ORRHES Meeting Minutes
August 26, 2003

Agenda Review, Correspondence and Announcements

Agenda Review. . Dr. Davidson noted the following changes to the published agenda. The discussion on the final draft report of the ORR needs assessment would begin at 2:15 p.m. instead of 2:45 p.m. The floor would be opened for public comments at 2:45 p.m. instead of 3:30 p.m. ORRHES’s vote on the needs assessment recommendations at 2:55 p.m. and an open forum with ATSDR staff at 3:00 p.m. were added as separate agenda items. The presentation on next steps in health education activities was deleted from the agenda.

All other agenda items remained the same: the needs assessment overview, discussion and recommendations beginning at 12:35 p.m.; remaining work group reports, recommendations and votes beginning at 4:00 p.m.; an update on the project plan at 5:45 p.m.; and ORRHES business beginning at 6:30 p.m. Mr. Lewis pointed out that before these changes were made to the agenda, an hour was set aside for him to present the Health Education Needs Assessment Work Group (HENAWG) findings and lessons learned from the project. His presentation on the needs assessment recommendations was now included in this agenda item, but his understanding was that the full hour would still be set aside for him to present the original topics.

Regardless of the revisions to the agenda, Mr. Lewis conveyed that the meeting should still be flexible to accommodate his full presentation and other unexpected items arising from ORRHES’s deliberations. He also emphasized the need for workgroup discussions to be clearly documented in writing to minimize any misunderstanding. Ms. Sonnenburg conveyed that ORRHES typically listens to presentations, engages in a discussion and takes a break before a vote is taken on recommendations. This approach allows the members to discuss recommendations off the record before the chair calls for a vote. However, this practice was not followed in the modified agenda.

To address this issue, Dr. Davidson should ask if ORRHES is ready to vote on the needs assessment report or needs more discussion time when the floor is opened for this agenda item. Ms. Sonnenburg added that she was not aware of these changes because the agenda was revised after the Agenda Work Group developed the document. Dr. Davidson responded to the comments as follows. The revised agenda is flexible and accommodates all issues ORRHES needs to address during the meeting. The changes were based on her discussion with ATSDR staff on the previous day. ORRHES’s vote on the needs assessment recommendations was added as a separate agenda item before the open forum with ATSDR because staff cannot make any comments to prejudice the vote. However, Dr. Davidson agreed to inquire about ORRHES’s readiness to vote on the document when the floor is opened for this agenda item.

Correspondence. No correspondence was noted for the record.

Announcements. Ms. Spencer distributed the current membership roster and asked the members to review their contact information for accuracy or make changes as needed. She mentioned that e-mail messages to some members have been returned to ATSDR as “undeliverable.”

Review of June 2003 ORRHES Meeting Minutes

Dr. Davidson entertained a motion to approve the previous meeting minutes. Mr. Hill so moved; Mr. Washington seconded the motion. There being no abstentions, opposition or further discussion, the June 3, 2003 ORRHES Meeting Minutes were unanimously approved with no changes.

Review of Pending ORRHES Action Items

Ms. Spencer provided a status report of three items listed as “pending” on the ORRHES list of recommendations and action items.

1. The Division of Health Education and Promotion (DHEP) will return to future ORRHES meetings to discuss health education programs that will be conducted in Phase II of the needs assessment.
   
2. ATSDR provided ORRHES with data on the uncertainties for air releases modeled in the Task 6 Report. Ms. Susan Kaplan’s initial request for this information was included in the briefing packets for the current meeting.
   
3. Mr. Jack Hanley of ATSDR will speak with Dr. Timothy Joseph of DOE to clarify the suggestion to update the compendium of all health-related research studies conducted at Oak Ridge. The outcome of this discussion will be reported at the next ORRHES meeting.

Update on the ORR Needs Assessment

Overview. Ms. Donna Mosby, the HENAWG Co-Chair, noted that HENAWG received the final draft needs assessment report in June 2003. The document was also distributed in the pre-meeting briefing packets for review by the remaining ORRHES members. She highlighted the key outcomes of the report. The goal of the needs assessment was to facilitate health decision-making of ORR residents. The project was designed to be completed in two phases with the needs assessment being conducted in Phase I and follow-up activities being implemented in Phase II. The purposes of the needs assessment were to develop new knowledge and insights about current health concerns and needs of target communities as well as to provide a summary of the findings.

The objectives of the project were to develop a sound foundation for a health education needs assessment; conduct the needs assessment; report results to the community and project sponsors; and make recommendations for a community health education action plan. Several activities were conducted to achieve the needs assessment objectives. First, efforts were made to interact with the community. The project investigators attended ORRHES and workgroup meetings, held conference calls and gave weekly updates. Second, the ORR historical literature was reviewed. Reports on environmental exposures and health issues related to the ORR site that have been published over the past 15 to 20 years by various health departments, environmental agencies and researchers were accessed and reviewed if available.

These data were used to examine the history and context of health concerns and priorities of residents; understand current issues of residents in a broader context; and finalize questions that would be asked during key resource interviews. Project investigators ensured that key resource interviews included questions about the health and current concerns of residents, educational strategies to address these issues, and the success or failure of previous programs. However, the interviewers did not ask questions about specific health issues to avoid biasing key resource responses.

Third, interviews were held with key resources. Health concerns of area residents were identified from persons who regularly hear about these issues in their professions or volunteer work or those with knowledge of these concerns based on an extensive or long-term relationship with residents. For purposes of the needs assessment, “key resources” were defined as health care providers, public health professionals and community members. Efforts were made to ensure that all health concerns known to key resources were included in telephone surveys and focus groups. The health issues most frequently mentioned during key resource interviews were cancer, respiratory disease, neurological or mental health conditions, heart disease, as well as smoking, substance abuse and other behavioral or social-related issues.

The needs assessment report concluded that findings from the key resource interviews were consistent with health concerns cited in historical Oak Ridge literature. Fourth, telephone surveys were conducted. Health issues of most concern to residents, health information needs, mechanisms to locate health information, and preferred methods to receive information were identified. Feedback was also obtained on whether health resources can be used as a mechanism to address concerns. Of the health conditions most frequently mentioned by telephone survey respondents, 21% listed heart disease as the number one concern and 14% stated cancer was the major issue.

Fifth, focus groups were convened. These discussions were designed to obtain additional information and a deeper insight on health concerns of residents; the rationale for these concerns; and issues mentioned during the telephone surveys. Focus group data were combined with results from the other components of the needs assessment to provide input on the health education action plan. One of the most significant challenges in conducting the focus groups was the disappointingly low number of participants. Nevertheless, two focus groups were convened with workers and elderly persons. The health concerns most frequently mentioned by participants were diabetes, obesity, heart disease, cancer, berylliosis, thyroid disease, autoimmune disease and suicide. Questions asked during the key resource interviews, telephone survey and focus groups are attached to the final needs assessment report in appendices.

The conclusions of the final needs assessment report are as follows. The relatively low response rate in all components of the project may be an indication of “study fatigue” within the ORR population. The needs assessment results may not reflect the views of all ORR residents since participants were somewhat different than the study area population. Health issues identified during the project were consistent with prior ORR reports and publications; these concerns focused on cancer, heart disease and respiratory problems. Physicians were most frequently cited as the method to obtain health information, while short written materials were the preferred format. Comments about health information and educational services widely varied.

Hospital-based programs were often favored, but no single educational strategy or resource was described as the best mechanism to meet the needs of ORR residents. Health information and educational programs are clearly comprehensive strategies to meet the priorities and goals of ORR residents. The needs assessment results were used as the basis to propose a health education action plan and formulate recommendations. The purpose of this component of the project is to enhance the capacity of the ORR population to make informed decisions about health issues by disseminating current health information that is relevant to recent and ongoing community input. The major focus areas of the health education action plan were found to be follow-up activities and future studies at the ORR site.

HENAWG Findings. Mr. James Lewis, the HENAWG Co-Chair, thanked several ORRHES members for their diligent efforts in reviewing the needs assessment report and providing valuable input: Mr. Gartseff, Dr. Malmquist, Ms. Mosby and Ms. Sonnenburg. He particularly recognized Mr. Al Brooks for his contributions in assisting HENAWG. He distributed a document that outlined ORRHES’s historical challenges and comments about the overall needs assessment process and also described the background of ORRHES’s involvement with the project.

ORRHES charged HENAWG with specific activities: critique the overall needs assessment methodology; assess the purpose, techniques and results of the four project components; review the report; evaluate results; and present formal recommendations to the full ORRHES. HENAWG established several evaluation criteria to fulfill its charge. First, were the priorities, surveys and other methodologies in the project design of the needs assessment appropriate? Second, were geographical areas and surrounding counties identified and included in the project? Third, did George Washington University (GWU) Medical Center, the needs assessment subcontractor, accomplish the goals and objectives established for the literature review, key resource interviews and telephone surveys?

As an additional resource during its evaluation of the needs assessment report, HENAWG also reviewed statements made by President George W. Bush in the ATSDR Final Performance Plan Report: “The government should be results-oriented and guided not by process, but guided by performance. There comes a time when every program must be judged whether a success or failure. Where we find success, we should repeat it, share it and make it the standard. And where we find failure, we must call it by its name. Government action that fails in its purpose must be reformed or ended.” Mr. Lewis opened the floor for other HENAWG members to weigh in on the final draft needs assessment report.

General

• ATSDR did not oversee its contractor or subcontractor, the Association of Occupational and Environmental Clinics (AOEC) and GWU, respectively. Due to the poor quality of GWU’s telephone survey, focus groups and other activities, ORRHES should not accept the final needs assessment report.
  
• The purpose, goals and objectives of the project are vague, not clearly defined, not associated with specific items, and poorly stated for comparative purposes.
  
• GWU’s flawed approach with the literature review, key resource interviews, telephone survey and focus groups does not present a strong rationale, firm foundation and solid data to build on the needs assessment and advance to Phase II activities.

Community Interaction

• GWU attended ORRHES and HENAWG meetings to obtain feedback on appropriate methods to outreach to the community and increase participation in the needs assessment. However, the techniques described in the final draft report and the extremely low participation rate in the project indicate that GWU did not implement ORRHES’s suggestions.
  
• Figure I-1 in the report depicts interaction with the Oak Ridge area community during all seven steps of the project: the proposal, literature review, site visit, key resource interviews, telephone survey, focus groups and final report. However, GWU’s communication with ORRHES dramatically decreased after the key resource interviews were conducted. Moreover, ORRHES had minimal input in the selection process for focus group participants and development of survey questions.
  
• Planning, marketing and community outreach strategies were weak. The advertisement seeking focus group participants was generic, vague and only mentioned “health concerns.” The two newspapers where the advertisement was published and the two radio stations where an announcement about the project was broadcast were not identified in the report. Therefore, few persons outside the Oak Ridge area would see the advertisement if the Oak Ridger was used. The same situation would be true for the Roane County News because no individuals in Meigs, Loudon, Knox or Morgan counties would see the advertisement. Only one day was set aside for focus group sessions.
  
• GWU asked each HENAWG member and the 70 key resources to provide names and telephone numbers of potential focus group participants. The report does not describe GWU’s outreach efforts to contact these individuals or the percentage of residents who accepted or declined the offer to participate in focus groups.

Telephone Survey

• The report states that GWU identified all telephone exchanges in the eight-county target area, but only 33% were used. The randomization process to select telephone exchanges was not transparent; the actual numbers GWU used were not identified as well. The 400 telephone calls made in the survey did not cover the entire Oak Ridge area. For example, one of the most impacted areas would not have been surveyed if the 376 exchange in Roane County was not used. The methodology was inappropriate and is an extreme shortcoming of the project. Sample telephone surveys should have been conducted in each of the eight target counties to ensure that all areas potentially affected by the ORR site were represented in the needs assessment.
  
• The report states that the needs assessment was designed to identify current health issues of residents in the ORR area and nearby counties. During the telephone surveys, however, GWU obtained information about current health issues of adult residents in Tennessee. This introduction may have contributed to the 70% of residents who refused to be interviewed. Of the 30% of telephone survey respondents, 84% were not interested in additional information about their health concerns.
  
• GWU did not mention uranium or other specific contaminants to avoid biasing the telephone surveys, but this technique yielded extremely generic responses. The needs assessment should have been conducted in a manner similar to the ORR dose reconstruction. This project was more specific and generated meaningful results that could be tracked. GWU’s approach with the telephone surveys is questionable and does not validate the project.

Focus Groups

• HENAWG spent a considerable amount of time and effort in identifying 15 categories of residents who should be contacted as focus group participants, including former ORR workers; surviving relatives of deceased persons; long-term residents downstream of the Clinch River; persons with long-term exposures to airborne plumes; children with genetic defects; and persons with long-term exposures and illnesses not directly related to ORR releases. HENAWG did not recommend hardly any of the categories GWU selected to participate in focus groups: mid-life women, long-term elderly residents, persons with respiratory diseases, cancer patients, heart disease patients, ill workers, and three groups of general residents. The final draft report does not list the 15 categories originally identified by HENAWG.
  
• The methodology to recruit focus group participants was severely flawed. The majority of information gathered during the focus groups was from eight workers, but onsite exposures among this population are beyond ATSDR’s mandate and ORRHES’s charter. The only other focus group was convened for elderly persons; only one individual participated.
  
• GWU did not review successful techniques that have been used to convene focus groups at other sites. For example, clergy, teachers and other groups trusted by the local community were extensively involved in recruiting participants.
  
• Key resources and focus group participants were interested in health information or education from credible and trustworthy sources only. The low participation rate in the focus groups suggests that the ORR community did not find GWU to be credible.

Key Resource Interviews

• The report mentions that physicians and other key resources at the ORR site rarely returned GWU’s telephone calls. The low response rate was heavily impacted by GWU’s location in Washington, DC and its inability to directly interact with key resources on a regular basis. GWU should have asked the Oak Ridge Field Office to hold face-to-face meetings with key resources and gather information.

Literature Review

• GWU was provided historical data from technical reports, telephone surveys, interviews, focus groups and other activities conducted at the ORR site over the past ten to 20 years. Dr. Henry Falk, the ATSDR Assistant Administrator, made statements to GWU about the project during the January 2001 ORRHES meeting. He hoped that the ORR needs assessment would assist in defining and clarifying concerns and issues and would also help ATSDR’s focus in completing site activities. Dr. Falk also informed GWU of ATSDR’s efforts in gathering community needs and concerns at the beginning of the project. Despite its access to ORR historical data and knowledge of Dr. Falk’s comments, GWU did not provide a detailed summary of community concerns in the final draft needs assessment report.
  
• GWU did not apply significant outcomes from historical data. For example, the final draft needs assessment report states that “study burnout” contributed to the low participation rate in the project. The state of Tennessee reached the same conclusion in the ORR dose reconstruction eight years previously.
  
• The report misinterprets historical data in some instances. For example, Table III-3 shows K-25 water contamination from 1940 to 2000, but K-25 was not built in 1940.

Public Comment Period

The Chair called for public comments on the needs assessment only; no attendees responded.

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