 2004). Quarantelli (1994) reported that personal experience
64
with a disaster forms a memorable experience that may affect response behavior and
preparedness activities. He says that the memory of a disaster affects both the individual
and the community in selective ways ranging from possible changes in personal response
behavior to the promotion of legislation that emphasizes mitigation.
Palm and Hodgson (1992, 2) found that those with the most intense experience
with the 1989 Loma Prieta earthquake experienced shifts in both attitude and behavior
towards future earthquake threat. They noted that the homeowners who expressed
increased concern for future earthquakes bought insurance more than those with lesser
amounts of experience, but the effect was not as great an increase as expected. The more
direct and significant the previous experience with a hazard, the more likely the
individual is to respond to future threats. In a study regarding the 1987 Edmonton,
Alberta tornado disaster, Blanchard-Boehm and Cook (2004) found that people with
previous disaster experience that includes injury to self or family member, damage to
property, or other direct experience with the tornado were significantly more likely to
take protective action to threats of future tornadoes than those with lower levels of
experience even ten years after the disaster.
Baker and Patton (1974) found that perceptions and attitudes towards future
hurricane threats were affected by varying levels of personal disaster experience.
Response and adjustment behavior to future hurricane risk within the three cities varied
according to the different levels of hurricane experience among the cities. Some studies
indicated discrepancies regarding previous experience and protective action. Carter
(1979) found that those with prior experience with hurricanes were not more prepared
and did not evacuate earlier than others in response to hurricane warnings. However, this
65
seemingly contradictory finding was clarified in another study later that year when
Carter, Clark, and Leik (1979) found that individuals without previous hurricane
experience evacuated sooner than those with more experience because those with more
experience wait for confirmatory cues to support the need to evacuate.
Experience with False Alarms
Hazards researchers investigating earthquake warning messages found that false
alarms might actually maintain increased preparedness levels (Farley et al. 1993). Mileti
and Fitzpatrick (1993) found that false alarms might enhance concern for future events,
although the proportion of the public that experience this effect is quite small. Breznitz
(1984) however, found false alarms decrease levels of concern to warning messages.
Atwood and Major (1998) investigated the ‘cry wolf’ or false alarm effect and
ensuing perceptual reduction in future message credibility. They noted that field work to
support this hypothesis is limited, but that there is evidence that some people trust and
respond to warning messages in decreasing amounts as the number of false alarms they
experienced increases. Large scale false alarms concern government officials as they
tend to reduce credibility for both scientific and governmental information sources (Gori
1993). False alarms theoretically reduce credibility of warning systems, resulting in less
attention given to the warning messages (Baker 1993; Mileti and Fitzpatrick 1993;
Atwood and Major 1998). Experience with false alarms for hazards may potentially
reinforce training and readiness education, or they might reinforce existing perceptions of
low vulnerability and doubt via Atwood and Major’s (1998) ‘crying wolf syndrome.’
66
Normalcy Bias
In a study of behavior and earthquake risk, Palm (1981) espoused a probability
threshold for taking protective action. If an individual perceives the probability of a
hazard as low, they then perceive the risk of the hazard as if it were zero. She explained
this phenomenon by the fact that people face many problems and hazards under normal
conditions and therefore attention must center on hazards which occur the most
frequently. Normalcy bias, then, encourages receivers to ignore early signs of a risk,
until more risk information or evidence appears.
Nigg (1993, 222) stated that personal interpretations of warning messages take
place within people’s ‘frames of normal expectations’ such that events continue to be
viewed as normal or non-endangering until sensory cues and/or social and
communication networks provide alternative meanings to the events and objects in the
physical environment. Normalcy bias must be overcome in order for protective action to
be undertaken (Nigg 1993). While evaluating patient medical status, normalcy bias
becomes especially important as common and ordinary diagnoses are usually preferred in
the absence of cues indicating otherwise.
When faced with an unexpected threat, individuals naturally tend to disbelieve the
risk information and continue their normal routine regardless of source of the information
(Perry, Lindell, and Greene 1981). Quarantelli (1980) stated that people under stress tend
to interpret data in terms of the known and familiar.

67
Social and Environmental Cues
Social and environmental factors are contextual factors that are unique to the
receiver and may also influence the risk communication process. Nigg (1993, 222)
affirmed that social factors play a role in individual response to threatening situations.
She stated that upon hearing a warning message, most people likely use ‘sensory cues’ to
assess whether or not they were truly in danger. In the case of tornadoes, high winds,
dark clouds, and stormy skies, reinforcing cues may come from the senses of the
environment. Individuals first hear a warning and then in a confirmatory step, they scan
the environment for supporting sensory cues. Certain observational cues supported the
message and help to push the person towards believing and acting upon the warning
(Cutter 1987). A lack of environmental cues, however, may reinforce existing doubts and
lessen perceptions of vulnerability, thus halting consideration of protective action.
Aguirre et al. (1993) found that confirmatory cues are critical to reducing human
victimization during tornado events. Night-time tornado events often exhibit increased
levels of victimization than those of day time events. People who are sleeping are not in
touch with media, social networks, or other methods of receiving a warning message
which prevents protective action. Further, darkness may prevent the witnessing of
threatening weather approaching, therefore blocking the receipt of confirmatory cues
which the experienced require to take protective action. Individuals who experienced
previous hurricanes were more familiar with the rapidly changing physical nature of the
storm, and therefore tended to wait for confirmation of expected landfall location before
evacuation. Greater experience with past hurricanes created a probability threshold
within the more experienced (Clark and Carter 1980). A probability threshold means that
68
individuals delay action until a point where they are personally satisfied that they are at
risk.
Demographic Factors
Some hazards researchers found that demographic characteristics influence
individual response to risk information. In one of the first studies of demographic factors
and their influence on response to risk, Wisner (1977) demonstrated that access to
drought adjustments varied according to wealth and poverty for farmers in Kenya.
Poverty induced limits to response abilities and behaviors which increased levels of
vulnerability have been identified by various researchers (O’Keefe, Wisner, and Baird
1977; Hewitt 1983; Burton, Kates, and White 1993).
Blanchard-Boehm and Cook (2004) found a relationship between increased levels
of education and protective action regarding tornado warnings. The higher the levels of
education, the more likely respondents were to take action to protect themselves and their
property. Higher education levels likely provided knowledge of risk and consequences
that may have increased the likelihood of protective action. As mentioned earlier, risk
communication consists of a process, not a singular event. Demographic variables such
as education, age, and length of employment reflect length of the potential risk
communication process and may be associated with increased opportunities to receive
training and information.

69
Message Characteristics
Message characteristics are the second category of major influences on the risk
communication process. Message characteristics consist of factors that are external to the
receiver. Mileti, Fitzpatrick, and Farhar (1990,16) stated that perceptions of risk do not
simply result from the singular receipt of risk information, but are created and maintained
through a complex process of multiple exposures and often multiple sources to the
information.
Mileti, Fitzpatrick, and Farhar (1990, 20) identified four general categories of
message characteristics that may influence the model behavioral stages: (1) message
content and style; (2) source of message, or aspects of channel through which messages
are conveyed; (3) frequency with which messages are given; and (4) traits associated with
individuals as well as organizations (source credibility) through which the message
arrives. Other researchers have defined message characteristics similarly (Sorenson and
Mileti 1987; Blanchard-Boehm 1992, 1998; Mileti and Fitzpatrick 1993).
Message Content and Style
Message content concerns the type and quality of the information being delivered.
Inclusion of geographic factors of the risk, such as identification of potentially affected
area serves to enhance the personalization of the threat which promotes the taking of
protective action. Freedman and Sears (1965) found that if the message content had
varied too much from previously held beliefs, agreement, internalization, and acceptance
of the information decreases.

70
Vague or non-specific information does not usually encourage the receiver to take
the desired action (Mileti, Fitzpatrick, and Farhar 1990; Blanchard-Boehm 1992).
Lundgren (1994, 55) states that effective risk messages contain key information that the
audience must possess in order to make the correct response decisions. She cautioned
that the technical content should not be over-simplified, but that the information should
be delivered to the audience in the most clear and straightforward manner possible.
Nigg (1993, 217) states that the identification of a scientific statement of danger is
not the end of the warning process, but rather the beginning of the dissemination process
which is possibly the most complex component of the system . Multiple hazards
researchers agree that in order for risk messages to be effective, they must clearly define
specific geographic region of risk, must denote specific actions to be taken, must name
likely consequences of inaction, must list temporal constraints of the risk, and must
provide the source of the risk information (Drabek 1986; Mileti and Sorenson 1987;
Aguirre et al.1993; Mileti 1999).
Numerous researchers have identified the importance of specific geographic and
temporal referents within risk communications. Quarantelli (1977) found that warnings
of imminent threats—even in response to rare events—were not usually ignored. In order
for the population to believe a risk message, the contents must include receiver specific
temporal and geographic referents (Quarantelli 1990). In a study of tornado watches and
warning and ensuing influence on tornadic victimization, Aguirre et al. (1993, 2) stated
that effective warning information must be accurate within both time and geographic
location. They found that regions that had been under announced tornado watches were
not likely to reduce victimization. However, regions with announced tornado warnings
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that contained specific time and geographic referents experienced reduced morbidity and
mortality during actual tornadic events. Tornado watches issued by the National Weather
Service are broad and generalized and lack specific geographic and temporal referents.
The lack of personally relevant threat information contained in watch messages rendered
them ineffective at reducing morbidity and mortality.
Risk findings relayed in probabilistic and theoretical terms have often been
perceived as vague and ambiguous by the at risk public (Nigg 1993, 225). Researchers
indicated that any perceived vagueness within warning messages would enable people to
reinterpret the risk message as non-threatening (Drabek 1968; Mileti, Drabek, and
Haas.1975; Perry, Lindell, and Greene 1981; Drabek 1986).
Palm (1981, 46) said that even when risks were widely publicized, it was unlikely
that they would reach the critical probability threshold needed to encourage mitigation
and preparation. Warning messages containing specific time and geographic references
were effective at decreasing tornado damage, injury and deaths (Aguirre et al. 1993, 2).
But, in order for warnings to be effective, people must perceive them as valid and
believable. Communication of risk information and public education helps the public
better perceive hazard risk (Mileti, Fitzpatrick, and Farhar 1990).
Source Credibility
When trust in the credibility of source of the risk message is not present, the risk
communication will be more likely to be ineffective (Slovic 2000). The sources of
information that the target population perceive credible should be utilized to maximize
trust and belief in the risk message (Drabek, 1969; Mileti, Hutton, and Sorenson 1981,
72
Quarantelli, 1993; Nigg 1993). Certain information sources may be perceived as more
credible and trustworthy delivery methods of bioterrorism information. Therefore,
particular sources may be more associated with increased perceptions of vulnerability and
response behavior, depending upon characteristics of the receiver. The most effective risk
message should originate from sources that are already trusted and perceived credible by
the receiver (Slovic 1993; Slovic, Flynn, and Layman 1991). Risk messages delivered by
groups and organizations with previously established credible relationships with the
receiver encourage acceptance of the risk information (Lundgren 1994; Mileti 1999).
Even when risk messages originate from trusted sources, the message may not have been
perceived as believable if estimates of damage were not provided, if the at-risk region
had been undefined, or if the imminence of the threat had not been clear (Nigg 1989).
Chaiken and Eagly (1976) investigated the complexity and presentation delivery
source of risk messages. They found that complex messages were difficult to follow and
recall when presented in a verbal media, but were better received in written form.
Lundgren (1994, 54) states that messages in the written format offer the benefit of
carrying more complex messages in either full or summary format depending on the
needs of the audience. She said that written messages are less expensive than messages
contained in television or other digital formats. Oral messages may be easily created, but
may be misunderstood by the target audience (Lundgren 1994, 87). When the need exists
to quickly deliver warning messages, oral presentations may be the most effective in the
short-term. But, to be most effective in the long term, a continuing series of presentations
to the desired audience might serve to reinforce the message and keep the audience
current on recent information and findings.

73
Sorenson (1983, 440) found that the public did not believe official sources of risk
and hazard information found within phone books, pamphlets and civil defense programs
to be significant sources of quality information. However, he did find that the broadcast
media effectively convinces people about hazard risks. Turner and colleagues (1979)
determined that the importance of source type changed over time. The perceived
credibility of electronic media sources of risk information decreased in importance over
time, while the credibility assigned to print media increased when the risk continued over
time.
Rodrigue and colleagues (1998) investigated the role of media and its role in
determining the social construction of the concepts of natural and technologic hazards.
They asserted that the role of broadcast media remain long underappreciated in the
literature. Frequency of contact with news stories and duration of coverage tend to
increase the opportunities to receive information on the risk, but not necessarily receipt of
quality technical details of the hazard, or the appropriate response. Media also plays a
critical role in setting agendas, or directing attention to particular issues thus generating
salience (Rodrigue et al. 1998). For example, following the events of September 11,
2001, terrorism has been a frequent topic on broadcast and print media.
Selection choices for best media source are complicated decisions that must
consider the imminence of the threat, type of threat, context, and opportunities to
disseminate information (Mileti and Sorenson 1990; Mileti and Fitzpatrick 1993; Mileti
1999). Visual messages such as videos or films may augment written or oral
presentations of risk by adding memorable graphics that serve to highlight important
facts, or demonstrate important relationships. Visual messages, however, are limited in

74
the amount of information they may provide and they lack the interactive ability to
address questions from the audience. Media selection decisions must consider audience,
context, timeframe of the risk, staffing issues, and the resources of the organization.
Decisions regarding channel or type of media are rarely made in isolation or
under ideal circumstances. In realistic short-term situations, the chosen delivery method
may be less than optimal, or ‘hap-hazard’ as the threat unfolds and may not reach all
members of the intended audiences. Long term pre-emergency risk messages have the
benefit of increased preparation time and may be provided orally through interactive
presentations and discussions. Long term messages may also be delivered in a more
organized manner through several media types to reach greater numbers within the
potentially affected audience. Written summaries of the information may also be
provided so that the audience may read over the information at their leisure (Lundgren
1994, 85-89). To further increase credibility, summaries of main points may be provided
during training to serve as quick reference guides that include sources for additional
confirmatory information.
Sorenson and Mileti (1991) asserted that the greater the perceived credibility of
the warning source, the more effective the warning. A credibility threshold must be
reached or exceeded, they stated, for risk information to be internalized by an individual.
Perceived source credibility formulations derive from complex, multifaceted factors that
depend on individual receiver characteristics. Once an individual has received risk
information and understands it, the perceived credibility of the source may significantly
influence or alter behavior and response (Perry and Greene 1982; Mileti 1999; Lindell
and Perry 2004; Rodriguez, Wachtendorf, and Russell 2004). Risk information from
75
sources with previously established trusted and reliable relationships actually increased
belief in the risk information (Hovland and Weiss 1951; Hovland, Janis, and Kelly 1953;
Perry 1982; Key 1986; Mileti, Fitzpatrick, and Farhar 1990; Blanchard-Boehm 1992;
Palm and Hodgson 1992).
Blanchard-Boehm (1998) asserted that an individual must simultaneously
perceive the source of risk information as trustworthy, honest, and competent. A lack of
any of these three components may reduce credibility to the point where the receiver
dismisses the information. The more favorable the risk information sources to the target
population, the greater the likelihood of encouraging protective action (Greene, Perry,
and Lindell 1981; Perry, Lindell, and Greene 1981; Hovland and Weiss 1982; Perry and
Greene 1982; Rosenthal 1990; Blanchard-Boehm 1998).
Lundgren (1994, 87) stated that advanced technical knowledge is necessary to
orally present risk information, but the speaker delivering the message must be perceived
credible by the audience and must be somewhat entertaining at the same time. Poor
public speakers, no matter how well educated, are poor choices to deliver important risk
messages she said.
Message Frequency
Another important message characteristic, frequency of exposure to the risk
message, occasionally has been found to influence the risk communication process. The
greater the number of encounters an individual has with risk information, the more
opportunities they have to hear and personalize risk information. Mileti and Beck (1975)
found that mass communicated risk warnings did not become a powerful contributor of
76
warning confirmation or belief, until several warnings had been received. Frequency of
exposures to risk information has been found to influence both the belief in the message
regarding potential hazard impacts, and the subsequent taking of protective action
(Drabek 1969; Mileti 1975; Perry, Lindell, and Greene. 1981; Okabe and Mikame 1982).
Frequency of contact with risk information may also increase through informal
sources of media such as communications with family members or through a social
network. Phone calls and other communications may serve to reinforce warning
messages through formal sources and may increase belief and protective actions (Okabe
and Mikami 1982; Perry and Greene 1982). Additional exposure to information from
formal and informal sources of risk information provide reinforcement of the original risk
message. Every additional encounter with risk information provides opportunities for
internalization, belief and protective action.
Education and Perceptions of Vulnerability
A growing body of evidence revealed that communication of risk information
encouraged the receiver to better perceive the risks associated with hazards which
enabled protective action (Kunreuther 1978; Mileti, Hutton, and Sorenson 1981; Mileti,
Fitzpatrick, and Farhar 1990; Blanchard-Boehm 1992, 1998; Palm and Hodgson 1992).
Therefore, the translation of knowledge into readiness and response capabilities must be
preceded by a perceived belief in personal vulnerability to life or property.
Effective education about risks creates uncertainty in the minds of the receivers
that encourages the individual to perceive personal risk, to question their safety, and to
potentially seek confirmatory information (Mileti 2004, 1). Covello, Sandman, and
77
Slovic (1988) provided five recommendations that encourage personalization of the risk
information. They stress that these points are particularly useful in communicating
quantitative risk information to a target audience and in the translation of technical
understanding into positive action:
• Use examples and anecdotes - hypothetical if necessary, real if possible - to make

the risk data come alive;
• Talk about yourself - what risks you personally find unacceptable or frightening,
how you and others close to you feel about the risk under discussion, or even
how you feel about the emotional distress you may be encountering at that
moment;
• Use concrete images to give substance to abstract risk data;
• Avoid distant, abstract, unfeeling language about death, injury, and illness; and
• Listen to people when they express their concerns. Reflect back to them your
understanding of the content of their comments and the emotions they are
expressing (p.11).
Palm and Hodgson (1992) also discussed factors of individual variability in the
translation of knowledge into action. After reviewing the literature, they found that
demographic factors do not consistently account for individual variability in response or
perceptions. But, Palm and Hodgson (1992, 9) identified five significant factors that
contribute to or influence response behavior.
1. The individual or household must have the available intellectual,

monetary and time resources to adopt effective mitigation
measures;
2. Individuals vary as to how they believe their destinies are
controlled by others. Those with a belief they can affect their own
circumstances, are more likely to seek out information and in this
process they come to believe that the risk and its solutions are real
and concrete;
3. Individuals personally calculate the probability that a disaster will
affect them based on decision-making heuristic errors and will
perceive the risk differently and then act differently from the intent
of the communicator;
4. Issues of time frame of the risk affect perceptions of vulnerability
and actions. If someone only plans on living in an area for a short
period of time, they might not consider the long term low
78
probability-although high impact-- events as personally relevant;

and
5. A major contributor affecting individual response is that of
salience of the hazards when compared to other concerns. Daily
problems and issues can override long term perceptions, planning
and preparedness of hazards.
All of Hodgson and Palm’s points have relevance to the communication of bioterrorism
risk to clinicians.
Mileti, Fitzpatrick, and Farhar (1990, 16) described the link between education,
perception, and behavior as a process rather than a singular event. They said that the
process-based concept of risk communication enables definition of stages between initial
information source input, processing, and ensuing behavioral output. Further, the process
concept connects cognitive perceptual events at different stages and provides
opportunities for increasing positive response. Risk messages provided through periodic
training strives to maintain bioterrorism vigilance among employees. Vigilance and ‘on
alert’ status among employees results from comprehensive training and education
programs.
Perceptions of vulnerability are receiver characteristics that reflect degree of risk,
danger and safety perceived by an individual. The degree to which one feels vulnerable
reflects understanding of the hazard, personal demographic characteristics, previous
experience with disasters, and the effectiveness of the actual risk communication.
Increasing levels of personal or community vulnerability should result from receipt of
risk information which increases the likelihood of taking protective action. Palm and
Hodgson (1992) discussed the translation of knowledge into action:
An individual’s response to a hazard cannot be predicted solely by drawing

conclusions about the amount of knowledge or experience he or she has with a
hazard. Individuals must not only be aware of the existence of the hazard, but,
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before they will take action, they must also translate this knowledge into a belief
that their own lives and property are susceptible to danger (p. 9).
As an ongoing complex process, risk knowledge and perceptions result from exposure to
various sources and various encounters with risk information as opposed to a singular
contact with information. The more efficient and complete the information learned by
the receiver, the longer it would be remembered (Hovland, Janis, and Kelly 1953).
Relevant information must be reinforced on a regular basis to maintain continued on alert
or vigilant status.
Risk communication model based research has arisen from more than 30 years of
previous research in a continuing effort to better integrate the complexities of decision
response behavior to risk messages. Risk communication model based methodologies
such as the GMHRC simulate the provision and processing of risk information by
individuals with varying personal characteristics, varying personal experiences and
varying personal histories as they progress through the model process behaviors of
hearing, understanding, believing, confirming, and responding to risk and threat
information (Mileti, Fitzpatrick, and Farhar 1990; Blanchard 1992; Mileti and Fitzpatrick
1993; Blanchard-Boehm 1998).
Mileti, Fitzpatrick, and Farhar (1990, 13) divided risk communication into two
subfields. The first sub-field consists of a pre-emergency low key warning and the
ensuing public interpretation and response to the information regarding the long term
risk. The second subfield focuses on emergency warning, interpretation and response to
communications about risk in the immediate future. This dissertation explores low key
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bioterrorism education and training messages through the contemporary GMHRC. The
low-key warning messages are “heard” or received by employees to enhance readiness
and preparedness outside the time frame of known events. In the absence of specific
geographic or temporal referents to future bioterrorism occurrences within the pre-
emergency period, a normalcy bias might exist, which results in a tendency for clinicians
to diagnose patients based on normal expectations and conditions. The findings from this
dissertation may provide guidance for overcoming normalcy bias.
The model process of ‘hearing’ demarcates the beginning of the risk
communication model process. However, long before the actual communication of risk
takes place, events occur and processes unfold within the lives of people that formulate
their unique personal characteristics which are based partially on life experience. How a
person processes and responds to a source of information results from their perceptions of
source credibility and through their personal information filters. Encouraging protective
behavior begins with changes in perceptions regarding the threat or risk. As attitudes and
perceptions of personal vulnerability become altered by new information, the possibilities
of enticing protective action are increased (Mileti, Fitzpatrick, and Farhar 1990).
Researchers found that ongoing hazards risk education and information
dissemination regarding risk of hazards augments understanding of long term risk
(Kunreuther 1978; Mileti et al. 1981; Turner et al. 1981; Mileti, Fitzpatrick, and Farhar
1990). Mileti, Fitzpatrick, and Farhar (1990) stated that few empirical studies measured
the impact of pre-emergency hazard education on risk perception and subsequent
mitigation behavior (p. 14). Though this deficiency has improved somewhat in the
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broader realm of hazards risk communication since the 1990 study by Mileti and
colleagues, few studies have investigated the hazard of bioterrorism.
The release of a bioterrorism agent generates a medical disaster that may
precipitate a variety of other crises including economic disruption, transportation
disruption in the case of quarantines, and vast social disruption. Unlike earthquake and
tornado risk information that must be delivered to the potentially affected general public,
the most critical bioterrorism information must be given to and internalized by medical
staff. The public may respond, prepare, and mitigate for many hazards including some
aspects of bioterrorism, but the most critical link for bioterrorism is early identification
directly by, or facilitated by, healthcare providers. Until identification, the responses and
recovery may not begin.

CHAPTER FOUR
THEORETICAL FRAMEWORK
As previously stated, the GMHRC served as the theoretical framework for this
dissertation and follows the behavioral stages outlined by Blanchard-Boehm (1998, 252).
Her work was built upon and refined earlier risk communication research that identified
the behavioral stages of risk communication in the tradition of Mileti and others (Mileti,
Farhar, and Fitzpatrick, 1990, 11; Mileti, Fitzpatrick, and Farhar 1990, 23; Blanchard-
Boehm 1992, 29; Mileti and Fitzpatrick, 1992, 1993).
Risk communication model based methodologies such as the GMHRC utilize a
basic framework to simulate risk communications and to enhance mitigation and
preparedness through communication of risk information (Mileti, Fitzpatrick, and Farhar
1990; Mileti and Sorenson 1991; Mileti 1999). The GMHRC conceptual model is listed
in Figure 7 below. An extensive review of the literature through which the GMHRC
evolved was provided in the previous chapter.
Risk communication model based research considers two broad categories of
influences that affect the behavioral stages. The first category consists of receiver
characteristics which are unique factors found in individual receivers including previous
experiences, beliefs, and demographics (Mileti, Fitzpatrick, and Farhar 1990, 23;
Blanchard-Boehm 1998, 252). The second category consists of message characteristics
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83
which are factors unique to the message itself such as source of message, credibility, and
frequency of exposure (Mileti, Fitzpatrick, and Farhar 1990, 23; Blanchard-Boehm 1998,
252). Measures of the behavioral stages and the factors that influence the behavioral
stages will be derived through the questionnaire.
Figure 7 The General Model of Hazards Risk Communication.

Source: Blanchard-Boehm (1998) (p. 254)
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The GMHRC Behavioral Stages
The GMHRC consists of five behavioral stages that simulate the risk
communication process consisting of hearing, understanding, believing, confirming and
responding to risk information as described by Blanchard-Boehm (1998, 252). Though
sequential in theory, the behavioral stages may differ among individuals at each stage in
the model process (Mileti, Fitzpatrick, and Farhar 1990, 18; Blanchard-Boehm 1998,
254).
The model stage of hearing consists of mandatory training provided through
employee training programs or through informal sources of bioterrorism readiness
information. Mileti, Farhar, and Fitzpatrick (1990, 19) stated that attention and concern
for a risk does not result from a single risk communication, but from an emerging risk
communication process that varies by individual, context, and circumstance.
The process of bioterrorism risk communication to healthcare workers is different
from risk communication to the general public for a variety of reasons. Receivers within
healthcare have increased homogeneity of certain receiver characteristics, such as
background medical knowledge, education levels, and type of employment. Formal
sources of bioterrorism risk messages within healthcare are targeted towards healthcare
workers and are not disseminated through media that typically delivers risk information
to the public.
Many healthcare organizations require mandatory attendance at bioterrorism
training courses. When typical risk messages are issued to the public, ‘captive’ audiences
such as these are rare and the process of hearing is more variable. One possible
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advantage resulting from hearing within the healthcare environment stems from the
potential to deliver bioterrorism information to higher percentages of the target
population through mandatory training. Different from many previous studies of risk
communication, the mandatory nature of formal bioterrorism training within healthcare in
this study provides a somewhat controlled behavioral stage of hearing.
The second behavioral stage of understanding occurs following hearing and
investigates understanding the factors of the risk as presented in the risk message (Mileti,
Fitzpatrick, and Farhar 1990; Blanchard-Boehm 1992; Mileti and Fitzpatrick 1992,
1993). If the message is misunderstood, the receiver loses an opportunity to realize their
risk which might reduce protective action. The behavior of understanding includes the
meaning that people may attach to the risk based upon individual receiver characteristics
and may vary from the desired risk communication goal (Mileti, Fitzpatrick, and Farhar
(1990, 19).
The behavioral stage of believing the risk message is the third behavioral stage of
the model process and addresses beliefs about the risk message. Mileti (1999, 142) stated
that believing the contents of a risk message depends largely on compatibility with the
receiver’s existing beliefs. Believing and understanding are separate behavioral stages
because some receivers may understand the message content, but not believe the risk
message (Mileti and Sorenson 1991). Some receivers may believe the risk message, but
not understand that they are at personal risk. Believing reflects cognitive decisions about
the risk message.
Confirming risk information may occur through a feedback loop in the risk
communication process. Mileti, Fitzpatrick, and Farhar (1990) stated that information
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seeking behaviors as well as the adoption of some mitigation measures actually increased
further protective action. Therefore, education and training messages serve as a positive
input to the risk communication system and may increase mitigation and preparedness.
New information obtained during training as well as existing doubts regarding the risk,
lingering questions, or a general need to reinforce or summarize information may
influence confirmatory behavior.
The final GMHRC behavioral stage consists of responding to a bioterrorism risk
messages through clinical vigilance. Different from risk messages of imminent warnings,
pre-emergency bioterrorism risk communication strives to provide receivers with the risk
and response information they need to launch a response when appropriate and to remain
vigilant until the time of onset. The message recipient must understand the risk message
and the recommended actions as well as believe in the personal salience of the risk. In
other words, the risk communication process should encourage the receiver to perceive
that they are personally at risk and that protective action is necessary, appropriate, and
possible (Palm 1990). The GMHRC rates responding through perception of personal
vulnerability towards future bioterrorist threats and the following section provides a brief
literature review of this methodology.
Vigilance as Responding
Blanchard-Boehm (1992, 17) asserted that behavioral changes in response to risk
messages are often not readily observable at the pre-emergency stage. Therefore
secondary behaviors provide surrogate indicators of effectiveness. She emphasized that
secondary behavioral changes might include an observable impact on perceptions of

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vulnerability. Drabek (1986, 77) reported that the impact of disaster training and drill
efforts during actual disasters remain largely unknown. True effectiveness of pre-
emergency risk communication may be gauged only during an actual event
Responding is generally defined as vigilance to the risk of bioterrorism. The
unique need for clinical vigilance for bioterrorism among healthcare providers reduced
the usefulness of gauging responding through preparatory planning or activities because
the earliest identification results from clinicians vigilance (as discussed in Chapter Two).
The preferred responding outcome for clinicians at the pre-emergency level results in a
vigilant state as measured through perceptions of risk and vulnerability. In the case of
bioterrorism events, actual occurrences had not occurred in Harris County at the time of
this writing. Therefore, surrogate variables provide the primary feedback available
during the pre-emergency period.
Various researchers have found links between perceptions of vulnerability and
response behavior as discussed in Chapter Three. The taking of protective action likely
results from perceived consequences of the risk, the perception of vulnerability held by
the individual regarding the risk information, and personal characteristics of the receiver
(Mileti, Fitzpatrick, and Farhar 1990, 23). Responses to risk messages result from a
complex and interrelated set of social and psychological intervening factors (Mileti,
Fitzpatrick, and Farhar 1990). They stated that perceptions of vulnerability are complex
formulations resulting from receiving a risk message, understanding, belief, and
personalization (p.25).
Mileti, Fitzpatrick, and Farhar (1990, 141) found that people with increased levels
of mitigation and preparedness activity, were more likely to perceive risk and
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vulnerability within their local communities. Increased levels of personal vulnerability to
hazards influence whether individuals actually act upon risk messages (Turner et al.
1981; Perry and Greene 1983; Perry and Lindell 1986; Palm et al. 1990; Blanchard-
Boehm 1992, 1998). Lundgren (1994, 54) stated that perceptions of an environmental
risk frame the reality of the risk in the receiver. She said that risk assessment, evaluation,
and subsequent decisions are not based solely on the technical understanding of the risk,
but on the perceptions of vulnerability among the audience.
Shadel and colleagues (2001, 349) found a general lack of bioterrorism awareness
among health care professionals and cautioned that low levels of perceived personal
vulnerability indicate that the risk of bioterrorism had not been internalized at the local
level. Higher levels of perceived personal vulnerability towards the risk posed by
bioterrorism are indicative of clinical vigilance in which the risk is not marginalized.
Clinicians who consider themselves and their community as potentially at risk
from a biological agent induced illness might have an increased likelihood of identifying
the early signals within their patient populations. Vigilant clinicians consider
bioterrorism as one possibility within the array of potential diagnoses that could be
assigned to a patient under the appropriate circumstances. Factors that contribute to
bioterrorism vigilance and readiness among health care workers must be better
understood because perceptions of vulnerability to the risk may influence confirmatory
information seeking behavior and ensuing preparedness levels (Shadel et al. 2003, 287).
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Influences on the GMHRC Behavioral Stages
According to the GMHRC, the five model behavioral stages may be altered by
two categories of influence: (1) receiver characteristics, which are factors unique to
individual receivers including previous training, previous disaster experience, perceptions
of vulnerability, beliefs about bioterrorism, experience with false alarms, and
demographics; and (2) message characteristics, which are characteristics unique to the
risk message itself including source type, frequency of exposure, and trainer credibility.
Mileti (1999, 143) noted that the influence of receiver and message characteristics varied
by hazard type as well as by target audiences. This research quantified and tested
receiver and message characteristics for influence on the bioterrorism risk
communication process. The literature review in Chapter Three included a review of
receiver and message characteristics and their range of influence on the risk
communication process.
Both message and receiver characteristics may be influenced or determined by the
sample group’s occupation. Degrees of homogeneity in receiver characteristics may arise
from groups of people within similar occupations. Message characteristics may also
vary by occupation. Potential utilization and availability of sources of bioterrorism risk
information, accessibility to individual sources, and level of exposure may vary by
occupational role. The GMHRC provided message and receiver characteristics to test for
influence on each behavioral stage.

90
Bioterrorism occurrences are primarily identified or detected by healthcare
providers and clinicians are the focus of this research. Therefore, healthcare providers or
clinicians are the primary group of concern for bioterrorism risk communication. But the
public and the TSICP attendees are investigated to provide a comparison from groups
with different occupationally generated exposures to bioterrorism risk communication.
To gauge pre-emergency bioterrorism risk communications surrogate indicators
provide assessment of positive outcomes within the GMHRC process. Different from
other hazards, preferred response activities for bioterrorism readiness risk
communications consist of a state of vigilance. Vigilance is rated through perceptions of
personal vulnerability to future bioterrorism occurrences.
Many risk communication researchers consider perceptions of vulnerability to be
indicators of pre-emergency readiness and response potential to hazards. Perceptions of
risk and vulnerability are an even more suitable gauge when the preferred outcome is a
state of vigilance. Higher levels of perceived personal vulnerability to bioterrorism may
be a consequence of successful bioterrorism training. Bioterrorism readiness levels
among healthcare providers within a defined geographic area, therefore, might provide an
indication of regional readiness and preparedness for bioterrorism occurrences. Findings
from this dissertation may provide feedback about levels of vigilance around Houston,
Texas.
The GMHRC advocates that the message recipient must hear a risk message,
understand the message and the recommended actions, believe in or personalize the risk,
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then possibly engage in confirmation, prior to responding behavior. The GMHRC
simulates the bioterrorism risk communication process through five behavioral stages as
influenced by receiver characteristics and message characteristics to derive modeling of
the bioterrorism risk communication process.

CHAPTER FIVE
METHODS AND INSTRUMENTATION
To model the bioterrorism risk communication process, feedback regarding
activity within all behavioral stages of the GMHRC was required. The questionnaire
provided measures to describe and test each model behavioral stage. Data collection for
the TSICP attendees was performed at several locations across the State of Texas. Data
for the HCHD clinicians, and the public were both collected within the city of Houston
located in Harris County, Texas.
Study Site
The City of Houston, within Harris County, Texas, ranks as the fourth largest city
by population among American cities (United States Census Bureau 2005). The 2005
population estimate for Harris County exceeded 3.6 million residents (United States
Census Bureau 2005). Harris County hosts one of the largest petrochemical and oil
refining complexes in the world. Considering the population size, and the industrial base,
Harris County appears to be a likely target for terrorists and therefore a worthy study site
for an investigation of bioterrorism risk communication.
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HCHD is the fourth largest public metropolitan healthcare provider in the nation
(by patient admissions) and is composed of two primary hospitals (Figure 8), a small
geriatric (non-emergency) hospital, and eleven community health centers that provide
health services to residents of Harris County (Harris County Hospital District 2005).
The Texas Medical Center, where Ben Taub General Hospital is located, lies within the
largest medical complex in the world. Situated in northeast Houston, Lyndon Baines
Johnson General Hospital lies between the city center and major petrochemical
complexes to the east. In the year 2005 HCHD hospitals received 56,156 patient
admissions and 1,162,220 outpatient visits (Harris County Hospital District, 2005).
The flagship hospital of HCHD, Ben Taub is commonly known to be one the best
trauma hospitals in the nation. Ben Taub General Hospital is a 588 licensed-bed facility
and reported 95,360 patient visits in 2005 (Harris County Hospital District 2005). There
were also more than 33,973 hospital admissions and 397,854 specialty clinic admissions.
Ben Taub stands as one of only two elite level I trauma centers in Harris County. Level I
trauma centers provide the highest available level of complex surgical and emergency
medical care.
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Figure 8 Locations of Ben Taub and LBJ General Hospitals within Harris County, Texas.
LBJ is more typical of an average sized hospital with 332 licensed beds. This
level III trauma center serves as the only emergency care facility in the northeastern
quadrant of Harris County. There were 66,678 emergency center visits, 252,652 specialty
clinic physician visits, and 21,125 hospital admissions during 2005 (Harris County
Hospital District 2005).
Ben Taub and LBJ are both designated receiving hospitals for disaster victims
within Harris County. As the largest single healthcare provider in the county, HCHD
contributes greatly to regional levels of disaster readiness and preparedness. HCHD

95
recognizes their role as a leader in regional readiness and provides disaster preparedness
training opportunities to their employees.
The Questionnaire
Data for this dissertation was collected through a questionnaire originally
designed by Blanchard-Boehm in 2003 to quantify bioterrorism risk communication
among TSICP members across the State of Texas. The questions were formulated to
evaluate and quantify the bioterrorism risk communication process through the GMHRC
behavioral stages of hearing, understanding, believing, confirming, and responding. The
questionnaire also established numerous receiver and message characteristics to assess
factors influencing the behavioral stages.
HCHD clinicians are the primary focus of this dissertation and the text and table
references to the questionnaire in the following chapters refer to the questionnaire version
provided to HCHD clinicians. As mentioned in Chapter One, the full version of the
questionnaire utilized for the HCHD clinicians is provided in Appendix One-A. The six
page questionnaire for TSICP attendees is provided in the original form in Appendix
One-B. Several questions were added to the HCHD questionnaire to provide respondent
data regarding clinicians. Full descriptions of the additional questions are provided in
Chapter Six. The six page questionnaire utilized for the public sample (Appendix One-
C) differed from the medical staff version in one set of questions. The medical
terminology in the questions of personal beliefs about bioterrorism readiness was
removed to decrease confusion. Instead, the public were asked general questions about
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their beliefs about bioterrorism readiness and response abilities by the government and
the medical community.
The Sample Groups
The survey was administered to five main sample groups as first described in
Chapter One. Data from the TSICP members were collected over a three year period
during 2004, 2005, and 2006. Data from the three groups of licensed HCHD clinicians
and the public were collected during February, March, and April 2006. The sample
groups are listed as follows:
1. TSICP attendees consisting of ICPs attending bioterrorism training

seminars throughout the State of Texas, hereafter referred to as
TSICP attendees;
2. Ben Taub Medical Doctors, hereafter referred to as Ben Taub
MDs;
3. Ben Taub Registered Nurses, hereafter referred to as Ben Taub
RNs;
4. LBJ Registered Nurses, hereafter referred to as LBJ RNs; and
5. The general public within Houston, Texas.
The Texas Society for Infection Control Practitioners Attendees
Unlike the other two sample groups, the TSICP attendee data was collected at
several locations across the State of Texas (Figure 9). The TSICP attendees were
sampled while attending the TSICP regional bioterrorism training seminars held
throughout the State of Texas during 2004, 2005, and 2006. Questionnaires were
distributed, completed and collected before the bioterrorism training began. Completed
questionnaires from 218 TSICP attendees were received.
The sample of TSICP attendees largely consisted of designated ICP or infection
control staff. The traditional role of ICPs has been to reduce spread of nosocomial
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(facility acquired) infection and they are concerned about bioterrorism as they would be
about any communicable diseases within their facility. Undiagnosed cases of
bioterrorism among the patient population present serious risks to maintaining the health
and safety of patients and staff. Disasters of many types might potentially impact
healthcare facilities in a variety of ways ranging from infrastructure and utilities, to
staffing and patient care capabilities. Regardless of the type of hazardous event, most
disasters impact facility infection control in some way. Due to the infectious nature of
many biologic agents, ICPs have long been recognized as critical to bioterrorism
readiness as well as to general disaster readiness. However, the typical ICP does not
conduct patient care and would not evaluate patients who might exhibit symptoms
produced by biological agents.

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Figure 9 Geographic Distribution of TSICP Attendees.
Harris County Hospital District Respondents
The sample of HCHD clinicians consisted of three separate samples of licensed
healthcare providers consisting of registered nurses (RNs) or medical doctors (MDs), at
Ben Taub or LBJ. Subjects recruited included healthy, non-patients who were employed
within an HCHD hospital. Completed questionnaires from 61 Ben Taub MDs, 231 Ben
Taub RNs, and 133 LBJ RNs provided a sample to assess the process of bioterrorism risk
communication within different clinicians. All subjects participated on a voluntary basis,

99
identified themselves only as RNs or MDs, and did not provide any uniquely identifying
information. As licensed registered nurses and medical doctors, all HCHD clinicians
were over 18 years of age and not of reduced abilities or reduced cognitive functions.
Completion of the questionnaire implied consent.
The Public Sample
Public respondents consisted of a random sample from the general public within
Harris County, Texas. Data from 265 respondents provided data for those not employed
within healthcare as a basis of comparison. Respondents were asked to verbally confirm
they were 18 years of age or older and that they were residents of Harris County.
Potential respondents who answered ‘no’ to either question were excluded from
participation. Households without English speaking members were also excluded due to
financial constraints posed by translation of the survey into other languages and also by
lack of availability of multilingual research assistants.
The TSICP attendees and the sample from the general public represented two
different occupational groups with varying opportunities for previous bioterrorism
training and education. Investigating these groups and the three groups of clinicians
facilitated comparison and provided an opportunity to identify associated GMHRC
factors that differ by occupation.
Data Collection Process
Prior to data collection, Institutional Review Board (IRB) approvals for research
on human subjects were applied for and received from the relevant agencies. IRB
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approvals are required when conducting research on human subjects primarily to ensure
safety of the human subjects. The Texas State University-San Marcos IRB was received
after a review process, but was contingent upon receiving the approvals from all other
relevant agencies (Appendix Two-A).
Ben Taub and LBJ are teaching hospitals and the IRB approval for research on
human subjects must be received from the organizations that provide clinical staffing as
well as from the individual hospitals. The first necessary IRB approval originated from
the Baylor College of Medicine and had to be sponsored by a faculty member. The
physician in charge of infection control at Ben Taub Hospital, Robert L. Atmar, MD,
agreed to sponsor the research and the approval was received (Appendix Two-B). Next,
letters were sent to the hospital Administrators and the Medical Chiefs of Staff for both
hospitals. Following IRB approvals from Ben Taub (Appendix Two-C) and LBJ
hospitals (Appendix Two-D), the data collection process obtained full approval.
Questionnaires were distributed to HCHD clinicians at several Nursing Directors
meetings as well as at ‘daily opener’ meetings directed by Physician Chiefs. Cover
letters (Appendix Two-E) describing the research project and providing contact
information for the Principal Investigator were attached to all questionnaires. Nursing
Directors and Physician Chiefs delivered questionnaires with explanatory cover letters to
their employees and asked for participation. Respondents were advised that completion
of the survey was fully voluntary and that they were able to decline participation at any
time. Further, they were advised that they may decline to answer any question at any
time for any reason. Directors and Physician Chiefs collected completed surveys and
held them for the Principal Investigator. Fifteen hundred questionnaires were distributed
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at Ben Taub. Four hundred and fifty surveys were distributed at LBJ hospital following
the same method of distribution through Directors of Nursing and Physician Chiefs.
During the planning phase of this project it was determined that obtaining random
sample of clinicians, would not be possible due to strict guidelines within HCHD that
prohibit distribution of employee names and contact information. Protection of names
and identifying information must occur for many legal reasons. Increased concern over
distribution of employee names may stem from recent legislation that criminalizes
distribution of patient names and medical information. Further, for an organization with
thousands of employees, the data quality of any employee lists would be questionable
without an active database manager, which did not exist. Lastly, a realistic distribution
method that would create a true random distribution of questionnaires did not exist. Only
a small percentage of clinicians maintain work email addresses and a physical mail
distribution system did not exist within HCHD.
HCHD administrators were very supportive of this project, but did not have the
ability or the inclination to expect more than voluntary participation of their staff. Also,
there were jurisdictional leadership issues as multiple agencies and institutions provide
clinical staffing within HCHD hospitals. For the previously mentioned reasons,
obtaining a true random sample proved impossible. When faced with the impossibility of
gaining a list of employee names, and the inability to randomly distribute questionnaires,
a sample of convenience was the only remaining option. Data collected from HCHD,
therefore, was received through a sample of convenience.
The public respondents were collected by a random sampling of households
within Harris County by telephone interviews. Research assistants dialed numbers that
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were randomly selected from the City of Houston phone book by the Principal
Investigator. Names and other uniquely identifying information were not collected.
Dillman and colleagues (1996) found that phone surveys often allow for more efficient
sampling of populations than personal interviews. Completion of phone surveys implied
consent.
Prior to conducting telephone interviews, all research assistants received an
information package that contained sources of information for respondents in the event
that respondents desired further information on the threats posed by bioterrorism (see
Appendix Two-F). Local mental health resources were also listed in the event that
completing the survey generated anxiety or concern in the respondent. Further, the name
and contact information of the Principal Investigator and supervisor was provided should
the participant desire more information on bioterrorism, if they desired a final report, or if
they wished to discuss anxiety generated by taking the survey.
Every effort was made to receive as many fully completed questionnaires as
possible. The TSICP attendees were encouraged to answer all questions and
completeness was verified by TSICP staff. The questionnaires that were completed by
the HCHD clinicians were checked for completeness by Directors of Nursing and
Physician Chiefs. Research assistants sought to obtain as many completed questionnaires
as possible by thanking respondents for their participation several times during the survey
process and by reminding respondents of the importance of the study. Questionnaires
with less than 80 percent completion were eliminated from the sample.
Upon completion of data collection, 908 completed questionnaires were received.
Two hundred and eighteen TSICP attendees provided completed questionnaires as listed
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in Table 5.1. HCHD clinicians provided 425 completed questionnaires. Two hundred
and sixty-five randomly selected members of the public completed surveys.
Table 5.1 Completed Questionnaires by Group.
SAMPLE SIZE BY GROUP N
TSICP Attendees 218
Ben Taub MDs 61
Ben Taub RNs 231
LBJ RNs 133
Public 265
TOTAL 908
Sample Representation and Data Considerations
The sample of the TSICP attendees represented only those who attended the
TSICP professional organization’s regional bioterrorism training seminars throughout the
State of Texas during 2004, 2005 and 2006. The TSICP professional organization
provided regional bioterrorism training seminars to members. Members consist largely
of medical staff who often require periodic bioterrorism training to maintain a current
health provider license. Approximately 96 percent of the actual attendees were surveyed
at the TSICP bioterrorism training seminars. None of the TSICP attendees refused to
participate, but 7 respondents were excluded because their questionnaires were greater
than 20 percent incomplete.

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Several important factors should be considered in regards to generalization of the
TSICP attendees’ sample to the larger population of ICPs throughout the State of Texas.
Hospitals with limited resources (which are numerous) may not be able to send staff to
training due to funding and staffing concerns. Therefore, the sample may over represent
hospital workers from hospitals with abundant staffing, resources, and training. The
sample of TSICP attendees may have over represented the untrained as it might have
represented the last remaining ICPs who had not received formal bioterrorism education
and training,.
The three samples of HCHD clinicians might also have biases. In all three
clinical samples the voluntary nature of the survey may have over represented the
clinicians who desired to please their boss or who were closer to the power structure of
the organization. Those without concern for bioterrorism may have decided not to
respond. Following discussions of response rates and potential biases among the three
groups of clinicians, some general biases that could apply to all sample groups are
included.
Two hundred questionnaires were distributed to Ben Taub MDs and 61 were
returned providing a response rate of 30 percent. Ben Taub is a teaching hospital in
which medical residents provide much of the medical care and therefore would only be
potentially generalized to other teaching, publicly funded hospitals. Medical residents
might have felt compelled to respond because their boss asked them to which might over
represented less experienced residents.

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Four hundred questionnaires were distributed to LBJ RNs and 133 completed
questionnaires were obtained providing a response rate of 33 percent. LBJ is a level III
trauma center, which limits potential generalization to other similar facilities.
Eight hundred questionnaires were distributed to Ben Taub RNs and 231 were completed
providing a response rate of 29 percent. Ben Taub is a level I trauma center, which limits
potential comparability to only level I trauma centers. Both Ben Taub and LBJ are
publicly funded hospitals which may limit comparability.
All data in this dissertation excluded people who were non-English speaking.
This dissertation was self-funded and the costs incurred from translating the survey into
other languages were prohibitive. This study did not exclude people that spoke English
in addition to other languages, nor did it exclude participants whose first language was a
language other than English. It is possible that those with lower levels of bioterrorism
knowledge might be more likely to have chosen not to participate in this voluntary study
which would over represent the more informed.
An additional limitation on comparability originates from the cross sectional
study design which mitigates causality inferences. The optimal method for assessing the
influence of varying types of information on various receivers consists of a randomized
assignment into usual and educational intervention with pre and post tests in each group
or a randomized block design in the case of multiple interventions.

106
Hypotheses and the GMHRC Process
The three clinical samples included in this dissertation provided an opportunity to
assess the impact of varying opportunities for hearing the bioterrorism risk message
through formal and informal sources. The sample groups—as generally defined by
occupation—exhibit general receiver characteristics based on occupation. Occupation
also contributes to access to and availability of risk messages.
The general hypotheses closely match the study questions listed earlier in this
dissertation. The five model behavioral stages and the multitude of receiver and message
characteristics that may influence each stage would have generated a large number of
hypotheses. The large numbers of potential hypotheses indicated a need to identify
general hypotheses. Each behavioral stage will be investigated individually in the
chapters that follow. The general hypotheses are discussed in the following section.
The model stage of hearing or the receiving of bioterrorism risk information was
assessed through quantifying the receipt of formal training provided through employee
training program as well as through informal sources. The mandatory nature of formal
bioterrorism training among healthcare workers might have resulted in more controlled
information dissemination than previous risk communication model based research. This
research provides an investigation of process differences arising from different
occupationally generated risk communication processes. The first hypothesis is stated as
follows:
• Hypothesis #1: Receiver and message characteristics are associated with the
GMHRC behavioral stage of hearing the risk message.
107
The behavior of understanding is the second stage of the GMHRC process. The
questionnaire derived understanding through a series of questions that assessed
respondent understanding of the risk posed by potential bioterrorist events. During the
pre-emergency stage of bioterrorism risk communication, information regarding
understanding of the risk message provided feedback for the effectiveness of previous
training efforts because those who did not understand the risk probably would not hold
the information required for actual vigilance. Measures of understanding derived from
questions addressing personal understanding of the risks and threats from future
bioterrorism occurrences. The second hypothesis is stated as follows:
GMHRC behavioral stage of understanding the risk message.
The behavior of believing is the third stage of the model process. Respondent
believing of the risk message derived from a series of questions that explored beliefs
about personal risk in comparison to beliefs about risk across the nation. Quantification
of the process of believing the risk message provided an indication of the likelihood of
perceived vulnerability change. The third hypothesis is listed as follows:
GMHRC behavioral stage of believing the risk message.
The GMHRC models confirming as action intended to supplement, confirm, or
summarize information about a risk message. During the confirming process, personal
information seeking behavior provided answers for lingering questions of doubt about the
validity of a risk, to confirm or verify previously held beliefs, or to resolve unanswered
questions. The fourth hypothesis is stated below:
GMHRC behavioral stage of confirming the risk message.
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The final model stage is responding, which during the pre-emergency period, was
gauged through levels of perceiving personal vulnerability (vigilance). Perceptions of
risk and vulnerability reflect many aspects of the risk communication process. In the pre-
emergency period, low-key warnings provide risk information and perceptions of risk and
vulnerability provide insight into personalization of the low-key risk messages. Increased
levels of perceived personal vulnerability among clinicians increased consideration of the
possibility of bioterrorism generated illness in their patient population. The fifth
behavioral hypothesis provides an assessment of responding (vigilance) and is stated
below:
GMHRC behavioral stage of responding to the risk message.
The final objective of this dissertation assesses the validity of the GMHRC
framework in the context of predicting individual response to bioterrorism risk
communication to healthcare providers. Prior to this dissertation, the model had not been
tested within bioterrorism risk communication. Previous risk communication studies
typically had investigated public or regional response to risk information. Identification
of bioterrorism risk communication patterns within the healthcare environment provides
information on the risk communication process and might provide strategies to augment
vigilance. Hypothesis six is stated as follows:
• Hypothesis #6: The behavioral stages of the GMHRC: (1) hearing; (2)
understanding; (3) believing; (4) confirming; and (5) GMHRC responding
behaviors are associated with receiver and message characteristics within
bioterrorism risk communication in the healthcare environment.
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Statistical Methods
The respondent data were analyzed using several different techniques depending
upon the type of variables and the questions to be investigated. The following methods,
as listed below, were utilized throughout the analysis: (1). Descriptive analysis of data
and findings; (2). Simple correlation tests (Spearman’s rank order correlation and Chi-
square); and (3). Logistic regression, a multivariate test used to identify contributing
factors to dichotomous outcome variables. The Statistical Package for the Social
Sciences (SPSS 2005) served as the analytical software for all data processing in this
dissertation. The help-guide within SPSS as well as Quantitative Data Analysis with
SPSS for Windows (Bryman and Cramer 1997) provided methodological guidance.
The descriptive analysis provided a basis for the discussion of the GMHRC
behavioral processes, and the receiver and message characteristics that contributed to
their outcome. Spearman’s rank order correlation was used to assess association between
groups (Kachigan 1986). Logistic regression was used to test the predictive power of the
receiver or message characteristics that served as independent variables with the
behavioral stage dependent outcome variables.
Several different indicators served as methods for rating the effectiveness of each
regression model (Bryman and Cramer 1997). The model chi-square statistic indicates
goodness of fit for the model in the context of the identified variables. The significance
value represented the probability of obtaining the chi-square statistic given the null
hypothesis stands as true. Another indicator of model effectiveness is the pseudo R-
square values. SPSS generates two pseudo R-square estimates and cautions that the ‘Cox
& Snell’ and ‘Nagelkerke’ R-square estimates are not necessarily comparable to typical
110
R-square values. The latter will be used as the R-square value in this study. Rather, they
served as indicators of the potential range of associated variance accounted for by the
model. Wald values are also provided by SPSS and they indicate the effectiveness or
contribution of individual independent values on the model outcome (SPSS 2005).
Non-responses for sources of formal training presented a unique challenge to
statistical analysis. Greater than 80 percent of the Ben Taub MDs did not receive formal
training. Greater than 80 percent of the samples of Ben Taub RNs and LBJ RNs received
training. Seven source variables existed for training sources, but the majority of
respondents only utilized one source. To avoid large numbers of missing data that would
have greatly reduced the sample sizes during regressions, non-responses for formal
sources of training were coded as source not used (0). Respondents who did not receive
formal training did not use the source of training. For the purposes of utilization of
independent variables, it seemed reasonable to interpret non-responses as ‘not used.’
The questionnaire provided measures through which to construct variables for the
behavioral stages of the GMHRC process. Investigation of the hypotheses of this
dissertation provided a greater understanding of the bioterrorism risk communication
process. The GMHRC framed the study questions, the research hypotheses and the
dependent and independent variables. Findings (discussed later in this dissertation)
identified factors that contributed to vigilance to future bioterrorism events. Findings
might also provide feedback for improving future training and education.
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Data collection provided information about the TSICP attendees, the HCHD
physicians and nurses, and the members of the public. As previously discussed in
Chapter Two, the group of primary concern for bioterrorism identification and response
were the physicians and nurses (clinicians) as they were the three sample groups that
likely controls early identification of onset. The TSICP members consisted of infection
control practitioners and were thought to have had the most access to bioterrorism
training and information and possibly the highest expected levels of readiness and
preparedness within healthcare. The sample from the public provided the baseline
knowledge found among the general population outside of healthcare.

CHAPTER SIX
DESCRIPTION OF SAMPLE DATA
Before testing the GMHRC behavioral stages in later chapters, this chapter
describes the results obtained by the questionnaire during data collection. The
questionnaire was designed to collect data about the bioterrorism risk communication
process by assessing the model behavioral stages and the influencing factors of receiver
and message characteristics among the five sample groups. This chapter is divided into
three main sections based upon receiver characteristics, message characteristics, and the
statistical process of identifying the independent variables for testing of the behavioral
stages in later chapters.
Receiver Characteristics
Descriptive analysis of the sample groups’ receiver characteristics provides an
understanding of the sample groups varying personal characteristics. Levels of formal
bioterrorism training will be the first established receiver characteristic.
112
113
Formal Bioterrorism Training
Of the 218 TSICP attendees, 52 percent had received formal bioterrorism training
prior to attending the TSICP seminar (Table 6.1). The remaining 48 percent reported that
they had not received previous formal training. From the sample of 61 Ben Taub MDs,
only 27 percent, or approximately 1 out of 4, had previously received formal bioterrorism
training. The Ben Taub RNs (83 percent) had greater than 3 times the levels of formal
bioterrorism training than did the sample of MDs. Of the 133 LBJ RNs, 86 percent
reported formal bioterrorism training and only 14 percent reported no previous training.
Of the 265 members of the public sample, only 21 percent reported previous
formal bioterrorism training. Most public respondents were employed outside of the
healthcare industry and held jobs that did not require bioterrorism training. These levels
of reported training might possibly overstate the actual levels because personal standards
for defining bioterrorism training among the public might be more relaxed than within
healthcare providers.
Table 6.1 Formal Training Levels.
PERCENTAGE PERCENTAGE
GROUP (TRAINING) N NO FORMAL TRAINING FORMAL TRAINING
TSICP Attendees 218 48 52
Ben Taub MDs 61 73 27
Ben Taub RNs 231 17 83
LBJ RNs 133 14 86
Public 265 79 21
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Informal Sources of Bioterrorism Information
Respondents were asked to list the other means (outside of formal training)
through which they had gained bioterrorism information. Respondents who reported no
informal information from any source are indicated in the ‘no sources of information’
column. Informal information sources are quantified through a binary variable and are
listed in Table 6.2. Information seeking activity among any of the sources was classified
as having received informal information about bioterrorism (1). Respondents who did
not receive any informal information from any source were classified as not having
information from informal sources (0).
The majority of respondents from all sample groups reported receipt of some type
of bioterrorism information from informal sources. The Ben Taub MDs reported the
highest levels of no information from informal sources of any sample group. The TSICP
attendees reported the highest levels of informal information of any sample group.
Table 6.2 Percentage of Informal Sources of Information.
(INFTOT) NO REPORTED INFORMAL REPORTED INFORMAL

GROUP N INFORMATION INFORMATION
TSICP Attendees 218 6.4 93.6
Ben Taub MDs 61 16.1 83.9
Ben Taub RNs 231 7.4 92.6
LBJ RNs 133 8.3 91.7
Public 265 12.3 87.7

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Previous Experience with Disasters
This section establishes the levels of disaster experience among the sample groups
as summarized in Table 6.3. The data indicated that slightly greater than 50 percent, or
roughly 1 out of every 2, TSICP attendees reported personal previous experience with
disasters. Ben Taub MDs, Ben Taub RNs, and the general public reported previous
disaster experience at a rate of approximately 2 out of every 3 respondents.
Approximately 3 out of every 4 LBJ RNs respondents reported previous disaster
experience. Experience with previous disasters was reported at higher levels among all
groups of HCHD clinicians and the public, than the TSICP attendees. Both the sample of
clinicians and the public sample were collected from within Harris County, Texas.
Table 6.3 Percentage of Previous Disaster Experience.
(PREVEXP)
NO PREVIOUS DISASTER EXPERIENCE WITH
N
EXPERIENCE PREVIOUS DISASTERS
GROUP
Ben Taub RNs 230 30.4 69.6
LBJ RNs 133 24.1 75.9
Public 265 33.9 66.1
To obtain additional information regarding the previous disaster experience of
respondents, personal and property loss amounts from previous disasters were assessed
116
(Table 6.4). Greater than 60 percent of the HCHD clinicians and the TSICP attendees
reported no recent losses from disasters. Between 5.2 percent and 6.8 percent of the
clinicians reported losses greater than $10,000. The public respondents reported no loss
from recent disasters among 56 percent of respondents.
Table 6.4 Percentage Damage Amounts from Most Recent Disaster.
(LOSSAMT1) NO $ 0 TO $1,001 TO $5,001 TO

N LOSS $1,000 $5,000 $10,000 $10,001+
GROUP
TSICP
113 67.6 6.4 11.4 6.8 7.8
Attendees
Ben Taub MDs 41 66.1 14. 12.9 0 6.5
Ben Taub RNs 161 60.2 18.6 10.4 5.6 5.2
LBJ RNs 101 64.7 13.5 9.8 5.3 6.8
Public 176 55.6 16.0 9.3 10.4 8.7
Dollar amounts of personal and property losses from other disasters were also
assessed through the questionnaire. The loss amounts are listed by sample group in
Table 6.5. Greater than 85 percent of the sample groups reported no losses from other
disasters. Respondents generally reported lower amounts of losses from other disasters
than they had reported for recent disasters, though the majority reported no losses.
Three questions rated impacts of previous disasters among the respondents
reporting previous disaster experience. With the exception of 37 respondents, most of the
TSICP attendees were excluded from this analysis as the questions of impacts were added
to the questionnaire after most of the TSICP attendee data had been collected.
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Impacts from previous disasters are listed in Table 6.6. Few respondents reported
injuries resulting from previous disasters. A more pervasive disaster impact was related
to transportation problems. Greater than 38 percent of the groups of clinicians and just
over 28 percent of the public sample reported travel or commuting problems. This
compares to quality of life impacts, where greater than 33 percent of all clinicians and
just over 28 percent of the public reported their quality of life was negatively impacted by
a previous disaster.
Table 6.5 Percentage Damage Amounts from Other Disasters.
(LOSSAMT2)
$1,001 TO $5,001 TO
N NO $ LOSS 0 TO $1,000 $10,001 +
$5,000 $10,000
GROUP
TSICP Attendees 113 89.5 5.0 2.3 1.8 1.4
Ben Taub MDs 41 90.3 6.5 3.2 0 0
Ben Taub RNs 161 93.5 1.7 1.7 0.4 2.6
LBJ RNs 101 85.0 8.3 1.5 1.5 3.8
Public 176 92.9 3.0 1.9 .7 1.5
Table 6.6 Impacts from Previous Disasters by Percentage.
(TRAVEL) (QOFLIFE)
(INJURY)
UNABLE TO QUALITY OF LIFE
INJURY
GROUP N DRIVE OR TRAVEL IMPACTED
TSICP Attendees 23 0 9.6 37.8
Ben Taub MDs 41 0 38.7 48.7
Ben Taub RNs 160 2.5 39.4 38.5
LBJ RNs 101 4.9 39.8 33.3
Public 175 .5 28.4 28.5

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Experience with Bioterrorism False Alarms
Experience with bioterrorism false alarms varied somewhat among the sample
groups (Table 6.7). Approximately 43 percent of TSICP attendees and a quarter of Ben
Taub MDs and Ben Taub RNs reported experience with false alarms. The LBJ RNs
reported the lowest levels of false alarms among the samples of clinicians which
accounted for slightly fewer than 10 percent of their sample. The public reported the
least experience with false alarms of any sample group. The questions addressing
experience with false alarms were also added to the questionnaire after most of the
TSICP attendees had responded, therefore only the responses from 2006 were included.
Table 6.7 Experience with False Alarms for Bioterrorism.
(FALSEALM) (NOFALSEALM)
N
GROUP NO YES MEAN FREQUENCY
TSICP Attendees 37 57% 43% 2.4
Ben Taub MDs 57 75.4% 24.6% 1.4
Ben Taub RNs 211 73.9% 26.1% 1.7
LBJ RNs 121 90.1% 9.9% 1.5
Public 256 94.9% 5.1% 2.2
Respondents were asked how their experience with false alarms made them feel in
relation to skepticism towards future threats (Table 6.8). Many respondents reported that
they felt ‘neutral’ or ‘somewhat more skeptical’ towards future threats. The feelings
generated by experience with false alarms are described in this chapter, but are not
utilized as variables in later analysis due to their low response rate.

119
Table 6.8 Feelings about Future Threats Generated by False Alarms.
PERCENTAGE BY SAMPLE GROUP

(FALSPERC)
SOMEWHAT SOMEWHAT
MORE LESS
GROUP N MORE NEUTRAL LESS
SKEPTICAL SKEPTICAL
SKEPTICAL SKEPTICAL
TSICP
15 6.7 33.3 33.3 0 26.7
Attendees
Ben Taub
13 7.7 7.7 38.5 30.8 15.4
MDs
Ben Taub
49 26.5 34.7 26.5 8.2 4.1
RNs
LBJ RNs 9 22.2 44.4 33.3 0 0
Public 12 0 8.3 66.7 0 25.0
Demographic Variables
Years of schooling among respondents are described in Table 6.9. As expected
by their medical education, Ben Taub MDs reported the highest mean of 20.5 years of
education. Attendees from the TSICP group reported a mean of 16.2 years of education.
Ben Taub RNs reported a mean of 15.7 years, while LBJ RNs reported a mean of 15.9
years of education. The public reported a mean of 15.1 years of education, which was the
lowest level of education for any of the sample groups.

120
Table 6.9 Mean Years of Education.
GROUP (SCHOOL) N MEAN YEARS OF SCHOOLING
TSICP Attendees 208 16.2
Ben Taub MDs 60 20.5
Ben Taub RNs 223 15.7
LBJ RNs 131 15.9
Public 258 15.1
Following the events of September 11, 2001, the Joint Commission on Healthcare
Accreditation (2005) required disaster readiness capabilities in hospitals that include
bioterrorism training in their Environment of Care accreditation standard 4.10. As
length of employment increases, so would the possibility of additional opportunities for
formal training.
Length of employment at current occupation by sample group is described in
Table 6.10. Respondents from the TSICP attendee sample reported a mean length of 7.9
years at their current occupation. The mean length of employment for Ben Taub MDs
was 5.6 years, which represented the lowest employment length of all sample groups.
The sample of Ben Taub RNs reported the greatest length of employment, with a mean of
14.3 years. LBJ RNs reported a mean length of employment of 15.7 years. The public
respondents reported a mean length of 11.2 years of employment.

121
Table 6.10 Length of Employment at Current Occupation.
GROUP (JOBLNGTH) N MEAN LENGTH IN YEARS RANGE
TSICP Attendees 218 7.9 0 to 40
Ben Taub MDs 61 5.6 0.60 to 30
Ben Taub RNs 231 14.3 0.25 to 40
LBJ RNs 133 15.7 0.25 to 34
Public 259 11.2 0.16 to 42
The findings for respondent ethnic affiliation are described in Table 6.11.
Approximately 3 out of every 4 TSICP attendees identified themselves as White-Anglo,
which was the largest reported ethnic category. The second most frequent ethnic
category among the TSICP attendees were Hispanics who accounted for a comparatively
small 13 percent of respondents. Of the 61 Ben Taub MDs, 49 percent identified
themselves as White-Anglo which was the most frequent category. The second most
frequent category among Ben Taub MDs was Asian-American (22 percent) and the third
most frequent category was African-American (17 percent). The largest ethnic category
among Ben Taub RNs was Asian-American (35 percent). White-Anglos accounted for
the second most frequent category (26 percent) and African-Americans (22 percent) were
the third most frequent category within the Ben Taub RNs. African-Americans
represented the largest ethnic category among LBJ RNs (38 percent) of respondents.
White-Anglo was the second most frequent category (27 percent) and Asian-American
(23 percent) were the third most frequent category among the LBJ RNs. White-Anglos
accounted for 62 percent of the public sample. Hispanics were the second most frequent
122
category (19 percent) and African-American were the third most frequent category (16 percent)
within the public sample.
Table 6.11 Respondent Ethnicity by Percentage.
GROUP NATIVE PACIFIC WHITE-

(JOBLNGTH) N ASIAN AFRICAN HISPANIC
AMERICAN ISLANDER ANGLO
OTHER
TSICP Attendees 206 1.0 3.4 13.2 1.9 0 78.6 1.9
Ben Taub MDs 59 22.0 16.9 6.8 1.7 0 49.2 3.4
Ben Taub RNs 223 35.0 22.0 3.6 1.3 8.5 26.0 3.6
LBJ RNs 120 22.5 37.5 5.8 0 5.8 26.7 1.7
Public 262 0.4 16.0 19.1 2.3 0.4 61.5 0.4
The mean years of respondent age for each sample group are described in Table 6.12.
Members of the TSICP attendees sample had a mean age of 47.8 years with a range from 27 to 68
years. The Ben Taub MD sample had a mean age of 33.2 years with a range of 25 to 58 years.
The sample of Ben Taub RNs had a mean age of 43.4 years with a range of 23 to 63 years. The
LBJ RN sample had a mean age of 44.4 years with a range of 22 to 62 years. Respondents from
the public sample were less homogenous than the other sample groups, with a range of 18 to 71
and a mean age of 43.5 years.
Table 6.12 Respondent Age in Years.
GROUP (AGE) N MEAN RANGE
TSICP Attendees 208 47.76 27 - 68
Ben Taub MDS 59 33.24 25- 58
Ben Taub RNs 213 43.35 23- 63
LBJ RNs 127 44.43 22 - 62
Public 262 43.51 18 -71

123
The receiver characteristics that were established and described in this section are
summarized in Table 6.13. The following table references the receiver characteristics in
reference to the version of the questionnaire utilized by the HCHD sample groups. Some
small differences existed between the HCHD version of the questionnaire and the two
versions utilized by the TSICP attendees and the public respondents. All three versions
of the questionnaire are located in the appendices. Crosswalks for the variables in
relation to the different versions of the survey are included in Appendix One-D for the
TSICP attendees and Appendix One-E for the public.
Beliefs
Sample group beliefs regarding perceptions of bioterrorism readiness and
preparedness were assessed using a Likert type perceptual scale. The questionnaire
utilized a 1 to 11 scale with numerical anchors to enhance consistent respondent
interpretation. A value of 1 designated ‘not at all likely’, a value of 6 indicated a ’50-50
chance’, and a value of 11 designated ‘extremely likely.’ Most of the TSICP attendee
data had been collected prior to when these belief questions were added to the
questionnaire. A small number of the TSICP attendee respondents completed their
questionnaires in 2006 and these are included in the descriptive findings, but are not
discussed due to the small sample size.
The first beliefs question asked respondents to rate their belief that early detection
of bioterrorism would occur during the critical early stages of symptom onset, which is
prior to onset of more severe and more recognizable symptoms. Ben Taub MDs had a
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Table 6.13 Receiver Characteristics (Experiential, Occupational, and Demographic).
TYPE OF QUESTIONNAIRE
# QUESTION SUMMARY VARIABLE NAME ROLE OF THE VARIABLE
VARIABLE CROSSWALK
1. Len g t h o f e mp l o y me n t Ratio J O B LN G T H Q .2 Ind ep en de nt
Pa rt of the
2. F o r ma l b i o te r r o ris m t r a i n in g D i c h o t o mo u s TR A I N IN G Q .3 Dep en d en t Va r iab l e
f o r He a rin g
In f o r ma l so u rc es o f Pa rt of the
3. i n f o r ma t i o n D i c h o t o mo u s IN F TO T Q .6 Dep en d en t Va r iab l e
f o r He a rin g
4. Pr evious exp e r ienc e w ith Dichoto mous PR EV EXP Q.23 Ind ep en de nt

disas te rs
5. T yp e o f mo s t r e c e n t p r e v i o u s No min al PE T YP E1 Q.24 a Des c ribed Onl y

e x p e ri e n c e
6. D o l l a r a mo u n t o f d a mag e Ord ina l DO L LA R1 Q.24 a Des c ribed Onl y

f ro m re cen t d is ast er s
7. T yp e o f o th e r p re v i o u s N o min al P E T Y P E2 Q .2 4 b D e s c rib e d O n l y
e x p e ri e n c e
8. D o l l a r a mo u n t f ro m o th e r O rd in a l D O L LA R 2 Q .2 4 b D e s c rib e d O n l y
d a mag e
9. Pe rsona l o r fa mi l y inju ry Dichoto mous IN JUR Y Q.24 c Des c ribed Only

f ro m h az ard
10. In ab ili t y to t ra v el o r D i c h o t o mo u s TR A V E L * Q .2 4 d Ind ep en de nt

co mmu te du e t o dis ast e r
11. Qua lit y of life affect ed b y D i c h o t o mo u s QOFLIFE * Q .2 4 e Ind ep en de nt

d i s a s te r
12. Ex p e ri en c e w it h f al se a la r ms D i c h o t o mo u s F A LS E A LM * Q .2 6 Ind ep en de nt
13. N u mb e r o f f a l s e a l a r ms Ratio N MB F A LS E* Q .2 6 Ind ep en de nt
14. Ef f ec ts o f f a lse a la r ms Ord in a l FA LS E PE R C * Q. 2 6 a Ind ep en de nt
15. Nu mb e r o f ye a rs o f Ratio SCHOOL Q. 27 Ind ep en de nt

schooling co mplet ed
16. Age Rat io AG E Q.28 Ind ep en de nt
17. In co me Ord in a l IN CO M E No t co l le cted Ind ep en de nt

f o r HC HD
No min al
18. Eth n i c g ro u p (8 E TH N IC Q. 3 0 Ind ep en de nt
cat ego ri es)
Eth n i c G ro u p : re c o d e d - No min al Q. 30
19. coll aps ed (5 (r eco d ed ) Ind ep en de nt
cat ego ri es)
*Missing data for 83% of TSICP attendees

125
mean level of 4.4 on the 11-point Likert-scale, which represented the lowest mean levels
of all sample groups. None of the Ben Taub MDs had higher than a value of 8. The LBJ
RNs had a mean belief level of 4.9 which ranked between Ben Taub MDs and Ben Taub
RNs. Ben Taub RNs had the highest levels of belief in early detection with a mean level
of 5.1.
The second beliefs question queried respondents about their belief in the ability of
existing surveillance systems to provide timely identification of bioterrorism. Ben Taub
MDs had the lowest mean belief levels of (4.9) of any sample group. None of the Ben
Taub MDs had higher than 9 on the 11-point scale. The LBJ RNs had belief levels that
ranked between Ben Taub MDs and Ben Taub RNs, reporting a mean belief level of 5.7.
The Ben Taub RNs had the highest mean belief level of any sample group (6.0).
The third question assessed beliefs regarding the ability to distinguish
bioterrorism from ordinary disease trends. The Ben Taub MDs again had the lowest
mean belief levels of 5.3 on the 11-point scale. The LBJ RNs again ranked between Ben
Taub MDs and Ben Taub RNs with a mean level 5.8. Ben Taub RNs had a mean belief
level of 5.9, which again ranked as the highest mean level.
The public respondents were asked to answer two general questions about their
beliefs in readiness and preparedness. The first question asked if they believed the
government would provide early detection of bioterrorism. The mean level of belief in
the public was 6.14 on the 11-point scale. The second question concerned belief that the
medical community will provide early detection of a bioterrorism occurrence. The mean
level of belief for the second question was 6.11 on the 11-point scale. The public
believed in readiness, preparedness and detection in levels slightly above 50 percent.

126
Thus it appears the public sample is evenly split on belief in the abilities of the medical
profession and the government to identify a bioterrorist occurrence.
Table 6.14 Beliefs About Bioterrorism Readiness.
BELIEF IN OR THAT: GROUP N MEAN MIN. MAX.
TS IC P At ten d e es 37 5.1 1 8
Ea rl y De te ctio n w ill Oc cur
when Bio te r ro r is m Ben T au b M Ds 61 4.4 1 8
S y mp t o ms a r e n o n -S p e c i f i c
(N O NS PE C I D ) Ben T au b RNs 220 5.1 1 11
LBJ R Ns 131 4.9 1 9
Ti me l y D et ec ti o n b y
Curren t Publ ic He alth Ben T au b M Ds 60 4.9 1 9
Surv eil lan ce S ys te ms
( ER LD E T) Ben T au b RNs 227 6.0 1 11
LBJ R Ns 132 5.7 1 11
Bio t er ro ris m w ill b e
D i s t i n g u i s h a b l e f ro m Ben T au b M Ds 61 5.3 1 11
O rd in a r y S yn d r o me T re n d s
(D I ST R E N D) Ben T au b RNs 221 5.9 1 11
LBJ R Ns 131 5.8 1 10
Ea rl y De te ctio n b y the
Pu b li c 265 6.14 1 11
G o v e rn men t ( E R L Y D E TG V )
Ea rl y De te ctio n b y the
Med ic al C o mm u n it y Pu b li c 265 6.11 1 11
( ER LY D ET MC )
Beliefs Regarding the Likelihood of Usage of Potential Bioterrorism Agents
The questionnaire assessed beliefs regarding the likelihood of potential
bioterrorism agents through a 4-point perceptual scale. Perceived risk by biologic agent
127
was quantified using a 1 to 4 scale. A response of 1 indicated ‘not very likely.’ A
response of four indicated ‘very likely.’
The TSICP attendee sample had the highest belief levels for the potential usage of
anthrax as a bioterrorist agent, while Ben Taub MDs had the lowest levels of beliefs for
anthrax (Table 6.15). The two samples of RNs had higher levels in belief that anthrax
was very likely than did Ben Taub MDs, but slightly less than the TSICP attendees. Ben
Taub RNs had lower belief levels in anthrax than the TSICP attendees but higher than
Ben Taub MDs. Ben Taub MDs generally had the lowest levels of belief in the
likelihood for all the various biological agents. The TSICP attendees exhibited higher
belief levels for most agents than did Ben Taub MDs, but somewhat less than the two
samples of RNs.
Beliefs Regarding Preparedness
Respondents provided their responses regarding levels of belief in preparedness
through an ordinal 4-point perceptual scale as described in Tables 6.18 and 6.19. This
data was not utilized in the analysis of the behavioral stages in the following chapters
because beliefs about preparedness do not link directly to the GMHRC with a single
exception. Individual preparedness in households was used as a dependent variable for
responding for the public sample only. Overall beliefs about preparedness for most listed
places clustered in the somewhat likely category with one exception. Ben Taub RNs had
lower levels of belief in the preparedness level of federal emergency management
agencies than other sample groups.

128
Table 6.15 Beliefs About Usage of Potential Biological Agents by Percentage.
NOT VERY SOMEWHAT SOMEWHAT VERY

AGENT GROUP
N
LIKLEY UNLIKLEY LIKLEY LIKELY
TSICP Attendees 214 1.4 9.3 41.1 48.1
Ben Taub MDs 61 6.5 19.4 51.6 22.6

Anthrax
(ANTHRAX) Ben Taub RNs 223 6.7 11.2 38.1 43.9
LBJ RNs 131 1.5 5.3 48.9 43.5
Public 265 1.1 8.3 48.7 41.9
TSICP Attendees 213 2.8 18.3 47.9 31.0
Ben Taub MDs 61 6.5 29.0 46.8 17.7

Botulism
(TOXINS) Ben Taub RNs 222 8.6 10.4 43.7 37.4
LBJ RNs 131 7.6 16.8 49.6 26.0
Public 265 4.2 19.2 42.6 34.0
TSICP Attendees 212 21.7 35.4 27.8 15.1
Ben Taub MDs 61 25.8 22.6 40.3 11.3

Ebola
(HEMMRAGE) Ben Taub RNs 219 11.9 21.5 41.1 25.6
LBJ RNs 129 7.0 17.1 61.2 14.7
Public 265 7.9 26.0 37.4 28.7
TSICP Attendees 213 6.1 20.7 42.7 30.5
Ben Taub MDs 61 16.4 31.1 34.4 18.0

E.coli
(ECOLI) Ben Taub RNs 213 11.7 14.6 39.9 33.8
LBJ RNs 130 4.6 20.0 54.6 20.8
Public 258 9.7 24.8 46.9 18.6
TSICP Attendees 213 4.7 17.8 48.8 28.6
Ben Taub MDs 61 18.0 29.5 37.7 14.8

Smallpox
(SMALLPOX) Ben Taub RNs 217 13.4 12.0 37.8 36.9
LBJ RNs 125 3.2 12.0 49.6 35.2
Public 264 20.8 20.1 38.3 20.8

129
Table 6.16 Beliefs Regarding Geographic Targets of a Bioterrorist Attack.
PERCENTAGE BY SAMPLE
PLACE GROUP
N NOT VERY SOMEWHAT SOMEWHAT VERY
LIKLEY UNLIKELY LIKLEY LIKELY
TSICP Attendees 212 0 .9 15.6 83.5
Ben Taub MDs 61 1.6 3.2 14.5 80.6

Large
Metropolitan Ben Taub RNs 228 .9 3.5 28.1 67.5
Area
LBJ RNs 132 0 4.5 20.5 75.0
Public 265 0 1.5 12.4 86.1
TSICP Attendees 213 3.3 26.3 57.7 12.7
Ben Taub MDs 61 8.1 29.0 54.8 8.1

Small to
Medium Sized Ben Taub RNs 223 11.2 33.6 43.0 12.1
City
LBJ RNs 131 12.2 34.4 43.5 9.9
Public 265 12.4 30.7 37.5 19.5
TSICP Attendees 211 28.0 48.8 16.6 6.6
Ben Taub MDs 61 56.5 35.5 6.5 1.6

Rural Area,
Outside City Ben Taub RNs 221 34.8 39.4 16.3 9.5
Limits
LBJ RNs 131 29.0 44.3 24.4 2.3
Public 265 42.1 36.1 13.9 7.9

130
Table 6.17 Beliefs Regarding Facility Targets of a Bioterrorist Attack.
TSICP Attendees 213 .5 1.4 12.7 85.4
Ben Taub MDs 61 1.6 0 29.0 69.4

Government
Buildings Ben Taub RNs 229 .4 2.2 21.0 76.4
LBJ RNs 131 .8 1.5 16.8 80.9
Public 265 .4 1.9 10.9 86.9
TSICP Attendees 212 3.8 11.3 32.5 52.4
Ben Taub MDs 61 3.3 29.5 41.0 26.2

Educational
Institutions Ben Taub RNs 230 2.6 20.9 36.1 40.4
LBJ RNs 131 3.1 6.1 47.3 43.5
Public 264 6.4 18.4 27.7 47.6
TSICP Attendees 213 .9 5.6 31.5 61.5
Ben Taub MDs 61 4.8 14.5 40.3 40.3

Law
Enforcement
Buildings Ben Taub RNs 224 3.1 9.4 34.4 53.1
LBJ RNs 131 2.3 5.3 32.8 59.5
Public 265 3.4 8.2 21.3 67.0
TSICP Attendees 212 2.4 13.2 34.0 50.5
Ben Taub MDs 61 9.7 21.0 37.1 32.3

Hospitals and
other Medical Ben Taub RNs 224 2.2 12.5 29.9 55.4
Facilities
LBJ RNs 131 2.3 15.3 39.7 42.7
Public 265 8.6 14.3 27.1 50.0

131
Table 6.18 Beliefs Regarding Agency Preparedness for an Attack within One Year.
PLACES GROUP
NOT VERY SOMEWHAT SOMEWHAT VERY
N
LIKLEY UNLIKELY LIKLEY LIKELY
TSICP Attendees 209 6.7 21.5 56.9 14.8
Ben Taub MDs 60 25.0 33.3 35.0 6.7

Local Law
Enforcement Ben Taub RNs 215 12.1 15.3 54.0 18.6
LBJ RNs 130 5.4 17.7 73.8 3.1
Public 263 17.1 11.8 51.3 19.8
TSICP Attendees 210 3.8 16.2 61.4 18.6
Ben Taub MDs 60 11.7 25.0 48.3 15.0

Local Healthcare
Facilities Ben Taub RNs 219 5.9 12.8 52.1 29.2
LBJ RNs 130 4.6 15.4 70.0 10.0
Public 263 12.2 11.4 54.4 22.1
TSICP Attendees 208 1.4 8.2 57.2 33.2
Ben Taub MDs 61 14.8 27.9 42.6 14.8

Federal
Emergency
Management Ben Taub RNs 218 34.8 39.4 16.3 9.5
Agencies
LBJ RNs 130 5.4 13.1 64.6 16.9
Public 263 9.9 16.7 48.7 24.7
TSICP Attendees 210 1.9 11.0 61.9 25.2
Ben Taub MDs 61 16.4 34.4 44.3 4.9

Your State
Government Ben Taub RNs 217 8.8 10.6 61.3 19.4
LBJ RNs 130 3.1 20.0 72.3 4.6
Public 263 8.7 21.3 49.0 20.9
TSICP Attendees 209 7.2 23.9 52.6 16.3
Ben Taub MDs 61 16.4 39.3 39.3 4.9

Your Local
Government Ben Taub RNs 217 10.1 14.7 57.1 18.0
LBJ RNs 130 4.6 22.3 70.0 3.1
Public 263 15.2 17.9 47.9 19.0

132
Table 6.19 Preparedness Beliefs Regarding an Attack within One Year.
PLACES GROUP
NOT SOMEWHAT SOMEWHAT VERY
N VERY
UNLIKELY LIKLEY LIKELY
LIKLEY
TSICP Attendees 209 14.8 39.2 39.7 6.2
Ben Taub MDs 61 16.4 55.7 23.0 4.9

Educational
Institutions Ben Taub RNs 218 6.0 25.2 56.9 11.9
LBJ RNs 130 10.0 30.0 56.9 3.1
Public 263 17.1 44.5 23.2 15.2
TSICP Attendees 209 3.3 15.8 52.6 28.2
Non- Ben Taub MDs 61 13.1 18.0 47.5 21.3

governmental
Preparedness Ben Taub RNs 217 4.6 12.4 52.5 30.4
Organizations
LBJ RNs 129 4.7 17.8 58.9 18.6
Public 260 13.5 12.3 43.5 30.8
TSICP Attendees 210 34.3 44.3 16.7 4.8
Ben Taub MDs 61 57.4 21.3 18.0 3.3

Neighborhood
Associations Ben Taub RNs 216 19.9 35.2 40.7 4.2
LBJ RNs 130 26.9 32.3 35.4 5.4
Public 255 51.0 27.8 19.6 1.6
TSICP Attendees 207 55.1 29.5 10.6 4.8
Ben Taub MDs 61 55.1 29.5 10.6 4.8

Individual
Households Ben Taub RNs 215 27.4 37.7 28.8 6.0
LBJ RNs 131 32.1 30.5 35.1 2.3
Public 262 57.6 20.6 19.8 1.9

133
Perceptions of Personal Vulnerability
Perceptions of vulnerability among respondents were established by a series of
questions that ranked perceived vulnerability to future bioterrorism occurrences for the
time periods of before and after the events of September 11, 2001. Perceptions of
vulnerability were assessed using a 1 to 11 Likert-scale ranging from ‘not at all likely’ (1)
to ‘extremely likely’ (11). The mid-range, or ‘50-50 chance’ of an attack was designated
by a 6 on the 11-point scale. It is important to mention that the values reported for the
time frame of before September 11, 2001 were reported at the same time as the post
September 11, 2001 data, and as such provide only an estimate from memory as opposed
to an actual before and after analysis.
Reported perceptions of personal vulnerability before and after the events of
September 11, 2001 are described in Table 6.20 according to three geographic scales.
The community level is interpreted as personal vulnerability and as such appears to be the
best measure of perceived risk. The sample of TSICP attendees had a mean perceived
community vulnerability of 6.5 on the 11-point scale. The Ben Taub MDs had the lowest
mean levels of perceived community vulnerability with a mean level of 5.8, which ranks
just under the mid-range or ‘50-50 chance’ value. Ben Taub RNs had a higher level of
perceived community vulnerability of 6.5. LBJ RNs had the highest perceptual level of
all groups, with a mean of 7.3. The sample from the public had the lowest levels of
perceived community vulnerability to future bioterrorism occurrences.

134
Table 6.20 Perceived Vulnerability to Future Bioterrorism Pre and Post 9-11-01.
Time Frame: Time Frame:

Before After
September 11, 2001 September 11, 2001
Question Group N Mean Mean
TSICP Attendee 216 4.6 9.0

Perceived Likelihood of
a Bioterrorism Attack Ben Taub MDs 61 4.6 7.9
Anywhere in the US
(PRIORVUS)
(POSTVUS) LBJ RNs 133 4.6 8.8
Public 265 4.9 8.8

Anywhere in the State of
Texas Ben Taub RNs 230 4.2 6.9
(PRIORVTX)
(POSTVTX) LBJ RNs 133 4.6 8.1
Public 265 3.8 7.9

Anywhere in the
Respondent’s
Community Ben Taub RNs 231 3.4 6.5
(PRIORVCOM) LBJ RNs 133 3.7 7.3
(POSTVCOM)
Public 265 2.3 4.9
The receiver characteristic data from this section are summarized in the following
table (Table 6.21). The column titled ‘questionnaire crosswalk’ lists the question number
from the questionnaire utilized by the HCHD clinicians.

135
Table 6.21 Receiver Characteristics (Beliefs and Perceptions).
TYPE OF QUESTIONNAIRE ROLE OF THE

# QUESTION SUMMARY VARIABLE NAME
VARIABLE CROSSWALK VARIABLE
1. P r i o r t o 9 -1 1 , p e r c e p t i o n o f Des c ript ive

In t erv al PRI OR V US Q.9
v u l n e rab i l i t y f o r T X Onl y
2. P r i o r t o 9 -1 1 , p e r c e p t i o n o f Des c ript ive

In t erv al PRI OR V TX Q.1 0
v u l n e rab i l i t y f o r T X Onl y
3. Prior to 9 -11, percep tion of l o cal Des c ript ive

In t erv al PRI OR VC O M Q.1 1
v u l n e rab i l i t y Onl y
4. P o s t 9 -1 1 , p e r c e p t i o n o f v u l n e ra b i l i t y Des c ript ive

Int erv al PO ST V US Q.12
f o r US Onl y
5. P o s t 9 -1 1 , p e r c e p t i o n o f v u l n e ra b i l i t y
In t erv al PO ST V TX Q.1 3 Ind ep en de nt
for TX
6. P o s t 9 -1 1 , p e r c e p t i o n o f l o c a l
Int erv al PO ST VC O M Q.14 Dep enden t
v u l n e rab i l i t y
7. Pe rc eiv ed cu rr ent ch anc es of a tta ck CH AN US , Not used -

Q .1 5 , Q .1 6 ,
in th e U S, TX , an d lo c al a re a Ord ina l CHANTEX, and data quality
a n d Q .1 7
CH ANC O M p ro b l e ms
8. P e rc e i v ed t h r e a t f ro m v a rio u s AN T HR AX Q.18 a
Biological agents TO X IN S Q .1 8 b
HE M MR A GE Q.18 c
Ord ina l Des c ript ive
EC OL I Q .1 8 d
SM A L LO X Q.18 e
OT H ER Q .1 8 f
9. Pe rc eiv ed thr e at f o r: S mal l to L IK E LR G Q.19 a De pe nd en t

M e d iu m C i t y , R u r a l A r e a , L IK E MD M Q .1 9 b Des c ript ive
Gove rn men t A g enci es , Edu ca tiona l L IK ER UR L Q.19 c Des c ript ive
Ord ina l
In st itu t io n s , L a w En f o rc e men t , L IK E GO V T Q .1 9 d Des c ript ive
L IK E ED UC Q.19 e Des c ript ive
L IK E LE Q .1 9 f Des c ript ive
10. Bel ief in ea r l y ident if ic at ion when NO NS P EC ID *

In t erv al Q. 20 Ind ep en de nt
s y mp t o ms a re n o n -s p e c i f i c
11. Bel ief tha t sur v eil lan ce w il l provid e ER LY D E T *

In t erv al Q.21 Ind ep en de nt
ea rl y id entif ic a tion
12. Bel ief tha t b iot er ro ris m w il l b e DI S TT RE N D *

In t erv al Q.22 Ind ep en de nt
d i s t i n g u i s h a b le f ro m o rd i n a r y t r e n d s
13. Bel ief s in P rep ar ednes s, du rin g a LO CA L L E Q. 25a Des c ript ive
potent ia l att ac k w ithin th ei r l o cal LO CH F Q. 25b Des c ript ive
co mmu n it y in t h e n ext ye ar FE DA G NC Q. 25c Des c ript ive
ST A TE G OV Q. 25d Des c ript ive
Ord ina l LO C G O V Q. 25e Des c ript ive
ED U IN S TI T Q. 25f Des c ript ive
NO NG O VE M R Q. 25g Des c ript ive
NE I GH AS S N Q. 25h Des c ript ive
IN D HO US E Q. 25i Des c ript ive

136
Following the establishment of respondent receiver characteristics, an
investigation of message characteristics provided insight into the type, source, and
frequency of previous bioterrorism training and education received by respondents.
The description of message characteristics begins with establishing the frequency of
formal bioterrorism training among the previously trained.
Frequency of Previous Bioterrorism Training
Healthcare workers might obtain formal training for bioterrorism on multiple
occasions and from a variety of sources. The receiver characteristic of previous
bioterrorism training was earlier quantified through a dichotomous variable, but this
section establishes the actual frequency of exposures to formal training among the
members of the sample groups who reported formal training.
Table 6.22 describes the frequency of formal bioterrorism training. Of the 112
TSICP attendees who reported previous training, the mean training frequency was 1.50
with a range of 1 to 4. Out of the 17 Ben Taub MDs who reported previous training, the
mean training frequency was 1.76 with a range of 1 to 5. Out of the 193 Ben Taub RNs
who reported previous bioterrorism training, the mean training frequency was 1.69 with a
range of 1 to 10. The LBJ RNs reported the highest frequency of training of any sample
group, with a mean frequency of 2.14 and a range of 1 to 5. Fifty-five members of the
public reported previous bioterrorism training at a mean frequency of 1.70 with a range
of 1 to 10.
137
Table 6.22 Formal Bioterrorism Training Frequency.
GROUP (FREQNCY) N MEAN FREQUENCY RANGE
TSICP attendees 112 1.50 1 to 4
Ben Taub MDs 17 1.76 1 to 5
Ben Taub RNs 193 1.69 1 to 10
LBJ RNs 114 2.14 1 to 5
Public 55 1.70 1 to 10
Sources of Formal Bioterrorism Training
This section describes the formal source of bioterrorism training through which
the behavioral process of hearing occurred. Within the healthcare environment there are
a variety of formal sources through which individuals may receive bioterrorism training.
General categories were listed on the questionnaire to facilitate completion of the
questionnaire and to decrease the need to write. It is important to state that because some
respondents reported multiple previous training opportunities, multiple sources were
reported and because of this, responses per training category are greater than 100 percent
for each sample group as described in Table 6.23.
Training sources were grouped into broad categories to facilitate analysis. The
source categories of mandatory employee disaster training that covered the topic of
bioterrorism readiness and general bioterrorism training were highly associated. These
two sources were grouped into one category due to their similarity and were classified as
a bioterrorism training course (TRAIN1). Interagency disaster planning and disaster
planning meetings were also grouped due to their high level of association that identified
138
their similar nature and classified as disaster planning group training (TRAIN2).
Bioterrorism training from a conference was categorized as a separate variable
(TRAIN3). Bioterrorism training from work meetings were categorized as (TRAIN4).
Respondents who indicated they received training through self-study or from personal
reading were identified in the source category of reading and self learning (TRAIN5).
Respondents who indicated an internet-based source of training were categorized as
having received training through internet-based sources (TRAIN6). Continuing
education requirements, often dictated by professional license requirements are typically
provided by professional organizations (TRAIN7).
Statistically significant differences in source of formal training existed for certain
sources (Table 6.23). Bioterrorism training courses (TRAIN1), disaster planning groups
(TRAIN2), and conferences (TRAIN3) exhibited group differences. Work meetings
(TRAIN4) exhibited sample group utilization differences between the tested sample
groups. The Ben Taub MDs were excluded from the chi-square test because there were
too few cases. The remaining three source categories were not analyzed because they
were utilized too infrequently by the three samples of clinicians to meet the minimum
requirements for a chi-square test.
Among the 112 TSICP attendees, bioterrorism training courses represented the
most frequently reported source, accounting for 43 percent of responses. The second
most frequent source was provided by disaster planning groups which consisted of 25
percent of the responses. Conferences were the third most frequent category and
accounted for 14 percent of the previous training. The previous training from the source
of professional organizations accounted for 11 percent of responses.

139
Of the 61 Ben Taub MD respondents, 17 reported formal bioterrorism training.
Conferences accounted for the largest percentage of training source categories at 47
percent. Formal bioterrorism training courses proved the second most common source
category and they accounted for 35 percent of responses. The third most frequent
category was training through professional organizations as indicated by 12 percent of
respondents.
Of the 193 trained Ben Taub RNs, 80 percent reported a bioterrorism training
courses as their source of previous training. Work meetings were the second most
frequently reported source category, but accounted for only a small segment (8 percent)
of the total responses. Of the 115 LBJ RNs who reported previous training, 90 percent
reported attending a formal bioterrorism training course. Similar to Ben Taub RNs, this
was the most widely reported previous training source. Conferences were the second
most frequent source category, but accounted for only 14 percent of respondents.
Disaster planning groups were the third most common source category and accounted for
a small (7 percent) number of responses.
Bioterrorism training through professional organizations exhibited higher levels
among the TSICP attendees and the Ben Taub MDs than either group of RNs. Disaster
planning groups and the internet-based sources displayed similar patterns as professional
organizations, which demonstrated higher levels among TSICP attendees and low levels
among HCHD clinicians and the public. Reading and self learning levels were slightly
higher among TSICP attendees and Ben Taub MDs than Ben Taub or LBJ RNs, though
few respondents from any of the sample groups reported this source.
140
Only 21 percent of the public reported formal training for bioterrorism. Of those
reporting training, greater than half (60 percent) reported training from a bioterrorism
training course. The two samples of RNs reported greater levels of training from formal
bioterrorism training courses, but these numbers may reflect lower standards for what
defines actual bioterrorism training among the public. Work meetings were the second
most frequent source category and accounted for 26 percent of responses. It is important
to mention that some respondents reported multiple exposures to formal training which
resulted in source categories that were greater than 100 percent for each sample group.
Table 6.23 Reported Training Sources Among Trained Respondents.
Percentage by Sample Group
Bioterrorism Disaster Internet- Professional

Work Reading and
Training Planning Conferences based Organization
GROUP Meetings Self learning
Course Groups (TRAIN3) information Training
(TRAIN4) (TRAIN5)
(TRAIN1) (TRAIN2) (TRAIN6) (TRAIN7)
TSICP
ATTENDEES 43 25 14 9 5 6 11
N = 114
BEN TAUB
MDS N = 35 6 47 6 6 0 12
17
BEN TAUB
RNS N = 80 6 5 8 0 0 2
192
LBJ RNS
90 7 14 3 0 1 0
N = 114
PUBLIC N =
60 11 2 26 4 4 9
57
Chi-sq.=
CHI Chi-sq.= Chi-sq.= Chi-sq.= 3.4
276.7 66.4 44.1 df = 4
SQUARE df = 4 df = 4 df = 4 Not sig.
*2 *2 *2
TEST p < 0.01 p < 0.01 p < 0.01 (p = 0.49)
*1
(*1) not enough cases to include Ben Taub MDs

(*2) not enough cases to include Ben Taub MDs, Ben Taub RNs and LBJ RNs
141
Sources of Informal Bioterrorism Training
The questionnaire provided measures of the various sources of informal
information obtained by respondents. It should be noted that the version of the
questionnaire utilized by the TSICP attendees did not specifically list the source category
of internet-based information as did the newer version used by the medical staff which
might have resulted in the smaller number of responses (59). However, some of the data
was captured because the questionnaire contained an ‘other’ category where sources and
frequency of usage were listed.
Source utilization differences existed for all of the sample groups (Tables 6.24
and 6.25). The clinicians and the TSICP attendees reported utilizing broadcast media
somewhat frequently at a rate greater than 37 percent. While the public reported utilizing
broadcast media very frequently at a higher rate than any other sample group. Both
groups of RNs reported utilization of broadcast media very frequently by greater than 33
percent of respondents. Printed media were utilized more frequently by TSICP attendees
and Ben Taub RNs and somewhat less frequently by Ben Taub MDs and LBJ RNs.
Approximately 44 percent of the TSICP attendees utilized internet-based sources
very frequently and 41 percent utilized internet-based sources somewhat frequently. This
compares to Ben Taub MDs who reported 14 percent utilized internet-based sources very
frequently and 44 percent somewhat frequently. The Ben Taub RNs had 18.2 percent
reporting internet-based sources very frequently and 40.6 percent reporting somewhat
frequently. The LBJ RNs utilized internet-based sources less frequently than Ben Taub
RNs. More TSICP attendees utilized books very or somewhat frequently than other
groups. The Ben Taub MDs utilized books less frequently than any other sample group.
142
Table 6.24 Informal Sources of Information (1).

INFORMAL
SOURCE GROUP N
DO NOT NOT VERY SOMEWHAT VERY
USE FREQUENTLY FREQUENTLY FREQUENTLY
TSICP Attendees 195 15.4 26.7 37.4 20.5
Ben Taub MDs 55 10.9 23.6 47.3 18.2

Broadcast
media Ben Taub RNs 223 4.5 16.3 46.0 33.2
(INFMED)
LBJ RNs 119 15.1 11.8 36.1 37.0
Public 263 7.6 8.4 35.6 48.4
Chi-square statistic = 69.5 df = 12 p < 0.01
TSICP Attendees 200 4.0 18.5 51.5 26.0
Ben Taub MDs 54 9.3 37.0 42.6 11.1

Print Media
(INFPRINT) Ben Taub RNs 223 3.7 14.8 52.4 29.1
LBJ RNs 116 13.8 19.8 47.4 19.0
Public 262 10.6 18.8 46.5 24.1
TSICP Attendees 59 6.8 8.5 40.7 44.1
Ben Taub MDs 55 22.0 20.0 44.0 14.0

Internet-Based
Information Ben Taub RNs 223 14.5 26.7 40.6 18.2
(INFINT)
LBJ RNs 111 27.7 27.7 30.7 13.9
Public 262 23.5 25.6 22.3 28.6
TSICP Attendees 175 12.6 26.2 38.3 22.9
Ben Taub MDs 53 69.8 16.3 4.7 9.3

Books
(INFBOOKS) Ben Taub RNs 223 24.3 29.7 31.1 14.9
LBJ RNs 114 43.6 28.7 22.3 5.3
Public 263 42.0 35.3 17.9 4.9

143
The remaining sources of informal sources of information are described in. The
majority of TSICP attendees obtained informal information about bioterrorism from
meetings at work very frequently or somewhat frequently, while the majority of Ben
Taub MDs did not (Table 6.25). Ben Taub RNs and LBJ RNs utilized meetings less
frequently than the TSICP attendees, but more than Ben Taub MDs. The majority of all
sample groups did not utilize conversations with co-workers either somewhat or very
frequently. Greater than 25 percent of Ben Taub MDs did not obtain any information
from conversations at work while 42 percent reported it as a not very frequent source.
Greater than 54 percent of Ben Taub RNs and greater than 27 percent of LBJ RNs
reported conversations at work somewhat frequently as a source of information.
Conversations with friends and family were not utilized by almost half of the TSICP
attendees. The two samples of RNs and the Ben Taub MDs reported low levels of the
friends and family source, but more than the TSICP attendees. Very few respondents
reported information from ‘other’ sources.
Message Credibility
The questionnaire assessed perceived credibility of the trainer from the most
recent formal training through 3-point scale where a value of 0 identified a response of
‘not credible’. A value of 1 identified the trainer as ‘somewhat credible.’ A value of 2
identified a ‘credible’ trainer.’ This question was added to the questionnaire after most of
the TSICP attendees data had been collected, the sample size reflects the respondents
from the year 2006 only.

144
Table 6.25 Usage of Informal Sources of Information (2).

INFORMAL
SOURCE GROUP N
DO NOT NOT VERY SOMEWHAT VERY
USE FREQUENTLY FREQUENTLY
FREQUENTLY
TSICP Attendees 197 4.6 18.8 44.7 32.0
Ben Taub MDs 53 42.9 40.5 16.7 0

Meetings
(INFMEET) Ben Taub RNs 223 5.6 24.1 43.8 26.5
LBJ RNs 120 13.6 35.5 35.5 15.5
Public 264 47.6 21.6 22.5 8.4
TSICP Attendees 194 13.0 38.6 39.1 9.2
Ben Taub MDs 56 25.6 41.9 23.3 9.3

Talk with co-
workers Ben Taub RNs 223 14.5 24.5 54.1 6.9
(INFWKTK)
LBJ RNs 118 22.4 36.7 27.6 13.3
Public 262 36.7 30.5 19.0 13.7
TSICP Attendees 172 48.8 36.6 12.2 2.3
Ben Taub MDs 45 35.6 33.3 28.9 2.2

Talk with
friends and
family Ben Taub RNs 220 28.4 38.5 27.0 6.1
(INFFANDF)
LBJ RNs 105 50.5 25.3 15.8 8.4
Public 262 25.6 32.6 27.8 14.1
TSICP Attendees 47 4.3 21.3 * 74.5
Ben Taub MDs 1 * * 100

Other sources
(INFOTH) Ben Taub RNs 1 * * * 100
LBJ RNs 6 66.7 33.3 * *
Public 2 50 50 * *
(*) Indicates zero responses.

145
Of the 16 Ben Taub MDs who reported formal training, more than 2 out of 3
believed their training source was credible (Table 6.26). None of the Ben Taub MDs
reported that their training source was not credible. Greater than 80 percent of the 179
Ben Taub RNs who reported previous training classified their formal training source as
credible. Approximately 3 out of 4 of the 111 trained LBJ RNs reported a credible
formal source. Only a few respondents from the two samples of RNs considered their
trainer not credible.
Table 6.26 Perceived Credibility of Formal Training.
GROUP (CREDIBLE) N CREDIBLE SOMEWHAT NOT-

CREDIBLE CREDIBLE
TSICP Attendees 29 a 72.4 20.7 6.9
Ben Taub MDs 16 b 68.8 31.3 0
Ben Taub RNs 179 81 14 5
LBJ RNs 111 73 21.6 5.4
Public 52 b 82.7 17.3 0
a Credibility of formal training was not asked of 83% of the TSICP attendees
b Small sample size reflects the high percentages of the untrained
The findings of reliability for the individual sources of information are included in
Tables 6.27 and 6.28. The majority of the TSICP attendees and the Ben Taub MDs,
considered broadcast media to be somewhat reliable while less than 25 percent
considered it to be a very reliable or an excellent source. Greater than half of the Ben
Taub and LBJ RNs considered broadcast media to be very reliable or an excellent source
of information. Printed media was considered somewhat reliable or very reliable by most
Ben Taub MDs and TSICP attendees. Book media was considered somewhat or very
reliable among most respondents. Thirty percent of the Ben Taub RNs and 20 percent of
146
the LBJ RNs considered book media an excellent source of information. Greater than
half of the TSICP attendees considered books very reliable or an excellent source.
Table 6.27 Reliability of Informal Sources of Information by Percentage (1).
INFORMAL WOULD SOMEWHAT VERY EXCELLENT

SOURCE GROUP N NEVER
RELIABLE RELIABLE SOURCE
RELY ON
TSICP Attendees 191 23.6 56.5 14.1 5.8
Ben Taub MDs 58 20.7 60.3 15.5 3.4

Credibility of
broadcast media Ben Taub RNs 198 5.1 37.9 34.8 22.2
(RELMED)
LBJ RNs 126 3.2 39.7 35.7 21.4
Public 245 5.7 33.1 40.4 20.8
TSICP Attendees 191 7.3 55.5 28.3 8.9
Ben Taub MDs 55 3.6 72.7 20.0 3.6

Credibility of print
(RELPRINT)
LBJ RNs 119 .8 30.3 45.4 23.5
Public 248 1.3 36.0 47.5 15.3
TSICP Attendees 172 4.7 28.5 46.5 20.3
Ben Taub MDs 56 10.4 54.2 25.0 10.4

Credibility of book
(RELBOOK)
LBJ RNs 111 5.9 45.5 28.7 19.8
Public 249 10.2 49.3 26.0 14.4
Ben Taub MDs considered work meetings to be a less reliable source of
information than either sample of RNs. Greater than half of the TSICP attendees, Ben
Taub RNs, and LBJ RNs stated that work meetings were either very reliable or an
excellent source. Conversations with coworkers were considered very reliable sources by
a higher percentage of TSICP attendees and Ben Taub RNs than other groups. The
147
TSICP attendees considered internet-based sources more reliable than other groups. Ben
Taub MDs thought that internet-based sources were less reliable than other groups. Few
respondents considered conversations with friends and family very reliable or excellent
sources, but the public thought somewhat more highly of this source than others.
Table 6.28 Reliability of Informal Sources of Information by Percentage (2).
WOULD NEVER SOMEWHAT EXCELLENT

INFORMAL SOURCE GROUP N VERY RELIABLE
RELY ON RELIABLE SOURCE
TSICP
192 6.8 22.9 42.2 28.1
Attendees
Ben Taub MDs 55 15.2 41.3 30.4 13.0

Credibility of
work meetings
(RELWKMT) Ben Taub RNs 180 3.9 25.0 43.3 27.8
LBJ RNs 113 1.8 17.7 48.7 31.9
Public 240 22.3 28.7 40.1 8.9
TSICP
181 19.3 47.0 28.7 5.0
Attendees
Credibility of Ben Taub MDs 53 46.5 39.5 14.0 0

conversations
with co-workers Ben Taub RNs 167 16.8 49.1 24.6 9.6
(RELWKTK)
LBJ RNs 106 25.5 51.9 12.3 10.4
Public 240 28.2 49.3 14.1 8.4
TSICP
86 2.3 16.3 47.7 33.7
Attendees
Credibility of Ben Taub MDs 52 13.5 67.3 15.4 3.8

internet-based
information Ben Taub RNs 183 8.2 29.5 41.0 21.3
(RELINT)
LBJ RNs 127 14.0 38.3 33.6 14.0
Public 245 19.7 41.0 22.6 16.7
TSICP
168 52.4 41.1 4.8 1.8
Attendees
Credibility of Ben Taub MDs 54 40.9 54.5 4.5 0

friends and
family Ben Taub RNs 162 29.6 52.5 13.6 4.3
(RELFANDF)
LBJ RNs 112 34.3 52.9 10.8 2.0
Public 240 24.5 40.0 25.9 9.5

148
The message characteristics are summarized in Table 6.29 and 6.30. The
summary includes a crosswalk reference to the individual questions from the
questionnaire according to the HCHD clinician version.
Table 6.29 Message Characteristics (1).
QUESTION TYPE OF VARIABLE QUESTIONNAIRE ROLE OF THE

#
SUMMARY VARIABLE NAME CROSSWALK VARIABLE
1. Frequency of training Ratio FREQNCY Q.3 a Independent
2a. Source of formal Independent

TRAIN1- 7 Q. 4
training:
2b. Mandatory disaster Independent

and general Dichotomous TRAIN1 Q. 4
bioterrorism training
2c. Interagency and Independent

disaster planning Dichotomous TRAIN2 Q. 4
meetings
2d. Conferences Dichotomous TRAIN3 Q. 4 Independent
2e. Work or unit Independent

Dichotomous TRAIN4 Q. 4
meetings
2f. Reading or self-study Dichotomous TRAIN5 Q. 4 Independent
2g. Internet-based Dichotomous TRAIN6 Q. 4 Independent
2h. continuing education Dichotomous TRAIN7 Q. 4 Independent
2i. TRAIN5 to 7 Independent

Dichotomous TRAING Q.4
(Collapsed categories)
3a. Formal training Q.5 Independent

Ordinal CREDIBL*
source credibility
3b. Recode of CREDIBL Independent

(collapsed somewhat
credible and not Dichotomous NEWCRED* Q.5 (recoded)
credible into one
category)

149
Table 6.30 Message Characteristics (2).
# QUESTION TYPE OF VARIABLE QUESTIONNAIRE ROLE OF THE

4a. Informal Sources of Independent

Q.6.
information:
4b. Broadcast media Dichotomous INFMED Q.6. Independent
4c. Print media Dichotomous INFPRINT Q.6. Independent
4d. Internet-based Dichotomous INFINT Q.6. Independent
4e. Books Dichotomous INFBOOK Q.6. Independent
4f. Meetings at work Dichotomous INFMEET Q.6. Independent
4g. Conversations with INFWKTK Independent

Dichotomous Q.6.
co-workers
4h. Friends and family Dichotomous INFFANDF Q.6. Independent
5a. Informal source Ordinal (4-point Independent

REL___ Q.8
credibility: scale)
5b. Recoded informal Independent

Four categories
source credibility = (REL___C) Q.8 (recoded)
collapsed to two
(variable)
5c. Credibility of RELMED Independent

Dichotomous Q.8
broadcast media (RELMEDC)
5d. Credibility of print RELPRINT Independent

Dichotomous Q.8
media (RELPRINTC)
5e. Credibility of book RELBOOK Independent

Dichotomous Q.8
media (RELBOOKC)
5f. Credibility of RELCONF Independent

Dichotomous Q.8
conference (RELCONFC)
5g. Credibility of work RELWKMT Independent

Dichotomous Q.8
meetings (RELWKMETC)
5h. Credibility of Independent

RELWKTK
conversations with Dichotomous Q.8
(RELWKTKC)
co-workers
5i. Credibility of Independent

RELINT
internet –based Dichotomous Q.8
(RELINTC)
information
5j. Credibility of friends RELFANDF Independent

Dichotomous Q.8
and family (RELFANDFC)
5k. Recode (grouped

RELFANDFC,
Dichotomous RELCG Q.8 Independent
RELBOOKC and
RELWKTKC)

150
Statistical Processing
This section addresses the data processing considerations prior to testing the
influence of message and receiver characteristics on the behavioral stages in later
chapters. Several variables had categories with low numbers of responses. To facilitate
statistical analysis among the three groups of clinicians, categories with low values were
collapsed.
The sources of reading and self-study (TRAIN5), internet-based information, and
continuing education through professional organizations (TRAIN7) were rarely reported
among any of the HCHD clinicians. These infrequent categories were grouped together
into one composite variable (TRAING). The results for previous training that include the
collapsed categories are listed in Table 6.31. It is important to note that some
respondents reported multiple exposures to formal training and because of this, responses
per training category are greater than 100 percent for each group.
As mentioned in Chapter Five, the respondents who did not receive formal
training would have been excluded from regression analysis without special processing of
the non responses. When the sources of formal training are utilized as independent
variables, non responses from those that did not receive formal training were coded as
‘did not use.’ This procedure does not exclude the untrained from statistical analysis and
reflects the responses that were provided. The full sample size that included any blank
responses from the trained are included in parentheses below and reflects the sample size
utilized during analysis.

151
Table 6.31 Collapsed Training Source Categories.
BIOTERRORISM DISASTER
TRAINING PLANNING CONFERENCES WORK COLLAPSED
GROUP (TRAIN3) MEETINGS OTHER
COURSE GROUPS
(TRAIN1) (TRAIN2) (TRAIN4) (TRAING)
TSICP Attendees 43 25 14 9 16
(N = 114)
Ben Taub
MDs (N = 17) 35 6 47 6 18
Ben Taub
RNs (N = 192) 80 6 5 8 2
LBJ RNs
90 7 14 3 1
(N = 114)
Public (N = 57) 60 11 2 26 9
The category of ethnicity was collapsed to remove categories with too few
members. Respondents reporting the ethnicities of Native American, Pacific Islander, or
‘other’ were grouped together and categorized as ‘other’. The description of ethnicity
that includes the composite category is listed in Table 6.32.
Table 6.32 Collapsed Ethnicity Categories.
Percentage by Sample Group
Group N Asian African White-

American Hispanic Other
American Anglo
TSICP Attendees 206 1.0 3.4 13.1 78.6 3.9
Ben Taub MDs 59 22.0 16.9 6.8 49.2 22.0
Ben Taub RNs 223 35.0 22.0 3.6 26.0 13.5
LBJ RNs 120 22.5 37.5 5.8 26.7 7.5
Public 262 .4 16.0 19.1 61.5 3.1

152
Credibility of informal sources were collapsed and dichotomized because
responses in some of the categories were too few. The two lower categories were
categorized as ‘less than credible’ and coded as a 0. The two higher categories were
categorized as ‘more credible’ and coded as a 1. The results for the dichotomized
credibility of informal source variable are listed in Tables 6.33 and 6.34 below.
Table 6.33 Dichotomized Percentage Credibility of Informal Sources (1).
INFORMAL GROUP N LESS MORE

SOURCE CREDIBLE CREDIBLE

Credibility of
broadcast media Ben Taub RNs 198 42.9 57.1
(RELMEDC)
LBJ RNs 126 42.9 57.1
Public 245 38.8 61.2

Credibility of print
media Ben Taub RNs 168 32.1 67.9
(RELPRINTC)
LBJ RNs 92 44.6 55.4
Public 248 51.1 48.9

Credibility of book
media Ben Taub RNs 164 45.7 54.3
(RELBOOKC)
LBJ RNs 111 51.5 48.5
Public 249 59.5 40.5

Credibility of work
meetings Ben Taub RNs 180 28.9 71.1
(RELWKMTC)
LBJ RNs 113 19.5 80.5
Public 240 51.0 49.0

153
Table 6.34 Dichotomized Percentage Credibility of Informal Sources (2).
INFORMAL GROUP N LESS MORE

SOURCE CREDIBLE CREDIBLE

Credibility of
work meetings Ben Taub RNs 180 28.9 71.1
(RELWKMTC)
LBJ RNs 113 19.5 80.5
Public 240 51.0 49.0

Credibility of
conversations at
work Ben Taub RNs 167 65.9 34.1
(RELWKTKC)
LBJ RNs 106 77.4 22.6
Public 240 77.5 22.5

Credibility of
internet-based
sources Ben Taub RNs 183 32.1 67.9
(RELINTC)
LBJ RNs 92 44.6 55.4
Public 245 51.1 48.9

Credibility of
friends and
family Ben Taub RNs 162 82.1 17.9
(RELFANDFC)
LBJ RNs 102 82.1 17.9
Public 240 64.5 35.5
Processing of Independent Variables
Regressions of the model behavioral stages will be performed in the following
chapters for the three samples of clinicians. The array of receiver and message
characteristics that the model identifies must be tested through simple correlation tests to
154
prevent problems arising from multicolinearity. Spearman’s and chi-square tests
identified variables with an association to each other which would cause multicolinearity
during regressions. The associated variables were considered in the context of the model
and the variables that were the most directly related to the model or provided the most
valuable contribution were retained.
The following tables (6.35 through 6.38) list the independent variables that were
associated with each other for the three clinical sample groups. If an independent
variable was associated with another variable for only one or two of the clinical sample
groups, the sample groups for which the association existed are indicated in parenthesis,
otherwise the association existed for all three clinical sample groups.
The associated independent variables relating to experiential, occupational, and
demographic receiver characteristics are listed below (Table 6.35). Many of the potential
independent variables exhibiting association to each other were variables that in the
absence of simple correlation tests would have seemed likely candidates for association
to each other. For example, previous disaster experience was associated with the
variables that quantified disaster impacts. Age exhibited an association with many of the
variables and this seems reasonable since it is generally known that age influences many
aspects of human activity.
The beliefs and perceptions receiver characteristics that exhibit an association to
other variables are listed below in Table 6.36. Perception of vulnerability at the national
(U.S.) level is highly associated with perceptions of vulnerability at the state (Texas)
level. This finding likely exists because perceptions of vulnerability at the national level
include Texas and are co-measuring some of the same factors. Perception of
155
vulnerability at the state level appears to be the better perceived vulnerability measure to
retain for inclusion due to the fact that this case study occurs in the State of Texas and the
national level is probably too coarse a scale or too general to provide a direct contribution
to the analysis.
Table 6.35 Associated Receiver Characteristics (Experiential, Occupational, and Demographic).
# ASSOCIATED WITH
QUESTION SUMMARY
VARIABLE QUESTIONNAIRE
1 = LBJ RNs
NAME CROSSWALK
2 = BT RNs
3 = BT MDs
Length of JOBLNGTH Q.2 AGE, FREQNCY, TRAIN1 (3),

1.
employment TRAING (1,2)
Previous experience PREVEXP Q.23 TRAVEL,QOFLIFE (2, 3),

2. with disasters AGE, INFFANDF (2), TRAIN1
(2), RELPRINT (2)
Inability to travel or TRAVEL Q.24d PREVEXP (2), RELINTC (3)

3. commute due to
disaster
Quality of life QOFLIFE Q.24e PREVEXP (2,3)

4.
affected by disaster
Experience with false FALSEALM Q.26 NMBFALSE, AGE (3)

5.
alarms
Number of false NMBFALSE Q.26 FALSEALM

6.
alarms
Number of years of SCHOOL Q.27 AGE (1, 2)

schooling completed RELFANDF (1,2), POSTVTX
7.
(2), INFFANDF (2), TRAIN2
(1,2), INFMED (1)
Age AGE Q.28 JOBLNGTH, SCHOOL (1, 2)

PREVEXP, INFINT (2),
RELBOOKC(3),
8.
NMBFALE(3), INFMED (3),
TRAIN3 (3), TRAING (3),
FREQNCY (3)
156
The three questions that address beliefs in the current ability to identify
bioterrorism are associated with each other and are likely measuring the same basic
belief. Belief that identification will take place through public health surveillance
(ERLYDET) exhibited association to many other independent variables and will be
excluded from consideration. Belief in early identification when symptoms are non-
specific (NONSPECID) and beliefs that trends resulting from bioterrorism will be
distinguishable from natural trends (DISTTREND) are the two remaining beliefs
variables.
Table 6.36 Associated Receiver Characteristics (Beliefs and Perceptions).
ASSOCIATED WITH
QUESTION VARIABLE QUESTIONNAIRE
# 1 = LBJ RNs
SUMMARY NAME CROSSWALK
2 = BT RNs
3 = BT MDs
1. Post 9-11, perception POSTVUS Q.12 POSTVTX

of vulnerability for US
2. Post 9-11, perception POSTVTX Q.13 POSTVUS, ERLYDET (1, 2),

of vulnerability for TX TRAIN1 (1,2), SCHOOL (2)
3. Belief in early NONSPECID Q. 20 ERLYDET, DISTTREND

identification when
symptoms are non-
specific
4. Belief that surveillance ERLYDET Q.21 NONSPECID, RELINTC,

will provide early INFPRINT (1), INFINT (1),
identification INFWKTK(1, 2), POSTVTX (1,
2) , RELBOOKC(1), INFMED
(2), INFFANDF (2),
RELWKMT (2)
5. Belief that bioterrorism DISTTREND Q.22 ERLYDET, NONSPECID

will be distinguishable
from ordinary trends
157
Bioterrorism training courses were associated with frequency of previous training
(FREQNCY) as listed in Table 6.37. Increased levels of bioterrorism training probably
increased the likelihood that a respondent would have attended one of the mandatory
courses at HCHD that covered bioterrorism readiness. Frequency of training will not be
retained for the regression modeling as the source variables appear to provide a better
understanding of the risk communication process and provide an avenue for gauging the
influence of source throughout the risk communication process.
Several sources of informal information were also associated with bioterrorism
training courses. This might result from attending training and the identification of
trusted sources for additional information that were imparted during training.
Alternatively, most respondents reported high levels of informal information seeking and
the association between a bioterrorism training course might simply result from high
levels of information seeking behavior that occur in the period of increased risk following
the events of September 11, 2001. Many of the variables for informal information
sources and the variables that rate reliability of informal sources of information were
associated with each other. These associations likely result from the individual questions
that asked respondents to provide reliability information for the sources they had utilized.
Many of the sources of informal information were associated with each other which
might indicate informal information seekers tend to utilize multiple sources.

158
Table 6.37 Associated Message Characteristics (1).
ASSOCIATED WITH
QUESTION VARIABLE QUESTIONNAIRE
# SUMMARY NAME CROSSWALK
1 = LBJ RNs
2 = BT RNs
3 = BT MDs
1. Frequency of FREQNCY Q.3 a TRAIN1, TRAIN2 (2), NEWCRED (3), AGE (3),
training JOBLNGTH , TRAING (2,3), RELWKMTC
2. Mandatory TRAIN1 Q.4

FREQNCY, TRAIN3 (1), TRAIN4 (3),
employee disaster
INFMEET, INFPRINT,LNGHTJOB (3),
training and
RELBOOKC (1), PREVEXP (2), INFPRINT (2),
general
POSTVTX (1, 2), INFMED (1,2), RELWKMTC
bioterrorism
(1,2)
training
3. Interagency TRAIN2 Q.4 RELMEDC (2, 3), FREQNCY (2), INFINT (1),
disaster planning INFMEET (1), SCHOOL (1,2), RELPRINT (1),
and disaster RELWKTK (1)
planning meetings
4. Conferences TRAIN3 Q.4 RELWKTKC, RELFANDFC (2), TRAIN4 (2,3),

INFMEET (2), AGE (3), TRAIN1 (1)
5. Work (or unit) TRAIN4 Q.4 TRAIN3 (2), INFINT (2), INFMEET (2), TRAIN1
meetings (3), TRAIN3 (2,3), AGE (3), POSTVTX (3)
6. Other (TRAIN 5 TRAING Q.4 NMBFALSE(1), AGE (3), FREQNCY (2, 3),
to 7 grouped) INFMED (3), RELPRINT (1), TRAIN1 (3),
RELWKMT (1), JOBLENGTH (1,2), , TRAIN1
(3)
7. Recode of NEWCRED Q.5 (recoded)

FREQNCY (3)
CREDIBL
8. Broadcast media INFMED Q.6 INFPRINT, INFWKTK (3), TRAIN1

(1,2),TRAING (3), INFBOOK (3), SCHOOL (1),
INFMED (3), RELPRINTC, RELINTC (3)
9. Print media INFPRINT Q.6 INFMED, INFWKTK, INFFANDF,RELMEDC,

RELPRINTC, TRAIN1 (2),
INFINT (3), ERLYDET (1), RELBOOKC (1),
RELWKMTC, RELWKTKC (1), RELFANDFC
10. Internet-based INFINT Q.6 RELWKMT (2),RELINTC (2), AGE (2),

sources INFBOOK (2) , INFFANDF(2), TRAIN2 (1),
INFPRINT (3), INFMEET, ERLYDET (1),
RELBOOKC (1), TRAIN2 (1), TRAIN4 (2)
11. Books INFBOOK Q.6 INFMED (3), INFINT (2), RELBOOKC (1,2)
159
Table 6.38 Associated Message Characteristics (2).
ASSOCIATED WITH
VARIABLE QUESTIONNAIRE
# QUESTION SUMMARY
NAME CROSSWALK
1 = LBJ RNs
2 = BT RNs
3 = BT MDs
12. Meetings at work INFMEET Q.6 TRAIN1, INFINT, RELMEDC, TRAIN2 (1),
TRAIN4 (2), TRAIN3 (2), RELWKMTC (2),
RELWKTKC (2)
13. Conversations with INFWKTK Q.6 INFMED (3) , INFPRINT, ERLYDET (1,2),
co-workers RELMEDC, RELWKTKC (2)
14. Friends and family INFFANDF Q.6 PREVEXP (2), RELFANDFC, INFINT (2),
SCHOOL (2), ERLYDET (2), INFPRINT
15. Credibility of RELMEDC Q.8 (recoded) INFMEET, INFWKTK, RELPRINTC,

broadcast media RELINTC, TRAIN2 , INFPRINT,
RELWKMTC (1)
16. Credibility of print RELPRINTC Q.8 (recoded) RELMEDC, RELINTC (2), INFPRINTC,
media INFMED, PREVEXP (3), RELBOOKC,
TRAIN2 (1), TRAING (1),
17. Credibility of book RELBOOKC Q.8 (recoded) RELPRINTC, RELMEDC, RELINTC,

media INFBOOK (1), INFINT (1), AGE (3),
ERLYDET (1), FREQNCY (1), RELPRINTC
(2), INFPRINT (1), TRAIN1 (1), RELBOOKC
18. Credibility of work RELWKMTC Q.8 (recoded) INFPRINT, RELWKTKC (3), RELINT (2),
meetings INFINT (2), INFMEET (2), TRAIN1 (1,2),
FREQNCY, RELMEDC (1), ERLYDET (2),
RELBOOKC, RELWKTKC, TRAING (1),
19. Credibility of RELWKTKC Q.8 (recoded) RELWKMTC, TRAIN3 (2), INFPRINT (1),
conversations with INFWKTK (2), INFMEET (2), TRAIN2 (1),
co-workers RELFANDFC (2)
20. Credibility of RELINTC Q.8 (recoded) RELPRINTC (2), TRAVEL (3), RELFANDF (3),
internet-based RELMEDC, INFMED (3), TRAVEL (3),
sources INFPRINT (2), RELBOOKC, RELWKMTC (2)
21. Credibility of RELFANDFC Q.8 (recoded) INFPRINT, TRAIN3 (2),

friends and family SCHOOL (1,2), RELWKTKC (2)
Each of the following five chapters investigates one of the model behavioral
stages and includes one final series of tests to identify variables to retain for inclusion in
the regression modeling of the behavioral stages. The decisions about which of the
remaining associated independent variables to retain in the regression model will be

160
reserved until simple correlation tests are performed against the dependent variable for
each behavioral stage as discussed in the following chapters.
Receiver Characteristics: Experiential, occupational, and demographic
Slightly more than 50 percent of the TSICP attendees reported having received
formal bioterrorism readiness training. Levels of training within the TSICP attendees
sample may be lower than the statewide population of ICPs because those who had
received previous bioterrorism training might consider themselves trained and not attend
additional bioterrorism training. Training requires investment of both employee time and
financial resources. Healthcare facilities are often understaffed and under funded, and
ICPs who had previously attended training may be deemed sufficiently trained by their
leadership, and denied approval to attend the TSICP bioterrorism training seminar. The
fact that the TSICP sample consists of those who were attending TSICP training, not an
actual sample of ICPs statewide, must always be considered when viewing these data.
The sample of Ben Taub MDs had only 27 percent of respondents with previous
formal bioterrorism training. The low levels of training among MDs illustrates that more
must be done to provide bioterrorism training to MDs. The two samples of RNs had
much higher levels of training than did the MDs. Previous bioterrorism training was
reported by 83 percent of Ben Taub RNs. The LBJ RNs reported the highest levels of
any group with 86 percent of LBJ RNs reporting previous training.
Levels of training and education among clinicians at HCHD provided a key into
understanding the degree of regional bioterrorism readiness as they were the group with
161
the most influence on early recognition of a bioterrorism occurrence. The previous
bioterrorism training among HCHD clinicians provided some feedback into regional
bioterrorism readiness levels within the Houston metropolitan area within Harris County,
Texas, as the greater the number of trained clinicians, the greater the chances that
clinicians might have the information they need to identify and investigate an unusual
trend in the critical early stages.
The members of the TSICP attendees’ sample reported lower levels of disaster
experience than the other sample groups. The TSICP attendees group consisted of TSICP
members from various urban and rural locations across the State of Texas. The sample
groups of HCHD clinicians as well as the public originated from within Harris County,
Texas. Geography may explain some of the identified differences in reported levels of
previous disaster experience as a variety of natural and technologic hazards may occur in
and around Harris County. A notable example of a recent hazard occurrence near Harris
County would be Hurricane Rita of September, 2005. Even though the hurricane did not
make landfall directly in Harris County, many residents experienced disaster conditions
involving food shortages, gasoline shortages, and power outages that lasted for several
days.
Experience with bioterrorism false alarms also varied by sample group. About 1
out of every 4 Ben Taub MDs and RNs reported experience with false alarms. Ben
Taub’s location within the Texas Medical Center, patient capacity, and trauma center
status likely draw patients who had encountered a substance thought to be a biological
agent. The LBJ RNs reported experience with false alarms at a rate of about 1 out of 10.
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Smaller in capacity and located outside of the Texas Medical Center, LBJ hospital did not
generate as much experience with false alarms among their RNs.
As expected, Ben Taub MDs reported the highest levels of education. Roughly 4
mean years lower than Ben Taub MDs, TSICP attendees reported the second highest
level of education. These higher levels of education found among TSICP attendees were
likely explained by their education relating to their infection control expertise. The Ben
Taub RNs exhibited slightly higher levels of education than the general public. It is
important to note that many RNs do not hold a bachelor’s degree. To become a
registered nurse, two different routes exist. The first route requires a two year associate’s
degree in nursing at an accredited nursing school. The second route requires a bachelors
of science in nursing. The two year option for obtaining a registered nurse license may
have contributed to the levels of education among the two samples of RNs.
The TSICP attendees’ sample reported just less than 8 mean years of employment
at their current jobs. Respondents from the TSICP attendees’ sample were in attendance
at a bioterrorism training seminar, so this sample may over-represent those with lower
lengths of time at their current occupation as it is possible that ICPs with greater lengths
of time at their occupations would have already received bioterrorism training and
therefore not attended. Ben Taub MDs reported a mean employment duration level of 5.6
years which was the lowest length of employment for any of the sample groups. This
finding seems appropriate as physicians that are fulfilling their residency requirements
provide much of the medical care at teaching hospitals such as Ben Taub, and the lower
length of employment might stem from higher proportions of recent medical school
graduates.
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Most of the TSICP attendees identified themselves as belonging to the white-
Anglo ethnic group. The second most frequent ethnic group among the TSICP attendees
were Hispanics. Almost half of the Ben Taub MDs identified themselves as white-
Anglo. The second most frequent group of Ben Taub MDs identified as Asian-
American. The third most frequent group identified themselves as African-American.
The most frequent ethnic category among Ben Taub RNs was Asian-American. White-
Anglo’s accounted for the second most frequent category, and African-Americans
accounted for the third most frequent category among the Ben Taub RN respondents.
African-Americans represented the largest ethnic category among LBJ RNs. The LBJ
RNs who identified as white-Anglo were the second most frequent category of
respondents. Asian-Americans were the third most common identified ethnic category.
The largest category within the public respondents identified as White-Anglo. Hispanics
and African-Americans were the second and third most frequent category among the
public sample.
The final established demographic variable was respondent age. Ben Taub MDs
were the youngest group, and as mentioned above, they are often recent medical school
graduates fulfilling residency requirements through Baylor College of Medicine.
Therefore, the younger age reflected in the Ben Taub MD sample may accurately reflect
the larger population of MDs at Ben Taub. The TSICP group represented the oldest
sample group with a larger range in age than any other group. The higher range of the
TSICP respondents resulted from the time required to obtain their level of infection
control specialization.
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Receiver Characteristics: Beliefs and perceptions
The Ben Taub MDs reported lower levels of belief in readiness, preparedness,
and the current ability to detect or identify bioterrorism than did the other sample groups.
The Ben Taub RNs reported the highest levels of belief in readiness and preparedness.
The LBJ RNs belief values ranked between Ben Taub MDs and Ben Taub RNs. The
public respondents were asked different questions than those employed within the
healthcare industry due to the expectation that the public would not be familiar with the
terminology; however, similar concepts were addressed. Overall the public respondents
reported higher levels of belief in the ability to detect and identify a bioterrorism
occurrence than other groups.
The anthrax attacks that followed September 11, 2001 were memorable events
with a lasting impact and the terrorist remain unidentified. Terror, deaths, injury, and
large financial consequences resulted from these events. Continuing media coverage and
the memorable impact of the story likely explain why anthrax ranked as the highest agent
of concern among all sample groups.
Ben Taub MDs had the lowest levels of belief in the likelihood of the various
bioterrorism agents. A possible explanation for the low levels of perceived agent risk
among Ben Taub MDs might be the generally low levels of formal training found among
Ben Taub MDs. Alternatively, their higher levels of education resulting from attendance
at medical school might have contributed to an increased threshold of expectation when
there is an absence of cues that a bioterrorist event is taking place. Therefore, these lower
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perceptual levels may possibly reflect caution towards seemingly rare events. Future
research could explore this issue further.
Perceived vulnerability at the community or local level provides valuable
feedback regarding personal perceptions and vulnerability towards future threats. As
discussed in Chapters Three and Four, it reflects the effectiveness of risk messages
through personalization of the risk. The sample of TSICP attendees had a mean
perceived community vulnerability of 6.5 on 11-point scale. The Ben Taub MDs had the
lowest mean levels of perceived community vulnerability reporting a mean level of 5.8.
The Ben Taub RNs had a higher level of perceived community vulnerability of 6.5. The
LBJ RNs had the highest level of any of the sample groups, with a mean of 7.3. The
sample from the public reported the lowest levels of perceived community vulnerability
with a mean of 4.9.
The perceptions of vulnerability towards future threats of bioterrorism were high
at the national level for all sample groups. Perceptions of vulnerability were lower at the
state level and even lower at the community level. Low levels of perceived vulnerability
might indicate that though respondents perceive general risk, they feel less certain about
personal vulnerability at the community or local level.
The TSICP attendees had a mean previous training frequency of 1.50, which was
the lowest frequency of any group. Their lower frequency of training might be due to
their higher professional standards for defining actual bioterrorism training. Another
reason for the lower frequency might be that the data was collected prior to attending a
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bioterrorism training seminar, so the sample might over-represent those with lower levels
of training.
The Ben Taub MDs had a mean frequency of training of 1.76, however only 27
percent (17) were trained. The only group with a higher frequency was LBJ RNs who
had a mean frequency of 2.14. The Ben Taub RNs had a mean previous training
frequency of 1.69. Registered nurses at HCHD received greater than three times the
previous training, than did medical doctors at Ben Taub. Frequencies of bioterrorism
training differences suggest that occupation might contribute to access and availability of
bioterrorism training.
Source of the risk message, as indicated within the GMHRC, relates to both
utilization of the particular sources of (hearing) and to credibility of the particular source.
Observed differences existed between sources of formal and informal sources between
groups. Reported sources of previous formal bioterrorism training varied by sample
group. Of the 17, Ben Taub MDs reporting training, the most frequent source category
was conferences. Formal bioterrorism training courses accounted for the second most
common source. But, the small sample size of previously trained Ben Taub MDs (N= 17)
might limit the usefulness of these findings.
The Ben Taub and LBJ RNs both reported greater than 80 percent of respondents
had received previous bioterrorism training through formal bioterrorism training courses.
This finding might indicate a recognized need to train staff or an active nurse training
program within HCHD. Aggressive internal training standards through the nursing
education program at Ben Taub likely explained the homogeneity of previous training
source among Ben Taub and LBJ RNs.

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As a group, TSICP attendees exhibited less homogeneity of previous training
sources than did registered nurses from HCHD. The TSICP attendees lived and worked
across the State of Texas and were employed by different healthcare organizations and
institutions from both rural and urban areas. The spatial variation in place of
employment among TSICP attendees may have contributed to the more varied source
types from which they received bioterrorism training.
These observed differences are tested for statistical significance in the next
chapter. Accessibility to sources might vary by job role and by job duties as well as by
various other factors including geography and organizational differences. The receiver’s
perceived credibility of each particular source also might influence perceptual and
behavioral response, and this relationship is explored further in later chapters.
Perceived credibility in regards to the source of previous bioterrorism training
was established among the HCHD clinicians and the public. Within all of the sample
groups, the majority of respondents considered their bioterrorism training source to be
credible. Ben Taub MDs reported the lowest levels of perceived source credibility. The
LBJ RNs ranked between Ben Taub MDs and Ben Taub RNs. The public sample
reported the highest levels of perceived credibility. The Ben Taub MDs exhibited the
lowest levels of perceived credibility, which may be due to their sample group’s high
educational levels resulting from medical school. Medical doctors provide diagnosis and
treatment of patients within healthcare facilities. When considering their patient care
responsibilities and their high levels of education, it seems appropriate that they might
have developed more restrictive standards for credibility than other sample groups.
CHAPTER SEVEN
THE BEHAVIORAL STAGE OF HEARING
“Hearing” is the first behavioral stage of the GMHRC and delineates the initiation
of the model process (Blanchard-Boehm, 1998). In this dissertation, hearing was broadly
defined as having heard or received bioterrorism readiness and preparedness information
and consisted of bioterrorism risk information from formal bioterrorism training and from
a variety of informal sources of information.
Some risk communication model based studies have investigated factors that
contributed to the risk communication process in targeted populations within the general
public. Mileti, Fitzpatrick, and Farhar (1990) assessed earthquake risk communication
among households in a region that had been identified by geologists as having a very
high potential for future large earthquakes in the short term. The hearing of the risk
message had occurred through a mass mailed informational brochure as well as through
informal sources of information and the sample population consisted of members of the
public who lived in several communities within an earthquake risk zone. The populations
of respondents were targeted because of their households’ geographic proximity to the
risk. Similar studies of earthquake risk communication through the general
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169
framework of the risk communication model were conducted by Mileti, Farhar, and
Fitzpatrick (1990) and Mileti and Fitzpatrick (1992, 1993).
Following in the tradition of Mileti, Fitzpatrick, and Farhar (1990), Blanchard-
Boehm (1998) investigated earthquake risk communication to individual households with
different degrees of risk based on geographic proximity to the earthquake fault zone
during a time of increased risk. She tested the risk communication model behavioral
stages for application within several California communities following the Loma Prieta
earthquake.
More recently O’Brien (2002) utilized the risk communication model to frame an
investigation of response activities and perceptions among groups with varying levels of
experience with the events of September 11, 2001 throughout Manhattan, New York. He
stated that this was the first application of the risk communication model outside of the
realm of natural disasters (p.2). In this preliminary report, O’Brien (2002) found that the
risk communication model proved useful for framing the investigation and noted that
some of the typical receiver characteristics such as previous experience with disasters did
not contribute to the model processes but that this was probably due to the unprecedented
scale of the September 11, 2001 events. O’Brien (2002, 4) stated that theoretical
development in the realm of terrorist attacks should be given priority by funding agencies
(p.2).
Unlike earlier risk communication model based investigations of households in
response to earthquake risk messages, this dissertation investigates risk communication
among healthcare providers who, as previously discussed (Chapter Two), have unique
importance to bioterrorism readiness and preparedness. Many of the risk communication

170
studies cited in Chapter Three investigated message and receiver characteristics that
contributed to hearing and responding to risk messages regarding natural disasters. These
risk messages were primarily issued through print or broadcast media to target audiences
who were not typically involved in response activities in a professional capacity.
Mandatory bioterrorism training within healthcare provides a more controlled
environment in which to test the behavioral stage of hearing within a population of
potential professional responders. Testing of the GMHRC receiver and message
characteristics that contributed to hearing the risk message among clinicians offers
insight into how the risk communication process varies among those who are thought to
be in a singular critical role for bioterrorism readiness and preparedness as discussed
throughout Chapter Two. The general hypothesis that guided this investigation is listed
as follows:
GMHRC behavioral stage of “hearing” the risk message.
Sample Group Differences in Hearing
Prior to testing the model process of hearing, this section describes and
establishes sample group differences within hearing. The sample groups in this
dissertation were purposefully chosen for inclusion because of their differing
occupational roles in the context of bioterrorism readiness and preparedness. Factors that
influence hearing among clinicians were the primary focus because of their critical
importance to bioterrorism readiness and preparedness as discussed in Chapters One and
Two. The TSICP attendees and the public were included in this discussion to provide a
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basis of comparison and to illustrate sample group differences in hearing through formal
and informal sources.
The questionnaire provided measures of formal bioterrorism training between the
five sample groups. Chi-square tests assessed differences in formal training between the
sample groups and identified statistically significant differences (p < 0.01) in previous
formal bioterrorism training (Table 7.1). The sample groups experienced unequal levels
of formal bioterrorism training.
Ben Taub MDs reported the lowest levels of hearing (27.4 percent) through
formal sources of any of the healthcare workers. The public reported the least hearing
(21.5 percent) through formal sources of any sample group. The LBJ RNs had the
highest levels of hearing (85.7 percent) through formal sources and the Ben Taub RNs
ranked a few percentage points behind the LBJ RNs (83 percent). This level of formal
training among TSICP attendees (51.6 percent), though higher than Ben Taub MDs, was
less than the two samples of RNs. However, the TSICP sample may understate the
population of trained statewide ICPs as the data were collected prior to a bioterrorism
readiness training seminar.
Respondents received informal information from a variety of sources as
introduced in Chapter Six. Respondents ranked the individual sources of information on
a 4-point scale. The listed sources of information served as the basis from which a
variable representing informal information was derived. The lowest value represented no
usage and these respondents were classified as not having received informal information
(0). Respondents who reported information from informal sources at any of the three
higher values on the four point scale were classified as having received informal
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information (1). The levels of informal information are listed below in Table 7.2. Chi-
square tests indicated differences in levels of informal information between the sample
groups but the observed degree of differences were less than for that of formal training.
Table 7.1 Formal Training.
GROUP N NO TRAINING TRAINING

(TRAINING) PERCENTAGE PERCENTAGE
Ben Taub RNs 231 17.0 83.0
LBJ RNs 133 14.3 85.7
Public 265 78.5 21.5
Chi-square statistic =
CHI-SQUARE TEST df = 4 p < 0.01
269.51
Informal sources of hearing were also different between the sample groups. The
TSICP attendees reported the most informal information and the Ben Taub RNs ranked
just behind the TSICP Attendees. The LBJ RNs reported the third highest levels of
informal information and the Ben Taub MDs reported the least. The public reported
more informal information from informal sources than Ben Taub MDs, but less than the
other groups. Hearing through formal sources occurred at different rates between the five
sample groups.
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Table 7.2 Informal Information.
NO INFORMAL INFORMAL
GROUP (INFTOT) N INFORMATION (0) INFORMATION (1)
PERCENTAGE PERCENTAGE
LBJ RNs 133 8.3 91.7
Public 265 12.3 87.7
CHI-SQUARE TEST df = 4 Chi-square statistic = 9.4 p < 0.05
Derivation of the Hearing Dependent Variable
Prior to the regression modeling, a dependent variable that encompasses the two
general categories of formal and informal hearing had to be derived. The levels of
hearing that occurred through formal training (Table 7.1) and informal sources (Table
7.2) served as the basis for the dependent variable. Respondents who had not heard the
risk message through either formal training or through informal sources were too few in
number (2.7 percent-TSICP, 9.7 percent-Ben Taub MDs, 2.6 percent-Ben Taub RNs, 2.3
percent-LBJ RNs, and 11.5-public, see Table 7.3) to create a separate category that would
have provided a 3-point ordinal scale dependent variable. Respondents who did not hear
through either formal training or informal sources of information were excluded from the
analysis of hearing.
The dichotomous dependent variable encompasses the two general categories of
formal and informal hearing and classified those who did hear through formal training or
informal sources as missing data which excluded them from the analysis. Formal training
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might have provided a higher quality, more controlled, and more consistent provision of
bioterrorism readiness information and was classified as the higher value (1) on the
dichotomous scale. Respondents reporting informal sources of information but without
formal training were classified as the lower value (0). Table 7.3 displays the percentages
of hearing by formal and informal sources among the clinical sample groups and
illustrates the derivation of hearing.
Identification of Independent Variables
This section addresses two final preparatory steps for the identification of
independent variables to model the behavioral stage of hearing. Simple correlation tests
assessed bivariate association between the array of independent variables and the
dependent variable. Decisions of retaining independent variables were based upon the
both the strength of the association and the contribution to the model process.
Simple correlation tests identified several independent variables with weak to
moderate association with hearing in the TSICP attendees. The formal training sources
of conferences (TRAIN3) and meeting at work (TRAIN4) both had a weak association to
hearing and to each other. Training from conferences (TRAIN3) was retained because it
had a stronger correlation to hearing. The informal source of internet-based information
(INFINT) and the informal source of books (INFBOOKS) were both associated:
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Table 7.3 Hearing Dependent Variable Summary.
HEARING DEPENDENT VARIABLE CLASSIFICATION

Missing data = no hearing (Q. 3 and Q.6) PERCENTAGE OF
SAMPLE GROUP
0 = informal sources only (Q.6) RESPONDENTS
1 = formal training (Q. 3)
TSICP No Risk Information = (missing data) 2.7

Attendees
Informal Sources of Information Only (0) 46.1
N = 218
Formal Training (1) 51.1
No Risk Information = (missing data) 9.7

Ben Taub MDs
N = 61

Ben Taub RNs
N = 231

LBJ RNs
N = 133

Public
N = 265
CHI-SQUARE
df = 4, Chi-square statistic = 268.510 p < 0.01
TEST
with hearing and each other. The informal source of internet-based information
(INFINT) was retained because it had the stronger association with hearing. Reliability
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in the informal source of internet-based information (RELINTC) had a weak association
with hearing as well as internet-based sources and was not retained.
Simple correlation tests of the Ben Taub MDs identified some weak and some
moderate associations with hearing among the associated independent variables. The
independent variables for training source of conferences (TRAIN3), collapsed
(infrequently reported) training sources (TRAING), informal information source
(INFMED), and length of time at job (JOBLNGTH) had weak associations with hearing
but were also associated with the receiver characteristic of respondent age (AGE) and
they were not retained. Age is particularly relevant for the model in the case of Ben Taub
MDs because many Ben Taub MDs are medical residents who were recent medical
school graduates. Increasing age of Ben Taub MDs reflects greater length of time at their
occupation and greater length of time out of medical school.
For the sample of Ben Taub RNs, simple correlation tests indicated weak
associations between previous disaster experience (PREVEXP), the informal source of
meetings at work (INFMEET), the informal source of printed media (INFPRINT), and
the dependent variable. However, these variables were also associated with the source of
bioterrorism training courses (TRAIN1) to an equal or greater degree than to the
dependent variable. The message characteristic of a bioterrorism training course
(TRAIN1) was the only retained independent variable because the association with the
dependent variable was stronger than for the other potential independent variables.
For LBJ RNs the message characteristic of a bioterrorism training course
(TRAIN1) exhibited a moderate to strong association with the dependent variable. (0.73).
The informal source of meetings at work (INFWKMT) had a weak relationship to the
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dependent variable but an even stronger (0.27) association to the source of bioterrorism
training courses and was not retained. Reliability of work meetings (RELWKMTC) was
the third independent variable with a weak (0.19) association to hearing and was retained.
The public sample had more numerous associations between the independent
variables and hearing. All of the formal training sources had moderate to strong
association with the dependent variable and weak to moderate associations with each
other. The source of bioterrorism training courses (TRAIN1) had the strongest
association to hearing and was retained. The informal source of media (INFMED) and
the informal source of meetings at work (INFMEET) had moderate association with
hearing and were retained.
Table 7.4 lists the independent variables that will be tested for association with
the behavioral stage of hearing. The lack of more numerous independent variables might
result from the mandatory nature of formal training among clinicians as well as the
relatively consistent levels of informal information.
Multivariate Modeling of Hearing
The clinicians are modeled through regressions because they are the sample
groups of primary concern for early identification of bioterrorism occurrences within
their patients as discussed in Chapter Two. The public and the TSICP attendees were
included as a basis of comparison. Hearing is the risk message input behavioral stage of
the model process and only a few independent variables were identified through simple
correlation tests to retain for testing of the behavioral stage of hearing (Table 7.4).
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Table 7.4 Independent Variables Retained for Regression of Hearing.
DEPENDENT INDEPENDENT VARIABLES BIVARIATE

VARIABLE
GROUP CORRELATION
COEFFICIENT
HEARING TSICP Formal training from conferences (TRAIN3), N 0.271**

Attendees = 217
The informal source of internet-based 0.261**

information (INFINT), N = 262
Ben Taub Respondent Age (AGE), N = 53 0.533**

MDs
Bioterrorism Training course (TRAIN1), N = 0.525**
61
Informal information source of conversations at -0.381**

work (INFWKTK), N = 56
Ben Taub RNs Bioterrorism Training course (TRAIN1), 0.549**

N = 231
LBJ RNs Bioterrorism Training course (TRAIN1), N = 0.732**

130
Reliability of work meetings (RELWKMTC), 0.190*

N = 113
Public Bioterrorism Training course (TRAIN1), 0.727**

N = 264
The informal source of broadcast media 0.409**

(INFMED), N = 263
The informal source of meetings at work 0.546**

(INFMEET), N = 264
* Significant at the .05 level.

** Significant at the .01 level
The model for TSICP attendees had a chi-square value of 14.90 that was
statistically significant at p < 0.01 (Table 7.5). One message characteristic was found to
contribute to hearing. Respondents who reported internet-based sources of information
(INFINT) were more likely to hear by a factor of 3.19. The model pseudo R-square value
was extremely weak (0.090) and 61.5 percent of the cases were correctly classified.
179
Table 7.5 Logistic Regression for Hearing: TSICP Attendees.
VARIABLE B WALD SIG. EXP(B)
The informal source of

the internet-based 1.158 13.962 .001 3.185
information (INFINT)
Constant -.271 2.545 .111 .763
Model Summary Nagelkerke Model Chi- Model Chi-square Sig. Correctly

R-square square value Classified
N = 213 0.090 14.898 p < 0.01 61.5%
The Ben Taub MDs’ model for hearing had a model chi-square value of 36.59
that was significant at p <0.01 (Table 7.6). The model identified one statistically
significant independent variable and it was a receiver characteristic. Respondent age
(AGE) was found to contribute to hearing. A one year increase in respondent age
increased the likelihood of hearing by a factor of 1.2. The pseudo R-square value was
0.72, and the model correctly classified over 88 percent of the cases.
Table 7.6 Logistic Regression for Hearing: Ben Taub MDs.
Respondent age
.178 6.168 .013 1.195
(AGE)
Constant -6.944 8.416 .004 .001
Model Summary Nagelkerke Model Chi- Model Chi-square Correctly

R-square square value Sig. Classified
N = 53 0.716 36.587 p < 0.01 88.7%
The models did not identify any statistically significant independent variables
(message or receiver characteristics) that contributed to the behavioral stage of hearing

180
for the Ben Taub RNs or the LBJ RNs. Only a few independent variables had been
retained through simple correlation tests and some of these exhibited a moderate bivariate
association to the dependent variable. However, these variables were not found to
contribute to the logistic regression model of hearing. The lack of independent variables
might be due to the mandatory and somewhat controlled nature of the training which
might have reduced the contribution to the process of hearing as greater than 80 percent
of these two samples of RNs had received formal training.
The publics’ model for hearing had a good fit with a model chi-square value of
115.90 that was significant at p <0.01 (Table 7.7). The model identified two statistically
significant independent message characteristics that contributed to hearing. Utilization of
the informal source of broadcast media (INFMED) decreased the likelihood of more
responding by a factor of 0.02. The informal source of meetings at work (INFMEET)
increased the likelihood of more responding by a factor of 46.71. The pseudo R-square
value was 0.58, and the model correctly classified over 84 percent of the cases.
Table 7.7 Logistic Regression for Hearing: Public.

-3.941 35.788 .001 .019
broadcast media (INFMED)

3.844 45.986 .001 46.709
meetings at work (INFMEET)
Constant .315 .520 .471 1.370
Nagelkerke Model Chi-square Model Chi-square Correctly

Model Summary
R-square value Sig. Classified
N = 264 0.579 115.901 p < 0.01 84.4%

181
This chapter investigated hearing which is the first behavioral stage of the
GMHRC. Prior to modeling the process of hearing through logistic regression, chi-
square tests assessed the differences of hearing among all of the sample groups. A
notable finding from this chapter lies in the identification of statistically significant
differences in levels of hearing through formal sources between the five sample groups.
With the exception of the public respondents, individual sample groups
represented populations engaged in different types of employment within healthcare. The
public sample provided baseline levels of hearing from those outside of the healthcare
industry. The HCHD clinician samples consisted of healthcare providers engaged in
varying levels of direct patient care that includes opportunities for identifying potential
biological illness within their patients. The TSICP attendees consisted of infection
control specialists, managers, and planners with employment related reasons to have
engaged in the hearing of bioterrorism risk messages, but typically without patient
evaluation responsibilities. Sample group membership contributed to different levels of
formal training that might result from varying opportunities and varying access to formal
sources.
The preparatory step prior to modeling consisted of identifying the most
appropriate independent variables. The sample of TSICP attendees had two message
characteristics that were identified through simple correlation tests as independent
variables. Formal training from conferences (TRAIN3) and the informal source of
internet-based information (INFINT) were both retained for testing.

182
The clinical sample groups differed in the independent variables that were
identified through simple correlation tests. One receiver characteristic respondent age
(AGE) and two message characteristics bioterrorism training courses (TRAIN1) and the
informal source of conversations at work (INFWKTK) were retained for the multivariate
model of Ben Taub MDs. Several independent variables with a weak bivariate
association with hearing were not retained. The training source of conferences
(TRAIN3), collapsed training sources (TRAING), informal information source
(INFMED), and length of time at job (JOBLNGHT) were also associated with the
receiver characteristic of respondent age (AGE). Age was retained because of its
particular relevance to the sample of Ben Taub MDs and because of the moderate nature
of the association with the dependent variable. Medical residents work longer hours than
many other healthcare providers and their residency requirements might inhibit their
ability to receive formal training.
The sample of Ben Taub RNs had weak bivariate associations between hearing
and previous disaster experience (PREVEXP), the informal source of meetings at work
(INFMEET), the informal source of printed media (INFPRINT). However, these
variables were also associated with bioterrorism training course (TRAIN1) and the
association was somewhat stronger than the relationship to hearing. The message
characteristic of a bioterrorism training course (TRAIN1) had a moderate bivariate
relationship with hearing and was retained.
Two message characteristics bioterrorism training courses (TRAIN1) and
reliability of work meetings (RELWKMTC) were retained within LBJ RNs. The
informal source of meetings at work (INFWKMT) had a weak relationship to the

183
dependent variable but, similar to the three variables that were not retained in the Ben
Taub MDs, it had an even stronger association to the source of bioterrorism training
courses than to the dependent variable and was not retained.
Modeling of hearing through logistic regressions tested the influence of
independent variables (message and receiver characteristics) during the behavioral stage
of hearing. Hypothesis #1 stated that message and receiver characteristics are associated
with hearing. The regression models identified some very limited support for hypothesis
#1 among the Ben Taub MDs, TSICP attendees, and the public.
One message characteristic was found to contribute to hearing in the model of
TSICP attendees. Respondents who reported internet-based sources of information were
more likely to be in the hearing category. Despite the one identified independent
variable, the model for the TSICP attendees was weak overall.
The model for the Ben Taub MDs had one identified independent variable that
contributed to hearing. Ben Taub MDs were more likely hear as their age increased
which might result from increasing opportunities to have engaged in the behavioral
process that coincides with age. Only 27 percent of the Ben Taub MDs reported formal
training which indicates they largely missed out on the ‘mandatory’ bioterrorism training
opportunities required by HCHD. Perhaps as age increases, so does the likelihood that
they will eventually be required to attend mandatory training.
The model for the public sample identified two statistically significant
independent message characteristics that contributed to hearing. Utilization of the
informal source of broadcast media decreased the likelihood of more responding. This
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compares to utilization of the informal source of meetings at work (INFMEET) that
increased the likelihood of more responding.
The logistic regression models for Ben Taub RNs and LBJ RNs did not identify
any statistically significant independent variables that contributed to hearing. This
finding might stem from the fact that this study investigated risk communication within
healthcare where the hearing of formal risk messages occurred in a somewhat controlled
environment. Formal training was largely imparted during mandatory employee training.
The two groups of registered nurses received formal training at a rate greater than 80
percent which likely diminished the influence of many of the independent variables for
these two groups. Further, the homogeneity among some of the receiver characteristics
within these three samples of HCHD healthcare workers might have contributed to the
lack of statistically significant independent variables.

CHAPTER EIGHT
THE BEHAVIORAL STAGE OF UNDERSTANDING
“Understanding” is the second behavioral stage of the GMHRC process.
Understanding was defined by assessing personal understanding of the bioterrorism risk
within a large metropolitan area such as Houston, Texas. Mileti and Sorenson (1990, 46)
stated that hearing and understanding the risk message are important factors that
contribute to personalization of a risk message. Receivers formulate perceptions of the
risk and the subsequent response behaviors based on their understanding of the message
(Mileti, Fitzpatrick, and Farhar 1990; Mileti and Sorenson 1990; Blanchard 1992, 1998;
Mileti and Fitzpatrick 1992, 1993).
According to the GMHRC, understanding is formulated within the individual
based upon the influence of receiver and message characteristics. Identification of the
characteristics that influence the behavioral stage of understanding provides knowledge
about how risk communication varies between different groups of clinicians. The
hypothesis that guided this chapter is listed as follows:
GMHRC behavioral stage of understanding the risk message.
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186
Derivation of Understanding
The questionnaire rated beliefs that large metropolitan areas might be the target of
a bioterrorism attack and this served as the basis through which understanding was
derived. Respondents rated their responses on a 4-point scale where a value of (1)
indicated not very likely, a value of (2) indicated somewhat unlikely, a value of (3)
indicated somewhat likely, and a value of (4) indicated very likely. The two lowest
categories had very few respondents per category for each sample group. The Ben Taub
MDs had 4.8 percent of respondents in the two lowest categories. The Ben Taub and LBJ
RNs had 4.5 percent and 4.4 percent in the two lowest categories. The TSICP attendees
had 0.9 percent in the two lowest categories and the public had 1.5 percent. The low
numbers of respondents in the first two categories prohibited the creation of an ordinal
scale dependent variable.
To facilitate statistical analysis, the three lower categories were collapsed and
grouped into the category of less understanding (0). Respondents reporting the highest
value were classified as the category of more understanding (1). The dichotomized
description of the recoded dependent variable for understanding is provided in Table 8.1.
The Ben Taub RNs had the lowest percentage within the more understanding category.
The Ben Taub MDs had the highest percentage within more understanding. The levels of
more understanding for the LBJ RNs ranked between the Ben Taub RNs and the Ben
Taub MDs.
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Table 8.1 Understanding Dependent Variable Summary.
“Understanding” the likelihood that large cities might

be the target of a bioterrorist attack (Q19.a)
ORIGINAL FORM OF
UNDERSTANDING (UNDERSTAND)
UNDERSTANDING 1 = Not very likely (grouped into less understanding)
2 = somewhat unlikely (grouped into less
VARIABLE
understanding)
3 = somewhat likely (grouped into less understanding)
4 = very likely (more understanding)
RECODED “Understanding” collapsed categories

(UNDERSTNDCL) PERCENTAGE
(DICHOTOMIZED) 0 = Less understanding OF
UNDERSTANDCL 1 = More understanding RESPONDENTS
TSICP Attendees Less Understanding (0) 16.5
N = 212 More Understanding (1) 83.5
Ben Taub MDs Less Understanding (0) 19.4
Ben Taub RNs Less Understanding (0) 32.5
LBJ RNs Less Understanding (0) 25.0
Public Less Understanding (0) 13.9
CHI-SQUARE TEST
Chi-square statistic = 29.969
df = 4 p < 0.01
Following derivation of the dependent variable, simple correlation tests clarified
which of the independent variables were related to understanding and should be retained.
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When associated with other independent variables, those with higher degrees of
association or a more direct model contribution were retained.
These final preparatory tests identified two or three independent variables with
weak to moderate bivariate association with understanding for the Ben Taub RNs, the
LBJ RNs and the public (Table 8.2). The Ben Taub MDs had three associated
independent variables associated with understanding. Formal training from work
meetings (TRAIN4) the informal source of friends and family (INFFANDF) and the
informal source of books (INFBOOKS) were all weakly associated with understanding
and were retained. The sample of TSICP attendees had only one independent variable
with a bivariate association. Perception of vulnerability at the state level had a weak
association with understanding and was retained.
Ben Taub RNs had two sources of formal training, conferences and work
meetings with bivariate associations with understanding and each other. The training
source of work meetings (TRAIN4) was not retained because it had a weaker association
with understanding. Perception of vulnerability (POSTVTX) and experience with false
alarms (FALSEALM) at the state level were retained. The informal sources of print
media (INFPRINT) and broadcast media (INFMED) were both associated with
understanding and with each other. Print media was not retained because it had the
weaker association with the dependent variable.
LBJ RNs had association with a variety of independent variables. Two of the
receiver beliefs questions, beliefs in the ability to provide early detection (ERLYDET)
(0.23) and beliefs in the ability identify onset when symptoms are non-specific
(NONSPECID) (0.194) were both weakly associated with understanding and with
189
perception of vulnerability at the state level (POSTVTX). Perception of vulnerability at
the state level was retained because it had a stronger (moderate) association with
understanding
The public sample had several message and receiver characteristics that were
associated with understanding. Several informal sources of information had a weak
association with understanding and with each other. The informal source of books
(INFBOOKS) was retained because it had the strongest association of the informal
sources. Reliability of broadcast media (RELMEDC) and reliability of print media
(RELPRINTC) were associated with each other and with understanding. Reliability of
print media was not retained because it had a weaker association (0.164) with the
dependent variable.
Multivariate Modeling of Understanding
The model for the TSICP attendees had a fairly good fit with a model chi-square
value of 18.53 that was statistically significant at p < 0.01 (Table 8.3). The single
independent variable was found to contribute to understanding. For every one unit
increase on the 11-point scale, the likelihood of being in the more understanding category
increased by a factor of 1.44. The pseudo R-square values were weak (0.141) and 83.5
percent of the cases were correctly classified.

190
Table 8.2 Independent Variables Retained for Regression of Understanding.

VARIABLE
SAMPLE GROUP CORRELATION
COEFFICIENT
UNDERSTANDCL TSICP Attendees Perception of vulnerability at the 0.285**

state level (POSTVTX), N = 212
Ben Taub MDs Training source of work meetings -0.261*

(TRAIN4), N = 61
Informal source of friends and 0.265*

family (INFFANDF), N = 45
Informal source of printed media -0.254*

(INFBOOK), N = 61
Ben Taub RNs Training from conferences 0.141*

(TRAIN3), N = 231
Perception of vulnerability at the 0.245**

Informal source of broadcast media 0.209**

(INFMED), N = 223
Experience with false alarms 0.151*

(FALSEALM), N = 210
LBJ RNs Disaster planning group (TRAIN2), -0.226*

N = 130
Reliability of internet-based sources 0.307**

(RELINTC), N = 127
Perception of vulnerability at the 0.393**

Public Perception of vulnerability at the 0.260**

The informal source of books -0.164*

(INFBOOK), N = 262
Reliability of broadcast media 0.356**

(RELMEDC), N = 241

191
Table 8.3 Logistic Regression for Understanding: TSICP Attendees.
Perception of
vulnerability at the state .366 16.509 .001 1.443
level (POSTVTX)
Constant -1.167 3.017 .082 .311
Model Summary Nagelkerke Model Chi-square Model Chi-square Correctly

N = 212 0.141 18.534 p < 0.01 83.5%
Three message characteristics, training source of meetings, informal sources of
friends and family, and informal sources of books were tested in the logistic regression
model for Ben Taub MDs. The model did not identify any statistically significant
independent variables. The weak bivariate associations may explain why there were no
statistically significant independent variables identified during multivariate analysis.
The model for the Ben Taub RNs exhibited a good fit with a model chi-square
value of 23.73 that was statistically significant at p < 0.05 (Table 8.4). The model
identified two receiver characteristics and one message characteristic out of the four
tested independent variables as contributors to understanding. Perception of vulnerability
to bioterrorism at the state level contributed to more understanding. A one unit increase
on the 11-point perceptual scale increased the likelihood that respondents would be
members of the more understanding category by a factor of 1.21. Respondents who
utilized the informal source of broadcast media were greater than twice as likely to be in
the more understanding category as others. Respondents who experienced a false alarm
for bioterrorism were approximately 2.26 times more likely to be in the more
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understanding category than others. The model for the Ben Taub RNs correctly classified
70 percent of the cases, and the pseudo R-square value was 0.15.
Table 8.4 Logistic Regression for Understanding: Ben Taub RNs.
Perception of
level (POSTVTX)
Informal source of
broadcast media .770 5.605 .018 2.159
(INFMED)
Experience with false

.814 4.455 .035 2.257
alarms (FALSEALM)
Constant -1.508 8.390 .004 .221

N = 210 0.148 23.725 p < 0.01 70.0%
The model for LBJ RNs identified two independent variables as contributors to
more understanding (Table 8.5). One of the independent variables was a receiver
characteristic. A one unit increase on the 11-point perceptual scale increased the
likelihood of more understanding by a factor of 1.88. The second independent variable,
disaster planning group training, was a message characteristic. The LBJ RNs who
received formal training from a disaster planning group were less likely to be members of
the more understanding category than others by a factor of 0.042. The model correctly
classified 78.9 percent of the cases. The pseudo R-square value was 0.36.
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Table 8.5 Logistic Regression for Understanding: LBJ RNs.
Perception of
level (POSTVTX)
Disaster planning group

-3.163 9.279 .002 .042
(TRAIN2)
Constant -3.509 10.808 .001 .030

N = 118 0.362 32.399 p < 0.01 78.9%
The public model identified two independent variables as contributors to more
understanding (Table 8.6). Perception of vulnerability at the state level was a receiver
characteristic. A one unit increase on the 11-point perceptual scale increased the
likelihood of more understanding by a factor of 1.42. The second independent variable,
reliability of work meetings (RELMEDC), was a message characteristic. The public
respondents who believed broadcast media were a reliable source of information were
more likely to be in the more understanding category than others by a factor of 9.10. The
model correctly classified 84.9 percent of the cases. The pseudo R-square value was
0.29.
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Table 8.6 Logistic Regression for Understanding: Public.
Perception of
level (POSTVTX)
Reliability of broadcast
2.203 23.007 .001 9.053
media (RELMEDC)
Constant -1.437 4.467 .035 .238

N = 118 0.294 45.515 p < 0.01 84.9%
Influence of Antecedent Behavioral Stage
Simple correlation tests were performed to test the influence of the preceding
behavioral stage of hearing on understanding. No statistically significant findings existed
between the behavioral stages of hearing and understanding for any of the sample groups.
The behavioral stage of hearing did not contribute to the behavioral stage of
understanding.
Understanding is the second behavioral stage in the model process. Levels of
more understanding exceeded two thirds in all of the sample groups. The Ben Taub RNs
had the lowest levels of more understanding (67.5 percent). The LBJ RNs had more
understanding in 75 percent of members. The sample of Ben Taub MDs had 80.6 of
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members in the more understanding category. The TSICP attendees had 83.5 percent and
the public had 86.1 percent in the more understanding category.
Factors that influence understanding provide knowledge about the sample groups
and their varying bioterrorism risk communication characteristics. The regression
models identified limited support for the general hypothesis #2 that stated that message
and receiver characteristics are associated with understanding for all groups except the
Ben Taub MDs. Simple correlation tests indicated only weak bivariate associations
among the three tested independent variables training from work meetings (TRAIN4), the
informal source of friends and family (INFFANDF), and the informal source of books
(INFBOOK) which might explain the lack of findings. Understanding in the Ben Taub
MDs must be controlled by factors that were not directly investigated.
The TSICP attendees tested one independent variable and it was found to
contribute to more understanding. Increased levels of perceived vulnerability at the state
level (POSTVTX) increased the likelihood of understanding.
Two receiver characteristics were identified within Ben Taub RNs as contributing
to more understanding. Increased levels of perceived vulnerability at the state level
(POSTVTX) increased the likelihood of more understanding. Experience with false
alarms (FALSEALM) also served to increase understanding. Perhaps the experience of
the false alarm provided a learning experience whereby the nurses obtained a better
understanding of the risk. One message characteristic also influenced understanding.
The Ben Taub RNs who reported informal information from the broadcast media
(INFMED) were more likely to understand. Perhaps utilization of broadcast media is

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indicative of a higher state of individual receptivity to the risk message or even of an
increased likelihood of accepting the information.
One receiver characteristic and one message characteristic contributed to
understanding in the LBJ RNs. Increased perception of vulnerability at the state level
increased the likelihood of more understanding. One message characteristic also
contributed to more understanding within the LBJ RNs. Receiving formal training from a
disaster planning group (TRAIN2) greatly decreased the likelihood of being in the more
understanding category. Infection control staff, ICPs, and healthcare administrators are
typically members of disaster planning groups. Perhaps these groups are not the best
method for training the typical clinician who may not have the background knowledge
that would ordinarily be found in disaster planning group members.
Both groups of nurses reported an association between perceptions of
vulnerability at the state level and more understanding. As discussed in Chapter Three,
perceptions of vulnerability might influence the risk communication process in many
ways. This finding supports the importance of perceived vulnerability for both groups
of nurses.
The public model for hearing had two independent variables that contributed to
hearing. Increased levels of perceived vulnerability at the state level (POSTVTX)
increased the likelihood of hearing. The second independent variable, reliability of work
meetings (RELWKMTC), was a message characteristic. The public respondents who
believed work meetings were a reliable source of information were more likely to be in
the more understanding category.

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The lack of association between the behavioral stage of understanding and the
antecedent behavioral stage of hearing might result from the unique nature of
bioterrorism risk communication. However, despite the lack of direct contribution by the
behavioral stage of hearing, some relationships with components of hearing were
identified. Ben Taub RNs increased understanding through the informal source of
broadcast media. The formal training source of disaster planning groups decreased
understanding in LBJ RNs. Possibly the most notable finding from this chapter involves
the importance of perceptions of vulnerability for all the sample groups except the Ben
Taub MDs.
CHAPTER NINE
THE BEHAVIORAL STAGE OF BELIEVING
“Believing” is the third GMHRC behavioral stage following “hearing” and
“understanding” of the risk message. In this dissertation believing the risk message was
defined by belief in the likelihood of a bioterrorist attack anywhere in the respondent’s
local community. The receiver must first hear, then understand, and then believe the risk
message prior to personalization of the risk (Mileti and Sorenson 1990, 46). Following
hearing a risk message, receivers formulate their perceptions of the message based on
their understanding and believing of the message (Mileti, Fitzpatrick, and Farhar 1990;
Mileti and Sorenson 1990; Blanchard 1992; Mileti and Fitzpatrick 1992, 1993;
Blanchard-Boehm 1998). The hypothesis that guided this section is listed as follows:
GMHRC behavioral stage of believing the risk message.
Derivation of the Believing Dependent Variable
The dependent variable for believing was derived from a question that assessed
the belief in a bioterrorism attack occurring in the respondent’s local community. This
question served as the basis for deriving believing because belief in the personal risk of
198
199
bioterrorism at the community level is indicative of personalization and acceptance of the
risk message.
The questionnaire ranked respondent beliefs about the bioterrorism risk at the
community level through an 11-point perceptual scale. Too few respondents existed in
many of the eleven levels of believing to utilize an ordinal scale dependent variable.
Descriptive analysis indicated the data fell into two broad categories and the spread of the
data for all sample groups was relatively similar. To facilitate statistical analysis,
believing was collapsed and dichotomized into the categories of less believing and more
believing. Believing values of 1 to 6 were classified as less believing (0) and values of 7
to 11 were classified as more believing (1). The collapsed and dichotomized values for
believing are listed in Table 9.1.
The sample of TSICP attendees had 43.1 percent of respondents in the higher
level of believing. The Ben Taub MDs had the lowest numbers of respondents (45.2
percent) in the more believing category than any of the sample groups except the public.
The public sample had only 25 percent of respondents in the more believing category.
Greater than half of the LBJ RNs were in the more believing category. The sample of
Ben Taub RNs ranked in between the Ben Taub MDs and the LBJ RNs but the values
were only slightly greater than Ben Taub MDs. Small descriptive differences existed
between the clinical sample groups.
The final preparatory steps for identifying independent variables consisted of
simple correlation tests performed with the dependent variable (believing). First, a set of
200
tests identified which of the remaining independent variables had a bivariate association
with believing. Second, a set of tests determined which of the previously identified
independent variables (that were associated with other independent variables) were the
best to retain based on the bivariate association. The decisions to retain independent
variables were based on the theoretical contribution to the model and the strength of the
relationship with believing.
Table 9.1 Believing Dependent Variable Summary.
ORIGINAL FORM “Believing:” Belief in likelihood of a bioterrorism

occurrence anywhere in your community (Q.14)
OF VARIABLE FOR
BELIEVING: 11-point perceptual scale
BELIEVING 1 = not at all likely, to 11 = Extremely Likely
COLLAPSED AND BELIEVE CL (DICHOTMIZED)

PERCENTAGE
DICHOTOMIZED 0 = lower levels of believing (1 to 6 - original scale) OF
BELIEVING 1 = higher levels of believing (7 to 11 - original scale) RESPONDENTS
TSICP Attendees 0 = lower levels of believing 56.9
N = 216 1 = higher levels of believing 43.1
Ben Taub MDs 0 = lower levels of believing 54.8
Ben Taub RNs 0 = lower levels of believing 54.5
LBJ RNs 0 = lower levels of believing 49.6
Public 0 = lower levels of believing 75
N = 265 1 = higher levels of believing 25
CHI-SQUARE TEST
df = 4 Chi-square statistic = 36.396 p < 0.01
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The TSICP attendee had only one independent variable with a bivariate
association with believing (Table 9.2). Perception of vulnerability at the state level
(POSTVTX) had a moderate association with believing and was retained.
The Ben Taub MDs had only two independent variables that exhibited a bivariate
association with the dependent variable. One of the independent variables was a receiver
characteristic and the other was a message characteristic. Perception of vulnerability at
the state level (POSTVTX) had a moderate association with believing. Reliability of
book media (RELBOOKC) as a source of information had a smaller but still moderate
association with believing. Both of these variables were retained for the regression.
Several message and receiver characteristics had a bivariate association with
believing in the Ben Taub RNs. The formal training source of work meetings (TRAIN4)
had a weak association with believing and was retained due to the importance of source
of formal training on the risk communication process despite also having a weak
association with perception of vulnerability at the state level (POSTVTX). Perception of
vulnerability at the state level had a moderate and the informal source of friends and
family (INFFANDF) had a weak association with believing and both were retained.
Three beliefs questions, the belief in the ability to provide non-specific detection of onset
(NONSPECID), the ability of public health surveillance to identify onset (ERLYDET),
and the ability to distinguish bioterrorism from ordinary syndrome trends (DISTTREND)
all had a weak association with believing. The belief in the ability to identify
bioterrorism when symptoms are non-specific (NONSPECID) was retained because it
had the strongest association with believing and was not associated with any of the other
202
retained independent variables. The receiver characteristic of ethnic group affiliation
(ETHNICRDC) had a weak negative association with believing and was retained.
The LBJ RNs had several message and receiver characteristics with a bivariate
association with believing. The formal training source of conferences (TRAIN3) had a
weak association (0.18) with believing but had a slightly stronger association (0.19) with
the receiver characteristic of perception of vulnerability at the state level (POSTVTX)
and was not retained. Perception of vulnerability at the state level was retained and had a
strong association with believing. Three beliefs questions (NONSPECID, ERLYDET,
and DISTTREND) assessed beliefs in the ability to identify and respond to bioterrorism
and all had weak associations with believing and with perception of vulnerability at the
state level. Belief in the ability to provide early identification by public health
surveillance (ERLYDET) had the weakest association (0.23) to perception of
vulnerability at the state level and the highest association (0.30) with believing and was
retained. Reliability in the formal source of the internet-based sources (RELINTC) had a
weak association with believing and perception of vulnerability at the state level.
Following the events of September 11, 2001 the internet has been touted during formal
training as a reliable source of bioterrorism risk information and it was retained because
of this importance.
The public sample had several independent variables associated with believing.
The receiver characteristic of perception of vulnerability at the state level (POSTVTX)
had a moderate association with believing (0.58) and was retained. Receiver belief in the
ability of the government to respond to bioterrorism (ERLYDETGV) had a weak
bivariate association (0.21) and was retained. Several informal sources of information
203
had weak associations with believing and with each other. The informal source of
broadcast media (INFMED) was retained as it had the strongest association of the
informal sources (0.25). Reliability in the formal source of conversations at work
(RELWKTKC) was retained as it had the strongest association (0.26) with believing.
Table 9.2 Independent Variables Retained for Regression of Believing.
BIVARIATE
DEPENDENT SAMPLE INDEPENDENT VARIABLES CORRELATION
VARIABLE GROUP COEFFICIENT
BELIEVECL TSICP Perception of vulnerability at the state level (POSTVTX), N = 216 0.550**
Attendees
Ben Taub Perception of vulnerability at the state level (POSTVTX), N = 61 0.689**

MDs
Reliability of book media (RELBOOKC), N = 56 0.434**
Perception of vulnerability at the state level (POSTVTX), N = 231 0.566**
Training source of work meetings (TRAIN4), N = 231 0.154*
Ben Taub Informal source of friends and family (INFFANDF), N= 223 0.186**
RNs
Belief in detection when symptoms are non-specific 0.166*
(NONSPECID), N = 220
Ethnicity (ETHNICRDC), N = 230 -0.149*
LBJ RNs Belief in the ability to provide early identification (ERLYDET), N 0.303**
= 131
Reliability of internet-based sources (RELINTC), N = 127 0.195*
Early detection by the government (ERLYDETGV), N = 265 0.206*

Public
Informal source of broad cast media (INFMED), N = 265 -0.252
Reliability of conversations at work (RELWKTKC), N = 227 0.259

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Multivariate Modeling of Believing
The model for the TSICP attendees had a good fit with a model chi-square value
of 67.59 that was significant at p < 0.01 (Table 9.3). Only one receiver characteristic was
retained for testing and it was found to contribute to believing. A one unit increase in
perceived vulnerability at the state level was found to increase the likelihood of more
believing by a factor of 1.93. The model pseudo R-square value was 0.36 and 74.5
percent of the cases were correctly classified.
Table 9.3 Logistic Regression for Believing: TSICP Attendees.
Perception of vulnerability
at the state level .656 46.623 .001 1.927
(POSTVTX)
Constant -7.278 47.126 .001 .003
Model Summary Nagelkerke Model Chi-square Model Chi- Correctly

R-square value square Sig. Classified
N = 216 0.361 67.591 p < 0.01 74.5%
The model for the Ben Taub MDs had a good fit with a model chi-square value of
28.74 that was statistically significant at p < 0.01 (Table 9.4). Both of the tested
independent variables contributed to believing. One receiver characteristic, perception of
vulnerability at the state level (POSTVTX), and one message characteristic, reliability of
the informal source of books (RELBOOKC), contributed to believing. A one unit
increase on the 11-point perceptual scale increased the likelihood of believing by a factor
of 2.42. Respondents who thought books were a reliable informal source, were more
205
likely to be in the more believing category by a factor of 6.61. The pseudo R-square
value was 0.61. The model correctly classified over 83 percent of the cases.
Table 9.4 Logistic Regression for Believing: Ben Taub MDs.
Perception of
vulnerability at the
.883 10.066 .002 2.418
state level
(POSTVTX)
Reliability of informal
source of books 1.888 4.201 .040 6.607
(RELBOOKC)
Constant -7.278 11.985 .001 .001
Nagelkerke Model Chi-square Model Chi- Correctly

Model Summary
N = 48 0.606 28.741 p < 0.01 83.3%
The regression model for the Ben Taub RNs exhibited a good fit with a model
chi-square value of 94.62 that was significant at p < 0.01 (Table 9.5). Three of the five
tested independent variables contributed to believing. The receiver characteristic of
perception of vulnerability at the state level (POSTVTX) contributed to believing. A one
unit increase on the 11-point perceptual scale increased the likelihood of more believing
by a factor of 1.95. The message characteristic of informal source of friends and family
(INFFANDF) also contributed to believing. Respondents who utilized the informal
source of friends and family were more likely to be in the more believing category by a
factor of 4.08. The receiver characteristic of belief in the ability to detect bioterrorism
when symptoms are non specific (NONSPECID) contributed to believing. A one unit
206
increase on the 11-point perceptual scale increased the likelihood of more believing by a
factor of 1.22. The two variables that were not found to be statistically significant,
reported ethnicity (ETHNICRDC) and the formal source of work meetings (TRAIN4)
had weak bivariate associations with the dependent variable which might explain the lack
of findings. The pseudo R-square value was 0.48. The model correctly classified over 76
percent of the cases.
Table 9.5 Logistic Regression for Believing: Ben Taub RNs.
Perception of
state level .669 48.515 .001 1.952
(POSTVTX)
Informal source of
friends and family 1.406 9.933 .002 4.081
(INFFANDF)
Belief in detection
when symptoms are
.195 3.842 .05 1.215
non-specific
(NONSPECID)
Constant -7.031 42.797 .001 .001

Model Summary value
R-square and Sig. Classified
N = 212 0.481 94.624 p < 0.01 76.4%
The model for the LBJ RNs exhibited a good fit with a model chi-square value of
94.72 that was significant at p < 0.01 (Table 9.6). Perceiving personal vulnerability at the
state level (POSTVTX) was associated with believing. For every 1 point increase on the
11-point perceptual scale, the likelihood of being in the more believing category
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increased by a factor of 3.25. Beliefs held by the receiver regarding the ability to provide
early detection of bioterrorism by existing public health surveillance (ERLYDET) also
contributed to believing. Every 1 point increase on the 11-point perceptual scale
increased the likelihood of more believing by a factor of 1.43. Reliability of the informal
source of internet-based sources (RELINTC) was not identified by the model and had a
weak bivariate association with believing which might explain the lack of findings. The
pseudo R-square value was 0.68. The model correctly classified over 84 percent of the
cases.
Table 9.6 Logistic Regression for Believing: LBJ RNs.
VARIABLE
B WALD SIG. EXP(B)
(BELIEVECL)
Schooling Perception of
vulnerability at the state 1.179 34.838 .001 3.253
level (POSTVTX)
Belief in the ability to

provide early
identification .357 6.684 .010 1.429
(ERLYDET)
Constant -11.513 33.534 .001 .001

R-square square Sig. Classified
N = 126 0.683 94.722 p < 0.01 84.8%
The model for the public exhibited a good fit with a model chi-square value of
78.26 that was significant at p < 0.01 (Table 9.7). Perception of vulnerability at the state
level (POSTVTX) contributed to believing. A one unit increase on the 11-point
perceptual scale increased the likelihood of more believing by a factor of 1.83. A one
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unit increase on the perceptual scale regarding the ability of the government to provide
early detection (ERLYDETGV) decreased the likelihood of more believing by a factor of
0.83. Utilization of the informal source of broad cast media (INFMED) also decreased
the likelihood of more believing by a factor of 0.31. Reliability of conversations at work
(RELWKTKC) as a source of information increased the likelihood of more believing by
a factor of 3.30. The pseudo R-square value was 0.44. The model correctly classified
over 81 percent of the cases.
Table 9.7 Logistic Regression for Believing: Public.
VARIABLE
B WALD SIG. EXP(B)
(BELIEVECL)
Schooling Perception of
level (POSTVTX)
Belief in the ability to

provide early identification -.186 5.524 .019 .830
by the government
(ERLYDETGV)
Informal source of -1.182 5.694 .017 .307

broadcast media (INFMED)
Reliability of informal
source of conversations at 1.194 7.267 .007 3.301
work (RELWKTKC)
Constant -4.199 15.085 .001 .015

R-square square Sig. Classified
N = 227 0.442 78.262 p < 0.01 81.9%

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Influence of Antecedent Behavioral Stages
Two behavioral stages precede believing in the GMHRC process and each stage
was tested for bivariate association with believing (Table 9.8). Those with a bivariate
association were identified for inclusion in the model of believing and were added to the
set of retained independent variables. The behavioral stage of hearing had no association
with believing for any of the sample groups. The behavioral stage of understanding,
however, was associated with believing in the TSICP attendees, the Ben Taub RNs, and
the LBJ RNs.
Table 9.8 Behavioral Stage Simple Correlation to Believing.
TSICP BEN TAUB

STAGE ATTENDEES BEN TAUB MDS RNS LBJ RNS PUBLIC
HEARING (n.s) (n.s) (n.s) (n.s) (n.s)
0.188** 0.259** 0.262**

UNDERSTANDING
(n.s) (n.s)
N = 212 N = 228 N = 132
** Significant at the .01 level. (n.s) = not significant
The TSICP attendees’ model for believing found that understanding was
associated with believing. However, adding the behavioral stage of understanding to the
regression weakened the fit of the model (Table 9.9). The model chi-square value was
32.30 and was statistically significant at p < 0.01. Perceived vulnerability to future
occurrences at the state level (POSTVTX) was associated with understanding and was
dropped from the model when understanding was added. Respondents in the more
understanding category were more likely to be in the more believing category by a factor
210
of 4.75. The pseudo R-square value decreased by approximately half (0.19) as a result of
adding understanding. The model correctly classified 66.4 percent of the cases which was
about 8 percent lower than the model that did not include understanding.
Table 9.9 Logistic Regression for Believing: TSICP Attendees.
Understanding
1.557 12.055 .001 4.745
(UNDERSTANDCL)
Constant -1.835 11.672 .001 .160
Nagelkerke Model Chi-square Model Chi- Correctly

Model Summary
N = 211 0.189 32.297 p < 0.01 66.4%
As indicated by bivariate association, the behavioral stage of believing was
associated with the antecedent stage of understanding in the Ben Taub RNs.
Understanding was added to the original set of retained independent variables.
Respondents with higher levels of understanding were more likely to be in the more
believing category by a factor of 2.60 (Table 9.10). Perception of vulnerability and the
informal source of friends and family remained associated at similar levels. In the new
model, receiver belief in the ability to detect when symptoms are non-specific
(NONSPECID) was dropped when understanding was added. The model R-square
increased very slightly to 0.50 and the model correctly classified a few more respondents
(77.7 percent).
211
Table 9.10 Logistic Regression for Believing: Ben Taub RNs.
Perception of
.677 44.808 .001 1.872
state level
(POSTVTX)
Informal source of
friends and family 1.431 9.943 .002 4.185
(INFFANDF)
The behavioral stage

of understanding .956 5.712 .05 2.601
(UNDERSTANDCL)
Constant -6.860 46.524 .001 .002

Model Summary Value
R-square and Sig. Classified
N = 211 0.502 99.388 p < 0.01 77.7%
Understanding was added to the regression model of believing for LBJ RNs as an
independent variable. The model did not identify understanding as a statistically
significant contributor to believing and the findings remain identical to the original
regression.
Levels of believing were similar between the clinical sample groups and the
TSICP attendees despite the lower levels of formal training found in the Ben Taub MDs
as described in Chapter Six. The sample of TSICP attendees had 43.1 percent of
respondents in the higher level of believing. The Ben Taub MDs and the Ben Taub RNs
had approximately 45 percent of respondents in the more believing category. Half of the
212
LBJ RNs were in the more believing category. Perhaps the additional years of education
from medical school augmented believing among the Ben Taub MDs resulting in levels
of believing that were similar to the two samples of RNs. The public sample had the
lowest levels with only 25 percent of respondents in the more believing category.
The model for the TSICP attendees had one receiver characteristic that
influenced believing. Higher levels of perceived vulnerability at the state level increased
the likelihood of more believing.
Both of the tested independent variables contributed to believing in the sample of
Ben Taub MDs. The receiver characteristic of perceived vulnerability at the state level
(POSTVTX) influenced believing. Higher levels of perceived vulnerability increased the
likelihood of more believing. The message characteristic of reliability of book media
(RELBOOKC) also influenced believing. Respondents who perceived books were a
reliable source of information were more likely to be in the more believing category than
others.
Three of the five tested independent variables contributed to more believing in the
Ben Taub RNs. Like Ben Taub MDs, higher levels of perceived vulnerability at the state
level (POSTVTX) increased the likelihood of being in the more believing category. The
message characteristic of informal sources of information from friends and family
(INFFANDF) influenced believing. The Ben Taub RNs who utilized this informal source
of information were more likely to be in the more believing category than those who did
not. Perhaps those who utilized this informal source are more susceptible to risk
information or perhaps reporting this source is indicative of respondent receptivity and
interest. A belief based receiver characteristic also influenced believing. Respondents

213
who reported higher levels of belief in the ability to provide early detection of
bioterrorism when symptoms are non-specific (NONSPECID), were more likely to be in
the more believing category than others. This finding highlights the importance of
existing personal beliefs on the risk communication process in Ben Taub RNs. Training
from work meetings (TRAIN4) and ethnicity of respondent (ETHNICRDC) were not
found to contribute to believing which might be due to the weak bivariate relationship
with believing.
Two of the three tested independent variables contributed to more believing in the
LBJ RNs and both were receiver characteristics. Similar to the other clinical sample
groups, higher levels of perceived vulnerability at the state level (POSTVTX) increased
the likelihood of more believing. Personal beliefs regarding the ability of public health
surveillance to provide early detection of bioterrorism (ERLYDET) were associated with
believing. Higher levels of these beliefs increased the likelihood of being in the more
believing category. The message characteristic of reliability of internet-based sources of
informal information (RELINTC) did not exhibit an association with believing. The weak
bivariate association might explain the lack of multivariate findings.
All four of the tested independent variables contributed to more believing in the
sample of the public. Higher levels of perceived vulnerability at the state level
(POSTVTX) and reliability in the informal source of conversations at work
(RELWKTKC) both increased the likelihood of more believing. Higher levels of beliefs
in the ability of the government to provide early detection of bioterrorism
(ERLYDETGV) were associated with lower levels of believing. Utilization of the

214
informal source of broadcast media (INFMED) decreased the likelihood of more
believing.
The behavioral process of believing was found to be influenced by some receiver
characteristics and some message characteristics though the influencing characteristics
varied by sample group. Therefore, some support was identified for the general
hypothesis #3 which stated that the behavioral stage of believing was associated with
receiver and message characteristics. These findings indicate that the behavioral stage of
believing is somewhat responsive in certain populations.
A notable finding from all of the sample groups is that higher rates of perceived
vulnerability at the state level influenced believing. Increased levels of personal
vulnerability enhanced believing for all groups which emphasizes the importance of this
receiver characteristic on the bioterrorism risk communication process. Believing was
also influenced by personal beliefs regarding the ability to identify bioterrorism onset for
both samples of nurses but not for the sample of Ben Taub MDs.
The behavioral stage of understanding was added to the model of believing for the
TSICP attendees, the Ben Taub RNs, and the LBJ RNs as indicated by bivariate
association. The TSICP attendee model removed perception of vulnerability at the state
level and identified understanding as the single associated independent variable. The
pseudo R-square value dropped when understanding was added to the TSICP model from
0.36 to 0.19. The model of Ben Taub RNs removed belief in nonspecific detection of
bioterrorism and replaced it with the behavioral stage of understanding while the pseudo
R-square value was moderate (0.50). Respondents with more understanding had
215
increased levels of believing for the TSICP attendees and the Ben Taub RNs.
Understanding was not associated with believing in the model of LBJ RNs.
CHAPTER TEN
THE BEHAVIORAL STAGE OF CONFIRMING
“Confirming” follows “hearing,” “understanding,” and “believing” in the
GMHRC process (Blanchard-Boehm 1998, 252). The GMHRC simulates confirming
through a feedback loop in the risk communication process but the sequential order of
confirming among the behavioral stages might differ among receivers (Mileti,
Fitzpatrick, and Farhar 1990, 18; Blanchard-Boehm 1998, 254). The actual order within
the series of behavioral stages is less important than the actual behavior.
Confirming is defined as a behavior that occurs when the receiver undertakes
action to personally confirm, summarize, reinforce, or resolve unanswered questions
about the bioterrorism risk. Receivers may engage in confirming through various formal
sources, various informal sources, or a combination of both. Confirming provides an
opportunity to influence the GMHRC process by either reducing or increasing responding
or vigilance. Depending upon individual receiver characteristics, confirming might
reinforce skepticism and disbelief or enhance vigilance. Increased vigilance to
bioterrorism is the desired outcome of the GMHRC process.
The information to be confirmed might have originated from formal sources,
informal sources, or a combination of both. Each receiver had unique receiver
216
217
characteristics that formulated understanding, believing, and the need for confirmation
behavior. Each risk message had unique message characteristics that influenced
perceptions of credibility by the receiver for each source of risk information which
influenced the need for confirming. The hypothesis that guided this chapter is listed as
follows:
GMHRC behavioral stage of confirming the risk message.
Derivation of the Confirming Dependent Variable
The questionnaire ranked the sources through which respondents gained informal
bioterrorism information. Frequency of utilization was ranked through a four point
perceptual scale, ranging from ‘do not use’ (1) to ‘very frequently use’ (4) for seven
individual sources. To derive the dependent variable of confirming, the frequencies for
each source of informal information were first recoded to better reflect an ordinal scale of
utilization. The recoded scale ranged from the ‘do not use’ category of zero (instead of
one) to the ‘very frequently use’ category of three (instead of four).
A summative scale of confirming behavior was derived (CONFIRMING) by
summing the numerical values for each informal source of information. Summative
scales are created to capture the range and variety among a group of similar variables.
The potential values of confirming ranged from no confirming behavior from any source
(0) to the maximum potential value for all sources (21). Numerical values in this
summative variable reflect both the frequency of source selection and the numbers of
sources utilized.
218
The data for confirming did not have any natural breaks that might have provided
an ordinal scale dependent variable. Further, a 3-point ordinal scale was not possible
because too few respondents existed (TSICP attendees 4.6 percent, Ben Taub MDs 6.4
percent, Ben Taub RNs 3.5 percent, LBJ RNs 3.0 percent and the public 8.6 percent) to
create an ordered category for not confirming. Collapsing and dichotomizing the original
variable provided the best solution. Dichotomization enabled logistic regression and
provided a consistent statistical analysis for each behavioral stage. The dichotomized
dependent variable consisted of less confirming (previous values of 1 through 7 = 0) and
more confirming (previous values of 8 through 21 = 1). Respondents that did not engage
in confirming were classified as missing data and were excluded from the analysis of
confirming.
The levels of confirming differed between the five sample groups. The TSICP
attendees had 70.3 percent while the public had 61.6 percent of respondents in the more
confirming category (Table 10.1). The Ben Taub MDs had the lowest percentage (37.2
percent) of respondents in the more confirming category. The Ben Taub RNs had a
similar percentage to the public (61 percent) in more confirming. The LBJ RNs had
confirming percentages (48.1 percent) that ranked between the Ben Taub RNs and the
Ben Taub MDs.

219
Table 10.1 Confirming Dependent Variable Summary.
ORIGINAL FORM CONFIRMING composite variable of sources and

frequency of informal information Recoded from
OF VARIABLE FOR Q. 6
(range: 0 to 21)
CONFIRMING composite
COLLAPSED AND CONFIRMCL (DICHOTMIZED)

PERCENTAGE
DICHOTOMIZED No confirming = missing data
OF
0 = less confirming (1 - 7 original scale)
CONFIRMING RESPONDENTS
1 = more confirming (8 - 21 original scale)
No confirming 4.6
TSICP attendees
0 = less confirming 25.1
N = 216
1 = more confirming 70.3
No confirming 6.4
Ben Taub MDs
N = 61
No confirming 3.5
Ben Taub RNs
N = 231
No confirming 3.0
LBJ RNs
N = 131
No confirming 8.6
Public
N = 265
CHI-SQUARE TEST
Chi-square statistic = 35.795 P < 0.01
df = 4
220
The final preparatory steps for identifying independent variables for modeling of
the behavioral stage of confirming consisted of simple correlation tests performed with
the dependent variable. These tests identified which of the associated independent
variables were also associated with the dependent variable and should be retained.
Simple correlation tests also identified which of the remaining independent variables had
a bivariate association with the dependent variable and should be retained as listed in
Table 10.2.
Most of the informal sources of information were associated with confirming and
each other in the sample of TSICP attendees. The informal source of printed media
(INFPRINT) and the informal source of books (INFBOOKS) were both moderately
associated with confirming and with each other and the informal source of books was not
retained. The informal source of printed media was not associated with the source of
work meetings (INFMEET) so both were retained. The informal source of internet-based
media was also retained. The informal source of conversations at work (INFWKTK,
0.295) was associated with confirming but had a stronger association with meetings at
work and was not retained.
The Ben Taub MDs had only message characteristics that were associated with
confirming. None of the receiver characteristics had a bivariate association with
confirming. The informal sources of internet-based information (INFINT) and the
informal source of print media (INFPRINT) both had a weak to moderate association
with confirming and each other. The informal source of friends and family (INFFANDF)
had a weak to moderate association with confirming and was retained. The informal
221
source of print media was not retained because it had a stronger association with the
informal source of internet-based sources (INFINT) than to confirming. The informal
source of broadcast media (INFMED) had a weak association with confirming and had a
weak to moderate association with most other informal sources and was not retained.
The informal source of conversations at work (INFWKTK) had a moderate association
with confirming and was retained.
Similar to the Ben Taub MDs, none of the receiver characteristics had a bivariate
association with confirming in the Ben Taub RNs and only message characteristics were
retained for the model of confirming. Many of the informal sources of information were
correlated with each other as well as with confirming. The sources with the stronger
associations with confirming and weak to no association with other independent variables
were retained. The informal source of friends and family (INFFANDF) was associated
with many of the informal sources including conversations at work and was not retained.
The informal source of internet-based information was not retained because it was
associated with many of the informal sources including informal conversations at work
which contributed to the decision to not retain. Conversations at work (INFWKTK)
serve as a commonly known source for job related information in the nursing community.
Nurses are collaborative by nature and hospital nursing units are typically cohesive
groups with an abundance of work related conversation. The informal source of books
was not retained due to a weak relationship with confirming and weak associations with
the other informal sources. The informal source of printed media (INFPRINT),
conversations at work (INFMED), and work meetings (INFMEET) were retained because
of moderate association with confirming. Many of the reliability of informal source

222
variables exhibited weak associations with confirming as well as each other. Reliability
of the informal source of internet-based information (RELINTC) and conversations at
work (RELWKTKC) had a stronger (though still weak) association with confirming than
did the other reliability variables. Reliability in the source of internet-based information
was retained but reliability of work meetings was not because it had a moderate
association to the informal source of work meetings.
Different from the other two samples of clinicians, LBJ RNs had two receiver
characteristics as well as several message characteristics associated with confirming.
The receiver characteristics of belief in the ability to provide early detection (ERLYDET)
and experience with false alarms for bioterrorism (FALSEALM) had weak associations
with confirming and were retained. As in the other sample groups, many of the informal
sources were associated with each other. Four informal sources of information, meetings
at work (INFMEET), books (INFBOOK), broadcast media (INFMED), and work
conversations (INFWKTK) had a bivariate association with confirming and were retained
due to a lesser degree of association to each other and a stronger association with
confirming. Reliability of book media (RELBOOKC) and reliability of internet-based
information had weak associations with confirming and with each other. Reliability of
book media was retained due to its higher (though still weak) degree of association with
confirming.
The public sample had several receiver and message characteristics associated
with confirming. The source of bioterrorism training through a training course
(TRAIN1) and perception of vulnerability at the state level (POSTVTX) each had a weak
association with confirming and were retained. The two beliefs questions, belief in the
223
ability to provide early detection by the government (ERLYDETGV) and the belief in the
ability to provide early detection by the medical community (ERLYDETMC) were both
associated with each other and confirming. The association between early detection by
the government (ERLYDETGV) and confirming was stronger and it was retained. Many
of the informal sources were associated with confirming and with each other. The
informal sources of internet-based media (INFINT) and meetings at work (INFMEET)
were both retained due to their stronger association with confirming. The message
characteristic of reliability in the broadcast media (RELMEDC) was also retained.
Multivariate Modeling of Confirming
The model for the TSICP attendees had a good fit with a model chi-square value
of 62.97 that was significant at p < 0.01 (Table 10.3). The model identified all three of
the tested independent variables (message characteristics) as contributing to more
confirming. Utilization of the informal source of printed media increased the likelihood
of more confirming by a factor of 9.72. Utilization of the informal source of meetings at
work increased the likelihood of more confirming by a factor of 6.74. The informal
source of internet-based information also contributed to more confirming, but did so at a
lesser degree (2.71) than the other two informal sources. The model correctly classified
79.4 percent of the cases, and the pseudo R-square value was 0.38.
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Table 10.2 Independent Variables Retained for Regression of Confirming.
SAMPLE CORRELATION
CONFIRMCL INDEPENDENT VARIABLES
GROUP COEFFICIENT
Informal source of printed media (INFPRINT), N = 223 0.401***

TSICP
Attendees Informal source of meetings at work (INFMEET), N = 220 0.333**
Informal sources of internet-based information (INFINT), N = 55 0.205*
Informal source of internet-based information (INFINT), N = 55 0.317*

Ben Taub
MDs Informal source of conversations at work (INFWKTK), N = 53 0.531**
Informal source of friends and family (INFFANDF), N =45 0.366**
Informal source of conversations at work (INFWKTK), N = 223 0.519**
Informal source of printed media (INFPRINT), N = 223 0.525**

Ben Taub
RNs Informal source of broadcast media (INFMED), N =223 0.327**
Informal source of meetings at work (INFMEET), N = 220 0.371**
Reliability in internet-based information (RELINTC), N = 183 0.257**
Experience with false alarms (FALSEALM), N = 121 -0.217*
Belief in the ability to provide early detection (ERLYDET), N = 0.192*

131

LBJ RNs
Informal source of books (INFBOOK), N = 114 0.429**
Informal source of broadcast media (INFMED), N =119 0.359**
Informal source of conversations at work (INFWKTK), N = 118 0.474**
Reliability of the book media (RELBOOKC), N = 111 0.212*
Bioterrorism training course (TRAIN1), N = 264 0.179*
Perception of vulnerability at the state level (POSTVTX), N = 264 -0.276**
Belief in early detection by government (ERLYDETGV), N = 262 0.341**

Public
Informal source of internet-based information (INFINT) , N = 262 0.357**
Reliability of the broadcast media (RELMEDC), N = 245 0.390**

225
Table 10.3 Logistic Regression for Confirming: TSICP Attendees.
Informal source of
meetings at work 2.274 29.457 .001 9.717
(INFPRINT)
Informal source of
meetings at work 1.907 21.327 .001 6.736
(INFMEET)
Informal source of
internet-based information .995 5.232 .022 2.705
(INFINT)
Constant -2.024 17.874 .001 .132
Nagelkerke Model Chi- Model Chi-square Correctly

Model Summary
R-square Square value Sig. Classified
N = 209 0.380 62.965 p < 0.01 79.4%
The model for the Ben Taub MDs had a good fit with a model chi-square value of
29.45 that was significant at p < 0.01 (Table 10.4). All three of the tested independent
variables contributed to confirming and were message characteristics. Members of the
Ben Taub MDs who utilized the informal source of internet-based information had an
increased likelihood of more confirming by a factor of 7.93. The informal source of
conversations at work increased the likelihood of more confirming by a factor of 18.48
and the informal source of conversations with friends and family increased the likelihood
of more confirming by a factor of 7.86. The model correctly classified 84.5 percent of
the cases, and the pseudo R-square value was 0.54.

226
Table 10.4 Logistic Regression for Confirming: Ben Taub MDs.
Informal source of
internet-based information 2.071 6.280 .012 7.930
(INFINT)
Informal source of
conversations at work 2.917 9.362 .002 18.480
(INFWKTK)
Informal source of friends

2.062 5.415 .020 7.863
and family (INFFANDF)
Constant -2.813 12.606 .001 .060
Nagelkerke Model Chi- Model Chi-square Correctly

Model Summary
R-square square value Sig. Classified
N = 53 0.539 29.445 p < 0.01 84.5%
The model for the Ben Taub RNs exhibited a good fit with a model chi-square
value of 134.21 that was statistically significant at p < 0.01 (Table 10.5). Five tested
independent variables contributed to confirming and all were message characteristics.
The Ben Taub RNs who utilized the source of conversations at work increased the
likelihood of more confirming by a factor of 10.29. The informal source of print media
increased the likelihood of more confirming by a factor of 11.58. The informal source of
broadcast media and meetings at work increased the likelihood of more confirming by
factors of 2.91 and 2.58 (respectively). Believing in the reliability of internet-based
information as a source of informal information increased the likelihood of confirming by

227
a factor of 4.26. The model correctly classified greater than 83 percent of the cases, and
the pseudo R-square value was 0.62.
Table 10.5 Logistic Regression for Confirming: Ben Taub RNs.
Informal source of conversations

2.331 19.631 .001 10.289
at work (INFWKTK)
Informal source of meetings at

2.449 28.715 .001 11.578
work (INFPRINT)
Informal source of broadcast

1.070 5.541 .019 2.914
media (INFMED)

.948 4.633 .031 2.581
work (INFMEET)
Reliability in the source of

internet-based information 1.450 11.308 .001 4.263
(RELINTC)
Constant -3.598 37.232 .001 .027
Model Summary Nagelkerke Model Chi- Model Chi- Correctly

R-square square square Sig. Classified
N = 220 0.618 134.209 p < 0.01 83%
The model for the LBJ RNs exhibited a good fit with a model chi-square value of
61.59 that was statistically significant at p < 0.01 (Table 10.6). Two receiver
characteristics were retained in the model but only one contributed to confirming. False
alarms had a weak bivariate association to confirming which might explain the lack of
contribution to confirming. Different from the other two samples of clinicians, one
receiver characteristic contributed to confirming. Higher levels of belief in the ability to
provide early identification of bioterrorism increased the likelihood of more confirming

228
by a factor of 1.59. All four of the tested message characteristics contributed to
confirming in the LBJ RNs. Those who reported work meetings and books as informal
sources of information increased the likelihood of more confirming by factors of 7.53 and
46.02 respectively. Those who utilized the broadcast media or conversations with
coworkers to obtain informal information increased the likelihood of more confirming by
factors of 22.40 and 7.40 respectively. The model correctly classified greater than 80
percent of the cases, and the pseudo R-square value was 0.65.
Table 10.6 Logistic Regression for Confirming: LBJ RNs.
Belief in the ability to provide .465 7.495 .006 1.591

early detection (ERLYDET)
Informal source of meetings at 2.019 6.520 .011 7.529

work (INFMEET)
Informal source of books

3.829 11.672 .001 46.024
(INFBOOK)

3.109 13.955 .001 22.402
media (INFMED)
Informal source of
conversations at work 2.001 7.537 .006 7.395
(INFWKTK)
Constant -6.387 15.701 .001 .002

N = 119 0.651 61.586 p < 0.01 80.6%
The model for the public exhibited a good fit with a model chi-square value of
111.15 that was statistically significant at p < 0.01 (Table 10.7). Two receiver
characteristics contributed to more confirming. Perception of vulnerability at the state

229
level (POSTVTX) contributed to confirming. A one unit increase on the 11-point
perceptual scale decreased the likelihood of more confirming by a factor of 0.77. Belief
in the ability of the government to provide early detection of bioterrorism increased the
likelihood of more confirming. A one unit increase on the 11-point perceptual scale
increased the likelihood of more confirming by a factor of 1.36. Three informal sources
of information (message characteristics) also contributed to more confirming. Utilization
of meetings at work increased the likelihood of more confirming by a factor of 11.65
while the informal source of internet-based information increased the likelihood by a
factor of 4.28. Reliability in the informal source of broadcast media increased the
likelihood of more confirming by a factor of 3.46. The model correctly classified greater
than 79 percent of the cases, and the pseudo R-square value was 0.53.
Table 10.7 Logistic Regression for Confirming: Public.
Perception of vulnerability at the state level

-.262 8.313 .004 .769
(POSTVTX)
Belief in the ability to provide early

detection by the government .307 13.356 .001 1.359
(ERLYDETGV)
Informal source of meetings at work

2.455 10.175 .001 11.652
(INFMEET)
Informal source of internet-based

1.453 13.436 .001 4.276
information (INFINT)
Reliability of the broadcast media

1.242 9.702 .002 3.463
(RELMEDC)
Constant -.804 .934 .334 .448
Nagelkerke Model Chi- Model Chi- Correctly

Model Summary
N = 237 0.529 111.148 p < 0.01 79.4%

230
Three behavioral stages precede confirming in the GMHRC process and each
stage was tested for association with confirming (Table 10.8). Similar to the behavioral
stages of understanding and believing, no association with hearing was identified for any
sample group. Confirming was not influenced by any of the preceding behavioral stages
for TSICP attendees, Ben Taub MDs, and Ben Taub RNs. Bivariate tests indicated a
weak association between the behavioral stages of understanding and confirming in the
LBJ RNs. Believing and understanding were weakly associated with confirming in the
public.
Table 10.8 Behavioral Stage Simple Correlation to Confirming.
TSICP BEN TAUB

STAGE BEN TAUB MDS LBJ RNS PUBLIC
ATTENDEES RNS
HEARING (n.s) (n.s) (n.s) (n.s) (n.s)
0.213* 0.178**
UNDERSTANDING (n.s) (n.s) (n.s)
N = 128 N = 245
-0.326**
BELIEVING (n.s) (n.s) (n.s) (n.s)
N = 245
* Significant at the .05 level. (n.s) = not significant

The model of the LBJ RNs did not identify understanding as a statistically
significant contributor to confirming and the findings from the original model of
confirming stand. The public sample model for confirming was tested for association
with understanding and believing. The model exhibited a good fit with a model chi-
231
square value of 126.31 that was statistically significant at p < 0.01 (Table 10.9). The
model identified the same independent variables as well as the behavioral stage of
understanding as contributors to more confirming. Perception of vulnerability at the
state level and belief in the ability of the government to provide early detection increased
the likelihood of more confirming at a similar rate as the previous model. The same three
message characteristics, meetings at work, the informal source of internet-based
information and the reliability in the informal source of broadcast media increased the
likelihood of more confirming. Respondents with more understanding were more likely
to be in the more confirming category by a factor of 9.02. The model correctly classified
81 percent of the cases, and the pseudo R-square value increased slightly to 0.58.
Confirmation occurs through a feedback loop in the GMHRC process that may
enhance readiness and preparedness. Confirmatory behavior provides an opportunity to
increase bioterrorism knowledge, perceptions of vulnerability, and readiness. The sample
of TSICP attendees had 70.3 percent of respondents in the more confirming category
which was the highest levels of more confirming of any sample group. This compares to
the public sample that had 61.6 percent of members in the more confirming category.
232
Table 10.9 Logistic Regression for Confirming: Public.
Perception of vulnerability at the state

-.341 11.477 .001 .711
level (POSTVTX)
Belief in detection by the government

.308 11.535 .001 1.360
(ERLYDETGV)
Informal source of meetings at work

3.034 12.219 .001 20.778
(INFMEET)
Internet-based information (INFINT) 1.700 16.026 .001 5.475
Reliability of the broadcast media

1.044 6.323 .012 2.840
(RELMEDC)
Understanding (UNDERSTANDCL) 2.199 13.142 .001 9.019
Constant -2.143 4.583 .032 .117

Model Summary R-square square square Sig. Classified
N = 237 0.584 126.310 p < 0.01 81.0%
The levels of more confirming were different between the three clinical sample
groups. Members of the Ben Taub RNs sample exhibited the highest levels of more
confirming of the clinicians. The LBJ RNs reported levels of confirming that ranked
between Ben Taub RNs and Ben Taub MDs. Members of the Ben Taub MDs sample
exhibited the lowest levels of more confirming. An anecdotal explanation for lower
confirming levels within the Ben Taub MDs originated from informal conversations with
Ben Taub MDs. The medical doctors indicated they were too busy to engage in
information seeking behavior (confirming), especially considering that patient care duties
would have to be neglected during these activities. Perhaps the need for confirmation did
not supersede patient care duties in the context of their perceived level of risk at that
233
time. An exploration of how to best provide information to MDs with a lack of available
time for confirming would be an excellent topic for future research.
Regression modeling found partial support for the general hypothesis #4 which
stated that message and receiver characteristics are associated with confirming. All five
sample groups identified message characteristics with associations to the behavioral stage
of confirming.
The analysis of TSICP attendees identified all three of the tested independent
variables as contributing to confirming. The informal source of printed media increased
the likelihood of more confirming to the largest extent of the three source variables. The
informal sources of meetings at work and internet-based sources also increased the
likelihood of more confirming.
Three message characteristics contributed to more confirming among Ben Taub
MDs and all were informal sources of information. Informal risk information from
internet-based sources, conversations with coworkers, and conversation with friends and
family all contributed to more confirming.
The analysis of Ben Taub RNs identified all five of the tested message
characteristics as contributors to confirming. The informal sources of broadcast media,
and meetings at work increased the likelihood of more confirming. The informal sources
of conversations at work and printed media increased the likelihood of confirming to a
greater extent than the other three sources. Respondents who considered internet-based
information as a reliable source of information were also more likely to confirm than
others.
234
Four message characteristics were found to contribute to more confirming in the
LBJ RNs. However, this sample was the only clinical group that also identified a
receiver characteristic that contributed to confirming, though the contribution was small
in comparison to that of the message characteristics. The receiver characteristic, belief in
the ability to provide early detection of bioterrorism, slightly increased the likelihood of
more confirming. All four of the message characteristics that contributed to confirming
were informal sources of information. Those who reported work meetings, books,
broadcast media, or conversations with coworkers as sources of informal information
increased the likelihood of more confirming.
The public model identified two receiver characteristics that contributed to more
confirming. Increased levels of perceived vulnerability at the state level contributed to
confirming. Increased levels of belief in the ability of the government to provide early
detection of bioterrorism also increased the likelihood of more confirming. Three
sources of informal information (message characteristics) also contributed to more
confirming. Utilization of meetings at work, the informal source of internet-based
information increased the likelihood of more confirming. Reliability in the informal
source of broadcast media increased the likelihood of more confirming.
It is notable that none of the formal bioterrorism training sources were found to
contribute to more confirming. Only informal sources of information were found to
contribute. Informal sources of information do not typically provide the controlled
quality of information that might be provided by formal training. The findings of
informal sources combined with a lack of contribution by formal training sources
indicates that some might be more responsive to informal sources than to training.
235
Informal sources are readily available but might provide insufficient information that
generates the need for confirming. Informal sources might contribute to bioterrorism
readiness by stimulating or encouraging bioterrorism confirming behavior.
One informal source of information, conversations with coworkers was identified
as a contributor to increased confirming in all three clinical sample groups. Clinicians
should be encouraged to talk with peers about bioterrorism questions, issues, and
planning in an interactive manner. Credible sources of information might also be shared
during conversations with coworkers as a method of further enhancing readiness.
Departmental or unit meetings that address bioterrorism might facilitate this process.
Healthcare workers in large hospitals work in a collaborative manner with many other
people. Discussions during work meetings might augment information from formal and
informal sources.
Another notable finding stems from the lack of receiver characteristics that
contributed to confirming. Confirming was not generally found to be influenced by
receiver characteristics that were tested in this research. However, respondents were
found to be influenced by exposure to informal sources of information. The data
indicated that message characteristics (informal source types) dominate the behavioral
stage of confirming.
The antecedent behavioral stages did not contribute to the confirming model of
healthcare workers. The model for the public was associated with understanding though
the independent variables previously identified remained in the model and the pseudo R-
square value increased only slightly. These findings indicate confirming was not
associated with the preceding behavioral stages.

CHAPTER ELEVEN
THE BEHAVIORAL STAGE OF RESPONDING
According to the GMHRC, risk information progresses through the four
behavioral stages of “hearing,” “believing,” “understanding,” and “confirming” prior to
“responding.” This dissertation investigated bioterrorism training at the pre-emergency
level when vigilance for potential cases is the main requirement for readiness.
Responding was defined by vigilance to biological agent induced illnesses in patients.
Clinical vigilance is critical to bioterrorism readiness because it enhances the likelihood
of early detection and provides the greatest opportunity to reduce both person to person
transmission and secondary intra-hospital transmission of bioterrorism agents (Filoromo
et al. 2003).
To be considered vigilant, clinicians must perceive vulnerability to bioterrorism
occurrences within hospitals or medical facilities because these are the locations where
they might have opportunities to detect a bioterrorism occurrence. Increased levels of
clinical vigilance result from effective pre-emergency risk communication as receivers
personalize the risk information.
Information about the hazard of bioterrorism reaches healthcare workers from
both formal and informal sources of information. Clinicians have varying receiver
236
237
characteristics based on employment and personal distinctions that contribute to the
processing of risk information. This chapter tests receiver characteristics and message
characteristics for contribution to responding. The hypothesis that guided this chapter is
listed as follows:
GMHRC behavioral stage of responding to the risk message.
Derivation of the Responding Dependent Variable
Responding for TSICP attendees and clinicians was derived from the
questionnaire by assessing perceived personal vulnerability in the location where
clinicians evaluate patients. Respondents were asked to indicate their belief regarding the
likelihood that hospitals and medical facilities might be the target of a bioterrorism
attack. This question is interpreted as responding through vigilance because it assesses
responding to the risk posed by bioterrorist threats within healthcare facilities where
clinicians would actually evaluate patients.
Vigilance for the public was defined similarly but through a different question
that assessed household readiness. Healthcare workers possess vigilance at healthcare
facilities to be considered vigilant. The public were defined as vigilant if they perceived
vigilance personally within their homes.
The original form of the responding dependent variable was a 4-point ordinal
scale. The lowest category on the original scale was too small in size (TSICP Attendees
2.4 percent, Ben Taub MDs 9.7 percent, Ben Taub RNs 2.2 percent, and LBJ RNs 2.3
percent) to utilize the dependent variable without collapsing the four categories. To
maintain consistency in statistical methods throughout the behavioral stage analysis,

238
responding was collapsed and recoded into a dichotomous variable. Respondents who
reported the three lowest values were coded as less responding (0). Respondents who
reported the highest value were coded as more responding (1).
Approximately half of the TSICP attendees (48.9 percent) and a third of the Ben
Taub MDs (32.3 percent) were classified as more responding (Table 11.1). The Ben
Taub MDs had the lowest levels of any sample group. This compares to Ben Taub RNs
who had more responding in greater than half (53.7 percent) which was the highest levels
of responding. The LBJ RNs had 42.1 percent of respondents classified as more
responding. The sample of the public had 41.5 percent in the more responding category
using the different dependent variable for responding.
The final preparatory steps for identifying independent variables consisted of
simple correlation tests performed with the dependent variable (responding). First, a set
of tests identified which of the remaining independent variables had a bivariate
association with responding. Second, a set of tests determined which of the identified
independent variables were correlated with other independent variables. The decisions to
retain independent variables were based on the theoretical contribution to the model and
the strength of their relationship with responding. The independent variables that were
retained for testing are listed in Table 11.2.

239
Table 11.1 Responding Dependent Variable Summary.
“Responding:” Belief in likelihood that hospitals and

medical facilities might be the target of a bioterrorist attack
ORIGINAL FORM
OF VARIABLE FOR Q.19
RESPONDING
RESPONDING
1 = Not very likely 3 = Somewhat likely
2 = Somewhat unlikely 4 = Very likely
RESPONDCL (DICHOTMIZED)
COLLAPSED AND PERCENTAGE
Missing data = (excluded)
DICHOTOMIZED OF
0 = less responding (previous 1 , 2 and 3 values)
RESPONDING RESPONDENTS
1 = more responding (previous value of 4)
Missing data 3.2

TSICP Attendees
0 = less responding 47.9
N = 212
1 = more responding 48.9
Missing data 0
Ben Taub MDs
N = 61
Missing data 3.0

Ben Taub RNs
N = 224
Missing data 1.5

LBJ RNs
N = 131
CHI-SQUARE TEST
Chi-square statistic = 10.009 P < 0.05
df = 3
RESPONDCL (DICHOTMIZED INDHOUSE) Q. 25 i.

COLLAPSED AND Missing data = (excluded)
DICHOTOMIZED 0 = less responding (previous 1 , 2 and 3 values) PERCENTAGE
RESPONDING 1 = more responding (previous value of 4) OF
RESPONDENTS
Missing data 2.2

Public
N = 265
240
The sample of TSICP attendees had several receiver characteristics that were
associated with responding. Respondent age (AGE) and length of employment
(JOBLNGTH) both had weak associations (-0.18 and 0.13) to responding and to each
other. Respondent age had the stronger associations and was retained. Perception of
vulnerability at the state level (POSTVTX) (0.33) had a weak to moderate association
and was retained.
The sample of Ben Taub MDs had only two independent variables with a
bivariate association with responding. One message characteristic, the training source of
conferences (TRAIN3) had a weak association with responding (-0.27). One receiver
characteristic, the belief in detection of bioterrorism when symptoms are non-specific
(NONSPECID) had a weak association with responding (0.28).
For the sample of Ben Taub RNs, several message and receiver characteristics
had a bivariate association with responding. The formal training source of work meetings
(TRAIN4) had a weak bivariate association (0.15) with responding and a slightly stronger
association with perception of vulnerability at the state level (POSTVTX), so it was not
retained. Perception of vulnerability had a weak but stronger association with responding
(0.27) and was retained. Both previous experience (PREVEXP) with disasters and the
disaster impact of travel and commuting problems (TRAVEL) had an association with
each other and with responding. Previous experience with disasters was retained because
it had a stronger though still weak association (0.27) with responding. Respondent age
had a weak association with responding (0.14) but was not retained because it had an
even stronger association with perceptions of vulnerability and previous disaster
experience. The experience of false alarms for bioterrorism (FALSEALM) was

241
associated with responding (0.28) and was retained despite having a weak association
with previous disaster experience because of the importance of testing this receiver
characteristic for influence in the healthcare environment. The informal sources of
broadcast media (INFMED) and print media (INFPRINT) both had weak association
with responding and with each other. The informal source of broadcast media had the
strongest association (0.15) with responding and was retained.
The sample of LBJ RNs had only one independent variable with a bivariate
association with responding and it was a receiver characteristic. Perception of
vulnerability at the state level (POSTVTX) was retained and it had a weak association
(0.26) with responding.
The sample of the public had several independent variables with a weak bivariate
association with the public sample dependent variable for responding. Length of time at
job (JOBLNGTH) had a weak bivariate association (0.19) and was retained. Perception
of vulnerability at the state level (POSTVTX) and early detection by the government
(ERLYDETGV) both had a weak association with the dependent variable and with each
other. Perception of vulnerability at the state level was retained as it had a stronger
(though still weak) association (0.13) with responding. Respondent age (AGE) had a
weak association (0.20) with responding and was retained. The informal source of
meetings at work (INFMEET) had a weak bivariate association (0.13) with responding
and was retained. The reliability of conversations at work as informal sources
(RELWKTKC) was associated with responding and was retained.

242
Table 11.2 Independent Variables Retained for Regression of Responding.

VARIABLE
SAMPLE GROUP CORRELATION
COEFFICIENT
RESPONDCL Length of time at job

-0.178**
(JOBLNGTH)
TSICP Attendees
Perception of vulnerability at the
0.326**
Training source of conferences

-0.266*
(TRAIN3), N = 61
Ben Taub MDs
Belief in detection when
symptoms are non-specific 0.276*
(NONSPECID), N = 61

0.271**
Previous experience with

0.267**
disasters (PREVEXP), N = 230
Ben Taub RNs
Experience with false alarms
0.280**
(FALSEALM), N = 221

0.149*
media (INFMED), N= 202

LBJ RNs 0.257**
Length of time at job

0.192**
(JOBLNGTH), N = 253

0.127*
Public Respondent age (AGE), N = 261 0.195**

0.127*
work (INFMEET), N= 262
Reliability of conversations at
work as an informal source 0.150**
(RELWKTKC), N = 223

243
Multivariate Modeling of Responding
The model for the TSICP attendees had a chi-square value of 31.64 that was
statistically significant at p < 0.01 (Table 11.3). Both of the tested independent variables
were identified as contributors to responding. Length of time at occupation
(JOBLNGTH) actually decreased responding slightly. For every one year increase in
length, the likelihood of responding decreased by a factor of 0.96. Perception of
vulnerability at the state level (POSTVTX) was found to contribute to responding. A one
unit increase on the 11-point perceptual scale increased the likelihood of responding by a
factor of 1.43. The model correctly classified over 64 percent of the cases though the R-
square value was fairly weak (0.19).
Table 11.3 Logistic Regression for Responding: TSICP Attendees.
Length of time at job

-.044 6.320 .012 .957
(JOBLNGTH)
Perception of
vulnerability at the .355 22.035 .001 1.426
state level (POSTVTX)
Constant -2.544 15.800 .001 .079

Model Summary
N = 212 0.185 31.639 p < 0.01 64.6%

244
The model for the Ben Taub MDs had chi-square value of 4.37 that was
significant at p < 0.05 (Table 11.4). A receiver character was the only independent
variable that was identified by the model. Belief in detection when symptoms are non-
specific (NONSPECID) contributed to responding. A one unit increase on the 11-point
perceptual scale increased the likelihood of responding by a factor of 1.39. The training
source of conferences was not significant which might result from the weak bivariate
association with responding. The model correctly classified 62.9 percent of the cases.
However, the pseudo R-square value (0.11) was extremely weak.
Table 11.4 Logistic Regression for Responding: Ben Taub MDs.
Belief in detection when

symptoms are non-specific .329 4.037 .045 1.390
(NONSPECID)
Constant -2.237 7.463 .006 .107

Model Summary
N = 55 0.095 4.365 p < 0.05 62.9%
The model for the Ben Taub RNs had a good fit with a chi-square value of 35.00
that was statistically significant at p < 0.01 (Table 11.5). Three of the five tested
independent variables were identified as significant contributors to responding. The
independent variables without an association, the informal source of information from
broadcast media, had a weak association with the dependent variable which might
explain its lack of contribution to responding. Perception of vulnerability at the state
level (POSTVTX) was found to contribute to responding. A one unit increase on the 11-
245
point perceptual scale increased the likelihood of responding by a factor of 1.23.
Previous experience with disasters (PREVEXP) increased the likelihood of responding by
a factor of 2.10. Experience with false alarms (FALSEALM) increased the likelihood of
responding by a factor of 3.98. All three of the independent variables that contributed to
responding in the Ben Taub RNs were receiver characteristics. The model correctly
classified over 64 percent of the cases though the R-square value was weak (0.21).
Table 11.5 Logistic Regression for Responding: Ben Taub RNs.

.204 11.749 .001 1.226

.741 4.798 .028 2.098
disasters (PREVEXP)
Experience with false alarms

1.380 11.610 .001 3.975
(FALSEALM)
Constant -2.222 15.738 .001 .108

Model Summary
N = 207 0.208 34.998 p < 0.01 64.3%
The model for the LBJ RNs had a chi-square value of 8.96 that was significant at
p < 0.01 (Table 11.6). Only one independent variable was identified through multivariate
analysis. Perception of vulnerability at the state level (POSTVTX) contributed to
responding. For every one unit increase on the 11-point perceptual scale, the likelihood
of responding increased by a factor of 1.28. Greater than 58 percent of the cases were
classified correctly by this model but the model R-square value was (0.09) very weak.
246
Table 11.6 Logistic Regression for Responding: LBJ RNs.
Perception of
vulnerability at the .249 8.378 .004 1.283
Constant -2.328 10.065 .002 .097
Nagelkerke Model Model Chi- Correctly

Model Summary
R-square Chi-square square Sig. Classified
N = 131 0.089 8.964 p < 0.01 58.8%
The model for the public had a chi-square value of 19.04 that was significant at p
< 0.01 (Table 11.7). The dependent variable for public responding assessed vigilance at
the household level and is not directly comparable to the other sample groups. One
receiver characteristic and one message characteristic were identified through
multivariate analysis. Respondent age (AGE) contributed to responding. For every one
year increase, the likelihood of responding increased by a factor of 1.03. Utilization of
the informal source of meetings at work (INFMEET) also increased the likelihood of
responding by a factor of 2.48. Greater than 63 percent of the cases were classified
correctly by this model, but the model R-square value was weak (0.11).
247
Table 11.7 Logistic Regression for Responding: Public.
Respondent age
.032 8.146 .004 1.033
(AGE)
Informal source of
meetings at work .910 8.722 .003 2.484
(INFMEET)
Constant -2.233 17.397 .001 .107
Model Summary Nagelkerke Model Model Chi- Correctly

N = 221 0.113 19.044 p < 0.01 63.3%
Four behavioral stages precede the final stage in the GMHRC process and each
stage was tested for association with responding (Table 11.8). As for all other behavioral
stages, hearing did not contribute to responding. The public was the only group that had
no association of any behavioral stage and responding. Understanding had a weak
bivariate association with responding for all sample groups but the public. Believing
contributed to responding for the Ben Taub RNs and LBJ RNs. Confirming had a weak
bivariate association with responding in the LBJ RNs. Bivariate associations indicated
the behavioral stages to add to regression models as independent variables.

248
Table 11.8 Behavioral Stage Simple Correlation to Responding.
STAGE TSICP BEN TAUB BEN TAUB LBJ RNS PUBLIC

ATTENDEES MDS RNS
HEARING
(n.s) (n.s) (n.s) (n.s) (n.s)
0.274** 0.251* 0.349** 0.324**

UNDERSTANDING
(n.s)
N = 211 N = 61 N = 222 N = 131
0.210** 0.253**
BELIEVING
(n.s) (n.s) (n.s)
N = 224 N = 131
0.198*
CONFIRMING
(n.s) (n.s) (n.s) (n.s)
N = 127
* Significant at the .05 level. (n.s) = not significant

The responding model for the TSICP attendees had a slightly increased chi-square
value of 37.38 that was statistically significant at p < 0.01 (Table 11.9). Both of the
tested independent variables and the behavioral stage of understanding were identified as
contributors to responding. The influence of length of time at occupation (JOBLNGTH)
remained the same and decreased the likelihood of responding slightly. Perception of
vulnerability at the state level (POSTVTX) was found to contribute to responding at a
slightly reduced rate. Respondents in the more understanding category had an increased
likelihood of responding by a factor of 3.38. The model correctly classified slightly more
than the model without understanding with 66.8 percent of the cases classified correctly.
The R-square value remained weak but was slightly increased to 0.22.
249
Table 11.9 Logistic Regression for Responding: TSICP Attendees.
Length of time at job .960

-.041 5.286 .021
(JOBLNGTH)
Perception of
1.358
vulnerability at the .306 15.127 .001
Understanding
1.218 6.629 .010 3.379
(UNDERSTANDCL)
Constant -3.214 19.200 .001 .040

N = 212 0.219 37.832 p < 0.01 66.8%
Understanding was added to the original logistic regression model of responding
and was found to influence responding. Ben Taub MDs with more understanding were
more likely to be in the more responding category by a factor of 10.58 Table 11.10. This
large influence emphasizes the importance of understanding the risk message. The model
R-square value increased from an extremely weak value of 0.10 to the weak level of 0.33.
The importance of understanding on responding provides valuable feedback to the risk
communication process of Ben Taub MDs.

250
Table 11.10 Logistic Regression for Responding: Ben Taub MDs.
Belief in detection
when symptoms are .396 4.638 .031 1.486
non-specific
(NONSPECID)
UNDERSTANDCL 2.359 4.103 .043 10.582
Constant -4.371 7.967 .005 .013
Nagelkerke Model Chi- Model Chi Correctly

Model Summary
R-square square Square Sig. Classified
N = 61 0.328 16.607 p < 0.01 75.8%
Bivariate correlation tests indicated that the behavioral stages of both believing
and understanding were associated with responding in the Ben Taub RNs. Understanding
and believing were added to the original responding model as independent variables. The
receiver characteristic of previous experience with disasters had contributed to
responding before the behavioral stages were included but did not contribute in the new
model. Perception of vulnerability at the state level and experience with false alarms
remained as independent variables with similar association with responding (Table
11.11). The behavioral stage of believing did not contribute but understanding did
influence responding. Once again, understanding was found to be an important
behavioral stage. Respondents with more understanding were more likely to respond by a
factor of 3.65. The pseudo R-square values were 0.27 and 67.6 percent of the cases were
correctly classified.
251
Table 11.11 Logistic Regression for Responding: Ben Taub RNs.
Perception of
vulnerability at the .160 .160 .009 1.174
Experience with false

1.459 1.459 .001 4.300
alarms (FALSEALM)
The behavioral stage of

understanding 1.295 1.295 .001 3.651
(UNDERSTANDCL)
Constant -2.213 -2.213 .001 .109

Model Summary
N = 207 0.266 45.790 p < 0.01 67.6%
Bivariate tests indicated a weak association between the behavioral stages of
understanding, believing, and confirming on responding in LBJ RNs. The behavioral
stages were added to the regression model as independent variables along with the single
retained independent variable. Understanding was the only independent variable that
was found to contribute to responding and increased responding by a factor of 6.92
(Table 11.12). Perception of personal vulnerability at the state level (POSTVTX) was
not a contributing factor in this model but it was also associated with understanding
which might explain the results. The new pseudo R-square value (0.16) was
approximately double the previous value (0.09) though it was still weak. The model
correctly classified 1 percent more of the cases (59.8 percent).

252
Table 11.12 Logistic Regression for Responding: LBJ RNs.
The behavioral stage of

understanding 1.934 11.340 .001 6.915
(UNDERSTANDCL)
Constant -1.872 12.146 .001 .154
Nagelkerke Model Model Chi- Correctly

Model Summary
N = 127 0.159 15.268 p < 0.01 59.8%
According to the GMHRC, responding or vigilance to bioterrorism is formulated
based upon individual receiver and message characteristics following hearing,
understanding, believing, and confirming. This chapter tested receiver and message
characteristics for association with responding which is the final stage of the GMHRC
process. Investigation of responding among the clinical sample groups facilitated
quantification of factors important to responding.
During the pre-emergency stage of risk communication, levels of vigilance
provide feedback for effectiveness of previous bioterrorism risk communications. The
descriptive levels of sample group differences in responding might be interpreted as an
evaluation of readiness levels at HCHD. The findings provided feedback into actual
levels of responding or clinical vigilance which might serve as an indicator of the
likelihood of identifying bioterrorism during the critical early stages by HCHD clinicians.
The Ben Taub RNs had the highest levels of responding with 53.7 percent classified as
253
vigilant. The LBJ RNs had the second highest levels of vigilance at 42.1 percent. The
lowest level was found in the Ben Taub MDs, where only about one third was vigilant.
Slightly less than half of the TSICP attendees, and 41.5 percent of the public were
classified as vigilant.
Both of the tested independent variables were identified as contributors to
responding in the sample of TSICP attendees. Perception of vulnerability at the statet
level contributed to responding. Length of time at occupation actually decreased
responding slightly. Every single year increase in length decreased the likelihood of
responding slightly.
The Ben Taub MDs analysis identified one contributing factor to the behavioral
stage of responding. Receiver beliefs in the ability to provide early detection of a
bioterrorism occurrence when symptoms are nonspecific were associated with
responding. Higher levels of these beliefs were associated with an increased likelihood
of responding through clinical vigilance. The formal training source of conferences was
the only other independent variable that had been retained for testing through bivariate
association with responding and was not identified as a contributor to responding.
The Ben Taub RNs analysis identified several receiver and message
characteristics with a bivariate association to responding. Two independent variables,
previous experience with disasters and experience with bioterrorism false alarms had a
weak association with the dependent variable which might explain the lack of
contribution to responding. However, increased levels of perceived vulnerability at the
state level (POSTVTX) were found to increase responding. Receiver experience with
254
both disasters and with false alarms for bioterrorism also increased the likelihood of
responding in Ben Taub RNs.
The LBJ RNs only identified one contributing receiver characteristic to the
behavioral stage of responding. No other variables were identified through bivariate
association. Increased levels of perceived vulnerability at the state level were found to
increase responding. It is important to note the importance of perception of vulnerability
at the state level (POSTVTX) for both Ben Taub and LBJ RNs. Both samples identified
perceptions of vulnerability as a factor that contributed to increased levels of responding.
This finding emphasizes the importance of perception of vulnerability to the risk
communication process among registered nurses.
The sample of the public identified one message characteristic and one receiver
characteristic that contributed to responding. Increasing years of age among respondents
contributed to responding. Utilization of the informal source of work meetings also
served to increase responding among the public.
The regression models identified some limited support for the general hypothesis
#5 that specified message and receiver characteristics were associated with responding.
Some independent variables were identified for all groups but the pseudo R-square values
were weak. None of the tested independent variables for any of the sample groups
provided a moderate or strong contribution to responding.
To gauge the influence of the model behavioral stages on the risk communication
process, the dependent variables for each behavioral stage with a bivariate association
with responding were tested for influence. This research did not identify support for
linkages of all four of the GMHRC behavioral stages to responding within the niche field
255
of pre-emergency bioterrorism risk communication. It is likely that bioterrorism risk
communications are specialized and different from typical risk communications of
natural hazards to public audiences. Further, the somewhat controlled nature of formal
training might diminish the role of hearing. Between 83.9 and 93.6 percent of
respondents from all samples (Table 7.2) reported informal information about
bioterrorism. The lack of contribution of hearing on the subsequent behavioral stages by
all sample groups might be explained by the pervasive nature of bioterrorism information
from a variety of sources following the events of September 11, 2001 and the subsequent
anthrax attacks.
Hearing, believing, and confirming did not contribute to the models of
responding. However, the behavioral stage of understanding was found to influence
responding for all groups except the public. Respondents in the category of more
understanding had an increased likelihood of responding for all clinical sample groups
and the TSICP attendees. More understanding was important to responding or vigilance
and this finding emphasizes the importance of understanding on the bioterrorism risk
communication process.
CHAPTER TWELVE
CONCLUSIONS
This dissertation provided an examination of five sample groups with different
levels of occupationally generated engagement in pre-emergency bioterrorism risk
communication. This research sought to explain the receiver and message characteristics
that were influential to the GMHRC behavioral stages in the context of bioterrorism risk
communication. Information about how the GMHRC process differs between healthcare
professionals provides information about pre-emergency bioterrorism risk
communication theory.
Mileti, Fitzpatrick, and Farhar (1990, 16) defined risk communication as a process
as opposed to a singular event. The process concept is critical to understanding the
divergence and similarities in outcomes among the sample groups. Especially during
times of political unrest and increased potential risk, multiple sources of formal and
informal bioterrorism risk information provide varying opportunities for hearing.
Bioterrorism risk communication at the pre-emergency level should impart
readiness and preparedness information with a critical focus on the identification process
which poses unique challenges. Identification of bioterrorism onset, as discussed in
Chapter Two, relies on two different pathways to detect an occurrence. The first pathway
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257
involves a fragile but slowly improving public health system that includes temporal
delays in the detection and investigation of unusual trends that might result from the early
signs of bioterrorism. The second pathway consists of vigilance and clinical judgment
based on medical, temporal, and geographic characteristics of patients within the context
of their personal medical status or within the context of larger patient populations. The
second pathway is the focus of this research.
At the pre-emergency level vigilance to future bioterrorism occurrences becomes
the optimal GMHRC responding outcome. Vigilant clinicians who note unusual trends
and then act to verify or disprove their suspicions may provide the earliest achievable
notification of a bioterrorism occurrence. Greater levels of vigilance (responding)
increase the likelihood that clinicians will notice the subtle clues of a biological agent
within their patient populations.
Hypothesis #6 stated that the GMHRC behavioral stages are associated with
bioterrorism risk communication. Partial support for hypothesis #6 was identified but the
stages that influence responding were limited. The factors that were found to influence
the GMHRC behavioral stages are summarized in the following sections. These findings
highlight important characteristics within the risk communication processes that vary
according to sample groups which were defined by varying occupational roles.
The Behavioral Stage of Hearing
Hearing, the first behavioral stage of the GMHRC, was defined by receiving
bioterrorism risk messages through formal training and informal sources of information.
Sample group differences existed in levels of hearing of formal training between the
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sample groups. These differences indicate that the sample groups had occupationally
controlled levels of exposure to formal bioterrorism training. Levels of hearing informal
information between the sample groups were more similar than those of hearing through
formal training. Comparisons between the sample groups emphasized the role of
occupation upon the process for hearing bioterrorism risk information (Table 12.1).
While just over half of the sample of TSICP attendees reported formal training,
this sample likely over represents the untrained ICPs throughout the State of Texas. The
TSICP attendees reported the highest level of informal information of any of the sample
groups.
Mandatory employee bioterrorism readiness training was not effective at reaching
medical doctors. The Ben Taub MDs reported less formal training than any of the other
clinical groups. This finding emphasizes the importance of finding better and more
effective methods for providing formal bioterrorism training to medical doctors. It is
commonly known in healthcare that some physicians do not attend the ‘mandatory’
trainings courses that nurses and other staff typically attend. Use of informal sources of
information exceeded 80 percent of the sample but was still the lowest levels of any of
the healthcare workers.
The sample of Ben Taub RNs had levels of formal training that exceeded 83
percent. Informal information was reported by 92.6 percent of BT RNs. The levels of
formal and informal information were similar among LBJ RNs. Approximately 86
percent of LBJ RNs reported formal training. Ninety-two percent reported informal
sources of bioterrorism risk information. The employee training programs at HCHD

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were much more likely to have reached both samples of nurses than the sample of
medical doctors.
The public sample reported 21.5 percent of respondents had received formal
training. However, a definition of bioterrorism training was not provided in the
questionnaire and the percentage of reported training might overstate the actual levels of
formal bioterrorism training. Those employed outside of healthcare might have a more
relaxed definition of bioterrorism training than healthcare providers. The levels of
informal information reported by the public are very similar to the other sample groups.
The levels of informal information reported by the public may represent the baseline
levels of informal information that are generally available to most members of the public.
Table 12.1 Levels of Formal Training and Informal Information for all Sample Groups.
GROUP FINDING
• 51.6% reported formal bioterrorism training

TSICP Attendees
• 93.6% reported informal bioterrorism information
• 27.4% reported formal training

Ben Taub MDs
• 83% reported formal training

Ben Taub RNs
• 86% reported formal training

LBJ RNs
• 21.5% reported formal training

Public
The behavioral stage of hearing was largely found not to be influenced by the
receiver and message characteristics investigated in this dissertation (Table 12.2). The
regression model identified only one independent variable that influenced hearing in the
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TSICP attendees. Respondents who utilized the informal source of internet-based
information were more likely to hear than others. Perhaps this finding identifies the
importance of internet-based bioterrorism risk information to the sample of TSICP
attendees. However, the model pseudo-R square value was extremely weak.
The sample of Ben Taub MDs was the only clinical group that reported a
statistically significant regression model of hearing. The single independent variable
associated with hearing was the receiver characteristic of respondent age. As age among
Ben Taub MDs increased, so did the likelihood of hearing. Increasing respondent age
among Ben Taub MDs might have increased the likelihood that the doctor would
eventually attend formal training, especially older doctors who were not medical
residents.
The models for Ben Taub RNs and LBJ RNs had no statistically significant
variables that contributed to hearing. The generally high levels of formal training and
informal information in both samples of nurses might partially explain the lack of
independent variables that were associated with hearing among the two samples of
nurses. Two sources of informal information were found to contribute to hearing in the
public sample. Utilization of the informal source of broadcast media decreased hearing
by the public. This compares to utilization of meetings at work which increased hearing.
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Table 12.2 Findings for the Behavioral Stage of Hearing.
Independent variables Finding and Influence towards

Sample Group
Hearing of Formal Training
TSICP attendees Message Characteristic: Informal source of Utilization increased the likelihood of
Pseudo R-square value = internet-based information (INFINT) hearing
0.09
Ben Taub MDs Receiver characteristic: Respondent age (AGE) Increasing respondent age increased
Pseudo R-square value = the likelihood of hearing
0.72
Ben Taub RNs none none
LBJ RNs none none
Message Characteristic: The informal source of Utilization decreased the likelihood of

Public broadcast media (INFMED) hearing
Pseudo R-square value =
0.58
Message Characteristic: The informal source of Utilization increased the likelihood of
meetings at work (INFMEET) hearing
The Behavioral Stage of Understanding
Understanding the bioterrorism risk message is of utmost importance to
bioterrorism readiness, preparedness, and identification. The risk message includes
detailed information regarding the potential biological-terror agents, medical findings,
and important geographic and temporal clues the agents might present. As in other forms
of risk communication, understanding is a critical link in the communication process.
Descriptive sample group differences existed within the behavioral stage of
understanding among the five sample groups. The levels of more understanding were
higher among Ben Taub MDs (80.6 percent) than other clinical groups despite their
significantly lower levels of formal training. Approximately two thirds of the Ben Taub
RNs and three quarters of the LBJ RNs were classified as having more understanding.
The lower levels of understanding found among the nurses might partially result from
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their not having attended medical school, though none of the independent variables
support this supposition. Future research may utilize a different questionnaire that
quantifies and tests different receiver characteristics that may contribute to group
differences in understanding.
The TSICP attendees and the public had higher levels of understanding than the
clinical groups. The TSICP attendees reported 83.5 percent of respondents in the more
understanding category while the public had 86.1 percent. It seems doubtful that the
public would truly understand the risk message more than healthcare workers. Perhaps
future research might collect data on understanding from a medical perspective in order
to truly gauge medical understanding of the facts related to readiness and identification.
Several important contributors to the behavioral stage of understanding were
identified through regression in both samples of RNs (Table 12.3). However, none of
the independent variables contributed to understanding in the Ben Taub MDs. Sample
group differences might result from receiver characteristics that were related to
occupation but not directly assessed in the questionnaire. Additionally, the behavioral
stage of hearing did not contribute to understanding, though independent variables that
are related to hearing risk messages from informal sources contributed to understanding
in the TSICP attendees and the public.
An important finding from both samples of nurses is that increased levels of
perceived vulnerability at the state level (receiver characteristic) increased levels of
understanding. Perhaps perceiving vulnerability indicates perceived salience of the threat
within the receiver and facilitates understanding of the risk message. Respondents who
perceived personal vulnerability might have been more likely to listen and pay attention
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during training which would have increased their understanding. Respondents without
formal training may have found informal sources of information to augment their
understanding.
Ben Taub RNs identified the informal source of broadcast media as influential to
higher levels of understanding. It is not known whether the informal source of broadcast
media contributed to understanding or if reporting this source is indicative of increased
levels of concern that facilitate understanding. The experience of a false alarm for
bioterrorism also increased the likelihood of understanding. The events of September 11,
2001 and the subsequent anthrax attacks generated concern among some members of the
public and as a result occasionally presented to healthcare facilities expressing concern
over possible exposure to a bioterrorist agent. Approximately one quarter of nurses at
Ben Taub reported this experience. Perhaps having experienced the false alarm enhanced
understanding through the process of responding to the false alarm. Ben Taub is widely
known in the Houston, Texas medical community as a hospital that frequently receives
patients who believe they might have been in contact with a biological agent due to its
status as a publicly funded trauma center.
Support was also found for the importance of source of previous training among
LBJ RNs. Previous training through a disaster planning group decreased levels of
understanding in LBJ RNs. This finding indicated that LBJ RNs were possibly more
responsive to different sources of training than were Ben Taub RNs. One likely
explanation for this finding might be the very different types of hospitals where these
nurses are employed. Possibly the differences in level of care provided by these hospitals
resulted in populations of nurses who understand differently in response to varying

264
sources. If the population of registered nurses at LBJ may be generalized to the larger
population of nurses at similar hospitals, the finding of source sensitivity may be a
critical piece of feedback to nursing education programs.
The public sample identified one receiver characteristic and one message
characteristic as contributing to understanding. Similar to both samples of nurses,
increased levels of perceived vulnerability at the state level increased levels of
understanding in the public. Reliability of the broadcast media as a source of information
also contributed to more understanding. Perhaps the broadcast media provided
information that helped the public to better understand the risks posed by bioterrorism.
Table 12.3 Findings for the Behavioral Stage of Understanding.
Independent variables Finding and Influence towards

Sample Group
‘More understanding’
TSICP attendees Receiver Characteristic: Perception of Increased the likelihood

vulnerability at the state level (POSTVTX) of more understanding
Pseudo R-square value = 0.14
Ben Taub MDs none none
Receiver Characteristic: Perception of Increased the likelihood of more

vulnerability at the state level (POSTVTX) understanding
Ben Taub RNs
Receiver Characteristic: Experience with false Increased the likelihood of more
Pseudo R-square value = 0.15 alarms for bioterrorism (FALSEALM) understanding
Message Characteristic: Informal source of Increased the likelihood of more

broadcast media (INFMED) understanding

LBJ RNs vulnerability at the state level (POSTVTX) understanding

Message Characteristic: Disaster planning group Decreased the likelihood of more
(TRAIN2) understanding

Public vulnerability at the state level (POSTVTX) understanding

Message Characteristic: Reliability of the Increased the likelihood of more
broadcast media (RELMEDC) understanding
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The Behavioral Stage of Believing
The differences in levels of believing between the sample groups were small and
not statistically significant. All three clinical sample groups reported close to half of their
members believed the risk message. The Ben Taub MDs had slightly lower levels (45.2
percent) of more believing than the Ben Taub RNs (45.5 percent) and the LBJ RNs (50.4
percent). The TSICP attendees had 43.1 percent of respondents in the more believing
category while the public had 25 percent.
The regression models of believing varied from weak to somewhat strong pseudo
R-square values for all the sample groups. Perception of vulnerability at the state level
was the only variable that contributed to believing in the TSICP attendees. Increased
levels of perceived vulnerability increased the likelihood of more believing in TSICP
attendees as well as all other sample groups. The Ben Taub MDs had increased levels of
believing in those who thought books were a reliable source of information. Informal
sources of information from friends and family enhanced believing in the Ben Taub RNs.
This compares to the public sample which had a decrease in believing in those who
utilized the informal information source of broadcast media. However, the source of
formal training was not found to influence believing among any of the sample groups.
Higher levels of personal beliefs about the ability to detect bioterrorism were
found to increase the likelihood of believing in the samples of Ben Taub RNs, LBJ RNs,
and decreased it for the public. However, it should be noted that the independent
variables that assessed beliefs were not directly comparable between the sample groups.
Higher levels of perceived vulnerability to future bioterrorism occurrences at the
state level contributed to believing for every one of the sample groups. Methods of
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Table 12.4 Findings for the Behavioral Stage of Believing.
SAMPLE GROUP INDEPENDENT VARIABLES FINDING AND INFLUENCE

TOWARDS ‘MORE BELIEVING’
TSICP attendees Receiver Characteristic: Perception of Increased the likelihood of more

vulnerability at the state level (POSTVTX) believing

Ben Taub MDs vulnerability at the state level (POSTVTX) believing

Message Characteristic: Perceived reliability in Increased the likelihood of more
the informal source of books (RELBOOKC) believing

Ben Taub RNs
Message Characteristic: Informal source of Increased the likelihood of more
Pseudo R-square value = 0.48 friends and family (INFFANDF) believing
Receiver Characteristic: Belief in detection when Increased the likelihood of more

symptoms are non-specific (NONSPECID) believing

LBJ RNs vulnerability at the state level (POSTVTX) believing

Receiver Characteristic: Belief in the ability to Increased the likelihood of more
provide early detection (ERLYDET) believing

Receiver Characteristic: Belief in the ability to Decreased the likelihood of more

Public provide early detection (ERLYDETGV) believing

Message Characteristic: Informal source of Decreased the likelihood of more
broadcast media (INFMED) believing
Message Characteristic: Reliability of informal Increased the likelihood of more

source of conversations at work (RELWKTKC) believing
increasing perceived vulnerability personalization of the risk message might increase
believing of future bioterrorism risk messages. Future research may investigate methods
for increasing perceived vulnerability as a tool for enhancing believing.

267
The Behavioral Stage of Confirming
Differences within levels of confirming were found between the sample groups.
The TSICP attendees engaged in confirming at 70.3 percent, the highest level of any
sample group. The Ben Taub MDs engaged in confirming at the lowest level (37.2
percent) of any of the sample groups. The LBJ RNs engaged in confirming more than the
Ben Taub MDs at a rate approaching 50 percent. The Ben Taub RNs engaged in
confirming more than any clinical group at a rate of 61 percent. The public sample
engaged in confirming slightly more at a level of 61.6 percent.
The confirming model pseudo R-square values were weak to somewhat strong for
all of the sample groups and message characteristics were the predominant influence
(Table 12.5). Three informal sources increased the likelihood of more confirming among
the TSICP attendees and the Ben Taub MDs. Printed media, meetings at work, and
internet-based sources of informal information increased the likelihood of more
confirming in TSICP attendees. Internet-based sources, conversations at work, and
conversations with friends and family increased the likelihood of more confirming in the
Ben Taub MDs.
Utilization of four informal sources, broadcast media, meetings at work, printed
media, and conversations at work all increased the likelihood or more confirming among
the Ben Taub RNs. Receivers who believed in the reliability of internet-based
information (RELINTC) also increased the likelihood of more confirming. The LBJ RNs
reported three informal sources of information, meetings at work, book media, and
broadcast media that increased the likelihood of more confirming. Different from the
other two clinical groups, LBJ RNs had one receiver characteristic that also influenced
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more confirming. The LBJ RNs with higher levels of belief in the ability to provide early
detection of bioterrorism were more likely to be in the more confirming category.
The findings for the sample of the public were somewhat different than the other
sample groups and identified two receiver characteristics and three message
characteristics as contributing to confirming. Increased levels of perceived vulnerability
at the state level decreased the likelihood of more confirming. Conversely, increased
levels of belief in the ability of the government to provide early detection of bioterrorism
increased the likelihood of more confirming. Three message characteristics, informal
information from work meetings, internet-based information, and reliability of the
broadcast media all increased confirming in the public sample. The differences in
occupation between the public and the other samples might have contributed to the
different patterns of influence to confirming.
A notable finding from this section is the lack of identified contribution to
confirming by sources of formal training. Only informal sources of information
contributed to confirming. The lack of findings for formal sources might indicate that
confirming behavior is not influenced by formal training. Another notable absence was
the lack of influence by perception of vulnerability at the state level in the healthcare
providers.
The Behavioral Stage of Responding
Previous pre-emergency risk communication research quantified responding
through assessment of disaster planning, preparation, mitigation, or other actions
undertaken to mitigate loss. In the context of response to pre-emergency bioterrorism

269
Table 12.5 Findings for the Behavioral Stage of Confirming.
SAMPLE INDEPENDENT VARIABLES FINDING AND INFLUENCE TOWARDS

GROUP ‘MORE CONFIRMING’
TSICP Message Characteristic: Informal source of print media (INFPRINT) Increased the likelihood of more confirming
Attendees
Message Characteristic: Informal source of meetings at work Increased the likelihood of more confirming
Pseudo R- (INFMEET)
square value
= 0.380
Message Characteristic: Informal source of internet (INFINT) Increased the likelihood of more confirming
Message Characteristic: Informal source of internet-based information Increased the likelihood of more confirming
Ben Taub (INFINT)
MDs
Message Characteristic: Informal source of conversations at work Increased the likelihood of more confirming
Pseudo R- (INFWKTK)
square value
= 0.539
Message Characteristic: Informal source of friends and family Increased the likelihood of more confirming
(INFFANDF)
(INFWKTK)
Ben Taub Message Characteristic: Informal source of print media (INFPRINT) Increased the likelihood of more confirming
RNs
Message Characteristic: Informal source of broadcast media (INFMED) Increased the likelihood of more confirming
Pseudo R-
square value
= 0.618 Message Characteristic: Informal source of meetings at work Increased the likelihood of more confirming
(INFMEET)
Message Characteristic: Reliability in informal source of internet-based Increased the likelihood of more confirming
information (RELINTC)
Receiver Characteristic: Belief in the ability to provide early detection Increased the likelihood of more confirming
(ERLYDET)
Message Characteristic: Informal source of meetings at work Increased the likelihood of more confirming
LBJ RNs (INFMEET)
Pseudo R
square value Message Characteristic: Informal source of books (INFBOOK) Increased the likelihood of more confirming
= 0.651
Message Characteristic: Informal source of broadcast media (INFMED) Increased the likelihood of more confirming
(INFWKTK)
Receiver Characteristic: Perception of vulnerability at the state level Decreased the likelihood of more confirming
(POSTVTX)
Receiver Characteristic: Belief in the ability to provide early detection Increased the likelihood of more confirming
Public (ERLYDETGV)
Pseudo R- Message Characteristic: Informal source of meetings at work Increased the likelihood of more confirming
square value (INFMEET)
= 0.529
Message Characteristic: Informal source of internet-based information Increased the likelihood of more confirming
(INFINT)
Message Characteristic: Reliability in the broadcast media (RELMEDC) Increased the likelihood of more confirming
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readiness training within healthcare, the assessment of response to risk information
appeared most appropriately quantified through gauging vigilance to future bioterrorist
occurrences through personal perceptions of vulnerability. The preferred bioterrorism
risk communication outcome produces a state of vigilance.
Responding levels varied by sample group. The TSICP attendees had 48.9
percent of members classified as more responding. The highest levels of responding
were found in the Ben Taub RNs (53.7 percent) while the LBJ RNs had somewhat lower
levels (42.2 percent) of respondents classified as more responding. The Ben Taub MDs
had the lowest levels of any sample group (32.3 percent).
Regression modeling identified two receiver characteristics that contributed to
responding in the sample of TSICP attendees (Table 12.6). Perception of vulnerability at
the state level increased the likelihood of more responding. Higher levels of perceived
vulnerability have been linked to responding by previous research as referenced in
Chapter Three. Increased length of time at job actually slightly decreased the levels of
responding. The decreased levels of responding that coincide with greater lengths of
employment might possibly result from the lack of prior emphasis on the threats of
bioterrorism earlier in their careers.
The Ben Taub MD model identified only one contributing factor for the
behavioral stage of responding. Receiver beliefs in the ability to provide early detection
when symptoms are nonspecific were associated with responding. Higher levels of belief
in the ability to provide early detection were associated with an increased likelihood of
responding through clinical vigilance.

271
The Ben Taub RN model identified three receiver characteristics that influenced
responding. Previous experience with disasters and experience with false alarms for
bioterrorism increased the likelihood of responding in Ben Taub RNs. Higher levels of
perceived vulnerability at the state level were found to increase responding in both the
Ben Taub RNs and LBJ RNs. No other independent variables had been retained for
testing through bivariate association for the LBJ RNs.
The public respondents had two independent variables that contributed to
responding, though the pseudo R-square value was weak. The dependent variable for
responding assessed vigilance at the household level and is not directly comparable to the
other sample groups. One receiver characteristic and one message characteristic were
identified through multivariate analysis. Respondent age (AGE) contributed to
responding. Utilization of the informal source of meetings at work (INFMEET) also
increased the likelihood of responding.
None of the tested independent variables for any sample group provided a
moderate or strong contribution to responding. Perhaps future research may attempt to
define different message and receiver characteristics that contribute to responding.
However, it is important to note the importance of perception of vulnerability at the state
level (POSTVTX) for all sample groups except the Ben Taub MDs. Increased levels of
perceived vulnerability contributed to more responding. This finding emphasizes the
importance of perception of vulnerability to the risk communication process and to
responding among registered nurses.

272
Table 12.6 Findings for the Behavioral Stage of Responding.
SAMPLE GROUP INDEPENDENT VARIABLES FINDING AND INFLUENCE

TOWARDS ‘MORE RESPONDING’
TSICP Attendees Length of time at job (JOBLNGTH) Increasing time at job decreased
the likelihood of more responding
Pseudo R-square
value = 0.19 Perception of vulnerability at the state Increasing levels increased the
level (POSTVTX) likelihood of more responding
Ben Taub MDs Belief in detection when symptoms are Increasing levels increased the
non-specific (NONSPECID) likelihood of more responding
Pseudo R-square
value = 0.10
Perception of vulnerability at the state Increasing levels increased the

Ben Taub RNs
Previous experience with disasters Increased the likelihood of more
Pseudo R-square (PREVEXP) responding
value = 0.21
Experience with false alarms Experience increased the
(FALSEALM) likelihood of more responding
LBJ RNs Perception of vulnerability at the state Increasing levels increased the
Pseudo R-square
value = 0.090
Public Respondent age (AGE) Increased the likelihood of more

responding
Pseudo R-square
value = 0.11 Informal source of meetings at work Increased the likelihood of more
(INFMEET) responding
The final stage for analyzing the bioterrorism risk communication process added
the antecedent behavioral stages to the suite of retained independent variables to test for
influence of preceding behavioral stages. An important finding from this analysis of
responding is that the behavioral stage of understanding increased the likelihood of
responding for all sample groups but the public.

273
Adding understanding as an independent variable to the original regressions
increased the effectiveness of the model through the measure provided by pseudo R-
square values. The model of TSICP attendees increased from 0.19 to 0.22. The model of
Ben Taub MDs increased from 0.10 to 0.33. The Ben Taub RNs model increased from
0.21 to 0.27 while the LBJ RNs increased from 0.09 to 0.16. The inclusion of the
measure of understanding, while generally increasing the pseudo R-square, might have
eliminated the associated and potentially more straightforward independent variables.
Further, the increase in the pseudo R-square value only contributed substantial
improvement beyond what had already been established for the sample of the Ben Taub
MDs.
Clinical Sample Groups Summary
Ben Taub Medical Doctors Risk Communication Process
Chapter Six established that Ben Taub MDs had the lowest levels of previous
training. Chapter Eight established that Ben Taub MDs had the highest levels of more
understanding of the three clinical groups though the levels of more understanding
between the three groups were not different at statistically significant levels. Chapter
Nine established that Ben Taub MDs had the lowest levels of believing (45.2 percent)
though the levels were very similar between the three clinical sample groups. Chapter
Ten established that Ben Taub MDs had the lowest level of more confirming and the
differences between sample groups were statistically significant. The levels of
responding were lowest among Ben Taub MDs (32.3 percent) as identified in Chapter
Eleven.
274
It seems possible that the lower levels of responding among Ben Taub MDs are a
reflection of the initial low training levels, occupational inhibitions to confirmatory
behaviors, and a lack of available time—especially among medical residents—to engage
in the bioterrorism risk communication process. However, none of the training sources
were found to be associated with responding and this supposition is not supported. The
belief in the ability to detect bioterrorism when symptoms are nonspecific was the single
independent variable that contributed to responding in Ben Taub MDs. Increasing levels
of this belief increased responding or vigilance though the pseudo R-square value was
extremely weak. Perhaps future research might investigate different or more specific
receiver and message characteristics for influence. The lower levels of responding
emphasize the importance of determining better and more effective methods of increasing
vigilance in the Ben Taub MDs.
The final analytic method added the antecedent behavioral stages that exhibited a
bivariate association with responding to the regression model. The Ben Taub MDs had a
stronger influence from the behavioral stage of understanding than the other sample
groups. Increasing levels of understanding increased clinical vigilance while the other
behavioral stages did not contribute. Methods of increasing understanding among Ben
Taub MDs would be an important topic for future research as this dissertation did not
identify any independent variables as contributors to the behavioral stage of
understanding in the Ben Taub MDs.

275
Ben Taub Registered Nurses Risk Communication Process
The Ben Taub RNs had the highest levels of clinical vigilance of any of the three
clinical sample groups with 53.7 percent in the more responding category. The Ben Taub
RNs had 83 percent of respondents reporting previous formal bioterrorism training which
was similar to the LBJ RNs, but greater than the Ben Taub MDs. The Ben Taub RNs had
the lowest levels of understanding (67.5 percent) but the differences from other clinicians
were not large. The Ben Taub RNs had comparable levels (45.5 percent) of believing to
the Ben Taub MDs (45.2 percent). The Ben Taub RNs had a greater number (61 percent)
of respondents in the more confirming category than the other two clinical sample groups
and the differences in confirming were significant between the sample groups. The levels
of more responding were somewhat different among the sample groups and the Ben Taub
RNs had the highest levels (53.7 percent) of more responding of any of the sample
groups.
The Ben Taub RN model identified three receiver characteristics that influenced
responding and generated a weak pseudo R-square value. Previous experience with
disasters and experience with false alarms for bioterrorism increased the likelihood of
responding in Ben Taub RNs. Higher levels of perceived vulnerability at the state level
also increased responding in the Ben Taub RNs.
Based on bivariate associations, the behavioral stages of understanding and
believing were added to the regression. Believing did not contribute but understanding
did influence responding. The inclusion of the behavioral stages into the model removed
previous experience with disasters from the model of responding. Perception of
vulnerability at the state level and experience with false alarms for bioterrorism remained
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and along with the behavioral stage of understanding provided a weak though slightly
stronger pseudo R-square value.
Chapter Eight found that perception of vulnerability at the state level contributed
to understanding as did the informal source of media and the experience with false
alarms. False alarms contributed to both understanding and to responding which
emphasizes the value of these experiences on increasing vigilance. Disaster drills are
often planned and conducted without prior knowledge of hospital staff which also
presents an opportunity to practice response plans similar to a bioterrorism false alarm.
Possibly bioterrorism drills might present the same benefit as false alarms and this would
be an excellent topic for future research.
Lyndon Baines Johnson Registered Nurses Risk Communication Process
The levels of formal training in the LBJ RNs were higher than any other sample
group (86 percent). Almost three quarters of LBJ RNs were described as being in the
more understanding category. Greater than half (50.4 percent) of the LBJ RNs were in the
category of more believing. About half of the LBJ RNs were in the more confirming
category and the differences in confirming were significant between the sample groups.
The LBJ RNs engaged in confirming more than Ben Taub MDs but less than the Ben
Taub RNs. The sample of LBJ RNs had levels of responding (42 percent) that were
below those for the Ben Taub RNs (53.7 percent).
Similar to the Ben Taub RNs, higher levels of perceived vulnerability at the state
level were found to increase responding in the LBJ RNs. No other independent variables
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had been retained for testing through bivariate association for the LBJ RNs. However,
the model R-square value was very weak.
Bivariate association indicated a weak relationship between understanding,
believing, and confirming and responding and these behavioral stages were added to the
responding model. The stepwise regression model removed perception of vulnerability at
the state level and identified understanding as the only contributor to responding.
Chapter Eight established that perception of vulnerability at the state level increased
understanding while disaster planning groups decreased understanding in the LBJ RNs.
Therefore, increasing the levels of perceptions of vulnerability and understanding may
improve responding for this occupational group.
Comparison of Findings
A few researchers have begun to explore the bioterrorism risk communication
process within healthcare. Accurate and effective communication of the bioterrorism risk
is essential to effective response and recovery. Determining the factors that are critical
to successful risk communication among healthcare providers may provide feedback on
how to most effectively increase awareness and ensuing clinical vigilance.
During their annual meeting in 2000, focus groups from the Association for
Professionals in Infection Control and Epidemiology (APIC) were surveyed by Shadel
and colleagues (2001). The purpose of their study was to identify ICP educational
priorities for bioterrorism preparedness education. They found clear evidence regarding a
lack of bioterrorism awareness in the United States and also that deficiencies in
knowledge of the consequences of a bioterrorism attack were pervasive among ICPs and
278
healthcare professionals nationwide. Shadel and colleagues (2001) found a general lack
of bioterrorism awareness and planning among health care and public health
professionals. Low levels of perceived personal vulnerability indicated that the threat
and risk of bioterrorism has not been internalized. Even in New York City, with an
established history of terrorism that predates September 11, 2001, they found low to non-
existent perceptions of vulnerability to a future local occurrence of bioterrorism.
In a subsequent research project, Shadel and her team (2003) resurveyed ICPs and
other healthcare officials again in November 2001. Despite dramatic increases in general
concern for bioterrorism following the events of September 11, 2001, 57 percent of
respondents believed a bioterrorism occurrence was unlikely to occur within their local
community. They found a distinct and notable lack of perceived vulnerability for
bioterrorism at the local level. Since pre-emergency perception of vulnerability
influences readiness and response during an actual event, they recommended ongoing,
updated, and standardized bioterrorism readiness and preparedness training. Shadel and
her colleagues (2003) advised that more funding for training and education would
enhance readiness for bioterrorist threats as well as for naturally emerging diseases.
Sterling and colleagues (2005) assessed the ability of clinicians employed outside
of the typical healthcare environment for their ability to provide early identification of
unusual disease trends including bioterrorism. Their findings indicated that occupational
healthcare providers might potentially experience opportunities to identify emerging
diseases or biological agent induced disease activity within employees during the critical
nonspecific symptom period, prior to when employees obtained emergency treatment.
However, the fact that only a limited number of citizens across the nation were employed
279
at workplaces with occupational health care providers, limited the effectiveness of this
method for identifying unusual disease trends.
Very few studies have investigated bioterrorism perceptions among clinical
healthcare workers. Even fewer studies have investigated the complex factors that
contribute to internalizing bioterrorism education and formation of clinical vigilance.
Bioterrorism, from the perspective of the healthcare worker, has been underappreciated
and understudied. This research provided information regarding the bioterrorism risk
communication process including occupationally-generated receiver characteristics,
perceptions of risk, education and training, formal and informal sources, and personal
characteristics of healthcare workers and how these factors interact to formulate
vigilance.
This dissertation established levels of training, understanding, believing,
confirming, responding and perceptions of vulnerability for the hazard of bioterrorism
among the group of primary concern—the clinicians. The findings from this research
support the conclusions of Shadel and colleagues (2001, 2003) and further advance the
body of knowledge by modeling the risk communication process among registered nurses
and medical doctors.
Conclusions
The GMHRC provided a useful framework through which to investigate the
bioterrorism risk communication process within healthcare. However, all five of the
model behavioral stages did not contribute to responding. The investigation identified
important information about the bioterrorism risk communication process. The lack of
280
contribution on responding by the model stages of hearing, believing, and confirming
might result from the unique characteristics of bioterrorism risk communication. With the
exception of the public, analysis for all sample groups identified understanding as an
important contributor to responding.
As mentioned previously, bioterrorism training requirements within healthcare
mandate bioterrorism readiness training for employees but this process remains
imperfect. The mandatory training did not reach all employees, and bioterrorism training
remains unequally distributed. Stern (2003) found that during the 1990s, hospitals and
other organizations lacked training and preparedness for bioterrorism events.
Determining percentages of trained medical staff (Chapter Six) established levels of
previous formal bioterrorism training, which provided some measure of readiness and
preparedness levels at HCHD.
Levels of vigilance as gauged through perception of personal vulnerability to
future bioterrorism occurrences provided a surrogate variable that indicates levels of pre-
emergency risk information from formal and informal sources as well as the likelihood of
a behavioral response. As discussed in Chapter Three, higher levels of perceived
personal vulnerability are indicative of increased likelihood of vigilance, as well as
subsequent behavioral action.
Following hearing the risk message, the desired response outcome is vigilance or
clinical vigilance. Different from more ordinary risk communications issued to the
public—which strive to impart risk information in tandem with readiness and
preparedness advice to the at risk public—bioterrorism risk communications issued to
healthcare providers strives to encourage vigilance as a response. The preferred outcome

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is for clinicians to remain vigilant for unusual trends and subtle clues for potential
bioterrorism within their patient populations.
Vigilant clinicians that are educated about bioterrorism and are on alert for subtle
clues of bioterrorism, represent a hopeful solution to the temporal delays posed by
traditional public health surveillance. Responding to future bioterrorism occurrences
among clinicians might affect patient evaluation and diagnosis and may control early
recognition of an unusual syndrome trend. Clinicians who do not perceive themselves
and their community as at risk, might not consider the possibility of a biological agent
among the spectrum of potential diagnoses. Clinicians must perceive themselves and their
community as at personal risk to bioterrorism in order to consider the possibility of
bioterrorism occurrences among their patients.
Partial support was found for the behavioral stages of the GMHRC.
Communicating risk to clinicians in the healthcare environment is different from issuing
warnings of natural hazards to the general public. Some differences make the risk
communication process more effective. Some differences create greater challenges.
Therefore, enhanced understanding of receiver and message characteristics that influence
the risk communication behavioral stages are desirable to best determine what factors
increase vigilance. This study provided information on the nature and structure of
bioterrorism risk communication by utilizing the GMHRC framework to identify critical
factors to the process.
Hearing, believing, and confirming did not contribute to the models of
responding. However, the behavioral stage of understanding was found to influence
responding for all groups except the public. More understanding was important to
282
responding or vigilance and this finding emphasizes the importance of understanding in
the bioterrorism risk communication process. Understanding was found to be enhanced
predominately by perception of vulnerability to future bioterrorist events.
This dissertation was not intended to rate or judge vigilance to future bioterrorist
events through actual medical knowledge. Clinical vigilance to bioterrorism in the
healthcare environment presents unique challenges and an improved understanding of
vigilance in relation to medical facts associated with potential biological agents might be
warranted. Future research might define responding (clinical vigilance) in healthcare
providers from a medical perspective and rate knowledge about the identification
characteristics.
Recommendations
Two very important elements emerged in these findings. The first highlights and
reemphasizes the findings from all the previous chapters regarding the important
differences arising from occupational role. Each group exhibited different process
behaviors and different process outcomes. This finding once again demonstrates that
clinicians are not a homogenous group and the most effective training must consider this
fact. Different methods of training should be developed and made available to registered
nurses and medical doctors. Separate training allows for tailoring that encourages
positive vigilance outcomes by considering the important group differences.
In an effort to maximize clinical vigilance, healthcare organizations utilize formal
bioterrorism training, perhaps the lack of findings for formal training in this study
indicate informal sources are better suited to deliver risk messages to clinicians. Early
283
detection provides the greatest opportunity to reduce person to person transmission as
well as secondary intra-hospital transmission of bioterrorism agents (Filoromo et al.
2003). Contaminated health care facilities must be closed and evacuated and may not
treat patients, which further elevates any crisis, especially a bioterrorist event. The
importance of early detection emphasizes the need to define more specific contributors to
vigilance in future research.
Considering the importance of medical doctors in the bioterrorism event
identification process, creative and new educational methods must be tested, explored,
and developed. These methods might include peer based continuing medical education
requirements or additional residency requirements. Whatever actual training method is
determined to be the best, it will likely be a quick reference based refresher course
regarding the main temporal and geographic identifiers of unusual disaster that could
signal an unusual trend requiring increased levels of investigation. Shorter in duration,
quick refreshers of bioterrorism information may provide the necessary information
without the time constraints and aggravation created by mandatory training.
Further investigation of the differences in response outcome levels between LBJ
RNs and Ben Taub RNs would provide greater insight into the maximization of vigilance.
LBJ RNs exhibited somewhat lower (by 8 percent) levels of vigilance than Ben Taub
RNs, though as reported in Chapter Six, their experience with formal training was 3
percent greater.
Because of the identified sample group behavioral differences in the risk
communication process, it would not be advisable to provide the same type and format of
bioterrorism readiness information to different types of healthcare providers. All

284
clinicians require training regarding the diagnostic aspects of various bioterrorism agents
within their patient population. Training sources originating from highly credible
medical specialist may provide the information that MDs require to be vigilant for
bioterrorism without increased levels of confirmatory behavior. Like MDs, RNs have a
lack of time for confirmatory behavior and personal sources should be made readily
available to minimize time loss and maximize quality of information.
Risk messages must be tailored to meet the needs of each type of healthcare
worker. Training and educational materials should be made available to medical staff
from their preferred sources. Employers must also assure that preferred sources are
readily available for usage by their staff. In hopes that confirmatory behavior will
enhance vigilance, clinicians who received training from disaster planning groups, should
be provided with a list of available, reliable, and trusted sources for personally seeking
bioterrorism information. Additionally, it may be advisable to supplement previous
bioterrorism training from disaster planning groups with more typical formal bioterrorism
training courses.
Confirming serves as an important behavior feedback loop within the GMHRC
that may augment the hearing of risk messages. This confirmatory stage provides further
opportunities to encounter risk information and may result in increased levels of
perceived vulnerability and vigilance. In order to promote confirmatory behavior, formal
bioterrorism training should always provide identification of credible, updated, and well
respected sources for clinicians to look for more information, especially internet-based
information. Employers should assure that clinician have access to their preferred
sources of bioterrorism information.

285
Though hearing was not found to contribute to responding, readiness information
must still reach the clinician in an effective manner. The most effective risk message
(hearing) must be tailored to the particular audience in every way possible. Bioterrorism
risk communication must be approached from a holistic perspective considering job
responsibilities and duties and the inherent time obligations, limitations, and
opportunities. For example, many nurses and quite a few doctors do not have personal
computers at work. For these clinicians, there is little need to tout internet-based sources
of bioterrorism information. Accordingly, the same is true for any source. Access and
availability vary by healthcare facility and by clinician. Bioterrorism risk communication
programs should consider alternative approaches to clinical education through mass-
produced mandatory training. New and creative ways of imparting bioterrorism
education and information might be more successful than mandatory training that most
medical doctors do not have the time or inclination to attend. Further, jurisdictional
issues of leadership exist at many healthcare facilities, especially teaching hospitals.
Administrators may have the goal of educating all clinicians about the bioterrorism
hazard, but rigorous residency programs often preclude attendance at such bioterrorism
training.
Future Research of Receiver and Message Characteristics
It appears likely that more investigation of additional receiver and message
characteristics may be found to influence responding among healthcare providers.
Perceptions of vulnerability for bioterrorism among healthcare providers are complex
formulations that develop over time. Several receiver characteristics were found not to
286
be statistically significant contributors to perceptions of vulnerability. Future
investigations might investigate more specific receiver characteristics, such as
understanding medical facts of the bioterrorism training message in an effort to identify
what factors enhance understanding and belief of the medical facts. Future investigations
might also quantify more specific source types and source characteristics that may be
associated with increased responding among healthcare workers. Identification of
sources that enable provision of bioterrorism information in the context of the
complicated and frenetic healthcare environment could help identify more effective
pedagogic methods within the contemporary healthcare environment.

APPENDIX ONE-A
Bioterrorism Questionnaire for Medical Staff

The following set of questions asks for your beliefs, perceptions, and knowledge about bioterrorism
and threats of future occurrences. You may be assured that your responses are anonymous and
confidential. To assure anonymity, please do NOT write your name anywhere on this questionnaire.
We truly appreciate you taking the time to provide information.
As a token of our thanks, we would be happy to provide you with a copy of our final report. If you
would like a report, please e-mail Jeff Cook at jeffcook@geo.txstate.edu.
Q-1. What is you current occupation?

.
Q-2. How long have you been working in this occupation?

.
Q-3. Have you received training for bioterrorism?
YES [If YES, how many times_____?]
NO [If NO, please skip to Q-5].
Q-4. From what sources did you receive training or education regarding bioterrorism? .
Mandatory employee disaster training Other:________________________

General bioterrorism training _____________________________
_______Interagency disaster planning
Continuing education _____None
_______Disaster planning Meetings
From Meetings at Work
_______Conference
Q-5. Think back to your most recent bioterrorism training, did you believe your trainer was credible?
Circle One: Yes Somewhat-Credible NO NO bioterrorism training
What would have made the information more

useful?_________________________________________________
Q-6. By what other means have you gained information about bioterrorism? [Please rank the sources by
frequency of use, where: "1" = Do Not Use, "2" = Not Very Frequently Used, "3" = Somewhat
Frequently Used, and "4" = Very Frequently Used.
Broadcast Media [TV and Radio] Other:________________________

Print Media [Newspapers, Pamphlets, Brochures] _____________________________
_______Internet _____________________________
Books _____________________________
From Conversations with Co-Workers
From Family and Friends
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APPENDIX ONE-A
Q-8. Referring back to the same sources of information in Q-6, please indicate how reliable these sources
are for informing you about bioterrorism where: "1" = Would Never Rely On, "2" = Somewhat Reliable,
"3" = Very Reliable, and "4" = Excellent Source for Reliable Information.

_______Internet _____________________________
Books _____________________________
Any other source(s) not listed [Please list and indicate degree of reliability.]
TO ANSWER QUESTIONS Q-9, Q-10, AND Q-11, PLEASE THINK BACK TO THE TIME
BEFORE THE TERRORIST ATTACKS OF SEPTEMBER 11, 2001.
Q-9. What was your prior belief about the likelihood of a bioterrorism attack occurring anywhere in the
United States? [Please circle the number that indicates your estimate of the likelihood prior to September
11th.]
Not at All 50-50 Extremely

Likely Chance Likely
1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
State of Texas? [Please circle the number that indicates your estimate of the likelihood prior to September
11th.]

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
Q-11. What was your prior belief about the likelihood of a bioterrorism attack occurring anywhere in
your community? [Please circle the number that indicates your estimate of the likelihood prior to
September 11th.]

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
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APPENDIX ONE-A
TO ANSWER QUESTIONS Q-12, Q-13, AND Q-14, PLEASE THINK ABOUT THE TIME SINCE
THE TERRORIST ATTACKS OF SEPTEMBER 11, 2001.
Q-12. What do you now believe about the likelihood of a bioterrorism attack occurring anywhere in the
United States? [Please circle the number that indicates your estimate of the likelihood since September
11th.]

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
State of Texas? [Please circle the number that indicates your estimate of the likelihood since September
11th. ]

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
Q-14. What do you now believe about the likelihood of a bioterrorism attack occurring anywhere in your
community? [Please circle the number that indicates your estimate of the likelihood since September 11th.]

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
Q-15. What do you believe the chances are of a widespread bioterrorism attack of the magnitude of the
anthrax attacks that occurred through the U.S. postal system after September 11, 2001 happening again
anywhere in the United States?
1 out of chances
[Please place your estimate in the blank space.]
anywhere in the State of Texas?
1 out of chances
anywhere in your community?
1 out of chances
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APPENDIX ONE-A
Q-18. Please indicate your belief as to the likelihood that the following substances might be used for a
bioterrorism attack. [Please circle your choice: "1" = Not Very Likely, "2" = Somewhat Unlikely, "3" =
Somewhat Likely," and "4" = Very Likely.
Not Very Somewhat Somewhat Very

Likely Unlikely Likely Likely
A. ANTHRAX 1 2 3 4
B. BIOLOGIC TOXINS
(Botulism etc...) 1 2 3 4
C. HEMMORRHAGIC AGENTS
(Ebola etc.) 1 2 3 4
D. E-COLI 1 2 3 4
E. SMALLPOX 1 2 3 4
F. OTHER 1 2 3 4
G. OTHER 1 2 3 4
Q-19. Please indicate your belief as to the likelihood that certain locations or facilities might be the target of
a bioterrorism attack. [Please circle your choice: "1" = Not Very Likely, "2" = Somewhat Unlikely, "3"
= Somewhat Likely," and "4" = Very Likely.

A. Large Metropolitan Area 1 2 3 4
B. Small to Medium-Sized City 1 2 3 4
C. Rural Area, Outside City Limits 1 2 3 4
D. Government Buildings 1 2 3 4
E. Educational Institutions 1 2 3 4
F. Law Enforcement Buildings 1 2 3 4
G. Hospitals and Medical Facilities 1 2 3 4
H. OTHER 1 2 3 4
I. OTHER 1 2 3 4
Q-20. Do you believe bioterrorism will be noticed in the early stages when symptoms are non-specific?

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
290
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APPENDIX ONE-A
Q-21. Do you believe existing syndrome surveillance systems will provide timely identification of
bioterrorism?

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
Q-22. Do you believe bioterrorism will be distinguishable from ordinary syndrome trends?

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
Q-23. Have you ever experienced any kind of disaster(s) such as fire, flood, tornado, hurricane, chemical
spill, etc? (circle the number)
YES [If YES, please go on to Q-24]
NO [If NO, please skip to Q-25, next page and proceed].
Q-24. Please indicate the degree of your personal and property losses from that/those disaster(s)?
A. Most recent experience with a Disaster. Disaster Type:
NO LOSS
SMALL LOSS [$0 to $1,000]
MODERATE LOSS [$1,000 to $5,000]
LARGE LOSS [$5,001 to $10,000]
EXTREME LOSS [$10,001 or More]
B. Other disaster losses .Disaster Type:.

NO LOSS
LARGE LOSS [$5,001 to $10,000]
Q-24c. Were you or a family member ever injured in a disaster? Circle One: Yes No
Q-24d. Have ever been unable to drive or travel due to a disaster? Circle One: Yes No
Q-24e. Has your quality of life been affected by a disaster? Circle One: Yes No
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APPENDIX ONE-A
Q-25. Please indicate how prepared you believe the following entities should a bioterrorism attack occur
in your community within the next year. [Please circle your choice: "1" = Not Very Prepared, "2" =
Somewhat Unprepared, "3" = Somewhat Prepared" and "4" = Very Prepared.

Prepared Unprepared Prepared Prepared
A. Your Local Law Enforcement 1 2 3 4
B. Your Local Hospital 1 2 3 4
C. Federal Emergency Agencies 1 2 3 4
D. Your State Government 1 2 3 4
E. Your Local Government 1 2 3 4
F. Educational Institutions 1 2 3 4
G. Non-Governmental
Organizations [e.g., Red Cross] 1 2 3 4
H. Neighborhood Associations 1 2 3 4
I. Individual Households 1 2 3 4
J. OTHER 1 2 3 4
Q-26. Have you or your organization experienced false alarms for bioterrorism?
YES If yes, how many?______ ______NO
Q-26a. How do previous false alarms make you feel about future bioterror risks?
Circle One: More skeptical, Somewhat more skeptical, Somewhat less skeptical, Less Skeptical,
No Change
THESE FINAL QUESTIONS ARE FOR DEMOGRAPHIC PURPOSES. YOUR ANSWERS ARE
COMPLETELY ANONYMOUS. WE HAVE NO WAY OF KNOWING WHO YOU ARE.
Q-27. How many years of school have you completed? ________________
Q-28. What is your age? ________(years)
Q-29. In what state (U.S.) or country were you born? ____________________(place)
Q-30. With what ethnic group do you identify? [Please circle the number.]
1. ASIAN-AMERICAN 2. AFRICAN-AMERICAN 3. HISPANIC 4. NATIVE

AMERICAN
5. PACIFIC ISLANDER 6. WHITE [ANGLO] 7. OTHER (Please Specify)_____________
WE APPRECIATE YOUR PARTICIPATION. MANY THANKS!

292
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APPENDIX ONE-B
Bioterrorism Survey Questionnaire
Denise Blanchard-Boehm, Ph.D., Project Director

Bioterrorism in Texas Study
Department of Geography
Texas State University
James and Marilyn Lovell Center for
Environmental Geography and Hazards Research
San Marcos, Texas 78666-4616
confidential. We truly appreciate you taking the time to provide information for this project on this
very important topic.
would like a report, please e-mail Dr. Denise Blanchard-Boehm at rb06@txstate.edu or call at 1-512-
245-3090.
PLEASE BEGIN THE SURVEY:
Q-1. What is you current occupation?
Q-3. Is this the first time that you have attended a workshop on bioterrorism?
YES [If YES, please proceed to Q-5.]
NO [If No, please answer Q-4 and Q-5.]
Q-4. What training or information have you received prior to this workshop? [Please write your comments
on the following lines.]
Q-5. By what other means have you become knowledgeable about bioterrorism? [Please rank the sources by
frequency of use, where: "1" = Do Not Use, "2" = Not Very Frequently Used, "3" = Somewhat Frequently
Used, and "4" = Very Frequently Used.
Broadcast Media [TV and Radio]

Print Media [Newspapers, Pamphlets, Brochures]
Books
Any other source(s) not listed [Please indicate.]
.
[Please go on to Q-6.]
I have never learned anything about bioterrorism from other sources.

294
APPENDIX ONE-B

Books
From Previous Workshops and Conferences
11th.]

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
11th.]

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
September 11th.]

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
294
295
APPENDIX ONE-B
11th.]

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
11th. ]

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
community? [Please circle the number that indicates your estimate of the likelihood since September 11th.]

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
1 out of chances
1 out of chances
1 out of chances
295
296
APPENDIX ONE-B
bioterrorism attack. [Please circle your choice: "1" = Not Very Likely, "2" = Somewhat Unlikely, "3" =
Somewhat Likely," and "4" = Very Likely.
A. ANTHRAX 1 2 3 4
B. BOTULISM-RELATED 1 2 3 4
C. EBOLA 1 2 3 4
D. E-COLI 1 2 3 4
E. SMALLPOX 1 2 3 4
F. OTHER 1 2 3 4
G. OTHER 1 2 3 4
Q-17. Please indicate your belief as to the likelihood that certain locations or facilities might be the target
of a bioterrorism attack. [Please circle your choice: "1" = Not Very Likely, "2" = Somewhat Unlikely,
"3" = Somewhat Likely," and "4" = Very Likely.

H. OTHER 1 2 3 4
I. OTHER 1 2 3 4
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APPENDIX ONE-B
NO [If NO or DON'T KNOW, please skip to Q-21, next page and proceed].
DON'T KNOW
Q-19. If YES, please indicate the disaster(s)
Q-20. Please indicate the degree of your personal and property losses from that/those disaster(s)? [Please
indicate disaster in Part A., and estimate your total monetary loss from your experience by choosing a
category in Part B ].
A. Disaster
NO LOSS
LARGE LOSS [$5,001 to $10,000]
B. Disaster
NO LOSS
LARGE LOSS [$5,001 to $10,000]
Q-21. Please indicate how prepared you believe the following entities should a bioterrorism attack occur
in your community within the next year. [Please circle your choice: "1" = Not Very Prepared, "2" =
Somewhat Unprepared, "3" = Somewhat Prepared" and "4" = Very Prepared.

297
298
APPENDIX ONE-B
Q-22. Where is the location of your employment? [Please indicate your city/town and your county].
THESE FINAL QUESTIONS ARE FOR DEMOGRAPHIC PURPOSES. AGAIN, WE WANT TO

EMPHASIZE THAT YOUR ANSWERS ARE COMPLETELY ANONYMOUS. WE HAVE NO WAY
OF KNOWING WHO YOU ARE.
Q-23. How many years of school have you completed? ________(years)
Q-25. In what state (U.S.) or country were you born? ________(place)
1. ASIAN-AMERICAN 2. AFRICAN-AMERICAN 3. HISPANIC 4. NATIVE

AMERICAN
5. PACIFIC ISLANDER 6. WHITE [ANGLO] 7. OTHER (Please

Specify)___________________.
Q-27. Please indicate the range of your total household income. (Please check one)
OVER $100,000 $50,000-$99,999 $30,000-$49,999
$20,000-$29,999 $15,000-$19,999 LESS THAN $15,000
WE APPRECIATE YOUR PARTICIPATION IN THIS SURVEY.

MANY THANKS!
298
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APPENDIX ONE-C
Bioterrorism Questionnaire for the Public
Research Assistant Name:______________________ Date______________________________
confidential. To assure anonymity, please do NOT write your name anywhere on this questionnaire.
We truly appreciate you taking the time to provide information..
would like a report, please e-mail Jeff Cook at jeffrey@txstate.edu
Q-1. What is your current occupation?
Q-3. Have you received training for bioterrorism?
YES How many times?____
Q-4. Where did you receive training or education regarding bioterrorism?
Mandatory employee disaster training Other:________________________

General bioterrorism training _____________________________
_______Interagency disaster planning _____________________________
Continuing education
_______Disaster planning Meetings
_______Conference
Did you believe the training was credible?___ Yes ___ NO___ SOMEWHAT CREDIBLE
Q-5. By what other means have you gained information about bioterrorism? [Please rank the sources by
frequency of use, where: "1" = Do Not Use, "2" = Not Very Frequently Used, "3" = Somewhat
Frequently Used, and "4" = Very Frequently Used.

_______Internet _____________________________
Books _____________________________
I have never learned anything about bioterrorism from other sources.

300
APPENDIX ONE-C

_______Internet
_______Books
From Previous Workshops and Conferences
_______From Conversations with Co-Workers
11th.]

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
11th.]

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
September 11th.]

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
300
301
APPENDIX ONE-C
11th.]

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
11th. ]

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
community? [Please circle the number that indicates your estimate of the likelihood since September
11th.]

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
1 out of chances
1 out of chances
1 out of chances
301
302
APPENDIX ONE-C
bioterrorism attack. [Please circle your choice: "1" = Not Very Likely, "2" = Somewhat Unlikely, "3" = Somewhat
Likely," and "4" = Very Likely.
A. ANTHRAX 1 2 3 4
B. BIOLOGIC TOXINS
(Botulism etc...) 1 2 3 4
C. HEMMORRHAGIC AGENTS
(Ebola etc.) 1 2 3 4
D. E-COLI 1 2 3 4
E. SMALLPOX 1 2 3 4
F. OTHER 1 2 3 4
G. OTHER 1 2 3 4
Q-17. Please indicate your belief as to the likelihood that certain locations or facilities might be the target of a
bioterrorism attack. [Please circle your choice: "1" = Not Very Likely, "2" = Somewhat Unlikely, "3" = Somewhat
Likely," and "4" = Very Likely.

H. OTHER 1 2 3 4
I. OTHER 1 2 3 4
Q-18. Do you believe bioterrorism will be detected in the early stages by the medical community?

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
302
303
APPENDIX ONE-C
Q-19. Do you believe the government will provide timely identification of bioterrorism?

1 2 3 4 5 6 7 8 9 10 11
| | | | | | | | | | |
Q-21. Please indicate the degree of your personal and property losses from that/those disaster(s)?
A. Most recent experience with a Disaster. Disaster Type:
NO LOSS
LARGE LOSS [$5,001 to $10,000]
B. Other disaster losses .Disaster Type:.

NO LOSS
LARGE LOSS [$5,001 to $10,000]
Q-22. Were you or a family member ever injured in a disaster? Circle One: Yes No
Q-23. Have you ever been unable to drive or travel due to a disaster? Circle One: Yes No
Q-24. Has your quality of life been affected by a disaster? Circle One: Yes No
Q-25. Have you experienced false alarms for bioterror? Circle one: Yes No
If YES, how many?____________ If No, skip Q25a
Q-25a. How do previous false alarms make you feel about future bioterror risks?
Circle one More skeptical, Somewhat more skeptical, Neutral, Somewhat less skeptical, Less
Skeptical
303
304
APPENDIX ONE-C
Q-26. Please indicate how prepared you believe the following entities would be should a bioterrorism attack occur in
your community within the next year. [Please circle your choice: "1" = Not Very Prepared, "2" = Somewhat
Unprepared, "3" = Somewhat Prepared" and "4" = Very Prepared.

G. Non-Governmental
Organizations [e.g., Red Cross] 1 2 3 4
F. Neighborhood Associations 1 2 3 4
G. Individual Households 1 2 3 4
H. OTHER 1 2 3 4
THESE FINAL QUESTIONS ARE FOR DEMOGRAPHIC PURPOSES. YOUR ANSWERS ARE
COMPLETELY ANONYMOUS. WE HAVE NO WAY OF KNOWING WHO YOU ARE.
Q-27. How many years of school have you completed?_______________
High school Bachelor's degree Master's degree PhD
Q-29. In what state (U.S.) or country were you born? ____________________.
Q-30. Please indicate the range of your total household income. (Please check one)
LESS THAN $15,000 _______$20,000-$29,999 $50,000-$99,999
$15,000-$19,999 $30,000-$49,999 OVER $100,000
Q-31. How many children are you financially responsible for? _____
1. ASIAN-AMERICAN 2. AFRICAN-AMERICAN 3. HISPANIC 4. NATIVE AMERICAN
5. PACIFIC ISLANDER 6. WHITE [ANGLO] 7. OTHER (Please Specify)_____________
304
305
APPENDIX ONE-D
TSICP Attendees Questionnaire Crosswalk
Receiver Characteristics (Experiential, Occupational, and Demographic)
VARIABLE CROSSWALK
1. Length of employment Ratio JOBLNGTH Q.2 Independent
2. Dichotomous TRAINING Q.3 Part of the Dependent

Formal bioterrorism training Variable for Hearing
Informal sources of Part of the Dependent

3. Dichotomous INFTOT Q.5 Variable for Hearing
information

4. Dichotomous PREVEXP Q.18 Independent
disasters
Type of most recent previous

5. Nominal PETYPE1 Q.20 Described Only
experience
Dollar amount of damage Ordinal

6. DOLLAR1 Q.20a Described Only
from recent disasters
Type of other previous

7. Nominal PETYPE2 Q.24b Described Only
experience
Dollar amount from other

8. Ordinal DOLLAR2 Q.24b Described Only
damage
Personal or family injury Added after data

9. Dichotomous INJURY collection
from hazard
Inability to travel or commute Added after data

10. Dichotomous TRAVEL *
due to disaster collection
Quality of life affected by Added after data

11. Dichotomous QOFLIFE *
disaster collection
Number of years of schooling

12. Ratio SCHOOL Q. 23 Independent
completed
13. Age Ratio AGE Q.24 Independent
14. Income Ordinal INCOME Q.27 Independent
15. Nominal ETHNIC Q. 26 Independent

Ethnic group (8 categories)
305
306
APPENDIX ONE-D
Receiver Characteristics (Beliefs and Perceptions)
# TYPE OF VARIABLE QUESTIONNAIRE ROLE OF THE

QUESTION SUMMARY
VARIABLE NAME CROSSWALK VARIABLE
Prior to 9-11, perception of vulnerability for

1. Interval PRIORVUS Q.7 Descriptive Only
TX

2. Interval PRIORVTX Q.8 Descriptive Only
TX
3. Prior to 9-11, perception of local vulnerability Interval PRIORVCOM Q.9 Descriptive Only
4. Post 9-11, perception of vulnerability for US Interval POSTVUS Q.10 Descriptive Only
5. Post 9-11, perception of vulnerability for TX Interval POSTVTX Q.11 Independent
6. Post 9-11, perception of local vulnerability Interval POSTVCOM Q.12 Dependent
Perceived threat from various Biological agents ANTHRAX Q.16a

TOXINS Q.16b
HEMMRAGE Q.16c
7. Ordinal Descriptive
ECOLI Q.16d
SMALLOX Q.16e
OTHER Q.16f
Perceived threat for: Small to Medium City, LIKELRG Q.17a Dependent

Rural Area, Government Agencies, Educational LIKEMDM Q.17b Descriptive
Institutions, Law Enforcement, LIKERURL Q.17c Descriptive
8. Ordinal
LIKEGOVT Q.17d Descriptive
LIKEEDUC Q.17e Descriptive
LIKELE Q.17f Descriptive
Belief in early identification when symptoms NONSPECID * Added after data

9. Interval
are non-specific collection
Belief that surveillance will provide early ERLYDET * Added after data
10. Interval
identification collection
Belief that bioterrorism will be distinguishable DISTTREND * Added after data

11. Interval
from ordinary trends collection
Beliefs in Preparedness, during a potential LOCALLE Q. 21a Descriptive

attack within their local community in the next LOCHF Q. 21b Descriptive
year FEDAGNC Q. 21c Descriptive
STATEGOV Q. 21d Descriptive
12. Ordinal LOCGOV Q. 21e Descriptive
EDUINSTIT Q. 21f Descriptive
NONGOVEMR Q. 21g Descriptive
NEIGHASSN Q. 21h Descriptive
INDHOUSE Q. 21i Dependent
306
307
APPENDIX ONE-D
Message Characteristics Assessed in the Questionnaire (1).
# QUESTION SUMMARY
TYPE OF VARIABLE QUESTIONNAIRE ROLE OF THE
1 Added after data

Frequency of training Ratio FREQNCY
collection
2a. Source of formal training: TRAIN1- 7 Q. 4 Independent
2b. Mandatory disaster and general Independent

bioterrorism training
2c. Interagency and disaster Independent

planning meetings
2e. Work or unit meetings Dichotomous TRAIN4 Q. 4 Independent
2i. TRAIN5 to 7 (Collapsed Independent

categories)
3a. Formal training source Added after data

Ordinal CREDIBL
credibility collection
3b. Recode of CREDIBL Added after data

Dichotomous NEWCRED
(collapsed) collection

Q.5.
information:
307
308
APPENDIX ONE-D

4g. Conversations with INFWKTK Independent

Dichotomous Q.5.
co-workers
4h. Friends and family Dichotomous INFFANDF Q.5 Independent

REL___ Q.6
credibility: scale)
5b. Recoded informal Independent

Four categories
source credibility = (REL___C) Q.6 (recoded)
collapsed to two
(variable)
5c. Credibility of RELMED Independent

Dichotomous Q.6
broadcast media (RELMEDC)
5d. Credibility of print RELPRINT Independent

Dichotomous Q.6
media (RELPRINTC)
5e. Credibility of book RELBOOK Independent

Dichotomous Q.6
media (RELBOOKC)
5f. Credibility of RELCONF Independent

Dichotomous Q.6
conference (RELCONFC)

Dichotomous Q.6

RELWKTK
conversations with Dichotomous Q.6
(RELWKTKC)
co-workers
5i. Credibility of internet RELINT Independent

Dichotomous Q.6
–based information (RELINTC)
5j. Credibility of friends RELFANDF Independent

Dichotomous Q.6
and family (RELFANDFC)
5k. Recode (grouped

RELFANDFC,
Dichotomous RELCG Q.6 Independent
RELBOOKC and
RELWKTKC)
308
309
APPENDIX ONE-E
Public Questionnaire Crosswalk
Receiver Characteristics (Experiential, Occupational, and Demographic)
VARIABLE CROSSWALK
1. Length of employment Ratio JOBLNGTH Q.2 Independent
2. Formal bioterrorism Dichotomous TRAINING Q.3 Part of the Dependent

training Variable for Hearing
3. Informal sources of Dichotomous INFTOT Q.6 Part of the Dependent

information Variable for Hearing
4. Previous experience with Dichotomous PREVEXP Q.20 Independent

disasters
5. Type of most recent Nominal PETYPE1 Q.21a Described Only

experience
6. Dollar damage from recent Ordinal DOLLAR1 Q.21a Described Only

disasters
7. Type of other previous Nominal PETYPE2 Q.21b Described Only

experience
8. Dollar amount from other Ordinal DOLLAR2 Q.21b Described Only

damage
9. Personal or family injury Dichotomous INJURY Q.22 Described Only
10. Inability to travel or Dichotomous TRAVEL * Q.23 Independent

commute due to disaster
11. Quality of life affected by Dichotomous QOFLIFE * Q.24 Independent

disaster
12. Experience with false Dichotomous FALSEALM * Q.25 Independent

alarms
13. Number of false alarms Ratio NMBFALSE* Q.25 Independent
14. Effects of false alarms Ordinal FALSEPERC* Q. 25a Independent
15. Number of years of Ratio SCHOOL Q. 27 Independent

schooling completed
16. Age Ratio AGE Q.28 Independent
17. Ethnic group Nominal ETHNIC Q. 32 Independent

(8 categories)
309
310
APPENDIX ONE-E
Receiver Characteristics (Beliefs and Perceptions) Assessed in the Questionnaire
# QUESTION SUMMARY

1. Interval PRIORVUS Q.7 Descriptive Only
TX

2. Interval PRIORVTX Q.8 Descriptive Only
TX
Prior to 9-11, perception of local

3. Interval PRIORVCOM Q.9 Descriptive Only
vulnerability
4. Post 9-11, perception of vulnerability for US Interval POSTVUS Q.10 Descriptive Only
5. Post 9-11, perception of vulnerability for TX Interval POSTVTX Q.11 Independent
6. Post 9-11, perception of local vulnerability Interval POSTVCOM Q.12 Dependent
Perceived current chances of attack in the Not used-data

7. Ordinal CHANUS Q.13
US quality problems

8. Ordinal CHANTEX Q.14
TX quality problems

9. Ordinal CHANCOM Q.15
local area quality problems
Perceived threat from various Biological ANTHRAX Q.16a

agents TOXINS Q.16b
HEMMRAGE Q.16c
10. Ordinal Descriptive
ECOLI Q.16d
SMALLOX Q.16e
OTHER Q.16f
Perceived threat for: Small to Medium LIKELRG Q.17a Dependent

City, Rural Area, Government Agencies, LIKEMDM Q.17b Descriptive
Educational Institutions, Law Enforcement, LIKERURL Q.17c Descriptive
11. Ordinal
LIKEGOVT Q.17d Descriptive
LIKEEDUC Q.17e Descriptive
LIKELE Q.17f Descriptive
Belief that bioterrorism will be detected in NONSPECID

12. Interval Q. 18 Independent
the early stages by the medical community
Belief that the government will provide ERLYDET

13. Interval Q.19 Independent
early identification of bioterrorism
Beliefs in Preparedness, during a potential LOCALLE Q. 26a Descriptive

attack within their local community in the LOCHF Q. 26b Descriptive
next year FEDAGNC Q. 26c Descriptive
STATEGOV Q. 26d Descriptive
14. Ordinal LOCGOV Q. 26e Descriptive
EDUINSTIT Q. 26f Descriptive
NONGOVEMR Q. 26g Descriptive
NEIGHASSN Q. 26h Descriptive
INDHOUSE Q. 26i Dependent
311
APPENDIX ONE-E
# QUESTION SUMMARY
1 Frequency of training Ratio FREQNCY Q.3 a Independent
2a. Source of formal training: TRAIN1- 7 Q. 4 Independent
2b. Mandatory disaster and Independent

general bioterrorism Dichotomous TRAIN1 Q. 4
training
2c. Interagency and disaster Independent

planning meetings
2e. Work or unit meetings Dichotomous TRAIN4 Q. 4 Independent
2i. TRAIN5 to 7 (Collapsed Independent

categories)
3a. Formal training source Q.4 Independent

Ordinal CREDIBL*
credibility
3b. Recode of CREDIBL Independent

(collapsed somewhat
Dichotomous NEWCRED* Q.4 (recoded)
credible and not credible
into one category)

Q.5.
information:
312
APPENDIX ONE-E
Message Characteristics Assessed in the Questionnaire (2)

4g. Conversations with co- INFWKTK Independent

Dichotomous Q.5.
workers
4h. Friends and family Dichotomous INFFANDF Q.5. Independent

REL___ Q.6
credibility: scale)
5b. Recoded informal source Four categories Independent

(REL___C) Q.6 (recoded)
credibility = (variable) collapsed to two
5c. Credibility of broadcast RELMED Independent

Dichotomous Q.6
media (RELMEDC)
5d. Credibility of print media RELPRINT Independent

Dichotomous Q.6
(RELPRINTC)
5e. Credibility of book media RELBOOK Independent

Dichotomous Q.6
(RELBOOKC)
5f. Credibility of conference RELCONF Independent

Dichotomous Q.6
(RELCONFC)

Dichotomous Q.6

RELWKTK
conversations with co- Dichotomous Q.6
(RELWKTKC)
workers
5i. Credibility of internet – RELINT Independent

Dichotomous Q.6
based information (RELINTC)
5j. Credibility of friends and RELFANDF Independent

Dichotomous Q.6
family (RELFANDFC)
APPENDIX TWO-A
Texas State University Institutional Review Board Approval
313
314
APPENDIX TWO-B
Baylor College of Medicine Institutional Review Board Approval

315
APPENDIX TWO-C
Ben Taub Hospital Institutional Review Board Approval

316
APPENDIX TWO-C
Ben Taub Hospital Institutional Review Board Approval

317
APPENDIX TWO-D
Lyndon B. Johnson Hospital Institutional Review Board Approval

318
APPENDIX TWO-E
Cover Letter to Medical Staff
March 2006
Dear HCHD Clinician,
I am writing to ask for your participation on an important bioterrorism research project.

Participation means voluntarily completing the attached anonymous survey that assesses your
perceptions about bioterrorism. All responses are confidential and names are not written on the
questionnaire. Further, you may decide not to participate at any time, and you may decline to
answer any question for any reason.
This research project is being organized and conducted by Jeffrey Cook, a doctoral student at
Texas State University under the direction of Dr. Robert Atmar, Baylor College of Medicine, and
Dr. Denise Blanchard-Boehm, Texas State University.
This project will investigate attitudes and perceptions of bioterrorism from the perspective of
healthcare providers. Your time and input are greatly appreciated and could help to increase
national bioterrorism preparedness, but there is no direct compensation for completing the survey.
Please contact me or my Advisor with any questions, concerns, or for more information.
Thanks,
Jeffrey Cook
Jeffrey Cook, Doctoral Student Denise Blanchard-Boehm, PhD

Texas State University Texas State University
Lovell Center for Hazards Research Lovell Center for Hazards Research
Department of Geography Department of Geography
Phone: 281-536-2199 Phone: 512-245-3090
Email: Jeffrey@txstate.edu Email: rb06@txstate.edu
Baylor College of Medicine IRB, H-18510.
Harris County Hospital District IRB (H-18510). Effective 02/07/2006 through 01/07/2007
Texas State University IRB, 05-0045. Effective 10/14/2005 through 10/14/2006.

319
APPENDIX TWO-F
Information for Respondents
General Information Sources for Bioterrorism and For Stress

Generated By The Threat of Bioterrorism.
Rev. 10-12-2005
Much of the latest and greatest information on bioterrorism comes from the
Centers for Disease Control:
For more information by the internet, go to:

http://www.bt.cdc.gov/
By Phone:
800-CDC-INFO
888-232-6348 (TTY)
Or, email:
cdcinfo@cdc.gov
Disaster Related stress information from the Centers for Disease Control:
http://www.cdc.gov/search.do?image.y=5&image.x=10&action=search&queryTe
xt=disaster+stress&x=8&y=3
Stress and disaster support from Holistic Online.
http://www.holistic-online.com/Remedies/Biot/biot_home.htm
Parents coping with disaster:
http://www.nymc.edu/wihd/projectcope/pc/parentguide2.html
State of Texas, Department of State Health Services
For more information by the internet, go to:

http://www.dshs.state.tx.us/preparedness/bioterrorism/
By Phone:
(512) 458-7729
320
APPENDIX TWO-F
State of Texas, Mental Health Agency
Phone: 512-454-3761
Toll-Free: 800-252-8154 (statewide)
Internet: www.mhmr.state.tx.us
State Mental Health Protection and Advocacy Agency
Phone/TDD: 512-454-4816
Toll-free: 800-252-9108 (Nationwide)
Internet: www.advocacyinc.org
Texas Federation of Families for Children's Mental Health
Phone: 512-451-3191
Toll-free: 800-860-6057
E-mail: tmhc@tmhc.org
Internet: www.tmhc.org
For further information and assistance, you may also contact those who
are conducting this research.
Please e-mail Jeff Cook at jeffrey@txstate.edu or call 281-536-2199.
Supervisor: Dr. Denise Blanchard-Boehm, rb06@txstate.edu

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VITA
Mark Jeffrey Cook, the son of Mary Coerver Cook and William Herbert Cook,
Jr., was born in Dallas, Texas, on December 15, 1967. After graduating from John Paul
II High School in Fort Saskatchewan, Alberta Canada in 1986, he entered Texas A&M
University where he received a Bachelor of Science in Recreation, Parks, and Tourism
Science in 1993. He worked, as a research assistant and a geographic information
systems technician at the Texas General Land Office for Texas Land Commissioner
Garry Mauro for six years. While employed at the Texas General Land Office he
received a Master of Applied Geography from Texas State University-San Marcos in
1998. While completing his Master’s work, his interest and passion for geography and
hazards research solidified and he entered the Texas State doctoral program in fall of
1999. Following completion of the doctoral coursework he accepted an employment
offer at Harris County Hospital District, in Houston, Texas as a Disaster Planning
Coordinator. While employed at Harris County Hospital District, the conceptual need for
the topic of this dissertation was identified.
Permanent Address: 335 S. Camac Street

Philadelphia, Pennsylvania 19107
This manuscript was typed by Mark Jeffrey Cook.

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Geography, Department of

Theses and Dissertations-Geography

Communicating Risk of the Bioterrorism

This paper is posted at eCommons@Texas State University.

CASE STUDY IN HOUSTON, TEXAS OF HEALTHCARE

PROFESSIONALS AND THE GENERAL PUBLIC

Presented to the Graduate Council

for the Degree

M. Jeffrey Cook, B. S., M. A. G.

San Marcos, Texas

Mark Jeffrey Cook

It is impossible to mention specifically all of the people and actions that

Dubbelde, Wendy Benedict-Schneider, Robert Atmar, Johnnie Stein, Jean Brender,

This manuscript was submitted on December 21, 2006.

LIST OF FIGURES ....................................................................................................... xiv

CHAPTER ONE INTRODUCTION..............................................................................1

PURPOSE OF THE STUDY.......................................................................................3

CHAPTER TWO BIOTERRORISM RISK COMMUNICATION

CHAPTER THREE RISK COMMUNICATION THEORY AND

DEFINITIONS AND CONCEPTS............................................................................43

CHAPTER FOUR THEORETICAL FRAMEWORK .................................................82

THE GMHRC BEHAVIORAL STAGES .................................................................84

CHAPTER FIVE METHODS AND INSTRUMENTATION .....................................92

CHAPTER SIX DESCRIPTION OF SAMPLE DATA.............................................112

RECEIVER CHARACTERISTICS ........................................................................112

CHAPTER SEVEN THE BEHAVIORAL STAGE OF HEARING..........................168

SAMPLE GROUP DIFFERENCES IN HEARING................................................170

CHAPTER EIGHT THE BEHAVIORAL STAGE OF

DERIVATION OF THE BELIEVING DEPENDENT VARIABLE......................198

CHAPTER TEN THE BEHAVIORAL STAGE OF CONFIRMING .......................216

DERIVATION OF THE CONFIRMING DEPENDENT VARIABLE..................217

CHAPTER ELEVEN THE BEHAVIORAL STAGE OF

DERIVATION OF THE RESPONDING DEPENDENT VARIABLE..................237

CHAPTER TWELVE CONCLUSIONS....................................................................256

THE BEHAVIORAL STAGE OF HEARING........................................................257

ONE SURVEY INSTRUMENTS AND VARIABLE CROSSWALKS………….287

TWO SUPPORTING DOCUMENTATION………………………………………313

REFERENCE LIST .......................................................................................................321

2.1 Summary of Possible Bioterrorism Identification Scenarios..................................... 29

3.1 Definition Latitude of Risk Communication ............................................................. 44

3.2 Important Factors of Risk Perception and Evaluation ............................................... 61

5.1 Completed Questionnaires by Group....................................................................... 103

6.1 Formal Training Levels............................................................................................ 113

6.2 Percentage of Informal Sources of Information....................................................... 114

6.3 Percentage of Previous Disaster Experience............................................................ 115

6.4 Percentage Damage Amounts from Most Recent Disaster...................................... 116

6.5 Percentage Damage Amounts from Other Disasters ............................................... 117

6.6 Impacts from Previous Disasters by Percentage...................................................... 117

6.7 Experience with False Alarms for Bioterrorism ...................................................... 118

6.9 Mean Years of Education........................................................................................ 120

6.10 Length of Employment at Current Occupation....................................................... 121

6.11 Respondent Ethnicity by Percentage ...................................................................... 122

6.12 Respondent Age in Years........................................................................................ 122

6.13 Receiver Characteristics (Experiential, Occupational, and Demographic) ............ 124

6.14 Beliefs About Bioterrorism Readiness.................................................................... 126

6.17 Beliefs Regarding Facility Targets of a Bioterrorist Attack ................................... 130

6.21 Receiver Characteristics (Beliefs and Perceptions) ................................................ 135

6.22 Formal Bioterrorism Training Frequency............................................................... 137

6.23 Reported Training Sources Among Trained Respondents...................................... 140

6.24 Informal Sources of Information (1)....................................................................... 142

6.25 Usage of Informal Sources of Information (2) ....................................................... 144

6.26 Perceived Credibility of Formal Training............................................................... 145