<%BANNER%>

Perceived Bioterrorism Preparedness and the Impediments to Bioterrorism Preparedness of Rural Physicians

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PERCEIVED BIOTERRORISM PREPAR EDNESS AND THE IMPEDIMENTS TO BIOTERRORISM PREPAREDNESS OF RURAL PHYSICIANS By GAVIN JOSEPH PUTZER A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY UNIVERSITY OF FLORIDA 2006

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Copyright 2006 by Gavin Joseph Putzer, MD, MPH

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This document is dedicated to Mom and Tricia.

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iv ACKNOWLEDGMENTS I thank my Mom for her constant and unremitting emotional support, guidance, and love. I thank Tricia for her unending emotional support and love. I thank my health services research a nd policy mentor, Paul, for his expertise, guidance, and support. I thank my qualitative research mentor Mirka, for her research methodology expertise and insight, ad vice, and support. I thank my other committee members for their insight and support.

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v TABLE OF CONTENTS ACKNOWLEDGMENTS.................................................................................................iv LIST OF TABLES...........................................................................................................viii LIST OF FIGURES...........................................................................................................ix ABSTRACT....................................................................................................................... ..x CHAPTER 1 INTRODUCTION........................................................................................................1 2 BACKGROUND AND LI TERATURE REVIEW....................................................12 Background of Disasters.............................................................................................12 Terrorism History and Perceived Threat....................................................................15 National Preparedness Efforts....................................................................................17 Rural Areas and Vulnerability to Bioterrorism..........................................................20 Local Preparedness Efforts and Public Health...........................................................22 Physician Perceptions of Bioterrorism Pr eparedness: A Review of the Literature Regarding National Studies.....................................................................................25 The Public Health System and Primar y Care Physicians Perceptions of Bioterrorism and National Bi oterrorism Preparedness...........................................37 Physician Perceptions and Knowledge of Bioterrorism Preparedness: A Review of the Literature Regarding Local Studies..............................................................52 Specific Research Questions and Contribution to the Literature................................62 3 EPISTEMOLOGY, THEORETICAL PERSPECTIVE & RESEARCH METHODS.................................................................................................................67 Ontological and Epistemological Considerations.......................................................70 Theoretical Perspective: Constructivism....................................................................73 Methods......................................................................................................................76 Participants.................................................................................................................77 Selection Criteria and Sampling..........................................................................77 Demographic Information...................................................................................80 Data Collection...........................................................................................................82 My Role in the AHRQ 1 UO1 HS14355-01 Grant.............................................82 Interviews............................................................................................................83

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vi Data Analysis..............................................................................................................86 Coding and Memos..............................................................................................89 Constant Comparative Method............................................................................92 Theory Building...................................................................................................92 Validity and Consistency............................................................................................93 Subjectivity Statement..............................................................................................101 Limitations................................................................................................................103 4 FINDINGS................................................................................................................108 Physician Professional Preparedness and its Associated Elements: Cognitive Preparedness, Clinical Preparedness, and Expectation Preparedness......115 Mental and Emo tional Health...................................................................................117 Physical Health.........................................................................................................121 Risk Factors for Mental Illn ess or Physical Illness..................................................124 Physician Professional Preparedness and its Associated Elements: Simulation Preparedness, Expectation Prepar edness and Resource Preparedness..................129 Physician-Patient Related Barriers...........................................................................134 Access Barriers..................................................................................................135 Communication Barriers...................................................................................139 Knowledge Barriers...........................................................................................141 Medical Interventions...............................................................................................144 Mental Health Interventions..............................................................................145 Mental and Physical Health Interventions.........................................................147 Physical Health Interventions............................................................................149 5 DISCUSSION AND CONCLUSIONS....................................................................152 Salient Points for Discussion....................................................................................152 Key Findings Regarding Rural Physic ians Professional Preparedness...................154 Health Policy Options & Implications Regarding Physician Preparedness.............159 Key Findings Regarding the Rural He althcare Systems Preparedness...................162 Health Policy Options & Implicatio ns Regarding System Preparedness.................164 Key Findings Regarding Physician Per ceptions of Rural Patient Factors................167 Health Policy Options & Implicatio ns Related to Patient Factors...........................171 Future Research Questions.......................................................................................173 Conclusion................................................................................................................175 APPENDIX A INTERVIEW QUESTIONS.....................................................................................176 B QUALITATIVE INTERVIEW CODING CHART.................................................177 C DOCTOR WILLIAMS INTERVIEW TRANSCRIPT............................................199 D DOCTOR SMITH INTERVIEW TRANSCRIPT....................................................202

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vii E DOCTOR DAVIS INTERV IEW TRANSCRIPT....................................................206 F DOCTOR JONES INTERVIEW TRANSCRIPT....................................................210 G DOCTOR BROWN INTERVIEW TRANSCRIPT.................................................214 H DOCTOR PHILLIPS INTERVIEW TRANSCRIPT...............................................216 LIST OF REFERENCES.................................................................................................219 BIOGRAPHICAL SKETCH...........................................................................................237

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viii LIST OF TABLES Table Page 2-1 Knowledge, Attitudes and Beliefs Regarding Smallpox and Smallpox Vaccination...............................................................................................................32 3-1 Participant Demographic Information......................................................................83 3-2 Clinical Background Information.............................................................................83

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ix LIST OF FIGURES Figure Page 1-1 Actual Versus Perceived Bioterrorism Preparedness...............................................11 2-1 Overview of Disasters..............................................................................................13 3-1 Qualitative Method Process.....................................................................................69 3-2 Detailed Qualitative Methods Process.....................................................................77 4-1 Rural Physician-Patient Bioterrorism Preparedness 109

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Abstract of Dissertation Pres ented to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Doctor of Philosophy PERCEIVED BIOTERRORISM PREPAR EDNESS AND THE IMPEDIMENTS TO BIOTERRORISM PREPAREDNESS OF RURAL PHYSICIANS By Gavin Joseph Putzer August 2006 Chair: R. Paul Duncan Cochair: Neale R. Chumbler Major Department: Health Services Research, Management, and Policy Recent public health emergencies such as the September 11, 2001, terrorist attacks on the World Trade Center in New York City, the use of anthrax as a bioterrorist tool against citizens, and other natural disasters in the United States have increased awareness of the nations vulnerability to large-scale emergencies. To moderate the risks and magnitude of public health emergencies derivi ng from such events, the United States has made emergency preparedness a priority for public health advocates and physicians. In particular, scant atten tion has been given to preparing physicians and other health care providers in the United States sparsely popul ated areas for public health emergencies such as bioterrorist events. Yet emergency preparedness in rural communities is a significant issue for the nation given that roughly 80% of Unite d States land is classified as rural and one-fourth of the United Stat es population lives in rural areas. The study utilized the interview data tran scripts from six rural physicians as the primary data with which to explain the state of emergency preparedness of rural physicians and to explain and better understand the barriers to preparedness encountered by these rural health care pr oviders. The principal objectiv es of this study were to x

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provide a greater description and understanding of rural physicians perceived preparedness regarding public health emerge ncies such as bioterrorist events. Physician participants expressed a lack of bioterrorism preparedness in five facets: cognitive, clinical, expectation, simulation and resource preparedness. In essence, rural physicians were unaware of the pertinent si gns and symptoms of bioterrorist-inducing agents, the relevant risk factors, and the a ppropriate therapeutic treatments. Additionally, rural physicians described thei r expectation preparedness as low. Physicians explained that although simulation exercises and corresponding training opportunities existed, many of them had not availed themselves to th ese endeavors. A dearth of resources, specifically a lack of specialty physicians, wa s also cited. Thus, rural physicians felt less than fully prepared both intellectually and professionally for a bioterrorist event. This study discovered that, although there are knowledge gaps in physicians bioterrorism education and trai ning, these gaps appear to be the result of personal choice and discretion. This study substa ntiates that there appears to be a significant need to take additional decisive steps to encourage rural physicians to attend bioterrorism preparedness seminars. Furthermore, it appe ars there is a compelling need for improved preparedness regarding biote rrorism knowledge surrounding the associated important risk factors and therapeutic medical interventions for bioterrorist infectious agents. Furthermore, it appears from this study that if rural physicians are provided with a greater number of resources financial, educationa l and technological they will inevitably feel better prepared and perceive more auspicious health outcomes for their patients. Thus, strategically implemented hea lth policy objectives can ha ve a tangible impact on the impediments identified in this study which have hindered rural physician preparedness. xi

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1 CHAPTER 1 INTRODUCTION Natural disasters such as earthquakes, tropical cyclones, floods, and volcanic eruptions have claimed approximately three million lives worldwide during the past 20 years, have adversely affected the lives of at least 800 million more people, and have caused more than $50 billion in property da mage (Office of US Foreign Disaster Assistance, 1995; National Academ y Press, 1987). Worldwide, a major disaster occurs almost daily, and natural disasters that re quire international assistance for affected populations occur weekly (Binder & Sanderson, 1987). Today, with increasing frequency, the gl obal community is witnessing complex human-induced disasters such as terroris t attacks resulting fr om the breakdown of traditional state structures, armed conflict, and the upsurge of ethnicity and micronationalism (Noji, 1997). The cause of these human-induced emergencies as well as the assistance provided to the afflicted is influenced by intense levels of complex political, social, and economic considerati ons (Noji, 1997). The number of refugees affected by a combination of natural and human-induced disasters has increased significantly over the last two decades to an estimated 17 million, and the number of persons displaced through other causes, though di fficult to estimate, is probably just as large (Noji, 1997). With both human-induced disasters and the numbe r of their victims increasing, disasters constitute a major public health problem. According to a United States Centers for Disease Control and Prev ention (CDC) study, the economic impact of a bioterrorist attack scenario with anthrax as th e agent per 100,000 citizens exposed

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2 would be approximately $26.2 billion (Kaufman et al., 1997). In the absence of an intervention preparedness program for th e 100,000 persons exposed, the anthrax cloud would result in 50,000 cases of inhalation an thrax, with 32,875 deaths (Kaufman et al., 1997). Although a large-scale biot errorist attack of that ma gnitude has not yet occurred in the United States, the brush with anthrax in October 2001 filled every American with a sense of fear and foreboding (Fottl er, Scharoun, and Oetjen, 2004). The widespread national media attention beli ed the fact that only five mortalities and 22 persons were actually contaminated from the anthrax bioterrorist attack. Yet our initial response to the an thrax attacks was marred by mi sinformation, confusion, and widespread public alarm which predominantly flowed from the lack bioterrorism preparedness. The fear of the unknown grippe d Americans as individuals flocked to doctors offices and emergency departments worried that they might have come in contact with anthrax. They demanded screen ing and testing for e xposure to anthrax, and begged for prescriptions for antibiotics deemed effective for treating anthrax exposure. Although only 22 individuals were infected, more than 10,000 people took antibiotics as a precautionary measure (CDC, 2005). Alarmingly, as panicked as the American public was with this anthrax scare, a full-blown release of a biologi cal agent could cause immeasurably greater levels of chaos, panic, and mass hysteria (Fottler et al., 2004). Consequently, it is particularly important that front-line he althcare responders such as primary care physicians are well trained and ed ucated regarding biot errorism agents in order to present clear information to allay th e fears of patients and the general public. The recent public health emergencies such as the September 11, 2001, terrorist attacks on the World Trade Center (WTC) in Ne w York City and the use of anthrax as a

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3 bioterrorist tool against citizens in the Un ited States have increased awareness of the nations vulnerability to large-scale emergencies. Bioterrorism is now perceived as a real threat to public health. Ma ny healthcare facilities have created emergency operations plans, but it is very questionabl e if all of our healthcare faci lities can effectively respond to a bioterrorist attack (F auci, 2002; Grow & Rubinson, 2003; Leavitt, 2003; Macintyre & Deatley, 2001). A number of reports have continued to show th at public health, healthcare facilities, and local and state govern ments are not ready for a bioterrorist event (Blair et al., 2004). For example, the mo st recent one on hospital preparedness by the U.S. Government Accountability Office (2003) came to that conclusion regarding urban hospitals. One may expect even less preparedne ss from rural hospitals (Blair, Fottler, and Zapanta, 2004). Perhaps the most disturbing information is that hospitals may be more prepared than before, but physicians offices and ambulatory clinics are not (Wolper et al., 2003). This is particularly problematic because most biological agents result in flulike symptoms. Thus, it is far more likely that in the early stages for infected or contaminated patients in the early stages to visit their family primary care physicians than to frequent the emergency de partment of a hospital. To moderate the risks and magnitude of public health emergencies deriving from such events, the United States has made emergency preparedness a priority for government and military agencies, public hea lth advocates, law enfo rcement, physicians, and other first responders. A lthough much of the aftermath of these events has resulted in an increased focus on agencies in ur ban areas (McHugh, Staiti, and Felland, 2004), it has also become clear that such a focus is necessary in rural areas. Rural areas are especially vulnerable to bioterrorism for a number of reasons (S tamm, 2002; Office of

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4 Rural Health Policy, 2002). National energy site s, nuclear sites, and hazardous materials manufacturers are often located in rural areas. In the advent of a bioterrorist event, rural communities may encounter a mass exodus of many urban residents to neighboring rural areas. Such an event could conceivably overwhelm the existing rural health infrastructure. Additionally, many rural communities are less well defended with respect to urban areas making them easier targets to release bioterrorist agents. Yet little attention has been given to preparing physicians in Ameri cas sparsely populated areas for public health emergencies such as biote rrorist events, even though experts warn the risks such incidents would pose to human health appear equa lly great in rural and urban areas (Stamm, 2002; Wetter, Daniell, a nd Creser, 2001; Treat et al., 2001). Unfortunately, there are few data to qu antify emergency preparedness in rural communities (Clawson & Brooks, 2003; Stamm, 2002; Office of Rural Health Policy, 2002). If emergency-related resources in ru ral areas are lacking, rural readiness for future emergencies may be compromised (Clawson & Brooks, 2003). Emergency preparedness in rural communities is a significant issue for the nation given that roughly 80% of United States land is classified as rural (Office of Rural Health Policy, 2002). One-fourth of the United Stat es population lives in rural areas. Rural communities are found in all states, and 65 m illion Americans live in these communities (Glasgow, Morton, and Johnson, 2004). Adequa te emergency preparedness in rural communities depends on coordinated effo rts among public health departments, community health centers, hospitals, and phys icians. However, rural public health departments tend to have less capacity and resources as well as less epidemiological surveillance capacity than their urban counterpa rts. For example, physicians and mental

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5 health providers are much less common on a pe r capita basis in rura l settings than in metropolitan or urban settings (Office of Ru ral Health Policy, 2003; Wallace, Grindeanu, and Cirillo, 2004). Further, in comparison to urban communities which typically have several hospitals, in many rural communities a single hospital may be the only nucleus of health planning, activity, and resources for th e entire community (Office of Rural Health Policy, 2002). However, national policy change s have encouraged hos pitals to downsize bed capacity in an effort to contain costs and, as a result, rural hospitals lack surge capacity for personnel and beds (Office of Rural Health Po licy, 2002). Rural physicians, similar to urban physicians, may lack the tr aining and resources to respond to a public health emergency such as a bioterrorist even t. Rural physicians are also more likely to provide care outside their specialty areas and do so more often than their counterparts in urban areas (Office of Rural Health Policy, 2003; Wallace et al., 2004). Even within the community of rural phys icians there is variation in emergency preparedness for bioterrorist events. Some rural commun ity physicians are completely unprepared, others are somewhat prepared, a nd some are taking active steps to achieve a level of preparedness that is c onsistent with the i nherent unpredictability of these events. Quite apart from their actual preparedness, physic ians have highly vari able perceptions of their preparation. It may be that some are we ll prepared but perceive themselves as illequipped, whereas others may have misplaced confidence in their degree of preparedness. Barriers to improved preparedness have been well documented and must be overcome in order for physicians to be prep ared (McHugh et al., 2004; Blair et al., 2004; Fottler et al., 2004; United States Govern ment Accountability Office, 2002). These

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6 barriers include but are not limite d to a dearth of applicable knowledge and education, a lack of finances, geographical isolation, a lack of communi cation or coordination, and a lack of access. However, we do not know wh ich barriers are most important in impeding rural physicians emergency preparedness for bi oterrorist events a nd if rural physicians are not prepared for public health emergencie s such as bioterrorist events because of these barriers. Thus, we do not know which of these impediments that rural physicians face are the most important to overcome in attempting to beco me better prepared for rural bioterrorist events. Thus, the purpose of this study is to describe and understand the variation in emergency prepare dness for bioterrorist events of physicians within the rural settings. An additional purpose is to attempt to explain the reasons why rural settings and rural physicians are unprepared or less prepar ed than they should be. The final purpose of this study is to identify barriers to preparedness, ther eby elucidating who is better prepared and why are they perceived as better prepared. Figure 1-1 illustrates a gra phical representation of the four principal spheres of inquiry that this study will examine. Of the f our spheres, the central focus of the research questions will be to examine th e two spheres of perception. An important distinction needs to be made between actual preparedness and perceived preparedness. This distinc tion is salient because actual emergency bioterrorism preparedness may or may not be synonymous with or equal to perceived preparedness. Actual preparedness involve s tangible experiences such as medical education and training in identifying bioterro rism agents and the co rresponding infectious diseases. Perceived preparedness involves those very same elements as well as the individual physicians percep tion of his/her preparedness. A physician may have had

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7 actual training and education and yet still not perceive himself/ herself as being prepared. For instance, a physician may have learned of the signs and symptoms and how to identify a bioterrorist incident but not perceive himself/hers elf as being prepared because of the lack of a tangible real -life experience. Thus, one of the spheres reflects actual emergency bioterrorism preparedness ( upper sphere) among rural physicians and the other reflects perceived emergency bioterro rism preparedness (left sphere). This same distinction may be made between actual barriers to preparedness and the perceived barriers to preparedne ss. A physician may be able to identify actual barriers to preparedness and these barriers may be rec tified a priori to an event. Yet this amelioration of actual or tangible barriers to preparedness may not even dispel an individuals perception of barri ers to preparedness. This is because individuals may feel that increased resources, education, or traini ng may assist in mitigating barriers, but may not completely resolve what is being perceived as a barr ier. Thus, the resolution of perceived barriers may not be possible. Nevertheless, the identification of these individual perceptions is important because perception is a powerful arbiter of actions that might influence preparedness. So one of the spheres reflects actual barriers to emergency bioterrorism preparedness (right sphere) among rural physicians and the other reflects perceived barriers to emergency biot errorism preparedness (lower sphere). This study is extracted from primary data of a larger study funded by the Agency for Healthcare Research and Quality (AHR Q). This larger study is an AHRQ 1 UO1 HS14355-01 grant entitled Bioterrorism Preparedness among Rural Florida Communities. The project is a two-year federally funded project to evaluate

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8 bioterrorism preparedness and health needs in rural North Central Florida and the Florida Panhandle. Florida is an important state to examine regarding bioterrorism preparedness for a number of reasons. As of 2005, it is the fourth most populated state in the nation with an estimated population of almost 18 million (U.S Census Bureau). Florida contains 67 counties and 37 are designated as rural count ies (U.S. Census Bureau). These rural counties possess similar attributes, impediments and socio-cultural characteristics that define rural areas across the United States Floridas annual tourist population is estimated to be between one million and f our million persons (Clawson & Brooks, 2003). This includes a significant porti on of international vi sitors, as well as transient tourists who number over 40 million during any given year (Clawson & Brooks, 2003). Thus, the implications for preparedness involving rural se ttings in Florida may be generalizable and therefore valuable from a policy perspective. The AHRQ grant projects prin cipal objective is to gain a better understanding of the treatment of rural residents following th e aftermath of bioterro rist and other public health emergencies. The aim of the proj ect is to promote public health emergency preparedness, including needs for long-term care, rehabilita tion services, chronic physical ailments, and mental healthca re. Interviews were conducte d with key organizations and individuals across the state of Florida to assess exis ting resources and response mechanisms in rural communities to meet anticipated health needs arising from bioterrorist events. The information obtaine d from these assessments may serve as the basis for recommendations to policymakers to improve bioterrorism preparedness in rural communities across the nation. The assessmen ts will highlight special concerns of

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9 certain priority populations, including women, ch ildren and families, and senior citizens. The project will also develop an interventi on to educate primary healthcare providers concerning important aspect s of mental healthcare. The interviews included questions regard ing the organization, annual budgets and funding sources, services provided at th e clinic, and patient socio-economic demographics. Questions were posed rega rding medical and ment al heath conditions commonly encountered at the clinic. Add itionally, questions were asked regarding policies concerning the various medical c onditions and training/ policies regarding infectious diseases and other agents that may be used in bioterrorist events. My research interests combined with my intellectual curiosity and my professional background within public health and as a phys ician have fostered unique yet related research questions to augment the larger fe derally funded projects objectives. This studys principal objectives are to desc ribe and explain physicians perceived bioterrorism preparedness and the indi vidual perceived impediments affecting physicians preparedness. The evidence obtained from this research is intended to serve as an addition to the core project. It w ill serve as the basis for policy and clinical recommendations and possible tool s to assist physicians and ot her healthcare providers to improve bioterrorism preparedness at medi cal sites and within health systems. Thus, this qualitative study will descri be the observed state of emergency preparedness and barriers impeding preparedne ss from the rural healthcare providers perspective. The interviewed healthcare prov iders were selectively sampled from sites in rural North Central Florida and the Florida Panhandle and include individual healthcare professionals who work in rural commun ity health centers (CHC), rural county

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10 Departments of Health (DOH), rural healthcare clinics, and rural private medical offices. The study will use the interview data transcript s from these sites and six rural physicians as the primary data with which to explain the perceived state of emergency preparedness of clinicians and to expl ain and better understand the barriers to preparedness encountered by these rural physicians. This study will not focus on empirical testing, but instead will qualitatively explore the varia tion or degree to which rural physicians consider themselves to be prepared for biot errorist events. In summary, this study will address two research questions: What is the perceived bioterrorism preparedness among rural physicians? How do the perceived impediments hinder rural physicians preparedness?

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11 Barriers to Emergency Bioterrorism Preparedness Emergency Bioterrorism Preparedness Barriers to Emergency Bioterrorism Preparedness Perceived Emergency Bioterrorism Preparedness Perceived Barriers to Emergency Bioterrorism Preparedness Figure 1-1: Actual Versus Per ceived Bioterrorism Preparedness

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12 CHAPTER 2 BACKGROUND AND LITERATURE REVIEW Background of Disasters A disaster by definition is a calamitous event, especially one occurring suddenly and causing great loss of life, damage, or hardship (Websters Dictionary, 1984). A disaster from a healthcare perspective may be defined as a catas trophic event which, relative to the manpower and resources availa ble, overwhelms a heal thcare facility and usually occurs in a short pe riod of time (Betts-Symonds, 1994). Thus, disasters are tragedies that overwhelm our communiti es, destroy our property, and harm our populations (Waeckerle, 1991). Disasters in general may be divided into either natural disasters or human-caused disasters (Figure 2-1). Natura l disasters include events such as hurricanes, earthquakes, and tornadoes The numbers of natural disasters, th e people affected by them, and the economic costs associated with them have been steadily increasing since the midtwentieth century (FEMA, 2003; Alexander, 1997; Berz, 1994; Berz, 1991). The number of people affected by natural disasters in the last 50 years equals about two-thirds of the worlds population (FEMA, 2003). These natu ral disasters have claimed approximately three million lives worldwide during the past 20 years, and have adversely affected the lives of at least 800 million more people, and have caused more than $50 billion in property damage (Noji, 1997).

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13 Disasters Induced Disasters (Human-Caused) Natural Disasters Intentional Unintentional Bioterrorism Other forms of Terrorism Figure 2-1: Overview of Disasters In the United States, presidential disaster declarations averaged 35 per year from 1976 to 2002 and were routinely sought for ev ents that exceeded state capabilities (FEMA, 2003). With both disasters and the num ber of their victims increasing, disasters are now recognized as a major public health pr oblem. Every state and territory in the United States has communities that are at risk from one or more natural hazards (Hays, 1990). The CDC has a principal responsibility to nationally prepar e for and respond to public health emergencies such as disasters, as well as to conduct investigations into the health effects and medical consequen ces of disasters (Noji, 1997). A disaster may also be induced or cau sed by humans, and this category includes both unintentional and intentiona l disasters. An unintentiona l induced disaster includes events such as the fire in one of the react ors at Windscale in Great Britain in 1957, the nuclear explosion at Chernobyl in 1986, or the mechanical failures th at led to the release of volatile radioactive materials in Pennsylvani a at Three Mile Island in 1978, whereas an

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14 intentional induced disaster is one in which the principal direct causes are identifiable deliberate human actions. The global comm unity is witnessing an ever-increasing number of complex emergencies resulting from the breakdown of traditional state structures, armed conflict, and the upsurge of ethnicity and micronationalism, including examples such as Bosnia, Somalia, and Rwa nda (Noji, 1997). The numbers of refugees affected by both natural disast ers and human-caused disasters have increased to an estimated 17 million (Noji, 1997). Another subset of these human-caused intentional disasters includes acts of terrorism accomp lished through the use of biological or chemical agents, explosives, or radiation. This study will focus on intentional domes tic disasters, or more specifically, bioterrorist events. Terrorism may be furt her subdivided into biological terrorism or other forms of terrorism. Bioterrorism may be defined as the intentional release of potentially deadly bacteria and/or viruses into the air, food, or water supply (Frist, 2002; Karwa, Currie and Kvetan, 2005). With th e events on September 11, 2001, and the subsequent anthrax attacks, the once seemingly remote threat of a bioterrorist attack in the United States is now a reality (CDC, 2001; Borio et al., 2001; Mayer, BersoffMatcha, and Murphy, 2001, Cherry, Kainer and Ruff, 2003; Jernigan, Stephens, and Ashford, 2001; Tucker, 1999; Trumbull & Abhaya ratne, 2004). The te rrorist attacks of September 11, 2001, demonstrated that the Un ited States is no longe r isolated from a dangerous world or protected by its geography. The other forms of terrorism include the use of explosives, chemicals, nuclear weapons, and radiation as instruments of mass de struction. Previous research related to terrorism such as the WTC disaster on September 11, 2001, will be included and

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15 reviewed as it relates to biote rrorism in general, but the cent ral thrust of this study is to examine rural physicians perceived emergenc y preparedness for terrorism, specifically bioterrorism, although also chemical and radi ation terrorism in the United States post September 11, 2001. Thus, the emphasis is very contemporary, i.e., late 20th century and early 21st century. Terrorism History and Perceived Threat Historically, there have been relatively few instances of the use of bioterrorist agents, but recently their use has escalated a nd the threat of a large-scale bioterrorist attack has become quite real (Jernigan et al., 2001; Inglesby, Grossman, and OToole, 2001). A recent report by the Monterey Institut e for International St udies found a total of 121 bioterrorist agent crimes have been comm itted since 1960, with a reported sharp rise in them since 1995 (Tucker, 1999). In 1999, there were a total of 175 incidents accounting for 25% of the total number sinc e 1900. This was followed by a dramatic peak in 2001 of 629 incidents, although 603 were hoaxes (Trumbull & Abhayaratne, 2004). Although the number of te rrorist incidents may have b een small by percentage in 2001, the increasingly omnipresen t threat and perception of a possible bioterrorist event and the subsequent hysteria that is produced can be quite disruptive. Bioterrorism may be defined as the intentional release of biological infectious agents, including microbes such as Bacillus anthracis (anthrax), Variola major (smallpox), Yersinia pestis (plague), or Clostridium botulinum toxin. Bioterrorism in the United States was seen with the use of Salmonella by the Rajneesh Sect in 1984. This was a bioterrorist event that resulted in 750 cases of salmonellosis with 45 hospitalizations and zero fatalities (Tor ok, Tauxe, and Wise, 1997; Tucker, 1999). Internationally, there were multiple failed bioterrorist attempts by the Aum Shunrikyo

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16 sect in Japan between the years of 1990 th rough 1995. The sects failed attempts consisted of the use of aerosolized anth rax and botulinum toxin with no reported casualties (Tucker, 1999; Henderson, 1999). And there was a bioterrorist event as recently as of October 2001 in the United States with the dissemination of anthrax spores through the United States Postal Service. Today oceans and borders are readily crossed, making the United States as vulnerable as other nations to acts of terrorism. Internati onal unrest and terrorism have become all too familiar to Americans. Although the predominant weapons of international terrorism continue to be impr ovised explosive devices, as evidenced by the bombings in London in July 2005 and Madrid in March 2004, acts of biological terrorism are a potential threat that could have serious immediate and long-term consequences. Bioterrorist agents could cause mass casual ties, resulting in significant morbidity and mortality, societal disrupti on, and long-term human and economic hardship (Danzig, 2003; Inglesby et al., 2000). The strain that such events would impose on the medical infrastructure-from hospital beds and pharmaceu tical supplies to emergency departments, primary care medical offices, and clinics-w ould probably be unprecedented, especially given the fact that an attack with biol ogical weapons would not be known in advance (Karwa, Bronzert, and Kvetan, 2003; Inglesby et al., 2001; Borio et al., 2001; OToole, 1999). The scientific advances in the field of microbial genomics, proteonomics, and related technologies further c ontribute to the fear of biological weapons use with potentially devastating results. With the dissolution of statesponsored biological weapons programs, the security surrounding this vast intellectual pr operty is questioned, theoretically making it easier fo r a rogue nation or radical extr emists to buy or steal it for

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17 use in terrorist activities (Karwa et al., 2005) Thus, despite few historical precedents, the possibility of a large cata strophic bioterrorist att ack is quite possible. National Preparedness Efforts Prior to the WTC Disaster on Septembe r 11, 2001, the CDC was designated by the United States Department of Health and Hu man Services to coordinate and lead an overall planning to upgrade national public health infrastructure and preparedness capabilities at the local, stat e, and federal levels to res pond to biological and chemical terrorism (CDC, 2000; Lillibridge, Bell, and Roman, 2000). Examples of this planning were Project Topoff and Operation Dark Wint er, which took place in May and June 2001, respectively, in the United States. Operati on Dark Winter was a role-playing exercise developed and produced by the Center for St rategic and International Studies, Johns Hopkins Center for Civilian Biodefense St udies, and ANSER (Analytical Services) Institute for Homeland Security to test the ability of the federal, state, and local governments to respond to mass-casualty incide nts of biological te rrorism (Inglesby et al., 2001). In the mock disaster, former seni or government officials played the roles of salient leaders as a way of testing the governments commun ication procedures and other processes that would be crucial to maki ng decisions about responses regarding a smallpox attack. During a period of two week s, the smallpox epidemic dispersed to more than 20 states and 10 countries, with 16,000 reported cases and 1,000 mortalities (Frist, 2002). The Dark Winter disaster exercise revealed a number of vulnerabilities in emergency bioterrorism preparedness. Opera tion Dark Winter suggested that the United States does not have adequa te supplies, effective organizational systems, or the communication networks necessary to deal with such an attack (Fri st, 2002; Inglesby et

PAGE 29

18 al., 2001). The exercise also re vealed that the pub lic health system and hospitals would be rapidly overwhelmed by the enormous increase in patient demand. Shortly after 9/11, in October of 2001, the anthrax attacks occurred and imposed enormous burdens on already strained pub lic health systems. Public health responsibilities after the anthrax attacks included providi ng expert consultative advice regarding the appropriate care to anthrax pa tients, investigating possible contamination sites, testing of numerous suspected mate rials, hospital surveillance for new cases, administration of antibiotic prophylaxis to tens of thousands of at -risk individuals, and providing risk communication to the public (Ger shon et al., 2004). These responsibilities were in addition to the routine delivery of e ssential services and a ffected nearly every sector of the public health infrastructure, including hospitals, clinics, pharmacies, and medical practices, all of whom reported a signi ficant rise in the number of patients with psychosomatic complaints and antibio tic requests (Gers hon et al., 2004). The response to the anthrax attack was a multi-disciplinary effort involving epidemiologists, public health official s, law-enforcement personnel, government agencies, laboratory staff, media organizati ons, health professionals, and others. The scale of this response exemp lifies the resources and planning needed for emergency bioterrorism preparedness in the United Stat es. Yet no amount of planning could have produced a good outcome without an astute physician who su spected and diagnosed the first case and immediately notif ied the appropriate authoritie s (Gerberding et al., 2002). Previous research has shown th at optimal preparedness for an epidemic of any infectious disease requires a multidisciplinary approach (Inglesby et al., 2000; Osterholm, 2001). This multidisciplinary approach to prepar edness includes a coordinated response from

PAGE 30

19 physicians, governments, law enforcement, and civilian authorities (I nglesby et al., 2000; Osterholm, 2001; Schoch-Spana, 2000; Waeckerle, 1991). This is equally important in preparing fo r an event of bioterrorism-the deliberate release of an infectious agent or toxin-as it is for naturally occurring outbreaks. Bioterrorism preparedness requires physicia ns to be aware of the possibility of bioterrorism at any time (G erberding et al., 2002, Inglesby et al., 2000). Plans can only be implemented effectively if physicians are aware of the possibil ity of bioterrorism, suspect and recognize an event when it occurs, notify public h ealth authorities promptly upon suspicion of such an event, and instit ute appropriate management. Broader public health aspects of bioterrorism preparedne ss, including primary pr evention measures, are also important areas for informed action by physicians. Medical education and training curricula must include information on key poten tial agents of biot errorism, and medical staffs, especially those, such as primar y care physicians, who ar e most likely to see patients affected by a biological weapon, requi re continuous educati on in this area. Moreover, physicians from other specialties may need sufficient knowledge of the likely clinical features of potential biological agents in order to recognize patients presenting with a compatible illness (G erberding et al., 2002; Karw a et al., 2003, Karwa et al., 2005). Today, in the aftermath of these attacks, additional efforts have been undertaken to enhance the United States preparedness agains t biological agents. Proper preparedness suggests the ability to respond to a threat and prevent morbid ity or mortality. The CDC identified five key components for a comprehe nsive public health response to an incident of terrorism: detection (surveillance), ra pid laboratory detection, epidemiological

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20 investigation and implementation of contro l measures, communication, and preparedness planning (Rose & Larrimore, 2002, Gerberding et al., 2002). Rural Areas and Vulnerability to Bioterrorism Rural communities are found in all states and 65 million Americans live in these communities (Rosenthal, 2003). The lack of a perceived threat to rural communities often leads to less bioterrorism preparedne ss (Sterling et al., 2 005; Shadel, Rebmann, Clements, Chen, Evans, 2003; McFee et al ., 2004). However, given that 65 million Americans live in rural locations, many in close proximity to potential military or economic targets, it is critical that these areas prepare to respond in the event of a bioterrorist attack (Office of Rural Health Policy, 2002). Rural areas are especially vulnerable to bioterrorism for a number of reasons (Clawson & Brooks, 2003; Office of Rural Health Policy, 2002; Rosenthal, 2003; Stamm, 2002). Rural areas comprise the source of most food and farming distribution, so localized bioterrorism against agriculture c ould threaten signifi cant portions of the country. Many cities obtain their drinking water from rural reservoirs with limited security. Many national energy sites, nuc lear sites, and hazardous materials manufacturers are located in ru ral areas. Contaminants coul d be dispersed to cities by crop duster aircrafts originati ng from rural airports (Stamm, 2002). Although rural areas are not high profile targets su ch as the WTC or the Penta gon, they are easier targets because of limited supervision and security. Bioterrorism involves the spread of various infectious disease agents in order to inflict harm or kill others. These agents are a likely choice of weapons by terrorists because they are easy to conceal and disper se among a population. Bioterrorist agents do

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21 not differentiate between indivi duals or geographical areas. The use of such agents could spread through a population rapi dly, thus causing implicatio ns to the healthcare system. The anthrax incident in late 2001 exposed some of the public health ramifications of bioterrorism. The fear of the unknown gripped Americans as individuals inundated physicians offices and emergency department s worried that they might have been exposed to anthrax. Many patients demande d screening and testing for exposure to anthrax and begged for antibiotic s deemed effective for treati ng anthrax exposure. Thus, access to care was severely affected during this crisis. Access to care describes the fit between the patient and the healthcare system. Penchansky (1981) defines access as a set of five specific dimensions. The specific dimensions are availability, accessib ility, accommodation, affordability, and acceptability. According to Penchansky (1981) problems with access to care, or more specifically with any of the component dime nsions of access are presumed to influence patients and the healthcare system in three m easurable ways. The first is that utilization of services, particularly entry use, will be lo wer. Second, clients will be less satisfied with the system and/or the se rvices they receive. Third, physician practice patterns may be affected. For instance, inadequate suppl y resources may cause physicians to curtail services, devote less than appropriate amounts of time to each of their patients, or use the hospital as a substitute for their short supply. The anthrax incident described in great detail above illustrated and highlighted each of these effects. A bioterrorist event in an urban area may also result in a mass exodus to a rural area, overwhelming rural physicians with il l and contaminated individuals (Clawson & Brooks, 2003). In a study conducted by Ro senthal (2003), it was found that, due to

PAGE 33

22 lack of funding and complacency, many local he alth departments were unprepared for the burden of responding to a biote rrorist attack. The Rosent hal study notes that health departments in rural communities, in part icular, are unequipped to provide 24-hour emergency response. Rosenthal (2003) also explained that nearly 20% of rural health departments have no Internet access and 10% do not have e-mail, all of which are critical for instant communication and information. Further, exacerbating rural areas vulnerability to bioterrorism is the fact that the number of physici ans and other healthcare providers in rural areas is often limited (Cla wson & Brooks, 2003). So in the event of a bioterrorist attack, rural communities may become overwhelmed and not be able to provide ancillary support for urban communities (Florida Department of Health, 2002). Moreover, augmenting these vul nerabilities, many rural community physicians do not feel immediately threatened by a bioterrorist attack, which often results in less professional preparation (Bartlett, 2001; Chen, Hickner, Fink, Galliher, and Burstin, 2002; Office of Rural Health Policy, 2002; Shadel et al., 2003; Sterling et al., 2005). Local Preparedness Efforts and Public Health Achieving local preparedness requires the translation of national policy initiatives into the implementation of local programs (M cFee et al., 2004). Today, an urgent need exists to take decisive steps to improve bioterrorism preparedness especially among healthcare professionals (Rose & Larrimore, 2002). Rose and Larrimore (2002) explain that the current generation of physicians and nurses feel unprepared in both their knowledge base and confidence levels to deal with potential biological terrorism and its consequence. Previous research has unders cored this point by s howing that community clinicians often are the fi rst to identify potential bi oweapon victims yet remain inadequately prepared clinical ly to address such events (McFee, 2002; Pesik, Keim, and

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23 Sampson, 1999; Sniffen & Nadler, 1999). Conse quently, it has become clear that there is a pressing need to rapidly educate and trai n medical personnel on the signs and symptoms and reporting mechanisms of bioterrorism-related diseases (Gershon et al., 2004). Few studies have examined bioterrorism prepar edness (Gershon et al., 2004), and several published reports provide eviden ce of both knowledge gaps and high levels of interest in bioterrorism-related training among physicians (American Medical Association [AMA], 2005; Heun, 2002; Sigmon & Larson, 2002). In order to contribute mean ingfully to the scholarly literature, we need to better understand perceptions, awareness, and th e extent of emergency bioterrorism preparedness among physicians. This study wi ll attempt to bridge those gaps and examine physicians perceptions of their biot errorism preparedness and their perceptions of the barriers to their emergency bioterrorism preparedness. This will provide an important link in understanding th e context under which the re search questions for this study were formulated. Preparedness is a state of readiness to res pond to a disaster, crisis or any other type of emergency situation. The Federal Emer gency Management Agency further defines it as the leadership, training, readiness and exercise support, and technical and financial assistance to strengthen citizens, communities, state, local and tribal governments, and provisional emergency workers as they prep are for disasters, mitigate the effects of disasters, respond to community needs after a disaster and launch effective recovery efforts (Bullock, Haddow, Coppola, Ergin, We sterman, and Yeletaysi, 2004). The CDC has implemented a national netw ork of education and training resources between colleges and universities known as the Centers for Pub lic Health Preparedne ss (CPHP) program.

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24 According to this program (CDC, 2005) public health preparedness involves strengthening the public hea lth workforce readiness thr ough implementation of programs for life-long learning, strengthening capacity at state and local levels for terrorism preparedness and emergency public health response, and developing a network of academic-based programs contributing to national terrorism preparedness and emergency response, by sharing expertise and resources across state and local jurisdictions. A 2003 report from the United States G overnment Accountability Office (GAO) states that four of five hospitals (81%) have a written emergency response plan that specifically addresses biote rrorism, and that 18% are de veloping one (United States Government Accountability Office [USGAO], 2003). Planning and preparing for bioterrorism is different for healthcare professionals than for other natural disasters principally because of the lack of experience and knowledge regarding bioterrorist agents and although the probability in any one city or town may be low, the risks nationwide are incredibly high (Jernigan et al., 2001; McGl own, 2004; Trumbull & Abhayaratne, 2004; Tucker, 1999). The more common weapons of terrorism (e.g., explosives) are visible; however, biological terrorism is an invisible enemy (McGlown, 2004). The bacteria and viruses unleashed may not be the same ones phy sicians deal with da ily. Most medical providers have never seen a patient with anthrax or tularemia; caregivers do not know how these diseases present in patients or how to appropriately protect themselves or others. These are unknown entities to medical providers and thus ar e easily dismissed. Further, the mere existence of institutional or clinical guidelines regarding bioterrorism preparedness plans does not assure that a phys ician actually perceives himself/herself as being personally prepared. Among other thi ngs, bioterrorism prep aredness plans are only

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25 as effective as the assumptions on which they ar e based. As with most disasters, it has been suggested that the threat must hit close to home and a ffect ones community directly before action is taken (McGlown, 2004) Thus, the current literature regarding physician and medical providers perceptions of preparedness for bioterrorism will be reviewed. So what follows is an intensive review beginning with the quantitative literature regarding physician perceptions of their bioterrorism preparedness and their perceived barriers followed by a review of the one qualitative study performed on this topic. Physician Perceptions of Bioterrorism Prep aredness: A Review of the Literature Regarding National Studies A study conducted by Alexander and Wynia in 2003 shows that there is minimal information about contemporary physicians sense of preparedness for bioterrorism, willingness to treat patients despite personal risk, or belief in the professional duty to treat during epidemics (Alexander & Wynia, 2003). Few physicians reported in this study that they or their practice are well prep ared for public health emergencies. This study explored physicians willingness to a ddress potential acts of bioterrorism by conducting a national random mail survey of a sample of 526 physicians involved in direct patient care. The survey focused on physicians perceived personal and workplace preparedness for bioterrorist at tacks. The survey asked physicia ns if their primary site of clinical practice was well prepared to play a role in handling a bioterrorist event. Twenty-two percent responded that they or thei r primary site of clin ical practice (private practice or a hospital setting) was well prep ared to play a role in responding to a bioterrorist attack. Personal and organizational preparedness were modestly correlated (r = 0.27). Physicians in primary care specialti es were significantly more likely than those

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26 not in primary care to report a willingness to treat, as were those who reported being more religious, being personally prepared, ha ving learned a lot about physicians roles in responding to bioterrorism post 9/11 and agreeing that physicians have a professional duty to care for patients in epidemics or w ith the Human Immunodefici ency Virus (HIV). On multivariate analysis, greater willingness to treat was associated with a belief in a professional duty to treat patients in epidemics, feeling personally prepared, and being in a primary care practice. The Alexande r and Wynia (2003) study has a few potential limitations. The study may have been influe nced by bias having been a mail survey, which relied on self-reporting. The type of bias distorting this study may have been what is known as socially desirable response bias. This type of bias occurs when respondents reply with a response that the respondents believe is acceptable both politically and socially. These findings have several implicat ions for healthcare providers and policymakers. First, they support concerns regarding bioterrorism preparedness among physicians. In 2002, Chen, Hickner, Fink, Galliher, and Burstin studied family physicians during a similar time period and found that only one-quarter felt prepared to respond to a bioterrorist event and that receipt of response tr aining were associated with preparedness. Competing priorities and th e perceived low likeli hood of a local attack may reduce physicians preparedness (Bartlett, 2001). Chen et al. also noted that there are no published validated measures of biote rrorism preparedness a nd limited data on the effectiveness of specific e ducational programs. The Al exander and Wynia (2003) study found that ones sense of personal prepar edness correlated with having learned a significant amount about bioterrorism since September 11, 2001 (correlation coefficient

PAGE 38

27 of 0.50). So, efforts to provide physicians wi th instructions for a general early response to medical disasters (such as where to report in an emergency situation) might foster a greater sense of readiness. In 2003, the Alexander and Wynia study s howed temporal trends that were noteworthy and yet also alarming. Both preparedness and the sense of professional obligation to treat during epidemics are declining according to a study conducted by Croasdale in 2002. These trends mirror th e substantial d ecrease in physicians use of online bioterrorism training programs throughout 2002 and the years th ereafter. Changes in these areas are not unprecedented. In a similar fashion, early in the HIV epidemic, physicians contentiously debated the dut y to treat (Emanuel, 1988). Arguments supporting a professional duty to tr eat in the face of uncertainty and risk have been based on multiple ethical and pragmatic grounds, in cluding appeals to virtue, beneficence, patients rights, the contract between physicians and society, and social utility (Bayer, 1988). Furthermore, W.D. Rosss seven prim a facie duties are generally accepted to comprise the central tenets of both prof essional duty and modern Western healthcare ethics today. The Alexander and Wynia study reported that 79% of physicians today perceive an obligation to car e for the HIV-infected pers on. Although the reasons for greater consensus of agreement today are co mplex, they are likely to include improved knowledge of medical transmission, medical societies position statements, legal standards, and changing societal values. Risk has traditionally been part of medical care and there have long been statements in th e American Medical Association professional codes of ethics as well as other medical academies professional code of ethics supporting the duty to treat (A MA, 2005). The Alexander an d Wynia study reinforces

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28 this consensus view, but not without reservations. In th e Alexander and Wynia study, 80% of physicians reported a willingness to treat patients without a priori knowledge of the level of risk while 20% refused to treat such patients. The st udy further states that only 55% agreed that physicians have an ob ligation to care for patients in epidemics even if doing so endangers the physici ans health (Alexa nder & Wynia, 2003). According to the Alexander and Wynia study, physicians who believe in a professionwide duty to treat have more than four-fold higher odds of reporting a willingness to treat during an outbreak involving an unknown initial level of risk The study concludes that although the validity of reports about future behavior cannot be ensured, physicians who deny an obligation to treat under conditions of risk are probably less likely to treat patients in an actual incident. The results suggest that efforts to ensure physicians readiness to address bioterro rist events should include a renewed emphasis on this longstanding professional obligation. This is es pecially important because physicians would be called on to be one of the frontline res ponders in a post-catastrophic event such as a bioterrorist event. Thus, physicians must be prepared ethically, intellectually, emotionally, and socially for such an event. Physicians and possibly other healthcare personnel need to be trained in identifyi ng rare infectious di seases, surveillance techniques, and epidemiology and quarantining procedures. According to the Alexander and Wynia study, Preparing physicians for biot errorism should entail providing practical knowledge, preventive steps to minimize risk and reinforcement of the professions ethical duty to treat. Similar factors shoul d be considered in en couraging the duty to treat in future epidemics or public health em ergencies such as a bi oterrorist event.

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29 Another study conducted by Cowan, Ching, Clark, and Kemper (2005) shows the willingness of private physicians to be invol ved in smallpox preparedness and response activities. The United States federal, st ate and local government s have implemented a program known as the National Smallpox Vacc ination Program (NSVP) to ensure that the public health system is prepared to respond quickly to a smallpox outbreak (Bush, 2002). This study exposes that it is unclea r whether the capacity, specifically the surge capacity of the public health system, is suffi cient to meet demand for vaccination in the event of a public health emergency such as th e release of a bioterrorist agent like anthrax or smallpox. An important aspect of biot errorism preparedness is su rge capacity. Surge capacity is a healthcare systems ability to rapidl y expand beyond normal services to meet the increased demand for qualified pe rsonnel, medical care, and pub lic health in the event of bioterrorism or other largescale public health emergencie s (AHRQ, 2005). The study expressed that to assure there is adequa te capacity for various smallpox vaccinations, public health officials may seek the help of other healthcare professionals such as primary care physicians engaged in private pr actice settings. Previous research has shown that individuals would seek care from their primar y care physician first in the event of a public health emergency over a hos pital or a department of health, if they thought they had contracted smallpox disease (Blendon et al., 2003; Green, Fryer, Yawn, Lanier, and Dovey, 2001; Lane & Fauci, 2001). The Cowan et al. (2005) st udy was a national random sample of 750 office-based direct patient care internal medicine physicians and 750 fam ily practice physicians drawn from an American Medical Association Mast erfile. The survey used was a 23-item

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30 questionnaire exploring the w illingness of private physicians to participate in pre-event and post-event smallpox vaccination activities. The study explored factors associated with this participation su ch as knowledge, attitudes, and beliefs about smallpox vaccination; sources of information a bout smallpox vaccination; and physician demographics and practice characteristics. In the Cowan et al. study, physicians were asked to consider a pre-event scenario in which interested adult members of the general public could voluntarily receive smallpox vaccin ations. Under this scenario, 61% of the physician respondents felt that vaccine should be administered in both a public health setting and in a private office clinical setti ng versus exclusively in one setting or the other. Thirty percent of physician responde nts would be somewhat willing or very willing to offer smallpox vaccination to intere sted patients in thei r practice (Cowan et al., 2005). However, most physic ian respondents were not very willing or not willing at all to offer the smallpox vaccination at th eir private offices (Cowan et al., 2005). The most likely reason according to the study as to why most physician respondents were not very willing or not willing at all to offer a smallpox vaccination at their private offices was because of a possible vaccination adverse event (68% of responde nts). Other reasons included a possible smallpox outbreak (53%) an d the risk of transmission of smallpox vaccine virus (52%) to others. Many phys ician respondents cited necessary factors before providing vaccination su ch as liability protection ( 95%), and guidance on program logistics (92%). Physicians were also asked in the Cowa n et al. (2005) study if they would be willing to participate in certain other pre-ev ent vaccination activities if they received proper training, liability protec tion, and compensation, and if capacity in their community

PAGE 42

31 to vaccinate interested member s of the general public was otherwise insufficient. Fiftynine percent reported that they would be will ing to offer vaccinations in their practice to first responders such as police, 28% would be willing to offer vaccination to interested community members, and only 26% would be a vaccinator at a public health clinic. In addition, the Cowan et al. study shows that 68% of physicians would be somewhat willing or very willing to evaluate their patients with suspected mild to moderate adverse reactions to smallpox vaccination, re gardless of at which location these patients had received their pre-even t vaccination (Cowan et al ., 2005). However, 14% of physician respondents were neutral and 18% woul d be not very wil ling or not willing at all to even evaluate their own patients (Cowan et al., 2005). This implies that the majority of physicians would be willing to v accinate first responders such as police, but are more reluctant to vaccinate the general pub lic. This is possibly due to similar reasons as stated previously of possible adve rse side effects and litigation. Among physician respondents, 59% woul d be willing to provide contact information for their practice to a federal re gistry of emergency smallpox vaccinators to facilitate rapid community response to a smallpox outbreak (Cowan et al., 2005). The study further stated that in preparation for responding to a possible outbreak, respondents would need training in rec ognizing smallpox (87%), vaccin e handling and administration (97%), and recognizing and trea ting vaccine adverse events (98%). This implies that many physicians perceive themselves as unprepared and realize the need for education and training. The Cowan et al. (2005) st udy also questioned physician primary care respondents under the scenario that the public health syst em may not have sufficient capacity to meet

PAGE 43

32 the demand for vaccination in the event of a smallpox outbreak. Respondents were asked whether they would be willing to participate in certain post-event activities. Eight-nine percent responded that they would be willing to offer vaccination in their practice to their patients. Sixty-four percent would be willing to offer v accination in their practice to members of their community who may not be their patients, but only 44% would be willing to be a vaccinator at a public health clinic. The survey also attempted to asse ss physicians knowledge, attitudes, and perceptions regarding smallpox vaccination an d smallpox in general. It asked the respondents to assess the extent to which they agreed with five statements in the table below. Table 2-1: Knowledge, Attitudes, and Beliefs Regarding Smallpox and Smallpox Vaccination Statement Agree Neutral Disagree In the next five years, a smallpox outbreak or attack is likely in the United States 13% 26% 61% Vaccination is effective in preventing smallpox disease. 88% 7% 5% Overall, the smallpox vaccine is safe. 35% 27% 38% I am confident in my ability to recognize symptoms of smallpox. 45% 22% 33% I am confident in my level of knowledge regarding the smallpox vaccine. 44% 21% 35%

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33 Although few respondents perceived the risk of a smallpox outbreak to be high (13%), the differences in perceived risk of an outbreak did not affect physicians willingness to offer vaccination in their pr actice under a pre-event smallpox vaccination program for the general public. Forty-five pe rcent of primary care physicians felt that they could recognize the symptoms of sm allpox and 44% were confident in their knowledge of the vaccine. Thus, many primary care physicians demonstrated a willingness to be involved in post-event activitie s and to participate in a system to plan for such a contingency. There are two main limitations in this study: the first is the validity of physicians predicted behavior based on hypothetical scenarios is unknown. Secondly, the low response rates (less than 25% of surveys co mpleted and returned) limit the external validity or the generaliz ability of the findings to other physicians in other settings. However, the results of this study suggest that there is a subset of primary care physicians in private practice that would be willing to a ssist public health offi cials in their smallpox preparedness and response efforts. Physicia ns in the study were reluctant to be selfvaccinated and this has been shown to be c onsistent with other studies involving hospitalbased smallpox vaccination response teams in the first stage of the NSVP (Benin, Dembry, Shapiro, and Holmboe, 2004; Evere tt, Coffin, Zaoutis, Halpern, and Strom, 2003; Everett, Zaoutis, Halpern, Strom, and Co ffin, 2004) and are also consistent with the low influenza vaccination rates of healthcare workers in general (CDC, 2004). The physicians lack of interest in preevent vaccination ha s implications for potential plans for a voluntary, pre-event smallpox vaccination for the general public. The capacity required to implement such a pr ogram would depend in part on the level of

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34 interest of the general pub lic in being vaccinated. A lthough the publics interest has previously been shown to be relatively high, it is also greatl y influenced by the vaccination decisions of practicing physicians (Blendon et al., 2003). In the Cowan et al. (2005) study, despite physicians reluctance to be vaccinated they did express some willingness to participate in pre-event smallpox activities. The study explains that private physicians are an option for expanding the capac ity to vaccinate first responders, which is the second stage of the NSVP. It explains th at public health officials would need to establish contact with the primary care physicians in thei r community to ascertain who is willing to help and how best logi stically to incorporate them into vaccination plans. The study also states that private physicians are no t as willing to particip ate in efforts outside their own practice. Therefore, if there is a need to incr ease the number of available vaccinators for public health c linics, planners will likely need to consider other health professionals, such as school nurses (Gulli on, 2004). According to the Cowan study, private physicians seem willing to vaccinate their own patients in the event of an outbreak scenario, but less willing to vaccinate the public in general. Thus, public health officials should ensure that these physicians are included in response planning efforts and determine how best to integrate their part icipation with that of other healthcare professionals. In numerous studies it has been indicated that physicians would need additional training in order to assist with bioterrori sm response efforts (Alexander & Wynia, 2003; Chen et al., 2002; Cowan et al., 2005; AMA, 2005; Heun, 2002; Sigmon & Larson, 2002). Providing appropriate guidance and training not only help s to assure that physicians feel prepared, but al so increases the chances that physicians will participate in

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35 response efforts and that the efforts will be successful (Alexander & Wynia, 2003; Gerberding, Hughes, and Koplan, 2002). A study conducted by Chen et al. (2002) s howed that 95% of family physicians agree that a bioterrorist attack is a real threat in the Unite d States. This study used a 37item questionnaire with a 3-category Likert scale, ranging from strongly agree or agree to neutral to disagree or s trongly disagree to measure physicians assessments of bioterrorist risk and prep aredness, specific clinical competencies, capabilities in bioterrorism response, and thei r prior level of intera ction with the public health system. Physicians were also asked re garding four biological agents they perceive may be used in a terrorist attack. In this study, physicians were categorized according to a self-reported location of rural, urban, or suburban, and respondents were also asked to describe the size of the p opulation in their area. Two survey items were the main outcomes of the Chen et al. study because they were believed to represent the key featur es of family physician preparedness: (1) knowing what to do as a doctor in the event of a suspected bioterro rist attack in my community, (2) knowing where to call to repo rt a suspected bioterro rist attack, (Chen et al., 2002). Students t-test and Pearsons chi square test were used to assess the statistical significance of the bivariate anal ysis. Multivariate logistic regression was performed to assess the effects of age, sex, geographic location, risk assessment, ability to gather information, and previous traini ng in bioterrorism preparedness on the main outcomes of interest. Ninety-five percent of family physicians believ ed that a bioterrorist attack is a real threat in the United States and 39% of family physicians believed a bi oterrorist attack are

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36 real threat to their local community yet only 19% believed that their local medical community could respond effectively. Furt hermore, only 27% believed that the United States healthcare system could respond effec tively to a bioterrorist attack and fewer (21%) believed that their local hospital or their local medical communities (19%) could respond effectively to an attack according to a random national survey of 614 family physicians (Chen et al., 2002). The Chen et al. study has both similarities and salient differences from the Cowan et al. (2005) and the Alexande r and Wynia (2003) studies. All three studies explain that physicians do not feel personally prepared to respond to bioterrorist events. However, the Chen et al. study reports that 95% of physicians perceive that a bioterrorist attack is both real and imminent while in the Cowan et al. study 13% of physicians perceive a bioterrorist attack with sm allpox as an agent is likely either now or in the next five years. According to the Chen et al. study 26% of physicians reported that they could respond e ffectively in the even t of a bioterrorist attack. In contrast, when asked if they c ould respond effectively to natural disasters or infectious disease outbreaks, a significantly higher percentage of physicians responded that they would know how to respond to thes e other public health emergencies. Sixtyfive percent of physicians responded that th ey could respond effec tively and would know what to do (p < .001) in the event of a natural di saster and 66% of physicians responded that they could respond effectively (p < .001) in the event of an infectious disease outbreak. After they combined responses for local hospitals and community preparedness, only 17% of physicians believed that both their local hospitals and their medical communities could respond effectively to a bi oterrorist attack, compared with 60% (p <

PAGE 48

37 .001) for a natural disaster and 56% (p < .001) for an infectious disease outbreak (Chen et al., 2002). So significantly fewer family physicia ns feel they are personally prepared as well as their local medical community and thei r local hospitals for a bioterrorist event than for a natural disaster or an infectious disease outbreak. Yet there are similarities between bioterrorist events and natural disast ers and infectious disease outbreaks in that early detection and reporting are also critic al to a timely and effective response to a bioterrorist event (CDC, 2000; Franz et al ., 1997; Kahn, Morse, and Lillibridge, 2000; National Academy Press, 1999;). The Public Health System and Prim ary Care Physicians Perceptions of Bioterrorism and National Bioterrorism Preparedness For most Americans, their first point of contact with the healthcare system is the primary care physician, who is therefore on the frontline in this new era of bioterrorism (Green et al., 2001; Lane & Fauci, 2001). Many victims of a bioterrorist attack may not know they have been affected, and because the symptoms caused by many bioterroristrelated agents mimic those of common conditi ons, primary care physicians will likely be in the position of diagnosing and managing initi al cases of bioterrori st-related illnesses (Gourlay & Siwek, 2001). Thus, a primary care physicians ability to identify cases and activate the public health syst em is a crucial step in effectively responding to a bioterrorist attack (Franz et al., 1997; Gor don, 1999; Haines, Pitts, and Crutcher, 2000). Several recent studies have concluded that the preparedness and infrastructure of the public health system are in adequate to deal with a bi oterrorist attack and need improvement (CDC, 2000; Garrett, Magruder, and Molgard, 2000; Inglesby et al., 2001; Kahn et al., 2000; Rosen, 2000). One survey found that fewer than 20% of emergency departments in the Pacific Northwest had pl ans for responding to a bioterrorist event

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38 (Wetter et al., 2001). However, these st udies, although examini ng the public health system, failed to discuss the critical role of primary care provide rs in responding to bioterrorism (Henretig, 2001; Sidel, 2001). Other studies have found that many local health departments are unprepared to respond to a bioterrorist at tack (Rosenthal, 2003; USGAO, 2003). According to the Chen et al. (2002) study, physicians felt more comfortable responding to other types of pub lic health emergencies, such as natural disasters or infectious disease outbreaks. This may be in part due to their pe rsonal experiences in dealing with these events, or may reflect the formalized trai ning in public health response that is part of the medical school curricul a. The reporting and response skills physicians would use in dealing with the public health system during a bi oterrorist event are similar to the ones that they would us e during natural disasters and in fectious disease outbreaks. Naturally, physicians experi ences with the public health system in responding to and managing natural disasters and infectious dis ease outbreaks are helpful, but a bioterrorist attack has unique features that require prim ary care physicians to be able to obtain and use information from public health sources and intelligence sour ces (National Academy Press, 1999). The Chen et al. study (2002) was the first to assess primary care physicians personal sense of preparedness for responding to a bioterrorist event. According to the Chen et al. (2002) study, biological agents p hysicians consider most likely to be used in a bioterrorist at tack include anthrax (96%), smallpox (82%), plague (28%), botulism (22%), ebola (16%), nerve gas (14%), tularemia (11%), E. coli (7%), Salmonella (5%), and influenza (4%). The study performed by Chen et al. also found that only 24% of the family physicians surveyed believed they could recognize

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39 signs and symptoms of an illness in their patients due to bioterrorism, and 38% rated their current knowledge of the diagnosis and mana gement of bioterrorism-related illness as poor. Furthermore, the Chen et al. study stat ed that only 18% of physicians had received previous training in bioterrori sm preparedness. Physicians who felt prepared for natural disasters were four times more likely than other doctors to know how to respond to a bioterrorist attack (36% versus 9%, p < .001). Physicians who felt prepared for infectious disease outbreaks were 6 times more likely th an other doctors to know how to respond to a bioterrorist attack (37% versus 6%, p < .001). Physicians felt better prepared for a bioterrorist attack if they had training in bioterrorism preparedness. Physicians who had received training were 3 times more likely th an other doctors to know how to respond to a bioterrorist attack (55% versus 20%, p < .001). Moreover, 98% thought it was important for them to be trained to identify a bioterrorist attack, and 93% of physicians said they would like such training. The Chen et al. study demonstrated that fa miliarity with the p ublic health system was not necessarily associated with physicians preparedness for bioterrorism. Ninetythree percent of physicians re port notifiable infectious di sease cases to the health department, only 57% (p < .001) reported knowing whom to call to report a suspected bioterrorist attack and only 56% of physic ians reported knowing how to get information if they suspected an attack in their commun ity (Chen et al., 2002). In the multivariate model, having received training in bioterrorism preparedness (odds ratio (OR) 3.9 [95% CI 2.4-6.3]), and knowing how to obtain informa tion in the event of a bioterrorist attack (OR 6.4 [95% CI 3.9-10.6]) were significan tly associated with physicians knowing what to do in the event of an attack. Believing th at bioterrorism was a real threat to their

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40 communities was also significantly associated with a physicians ability to recognize signs and symptoms of a bioterrorism-related il lness (OR 1.9 [95% CI 1.2-2.9]). In the Chen et al. study, physicians preparedness wa s not associated with geographic location, residence (rural, urban or s uburban), age, or gender. One limitation of the Chen et al. (2002) study was that the survey instrument did not define bioterrorism, but relied on the re spondents personal perceived definitions of bioterrorism. Although the timing of the surv ey coincided with na tional media attention on the anthrax cases, there was not a high le vel of confidence or knowledge in dealing with bioterrorism. In a study conducted in 2005 by David Ster ling and colleagues, the issue of a possible bioterrorist event occurring at th e workplace is examined. The rationale for most preparedness training of healthcare prof essionals is based on the assumption that most persons infected followi ng a bioterrorism incident wi ll present first to emergency departments of acute care facilities or to ambulatory settings such as private physician offices, and such incidences would be recogn ized, appropriately tr eated, and reported to the local health departments (Sterling et al., 2005 ). The Sterling et al study explains that an alternative first po int of contact is industry, a lo cation where workers gather and disperse on a regular and documented basis, an d require healthcare. St erling et al. further explains that in industry there are health pr ofessionals responsible for the health, safety, and on-site well-being of the workforce a nd surrounding community; these professionals are in a position for early rec ognition, surveillance, and isola tion. It is the belief of the authors of this study that target ed education, therefore, must be provided to these health professionals. Several studies have asserted that no United States asset is considered

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41 safe from terrorist actions and large cities are not the only targets (Gwerder, Beaton, and Daniell, 2001; Sterling et al., 2005). In a ddition, the lack of a publicized threat to industry may impact the risk perceptions of occupational health professionals and downplay the need for increas ed awareness, preparedness, and response at industrial settings (Sterling et al., 2005) This lack of awareness a nd preparedness at the workplace would probably diminish the contribution th at occupational health professionals can make to bioterrorism preparedness. A limitation of the Sterling et al. study is that it does not state which types of workpl aces (i.e., industrial, financial, or others) are involved and 87% of the workplaces examined are in the five Midwestern states of Missouri, Indiana, Michigan, Wisconsin, and Illinois. To address perceptions of preparedness a nd risk as well as preferred educational delivery methods for bioterrorism and emerging infections-related materials, a survey of occupational physicians was perf ormed during the spring of 2 001. Within the two months following the September 11, 2001, terrorist att ack and subsequent an thrax bioterrorism event, and before release of any results from the first survey, a follow-up mail survey was initiated in November 2001. Previous studies have corroborated this study and concluded that the risk of a possible biot errorist event is increasing a nd that physicians need to be prepared and educated (Henderson, 1999; Tu cker, 1999; Jernigan et al., 2001; Rose & Larrimore, 2002; Trumbell, 2004; Sterling et al., 2005). The survey instrument used was modified from a previous national survey of physicians (Shadel et al., 2003) to examine occupational physicians preparedness. The instrument assessed several factors: the percei ved threat of bioterro rism, past training, barriers to training, access to instructional technology, and preferred medium for

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42 education and training. Percep tion questions were based on a st andard Likert scale of 1-5 or important to not important. The survey was disseminated at a 2001 spring conference, Central States Occupational Medicine Associ ation, for occupational physicians and then collected. Following September 11, 2001, th e survey was modified and a follow-up survey was mailed to all physician participants from the conference. Response rates to the pre-September 11 and post-September 11 survey were 58% (n = 56) and 33% (n = 33), respectively. No significant demographic differences were observed between the respondents of the pre-su rvey and the post-sur vey. Eighty-eight percent considered themselves to be comput er proficient and the assumption was that computer proficiency does not change consider ably over a brief six month period of time. In each survey more than 80% were located in urban or suburban locations. There were statistical differences noted during the presurvey based on both the city involved (p = .023) and the size of the facility (p = .004), regarding the like lihood of the public health surveillance system to detect a bioterrorist event. The study found that the smaller the city and the larger the facility, the great er the perception that an event would be recognized. It also found that the larger the city then the greater the perception among physicians that a bioterrorist attack would occur near their place of work (p = .019). Naturally, perceptions of likelihood of another bioterrorism event increased between the pre-September 11 and the post-Sept ember 11 survey. In the pre-survey, 61% of respondents felt it would happen in the Un ited States, 21% expect ed that it would happen near their place of work, and 42% had r eceived bioterrorism training. In the postsurvey following September 11, 2001, 94% believe d another event was likely to occur in the next five years, only 45% believed it would occur near them, and over 90% had

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43 received some training. When participants were asked if another bioterrorist attack would occur over the next five years, a statistically significant difference emerged between the pre-survey and the postsurvey respondents perceptions (p < .001). The statistically significant increase in perceived risk between the surveys was notable for a local occurrence, i.e., expecting it to happen near their place of work (p = .012). When participants were asked how likely they would be to seek information regarding bioterrorism preparedness in the pre-Sept ember 11 surveys, 60.7% responded very to somewhat likely. Whereas when the same question was posed in the post-September 11 survey, 93.8% responded very to somewhat likel y. This difference wa s also statistically significant (p < .001). Participants who had receiv ed bioterrorism training prior to the pre-survey did not differ signifi cantly in their responses to the survey than those who had not received any training, although they were even less likely to believe that a bioterrorist attack would occur near their work (13%). This poses an interesting question, one which this study will attempt to clar ify through examining the per ceptions of preparedness of rural physicians regarding biote rrorist events. Fifty-eight percent of the participants indicated that they had not received any biot errorism training prior to the pre-survey. These participants listed four similar barrier s as the most common: no training available (59.4%, 53.6%), no continuing me dical education training credits as part of their training (37.5%, 32.1%), not part of their responsibility (25%, 42. 9%), and no time dedicated (21.9%, 25%). Occupational physic ians noted that their first notifications for a suspected bioterrorist event would be the local health department (70.9%), followed by the state health department (65.5%), CDC (61.5%), an in-house infectious disease physicians (58.2%). The post-September 11 surveys show ed a significant increase in notification for

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44 a bioterrorist event to the lo cal health department (96.8%, p =.004) and a decrease in notification to the stat e health department and the CDC. The responses for those with prior bioterrorism training during the pre-surv ey were similar to the overall post-survey results. During a bioterrorist event, timely access to information is essential. The preferred information sources to contact during a crisis were the CDC, state and local health departments, and in-house infectious disease physicians. The preferences did not change following September 11, but their rank order ch anged. The use of in-house infectious disease physicians increased from 43.6% to 53. 3% and the local hea lth department from 40% to 53.3%. The use of poison control hotl ine decreased by a statistically significant factor of four (p < .05). A comparison was performed of the prefe rred method of receiving education and training. The preferred methods of the presurvey were professional meetings (69.6%), followed by Internet access (35.7%), journal re view (30.4%), and CD-ROM (23.2%). In the post-survey following September 11, profe ssional meetings were still most preferred (64.5%) but the use of video (35.5%, p < .05) and grand rounds (19.4%, p < .05) were statistically significant fo r preferred methods. There were a few limitations in this study. The study was a small study with 56 respondents in the pre-survey and only 33 res pondents in the post-survey. The study was national, yet a few different states were re presented in the pre and post surveys although the authors note that they were demographically similar thus making it less generalizable. Another limitation is that the first survey was performed at a conference and the second study was a mail survey, which has its own inherent limitations.

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45 Even though over 90% of the physicians ha d received immediate training following September 11, additional traini ng/education needs were demo nstrated (Sterling et al., 2005). Previous research corroborates this finding (Alexander & Wynia, 2003; AMA, 2005; Chen et al., 2002; Cowan et al., 2005; Heun, 2002; Sigmon & Larson, 2002). Although training and education modules can be designed without information based on the population that can be on the receiving e nd, it then rarely accomplishes its goal. Results from this survey can serve as a basi s for designing various levels of targeted training and educational material specific to the perceived need method of obtaining information, and the format considered to be most conducive for lear ning (Sterling et al., 2005). Sterling et al. further notes that th e potential consequences from lack of bioterrorism preparedness due to low perception of need and threat awareness need to be addressed. In sum, the previously conducted studies suggest that physicians studied in this literature review may not be pr epared for bioterrorist events The majority of physicians interviewed acknowledged that po st September 11, 2001, the thre at of a bioterrorist event was heightened. Many of the respondents also reported that they had received bioterrorism training because of the height ened threat. Yet, despite the training, physicians expressed an even greater need for additional bioterrorism training and education. Continuing medical education (CME) is an evolving process of education for physicians that foster the individuals commitment to lifelong learning, optimal development, and maintenance of medical knowledge and skills. CME is also intended to enhance the ability of physicians and hea lthcare professionals to provide excellence in

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46 patient care, health maintenance, and di sease prevention with resultant improved outcomes of care of their patient population. Physicians have been confronted with th e need to keep their knowledge current for many hundreds of years. Ell (1984) describe s CME that was practi ced in Venice from 1300 to 1800. Practitioners were required to a ttend a yearly refresher course in anatomy in order to renew their licenses. In the Un ited States, no formal attempts at requiring CME were required until 1932, when the Ameri can Association of Medical Colleges first proposed mandatory CME. After several d ecades of discussion and debate, in 1947 the American Academy of General Practice bega n to require 150 hours of CME every three years as a condition of membership (AMA, 1999). In 1975, the Accreditation Council for Continuing Medical Education (ACCME) was formed as a consortium of seven organizations which all have interests in CME (ACCME, 1999). Since that time, the AMA and the ACCME have played principal roles in the development and accreditation of CME. In a survey conducted in 1995, the AMA found that thirty-one states required proof of CME for re-licensure, and by 1997, twenty-four specialty boards had made CME a requirement for certification or re-certifi cation (AMA, 1999). These requirements have led to a burgeoning of formal contin uing medical education programs. Traditional continuing medical educati on consists of physic ians attending a meeting at their local hospital. The meeti ng ordinarily contains a lecture regarding a medical condition or a procedure. Sometimes the lecture may be based on a real or simulated case. This is often known as gra nd rounds. Typically the lecturer speaks for 40-45 minutes and leaves time for a five to ten minute question and answer period at the end. A lecturer ordinarily presents the information with computer generated slides and a

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47 handout of salient points is dist ributed. There is generally no pre-lecture or post-lecture test of knowledge. Physicians earn credit by placing their name on a sign-in sheet. This formatted lecture remains the dominant form of CME, although it has been difficult to prove if continuing medical educa tion results in any change in the physicians practice behavior (Davis et al ., 1999). Yet despite the rese rvations, there are important non-academic advantages to continuing medi cal education lectures. The individual physicians attending such CME lectures may l earn that the lecturer, who is often also a physician, may practice in the same comm unity or a nearby community and accepts patients with the conditions discussed or requiring the discussed procedures. Furthermore, although anecdotal, it appears ad vantageous from a collegial or social atmosphere. The CME meetings allow physicians to encounter other physicians and learn what is new in the hospitals, among other physicians, and in the local medical community. Merriam (1996), in a review of adult learning theories, fi nds a number of implications for the education of health prof essionals. The first, she explains, is to develop self-directed learners. Merriam (1996) explains that no amount of academic preparation, undergraduate or graduate, or c ontinuing professional education will be able to keep pace with changes in the health field. Professionals must take it upon themselves to be lifelong learners and to engage in learning projects to remain current. Merriam (1996) also explains that a second implication is that the more signi ficant learning is that which is situated in the context of adult life or in actual activity. Sh e further explains that some of these activities include lectures, internships, apprenticeships, mentorships, and case-study instructional methodologies. Thus continuing medical education seminars

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48 offer opportunities for physicians to engage professionally, intellect ually, and socially with advances in medicine and public health. In 2003, Shadel and colleagues performe d a national needs assessment survey, which measured infection contro l practitioners perception of th e risk of bioterrorism in the United States and in their community. Th e needs assessment study also examined the proportion of infection contro l practitioners with prior training in bioterrorism preparedness, and the barriers to receipt of such bioterrori sm education (Shadel et al., 2003). The study used an SPSS software package to randomly identify 4000 infection control practitioners from a membership list of the Association for Professionals of Infection Control and Epidemiology. Shadel and colleagues mailed a 35-question survey to measure these factors (Shadel et al., 2003). The survey instrument was pre-tested for format and content. The healthcare profe ssionals involved in the pilot testing were excluded from the random sampling. The quest ions were evaluated in 20 qualitative telephone interviews with h ealthcare professionals. The instrument assessed the perceived threat of biote rrorism, the extent of the respondents past bioterrorism training, a nd the perceived barriers to bioterrorism training. The questionnaire also addresse d access to technology and the preferred instructional design and medium for delivery of educational opport unities and reference materials. The survey questions regarding pe rceptions of risk were evaluated using a 1-5 Likert scale (1 being very likely and 5 being very unlikel y). Thirty-one and one-half percent or 1260 respondents fr om the original sample of 4000 participated in the mail survey. Approximately half of the respondents described themselves as working in direct

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49 patient care with most describing their work en vironment as an inpatient care facility. In this national survey, 450 participants or 36.6% worked in rural areas. The perceptions of risk regarding the inten tional release of a bi oterrorist agent in the United States in the next five years (p = .475) or in the infec tion control practitioners work community (p = .199) did not differ by type of occupational setting (patient care, public health, or administration). The like lihood that a respondent would seek more information about bioterrorism prepar edness was affected by the respondents occupational setting (p < .01), with significant differe nces between those working in administration and patient care (p < .01). A smaller propo rtion of those respondents working in administration (40.9%) were like ly to seek out bioterrorism information compared with those working in di rect patient care (50.2%). The study found significant differences betw een regions of the country when they assessed the perceived potential threat of a bioterrorist even t occurring in the next five years in the United States (p = .022), and in the infecti on control practitioners work community (p < .01). Infection control practitioners in the South were more likely to believe a terrorist attack would occur in the ne xt five years in the US compared to those in the Midwest (p = .13). Also, infection control pract itioners in the South (86.6%) were more likely to seek out bioterrorism pr eparedness information compared to those practitioners in the Midwest (79.5%; p = .45). Eighty percent of the infection control practitioners from the South believed that a bioterrorist attack was very likely to somewhat likely in the US compared with the Northeast (74.3 %), the Midwest (71.8%), and the West (71.4%). Approximately one -third (32.2%) of all infection control practitioners believed that a bioterrorist attack was likely or somewhat likely in the next

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50 five years in their community. There were no statistically significant differences by community size (urban or rural) when infecti on control practitioners ranked the perceived risk of a bioterrorist even t in the next five years (p =.923). Yet the responses differed when participants assessed the risk regarding their own community (p < .01). Participants were more likely to believe th at a bioterrorist event was very likely to somewhat likely to occur in the United States during the next five y ears than in their own community (74.4% versus 32%). Interestingly, how likely (i.e., very likely to somewhat likely) those participants believed that a bioterrorist event would occur in their community in the next five years differed significantly (p < .001), between communities of different sizes: rural (16.1%), suburban (40.1%) and urban (42.0% ). Differences were also found between rural, suburban, and urban communities regarding how likely they would be to seek informa tion on bioterrorism preparedness (p < .01). Fewer than half (41.7%) from a rural community reported that they were very likely to seek out more information. This studys intent is to cont ribute information to th e literature to help clarify and possibly explain rural physicians pe rceived bioterrorism preparedness. It is also the intent of this study to examine how the barriers rural phys icians encounter may pose impediments to garnering educational tr aining or information and thereby possibly explain rural physicians perceived behaviors and practice patterns Only 56% of the respondents reported prio r training in bioterrorism preparedness. Those who reported prior biot errorism training were more likely to believe that a bioterrorist attack would occur in the next five years in the United States (p < .001). Most of the respondents who re ported prior bioterrorism tr aining (51.8%) were involved in direct patient care. Respondents reported that the two most common barriers to

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51 receiving training were no tr aining opportunities (70.2%) a nd no dedicated work time for training (19.4%). Among those who had prior bioterrorism training, most had attended a session on bioterrorism at a professional mee ting (56%), obtained information through a journal article (54.5%), or at tended an in-service lecture (3 3.4%). The three preferred training methods were the followi ng: lecture at a professional meeting (59.6%), training video (32.3%), and satellite teleconference (29.2%). A larger proportion of members from rural areas selected videos (38.6%) or CD-ROM (17.4%) as the preferred method for education delivery than those in urba n (27.6%, 13%) and suburban areas (30.2%, 11.8%) respectively. This study has a limitation in that the partic ipants surveyed were all members of the Association for Professionals of Infec tion Control and Epidemiology so one may conclude that they may have perhaps been be tter prepared than other physicians. This study was a randomly selected national sa mple, which provided the opportunity to evaluate regional differences and community si ze differences. This study showed that healthcare professionals in rural areas were th e least likely to report that a bioterrorist event might occur in their community. Mo reover, fewer than half of healthcare professionals from rural communities were likely to seek out additional information regarding bioterrorism prepare dness. Thus, increased attentio n and vigilance is needed to increase the awareness of rural healthcare pr ofessionals who may not believe that they are at risk to ensure that these rural physic ians are prepared for a possible bioterrorism event. Satellite teleconferences as an educational training method is particularly interesting for rural community physicians because of their remote locations and limited access. According to the Shadel et al. ( 2003) study, the satellite teleconference was

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52 considered a preferred method of training; although in a study conducted on a national sample of physicians (Shadel et al., 2001) it was one of the leas t preferred methods. Physician Perceptions and Knowledge of Bi oterrorism Preparedness: A Review of the Literature Regarding Local Studies In 2004, a study conducted by Gershon and colleagues showed the knowledge, attitudes, and intended behavi ors of New York City clinic ians regarding bioterrorismrelated diseases. Data on urban clinicians knowledge and attitudes toward bioterrorism and related diseases were collected using a self-administered questionnaire after a 3.5hour educational intervention program was perf ormed with presentations regarding up-todate case information as well as information on the New York City Department of Health bioterrorism preparedness procedures. The lectures were supplemented with printed literature and handouts, includ ing a copy of the slide pres entations, rolodex card with New York State and New York City Health Department contact and reporting numbers, and seminal journal article s on clinical presentati on of bioterrorism. The Gershon et al. (2004) study administ ered a post-presentation questionnaire consisting of 37-items designed to evalua te their knowledge, beliefs, and confidence regarding their abil ity to diagnose, treat, a nd report certain diseases of bioterrorism such as anthrax, smallpox, tularemia, plague, and botulism. The questionnaire also evaluated their own concerns and fears regarding the cont agious nature of the bioterrorist agents. They asked questions related to clinicians degree of exposur e to the WTC disaster (e.g., witnessing the event at the time it happened eith er in person or on television or having reexposure through television broadc asts) to determine the impact if any, this had on their bioterrorism attitudes and beha vioral intentions. Items re lated to physicians emergency preparedness and response were also included in the questionnaire. Statistical analyses

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53 were conducted to measure knowledge, c onfidence, concerns, infection control intentions, and educational needs. A total of 377 practitione rs attended the program; of these, 310 completed the questionnaire (82% response rate ). Most of the survey resp ondents were male physicians (55.2%) with a mean age of 52.9 years. Th e mean years of practicing medicine was 23.3 years and 36% were internal medicine speci alists. After the three and one-half hour educational seminar, on a set of five basic knowledge questions, 69.6% of the participants had correct responses for reporting require ments although in other areas of knowledge such as appropriate diagnostic testing (65.2%) and differe ntial diagnoses (41.6%) the correct responses was not particularly hi gh even after the educational intervention program. Many participants reported in creased confidence in biote rrorism preparedness with regard to recognizing diseases of bioterrori sm (88.6%), the ability to address patient concerns (83.2%), the ability to treat bioterrorism diseases ( 74.6%), the ability to report bioterrorism diseases (72.6%), and the abil ity to adopt appropri ate infection control procedures (68.7%). Almost 38% reported increased confidence in the United States governments ability to protect the publics health during a bi oterrorist attack and 13.9% reported increased confidence in the Unite d States governments preparedness for a bioterrorist event. Physicians reported overall concern about future biote rrorist attacks (77.4%) and specifically concern about anth rax (58.4%) and smallpox (61%). They also reported high levels of concern regarding bioterrorism among their patients; 90.5% of clinicians reported that they provided care to patients with complaints related to fears of

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54 bioterrorism during a two month period before training program. There was no significant correlation found betw een clinicians media exposure to WTC disaster and their bioterrorist-relate d concerns. Yet clinicians who reported high degrees of television exposure to the WTC disaster were 2.4 times more likely to volunteer in the disaster relief efforts (e.g., assist in rescue center s, emergency rooms, outpatient settings, or donate money and supplies) with an odds rati o of 2.45 (95% confidence interval [CI] = 1.12-5.35) than those who had limited exposure. Also, regarding the clinicians concerns, 61% were personally concerned about the risk of contracting smallpox and 58.4% were personally concerned about the ri sk of contracting anthrax as a result of bioterrorism. This may be in part due to the fact that the federal government, the media, and the medical societies placed an emphasis on bi oterrorism and its related issues. The clinicians expressed interest in a dditional training on clinical diagnosis of bioterrorism diseases (84.2%), infection control aspects of bioterrorism (81.9%), treatment aspects of bioterrorism diseas es (81.6%), and psychological aspects of bioterrorism (74.5%). Training needs did not differ based on experience in treating patients at risk for exposure to anthrax. One limitation of the Gershon et al. (2004) study was the use of a single questionnaire, which precludes the ability to evaluate the effectiveness of the program in terms of its impact on the ba seline knowledge and attitude s of clinicians. Another potential limitation is that the sample is of participants limited to the greater New York City area, and may therefore be difficult to generalize these findings to clinicians from other parts of the country.

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55 Rose and Larrimore performed a study in late 2002 to examine knowledge and awareness concerning chemical and biological terrorism among clinicians. This survey was used to assess the knowledge base of healthcare providers at an urban medical center in preparation for developing a workshop on dom estic terrorism preparedness. Rose and Larrimore then conducted a second survey assessing domestic terrorism preparedness among infection control personnel and nurse educators. This study reports results of a knowledge and awareness survey on bioterrorism agents prior to September 11, 2001. A po ssible limitation is that both surveys were conducted in the northeastern United States because the Gershon et al. (2004) found that geography may matter and the surveys were conducted prior to Se ptember 11, 2001. During the year of 2000, a total of 291 health care professionals (e.g., nurses, physicians) completed the survey on knowledge and awarene ss of chemical and biological terrorism. The knowledge scores for all respondents were low, with less than one-fourth answering the questions correctly. Few respondents had ever used respirator y protective equipment (32.6%), Hazmat level protective clothing ( 10.3%), or used decontamination showers (5.2%). Additionally, almost half of the res pondents indicated that they were not certain they would report to work in the event of a domestic terrorism attack (46.7%). Less than 23% of the respondents reported confiden ce in providing health care related to a hypothetical terrorism event. The differ ence in scores among healthcare providers, specialty groups, and gender were no t statistically significant. A study conducted in mid-2001 by Lanzilolti and colleagues, examined Hawaiian medical professionals. The intent of the La nzilolti and colleagues study was to assess the availability of doctors and nur ses to staff non-hospital medical facilities for mass casualty

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56 incidents resulting from the use of weapons of mass destruction or othe r terrorist events. The study also examined the level of knowledge and skills that these medical professionals possessed as related to the tr eatment of victims involved in terrorist incidents. This study consisted of a large-s cale mail survey administ ered to medical and nursing professionals residing and working in the state of Hawaii (Lanzilolti, Galanis, and Leoni, 2002). This study examined the availability and capa bility of medical professionals to respond to casualties caused by weapons of mass destruction. Although this study had a low response rate (23%, n = 3386 for physicians; and 22.4%, n = 2775 for nurses), the findings yielded similar results to other studies reported in this literature review (Alexander & Wynia, 2003; Chen et al., 2002; Gerberding et al., 2002; Gershon et al., 2004). As in other studies discussed in th is literature review exploring these issues, the investigators found that both physicians and nurses reported having low knowledge levels regarding bioterrorism agents such as smallpox, anthrax, tularemia, plague, and botulism. Also as in previous studies men tioned above, the investig ators found that both the physicians and the nurses had a perceive d inability to recogni ze and treat patients with diseases of bioterrorism The Lanzilolti et al. study al so reported that less than 10% of the physicians in the sample consider themse lves able to treat vi ctims of bioterrorist incidents. In contrast, the respondents in the study reported gene rally high levels of willingness to report to duty during a biote rrorism incident, with a positive correlation seen between high levels of self-reported knowledge, aw areness, and willingness to respond. Thus, the study concludes that it may be possible to increase clinicians willingness to respond to a bioterrorist em ergency through physicians education and training. This conclusion has been supporte d by several other studies examined within

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57 this literature review (Ale xander & Wynia, 2003; Chen et al., 2002; Cherry et al., 2003; Croasdale, 2002; Gerberding et al., 2002; Gershon et al., 2004). The limitations of the Lanzilolt i et al. (2002) study include the low response rate of only 23%, which may not accurately reflect many of the physicians perceptions. Another limitation in the study is the possibility of set res ponse bias, which may lead to biased results. Set response bias often occu rs with large-scale written or mailed surveys when respondents reply by marking the same re sponse repeatedly to facilitate completion of the survey. My study will attempt to cont ribute to the literature in a novel fashion by examining physicians from a rural region in Fl orida from a qualitative perspective using semi-structured interviews rather than surveys to examine their perceptions to bioterrorism preparedness. Another pot ential limitation with the Lanzilolti and colleagues study is that the sample consists of participants limited to Hawaii, and it may therefore be more difficult to generalize these findings to clinicians from other parts of the country. A small study by Rico, Trepka, and G uoyan entitled Knowledge and Attitudes about Bioterrorism and Smallpox: a Survey of Physicians and Nurses, was performed in 2002. This study surveyed licensed physicians (n = 134) and nurses (n = 121) in MiamiDade County. The investigators found that 97% of physicians and 92% of nurses were interested in receivi ng bioterrorism training (Rico et al ., 2002). The interest among both physicians and nurses was especially keen for training on the r ecognition of potential bioterrorist events and on the overall public health response to these emergencies. Only 21% of physicians and 7% of nurses in the samp le of participants be lieved that they had updated knowledge on the signs, symptoms, tr eatment, modes of transmission, and

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58 communicability of class A bioter rorist agents (e.g., smallpox, anthrax, tularemia, plague, and botulism). This study also confirms other studies pertinent to th is literature review, which explain that most clinicians perceive themselves as unprepared to effectively deal with bioterrorism (Alexander & Wynia, 2003; Chen et al., 2002; Heun, 2002; Sigmon & Larson, 2002). A limitation of this study is the small sa mple size of 134 physician participants. A small sample size may not accurately represent or depict the perceptions of a population. Another limitation of the st udy is the set response bias with survey methodology. Another potential limitation is that the sample is of participants limited to the Miami, Florida or the Dade County area and it is ther efore difficult to generalize these findings to clinicians from other parts of the country. A study performed by Alder, Clark, White Talboys, and Mottice in 2004 examined physician preparedness for bioterrorism r ecognition and response. A survey was performed that included 30 rural and urban phys icians in Utah. The survey included a needs assessment regarding roles, current le vels of preparedness, interest in further training, and preference for training met hods. The physicians were from various specialties: four family medicine physicians, five general internists, fi ve pediatricians, six emergency medicine physicians, five infectious disease specialists, three dermatologists, and two radiologists, and were grouped as primary care (i.e., family medicine, general internist, and pediatricians), emergency car e (i.e., emergency medicine physicians) or specialty care (e.g., infectious disease speci alists, dermatologists, and radiologists). This qualitative study assessed the att itudes and assumptions of practicing physicians regarding bioterrorism prepar edness by using individual and small group

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59 semi-structured interviews. Participants were asked about their perceived risk of bioterrorism, current roles and ability to dete ct and respond to events, interest levels in bioterrorism training, and pref erences for educational offerings. Quota sampling, based on physician specialty and community or tertia ry/academic practice was used to select participants. Primary care physicians estimated that a direct local attack is unlikely, yet possible. Emergency medicine and infectious disease spec ialists had similar responses. They both felt that a national bioterrorist attack was more imminent than a local attack, yet a national attack may have local consequen ces. Infectious disease specialists, dermatologists, and radiologists stated that the likelihood of a local attack was extremely unlikely. The physicians perceived role for detec ting and responding to bioterrorism was found to be related to their type of practice. Both pr imary care and infectious disease physicians felt that in the event of a bioterrorist attack they would be expected to link into the public health infrastructure and notify emergency personnel. Primary care physicians felt, because of their ongoing relationships with pre-existing patients, that they would be able to detect unusual disease patterns and link the patients to medical specialists. Primary care physicians also adm itted that they are not adequa tely prepared to recognize and treat bioterrorism related diseases. One primary care physician stated, I could see patients today whose symptoms could be attribut able to any one of the biological agents. Im not going to be thinking about that because number one, I cant distinguish the usual from the unusual right now, (Alder et al., 2004, p 70). Emergency care physicians felt that they would identify th e index case and act as th e primary medical respondent

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60 because they are familiar with diseases caused by bioterrorism agents. One emergency physician stated, I think theres a good chance we would be one of the first people to identify it if there was actual ly an event, (Alder et al., 2004, p 72). Infectious disease physicians felt confident in their ability to recognize and respond to uncommon diseases, including those caused by bioterrorism agents Their confidence was partly due to an increased emphasis on bioterrorism-focused continuing medical education. One respondent stated, I think one thing that maybe the anthrax case taught us was that if youre not thinking about it, youre not going to catch it, (Alder et al., 2004, p 72). Both dermatologists and radiologists felt that their primary role would be to support primary care physicians. Respondents cited time constraint and ot her competing demands as the primary reasons for not being able to spend more time dedicated to bioterrorism preparedness. One family practitioner stated, You have to th ink of a disorder in order to ask the right questions or to do the right physical exam. It s not seeing is believing, its believing is seeing. You have to have that mental mode l, (Alder et al., 2004, p 72). Most family practice physicians wanted general informa tion about disease processes and a better understanding of how to link into the medical specialists hi erarchy, which could assist with patients with bioterrorism diseases. One family practice physician explained, I wouldnt expect most family physicians to be able to say here are the diagnostic criteria for anthrax. How important is it that I know the diagnostic criteria? Again, there is a certain amount of information I know I can l ook up anywhere, (Alder et al., 2004, p 72). Infectious disease physicians fe lt that all physicians should ha ve a basic understanding of diseases consistent with bioterrorism. On e participant stated, I think their most

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61 important preparation is recogni tion of diseases, and they ought to have some inclination or readiness with regards of how to prevent spread, (Alder et al., 2004, p 73). Another participant pointed out that if primary care physicians are involved in surveillance, the level of general bioterrorism pr eparedness would increase. Preferences also varied according to medi cal specialty regarding which methods are preferred for training and continuing educat ion. Primary care physicians requested training from health department personnel, fellow primary care physicians, or infectious disease specialists with expertise in biote rrorism recognition and response. Primary care physicians wanted to incorpor ate training into existing activ ities, such as CME activities or professional meetings. In addition, they wanted to be provided with quick reference materials. Emergency physicians wanted Webbased training activitie s, disaster training drills, and exercises that include informa tion regarding bioterrorism agents. All physician specialists suggested grand rounds and physician meetings as valuable to provide education and training. One possible limitation with the Alder et al. study includes the use of a small focus group, which may bias results. Several of the interviews only included a few respondents representing large medical sp ecialty groups. Although the study includes a sample of participants limited to the one st ate, Utah, it is a well-conducted qualitative study. Qualitative studies ar e less concerned with quantita tive external validity or generalizability across studies and are rather more concerned with what is known as internal generalizability. This is because qua litative researchers st udy a single setting or a small number of individuals or sites, us ing purposeful sampling rather than probability sampling, and they rarely make explicit cl aims about the generalizability of their

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62 accounts (Maxwell, 2005). Thus, the objective of qualitative research is to understand the particular in depth rather than findi ng out what is generally true of many. Specific Research Questions and Contribution to the Literature Any bioterrorism event or threat of an ev ent is a public health and community issue in which the medical community has a major leadership role. Physicians have a dual responsibility to educate the community and prepare for any event. Although only a few physicians would likely recognize the sentinel case in a bioterrorist event, the overall public health management would involve ev ery physician. Consequently, physicians must be knowledgeable to accurately addre ss questions from patients, friends, and acquaintances. Furthermore, every physician mu st be prepared to take an active role should a bioterrorist event surface in his/ her community. Thus, each physician has a significant role to assume in our nati ons defense against bioterrorism. The intent of this literature review was to expose the need for rural physicians to be prepared for public health emergencies such as bioterrorist events. This literature review has shown that physicians feel better prepar ed to respond to other disasters such as natural disasters and infectious disease outbreaks than biot errorist events (Alexander & Wynia, 2003; Chen et al., 2002). It has shown that physicians need and request additional training and CME re garding bioterrorism (Alexa nder & Wynia, 2003; Chen et al., 2002; Heun, 2002; Sigmon & Larson, 2002). It has further been demonstrated that when physicians are provided continuing medical education and training regarding bioterrorism, they perceive themselves as be tter prepared to respond to a public health emergency such as a bioterrorist attack (Alexander & Wynia, 2003; Chen et al., 2002; Cherry et al., 2003; Croasdale, 2002; Gerber ding et al., 2002; Gershon et al., 2004). With improved training and continuing medical educ ation, physicians also perceive fewer

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63 barriers to delivering patient care because they feel better prepared (Alder et al., 2004; Cherry et al., 2003; Cowan et al ., 2005; Sterling et al., 2005). Bioterrorist agents can cause a vast array of constitutional symptoms such as fever, chills, headache, nausea, vomiting, and diarrhea. Bioterrorist agents can also cause more severe physical symptoms such as chest pain, pneumonia, convulsions, paralysis, and mortality. Bioterrorist agents also impact mental health in th at they invoke or exacerbate fear, anxiety, acute stress disorder, depressi on, and other mental health conditions. Thus, rural physicians preparedne ss for organic and mental h ealth conditions related to bioterrorism is vitally important so when they encounter such signs and symptoms in patients they can discern and diagnose the condition e xpediently. Bioterrorism preparedness requires physicians to be aware of the possibility of bioterrorism at any time (Gerberding et al., 2002, Inglesby et al., 2000). Plans can only be implemented effectively if physicians ar e aware of the possibility of bioterrorism, suspect and recognize an event when it occu rs, notify authorities promptly upon suspicion of such an event, and institute appropriate management. Broader public health asp ects of bioterrorism prep aredness, including primary prevention measures, are also important ar eas for informed action by physicians. Medical education and traini ng curricula must include information on key potential agents of bioterrorism, and medical professionals require continuous educa tion in this area, especially those, such as primary care physicians, who are most likely to see patients affected by a biological weapon. Moreover, physicians from other specialties may need sufficient knowledge of the likely clinical features of potential biological

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64 agents in order to recognize patients presenti ng with a compatible illness (Gerberding et al., 2002; Karwa et al., 2003, Karwa et al., 2005). This study exposes the need that exists to take decisive steps to improve bioterrorism preparedness among physicians. Ye t as previously stated in this literature review (Rose & Larrimore, 2002), the curr ent generation of physicians perceive themselves as unprepared in both their knowledg e base and confidence le vels to deal with potential biological terrorism and its consequences. Previ ous research has underscored this point by showing that community clinicia ns often are the first to identify potential bioweapon victims yet remain inadequately prep ared clinically to address such events (McFee, 2002; Pesik et al., 1999; Sniffen & Nadler, 1999; Varkey, Poland, Cockerill, Smith, and Hagen, 2002). Consequently, it has become clear that ther e is a pressing need to rapidly educate and train medical pers onnel on the signs and sy mptoms and reporting mechanisms of bioterrorism-related diseases (Gershon et al., 2004). Few studies have examined bioterrorism preparedness (Gershon et al., 2004), and severa l published reports provide evidence of both knowledge gaps and hi gh levels of interest in bioterrorismrelated training among physicians (AMA, 2005; Heun, 2002; Sigmon & Larson, 2002). So, while the previous literature is both pertinent and valuable, there still remains a void in the literature on the understanding of public health emergency preparedness and especially of bioterrorism preparedness. Ba sed on this literature review, there also has not been a significant amount of attention devo ted to rural areas. Consequently, there remain gaps in the perceptions of prepar edness among rural physicians. Furthermore, most of the studies that do exist address the issue exclusively from a quantitative perspective (Alexander & Wynia, 2003; Chen et al., 2002; Shad el et al., 2003; Sterling et

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65 al., 2005). With the exception of the Alder et al. study (2004), there is not an in-depth qualitative examination of physicians perceived emergency preparedness for bioterrorism. Thus, the topic could bene fit tremendously from further qualitative exploration. The Alder study exposed physicians at titudes and assumptions regarding bioterrorism preparedness in the state of Utah This study will furt her contribute to the literature regarding bioterrorism preparedne ss by providing an informative qualitative inquiry. This study has three prin cipal distinctions from the Al der study. First, there is a focus on perceptions of physicians from rurally designated areas in the state of Florida. Florida occupies an especially important place regarding bioterrorism. It has the largest coastline of the 48 contiguous states, which could serve as a major route of access for bioterrorism. It also has a large rural population with 37 designa ted rural counties. Moreover, Florida has a diverse ethnic population along with nu merous national and international tourists exceeding more than 40 million during any given year (Clawson & Brooks, 2003). Second, this study focuses exclusively on primary care community physicians in rural healthcare settings. Rura l healthcare settings have few primary care community physicians and often lack specialty physicians altogether. Several previous studies have shown that prim ary care community physicians (McFee, 2002; Pesik et al., 1999; Sniffen & Nadler, 1999; Va rkey et al., 2002) will most likely be the first to encounter sentinel bioterrorist events. Thus, this study is pa rticularly relevant to rural healthcare settings with primary care commun ity physicians. Third, this study will focus on the perceived barriers that prevent ample professional preparedness among rural physicians.

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66 I propose an intensive qualit ative study of key informant physicians from rural counties in North Central Florida. Rural physicians from these counties are hypothesized to vary in their bioterrorism preparedness because of diverse professional and pragmatic experiences, their varying degrees of traini ng and education regarding bioterrorism, and the variation of impediments or barr iers to delivering medical care. The study will use the interview data transc ripts from six rural physicians as the primary data with which to explain the st ate of emergency preparedness of physicians and to explain and better understand the barr iers to preparedness encountered by these rural healthcare providers. This study will not focus on empirical testing, but instead will qualitatively explore the varia tion or degree to which rural healthcare providers consider themselves to be prepared for bioterrorist events. Thus, this study will address two principle research objectives. The first obj ective is to describe and understand how rural physicians perceive and explai n their state of emergency pr eparedness particularly for a bioterrorist event. The s econd research objective is to describe and understand how the barriers that these rural phys icians perceive to be opera tive affect their emergency bioterrorism preparedness. The long-term objective of this study is to provide a grea ter description and understanding of rural physicians percei ved preparedness regarding public health emergencies such as bioterrorist events. Th e principal objectives of this study are to expose the current state of ru ral bioterrorism preparedness and to provide policy options to improve the rural healthcare systems biote rrorism preparedness. Thus, the findings of the proposed study should be relevant to rese archers in the disciplines of public health and rural medicine, as well as prac titioners in health policy.

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67 CHAPTER 3 EPISTEMOLOGY, THEORETICAL PERSPECTIVE & RESEARCH METHODS This chapter begins by providing a brie f description of the epistemology and proceeds to explain constructivism as a th eoretical perspective. The conventional qualitative inquiry format of epistemology followed by the theoretic al perspective is followed (Figure 1). Although it should be noted that the epistemology and the theoretical perspective are inextricably integrated and intertwined (Crotty, 2003) and may have on occasion arrows pointing in both the reverse as well as the forward direction. Chapter three begins with the methods of semi-structured interviews and constructivist grounded theory (Charmaz, 2004, 2005). Next participant selection, participant demographics, and interviews ar e discussed. This is followed by grounded theory and data analysis. The chapter conti nues with an explanation of how validity is defined from both a quantitative and a qualita tive perspective and the qualitative validity measures employed in this study. The chapte r concludes with the limitations of the study and a subjectivity statement that describes my professional and pers onal experiences as a physician, related to physicians and emergency preparedness. Quantitative and qualitative researchers use similar elements in their work. They state a purpose, pose a problem or raise a quest ion, define a research population, develop a time frame, collect and analyze data, a nd present outcomes (Glesne, 1999). Yet qualitative research also has salient differences from quantitative research. Quantitative researchers assume a fixed, measurable realit y exists which is external to people. In contrast, qualitative researchers are generall y supported by the inte rpretivist paradigm,

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68 which portrays a world in which reality is socially constructed, complex, and everchanging. The belief for constructivists is that social realities are constructed by participants in social sett ings. To understand the nature of constructed realities, qualitative researchers interact and talk with participants about their perceptions. So qualitative researchers regard their research task as co ming to understand and interpret how the various participants in a social sett ing construct the world around them (Glesne, 1999). Epistemology Theoretical Perspective Methods Figure 3-1: Qualitative Method Process In qualitative research study, researc h design should be a reflexive process operating through every stage of a project (Hammersley & Atkinson, 1995, p 24). The activities of collecting and analyzing da ta, developing and modifying theory, and addressing validity threats are usually all occu rring at the same time, each influencing all of the others (Maxwell, 2005). Qualitative research studies have become more prevalent in health services research and particular ly the medical community (Crabtree & Miller, 1999; Frankel, 1999). For example, two prom inent qualitative resear chers, Miller and

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69 Crabtree, developed a document for the Info rmation Mastery Working Group to identify qualitative articles worthy of review for the medical journal, The Journal of Family Practice and Evidence-Based Practice (Crabtree & Miller, 1999). The Journal of Family Practice and Evidence-Based Practice has a web page in which supplementary materials for published articles can be placed. Crabtree an d Miller (1999) explain this is akin to an external audit. Qualitative research rests on assumptions th at reality is socially constructed and variables are complex, interwoven, and difficu lt to measure. To understand the nature of constructed realities, qualitative researchers in teract and talk with relevant participants about their perceptions. The re search approach is descript ive and inductive in nature, searches for patterns, and may result in th e formulation of hypotheses and theory. Qualitative research has the principal pur poses of understanding and interpretation (Maxwell, 2005). According to Crotty (2003) and other qualitative researchers (LeCompte & Preissle, 1993; Miles & H uberman, 1994; Robson, 2002; Rudestam & Newton, 1992, p 5), the following components are important in research design: the research questions, methods and validity. Th ere are three principa l elements of the methodological research process (Crotty, 2003). This chapter will examine these important elements by addressing the followi ng three questions: What methods will be used?, What theoretical pers pective lies behind the methodology in question?, and What epistemology informs this theoretical perspective? Thus, what follows is an explanation to each question beginning with the epistemolo gy, followed by the theoretical perspective and then the methods themselves.

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70 Ontological and Epistemological Considerations Prior to embarking on any kind of qualita tive research, it is important for a qualitative researcher to consider and then identify assumptions regarding what constitutes valuable knowledge (Crotty, 1998) The epistemology that the researcher finds to be the most suitable should se rve as the foundation on which research methodology selection and implementation will be grounded (Crotty, 1998). According to Maxwell (2005), ontology is a set of general philosophical assumptions about the nature of the worl d and epistemology is how one can understand it. Epistemology is the theory of knowledge embedded in the theore tical perspective and thereby in the methodology (Crotty, 2003). So, an epistemology is a way of understanding and explaining how one knows what one knows (Crotty, 2003). Epistemology deals with the na ture of knowledge, its possibil ity, scope, and general basis (Hamlyn, 1995). According to Maynard (1994), epistemology is concerned with providing a philosophical gr ounding for deciding what kinds of knowledge are possible and how a person can ensure that their knowle dge is both adequate and legitimate. In essence, there is a need to identify, explain, and justify the epistemological stance. As participants in this study, the rural physicia ns share their perceptions and thereby inform the interviewers what knowledge is and the reality is wh at is reported in the study. There are several types of epistemologies: objectivism, constructionism and subjectivism. An objectivist epistemology holds that meaning, and therefore meaningful reality, exists as such apart from the operati on of any consciousness. An illustration of objectivism is that a tree in the forest is a tr ee, regardless of whethe r anyone is aware of its existence or not. As an object of that kind (objectively, therefore), it carries the intrinsic meaning of tree-ness (Crotty, 2003, p 8). Crotty further explains that when

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71 human beings recognize a tree, they are simp ly discovering a meaning that has been lying there in wait for them all along. Constructionism is another type of episte mology which rejects this view of human knowledge. According to constructionism, ther e is no objective truth waiting for us to discover it. Truth, or meaning, comes into existence in and out of our engagement with the realities in our world. There is no meaning without a mind. Meaning is not discovered, but constructed. According to Crotty, in this understanding of knowledge, it is clear that different people may construct meaning in different ways, even in relation to the same phenomenon. Crotty (2003) argues th at this is precisely what one finds when one moves from one era to another or from one cu lture to another. In this view of things, subject and object emerge as partners in the generation of mean ing (Crotty, 2003). This study embraces constructionism as its principal epistemological stance. Constructionism is the view that all knowledge and therefore all meaningful reality as such, is contingent upon human practices, bei ng constructed in and out of interaction between human beings and their world, and developed and transmitted within an essentially social context (C rotty, 2003). According to constructionism, one does not create meaning, but one constructs meaning. Human beings construct meanings as they engage with the world they are interpreting. As Crotty explains, the world is always already present, and although the world a nd the objects in the world may be in themselves meaningless, they are partners in the generation of meaning. Thus, constructionism brings the interaction between subject and object to the forefront. Crotty (2003) explains that the image evoked from this interaction is the subject or humans engaging with their object or the world. Thus, constructionism brings objectivity and

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72 subjectivity together and unites them and it is in and out of this interplay that meaning is born. Subjectivism is another type of epistemo logy. In subjectivism, meaning does not come only from the interplay between subjec t and object, but is imposed on the object by the subject (Crotty, 2003). A ccording to Crotty, in subjectivism one makes meaning out of something or one imports meaning from so mewhere else. The meaning ascribed to the object may come from ones beliefs, or from ones professional experience, or from ones personal experiences, or from ones educationa l background, or from re ligious beliefs, or from primordial archetypes located within a collective unconscious, or from other realms. So, meaning comes from more than an interaction between the subject and the object to which it is ascribed (Crotty, 2003). To be consistently subjective means to distinguish scientifically-established objective meanings from subjective meanings that people hold in everyday fashion and that reflect or appear or perceive or mirror obj ective meanings. Subjective meanings are very important within an indi viduals life to asce rtain an individuals meaning making, perceptions, and reflections. T hus, subjectivism is an effort to identify, understand, describe, and maintain the subj ective experiences of the respondents. In essence with this context, the epistemological stance of constructionism is in search of the individual rural physicians subjective experiences and constructed meanings, perceptions, and understandings of emergency bioterrorism preparedness, and the impediments preventing their preparedness. The rural physicians perceptions and their individual meaning-making processes produ ce the source of information, truth, and knowledge.

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73 Theoretical Perspective: Constructivism Epistemology provides a philosophical b ackground for deciding what kinds of knowledge are legitimate and adequate. Epistemology is the theory of knowledge embedded in the theoretical perspective. The theoretical perspective is the philosophical stance that shapes our met hodologies, providing a context for the process and grounding its logic and criteria. The theoretical pers pective is a statement of the assumptions brought to the research task and reflecte d in the methodology as one understands and employs it (Crotty, 2003). Thus the theoretical perspective is a way of looking at the world and making sense of it. It, too, involves knowledge and embodies a certain understanding of what is en tailed in knowing, that is, how one knows what one knows (Crotty, 2003), although, as has been previously stat ed, knowledge is generally considered more the realm of the epistemol ogy, but there is overlap (Crotty, 2003). In this study, the form of inquiry and data collection employed invol ves selective sampling with semi-structured interviews. By the very nature of the interviews, some of the assumptions relate to matters of language a nd issues of subjectivity and communication. To account for these assumptions and justif y them requires an explanation of the theoretical perspective. Consequently, the theo retical perspective is an elaboration of our view of the human world and social life within that world, wherein such assumptions are grounded. Research in the constructivist vein require s that one does not remain straitjacketed by the conventional meanings that one has b een taught to associate with the object. Instead, such research invites one to approach the object in a radica l spirit of openness to its potential for new or richer meaning (Cro tty, 2003). Constructivi sts believe that the social constructions of indivi duals and groups are not more or less true in an absolute

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74 sense, but, simply more or less informed a nd/or sophisticated (L incoln & Guba, 1985, p 111). Constructivism asserts that nothing re presents a neutral perspective, that is, nothing exists before consciousness shapes it into something perceptible (Kincheloe, 2005). In constructivist theory, different in dividuals coming from diverse backgrounds will perceive and see the world in different ways. The backgrounds and expectations of the observer will also shape perception (Kinch eloe, 2005). Constructivist theory defines shared constructs and meanings as situated; that is, they are locat ed in or affected by the social, political, cultural, economic, et hnic, age, gender, and other contextual characteristics of those who espouse them (LeCompte & Schensul, 1997). These characteristics influence how individuals th ink, believe, and present themselves. Thus, interpretations cannot be separated from the inte rpreters location in th e web of reality. Ones interpretive facility involves unders tanding how historical social, cultural, economic and political contexts construct one s perspectives on the world, self, and others (Kincheloe, 2005). The knowledge that constructiv ist research produces is grounded on the assumption that the world is shaped by a complicated, weblike configuration of interacting forces. Knowledge producers, like ever yone else, are inside, not out side, the web. The knower and the known are inseparablethey are both a part of the complex web of reality. No one in this web-like configur ation can totally escape the we b and look back at it from afar. Indeed, one must confess his/her s ubjectivity and one mu st recognize his/her limited vantage points (Kincheloe, 2005).

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75 To recognize how ones particular view of the web shapes the conception of social, psychological, and educationa l reality, one also needs to understand the historical location. According to Kinche loe (2005), the world is socially constructed, that is, what one knows about the world always involves a knower and that which is to be known. Kincheloe states that how the knower c onstructs the known is principally through perceptions and reflections which constitutes what one thinks of as reality. He explains that all knowers are both hi storical and social subject s. Each person is from somewhere, which is located in a particular historical time frame. These spatial and temporal settings always shape the nature of our constructions of the world. Not only is the world historically and soci ally constructed, but so al so are people and the knowledge people possess. He explains that individuals create themselves with the cultural tools at hand. A person operates and constructs the wo rld and his/her life on a particular social, cultural, and historical playi ng field (Kincheloe, 2005). Schwandt states that constructivists are deeply committed to the contrary view that what one takes to be objective knowledge and truth is the re sult of perspective (Schwandt, 1994, p 125). Constructivists e mphasize the instrumental and practical function of theory construction and knowi ng (Schwandt, 1994, p 125). Constructivism is primarily focused on an understanding of an individual in the contex t of the social. It involves the meaning-making activity of th e individual mind (Crotty, 2003; Schwandt, 1994), and further explains the unique experien ce of each of us. It suggests that each ones way of making sense of the world is valid and worthy of re spect as any other, thereby tending to ameliorate any innuendo of a critical spirit. The role of perceptions and reflections are the essent ial components in the formulation of individual meaning-

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76 making and understanding. Therefore, cons tructivism describes the individual human subject engaging with objects in the world and making sense of them (Crotty, 2003). Constructivism as a theoretical perspectiv e facilitates individual meaning-making, perceptions, and reflections as crucial elements. This theoretical perspective will assist in understanding rural physicians perceptions of their own perceptions to emergency bioterrorism preparedness. It also assist s in understanding the ba rriers rural physicians perceive as impediments to em ergency bioterrorism preparedness. Constructivism as a theoretical perspective guides the study research inquiries and the purposes of the study to understand the perceptions and reflections of rural physicians preparedness for a bioterrorism event. Figure 3-2: Detailed Qual itative Methods Process Methods This section describes the strategies that were used to recruit participants and collect data, as well as the analysis procedur es employed. This study uses qualitative methodology to describe and understand rura l physicians and h ealthcare providers perceptions regarding emerge ncy bioterrorism preparedne ss and the perc eived barriers encountered in preparedness. The detailed description of the methods used for this inquiry is presented for the reader to be ab le to adequately eval uate the rigor of the research process and findings. E pistemology Constructionism Theoretica l P erspective Constructivism M ethods Semi structured Interviews Grounded Theory

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77 Participants Selection Criteria and Sampling Crabtree and Miller (1999) ask how resear chers select a sample from a larger pool for closer scrutiny. They further ask how can one feel confident that the sample chosen is appropriate and adequate (Crabt ree & Miller, 1999). In such qualitative data collection, a challenge involves determining when one ha s exhausted new information or reached a saturation point. My qualitative study declares based on the rich content of the interview participants that new data w ould not emerge with additional interviews. Thus, additional data collection would merely re sult in repetitive data thereb y suggesting data saturation. Patton suggests that qualitative research typ ically focuses in depth on relatively small sample sizes, even single cases (n =1), se lected purposefully (Patton, 1990, p 168). Patton contrasts this with qua ntitative research designs, wh ich typically depend on larger samples selected randomly (Patton, 1990, p 169). Qualitative research uses field or documentary/historical research styles, and the sampling is driven not by a need to generalize or predict, but rath er by a need to create and test new interpretations (Crabtree & Miller, 1999). Typically, the investigator intends to increa se the scope or range of the data to reveal multiple realities and/or cr eate a deeper understanding (Crabtree & Miller, 1999). This is what McWhinney refers to as an acquaintance with particulars (McWhinney, 1989). It allows for the developm ent of theory that takes into account local conditions (Bogdan & Biklen, 1982; Glaser & Strauss, 1967; Guba & Lincoln, 1989; Lincoln & Guba, 1985; Patton, 1990). Thus, in field or documentary /historical research, sampling strategies strive for info rmation richness (P atton, 1990). There are several possible goals of purpos eful selection accord ing to qualitative researchers (Creswell, 2002; Guba & Linc oln, 1989; Maxwell, 2005). Purposeful

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78 sampling is also known as criterion-based se lection (LeCompte & Pr eissle, 1993; Patton, 1990). This study employs purposeful sampli ng, which is conventionally used in grounded theory research (Glase r & Strauss, 1967; Strauss & Corbin, 1990). The goal of using purposeful sampling in this qualitative study was to ascertain the representativeness or typicality of the rural sett ings and the individuals. An additional objective was to compare the settings and individuals. Purposeful sampling is a strategy in which particular settings, persons, or activities are selected deliberately in order to provide information that cannot be gotten as well from other choices. This study used what Weiss (1994, p 17) explains as the use of panels-people who are uniquely able to be in formative because they are expert in an area or were privileged witness to an event. In this study, physicians were selected purposefully from rural coun ties in North Central Florid a to explain their current perceived emergency preparedness and the perceived impediments to bioterrorism preparedness. This purposeful sampling was performed to aid the grounded theory development and the grounded theory coding process or as, Strauss and Corbin (1990) state: for verifying the stor y line, relationships between ca tegories, and for filling in poorly defined categories (p 187). Physician participants were recruited from several rural counties in North Central Florida. The counties included were Levy County, Gilchrist County, Dixie County, Bradford County, and Putnam County. This was done to select cases that illustrate or highlight diverse variations and to identify what is typical, normal and common regarding rural physicians perceptions of emergency bioterrorism preparedness and the perceived barriers. Although the degree of experi ence and medical specialty varied, each

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79 participant selected to participate in this inquiry was a physician from a rural county practicing medicine in a rural setting in No rth Central Florida. These physicians were selected from county departments of health medical clinics, and community health centers. All of the participant physicians were from federally-designated metropolitan statistical areas that were classi fied as rural in 2003 and 2004. The educational background and, more im portantly, the partic ular professional specialty of the pa rticipants are important because the ma in purpose of this research is to describe and understand the perceptions of physicians emergency bioterrorism preparedness. Additionally, the fact that these physicians were from rurally designated areas is important. Physicians in rural commun ities play an essential role in the safety net in the event of a bioter rorist attack (Office of Rural Health Policy, 2002). If a bioterrorist attack were to occur in an urban area, the evacuation of the urban area could result in a mass exodus of people migrating into the ru ral communities, with many needing medical care. Also, the converse is true as rural he alth providers may be called upon to enter the urban areas to lend support to the physicians there in order to meet all the needs of the victims. Thus, it is essential that physicians practicing in hospitals, and also those in private practice, be well traine d and able to respond in the ev ent of a bioterrorist attack (Gerberding et al., 2002). In pr ior research studies in which physicians were interviewed to gain information regarding their emerge ncy bioterrorism preparedness, the data generated revealed that physicians felt more prepared to deal w ith infectious disease outbreaks and natural disasters than emergenc y bioterrorism events (Alexander & Wynia, 2003; Chen et al., 2002).

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80 Participants were interviewed at their pl ace of employment. Each participant had either a medical doctorate (M.D.) or a doctora te of osteopathic medi cine (D.O.) and had practiced medicine prior to September 11, 2001 and five of the six had practiced medicine at the same site prior to Septembe r 11, 2001. Physician participants were from primary care specialties including family medi cine, internal medicine, pediatrics, and emergency medicine. This was done for seve ral reasons. It was performed because in many of these rural areas there was only one physician and it was also employed to identify and search for important comm on patterns across diverse variations. Demographic Information Six physicians from the rural North Centra l Florida counties of Levy, Gilchrist, Dixie, Bradford and Putnam Counties were recr uited to participate in this study. This number of participants has been successful in previous qualitative research examining family physicians and patients perceptions a nd personal experiences with pain (Miller, Crabtree, Addison, Gilchrist, and Kuzel, 1994). This number of participants allows the researcher to gather an ampl e amount of data to obtain va lidity, while at the same time limiting the amount of data generated so th at the researcher can provide in-depth descriptions of the particip ants perceptions (Crabtree & Miller, 1999; Merriam, 1995; Patton, 1990). Patton (1990, p 185) further states t he validity, meaningfulness, and insights generated from qualitative inquiry ha ve more to do with th e information-richness of the cases selected and the analytical capab ilities of the researcher than with sample size. Of the six participants, five had a M.D. degree and one had a D.O. degree. Two participants were from county Departments of Health (Levy and Di xie), and the others were from rural health clinics (Fanning Sp rings, Shands at Star ke, Trenton Medical Center, and Putnam Family Medical and Dent al). Three physicians were trained and

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81 practiced as family practitioners, one was trai ned and practiced as an internal medicine physician, one was trained and practiced as a pediatrician, and one was trained as a preventive medicine or public health physicia n and also practiced emergency medicine. Background information describing each of the participants was important when seeking their perception of emergency biot errorism preparedness and barriers to emergency bioterrorism preparedness because any similarities or differences between participants may have influenced how they viewed the world. Background information was collected from each participant during the interview (See Appendix A: Interview Questions). Table 3-1 shows basic dem ographic information from each of the participants. Each of the physicians had uni que medical experiences with bioterrorism emergency preparedness. Each physician, save one, was employed and practicing medicine at the site prior to September 11, 2001, and prior to the bioterrorism anthrax attacks in October of 2001. One physician was practicing medicine but at a different location. Table 3-2 shows clinical backgr ound information for each physician, including degree, specialty, years practicing medicine, y ears practicing medicine at the facility, and rural county. Pseudonyms were used for each physician participan t to protect their identity (Table 3-1 and Table 32 contain the pseudonyms).

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82 TABLE 3-1: Participant Demographic Information Participant Age Gender Ethnicity County Doctor Williams 46 Male Caucasian Gilchrist/Levy Doctor Smith 42 Male Caucasian Levy Doctor Davis 48 Male Caucasian Bradford Doctor Jones 35 Male Caucasian Gilchrist Doctor Brown 49 Male Caucasian Putnam Doctor Phillips 38 Female AsianAmerican Dixie TABLE 3-2: Clinical Background Information Participant Degree Specialty Years in Medical Field Years at Medical Site Doctor Williams M.D. Family Medicine 12 12 Doctor Smith D.O. Internal Medicine 16 3 Doctor Davis M.D. Public Health/ Preventive Medicine and Emergency Medicine 21 21 Doctor Jones M.D. Family Medicine 9 2 Doctor Brown M.D. Family Medicine 23 4 Doctor Phillips M.D. Pediatrics 12 4 Data Collection Data collection consisted of participant semi-structured interviews. The specific strategies used to collect data through these means are described in the following section. My Role in the AHRQ 1 UO1 HS14355-01 Grant I became a member of the research team wh en asked to participate by the principal investigator in early 2004. One of my roles was to assist with the interviewing of key participant respondents. My ot her role in the research proj ect was to assist with the coding of the participant transcripts using the soft ware program ATLAS.

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83 I chose to compose this study using this data because of my interest in both physician emergency preparedness and because of the loss of a friend and physician colleague as a result of the September 11, 2001, terrorist events. Fu rther, as a physician, I am naturally interested in how physicians perceive their prepar edness regarding public health emergencies. Interviews The methods selected for data collection shoul d take into consideration the fact that it is not the researcher s perception that is of interest (Moustakas, 1994; Seidman, 1991). In qualitative research, a common approach is to use open-ended semi-structured interviews to gather data from participan ts (Kvale, 1996; Moustakas, 1994; Seidman, 1991). Interviews are the primary source of da ta in constructivist research because, if structured properly, they allow the resear cher to gather data while simultaneously reducing the influence of researcher bi as (Moustakas, 1994; Seidman, 1991). Research interviews vary on a series of dimensions. This study employs a semistructured interview format. Such a format facilitates an a priori sequence of interview question formulations, yet also embraces flex ibility during the interview session to focus on topics of importance for the participants. According to Kvale ( 1996), interviews also differ in their openness of purpose. In this qualitative study, the in terviewers explained the purpose and posed direct questions fr om the inception of the interview. The interview questions asked of each part icipant were brief and simple. Many of the types of questions that ar e considered useful by qualitati ve researchers (Kvale, 1996; Seidman, 1991) in semi-structured interviews were included. For instance, the types of interview questions asked in cluded introducing questions, pr obing questions, specifying questions, structuring questions, direct questions, and indirect questions (Kvale, 1996).

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84 The interview objective was to elicit a physicians per ceptions of preparedness by asking the types of organic and mental h ealth conditions likely to be encountered following a bioterrorist event a nd the risk factors associated with developing medical or mental health conditions. The intervie w questions also elicited the perceived impediments a rural physician or the phys icians patients may encounter in accessing healthcare and whether these would be exace rbated during or following a bioterrorist attack. The questions probed into the level of perceived education and training that is important and appropriate regarding biot errorism agents and preparedness. Representative interview questions included (1) What types of physical conditions do you think you would be likely to see in patients fo llowing a terrorist attack ? (2) What types of mental health disorders do you think you woul d be likely to see in patients following a terrorist attack? (3) Are you aware of any risk factor s for developing medical problems following a bioterrorist atta ck? (4) Are you aware of any risk factors for developing mental health problems following a bioterrorist attack? (5) What kinds of things can get in the way of accessing healthcare for people serv ed at this clinic? and (6) How important is it for healthcare providers to receive tr aining for bioterrorism ? Appendix A contains the complete list of interview questions. Prior to each interview a one page summary of the intent and objectives of the grant awarded from the Agency for Healthcare Qual ity and Research was mailed to each of the clinics administrators. Tw o academic faculty members conducted each interview, with one member asking questions and the other memb er recording field not es and reflections. To help the participants feel comfortable, each interview was conducted at the clinic in the physicians personal office. One of th e interviews was conducted at a physicians

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85 office which was not located on the physical clin ical site. Two of the interviews were conducted with two respondents, a physician and a healthcare administrator, present during the interview; while the other interviews were conducted with only a physician respondent. Each interview was audio r ecorded and transcri bed verbatim by a transcriptionist. After, the transcriptions were completed the researcher compared samples of the interview transcriptions with the audio recordings si de-by-side to assess accuracy. The interviewers began each interview, prio r to the audio recording, with a briefing or verbal explanation of the intent and research objectiv es of the study. This was performed not only to explain the intent of the interview and the project but also to develop rapport with each res pondent prior to engaging in the interview. Each candidate agreed to participate in the study voluntarily, potential benefits and an ticipated risks were explained, and each signed an informed consent form. Each respondent was assured that the interview would remain confidential. Monetary compensation of twenty-five dollars was provided to each participants clinic or h ealth center. This was provided as a token of appreciation and was not viewed as paymen t for participating. The University of Florida Institutional Review Board granted approval for the study. The interviews ranged from forty-five mi nutes to one hour in duration, which is within the 60 minute durati on suggested by Seidman (1991). The duration is suggested for two reasons. First, if the interview is too long the participant and/or the researchers may tire and become inattentive. Second, the duration enabled the busy physicians to schedule a reasonable amount of time. The in tent was for each research interview to proceed like a normal conversation yet have a specific purpose and structure (Kvale,

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86 1996). Each participant was aske d at the conclusion of the inte rview session if there were any additional information that the respondent would like to add to th e interview. Several of the physician respondents asked how the resear ch data would be utilized. In general, the respondents were engaging and eager to discuss preparedness and their previous experiences. Data Analysis This section describes the specific strategies that were employed to analyze the data collected through the semi-struc tured interviews. This study uses grounded theory to analyze the relationships between rural physic ians and their social structure that pose theoretical and practical con cerns with respect to their perceptions of bioterrorism preparedness. Grounded theory method is a set of flexib le analytic guidel ines that enable researchers to focus their data collection a nd to build inductive middle range theories through successive levels of data analysis and conceptual development (Charmaz, 2005). Grounded theory studies emerge from wrestli ng with data, noting similarities, making comparisons, developing categories, and in tegrating an analysis (Charmaz, 2005). Grounded theory entails developing increas ingly abstract idea s about research participants meanings, actions, and their world, as well as seeking specific data to fill out, refine, and check the emerging conceptual categories (Charmaz, 2005). Data and ideas are not merely objects that one pa ssively observes and compiles (Holstein & Gubrium, 1995). Rather, data results from an analytic interpretation of a participants world and from the processes constituting how this world is constructed (Charmaz, 2005).

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87 Charmaz (2005) explains that the entire research process is interactive because one brings past interactions and current interests into the research and one interacts with his/her empirical materials and emerging ideas. Grounded theory methods locate subjective and collective experience into larger structures and increa se understandings of how these structures work (Clarke, 2003, 2004; Maines, 2001, 2003). Thus, grounded theory method offers integrated theoretical st atements that ultimately will lead to an increased understanding of how rural physicians perceive d bioterrorism preparedness develops, changes, or continues. Glaser (2002) treats data as something sepa rate from the researcher and implies that data are untouched by a competent researchers interpretations. If researchers interpret their data, then according to Glaser (2002), these data are rendered objective by looking at several cases. However, a limitation of both qualitative and quant itative research is that no analysis is neutral because research ers do not come to their studies uninitiated (Denzin, 1994; Morse, 1999; Schwandt, 1994, 2000). Charmaz (2005) argues what one knows shapes, but does not necessarily determine, what one finds. A constructivist grounded theory (Charmaz, 1990, 2000, 2003; Charmaz & Mitchell, 2001) adopts grounded theory guidelin es as tools but does not subscribe to objectivist or positivist assumptions. Pos itivism can be characterized as a world composed of observable, measurable facts and it implies that measurable reality exists external to people (Glesne, 1999). Construc tivists, instead, portray a world in which reality is socially constructed, comple x, and ever-changing (Glesne, 1999). So, a constructivist approach emphasizes the studied phenome non rather than the methods of studying it and close attention is given to em pirical realities and our collected renderings

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88 of them as well as locating oneself in these realities (C harmaz, 2005). Charmaz (2005) explains that it does not assume that data simply await discovery in an external world or that methodological procedures will correct limited views of the studied world. Charmaz further explains that it does not assume that impartial observers enter the research scene without an interpretive frame of reference. Rather, what observers see and hear depends upon their prior interpretive frames, biographi es, and interests as well as the research context, their relationships with research participants, and modes of generating and recording empirical materials (Charmaz, 2005) Thus, constructivist grounded theory places an emphasis on participants experien ces. In this view, subjective meanings emerge from experience, and they change as experience change s (Reynolds, 2003). Charmaz (2005) explains that no qualitativ e method rests on pure induction rather the questions that are asked of the empirical wo rld frame what one knows and one shares in constructing what one defines as data. In a similar fashion, the conceptual categories arise through our interpretations of data rather than from them or from our methodological practices (Glaser, 2002). Thus, the theoretical analyses are interpretive renderings of a reality, and not merely an objective reporting of it (Charmaz, 2005). In this study, constructivist grounded theory offers a systematic approach to health services research that foster s integrating subjective experien ce with social conditions in the analyses. An interest in health services research and, more specifically, bioterrorism preparedness and barriers faci ng rural physicians and their pati ents means attentiveness to ideas and actions concerning perc eptions of preparedness, per ceptions of barriers to being prepared for bioterrorism, education and traini ng, and previous experi ence with disasters. It signifies thinking about rura l areas, scarce resources a nd healthcare personnel, and the

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89 threats posed to rural healthcare settings. It prompts an assessment and a reassessment of the preparedness perceptions and roles of physicians in rural healthcare settings. Thus, it requires looking at both percep tions and realities. Theref ore, contested meanings of shoulds and oughts come into play (Charmaz, 2005). Unlike positivists, constructivists openly bring their shoulds and oughts into the discourse of inquiry (Charmaz, 2005). Coding and Memos Coding is the first step in taking an anal ytic stance toward th e data in grounded theory. The initial coding phase in grounded th eory forces the researcher to define the action in the data statement (Charmaz, 2005). Standard grounded theory practice uses active, immediate, and short codes focusi ng on defining action, explicating implicit assumptions, and seeing processes (Charmaz, 2005). By engaging in line-by-line coding, the researcher makes a close study of the da ta and lays the foundation for synthesizing it (Charmaz, 2005). This is what was performed in this study on each of the participants. Charmaz (2005) explains that c oding gives a researcher analytic scaffolding on which to build. So each interview can in form earlier data. This means in essence that a researcher can discover a lead through developing a code in one inte rview and can then go back through earlier interviews and ta ke a fresh look as to whethe r this code sheds light on earlier data (Charmaz, 2005). This was pe rformed on each interview in this study and consequently ensures the data has multiple readings and renderings. According to Glaser (1978, p 55), Coding gets the analyst off the empirical level of fracturing the data, then conceptually grouping it into codes that then become the theory which explains what is happening in the data. The coding practices will help to uncover our assumptions, as well as those of our research participants (Charmaz, 2005).

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90 Rather than raising our codes to a level of objectivity, one can raise questions about how and why one developed certain codes (Cha rmaz & Mitchell, 2001; Glaser, 1978, 1992, 2001; Strauss & Corbin, 1990, 1998). This was performed by the use of memos attached to the coded interview transcripts and with re gular colleague input. Memos assist in the development of thoughts. According to seve ral qualitative researchers, memos assist principally by getting your thoughts down as they occur, no matter how preliminary or in what form (Glaser & Strauss, 1967; Glesne 1999). Memo writing also frees your mind for new thoughts and perspectives (Glesne, 1999). Regular colleague input is another way to break open our assumptions, that is, to ask colleagues to engage in the coding (Charmaz, 2005). This was performed by asking multiple health service researchers and healthcare professionals for their input into the coding process. Each professional brought divergent experiences to the open coding and their responses to the data at times called for scrutiny of my own coding. The use of multiple researchers is a form of triangulation. Triangulated fi ndings contribute to credibility and validity (Glesne, 1999; Denzin, 1970). I read the interview transcripts on severa l occasions. They were also read by a colleague as well as members of the resear ch committee. The grounded theory analysis process consisted of three main levels of coding analysis: open coding, axial coding and selective coding. I used open coding to de velop a list of codes. The codes used for analysis were derived from the participants actual words. In some instances, researcherimposed codes were used to identify lengthy se gments of text that was related to the individual code. Codes were attached to the smallest section of text that was related to

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91 the individual code. Coded sections range d in size from individual words to entire paragraphs of text, depending on the richne ss and depth of the description. Axial coding is the process of looking fo r relationships between categories of data, that is, the connecting phase of analysis (Crabtree & Miller, 1999; Glaser & Strauss, 1967). After the individual in terviews were coded, the c odes were transferred onto codesheets to look for connections between th e codes. After the codes were transferred to the codesheets, they were reviewed to el iminate any redundancy. Thus, the codes were reduced to a list of non-overlapping terms and then the data was put back together by making connections between the codes. Axia l coding then was used to compile the open codes onto the codesheets and to examine th em for connections be tween a category and subcategories, (i.e., similarities or differences). The axial codes were used to construct individual textural descripti ons of the experience. When constructing these descriptions, I returned to the text of the interview transc ripts to ensure that the descriptions were accurate and to include all pertin ent quotations to add to the richness of the descriptions. Lastly, selective or focused codes were devel oped. Selective codes use initial codes that reappear frequently to sort large amounts of data. Thus, this type of coding is more directed (Charmaz, 1983, 1995; Glaser, 1978). Th is part of the analysis was performed by developing selective codes and then connecting these codes with a particular category. Appendix B contains the coded transcriptions. These codes account for most data and categorize them most precisely (Charmaz, 2005). Making explicit decisions about selecting codes gives us a check on the fit between emerging theoretical framework and the empirical reality it explains (Charmaz, 2005). The constant comparative method was

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92 used throughout the process to compare data from the six physician interviews and to compare categories developed with other categories. Constant Comparative Method Grounded theory is a comparative method in which the researcher compares data with data, data with categories, and ca tegories with categories (Charmaz, 2005). Grounded theory is based on a general method of comparative analysis as a strategic method for generating theory (Glaser and St rauss, 1967, p 21). Glaser and Strauss (1967, p 35) state that the elements of theo ry that are generated by comparative analysis are, first, conceptual categories and their conceptual properties; and second, hypotheses or generalized relations among the categorie s and their properties. Charmaz (2000, 2002) explains that constructivi st grounded theory involves an interactive nature with the data with an emphasis on the participants experiences. To understand the nature of constructed real ities, qualitative researchers interact and talk with participants about their per ceptions (Glesne, 1999). Thus, a number of grounded data theorists have collected rich data when relying pr imarily on interviews (Baszanger, 1998; Biernacki 1986; Charmaz, 1991, 1995). In this study, the constant comparative method was employed to compare th e interview data from each of the six rural physicians. Each participants interview comments provided insight into his/her perceptions regarding bioterro rism preparedness and the comparisons between the rural physicians revealed salient similarities and differences. Theory Building Glaser (1978, p 5) explains that grounded theory arrives at relevance, because it allows core problems and processes to emer ge. Glaser (1978, p 16) states that grounded theory is a detailed grounding by sy stematically analyzing data sentence by

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93 sentence by constant comparison as it is c oded until a theory results. The theory emerges as a result of the coding process. The result sought in grounded theory is a small set of highly relevant categories and th eir properties connected by theoretical codes into an integrated theory (G laser, 1992, p 42). The sele ctive codes thereby form the foundations for theory, and the theory illustra tes the relationships between the selective codes. The progression through these stages led th e researcher to a description of the perceptions of rural physicians perception of bioterrorism preparedness and the barriers they perceive and their patients face regard ing preparedness. For the doctoral study, I completed all of the stages of grounded theory analysis as evidenced by the descriptions provided in Chapter 4 as well as the coding categories which may be found in Appendix B and the sample coded transcripts whic h may be found in Appendices C-H. Validity and Consistency The differences in approach to social science research have been documented by many scholars (Cicourel, 1964; Crabtree & Miller, 1999; Patton, 1990). Several researchers corroborate that what is required is a specification of each of the approaches or traditions that make up a pa radigm or approach, a descripti on of the rules or canons of evidence used in each, and an account of its su ccess or failure in persuading the reader of its goodness (Altheide & Johnson, 1994; Cr eswell, 1998; Mays & Pope, 1995b). Traditions such as grounded theory (Strau ss & Corbin, 1990) as well as the method of interviews (McCracken, 1988) have canons of evidence for researchers to follow. There have been numerous discussions in the clin ical health and medical research literature about these canons of evidence (Elder & Mi ller, 1995; Inui & Fr ankel, 1991; Kuzel, Engel, Addison, and Bogdewik, 1994; Kuzel & Like, 1991; Mays & Pope, 1995a), with some common agreement that verification and validation procedures include tactics such

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94 as peer debriefing, thick desc ription, member checking, external audits, and searching for confirming and disconfirming cases (Creswell, 1998; Kuzel & Like, 1991). The goal of all of these procedures is to provide checks and balances on the accuracy and trustworthiness of the data and analysis (C reswell, 1998). Creswell (1998) suggests that at least two of these should be present in any given study. But the ultimate test is that the report carries sufficient conviction to enable someone else to have the same experience as the original observer and appreciate th e truth of the account (Mays & Pope, 1995b, p 111). Questions posed to qualitative researcher s reflect concerns with the validity and reliability of the research findings. These questions reflect legitimate concerns about the rigor of qualitative research ; they also reflect philos ophical assumptions underlying a quantitative or positivist worldvi ew and are thus inappropriate for assessing the rigor of a qualitative study (Angen, 2000; Maxwell, 2005; Merriam, 1995). Rigor is as valid a concern in qualitative research as in any other kind of research, but qualitative researchers employ different means to ensure validity and reliability in a study. Qualitative researchers argue that validity a nd reliability need to be examined from a qualitative or interpretive worldview (A ngen, 2000; Maxwell, 2005; Merriam, 1995). When evaluating the validity of qualitative research, the accuracy of the findings, or truthfulness, is what is being evaluated (Angen, 2000; Merriam, 1995; Wolcott, 1990). Qualitative research persuades through its classical strengths of concrete depiction of detail, portrayal of process in an active mode and attention to the perspectives of those studied (Firestone, 1987, p 19-20) In this study, I am examining how rural physicians from North Central Florida perceive their bi oterrorism preparedness and the barriers to

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95 preparedness. Notions of validity and reliabi lity must be addressed from the perspective of the paradigm out of which the st udy has been conducted (Merriam, 1995). Qualitative researchers have approached rigor from several angles (Merriam, 1995). A few qualitative researchers explain the standard, positivist threats to validity and reliability made famous by Campbell and Stanley (1963) and Cook and Campbell (1979) to demonstrate how qualitative resear ch addresses these threats. History, maturation, observer effects, selection and regression, mortality, and spurious conclusions can be addressed from a qualitati ve research perspective as demonstrated by several studies (Goetz & LeCompte, 1984; Guba & Lincoln, 1981). Yet, more commonly, writers make the case that qua litative research is based on different assumptions regarding reality, thus demandi ng different conceptual izations of validity and reliability (Angen, 2000; Lincoln & Guba, 1985; Maxwell, 2005; Merriam, 1995; Miles & Huberman, 1994; Richardson, 2000). Internal validity se eks to address how congruent ones findings are with reality. Merriam (1995) explains that th ere are interpretations of reality; in a sense the researcher offers his or her interpretation of someone elses interpretatio n of reality. Just as in quantitative research there are things that a researcher can do (such as control for extraneous variables) to ensure that findings are valid according to that paradigms notion of reality, so too in qualit ative research (Merriam, 1995). External validity or generalizability is th e extent to which findings can be applied to other situations. In quantitative research external validity is an important criterion for valid research, but there are limitations with this approach. In quantitative research, random sampling may have been used, but genera lizations are made w ithin certain levels

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96 of confidence where outliers ordinarily become part of the variance. Furthermore, when dealing with human beings it is extremely difficult to apply statistically-based generalizations to individual persons. Qu alitative research rarely selects a random sample which is required in order to gene ralize to the population from which the sample was selected. Thus, generalizability is seen w ithin cases in qualitative data but not across samples. This distinction is what Maxwell (1992) explains as internal versus external generalizability. Maxwell (1992) explains that internal generalizability refers to the generalizability of a conclusion within th e setting or group studied, while external generalizability refers to its generalizabil ity beyond that setting or group (Maxwell, 2005). External generalizability is often not a crucial fa ctor for qualitative studies whereas internal generalizability is embraced as a salient vali dity criterion for qualitative research. This is because qualitative resear chers study a single set ting or a small number of individuals or sites, using theoretical or purposeful sampling rather than probability sampling, and they rarely make explicit cl aims about the generalizability of their accounts (Maxwell, 2005). Thus, the objective of qualitative research is to understand the particular in depth rather than finding out what is generally true of many. Yet this does not mean that qualitative studies are never generalizable beyond the setting or informants studied (Maxwell, 2005 ). According to Maxwell (2005), qualitative studies often have what is known as face gene ralizability, which means that there is no obvious reason not to believe that the results apply more generally. Furthermore, the generalizability of qualitative studies is us ually based not on explicit sampling of some defined population to which the results can be extended, but on the development of a theory that can be extended to other cases (Becker, 1991; Ragin, 1987; Yin, 1994).

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97 Hammersley (1992, p 189-191) a nd Weiss (1994, p 26-29) list ed a number of features that lend plausibility to gene ralizations from non-random samp les, including respondents own assessments of generalizabil ity, the similarity of dynami cs and constraints to other situations, and the presumed depth or unive rsality of the phenomenon studied. Maxwell (2005) explains that these char acteristics can provid e credibility to generalizations from qualitative studies. Some qualitative researchers may view ex ternal validity as reader or user generalizability. Merriam (1995) e xplains that in this view of external validity, people in those situations determine the extent to wh ich findings from an investigation can be applied to other situations. It is not up to the researcher to speculate how the findings can be applied to other settings; it is up to the consumer of the research. Reliability is concerned with the question of the extent to which ones findings will be found again (i.e., the results can be replicat ed). In the physical sciences, reliability revolves around repeated meas ures of a phenomenon, and the more times a study can be replicated, the more reliable the phenomenon is thought to be. However, in the social sciences the notion of reliability in and of itself is problematic. Studying people and human behavior is not the same as studying inanimate matter because human behavior is never static (Merriam, 1995). Cronbach (1975, p 123) notes an actuarial table describing human affairs changes from science in to history before it can be set in type. Moreover, the scientific notion of reliabi lity assumes that repeated measures of a phenomenon, which produce the same results ther eby, establish the trut h of the results. But Merriam (1995) explains that measurements and obser vations can be repeatedly wrong, especially where human beings are invo lved. Scriven (1972) further explains that

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98 a lot of people experiencing the same thing do not necessarily mean that their accounts are more reliable than that of a single individual. Qualitative research seeks to understand th e world from many perspectives and the many possible interpretations of those in th e world. Thus, there is no benchmark by which one can take repeated measurements and establish reliability in the absolute sense (Merriam, 1988, p 170). Replication of a qualita tive investigation will not yield the same results as it may in quantitative research. In qualitative research both sets of results stand as two interpretations of the phenomenon. Lincoln and Guba (1985, p 288) explain that instead of reliability one can strive for dependability or consistency. They suggest that the real question for qualitative research ers is not whether the results of one study are the same as the results of a second or thir d study, but whether the results of a study are consistent with the data collected. Therefor e, consistency can be ensured by the use of a peer examination and an audit trail. As previously discussed, qualitative resear ch uses several stra tegies to strengthen validity and consistency. This study will em ploy peer or colleague examinations, audit trails, investigator triangulation, member checks, and a statement of the researchers experiences in a subjectivity statement. Th ese strategies were used to augment the trustworthiness or research valid ity of this study. Peer revi ew enables external reflection and input on ones work. Audit trails invol ve an outside person examining the research product through auditing the anal ytic coding (Glesne, 1999). The purpose of investigator triangulation is not the simple combination of different kinds of i nvestigators, but the attempt to relate them so as to counteract th e threats to validity identified in each (Berg, 1995, p 5). Member checking is important because it provides an opportunity to share

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99 interview transcripts with research participan ts to make sure their ideas are represented accurately (Glesne, 1999). A clarification of researcher bias is a reflection upon the researchers own subjectivity and how it will used and monitored in the research (Glesne, 1999). Each of the aforementioned strategies of increasing validity and trustworthiness and how they were implemented within this study warrants discussion. Peer examination provides a check that the investigator is plau sibly interpreting the da ta so someone else can be asked whether the emerging results appear to be consistent with the data collected (Merriam, 1995). Peer or colleague examina tion involves asking peers or colleagues to examine the data and to comment on the plau sibility of the emerging findings (Frankel, 1999). Peer reviews (Frankel, 1999; Lincol n & Guba, 1985) were employed during this study to reduce bias in the data analysis wher eby all stages of the research project were shared with members of th e research committee. I as ked peers and colleagues to externally reflect and examine the data findings. An audit trail suggested by Guba and Linc oln (1981) operates on the same premise as when an auditor verifies the accounts of a business. In order for an audit to take place, the investigator must describe in detail how data were collected, how categories were derived, and how decisions were made th roughout the inquiry (Merriam, 1988). Goetz and LeCompte (1984, p 216) suggest that the audit trail should be so detailed that other researchers can use the original report as an operating manual by wh ich to replicate the study. An audit trail was perf ormed explicating the methods and steps of participant selection criteria and procedures, dem ographic information, data collection, transcriptions, and data analysis.

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100 Triangulation may be broadly defined as i nvolving varieties of da ta, investigators, and theories, as well as methodologies (D enzin, 1970). Triangulation may be more narrowly defined as multiple investigat ors collecting inform ation (Maxwell, 2005; Denzin, 1970). This study employed triangulat ion of investigators while collecting the data and during the data analys is process to help validate and achieve greater trust in the study. As previously described in this chapter, during the collection of data, each interview consisted of two investigators: one posing the interview questions and the other recording field notes. Also, during the open coding of the data analysis process, the codes were created and scrutinized by multiple investigators. According to numerous qualitative resear chers, respondent va lidation or member checks involve taking data collected from study participants and the tentative interpretations of these data back to the people from whom they were derived and asking if the interpretations are plausible, or if they ring true (Bryman, 1988, pp 88-90, Lincoln & Guba, 1985; Maxwell, 2005; Merria m, 1995). Member checking is considered a very important way of ruling out the possibili ty of misinterpreting the meaning of what participants say and do and th e perspective they have on what is going on, as well as being an important way of identifying the re searchers biases and misunderstandings of what was stated (Maxwell, 2005). Member checking is used in many methods of qualitative research and is important wh en describing construc tivist perspectives (Merriam, 1995). I assessed the tr uthfulness of the data collect ed from the participants by using member checks (Bryman, 1988; Li ncoln & Guba; 1985; Merriam, 1995) throughout the data analysis proc ess. The information was sh ared with the participants following the transcription process. The partic ipants were asked to review the transcripts

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101 for any disparities and the audio tapes were reviewed again to ensure transcription authenticity. Thus, the participants we re given the opportunity to correct any misconceptions or misunderstandings. Upon re view, the participants found no disparities with their verbal account a nd the audio recordings. A subjectivity statement is a statemen t of the researchers experiences, assumptions, and biases, which enable the read er to better understa nd how the data might have been interpreted in the manner in which they were interpreted. A subjectivity statement explains the authors education, prior knowledge, values and beliefs to better understand the authors affective reactions to th e data that will be ex amined and analyzed (LeCompte & Preissle, 1993; Merriam, 1995; Richardson, 2000). I included a selfreflexivity or subjectivity statement, which describes a clarification of my own experiences, biases, and assumptions as a primary care physician. Subjectivity Statement The subjectivity statement is provided so that all related experiences of the researcher are presented transparently. This ensures that the reader can critically examine the truthfulness of the research as being bias free, which contributes to the validity of the research. The explicit incorporation of id entity and experience in your research has gained wide theoretical and philosophi cal support (Berg & Smith, 1988; Denzin & Lincoln, 2000; Jansen & Pes hkin, 1992). As a researcher engaging in a constructivist study of rural physicians a nd healthcare providers perceptions of emergency preparedness and the barriers to preparedne ss, I have life experien ces as a physician and at times in rural settings. Although I have limited experience specifically in emergency bioterrorism preparedness, my views of physician emerge ncy preparedness must be bracketed in order to study the perceptions from a novel perspective. I am a Caucasian

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102 male who has lived in the state of Florida fo r the last four years where the primary data has been collected. In addition to residing in the state, I ha ve practiced medicine in the state, albeit not in an area that would be classified as rural. Prior to beginning my doctoral program at the University of Florida in the Department of Health Services Research, Ma nagement and Policy, I practiced clinical primary care medicine and have been a healthcar e consultant. In those roles, I have been responsible for coordinated acu te and chronic patient care in volving general internal and family medicine, and emergency medicine in the hospital, nursing homes, and outpatient settings. I also have experience in creati ng and instituting disease protocols in chronic disease management and conducting healthcare consulting research serving as a medical writer and editor for an alternative and complementary medicine firm. In addition to clinical ex perience as a physician and a healthcare consultant, while at Harvard I was formally educated on disa ster management through didactic courses and seminars and created with the assistan ce of another physician colleague a public health/bioterrorism website on Nuclear Di saster Management entitled Chernobyl: Anatomy of a Disaster. Recently, as an adj unct faculty member at the University of Central Florida, I created and instruct a course entitled, Health Issues in Disaster Preparedness. This course focuses on disa ster preparedness and related mental and physical health issues for natu ral catastrophic events-such as hurricanes, earthquakes; and induced or human-caused disasters-such as bioterrorism and chemical terrorism. Beyond professional activities, I have pers onal life experiences that are noteworthy and unfortunately have been touched by terrori sm. I unfortunately lost a colleague, and more importantly a dear friend, whom I worked with at the United States Department of

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103 Health and Human Services. He was present on one of the airplanes that departed from Washington, D.C., on September 11, 2001, and wa s subsequently hijacked and crashed. Limitations This study has several limitations. Accordi ng to a positivist pers pective, there is a limitation regarding external validity with qualitati ve research and therefore of this study. Yet, qualitative research has alternativ e conceptions of external validity and generalizability (Maxwell, 2005). Another pote ntial limitation is that the sample is of participants limited to the rural areas in North Central Florida, and may therefore be difficult to externally generalize these findings to clinicians in urban sectors of the country. This study does have multi-site designs, but it has the limitation of not having multiple participant physicians at each site, often from necessity because there was only one physician at a rural site. A strategy to improve qualita tive external validity is to use several participants from several sites to represent the variation, which may allow the results to be applied to a greater range of other similar situations. Another possible limitation of this study is a selection problem which is known as key informant bias by Pelto & Pelto (1975, p 7). This study used key informant interviews of six physicians located in rural areas to describe their percei ved preparedness and the barriers. This is a limitation principally because when one relies on a small number of informants for a significant part of the data it may not guarant ee that the selected informants views are typical (Maxwell, 2005). This study has another limitation involvi ng investigator subjectivity, although subjectivity may be considered both a lim itation and an asset. Several well-known researchers have challenged the notion of s ubjectivity as something negative (Denzin & Lincoln, 1994; Glesne, 1999; Oleson, 1994; Peshkin, 1988; Wo lcott, 1995). Qualitative

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104 researchers recognize that subjec tivity is always a part of research from deciding on the research topic to selecting frames of interpretation (Glesne, 1999). However, subjectivity can be monitored to ensure more trustwor thy research and subjectivity itself can contribute to research (Angen, 2000; Glesne, 1999). Glesne ( 1999) explains that part of being attuned to ones subjective lenses is being attuned to your emotions. Ones emotions help to identify when subjectivity is being engaged. Instead of being suppressed, ones feelings should be used to inquire into perspectiv es and interpretations and to further shape questi ons through re-examining assumptions (Glesne, 1999). According to Kleinman & Copp (1993, p 33) Ignoring or suppressing feelings are emotion work strategies that divert our atte ntion from the cues that ultimately help us understand those we study. Thus although s ubjectivity is embraced by the qualitative research community, it is also considered a limitation by others and something to note from ones research. As a physician, I am invested in the search for a better understanding of how prepared rural physicians perceive themselves to be for a catastrophic event. After lo sing a colleague during the September 11, 2001, terrorist attacks, my researcher bias regarding th e need for greater catastrophic emergency physician preparedness is declared within my subjectivity statement. Thus, my attachment as a member of the medical profession introduces a limitation. Another limitation regards the data collection and transcription. The interviews are vulnerable to self-report bias by a participant. Another limita tion is that I did not conduct each interview personally, although the prin cipal investigators were present and conducted each and every participant interview. Furthermore, I did not transcribe the tape recorded interviews. Naturally, the mo st accurate rendition of what occurred is on

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105 the recorded tape (Bogdan & Bi klen, 1998). Transcription of audio taped interviews and conversation has become the norm in most qualitative research (Sandelowski, 1994). How content is both heard and perceived by the transcriptionist and the form and accuracy of its transcription play a key role in determining what data are analyzed and with what degree of dependability (MacLean, Ma yer, and Estable, 2004). I listened to each of the taped interviews performing a proc ess known in the qualita tive literature as spot checking (MacLean et al.). Moreover, I personally edited the transcriptions to ensure verbatim transcription. Verbatim tran scription has been cited as critical to the reliability (Seale & Silverman, 1997) and to the validity and trustworthiness (Easton, McComish, and Greenberg, 2000) of qualitative research. Yet this is still a limitation because transcribed text can never totally captu re the complexity of the interaction nor be completely error-free (Sandelowski, 1994). The grounded theory data analysis and c oding represents another limitation. Previous researchers have stated that qua litative research employing grounded theory analysis is limited because reports are not as straightforward as their authors report them to be (Richardson, 1994). Conrad (1990) and Riessman (1990) suggest that fracturing the data in grounded theory research might limit understanding because grounded theorists aim for analysis rather than th e portrayal of subjects experiences in its fullness. From a grounded theory perspective, fracturing the da ta means creating codes and categories as the researcher defines themes within the data. This was performed on the data and is a limitation because fracturing the data may lead to separating the experience from the experiencing subject. Yet Glaser and St rauss (1967) explain th at this strategy is important because it helps researchers a void the tendency to remain immersed in

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106 anecdotes or stories. Furthermore, it preven ts researchers from becoming immobilized or overwhelmed by voluminous data and it creates a way for the researcher to organize and interpret data (Glaser & Strauss).

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107 CHAPTER 4 FINDINGS This chapter will highlight the central fi ndings regarding the principal research question of rural physicians perceived pr eparedness for a bioterrorist event. Additionally, it will expound on the second research quest ion involving the perceived difficulties or impediments confronting rural physicians and their preparedness. The chapter proceeds by sharing the rich descriptions of six rural physician participants perceptions of their bioterrorism prepare dness and its associated elements: cognitive preparedness, clinical preparedness, expect ation preparedness, simulation preparedness and resource preparedness. The components re lated to the patients mental and medical condition and the patients perception of th eir own morbidity and mortality will be illustrated. The chapter follows by explaini ng the perceived component barriers related to a bioterrorist even t that impedes the physician-patien t relationship. It concludes by illustrating the dynamic of physician medical inte rventions such as treatment or therapy for patients in the midst of a perceived biote rrorist event w ith physician-patient barriers. This section begins by providing an intr oduction explaining the conceptual diagram illustrated in Figure 4-1. The individual co mponents in Figure 4-1, as well as their relationships and interrelationships will be examined to explicate the connections between the figure and the quali tative data. The summary of Figure 4-1 is followed by a more extensive discussion in conjunction with data examples of the studys findings.

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108 Figure 4-1: Rural Physician-Pa tient Bioterrorism Preparedness The asterisks (*) represent axial codes. Context Bioterrorist Event Physician Perception of Preparedness Physician Professional Preparedness Cognitive Preparedness* Clinical Preparedness* Expectation Preparedness* Simulation Preparedness* Resource Preparedness* Patient Perception o f Morbidity & Mortality Patient Condition Mental Health Emotional Health Physical Health Exacerbation of Pre Existing Condition* Medical Intervention: Recommendation Treatment Therapy Physician Patient Related Barriers: Access Barriers Financial Barrier* Increased Patient Load* Transportation Barrier* Resource Barrier* Physician Patient Related Barriers: Comm unication Barriers Social Barrier* Respect Barrier* Literacy Barrier* Knowledge Barriers

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109 Figure 4-1 is a conceptual diagram illu strating a contextual situation of a bioterrorist event. When describing bioterrorism preparedness, there is the context (outermost circle) and the specter of a bioterrorist event (second outermost circle) which thereby influence physicians perceptions of th eir professional prepar edness, as well as rural patients and their associated medica l conditions. Physicians possess a personal perception of professional or medical prepare dness which is shaped by their context in a rural demographic setting and the threat of a possible bioterrorist event. The physician perception of preparedness (i.e., in Figure 4-1 represented wi th a spherical line pattern of two dots and a dash surrounding physician prof essional preparedness) explains how an individual physician perceives hi s/her preparedness for a bioterrorist event. It includes a physicians cognitive perceptions and perceive d expectations that he/she will rely on medical experts assistance in the advent of a bioterrorist attack in divulging overt physical and mental signs, patient sympto ms, and corresponding treatments. Thus, a physicians perception of prepar edness is the sphere that su rrounds, interacts and thereby influences perceived elements of a phys icians professional preparedness. Although perceived emergency bioterrori sm preparedness and actual emergency bioterrorism preparedness are inextricably li nked and intertwined they may or may not be comparable or equal to one another. Ac tual preparedness involves tangible clinical training and experience along with corres ponding medical education related to bioterrorism and its associat ed infectious agents. Per ceived preparedness involves many of these very same elements, as well as th e individual physicians perception of his/her preparedness. A physician may have had actua l training and educati on and yet still not perceive himself/herself as being prepared, merely because he/she has not experienced a

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110 tangible real-life clini cal experience. In contrast, a physician may have performed actual mock emergency bioterrorism simulation exerci ses, received actual clinical educational training and perceive himsel f/herself as prepared yet have the perception and the expectation that an actual bi oterrorist event may occur as rare in probability. The identification of these indi vidual perceptions is importa nt because perception is a powerful arbiter of actions that may infl uence preparedness. Several physician participants have not profe ssionally experienced catastrophi c events; nevertheless, they have perceptions, expectations, and anticip ations of emergency preparedness and the possible impediments that they may encounter in the event of a biote rrorist attack. Other physician participants may have professiona lly experienced actual catastrophic events such as September 11, 2001, and the subse quent anthrax dissemination and they have pragmatic responses and explanations regard ing preparedness and the impediments to the physician-patient relationship. Moreover, these physician participants will also have perceptions regarding future event impediments and preparedness. These findings concentrate on describing a nd explaining rural physicians perceived professional or medical preparedness and th e perceived impediments. The physician professional preparedness is influenced by several interrelated elements: cognitive preparedness, physician sensitivity to symptoms and the condition of the patient or clinical preparedness, expect ation preparedness, simulation preparedness, and resource preparedness. Each of these elements is illustrated in the diagram and represented by axial codes that together comprise the selective code of physician professional preparedness. How mentally prepared a physician pe rceives himself or herself may be explained as cognitive prepar edness. Yet cognitive preparedness involves

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111 additional complexity beyond merely personal perceived mental preparedness that an event may occur. It also involves a scient ific and educational know ledge, as well as an analytical reasoning acumen coupled with the corresponding conf idence to identify bioterrorist agents from more pedestrian, ubiquitous clinical infectious diseases such as the common cold virus or the influenza viru s. Although the symptoms of the influenza virus may be similar to the symptoms caused by a bioterrorist infecti ous agent, cognitive preparedness involves a physician realizi ng an entire contextu al sphere and the consequent event-dependent situation. T hus, cognitive preparedness involves a physician being able to discern between a clinical mani festation of a verifiable medical infectious disease condition related to a bioterrorist agent such as smallpox or anthrax from the common and yet often similar or related symptoms of organic and/or mental illness. Clinical preparedness involves medical doctors being aware, sympathetic, and empathetic to patient symptoms and conseque nt conditions. It also is closely aligned with cognitive preparedness. A physician must be aware of the possibility of a bioterrorist event, mentally prepared if su ch an event occurs, as well as sensitive to patient symptoms and the corresponding overt a nd covert medical signs if such an event has occurred. Expectation preparedness is another type of physician professional preparedness. It is also similar to cognitive preparedness, par ticularly with respect to the need for mental keenness and awareness. A phys ician must anticipate the pos sibility of a catastrophic event such as a bioterrorist event and be prep ared mentally for the aftermath of such an event which may be manifested by a patient s altered condition and behavior. So, expectation preparedness invol ves physicians not only anticip ating, but also accepting the

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112 reality that a bioterrorist attack may ind eed occur within their area. Expectation preparedness involves physicians accepting that a bioterrorist event will affect both them and their healthcare facility. It also en compasses a physician possessing the clinical judgment to consider such an event when pati ents present with symp toms of an infection that may or may not be related to a bioterrorist agent. Simulation preparedness is a type of phys ician professional preparedness which is also related to the other types of preparedness. It involves the actual traini ng pertinent to bioterrorism. Simulation preparedness may in clude educational clin ical training through continuing medical education pr eparatory seminars, as well as learning performed on an individual basis by physicians through the reading of pertinent medical journals. Simulation training also may in corporate relevant training dr ills and simulation exercises depicting possible bioterrorist scenarios. The objective of si mulation training is to assist physicians in their preparation for a possi ble bioterrorist even t by offering on-site pragmatic, hypothetical clinical experien ces of such catastrophic events. Resource preparedness involves a rural phys ician being able to rely on other healthcare facilities during a catastrophic event. It also includes a rural physician being able to rely on other health care providers such as ment al health specialists (i.e., psychiatrists and psychologists) during a crisis. Thus, it invo lves rural physicians having the perception that there will be enough health care facilities such as clinics, private medical offices, and hospitals as well as enough healthcare practitioners available to respond during a bioterrorist attack. Resource preparedne ss also consists of the perception that these healthcare facilities and practitioners will have extended hours to accommodate the increased number of patients.

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113 The outermost dotted line in Figure 4-1, which surrounds the sphere enclosing physician perception of preparedness a nd the sphere encompassing physician professional preparedness, serves a filtering f unction. The filtering function denotes the barriers impeding perceived physician professional prep aredness and the obstacles hindering physicians from admi nistering medical interventions intended to help allay patient conditions. Thus, the physician-patient related barriers hinder patients from receiving salient medical inte rventions from physicians. A medical intervention may include medical recommendations, medical treatments such as pharmaceuticals, and medical therapy such as counseling and psychotherapy. These interventions are performed by the physician with the objective to alleviate or ameliorate the patients infirmed condition. However, the physicianpatient related barrier s pose difficulties and thereby hinder patients from receiving appropria te interventions. Thus, patients will have greater difficulty recovering from exacerbations of pre-ex isting conditions or from recently contracted illnesses in the event of a bioterrorist attack in rural contextual settings. These physicianpatient impediments include three major types: access barriers, communication barrie rs, and knowledge barriers. Access barriers (i.e., selective code) consist of financial barriers, increased patient load barriers, transportation barriers, and resource barriers (i.e., axial co des). Communication ba rriers (i.e., selective code) include obstacles such as social barriers, literacy barriers, and respect barriers (i.e., axial codes). Knowledge barriers may involve physicians who lack relevant medical knowledge and/or appropriate treatment knowle dge or patients who have not received information or knowledge pertinent to the biot errorist event. Each barrier adversely affects the physician-patient relationship.

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114 The patient perception of morbidity a nd mortality is influenced by several elements. Rural patients perceptions of mo rbidity and mortality are influenced by their rural context, the speculative or precipitating bioterrorist event, their perception of physicians professional preparedness, and the physician-patient related barriers impeding proper medical interventions. Patie nts may perceive their own medical preexisting conditions as worsening with the possibi lity of a bioterrorist event. Patients may also perceive the introduction of nascent, incurable afflicti ons arising from infectious etiological agents with the distinct possibili ty of mortality as a likely outcome in the context of a bioterrorist even t. Thus, the patient condition which comprises the mental, emotional, and physical state of a patient will be influenced and altered. In addition, patients with previous health conditions may experience an exacerbation of their preexisting physical and mental cond itions. A catastrophic event su ch as a bioterrorist event may precipitate a worsening of a patients chronic medical condition such as a previously stable condition of asthma or hypertension. Or it may affect a patie nts chronic mental condition such as a previously stable condition of genera lized anxiety disorder or depression. Physician Professional Preparedness a nd its Associated Elements: Cognitive Preparedness, Clinical Preparedne ss, and Expectation Preparedness Professional preparedness involves the physic ians sensitivity to patient symptoms and cognitive preparedness of the perceived risk factors, health disorders and treatments in the expectation of such an event. Physician professional preparedness or, more specifically, the elements of cognitive preparedness and expectation preparedness involves the steps that physic ians perceive and anticipate can be performed to assist

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115 patients in both the immediate aftermath and in the ensuing months that follow a bioterrorist attack. It may be argued that following a biote rrorist event the number of rural patients visiting rural healthcare facilities will drama tically increase for a number of reasons. It can further be argued that some of these pati ents will have been afflicted with bonafide organic illnesses or mental illnesses while others will have self-perceived illnesses. Bioterrorist agents such as anthrax or sm allpox can induce infec tious diseases which require medical attention. Consequently, so me patients will present with a significant worsening of a pre-existing medical condition such as an exacerbation of their chronic obstructive pulmonary disease. Other individuals will be affected by such a traumatic catastrophic event and present to healthcare facilities with me ntal health symptoms such as generalized anxiety. Pr eviously stable and well-medi cated patients will have a worsening of their mental health conditions a nd will present to health care facilities with an exacerbation of their post-tr aumatic stress disorder (PTSD) anxiety, or depression. Moreover, there will be anothe r group of patients that visit a healthcare facility without any medically relevant or medically identifia ble condition. This group of patients will simply react to the adverse event replete with emotions of concern and excessive worrying which may foster a self-perceived illness which compels them to visit a healthcare facility. These patients may be iden tified as the worried-wel l. As stated, they may not have any true medical condition, but in the advent of a catastrophic event concomitant with the sensational media attent ion devoted to the subject, they perceive their own morbidity and even possibly their ow n mortality and seek medical services.

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116 Mental and Emotional Health Two of the physician particip ants reported a significant increase in the number of patients after the September 11, 2001, and s ubsequent anthrax dissemination terrorist incidents. Three other physician participants speculated that there would be an increase in the number of patients with mental health conditions following a bioterrorist event. Doctor Smith explains that after September 11, 2001, he witnessed an increasing number of patients presenting with exacerbations of pre-existing mental health conditions, most notably depression and anxiety. This increase d patient load is an illustration of an access barrier. This is principally because an in creased patient load adversely affects two components of healthcare access-the availabi lity of healthcare services and the accommodation of patients seeking healthcare services. Consequently, Dr. Smith was inundated with an increased number of patient s with actual illnesse s and other patients with self-perceived illnesses, which exacer bated the physician-patient accessibility impediments and thereby imposed additional pressures on the rural medical infrastructure. Doctor Smith explains that many of these patients had been previously stable on medications, but they were personall y affected by the terror ist incidents, having lost family members or friends. Thus, one may infer that patients with previously stable conditions deteriorated conse quent to 9/11 and there was an increase in the number of patient visits to healthcare facilities. Ma ny of these affected patients presumably asked physicians if they had been exposed to infecti ous diseases and if they could be tested for various possible conditions and diseases. This presumably diminished the availability of resources and the accommodation by medical personnel. The increasing number of patients pres enting to healthcare facilities would presumably include patients afflicted with authentic illnesses and patients presenting with

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117 self-perceived illnesses. Doctor Davis infers that with a bioterrori st event the number of anxious patients presenting to the emergenc y room would probably increase as well as the number of people that think they are infe cted. This physician participant captures the essence of perceived illness and its conse quences. In the event of a bioterrorist attack, Dr. Davis perceives th at the patient load would in crease because the number of healthy patients who are concerned that they may be sick would increasingly present to the emergency room. This commensurate incr ease in patients who are otherwise healthy but who perceive that they are ill would serve to exacerbate previous barriers to accessing healthcare and thereby further adversely a ffect the ill individuals who truly need healthcare services from the emergency room. When Doctor Williams was queried regarding the kinds of mental health problems that a physician may encounter after a terror ist attack, such as the WTC bombing or an infectious disease outbreak such as anthra x dissemination, he responds post-traumatic stress disorder, anxiety, a nd substance abuse would proba bly flare more. Doctor Williams perceives a worsening of mental heal th illnesses due to the traumatic stressors incurred by a bioterrorist even t. He states that depressi on would increase, but probably not until later and especially if people knew they had b een directly affected by a bioterrorist agent. Depressi on is a clinical condition that insidiously develops and may originate as a result of an adverse event whic h deleteriously affects an individuals life. Depression is a profound feeling of sadness and hopelessness that is often also accompanied by physical symptoms. Thus, a bioterrorist event would exacerbate preexisting mental illnesses such as depression, as well as chronic medical conditions such as pulmonary disorders. It may be argued that patients who previously were medically

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118 stable on psychotropic medicati ons and were receiving appr opriate psychotherapy would suffer setbacks in their medical illnesses. Doctor Jones corroborat es other participants comments by articulating that after a bioterrori st event he would anticipate an increasing exacerbation of most peoples an xieties. Doctor Jones explains that he perceives that mental illnesses such as PTSD would increase after an event. Post-traumatic stress disorder is a psychiatric disorder that can occur following the experience or witnessing of life-threatening catastrophic events such as na tural disasters or terrorist incidents. Most survivors of trauma return to normal after a period of time. However, some individuals will have stress reactions that do not disappear on their own, or may even get worse over time. These individuals may develop PTSD. People who suffer from PTSD often relive the experience through nightmares and flashback s, have difficulty sleeping, and feel detached or estranged; these symptoms can be severe enough and last long enough to significantly impair an individuals daily life. Post-traumatic stress disorder is also marked by clear biological changes as well as psychological symptoms. This disorder is complicated by the fact that it frequently occu rs in conjunction with other related mental health conditions such as depression, s ubstance abuse, problems of memory and cognition, and other problems of physical and mental health. The disorder also may be associated with impairment of an individuals ability to function in so cial or family life, including occupational instabil ity and marital strife. The increase in exacerbations of pre-existing mental health c onditions, along with newly formed mental health conditions following a bioterrorist event, would augment the patient load presenting to healthcare facilities and thereby overwhelm extant he althcare personnel and resources.

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119 It may be argued that patients perceive th eir own morbidity and mortality-mentally, emotionally and physically-when confronted with the specter of a bi oterrorist event. During a catastrophic event, many patients will be replete with emotions of anxiety, distress and trepidation regarding their pe rceived health condition. Doctor Smith comments that there was an increase in the number of patients expressing difficulties sleeping and feelings that the world is going to end. This quote helps to explain the patient condition in the event of a bioterrorist attack. It may reflect an emerging mental health condition such as depression or anxiet y or a resurfacing of pre-existing conditions such as PTSD. So, many rural patients w ill reflect on the fragility of their life and consequently express apocalyptic feelings duri ng such an event. Doctor Jones explains that it would depend on the kind of bioterrorist event. The magnitude of the event, that is, the size of the event and the number of peopl e affected, would be cr itical. If an event affects a small number of individuals, the perv asive perception may be that it is unusual and probably will not affect them personally. However, a large event that affects a significant number of individua ls will evoke widespread feelings of fear, anger, and bereavement. Moreover, the type of bioterrori st infectious agent released during an event and the location of the bioterro rist event may be important. It may be inferred that rural residents perceive that geogra phical isolation may preclude th em from the vicissitudes of urban life. But, if a catastrophic event were to occur in a rural ar ea or if there were a tangibly perceived threat in a rural setti ng, it may evoke a submerged unease among rural residents that no place is sa fe. Doctor Davis is a physic ian who is employed in an emergency room. He reiterates what severa l other physician colleagues stated regarding the importance of the magnitude of the bioterrorist attack. He articulates that it depends

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120 on how big the event is and how many people ar e involved. So, Dr. Davis perceives that the larger the event then th e greater the ensuing emergency room patient load. An adverse event would mandate the need for addi tional access to a heal thcare facility. Yet many rural healthcare facilities may already lack adequate access due to patients geographical isolation, transportation difficu lties, and financial constraints. Thus, a deleterious catastrophic event c ould thereby further cripple rural emergency room access. In contrast with the other physician pa rticipants, Dr. Brown articulates that how the bioterrorist event is handled will affect rural residents hea lth. Although Dr. Brown does corroborate with each of the other physician participants by explaining that a bioterrorist event can also create hysteria and anxiety, he markedly differs from other participants regarding his perception of the importance of the management of the catastrophic event. He explains that, depe nding on how a bioterrorist event was handled, it may transform an individual into a type of depressive disorder patient whereby this individual will express sentiments of hopelessness and helplessness. Thus, one may presume that if patients perceive a catastr ophic event is being adeptly managed, they will not have the same degree of perceived hys teria and anxiety-provoking mental ill health effects. This is significant because it fu rther highlights the centr al role of perceived physician professional preparedness. If patients perceive physicians to be professionally prepared then one may presume that patients will not exhibit as many adverse emotional and mental health symptoms. Physical Health It may be argued that the physical health disorders manifested in patients following a bioterrorist event would depe nd on the infectious agent. In general, infectious agents will induce constitutional symptoms such as general malaise, fever, diarrhea, and muscle

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121 pain. If the infectious agent were anthrax, one would expect a manifestation of these constitutional symptoms as well as other symp toms contingent on the type of anthrax. There are several variants of anthrax: cu taneous, gastrointestin al, oropharyngeal, and inhalational. Each type of anthrax would elicit different physical symptoms in patients. Cutaneous anthrax would affect the integum entary system. Gastrointestinal and oropharyngeal anthrax would affect the gastro intestinal system wh ile oropharyngeal and inhalational anthrax would affect the respirat ory system. If the infectious agent were smallpox one would expect systemic symptoms such as severe muscle aches, lethargy, abdominal pain, and vomiting, as well as a rash with associated smallpox lesions. Smallpox affects the respiratory a nd gastrointestinal systems. Many bioterrorist agents are transmitted by respiratory vectors, thus a physician would expect respiratory struct ures to be adversely affect ed. Respiratory structures include the mucous membranes or the linings of the mouth and nasal cavity along with the other associated respiratory anatomical structuresthe sinuses, pharynx, auditory canals, Eustachian tubes, bronchi, and the l ungs. Doctor Williams explains that he perceives the physical health problems most likely to be encountered would depend totally on what the agent is. He believe s that physical health problems would be affected by the type of bioterrorist infectious agent. Respiratory bioterrorist agents would induce respiratory symptoms, while neurot oxic bioterrorist agents would elicit neurological symptoms. When queried rega rding anthrax or a nerve agent specifically, he explains that I dont know the findings that well. In a similar fashion, Dr. Phillips also perceives that physical health problem s likely to be encountered depends on the kind of event. She also co rroborates with Dr. Williams comments by explaining: if it

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122 were a respiratory event, we would look for respiratory symptoms, so it is dependent. Doctor Brown explains that several physical signs would be present. He explains that mucous membranes would be affected, as we ll as the gastrointestinal and respiratory systems. Similarly, Dr. Brown perceives th at the physical health problems encountered would depend on what the attack entailed. He explains that we may see respiratory symptoms or other physical symptoms, but th at the clinical presentation of physical symptoms encountered would be predicated on the event. Thus, each physician explains that the medical symptoms and corresponding illnesses would be contingent on the type of infectious bioterrorist agen t. Doctor Brown further elab orates by explaining that when you think of bioterrorism, you think of agents that are physically capable of affecting morbidity and mortality rates. Bioterrorist agents are perceive d by physicians as lifealtering and life-threat ening and mandating appropriate attention. Although patients may lack the scientific knowledge re garding bioterrorist agents, th ey appreciate the grave and solemn danger of infectious bi oterrorist agents. Patients appreciate the high degree of correlation between infectious bioterrorist agents and the associated morbidity and mortality. This awareness highlights a nd substantiates patients underlying self perceptions regarding their own mental, emotional, and physical health conditions. Patients increasingly perceive their own illnes ses and possible morbidities when there is uncertainty and/or fear of the unknown. Th is uncertainty or trepidation is further exacerbated by a lack of knowledge and a lack of pertinent information. It has been argued that in the advent of a bioterrorist incident, the number of patients presenting with bonafide medical condi tions will increase, as well as the number of patients presenting with feigned conditions. One may also argue that many infectious

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123 diseases manifest clinically with similar symptoms. Many infectious agents induce similar constitutional symptomsfevers, na usea, vomiting, and muscle aches. Consequently, it may be difficult to discern one infectious disease from another. Doctor Jones comments that you will have a pletho ra of patients presenting with all the symptoms-real or thought up. Dr. Jones states that there wi ll be an increase in patients who truly need care and pa tients who are the worried about their perceived own morbidity and possible mortality an d therefore perceive that they need medical attention. Doctor Jones explains that if you look at anthrax, you get a fever, cold and cough. How many people do we have that have that ? He explains that with many of the respiratory bioterrorist-induced illnesses th e early symptoms mimic the common cold. This statement underscores the importance of physician professional preparedness from several elements: cognition, expectation, and se nsitivity to symptoms. Physicians need to be cognitively prepared to be able to discern commonly encountered patient symptoms emanating from common infectious agents from other similarly encountered patient symptoms from rarer bioterrorist infectious ag ents. Physicians need to have bioterrorist expectation awareness and c ontextual awareness to cons ider bioterrorist-induced infectious agents as a possibility among pres enting patients to a hea lthcare facility. And physicians need to be sensitive to patients presenting descriptions of their symptoms. Risk Factors for Mental Illness or Physical Illness Risk factors are tenets th at predispose one to medical conditions. Many mental illnesses and physical illnesses possess non-modifiab le risk factors. Non-modifiable risk factors are elements that cannot be altered such as age, gender, family history, and ethnicity. For instance, in general, risk f actors for contracting me ntal illness include a previous personal history of me ntal illness or a family hist ory of mental illness. Many

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124 medical and mental health conditions possess non-modifiable risk f actors contingent on age, gender, and family history. It may be argued that there are few known risk factors regarding how to prevent bioterrorist induced illnesse s. The best preventive steps often include vaccinations against infectious agents. Doctor Williams expl ains that he is not familiar with the risk factors or clinical manifestati ons of certain biolog ical infectious agen ts or of neurotoxic agents. He specifically expl ains, I would think for bi ological, obviously impaired immune status, so anything that does that and old age being a big one, and multiple chronic diseases being another one, certain medications. Im paired immune status is a risk factor for any patient who is older or has suffered from chroni c medical conditions. Thus, each of those risk factors is interrelate d. Occasionally, prescribed medications may predispose a patient to a condition that otherw ise would not have been caused without the medication. When asked about risk factors for developing mental disease, Dr. Williams responds I can guess what some might be, but I dont know any studi es or research on that. This lack of knowledge would be classified as a knowle dge barrier and would affect this physicians perception of prepar edness as well as his cognitive preparedness for such an event. It would also affect hi s sensitivity to patient symptoms because he may not be able to detect early or novel sy mptoms associated with stress or mental anxiety. This lack of detection may advers ely alter his choice of medical interventions and thereby deleteriously affect the patients condition. In a similar fashion when Dr. Smith is asked of his awareness regarding risk factors, he states: I think that there are risk factors. I cant quote an article. Anyone who has a preexisting illness, there is no questioning that an event like that is going to impact on their consciousness and could

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125 make things worse. Again, there is a know ledge barrier present w ith this physician as well. This knowledge barrier will once again affect the perceptions and the elements of professional preparedness. Doctor Brown, si milar to the other physic ian participants, is not aware of any risk factors for devel oping mental health problems following a bioterrorist attack. He says: I think using some common sens e that past history of posttraumatic stress disorder or a ny type of involvement in war, criminal, or stress-related issues that come from senses of loss of control and co-morbidities, like anxiety, depression. This physician participant res ponds with uncertainty, but formulates an educated perception of precipitati ng or predisposing factors. In contrast, two of the physicians declare wi th conviction predisposing risk factors. When Dr. Davis is queried regarding risk f actors he confidently e xplains, I know that depression will be. I will go back to the type of event, how closely it hit home, family or workplace. It will vary for everybody invol ved. This physician participant perceives that the type and size of the event will affect the preparedness and impediments to preparedness. He perceives that all rural inhabitants will be affected by such an event. He further perceives that each rural inhabitant will be affected in a multitude of settings. In essence, rural residents will have their familial life as well as their occupational life affected by such an event. Thus, Dr. Davis perceives that rural residents will be affected socially, emotionally, mentally, and physically by a bioterrorist event. Doctor Jones also discusses risk factors with greater certaint y: If you have anxiety, you will have problems with anxiety. I think that the people that already have a diagnosis will be at risk for worsening. If you have pre-existing mental health condition, th e inherent stress associated with a bioterrorist event will precipitate an exace rbation of your condition.

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126 There are several salient interpretations th at may be formulated from the findings regarding the question of what types of hea lth disorders does a physician anticipate or expect after a bioterro rist attack. This question and the corresponding findings unearth a physicians perception of pending illness and th eir perceived profe ssional preparedness for such as illness. It certainly may be argued based on the findings that after such a traumatic event the number of patient visits to physicians would increase. These patients would explain to the physician that since the event they have been experiencing a constellation of newly-acquired symptoms or an exacerbation of previous medical problems. So, a patient with a previously stable heart condition may react to such a bioterrorist event with incr eased chest pain (i.e., an exacerbation of their medical condition). Or, a patient stab le on medication for generalized anxiety disorder may report increased feelings of nervousness, difficulty performing daily tasks or with general functioning during the day, diffi culty sleeping, or perhaps fe elings of uncertainty and doom which are therefore inhi biting their mental acumen, lifestyle and productivity. Patients may also complain of mental stress coinciding with physical symptoms such as anxiety concomitant with an increased heart rate and labored or di fficulty breathing. Traumatic events are well publicized by the media through sources such as the television, newspapers, the Internet, and myriad other media outlets. Although some rural residents may not have all of these mode s of transmission, most have at least one mode of telecommunication; t hus, the media may influence a nd thereby affect their daily lives. After rural residents obs erve catastrophic events or h ear from media outlets of a possible looming threat of bi oterrorism, it adversely affects their emotional, mental, social, and physical functioning. Conseque ntly, it contributes to patients seeking

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127 healthcare services and the increased patient lo ads at these rural healthcare facilities. Many residents will decide to visit rural health clinics and hospitals to ascertain their own health status in light of such an event. Patients want accurate and reliable information and knowledge, as well as reassurance regardin g their health status and conditions. In this study, the knowledge barriers most ofte n manifested are regarding physicians not being aware or certain of risk factors surr ounding medical and mental health illness in the advent of a bioterrorist agen t. This lack of knowledge by physicians is demonstrated by a lack of cognitive professional preparedness. The knowledge barrier may deleteriously affect medical intervention choi ces by physicians thereby aff ecting their patients health outcomes. Four physicians expected or witnessed an increase in the number of patients visiting healthcare facilities. Doctors Da vis and Jones, unlike some of the other physicians, also explained that there will be an increase in the number of people who think they are infected (i.e., the number of patients who presume themselves to be sick, when in reality they may not be sick). These patients comprise what may be known as the worried-well. Or these patients who pr esume sickness may actually have tangible physical symptoms attributable to a co mmon malady (e.g., a common cold) and yet presume they have contracted some rare infec tious disease reported on the television or in the newspapers that presents with similar symptoms. Thus, these patients may truly believe they have been afflicted with a biote rrorist agent such as smallpox or anthrax. This heightened arousal and trepidation facili tates these individuals to seek medical care and attention and thereby furthe r increases the patient load on rural health clinics and physicians. Many of the physicians expect and anticipate that th e increase in real or self-

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128 perceived medical disorders woul d be contingent on the size of the event and the number of individuals affected by the event. Physician Professional Preparedness and its Associated Elements: Simulation Preparedness, Expectation Preparedness, and Resource Preparedness Simulation experience preparedness and res ource preparedness are other poignant components of physician professional prepare dness. These elements of preparedness were examined and assessed by questions such as, Have you had an opportunity to learn about biological terrorist agents? and, Wh at level of importance should be placed on receiving bioterrorism traini ng? These questions also fu rther divulge an individual physicians expectation preparedness regard ing a possible biote rrorist event. It may be argued that physicians need to be trained regarding bioterrorism as they are trained regarding other me dical conditions. Training should consist of both pragmatic and educational components. Thus, the trai ning should include simu lations and exercise drills depicting mock bioterro rist events. Physicians need to attend continuing medical education seminars which incorporate both a me ntal health and a physic al health didactic component to maintain medical recertification. Lastly, tr aining should include individual studying of peer-reviewed medical journals with occasional examinations for medical recertification. This individual studying will compel physicians to remain aware of disaster preparedness updates a nd to consult with renowned in fectious disease experts at federal centers such as the CDC for salient advice. Doctor Smith explains that he believes that a presentation regarding biot errorism was performed at the health department site, but I didnt get to attend it. He explains that I attended some of the web meetings for the department of health pu t on regarding smallpox and bioterrorism. It has come up in seminars that I have been to for medical educati on in the last couple

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129 years. It may be argued that recently there has been a larger emphasis placed upon bioterrorism training at c ontinuing medical education seminars. These educational seminars are conducted by both state and natio nal medical societies. These continuing medical education seminars typically consist of discussions by renowned medical experts in the medical discipline of infectious di sease sharing information regarding clinical presentation and treatment options for bioterrorist infectious agents. Doctor Smith states that we were involved in the smallpox v accination campaign and we had to make a presentation to the community, to the polic e, to the emergency operations center. Vaccinations for smallpox and bioterrorism presentations performed by physicians benefit local emergency personnel and provide reassurance to the publ ic. This type of local effort certainly can allay fears and concerns among non-medical emergency personnel and among rural residents who may see, hear, or read about such presentations and feel or perceive that their community is prepared for such a catastrophic event. It may also be argued that many physician s now place a greater level of importance on bioterrorism education and training in the aftermath of 9/11 and the subsequent anthrax bioterrorist attacks. When discussi ng the importance of biot errorism training, Dr. Brown states I think that it is. There is ce rtainly a place for it. We all recognize that. It was lower in the list before 9/11. It is the world in which we live in. I think we all recognize that. Do we see anthrax everyday? No, but it does come up. I have never seen a case of smallpox. But, nonetheless, we know what it looks like. Is it something we have studied? No, but we are all aware of it. This physician pa rticipant expresses the sentiment that bioterrorism training is important, but tempers the importance by stating that it is not a pathological c ondition that is seen every day. Doctor Brown also exposes

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130 that many healthcare professionals lack the pertinent information and knowledge regarding bioterrorism. This exemplif ies the knowledge barrier existing among physicians regarding bioterrorist agents. However, he tempers the knowledge barrier by expressing that physicians are aware of biot errorist agents. It may be argued that continuing medical education places a priority on bioterrorism education and training. It is consistently being updated and transmitted to rural physicians. Thus, one may argue a pertinent question is whethe r these physicians are view ing and/or studying this transmitted information. Doctor Brown also exposes the component of physician professional preparedness known as expect ation preparedness. This expectation preparedness is expressed by his perception th at a bioterrorist attack is possible and certainly more possible after September 11, 2001. Thus, although the probability of a bioterrorist-induced illness is significantly lower than the probability of other medical illnesses, it is imperative for physicians to be pr epared for the possibili ty of a bioterrorist event. Doctor Phillips also responded similarly to the other physician participants when she explained of opportunities to learn about bioterrorism through training programs. She explained that she had read medical j ournals on her own rega rding bioterrorism. Doctor Phillips states: A lot of time depending on what the situation or crisis is. They will have issues or discussions about them. When asked if it is important for healthcare providers to receive training regarding bioterrorism, she re sponds, Yes. As the public gets information, if they want information, I am sure their questions will be directed to the health department. It is important for our people to know what information and answers to give. They need to be consistent in information. Th is physician participant

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131 explains the important connection between physic ians and patients. Patients perceptions of their own physical morbidity or morta lity will be shaped by their physicians professional preparedness, or at least by how that patients perceive their physicians preparedness. If a patient perceives a physician as being unprepared for a possible bioterrorist event, it may adversely affect that patients overall health status. Furthermore, if a patient perceives a physicia n as being unprepared, it also may affect whether the patient chooses to comply with the physicians recommendations. A patient may feel that an unprepared physician may e rroneously diagnose their condition and fail to provide the proper treatment. Thus a patients perception of the medical communities preparedness coupled with proper communication and information dissemination is critical to bi oterrorism preparedness. When Dr. Davis is asked about bioterrori sm training services that have been offered, he explains that he has attended lots of them. Doctor Davis articulates we have done some drills. From a bioterrorism standpoint about mechanics of hazmat, we have had classes here and ther e. I will get our pe ople prepared to handle the actual event itself. There are small group discussions. Theres a lot of asking what if, how do we handle such and such? The first wave of people that we will see will be the mental health people. The people who truly have an exposure to the event will probably remain on the scene. Dr. Davis also explains: We did a physician continuing education day with a fair amount of bioterrorism stuff. We we re talking about smallpox and anthrax. In contrast to some of the other physician pa rticipants, it appears that this physician participant feels quite co nfident and well-prepared to respond to a bioterrorist event. He has attended numerous medical and non-me dical educational seminars regarding

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132 bioterrorism preparedness with simulation training involving mock exercises and drills. He further elaborates that there has been significant integration with other emergency county officials during the educational seminars and the simulation training experiences. This physician participant perceives that rura l residents afflicted with mental illnesses will probably be the first to present to the emergency room. One may interpret that patients afflicted with mental illnesses will experience exacerbations of their pre-existing illnesses and thereby deteriorate rapidly during a bioterrorist event. Thus, these mentally unstable patients will present to the emergenc y room for medical care before emergency workers directly involved with the incident. It appears fr om this physician participants perspective that the emergency center is prep ared to handle a major crisis such as a bioterrorist event. Doctor Jones also explains of opportunities to learn about biote rrorist agents. He states: Yes, we have had opportunities. Have we taken advantage of those opportunities? No. The last time we did so mething was two years ago. Unlike other participants, this physician explains that oppor tunities to become better acquainted with bioterrorism have been available, but not uti lized. Thus, it may be interpreted that this physician perceives or feels less prepared for su ch an event. Doctor Jones says it is important for healthcare providers to receiv e training for bioterrorism or other public health emergencies. He explains: relative to other things, a five or a seven [on a scale of 1-10]. Some people would ask why not a ten? Bioterrorist acts may happen and can happen, but the everyday realities of deali ng with peoples problems happen every day. You have so many hurdles to get there that you need to make choices. You need to decide if you are going to trai n on mental health or the in -services you need. We need

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133 and are prepared. This physician percei ves a need for bioterrorism preparedness through education and traini ng but with the caveat that ordinary, common medical complaints are not sacrificed in the priority process. There are difficult choiceschoices between devoting resources to alleviate chr onic medical conditions or to the looming threat of a possible bioterrorist event. Hea lthcare resources are finite and often needed for competing interestsphysic al health maintenance of common medical conditions, or mental health maintenance, or bioterrorism preparedness. Presumably, it may be argued that resources need to be allocated to each of these sectors. However, the proportion of resources devoted to each sector is also importa nt. It may be interpreted that a significant proportion of healthcare res ources should be designated to common medical and mental health conditions. Thus, biot errorism preparedness appears to be lower on the priority list than these other issues. Neverthele ss, despite the limited resources and the conspicuous reality of difficult decisions, it is imperative for physicians to be adequately educated and trained or, in other words pr epared for a possible bioterrorist event. Physician-Patient Related Barriers There are three major physicianpatient related barri ers identified in this study that affect rural physicians professional preparedne ss and their ability to dispense of proper medical interventions to improve rural patien ts health conditions. The physician-patient related barriers include access barriers, communication barriers and knowledge barriers. Access Barriers Several physician participants mention ba rriers that individual s may encounter in accessing medical care to improve health c onditions. Access to healthcare may be thought of as a concept that describes the fit between the patien t and the healthcare system. Access to healthcare may include elements such as affordability, availability,

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134 accommodation, and accessibility. Barriers to accessing healthcare will adversely affect patients entry into or use of the healthcare sy stem and one or more of these elements. There are four types of access barriers discussed in these findings: financial, increased patient load, transportation and resource barriers. Patient financial difficulties are inextricably linked to healthcare access barriers. A rural patients disposable personal income is an important element in determining affordability of healthcare services and subs equently an important determinant regarding personal access of medical care. Doctor Williams explains, Finances become bigger because theyre willing to do it, but they may ha ve a harder time affording it. Taking the costs of medicine becomes a problem. That is a problem with psychiatric medicines, too, but its a bigger problem with physical ones. In essence, patients who wish to adhere to the treatment regimen prescribed by their physician may fail to comply because they cannot afford the cost of their medications. Affordability includes a patients existing health insurance and prescription drug cove rage and the physician s health insurance requirements. Thus, a patient without the ability to pay for healthcare services or a patient without adequate and appropriate h ealth insurance will encounter financial barriers that impede access to healthcare. Doctor Brown mentions that there are so many blocks to access of care. Another example of an access to care ba rrier is an increased patient load. An increased patient load refers to the fact that during a disaster such as a bioterrorist event the perception and expectation is that the number of patient s frequenting physicians would dramatically increase. Consequently, a healthcare facili ty and the associated physicians would be inundated with an increased number of pa tients with actual illnesses and patient-

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135 perceived illnesses. An increased patient lo ad adversely affects both the availability of healthcare services and the accommodation of patients seeking healthcare services. An increased patient load affects the availability of healthcare services by altering the relationship between the volume and type of existing services and resources with the increased patient volume and the increased need s of these patients. The increased patient load would affect the accomm odation of patients by altering the relationship by which the supply of resources is organi zed to accept patients. This supply would be disrupted because appointments would be delayed and hours of operation at the clinic and physician hours would need to increase. In addition, an increased load would affect patients ability to accommodate to these elemen ts as well as the patients perceptions of their appropriateness. Furthermore, whether a bioterrorist event is merely perceived or actually does indeed happen, patients will seek physicians and healthcare which will increase the patient load and consequently diminish access to healthcare physicians and healthcare resources. This may serve to fu rther exacerbate the ot her physician-patient related impediments by augmenting communicat ion barriers and subsequently imposing additional stresses on the rural medical infrastructure. Transportation difficulties and impediments also may be thought of as an access to care barrier. When asked what kinds of th ings can get in the wa y of people accessing healthcare at rural clinics, Doctor Jones expl ains We are seeing that more with the cost of gas. A lot of families have only one vehicle. If dad is at work, the mom may have the child, but there is no way to ge t here. A lot of people around he re also have cars that are older and less efficient. Tr ansportation barriers include issues such as the lack of a reliably performing automobile, or the lack of an automobile entirely, or the prohibitively

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136 high expense associated with gasoline and tr ansportation costs. Doctor Smith explains that My patients cannot get transportation. They have a doctors appointment two months in advance and then their ride falls through and they cannot make it. Consequently, patients facing transportation ba rriers often fail to receive timely and appropriate medical care. Tr ansportation barriers thereby affect the accessibility of healthcare services. Accessibi lity may be thought of as the relationship between the location of patients and the lo cation of physicians and health care facilities. It must account for patient transportati on resources, travel time, distance between the patient and the facility, and cost. Resource barriers are yet another type of access barrier that adversely affect many of the components of access to healthcare services. Resource barriers limit the availability to use the service-producing cap acity of resources. Thus, resource barriers include a lack of medical infrastructure such as a lack of hospitals within close proximity to rural inhabitants, a paucity of adequately trained heal thcare personnel (e .g., generalist physicians, specialty physicians, and nurses) a dearth of medical equipment, and a scarcity of facility exam room s and infectious disease isola tion and quarantining rooms. It may be argued that access to specialty phys icians is especially difficult for rural patients. Doctor Jones explai ns that the most significant obstacle he encounters involving his rural patients is accessing specialty medical care. He st ates Our biggest barrier to specialized care is being able to get people in. Any speci alty care-insurance is a big hurdle. This difficulty in accessing specialty care may be interpreted by a number of different explanations. One may interpret that there is merely a lack of specialty care physicians residing in rural sett ings. Or, it may be that speci alty care physicians are quite

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137 particular regarding what type of health insu rance they accept from their clients. Another interpretation is that specialty care physicia ns may be geographically isolated from rural residents. Thus, it may relate to or further buttress other access barriers such as transportation difficulties. Primary care physicians are considered to be the frontline physicians. Primary care physicians include family practitioners, general internists, preventive medicine physicians, and pediatricians. Broadly sp eaking, all other physicians would be considered specialty physicians. Thus, speci alty physicians would include psychiatrists and infectious disease physicia ns. It can be argued that psychiatrists and infectious disease specialists would assume a greater prominence in the event of a bioterrorist attack. Psychiatrists would be needed to tr eat refractory mental health disorders while infectious disease specialists would be require d to assist with the management of patients afflicted by bioterrorist-indu ced infectious agents. Many of the physicians articulated several of the physician-patient related barriersfinancial, excessive patient load, transportati on, and resourcesthat severely hinder access to healthcare services. In sh arp contrast to each of the ot her physician participants, when Dr. Davis is queried regarding ba rriers to accessing care for his patients, he states I hope not. Insurance status is notwe take ev erything. We pride ourselves on having good access. Unlike the other rural physician partic ipants, one may interpret that Dr. Davis perceives access by patients to rural physicia ns and to the emergency room as open and available. Although Dr. Davi s does temper his comments by stating that he hopes there are not any impediments; he explicitly declares that health insurance is not an impediment. One may interpret that there are limited financial barriers, at least related to

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138 health insurance, because this physician is employed in the emergency room. However, as previously discussed, access is a complicat ed concept that involves myriad elements including financial affordability, patient load and consequent healthcare availability and accommodation, a means to transportation and ac cessibility and resource availability. Thus, in essence, one may interpret that if a patient can physically arrive at the emergency center by some mode of transpor tation then the patient will receive the necessary medical care. Communication Barriers Another set of physician-patient related ba rriers includes communication barriers. There are three types of comm unication barriers identified in this study: social, respect and literacy barriers. Social barriers adversely affect the physician-patient dynamic and include geographical isolation, a lack of tel ecommunication, and a lack of social support. One physician expressed communication barrie rs as presenting an impediment to administering medical care. Doctor Smith states that people who do not have a good support system through communication and people who are more isolated would tend to have more trouble coping with something like th at because they are not able to talk about that as much with others. People in rural areas would have more difficulties with those things. A lot of my patients dont even have telephones. They just see what is in the papers or maybe what they see on the T.V. In rural areas, patients, physicians, and healthcare facili ties may not be concentrated or within a close proximity to one another, which may hinder means of communication. Geographical is olation also may preclude a physician from being able to reach a patient by conventional telecommunicat ion methods such as through the use of telephones, facsimiles, or elec tronic mail. Thus, geographica l isolation may lead to a

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139 lack of timely information which may adve rsely affect a pati ents condition. Geographical isolation can also further affect access barriers For example, geographical isolation may slow delivery of vital healthcare resources or personnel from other clinical sites during a crisis. Thus, geographical di stance and isolation may not only lead to communication barriers, but also contribute to transportation and access difficulties. Social barriers may preclude patients from having a support system (i.e., family or friends) to assist them to emotionally cope w ith stressful events. This lack of a social support system may further adversely affect a patients mental and physical condition. Consequently, social barriers engender feelings of isolation and highlight difficulties encountered among rural residents when th ey attempt to communicate with other community members. It appears that ma ny rural patients encounter numerous social barriers and that these will only worsen in the advent of a bioterrorist event. Literacy and respect barriers also re side under the auspice of communication barriers. Doctor Smith elaborates on barri ers in communication that exist between the physician and the patients by stating that you cant use really big words sometimes. I have had some complaints from patients abou t them not getting it, but not many. It is real important for them not to feel like so meone is looking down at them. Literacy barriers are illustrate d by patients not understanding the medical rhetoric or jargon of physicians. Physicians need to appreciate th at each rural patient has a differing level of education. Some patients may need physic ians to explain medical conditions slowly, repeatedly, or in a simplified and easy to unde rstand fashion. Thus, it is important to evaluate each patients cognitive ability and subsequently convey information in a comprehendible manner. Yet it is equally im portant for physicians to explain medical

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140 terminology and conditions in a respectful fashion to patients. Physicians need to honor a patients autonomy and intelligence. Resp ect barriers involve patients expressing or exhibiting sentiments of resentment if they feel that physicians are disparaging or condescending. If patients feel that the physic ian is talking down to them, they may feel disrespected and this may affect a patient s compliance with medical interventions suggested by the physician. Knowledge Barriers The final type of physician-patient relate d barrier which affects medical care and subsequent interventions to patients is a knowledge obstacle. Knowledge barriers specifically address a physician s knowledge related to biote rrorism. Yet these barriers also adversely affect a patient because if a physician is uncertain regarding bioterrorist infectious agents then the patient may suffe r by receiving the wrong clinical diagnosis or worse yet an improper or unnecessary medical intervention. Such an improper or unnecessary medical intervention may lead to an iatrogenic outcome (i.e., an unnecessary intervention performed by the physician with an adverse outcome de leteriously affecting the patient). Knowledge barriers may also include a physician bei ng unaware or lacking the knowledge regarding the clinical manifestati ons of an infectious bioterrorist agent. This dearth of knowledge may lead to a failure to differentiate a bi oterrorist agent causing an illness from perhaps a more common, yet si milarly presenting infectious illness. Or these knowledge barriers may include a physicia ns lack of knowledge regarding the risk factors or the recent sc ientific research data and the standards of care to employ when treating bioterrorist-induced infectious diseases. Thes e knowledge barriers may also include elements such as a physicians lack of knowledge regarding which expert to contact or consult to discuss cl inical manifestations of a po ssible infectious outbreak.

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141 Each of these knowledge barri ers adversely affects a physic ians acumen and choice of medical interventions and possi bly their patients condition. Several physiciansDoctors Smith, Williams, Phillips, and Brown expresse d knowledge barriers. Doctors Smith and Williams expressed a dearth of knowledge re garding appropriate prevention measures and treatments. These two physicians also ex pressed their lack of knowledge related to recent medical research concerning bioterro rist inducing infectious agents. One physician, Dr. Brown explained that I have never seen a case of smallpox. Several physicians expressed uncertainty regarding ment al health and physical health risk factors for a bioterrorist agent. Every physician participant illustrate d barriers impeding physicians from administering medical interventions to rural patients. Each participant discussed elements such as financial obstacles, increased patient load during a crisis, transportation barriers, and resource barrier s. Notably, one physician, Dr. Davis, employed in the emergency room, commented that his patien ts do not encounter difficulties with accessing healthcare. One physician particip ant discussed communication barriers such as social barriers, literacy barriers, and respect barriers as adversely influencing patient care. Many physician participants commented on their own lack of knowledge regarding bioterrorism-induced maladies, associated risk factors, a nd valid scientific research studies. This lack of knowledge poses a formidable barrier to both medical or professional preparedness and medical inte rventions. If rural physicians lack the necessary knowledge regarding bioterrorism, it will affect their perceptions of their personal preparedness and consequently may aff ect their actual preparedness. This lack of knowledge perception may also be obser ved by their patients. Or, it may be

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142 unintentionally conveyed by physicians to thei r patients. Thus, patients then may perceive a greater sense of their own morbid ity and possible even their own mortality. This perception by patients will probably affect their patient condition. It may cause an exacerbation of a previously stable mental il lness or a worsening of a chronic physical illness. These exacerbations will delete riously affect patients physical, mental, emotional and/or social states or conditions. It also may adversel y affect how a patient interprets a physicians medical interventional advice. If a patient perceives that a physician is ill-prepared for a catastrophic even t he/she may lose faith in the physicians assessments or recommendations regarding trea tment. Consequently a patient may fail to comply with the interventional regiment outlined by the physician thereby further adversely affecting their health condition. Ideally, if there were not any barriers with in this catastrophic event context, there would be substantial overla p between both the spherica l line surrounding physician perceptions of preparedness a nd the spherical line surroundi ng patient perceptions of mortality and morbidity. Presumably, a phys icians perception of his/her preparedness for a catastrophic event would more closely coincide w ith a patients perceptions of his/her own morbidity and mortality. So, physician professional preparedness and medical interventions to facilitate impr ovements in patient conditions would be unhindered. This would presumably lead to an improved physician-patient dynamic and contribute to considerably more ideal and successful medical interventions and health outcomes. Medical Interventions Each physician was also asked what they pe rceive to be the best treatment options for patients following a bioterro rist attack. These questions not only examine appropriate

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143 medical interventions, but they also fu rther expose a physic ians professional preparedness and the associated elements. Medical interventions may include pharmaceutical treatment, counseling ther apy, preventive therapy, or medical recommendations. The principal objective of medical interventions is to improve the patients health and condition. Thus, specifi c questions addressing medical interventions focus on the tasks performed by the physician to ameliorate patient suffering following a catastrophic event. Each phys ician was questioned regarding what immediate steps could be performed after a bioterrorist event a nd how would a physician monitor a patients mental health and medical care following a bi oterrorist attack in the longer term. Medical interventions often bridge the important connect ion between the physician and the patients health condition. If a patie nt perceives a physician as unprepared for a bioterrorist event, it adversely affect s a patients compliance with the medical interventions outlined by the physician. Th is lack of preparation by the physician may manifest to patients as the physician lacki ng knowledge regarding bioterrorist-induced agents or as the physician lack ing pertinent or timely inform ation regarding a catastrophic bioterrorist event. Mental Health Interventions Several physician participan ts acknowledged that counse ling should be the salient method of mental health intervention. Doctor Phillips explains that the best treatment options following a bioterrorist attack would be: counseling, on a long term basis. She states that it depends on how much understanding you have about the situation. Several of the physicians also expressed sentiments of sensitivity to the pa tients symptoms and condition. When asked regarding steps to mon itor patients in the weeks or months that follow an attack, Dr. Phillips responds, It depe nds on what kind of bioterrorism attack is

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144 there. A lot of it would be reassurance. If you do not have these symptoms chances of you getting sick is less. A lot of them w ill have a fear of dying. This physician participant also expresses the common theme that the type of bioterrorist agent is especially important. This sentiment was expressed by many of the physicians when questioned regarding how to prepare for physical health problems that may be encountered following a bioterrori st event. This physician also expresses that the type of infectious agent is important with regards to medical intervention as well. Doctor Williams responds, I guess education. Just let them know it is a tough time and its stress on people and response to that stress on people ca n get them mentally out-of-shape. And, theres help if they need it. And, ther es nothing wrong with them if they are having responses they dont understa nd. Although this physician expresses a sentiment of uncertainty, he also expresses sensitivity and empathy to a patients symptoms and condition. These are examples of physicians whose profes sional preparedness can allay mental stressors and assist in mitigating a patien ts symptoms and deteriorating condition. It may be argued that prevention is a n ecessary tenet of emergency bioterrorism preparedness. Prevention may include resour ces such as vaccines, isolation rooms, and educational literature regarding bioterrorist agents. One phys ician expressed the need for prevention as a method of physician medical in tervention preparedness for a bioterrorist event. Doctor Williams states that acute intervention is very important. There is also bound to be some preventative stuff that can be done. I dont know what it is, but I bet someone has a darn good idea. Wed try to look at what can be done. Im sure something can be done that would diminish th e impact and diminish future problems, but I dont know what those approaches would be. This physician participant articulated the

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145 importance of acute and rapid interventi on and prevention as a method of physician preparedness, but with uncertainty regard ing what prevention was needed to avert bioterrorism-induced illnesses. This is an exemplifi cation of a knowledge barrier regarding medical intervention. Thus, it may be argued that rural primary care physicians need advice from infectious disease me dical specialists regarding the preventive measures and treatment interventions need ed to improve patients mental health conditions. Doctor Williams also expressed that he would monito r a patients mental healthcare in the weeks or months following a bioterrorist attack by asking about it much more. This conveys the elements of cognitive and expectation preparedness on the part of an astute physician. Such an astute physician is one who will assist patients in feeling at ease when discussing their symp toms after a catastr ophic event. When patients feel comfortable and witnesses the compassion and sensitivity of the physician, they are more apt to discuss mental h ealth symptoms related to an event. Doctor Smith articulates the need for c ounseling intervention by stating: We can have an open house to talk about it, have a group therapy. Talk on the telephone might work. Sending letters to the ones, but some cannot read and some cannot read well. This physician participant expr esses some of the communicati on barriers that adversely affect the physician-patient dynamic in rura l settings. Consequently, many medical interventions may be impeded by lack of te lecommunication methods. Patients in rural settings may not have telephones or may not be literate. Furthermore, mailing letters may delay treatment options for patients who n eed expedient medical care and counseling. Doctor Smith explains that post-9/11, When th ey came out to talk about it, we would try to make sure that they were knowledgeable abou t whats happening. If they have lots of

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146 facts, its going to ease their mind and then we try and answer their questions. In rural areas, there are lots more isolation, lots more barriers to communication. One person communicating to a mass audience is very difficult. It is not real feasible. This physician participant explains post-Septem ber 11, 2001 there were open dialogues with patients despite physician-patient related barriers such as knowl edge and social barriers. This doctor explains that he lacks the knowledge of how to communicate regarding a catastrophic event to a large number of ru ral residents within a rural context. Geographical isolation is yet another type of communication barrier that affects social relations. It can adversely affect medical interventions because of the difficulty in disseminating information and knowledge. Ge ographical isolation also precipitates access barriers such as transportation difficulties. This is because many patients do not possess automobiles or cannot affo rd gasoline to drive their au tomobiles. These barriers impede physician-patient enc ounters and hinder the medical interventions suggested by the physicians for their patients. Mental and Physical He alth Interventions Chronic physical health maladies may cau se mental health symptoms such as anxiety and depression. Moreover, mental health maladies like chronic stress may precipitate organic illnesse s. Two physicians introduce an important and distinct corollary regarding treatment. Medical interventions should include treatments targeted at both the mental and physical health stat us of a patient. Although each of these physicians maintains that counse ling is the integral treatment component of mental health disorders in the advent of a bioterrorist even t, both physicians believe that an integration of mental healthcare with medi cal care is vitally important. Thus, interventions should consist of simultaneous treatm ent by the primary medical care physician coupled with the

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147 mental healthcare physician to improve the patie nts overall condition. Doctor Brown, similar to other colleagues, explains that following an attack the best treatment option would be one-to-one and group counseling. Access to mental health counseling is extremely important. Dove-tailing that w ith discussion with and treatment by their primary care physician is also very important And, integration of their primary care provider with the counseling. He further explai ns that the first step is reassurance that this is what is going on and that there are some stable things here. I think that medication can be important. Thus, this physician expr esses that counseling, medications and other relevant physical interventions should be inte grated. In a similar fashion, Doctor Jones explains when asked about treatment options for mental disorders fo llowing a bioterrorist attack that I think counseli ng is our only choice. You have depression and anxiety after an attack. He further comments when asked regarding steps to monitor a patient after an attack, It has to be on the forefront. You ha ve to have a screening question. You have to look at blood sugar, blood pressure, anxiety, depression. It will worsen all of them. Stress itself is not healthy for the body. A sc reening question is imperative to divulge a possible mental health disorder. Screening que stions may assist in revealing depression, substance abuse, anxiety, a nd other conditions. They often open the door for a dialogue regarding symptoms and reassurance. It is also important to orde r laboratory assays to examine pertinent physiological parameters (i.e., blood sugar and blood pressure) which are essential to expose the physical status component. Physiological parameters may reveal an underlying disorder su ch as diabetes or hypertension An integration of mental and physical health components may lead to improved medical interventions and corresponding patient conditions.

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148 Physical Health Interventions Many physician participants be lieve that the manifestati on of physical symptoms is highly contingent on the infectious agent. Consequently, medical in terventions would be dependent on the physicians knowledge, experience, the type of infectious agent, and the presenting signs and symptoms of the patient When Dr. Williams is asked regarding treatment options of patients with medical conditions, he responds Whatever experts recommend. Id have to look up and see what theyd say which symptoms merit what treatment and who to monitor. This high lights the knowledge barri er which has also been expressed by several other physician pa rticipants regarding medical management and treatment. Yet, in contrast with some of the other knowledge impediment explanations, this quote expre sses a different sentiment. This physicians comments may be interpreted as an individual who does i ndeed lack sufficient knowledge, but would be willing to learn from other medical experts and use the pertinent information during an incident. Physicians need to anticipate possible infectious agents, be aware of pending patient signs and symptoms and be pr epared to conduct appropriate medical interventions. Doctor Phillips mentions that to assist a patient on a long-term basis after a bioterrorist attack that you w ould have a whole list of things to keep an eye out for. This exemplifies the vast number of ment al signs and physiological parameters that necessitate careful monitoring. This reinforces several of the important elements of perceived emergency bioterrorism prepare dness: a physicians sensitivity to patient symptoms, cognitive preparedness and expectation preparedness. Doctor Davis explains, If an event occurr ed then the people we see in the ER for chest pain, nausea, headaches, those would have to be looked at in a different light. You

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149 just dont know where that is coming from. We would rely heavily on family practices in the area. We may see a lot of people that ma y have work-related inju ries. They may not be sleeping well. In contrast with other participants, Dr. Davis explains that common physical symptoms may be deri ved from an underlying mental disorder. They may be manifestations of acute mental stress or precipitated by a bi oterrorist agent that induces respiratory or gastrointestinal symptoms He also comments regarding the unknown source. One may interpret this statement as testimony that this physician is cognitively prepared and at least would perceive or anti cipate the possibility that a patient presenting to the emergency room may have been expos ed to a bioterrorist-induced infectious disease. Resource preparedness is essent ial and the emergency room would depend on local family practitioners for assistance and po ssibly information relate d to a bioterrorist event. Patients may not be sleeping probabl y because of the impos ed mental stress and anxiety of such an event. This overwhe lming anxiety and distre ss would probably lead to an increased number of patients presenting to healthcare facilities and a worsening of physician-patient related barriers. In summary, each of these physician participants explai ns that counseling therapy would be the best option for mental health diso rders. Prior to such therapy, a screening question should be required to divulge the underlying anxiet y, fear and stress followed by a discussion elaborating on the magnitude and the type of bi oterrorist event. The treatment would require physicians providing reassurance during the counseling sessions and possibly medications to select patients. The principal objective of the counseling is to allay patients mental and emotional st ressors. However, three of the physician participants mention the importance of integration between the mental health intervention

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150 components and the physical health components. This integration between the mental health practitioner (e.g., psychiatrist) and the primary care physician is important to improve the patients overall health condition. So treatment should include therapeutic medications if physiological he alth parameters are abnormal following laboratory assays performed by primary care physicians. Thus, this cross-referenci ng of healthcare to encompass the physical, mental and emotiona l health components can assist with the overall medical interventions to thereby improve both the immediate and the long-term condition of the patient followi ng a bioterrorist event.

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151 CHAPTER 5 DISCUSSION AND CONCLUSIONS This chapter includes a discussion of the salient themes emerging from this study along with their health policy implications. The chapter is organized in the following fashion. First, there is a recapitulation of the problem and the corresponding research inquiry rationale is discussed. Next, study findings are interp reted and discussed in terms of three principal discussion poi nts. This is followed by impl ications and possible health policy intervention options. Chapter five concludes with suggestions for future research. Salient Points for Discussion The principal objectives of this study are to provide a more thorough description and understanding of rural physicians perceive d preparedness regarding public health emergencies such as bioterrorist events th an those published previously. Two specific research questions we re addressed: What is the perceived bioterrorism preparedness among rural physicians? How do the perceived impediments hinde r rural physicians preparedness? The study addressed these research questi ons through the use of semi-structured interviews to elicit detailed information re garding perceived biote rrorism preparedness among rural physicians. Preparedness was unearthed by questioning rural physicians regarding components such as the physical and mental heal th signs and symptoms and the risk factors most likely to be enc ountered, as well as the possible corresponding therapeutic medical interven tions. Upon examination of these components a more complete picture of perceived bioterrorism preparedness is formulated. Perceived

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152 preparedness also was examined by queryi ng physician participants regarding the importance that each physician placed on bioter rorism education and training, as well as from the perspective of the availability of bioterrorism training and educational opportunities. Few studies prio r to the current research had examined any components related to bioterrorism prepar edness (Gershon et al., 2004). T hus, the findings from this study should provide relevant in formation to researchers part icularly in the areas of health services research, health policy and rural medicine concer ned with catastrophic events and bioterrorism preparedness and the perceived impediments preventing appropriate preparedness. The principal findings emerging from this study may be summarized as follows: 1. The rural physicians do not perc eive themselves as medically or professionally prepared for a bioterrori st event from several perspectives. The clinicians perceive themselves as unprepared in five specific facets: cognitive preparedness, clinical prep aredness, expectation preparedness, simulation preparedness and resource preparedness. 2. The rural physicians perceive th e rural healthcare system as being unprepared. It is perceived that sy stem preparedness has two principal elements: providers and patients. Providers link thei r own lack of bioterrorism preparedness to the over all rural healthcare systems lack of clinical preparedness. This link be tween rural physician preparedness and system preparedness entails limitations on the number of available physician specialists, hea lthcare facilities, and a lack of timely and effective communication to be prepared.

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153 3. The second part of rural healthcare sy stem preparedness involves patients. The patient aspect of system prepar edness includes the rural patients and their access to trans portation, their fiscal capacity to pay for medical care, their knowledge about their own need s, and their confidence in the medical professionals. Each of the above points will be discussed in greater detail below. Key Findings Regarding Rural Physic ians Professional Preparedness A significant finding emerging from this study was the lack of professional preparedness among rural physicians. Previous literature had shown that physicians felt better prepared to respond to other disasters such as natural disasters and infectious disease outbreaks than to bioterrorist events (Alexa nder & Wynia, 2003; Chen et al., 2002). It had also been shown in previous re search that community clinicians are often the first to identify potential bioweapon victims; yet they we re inadequately prepared from a clinical perspective to address such events (Mc Fee, 2002; Pesik et al., 1999; Sniffen & Nadler, 1999; Varkey et al., 2002). One previous research study demonstrated that the current generation of physicians pe rceived themselves as being unprepared in their knowledge base and with re spect to their confidence leve ls to deal with potential biological terrorism and its conseque nces (Rose & Larrimore, 2002). According to the findings reported in this study, it appears that rural physicians do not perceive themselves to be fully prepared for bioterrorist events on several fronts. By describing rural physicians perceived prof essional medical preparedness on these dimensions, the study elaborated on curre nt understanding while providing new knowledge of nuance and detail.

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154 Medical or professional preparedness was ex amined from the elements of cognitive preparedness, clinical prepare dness or sensitivity to patient symptoms and/or conditions, expectation preparedness, simulation prep aredness, and resource preparedness. Cognitive preparedness encompasses the physicians scientific and educational knowledge, as well as analyti cal reasoning acumen. Cogniti ve preparedness involves a physician being able to discern between clinic al manifestations of medical infectious disease conditions related to a bioterrorist agent such as smallpox or anthrax and the common and, yet often similar, symptoms of other infectious illnesses. Clinical preparedness involves a physicia n being aware, sympathetic, em pathetic, and sensitive to patient symptoms along with the corresponding ove rt and covert medical signs if such an event has occurred. Expectation preparedness is similar to cognitive preparedness, particularly with respect concerning the n eed for mental keenness and awareness. A physician must anticipate the possibility of a catastrophic event such as a bioterrorist event as realistically feasible and consequently be prepared professionally for such an event. So, expectation preparedness involves a physician not only anticipating, but also accepting, the reality that a bioterrorist attack may indeed occur within his/her geographical area. Simulation preparedness involves the actua l training pertinent to bioterrorism. Simulation training includes relevant training drills a nd mock exercises depicting possible bioterrorist scenarios. Simulati on preparedness may also involve educational clinical training through contin uing medical education preparat ory seminars, as well as individual directed study lear ning by physicians through the r eading of pertinent medical journals. Resource prepare dness involves a rural physicia n believing there are ample

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155 healthcare resources in the rural community at his/her disposal. More specifically, it involves rural physicians having the percep tion that there will be enough access to healthcare facilities such as clinics, priv ate medical offices, and hospitals, as well as enough healthcare practitioners available to respond during a biote rrorist attack. Physician participants expre ssed a lack of bioterrorism preparedness along all five of these dimensions. The rural physicians in this study expressed that their perceived professional preparedness was hi ghly dependent on the type of bioterrorist agent involved in the catastrophic event. They expressed that they felt or perceived themselves as being especially unprepared regardi ng the signs and symptoms of sp ecific bioterrorist agents. For example, research participants indicated th at they were not sure they would recognize the signs and symptoms of a biot errorist induced infectious di sease if faced with a patient who had been exposed. Furthermore, responde nts articulated that they felt unprepared regarding relevant risk factor s and appropriate medical inte rvention options for patients afflicted by bioterrorist-induced infectious agents. For instance, rural physicians indicated that they were uncertain of risk f actors. The participants expressed a need for greater overall cognitive and c linical preparedness. In essence, the findings demonstrate that rural physicians in th is study were unaware of the pertinent mental and physical health signs and symptoms of bioterrorist-inducing agents, the relevant risk factors, and the appropriate treatments. This lack of knowledge was particularly evident with reference to physical health symptoms, risk factors, and therapeu tic interventions. The participants did express some confidence that patients afflicted with pre-existing mental and/or physical illnesses w ould presumably suffer from an exacerbation of their conditions.

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156 Rural physicians described their individua l expectation preparedness regarding the likelihood that a bioterro rist event would occur as low or not deeming immediate priority relative to the degree of other medical illnesses. They simply did not believe that a bioterrorist event was as likely as many ot her contingencies that they considered comparably important. This finding of low expectation preparedness among rural physicians is worrisome because professiona l preparedness requires an ever-present anticipation of the possi bility of such an event transp iring. A physicians anticipatory behavior regarding any medical condition, common or uncommon, is essential to medical preparedness. Thus, physicians who perceive the threat of bioterro rism as a distinct possibility will presumably devot e greater attention to detail and remain more clinically astute, presumably resulting in better profe ssional preparedness. Rural physicians further explained that although simu lation exercises and corres ponding training opportunities existed, few had availed themselves of thes e endeavors. This consequence may be attributable to the low expectation prepar edness. The last element of professional medical preparedness involves rural physic ians perceptions of their resource preparedness. A dearth of supportive res ources, specifically a lack of specialty physicians, was cited by the rural physicians. In fact, this paucity of specialty physicians was perceived by one participant as the most significant barrier affecting professional preparedness and presumably hindering patient access to the medical services that might be necessitated by a bioterrorist event. Thus the rural physicians in this study felt less than fully prepared professionally, intellectually, and pragmatically for a bioterrorist event.

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157 A few previously published reports provi ded evidence of knowledge gaps, as well as a high level of interest in bioterrorism-related trai ning among physicians (AMA, 2001; Heun, 2002; Sigmon & Larson, 2002). Previous research also demonstrated that when physicians are provided continuing medi cal education and training regarding bioterrorism, they perceived themselves as be tter prepared to respond to a public health emergency such as a bioterrorist attack (Alexander & Wynia, 2003; Chen et al., 2002; Cherry et al., 2003; Croasdale, 2002; Ge rberding et al., 2002; Gershon et al., 2004). Physicians in this study stressed the importance of, as well as the need for continuing medical education seminars and si mulation preparatory tr aining related to bioterrorism. Moreover, the physician part icipants described numerous available opportunities to become better educated regardin g bioterrorism agents. Yet, despite these educational opportunities, the rural physicians in this st udy expressed that they often did not attend the seminars. Thus, this st udy has discovered that although there are knowledge gaps in physicians bioterrorism education and training, these gaps are attributable to a significant degr ee to their personal choice an d discretion. Interestingly, the rural physicians in this study expressed an interest in appearing prepared or in being perceived by others as bei ng prepared. This seemingly paradoxical finding presumably indicates that rural physicians perhaps do not have as high a le vel of interest in actually participating in bioterrorism training and education as they profess or as other previous studies (Alexander & Wynia, 2003; Chen et al., 2002; Heun, 2002; Sigmon & Larson, 2002) have documented. Previous studies (Blair et al., 2004; McHugh et al., 2004), along with preparedness-funding directives, have been focused predominantly on urban areas and physicians and not on rural areas or rura l physicians. Thus it may be as one rural

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158 doctor in this study explained th at rural physicians are motivat ed to attend bioterrorism preparedness educational seminars, but they d eem seminars pertinent to other facets of their practice as more important Rural physicians may believe that a bioterrorist event has a greater likelihood of occurring in an ur ban area. Consequently, rural physicians have chosen to instead attend medical educ ation seminars highlighting more-commonly encountered medical conditions. The findings of this study suggest that rural physicians believe it is important to be prepared for a possible bioterrorist event, but not at the expense of being prepared to prevent or respond to more common illnesses and more likely events. In contrast to the other rural physicians in this study, one physician participant expressed the perception of fee ling quite prepared for a biote rrorist event. This doctor explained that part of his employment duties included attending county emergency preparedness meetings and educational semi nars. As a consequence, this physician participant felt more prepared than others because he had not onl y requested additional educational opportunities, but he had act ually attended numerous medical and nonmedical educational seminars, met with county emergency officials, and participated in numerous small group discussions regard ing bioterrorism preparedness. Health Policy Options and Implicatio ns Regarding Physician Preparedness Health policies include decisions made by different levels of governmentfederal, state and localwhich affect or influence groups or classes of individuals (such as physicians, rural inhabitants) or types or categories of orga nizations (such as hospitals, health departments, and rural healthcare clinic s). Health policies may take any of several forms. Some policies are decisions made by le gislators that are codi fied in the statutory language of enacted legislati on. Others are the rules a nd regulations established to

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159 implement legislation or to operate government. Still others are judicial decisions related to health. All of the various forms of health policies fit into one of two basic categoriesallocative or regulatory (Longest 2001). Allocative policies are designed to provide net benefits to some distinct group or class of individuals or organi zations, often at the expense of others, in order to ensure that the public objectives are met. Such policies, in essence, are mechanisms through which po licymakers seek to alter demand for or supplies of particular products and services or to provide access to products and services for certain people. Regulatory policies are de signed to influence the actions, behaviors, and decisions of others through directive approaches. The government establishes regulatory policies for the purpose of ensuring th at public objectives ar e met (Longest). This study substantiates that there appears to be a signifi cant need to take additional decisive steps that are more effective than the current strategies to encourage rural physicians to improve their bioterrorism pr eparedness. One important device for such improvement is continuing medical education. This study demonstr ates, however, that the simple existence of such educationa l opportunities is not sufficient to induce participation. According to the findings from this study, there appears to be a perceived demand among rural physicians for improve d bioterrorism preparedness knowledge, specifically regarding the pertinent signs a nd symptoms, the associ ated important risk factors and the possible therapeutic medical interventions of infectious bioterrorist agents. Thus, this studys findings and the id entification of this problem suggest there should be an emphasis on improving the linka ge between education, training, and research in bioterrorism disaster preparedness.

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160 Academic training programs should be de veloped which recognize the importance of disaster mental and physical health. The scientific and medical knowledge base regarding mental health need s greater attention, inquiry, and research. Providers of continuing education should offer increased opportunities in human-induced disaster preparedness. Medical profe ssionals involved in providing h ealthcare services in humaninduced disasters should broadly disseminat e and publish their pragmatic experiences while also providing careful attention to the id entification of areas where further research is needed. Following the identification of policy op tions, it is important to consider implementation methods. It may be particul arly valuable to explore the option of providing financial incentives to rural physicians to in crease and facilitate their participation in bioterrorism preparedness programs. Yet it may also be argued that financial resources would be better served if applied to other endeavors such as improving rural technological infrastructure ra ther than to encour age participation in preparedness seminars among rural physicians. A different implementation option may include focusing on altering physician behavior. Such an option may involve a di rective through the use of a state imposed regulatory policy. The implementation of su ch a regulatory policy may lead to improved bioterrorism preparedness among physicians. An educational directive involving bioterrorism preparedness could be inco rporated into both medical school academic curricula and residency training programs to encourage assimilation of pertinent preparedness knowledge among young physicians Although it is a more stringent solution than voluntary physician participation with financia l incentives, another state

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161 imposed regulatory policy could be applied to community physicians. Such a policy might require participation among practicing rural physicians by ma ndating bioterrorism preparedness continuing medical educati on seminar completion as a contingency to procuring medical licensure recertification. This would increase a physicians professional knowledge base, training experi ences, and clinical preparedness. Consequently, rural physicians would be prep ared, would perceive themselves as being better prepared, and would be perceived by others as better prepared. Key Findings Regarding the Rural Healthcare Systems Preparedness Another salient theme emerging from this st udy involves the clini cal aspects of the healthcare system. The findings of this st udy suggest rural physic ians perceive the overall clinical healthcare system as unprepar ed for a bioterrorist event and they believe the rural segments of that system to be especi ally unprepared. It is perceived that system preparedness has two principally linked elem ents involving both physicians and patients. Physicians appear to link their own lack of bioterrorism prep aredness to the overall healthcare systems lack of preparedness. This perceived link between rural physician preparedness and the components of sy stem preparedness entails two salient impediments. The perceived system barrier s confronting rural physicians hinder them from feeling prepared. Furthermore, the findi ngs reported in this research also revealed that rural physicians believe that these pe rceived barriers will hinder their professional preparedness by impeding their capacity to de liver appropriate medical care interventions intended to allay patient suffering. This perception that the system is itself unprepared is principally centered on the findings expressed by the rural physicians re garding the need to address healthcare system impediments to the effective delivery of care. The impediments identified in this

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162 study include the lack of health care resources and dearth of effective and efficient means of communication. More specifically, the ru ral physicians cite a need for increased clinical healthcare resources such as a dditional primary care physicians, specialty physicians (i.e., mental health and infectious disease specialists), a greater number of nurses, and more healthcare clinical facili ties adequately equippe d with isolation and infectious disease quarantining space, along w ith additional laboratories and equipment. The physicians also perceive inadequa te telecommunication technology as an impediment to system preparedness and their pr ofessional preparedness. It is particularly interesting that participants in this study appear to believe that if there were additional clinical resources then merely the increased volume of healthcare re sources would in and of itself result in better prof essional preparedness. Yet none of the rural physicians seem to acknowledge that many of these increased re sources may sit idle in the absence of a bioterrorist event. Nevert heless, the talents and abilities of a suitable healthcare workforce cannot be overestimated in assessing preparedness. An adequate healthcare workforce constitutes one of the basic resources needed to provide health services. The rural physicians in this study commented that the perceived resource barriers served as impediments to their professional prepar edness. According to the findings in this study these perceived impediments would adversely affect patient access to care. The individual components comprising access to healthcare have previously been explained by Penchans ky (1981) as availability, accessibility, accommodation, affordability, and acceptability. Availability is used by Donabedian ( 1973) to refer to the service-producing capacity of resources. Resource barriers may involve a lack of medical infrastructure

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163 such as a lack of hospitals within close proxim ity to rural residents, a lack of adequately trained healthcare personnel (e.g., generalist physicians, specialty physicians, and/or nurses), a scarcity of clinical exam rooms, a dearth of needed medical equipment, and/or a paucity of infectious disease isolation and quarantining rooms. Physician participants mentioned concerns regarding each of thes e components. This study was focused on the immediate concern regarding the perceived cu rrent state of rural physician preparedness given the existing leve l of resources. Yet, it appears from this study that the rural physicians link their professional and clinical bioterrorism preparedne ss to the healthcare systems preparedness and the available supply of healthcare resources. Health Policy Options and Implicat ions Regarding System Preparedness The rural healthcare systems infrastruc ture faces major challenges today. The September 11, 2001, terrorist attacks and th e dissemination of anthrax in the United States subsequently imposed even greater expectations and burd ens on rural healthcare systems and their associated elements (i.e., f acilities and physicians) to develop expanded emergency response systems. This increased burden has been further exacerbated by the known critical shortage of hea lthcare providers in rural area s (Escarce, Polsky, Wozniak, and Kletke, 2000; Knapp & Hardwick, 2000; Seago, Ash, Spetz, Coffman, and Grumbach, 2001). If bioterrorism response serv ices are to function optimally the structural aspects of the healthcare system should be examined. There appears to be a need for stable organizational and political structures to suppor t and nurture preparedness initiatives. In the past, scant support has been provided to rural public health emergency preparedness efforts. National efforts operate through the states, and state offici als often have many competing priorities. Unfortunately, unless a state experiences the threat of frequent

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164 disasters, planning and preparedness for su ch public health emergencies is often an ancillary consideration. According to a repor t released from Trust for Americas Health (TFAH), the state of Florida was one of only tw o states to achieve a score of nine out of ten regarding state public health preparedness for bioterrorist atta cks and other health emergencies (TFAH, 2004). It appears that Floridas previous experience with natural disasters, or more specifically hurricanes, may have also assisted with the states bioterrorism preparedness efforts. The TF AH report and the increasing threat of humaninduced disasters, suggests that there should be greater atte ntion devoted to state public health emergency preparedness along with a renewed emphasis on rural health policy priorities. The findings of this study would subs tantiate that state governments should consider employing both alloca tive and regulatory policies to assist rural healthcare systems in their overall preparedness for bi oterrorist events. State governments might also employ regulatory policie s as a method to assist with the removal of extant impediments to thereby assist rural physicians to become better prepared or at least to perceive themselves as being better pr epared to combat bioterrorist agents. Organizations funding bioterrorism and human-induced disaster research should place a high priority on proposals seeking to ex plore topics related to preparedness and prevention. Organizations funding disaster preparedness research should encourage research into the efficacy of various disaster mental health interventions and into the evaluation of disaster servi ce programs. There appears to be a need for sound applied research and program evaluation to assess th e efficacy of various medical interventions that are possible responses to various bioterrorist agents. Federal, state and local

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165 organizations involved in providing services in huma n-induced disasters should disseminate and publish their experiences indi cating where additional research inquiry is needed. Additionally, health po licies imposed by the state gove rnment can effectively alter the provision of resources by increasing financing mech anisms and increasing the number of healthcare personnel. A stat e policy response may include additional investments in the form of financial incen tives provided to public medical schools and residency programs when their medical gradua tes agree to practice in rural areas for a specified duration of time. Such an incentive laden reward program would stimulate medical school institutions and academic medi cal centers to promote rural health to young physicians. An alleviation of health care resource barriers would presumably improve rural physician preparedness, as well as facilitate improved medical interventions and health outcomes. Furthermor e, it may be argued that if physicians feel better prepared professionally then they w ould presumably know which additional healthcare resources would be mo st applicable for bioterrorism preparedness. Policies also should be directed toward improving the technological means of communication in rural setti ngs. Technology may be thought of as the application of science to the pursuit of health. Technologi cal advances result in better methods of communication (e.g., Internet scientific and clinical updates, e-ma ils, telemedicine). However, large capital investme nts would be required to crea te rural healthcare system information technology. Moreover, widespr ead adoption of information technology may require behavioral adaptations on the part of physicians and organizations. Nevertheless, funding for the research and development that leads to informational technology

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166 advancements is an important way that health policy can affe ct the pursuit of preparedness. Communication barriers as a re sult of geographical isolation were cited in this study as an obstruction to pe rceived medical preparedness. Improved or unencumbered communication would facilitate the dissemination of applie d knowledge, experience, and information. The principal methods to improve communication should focus on improving access to the Internet, as well as en couraging professional consultation. The Internet can be used to impr ove preparedness by utilizing app lications such as incident reporting, videoconferencing among public he alth officials during bioterrorism emergency situations, epidemiology and diseas e surveillance, and de livery of alerts to rural physicians. Moreover, Internet access along with national consultation can help mitigate communication barriers by enabling the sharing of medical specialists thoughts, experiences and wisdom with rural physicians to thereby further expand their knowledge base. Thus, improved information technol ogy and the concomitant expanded means of telecommunications represent an importan t healthcare resource investment that presumably would have a significant impact on rural physicians preparedness and on the rural healthcare systems preparedness. Key Findings Regarding Physician Perceptions of Rural Patient Factors Another important theme emerging from th is study involves th e rural physicians perceptions regarding the non-cl inical aspects of the health care system. This may be classified as the second part of the rural healthcare system prep aredness and it includes the perceived link between the sy stem and patients. The patient aspect of this link with system preparedness involves the rural physic ian participants per ceptions of the rural patients. More specifically this aspect includes the phys icians perceptions regarding

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167 their patients accessibility to transportation, their capacity to pay for medical care, and their perceived confidence in me dical professionals. The ru ral physicians of this study viewed these non-clinical dimensions as impediments to preparedness. However, additional inquiry is warranted because it is not clear from this study whether this view represents concerns about th e current situation or some notion that these non-clinical dimensions would be altered in the event of a bioterrorist attack. An important determinant of health prepar edness is the availab ility of and access to health services. Health serv ices can be preventative, acute, chronic, restorative, or palliative in nature (Longe st, 2001). The production and dist ribution of health services require a vast set of resources including finances, people, and technology. Health services are provided through th e healthcare system, which is composed of organizations that transform these resources into health serv ices and distribute them to patients. The findings of this study exposed rural physicians perceptions of the impediments that are imposed by the rural healthcare system on patients. These impediments limit rural patients access to care. Thus the physician participants expressed access (e.g., financial or means of transportation) as a formidable perceived impediment to both system and patient bioterrorism preparedness. Access may be thought of as a general c oncept that summarizes a set of more specific dimensions describing the fit between the patient and the healthcare system (Penchansky, 1981). Access barriers preclud e physicians from administering salient medical care and appropriate interventions to patients. As noted by Penchansky, the specific dimensions of access include: a ffordability, availability, accommodation, accessibility, and acceptability. This study demonstrated that rural physicians perceive

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168 access barriers will adversely affect rural pa tients entry into or use of the healthcare system along one or more of these dimens ions. Freeborn and Greenlick (1973, p 68) seemingly refer to a number of these dimensions when describing access, such as accessibility, accommodation, and availability, when they say that individuals should have access to the system at the time a nd place needed, through a well-defined and known point of entry. A comprehensive range of personnel, facilities and services that are known and convenient should be availabl e. These five dimensions represent closely-related phenomena which explain why they have been seen as part of a single concept: access (Penchansky). Rural physicians expressed financial barrier s or the lack of affordability as a perceived impediment to bioterrorism prep aredness. Fein (1972) emphasizes personal income as a key to affordability and as a major determinant of access to care. Affordability is the relationship of prices of healthcare services and physicians insurance requirements to the patients income, ability to pay, and existing health insurance (Penchansky, 1981; Bice, Eichhorn, and Fox, 1972). Availability may be defined as the relationship of the volume and type of existi ng services and resour ces to the patients volume and types of needs. Pe nchansky explains that it refe rs to the adequacy of the supply of physicians, of healthcare facilities such as clinics and hospitals, and of specialized care such as mental health and emergency care. According to Penchansky, accommodation is the relationship between the manner in which the supply of resources is organized to accept patients, the patients ability to accommodate these elements, and the patients perceptions of their appropriate ness. The supply of resources includes such elements as appointment systems, hours of operation, walk-in fac ilities, and telephone

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169 services (Penchansky). Accessi bility is the relationship be tween the location of supply and the location of patients, taking account of client transportation resources and travel time, distance, and cost (Pen chansky; Bice et al.). According to the findings in this study, access barriers affect rural physicians, the rural patients, and the rural healthcare system in a multitude of ways. Access barriers alter physicians personal and professional perceptions with re spect to clinical preparedness, resource preparedness, and thei r confidence. However, access barriers do not only affect physicians, but they also aff ect rural patients. Irre spective of whether a bioterrorist event is perceived or actually does happen, patients will seek physicians and medical care. Yet if an incident is perceive d or does indeed happen, this will inevitably cause an increase in the number of patients presenting to healthcare facilities. This increased patient load will overwhelm the rura l physicians and affect their professional preparedness. In addition, this inundation of patients presumably will further diminish timely access to physicians and pert inent healthcare resources. Rural patients perceived confidence in th eir medical professionals is affected by physicians perceived knowledge deficiencies. Physician knowledge deficiencies include rural doctors lacking relevant education, training, and professional preparedness. Regrettably, rural physician s in this study appear to lack the medical acumen and preparedness to properly diagnose, evaluate a nd treat patients afflic ted with bioterroristinduced infectious agents. These defici encies may be reflected and manifested by pervasive feelings of uncer tainty or unease on the part of the rural physician. Unfortunately, this uncertainty and unease often is inevitably transparent to patients. According to this study, these readily vi sible feelings of uncertainty and unease

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170 encumbering physicians adversely affect patien ts perceptions of thei r physicians. This lack of preparedness only serves to precip itate more patient unease. Consequently, patients perceiving a physicians lack of professional prepar edness may begin to feel less confident in their physician. This is particularly troublesome because patients may decide not to heed a physicians advice and clinical recommendations. Patients may begin to doubt the need and the efficacy of the medical interventions proposed by the physician. The findings of this study furt her explain that patie nts with pre-existing chronic physical conditions presumably will feel worse in the advent of a bioterrorist event. This is perceived to be principally true because patients may have a fear of the unknown and the subsequent chaos and diso rder which accompanies a disaster. Moreover, individuals afflicte d with mental illnesses emanating from past traumatic experiences will probably become clinically unstable. And many individuals without any ostensible organic conditions may seek medical care, if for no other reason than simply for professional reassurance. So, despite th e fact that some individuals may not have been personally affected by the incident, th ese patients may wish to nevertheless ensure that they are still healthy. These patients who worry if they are we ll will therefore seek medical services which will further affect access to care by exacerbating patient loads and imposing additional burdens on th e rural medical infrastructure. Health Policy Options and Implicat ions Related to Patient Factors Health, whether of individuals or populations, is a functi on of several determinants (i.e., genetic endowment; physical, sociocultu ral, and economic envi ronments; lifestyles and behaviors; and health services). H ealth policy directly affects each of these determinants and, consequently, health (Longest ). Health policies strategically influence the nature of the health services availa ble to patients through their impact on the

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171 resources required to produce the services, as well as on the healthcare system through which the services are organized, delivered and paid for (Longest, 2001). As a result, health policies play a direct and formative role regarding medical preparedness efforts and tangibly influence the health of the American populace. Rural physicians in this study identified acces s barriers as a central impediment to the rural healthcare system and to rural patient preparedness. Access to care may be affected by broad health policies. One policy intervention option may include mobilizing physicians and other healthca re personnel on a locum tenens basis from neighboring areas during a bioterrorist incident. Although a transient increase in the number of medical professionals may temporarily impr ove patient access to medical care, it is probably not a viable long-term solution. Health policy decisions that increase the allocated financial resources devoted to eradicating access barriers would collectively assist rural physicians, patients and the h ealthcare systems perceived preparedness for bioterrorism. Yet, to increase allocated financial resources to rural healthcare necessitates removing resources from somewhere else. Thus, it is imperative to devote considerable attention and thought to the many parameters surrounding such options before embracing policy decisions and subsequent implementation. Policy decisions related to bioterrorism preparedness will need to account for several current trends that ostensibly will affect the rural healthcare system and patients. It may be speculated that disasters, natural and human-induced, will continue with regularity, as well as transparency because of electronic media transmitting and relaying live photographs of disasters throughout the world. It also appears that public expectations regarding the health service delivery capacities of hospitals and clinics in

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172 disaster situations will increase. Yet, budge tary cuts in the pub lic sector will also probably continue, as will furthe r benefit cuts in health in surance packages. Thus, the capacity of local rural public health de partments and physicians to fulfill their responsibility to their communities in times of di sasters will be severely tested. Many of these problems do not have any readily available transparent solutions. However, identification of these problem s may assist policymakers cons idering future health policy decisions. Future Research Questions The 1979 Institute of Medicine (IOM) panel defined the field of health services research in the following manner: Health services research is inquiry to produce knowledge about the structure, processes or effects of personal health services (IOM, 1979, p 14). Health policy analysis applie s this knowledge in defining problems and evaluating policy alternatives. More recently, a committee convened by the Academy of Health Services Research and Health Policy (now known as AcademyHealth) in 2000 defined health services research as the multid isciplinary field of scientific investigation that studies how social factors, financi ng systems, organizational structures and processes, health technologies, and persona l behaviors affect acce ss to healthcare, the quality and cost of healthcare, and ultimately our health and well-being. Its research domains are individuals, families, orga nizations, institutions, communities, and populations (Lohr & Steinwachs, 2002, p 8). Qualitative research is a form of inquiry th at is particularly valuable at identifying and describing problems. So this study did not focus on empirical testing, but instead qualitatively explored the degr ee to which rural physicians c onsidered themselves to be prepared for bioterrorist events. More sp ecifically, this study exposed that increased

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173 preparedness among rural physicians appears to be needed and that there are impediments which appear to be hindering such medica l preparedness. In summary, this study identified and described the problem of rura l physicians need for in creased bioterrorism preparedness. It also identified the causes of this problem, that is, the barriers suggested by this study which prevent ru ral physicians, patients, and the rural healthcare system from being prepared. Lastly, this study raised interpretative findings which are suggestive of some of the possible remedi al policy options. The logical progression would be to further examine some of th ese policy options by implementation with subsequent evaluation. The problem of what works in health policy has long been of interestto governments, health professiona ls, researchers and decision makers (Lin & Gibson, 2003). Thus, there is a need to co llect evidence to substantiate and warrant policy decisions because the absence of credib le evidence has been used in the health sphere to question or discredit co mpeting theories or practices. This study raises several interesting futu re public health a nd health services research questions. One fundamental que stion that remains unexplored involves examining why rural physicians fail to at tend bioterrorism preparedness educational seminars. This study focused on the curre nt perceived state of rural physician preparedness given the level of pre-exis ting healthcare resources. Yet, another interesting question provoked from this st udy involves whether rural physicians view their own professional bioterrori sm preparedness as simply an issue of requiring a greater number of resources for the he althcare system. Future inqui ry could further explore the present concern, irrespective of current healthcare resource capacity, and address how we can best ensure that we are as prepared as we can be for a possible bioterrorist event.

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174 This may also be directed at examining the current state of biote rrorism preparedness in other states from both urban and rural perspectives. This may be accomplished by performing survey research of physicians from designated settings in other states. If state and/or federal governments wi sh to consider allocative policies by providing subsidies to rural physicians to improve preparedness, then measures to examine the effectiveness of such policies should also be examined. Thus, a further exploration utilizing quantitative studies involving cost-benefit and cost-effective analyses to help guide future policy dire ctions would be justified to ponder the ramifications of devoting a larger number of financial resources to improving rural healthcare versus other endeavors. Conclusion Any bioterrorism event or the threat of an event is both an important public health and community issue requiring th e medical community to assume a substantial leadership role. Physicians have a dual responsibi lity to educate the community and to professionally prepare for such an event. Although only a few physicians would likely recognize the sentinel case in a bioterrorist event, the overall public health management response might very well involve every physic ian. Consequently, physicians must be particularly astute and knowledgeable to accurately address questions from patients, colleagues, officials, and others. Furthermor e, every physician must be prepared to take an active role should a bioterrorist event surface within his/her community. Thus, each physician has a significant role to assume in our nations defense agai nst bioterrorism. Bioterrorist agents can cause a vast arra y of signs and symptoms with severity ranging from mild to those that result in mortality. Bioterrorist agents also significantly impact mental health status, specifically by invoking or exacerbating fear, anxiety,

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175 depression, acute stress diso rder, and other mental health conditions. With fewer colleagues and attenuated prof essional networks it is espe cially important for rural physicians to achieve a high level of indivi dual bioterrorism pr eparedness regarding organic and mental health condi tions, risk factors, and possi ble medical interventions. Thus, when rural physicians encounter th e conspicuous and the covert signs and symptoms of conditions that may reflect biot error manifested in their patients; they should be able to discern and diagnose the conditions expediently and with efficacy. Broader public health asp ects of bioterrorism prep aredness, including primary prevention measures, are important areas fo r informed action by physicians. Medical education and training curricula must include information on salient potential agents of bioterrorism, and medical professionals, espe cially those such as primary care physicians who are most likely to see pa tients affected by a biologi cal weapon require continuous education in this area. Moreover, physicia ns from other specialties need sufficient knowledge of the likely clinical features of potential biological agents in order to recognize patients presenting with a compatible illness (Gerbe rding et al., 2002; Karwa et al., 2003, Karwa et al., 2005). Bioterrorism preparedness requires physicia ns to be aware of the possibility of bioterrorism at any time (Gerberding et al., 2002, Inglesby et al., 2000). Plans to circumvent or be adequately prepared for bi oterrorist incidents can only be implemented effectively if physicians are aware of the possibility of bioterrorism, suspect and recognize an event when it occu rs, notify authorities promptly upon suspicion of such an event, and institute appropriate medical interventions and management protocols.

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176 APPENDIX A INTERVIEW QUESTIONS Questions one and two describe background in formation of the participants whereas questions three through thir teen will be examined with grounded theory. 1. What is your position here? 2. What is the size of your patient load? 3. What types of mental health conditions do you think you w ould be likely to see in patients following a terrorist attack? 4. Are you aware of any risk factors for de veloping mental health problems following a bioterrorist attack? 5. Are you aware of any risk factors for developing medical problems following a bioterrorist attack? 6. What types of medical c onditions do you think you would be likely to see in patients following a terrorist attack? 7. What do you think are the best treatment options for people who develop mental health conditions following a bioterrorist attack? 8. What do you think are the best treatment options for people who develop medical conditions following a bi oterrorist attack? 9. What steps could be taken to help pa tients immediately after an event? 10. How would you monitor patients mental health and medi cal care in the weeks and months following a bioterrorist attack? 11. What kinds of things can get in the way of accessing healthcare for people served at this clinic? 12. Have you had an opportunity to learn about biological agents a nd resulting medical needs in ways such as courses or in-servi ces at other institutions or reading on your own? 13. How important is it for healthcare providers to receive training for bioterrorism?

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177 APPENDIX B QUALITATIVE INTERVIEW CODING CHART ATA EXAMPLES OPEN CODES AXIAL CODES SELECTIVE CODES Depends on kind of event Depends on kind of event Event dependent Context dependent If it were a respiratory event, look for respiratory symptoms Hypothetical Respiratory Scenario Event dependent Context dependent Preparedness for Respiratory Symptoms Cognitive Preparedness Physician Professional Preparedness Depend on what the attack entailed Depend on what attack entailed Event dependent Context dependent If we are looking at someone running into a fertilizer plant, then you are looking at respiratory problems Hypothetical Respiratory Scenario Event dependent Context dependent Preparedness for Respiratory Symptoms Cognitive preparedness Physician Professional Preparedness If we are crop dusted with Anthrax, you look at respiratory problems Hypothetical Scenario Event dependent Context dependent Preparedness for Respiratory Symptoms Cognitive preparedness Physician Professional Preparedness

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178 Here it is a little harder because we are not as concentrated Not as Concentrated Social Barrier Communication Barrier You will have all the symptoms whether they are real or thought up Preparedness for all types of symptoms Cognitive preparedness Physician Professional Preparedness If you look at Anthrax, you get a fever, cold, and cough. Hypothetical Scenario Event dependent Context dependent Preparedness for Respiratory Symptoms Cognitive Preparedness Physician Professional Preparedness For a lot of the airborne stuff, the early symptoms are similar to the common cold. Preparedness for Respiratory Symptoms Cognitive Preparedness Physician Professional Preparedness It depends on what it is It depends on what it is Event dependent Context dependent Those physical symptoms will explode Preparedness of increase in physical symptoms Cognitive preparedness Physician Professional Preparedness It depends totally on what the agent is Depends on the agent Event dependent Context dependent Smallpox type rash Agent provoking symptoms Cognitive preparedness Physician Professional Preparedness Smallpox Skin lesions Agent provoking symptoms Cognitive preparedness Physician Professional Preparedness Drawing a blank Drawing a blank Lack of Knowledge Knowledge Barrier Dont know the findings that well Do not know the findings Lack of Knowledge Knowledge Barrier

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179 Whatever experts recommend Whatever experts recommend Rely on Expertise Perception of Preparedness Have to look it up A need for additional knowledge Lack of Knowledge Knowledge Barrier See what experts say which symptoms merit what treatment and who to monitor Expert evaluation of what to do Rely on Expertise Perception of Preparedness We had 9/11, and I saw a lot of anxiety 9/11 and anxiety as an outcome Clinical Preparedness Physician Professional Preparedness People stable on medication for anxiety and depression coming with exacerbations Exacerbation of anxiety and depression Exacerbation of pre-existing mental conditions Exacerbation of pre-existing condition People who were previously diagnosed having exacerbation Exacerbation of previous diagnosis Exacerbation of pre-existing physical condition Exacerbation of pre-existing condition New patients coming in New patients Increased patient load Access Barrier People complaining of insomnia, cannot sleep Insomnia Clinical Preparedness Physician Professional Preparedness Very nervous thinking Nervous thinking Clinical Preparedness Physician Professional Preparedness World is going to end End of world Fear of Uncertainty Perception of Morbidity and Mortality Mostly anxiety and depression Anxiety as an outcome Clinical Preparedness Physician Professional

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180 Preparedness Exacerbation of peoples anxieties Exacerbation of anxiety Exacerbation of pre-existing mental condition Exacerbation of pre-existing condition Depends on what kind of bioterrorism Kind of bioterrorism Event dependent Context dependent Deal with posttraumatic stress disorders Deal with PTSD Exacerbation of pre-existing mental condition Exacerbation of pre-existing condition Component of stress and shock Stress and shock Fear of uncertainty Perception of Morbidity and Mortality Being in fear will wear on them, we all noticed that after 9/11 9/11 and fear Fear of uncertainty Perception of Morbidity and Mortality Increase in people in the ER Increased visits Increased patient load Access Barrier Asked if there was exposure Asked if they were exposed Fear of possible exposure Perception of morbidity and mortality Patients asking if they could be tested for things Asking to be tested Clinical Preparedness Physician Professional Preparedness Post-traumatic stress disorder PTSD as an outcome Clinical Preparedness Physician Professional Preparedness Anxiety Anxiety as an outcome Clinical Preparedness Physician Professional Preparedness Substance use would probably flare more Increase in Substance use as an outcome Clinical Preparedness Physician Professional Preparedness Depression Depression as an outcome Clinical Preparedness Physician Professional Preparedness

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181 Extra fuel on the fire for people with chronic problems Extra fuel on the fire for Chronic problems Exacerbation of pre-existing physical conditions Exacerbation of pre-existing condition Anxious people Anxious Clinical Preparedness Physician Professional Preparedness People that think they are infected Suspicious of infection False Interpretation of illness Perception of Morbidity and Mortality Cant quote an article Cannot quote a medical journal article Lack of Knowledge Knowledge Barrier Cant write an article Not confident to write an article on bioterrorism Lack of Knowledge Knowledge Barrier Person who is sneezing and knows it is Anthrax instead of the flu Anthrax False Interpretation of illness Perception of morbidity and mortality Those that have a stomach virus and think it is botulism or salmonella poisoning Botulism or Salmonella False Interpretation of illness Perception of morbidity and mortality Depression Depression as an outcome Clinical Preparedness Physician Professional Preparedness Depends on how big the event is Event size Event dependent Context dependent How many people are involved Number involved Event dependent Context dependent Some of the schizophrenics and people that have psychosis probably need a little bit of understanding and Schizophrenia and Psychosis Mental Health Disorder Clinical Preparedness Physician Professional Preparedness

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182 help in dealing Panic attack Panic Attack as an outcome Clinical Preparedness Physician Professional Preparedness Anxiety disorders Anxiety disorder as an outcome Clinical Preparedness Physician Professional Preparedness Generalized anxiety Generalized Anxiety as an outcome Clinical Preparedness Physician Professional Preparedness Think of bioterrorism, you think of agents that are physically capable of morbidity and mortality Bioterrorism agents Perception of illness Perception of morbidity and mortality Skin and mucous membranes, gastrointestinal, and airborne kinds of things. Skin and mucous membranes, gastrointestinal, and airborne Clinical Preparedness Physician Professional Preparedness Hysteria Hysteria as an outcome Clinical Preparedness Physician Professional Preparedness Anxiety Anxiety as an outcome Clinical Preparedness Physician Professional Preparedness Depending on how it is handled Depends on situation Event dependent Context dependent Can turn into depressive type of disorders Depression as an outcome Clinical Preparedness Physician Professional Preparedness Hopelessness Hopelessness Clinical Preparedness Physician Professional Preparedness Helplessness Helplessness Clinical Preparedness Physician Professional

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183 Preparedness What am I to do? Hopelessness Clinical Preparedness Physician Professional Preparedness Would be the same in any type of disaster scenario Type of Disaster scenario Event dependent Context dependent Impaired immune status Impaired immune status Clinical Preparedness Physician Professional Preparedness Sensitive to Old age Sensitive to Old age Clinical Preparedness Physician Professional Preparedness Multiple chronic diseases worsening Chronic diseases worsening Pre-existing physical health condition Exacerbation of pre-existing health condition Certain medications Medications Physician aware of treatment Physician Professional Preparedness Pre-existing mental illness Pre-existing mental illness Pre-existing mental health condition Exacerbation of pre-existing condition Bioterrorist Event is going to impact on their consciousness and could make things worse Bioterrorist event could make health worse Clinical Preparedness Physician Professional Preparedness Cant write an article but I think Cannot write a medical article Lack of Knowledge Knowledge Barrier People who do not have a good support system through communication Lack of support system Social Barrier Communication Barrier People who are more isolated have Trouble Coping Social Barrier Communication Barrier

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184 more trouble coping People in rural areas would have more difficulties with those things Rural setting Social Barrier Communication Barrier Little better off for some because of the internet and communication Internet Social Barrier Communication Barrier A lot of my patients do not even have telephones No telephone Social Barrier Communication Barrier Just see what is in the papers Newspaper information only Social Barrier Communication Barrier Maybe what they see on television Possible Television information Social Barrier Communication Barrier Lot of doom and gloom and that is upsetting a lot of people Upsetting people Perception of upsetting situation Perception of morbidity and mortality If you have anxiety, you will have problems with anxiety Hypothetical mental health condition Event dependent Context dependent Preparedness for anxiety Cognitive preparedness Physician Professional Preparedness If you have depression, you will have problems with depression Hypothetical mental health condition Event dependent Context dependent Preparedness for depression Cognitive preparedness Physician Professional Preparedness ADHD will be complicated Hypothetical mental health Event dependent Context dependent

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185 condition Preparedness for ADHD Cognitive Preparedness Physician Professional Preparedness All of them will be complicated Hypothetical mental health condition Event dependent Context dependent Preparedness for all complications Cognitive Preparedness Physician Professional Preparedness People who already have a diagnosis will be at risk for worsening Hypothetical worsening of condition Event dependent Context dependent Preparedness for worsening of condition Cognitive Preparedness Physician Professional Preparedness Can guess what some risk factors might be Can guess what some risk factors may be Lack of knowledge Knowledge Barrier Dont know any studies or research on risk factors Dont know any studies or research Lack of knowledge Knowledge Barrier Prior mental illness Prior mental illness Pre-existing mental condition Exacerbation of pre-existing condition Family history of mental illness Family history of mental illness Pre-existing family history of mental condition Exacerbation of pre-existing condition Prior suicide attempts Prior suicide attempts Personal prior experience Personal Patient Preparedness Substance abuse could be a risk factor Substance abuse as an outcome Pre-existing mental condition Exacerbation of pre-existing condition Social isolation Social isolat ion Social Barrier Communication Barrier Depression as Clinical Physician Professional

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186 Depression an outcome Preparedness Preparedness Will go back to the type of event Type of event Event dependent Context dependent How closely it hit home, family or workplace How close to home and family Personal prior experience Patient Condition Will vary for everybody involved Varies Event dependent Context dependent No risk factors and yes risk factors Uncertainty of risk factors Lack of Knowledge Knowledge Barrier Depending on how they were before Previous health status Personal prior experience Patient Condition Past experience Past experience Personal prior experience Patient Condition Family history Family history Family history experience Patient Condition No risk factors No risk factors Personal prior experience Patient Condition Past history of post-traumatic stress disorder Post-traumatic stress disorder as an outcome Exacerbation of pre-existing mental health condition Exacerbation of pre-existing condition Any type of involvement in war, criminal, and stress-related issues that come from senses of loss of control and comorbidities like anxiety and depression Previous Involvement Personal prior experience Patient Condition Whole list of things to keep an eye out for Awareness Physician awareness Physician Professional Preparedness Counseling is our Counseling

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187 only choice Counseling Treatment Therapy Depression and anxiety after an attack Depression and anxiety as an outcome Clinical Preparedness Physician Professional Preparedness Acute intervention is very important Acute intervention Acute Treatment Treatment Dont know exactly Dont know Lack of Knowledge Knowledge barrier Bound to be some preventive stuff Some prevention Prevention Therapy I dont know what those approaches would be Dont know Lack of Knowle dge Knowledge barrier Something that would diminish the impact and future problems Some approach to diminish impact and future problems Lack of Knowledge Knowledge barrier Depends on the event Depends on event Event dependent Context dependent One on one counseling Counseling Counseling Treatment Therapy Medication adjustment Medication adjustments Medication Treatment Treatment Group setting Group counseling Counseling Treatment Therapy Stress debriefers Debriefers Counseling Treatment Therapy Everybody needs to have whatever he or she needs to deal with it Needs to cope with situation Personal experience Patient Condition There is no standard No standard L ack of Knowledge Knowledge barrier Counseling Counseling Counseling Treatment Treatment Depends on how much understanding you have about the Understanding of situation Physician awareness Physician Professional

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188 situation Preparedness One to one counseling One-to-one counseling Counseling Treatment Therapy Group counseling Group counseling Counseling Treatment Therapy Access to mental health counseling is extremely important Mental Healthcare Counseling Access Mental Healthcare Access Access Barrier Discussion with and treatment with their primary care physician Primary Care physician counseling Counseling treatment Therapy Integration with primary care provider with counseling Primary care provider counseling Counseling Treatment Therapy Reassurance Reassurance Treatment Recommendation Recommendation Medication can be important Medication Medication Treatment Treatment Making contact with the community Community contact Social Barrier Communication Barrier Open house to talk about it Advice Treatment Recommendation Recommendation Have a group therapy Advice Treatment Recommendation Recommendation Patients cannot get transportation No Transportation Transportation Barrier Access Barrier Difficult to reach them Cannot Reach Social Barrier Communication Barrier Talk on telephone might work Maybe Telephone Social Barrier Communication Barrier Sending letters, but some cannot read Cannot read Literacy Barrier Communication Barrier After 9/11, when they came out to 9/11 Knowledge Reassurance Recommendation

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189 talk about it and try to make sure they are knowledgeable about what is happening Treatment Have lots of facts to ease their mind Advice Reassurance Treatment Recommendation Try to answer their questions Answer Questions Reassurance Treatment Recommendation In rural areas, lots more isolation Isolation Social Barrier Communication Barrier In rural areas, lots more barriers to communication Rural setting Social Barrier Communication Barrier One person communicating to a mass audience is difficult Difficulty with mass communication Social Barrier Communication barrier Bioterrorism Education Bioterrorism Education Cognitive preparedness Physician Professional Preparedness Let them know it is a tough time Advice Reassurance Treatment Recommendation Stress on people and response to that stress can get people mentally out of shape Stress and health response Clinical Preparedness Physician Professional Preparedness There is help if they need it Advice Reassurance Treatment Recommendation Nothing wrong with them having responses they do not understand Advice Reassurance Treatment Recommendation People that we see in the ER would need to look at why the event occurred Need to look at why event occurred Cognitive Preparedness Physician Professional Preparedness

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190 For chest pain, nausea, and headaches; those would have to be looked at Preparedness for physical health symptoms Clinical Preparedness Physician Professional Preparedness Just dont know where that is coming from Dont know Lack of Knowledge Knowledge Barrier Rely heavily on family practices in the area Reliance on Medical Family Practices Resource Preparedness Physician Professional Preparedness An initial screen Screening Cognitive Preparedness Physician Professional Preparedness May not be sleeping well Preparedness for physical health symptoms Clinical Preparedness Physician Professional Preparedness See more domestic violence due to the event Preparedness for physical health symptoms Clinical Preparedness Physician Professional Preparedness See more accidents due to the event Preparedness for physical health symptoms Clinical Preparedness Physician Professional Preparedness Preparedness has to be put on the forefront Importance of Preparedness Cognitive Preparedness Physician Professional Preparedness Have to have a Screening question Screening Cognitive Preparedness Physician Professional Preparedness Think majority of people would look at a list of differentials Evaluation of list of differentials Cognitive Preparedness Physician Professional Preparedness Have to look at blood sugar, blood pressure, anxiety, and depression Evaluation of physical symptoms Clinical Preparedness Physician Professional Preparedness Will worsen all of the symptoms Preparedness for all symptoms Cognitive preparedness Physician Professional Preparedness

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191 Stress is not healthy for the body Physical Health Symptoms Clinical Preparedness Physician Professional Preparedness Psychiatrists and psychologists need to be available for referral Availability of healthcare specialists Resource Preparedness Physician Professional Preparedness Depends on what kind of bioterrorism attack Depends of kind of bioterrorism Event dependent Context dependent Reassurance Reassurance Therapy Reassurance Treatment Recommendation Tell them the facts Tell them the facts Reassurance Treatment Therapy Psychological Approach rather than physical or medical Reassurance Therapy Reassurance Treatment Therapy Have a fear of dying Fear of dying Fear of Uncertainty Perception of Morbidity and Mortality First identify that it is an issue by educating providers and staff Education of providers Cognitive Preparedness Physician Professional Preparedness Rearranging schedules of mental health counselors Availability of healthcare specialists Resource Preparedness Physician Professional Preparedness Increase awareness Increase Awareness Physician Awareness Physician Professional Preparedness Increase availability Availability of healthcare specialists Resource Preparedness Physician Professional Preparedness After hours and extended hours Availability of healthcare specialists Resource Preparedness Physician Professional Preparedness If we need more Resource dependent Resource Physician

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192 intensive care, we would include the hospital as well Preparedness Professional Preparedness After 9/11, ask how are you doing How is patient doing. Physician Awareness Physician Professional Preparedness Validate the fact that they could feel bad about that Validate feelings Reassurance Treatment Therapy Could talk to me and discuss with me how they were doing Discussion of how patient is doing Reassurance Treatment Therapy try to put it in that context feelings you know could be having some kind of exacerbation would be like Validate feelings Reassurance Treatment Therapy Ask about symptoms Ask about symptoms Clinical Preparedness Physician Professional Preparedness Education regarding bioterrorism Bioterrorism education Cognitive Preparedness Physician Professional Preparedness Have monthly provider meetings Monthly Providers meetings Cognitive Preparedness Physician Professional Preparedness Get updates from the Department of Health Educational Updates from DOH Cognitive Preparedness Physician Professional Preparedness Vaccinate against smallpox Smallpox vaccination Cognitive preparedness Physician Professional Preparedness Talk about our disaster preparedness Discuss Disaster Preparedness Cognitive Preparedness Physician Professional Preparedness We plan for Resource planning Resource Physician Professional

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193 resources Preparedness Preparedness Instrumental as far as medication Medication importance Medication Treatment Treatment Medical staff come in to clinic Availability of healthcare specialists Resource Preparedness Physician Professional Preparedness Transportation can be a problem Lack of transportation Transportation Barrier Access Barrier Stigma can be a problem Stigma associated with mental health Social Barrier Communication Barrier No medical infrastructure No medical infrastructure Lack of Resources Access Barrier Not enough Money Lack of money Fina ncial Barrier Access Barrier Barriers in communication Barriers in Communication Social Barrier Communication Barrier Cant use really big words Cant use really big words Literacy Barrier Communication Barrier Important for them not to feel like someone is looking down at them Not looking down at them Respect Barrier Communication Barrier So many blocks to access of care Blocks to access care Lack of Access Access Barrier Lack of Transportation Lack of Transportation Transportation Barrier Access Barrier Funding issue Lack of money Fina ncial Barrier Access Barrier Driving issues Driving issues Transportation Barrier Access Barrier Reluctant to travel Reluctance to travel Transportation Barrier Access Barrier Not enough Gas money Not enough gas money Financial Barrier Access Barrier

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194 No medical insurance No medical insurance Financial Barrier Access Barrier Transportation problems Transportation problems Transportation Barrier Access Barrier Cost of gas Gas money Financ ial Barrier Access Barrier Only have one vehicle, no way to get here. Only have one vehicle, no way to get here. Transportation Barrier Access Barrier Fixed incomes Fixed Incomes Financial Barrier Access Barrier Cars older and less efficient Cars older and less efficient Transportation Barrier Access Barrier Finance difficulty Finance difficulty Financial Barrier Access Barrier Harder time affording medicine Harder time affording medicine Financial Barrier Access Barrier Costs of medicine Costs of medicine Financial Barrier Access Barrier Access to specialists causes some problems Access barrier to healthcare specialists Lack of Access Access Barrier Didnt get to attend the bioterrorism seminar Didnt get to attend the bioterrorism seminar Lack of Knowledge Knowledge Barrier Several presentations regarding smallpox vaccination Education regarding smallpox Cognitive Preparedness Physician Professional Preparedness Attended several web meetings for the DOH regarding bioterrorism DOH Web Educational Meetings Cognitive Preparedness Physician Professional Preparedness Bioterrorism has come up in seminars for medical Bioterrorism Education seminars Cognitive Preparedness Physician Professional

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195 education the past several years Preparedness Read medical journals regarding bioterrorism Read Medical Journals regarding bioterrorism Cognitive Preparedness Physician Professional Preparedness A lot of time and discussions of bioterrorism Discussions regarding bioterrorism Cognitive preparedness Physician Professional Preparedness What you have to do as a private practitioner What you have to do as a private practitioner Cognitive Preparedness Physician Professional Preparedness Discussed acute mental health problems in seminar Mental health education seminars Cognitive Preparedness Physician Professional Preparedness Lots of in-service training opportunities Training opportunities Cognitive preparedness Physician Professional Preparedness Piles of in-service training opportunities Training opportunities Cognitive preparedness Physician Professional Preparedness State EMS meetings educate regarding bioterrorism Bioterrorism Educational meetings Cognitive Preparedness Physician Professional Preparedness Talking about bioterrorism and planning for it Discussions regarding bioterrorism Cognitive Preparedness Physician Professional Preparedness Met with county emergency management director County Emergency Management meetings Cognitive Preparedness Physician Professional Preparedness Done some drills Drills Simulation Preparedness Physician Professional Preparedness Classes regarding Hazmat Hazmat classes Cognitive Preparedness Physician Professional Preparedness I will get people prepared to handle Get people prepared to handle the actual Simulation Preparedness Physician Professional

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196 the actual event itself event Preparedness Small group discussions Discussion Cognitive Preparedness Physician Professional Preparedness Lot of asking what if Asking what if Cognitive preparedness Physician Professional Preparedness How do we handle such and such How do we handle Cognitive preparedness Physician Professional Preparedness First wave of people will be the mental health people Perception of Post BT Event Assessment Cognitive Preparedness Physician Professional Preparedness People who truly have exposure to the event will probably remain on scene Perception of Post BT Event Assessment Cognitive Preparedness Physician Professional Preparedness People who show up at our door, get in their car and drive here we will absolutely know that they have had exposure Perception of Post BT Event Assessment Cognitive Preparedness Physician Professional Preparedness Physician Continuing education program was done regarding bioterrorism Continuing education regarding bioterrorism Cognitive Preparedness Physician Professional Preparedness Discussed smallpox and anthrax Smallpox and Anthrax discussion Cognitive Preparedness Physician Professional Preparedness Yes, there are opportunities to learn about bioterrorist agents, but have not taken advantage of them Learning Opportunities regarding bioterrorist agents Cognitive Preparedness Physician Professional Preparedness Not taken advantage of learning Lack of Knowledge Knowledge Barrier

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197 opportunities regarding BT agents Some aspect of mental health education discussed Mental Health Education focus Cognitive Preparedness Physician Professional Preparedness It is important to discuss bioterrorism BT discussion importance Cognitive preparedness Physician Professional Preparedness Bioterrorist acts may happen and can happen BT acts happen Expectation preparedness Physician Professional Preparedness We are prepared We are prepared Expectation Preparedness Physician Professional Preparedness Would expect ER people would be a 9 out of 10 prepared ER preparedness Simulation preparedness Physician Professional Preparedness ER nurses a 9 or a 10 ER provider preparedness Simulation preparedness Physician Professional Preparedness ER nurses may need to do stuff in the office with coordination of patients ER provider preparedness Simulation preparedness Physician Professional Preparedness Yes, providers need a level of awareness Provider awareness Physician awareness Physician Professional Preparedness Probably will not be first to treat a known event Perception of Post BT Event Assessment Cognitive Preparedness Physician Professional Preparedness It is important for doctors to know what information and answers to give Knowledge to provide Cognitive preparedness Physician Professional Preparedness Physicians need to be consistent with Physician need to provide consistent Cognitive preparedness Physician Professional

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198 their information information Preparedness Certainly there is a place for bioterrorism training BT training Simulation Preparedness Physician Professional Preparedness Was lower in the priority list before 9/11 Post 9/11 priority Physician awareness Physician Professional Preparedness Do we see Anthrax everyday, no, but it does come up. Anthrax occurs Expectation preparedness Physician Professional Preparedness Never seen a case of smallpox, but we know what it looks like Smallpox symptoms Clinical Preparedness Physician Professional Preparedness We are all aware of smallpox Smallpox awareness Physician awareness Physician Professional Preparedness Updates from the Department of Health to the providers DOH updates Cognitive preparedness Physician Professional Preparedness Recognizing trends in medical symptom patterns is talked about Recognition of medical symptom trends Clinical Preparedness Physician Professional Preparedness

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199 APPENDIX C DOCTOR WILLIAMS INTERVIEW TRANSCRIPT Interviewer 1: If you could start by telli ng me about your position at this clinic? Respondent: Im a family physician and I work there one day per week and have been there for 12 years, I guess. Although were a family practice, we have a fairly narrow rank of patients, older for the most part, males and females, but a broad range of problems. Interviewer 1: What is your esti mate of your active patient load? Respondent: Probably average about 15 or so per day. Interviewer 1: So, now we're going to talk a little about the kinds of mental health problems that you might encounter in patients af ter a terrorist attack, such as the attacks on the World Trade Center, or perhaps a diseas e outbreak of an agent such as anthrax. What types of mental disorders do you think you'd be likely to see in patients following such an event? Respondent: If it was in our area? Interviewer 2: If it were dire cted here or they happened to be caught in the area where it happened. Respondent: Well PTSD definitely. Anxiet y and substance use would probably flare more. Depression, I think maybe later esp ecially if people they knew were directly affected. And, it would throw extra fuel on the fire for people who had chronic health problems, like schizophrenia or bipolar. Interviewer 1: What do you think are the best treatment options for people who develop mental disorders following a rural bioterrorist attack? Respondent: I know acute intervention is very important. I dont know exactly what they do with those, but after Hurri cane Andrew, it was real importa nt to have acute mental health services availabl e. And, there is bound to be some preventative stuff that can be done then. I don't know what it is, but I bet someone has a darn good idea. And, I would try to put that in, and if th ey werent, we'd try to look at what can be done along those lines. I'm sure something can be done that woul d diminish the impact and diminish future problems, but I don't know what those approaches would be.

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200 Interviewer 1: Are you aware of any risk factor s of developing a mental health disorder following a mental health attack? Respondent: I can guess what some might be, but I don't know any studies or research on that. Interviewer 1: What steps do you think could be taken to help people immediately after the event, such as people who ha ve had those risk factors? Respondent: I guess education. Just to let them know it is a tough time and it is a stress on people and the response to that stress on people may cause them to get mentally outof-shape and there's help if they need it. And there's nothing wrong with them if they're having responses they don' t understand and that there's ways to help it. I: What barriers can get in the way of people accessing mental healthcare following a bioterrorist attack? Respondent: I think there'd be a lot more lo cal stuff. Someone would set up some local things probably. Again, we'd be dependant on state action or federal relief. That would probably change. Wed probably all become mo re knowledgeable. We'd do a better job. They might be more reluctant to travel, after something like that. But, most of them can't get much more reluctant. Other barrier, gas money is a big problem for older people. Gas money to get to other places is a big, bi g problem. Actually gas money is usually a problem for young people, who are borderline poverty, and either just the husband is working, or the husband and wi fe are working, the family is large, and they have no medical insurance. They just don't have whatever it is, $10 or $15 once a week or twice a week to drive back and forth, and so it's a significant barrier for a number of people. Interviewer 1: How would a bi oterrorist attack change how you might monitor a patient's mental healthcare? Say in th e weeks or months following. Respondent: Ask about it much more. Interviewer 1: So now I'm going to ask you a bout some kinds of physical health problems that you might encounter in patients following a terrorist attack or bioterrorist attack. What types of conditions do you think you'd be likely to see in patients following those kinds of events? Respondent: Well, it depends totally on what the agent is. Interviewer 1: What about if there was smallpox? Respondent: Smallpox-type rash. I: What about anthrax?

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201 Respondent: Certain kinds of skin lesions that are typical. I'm drawing a blank, what else? Interviewer 1: Nerve agent? Respondent: Again, I don't know the findings that well, but I would think paralysis, alterations in consciousness in groups of people. Interviewer 1: What do you think are the best treatment options for people who develop those kinds of conditions following a bioterrorist attack? Respondent: Whatever experts r ecommend. I'd have to look up and see what they'd say: which symptoms merit what treatment and who to monitor. Interviewer 1: Are you aware of any risk factors for develo ping these kinds of medical problems after a bioterrorist attack? Respondent: Well, I would think for biological obviously impaired immune status, so anything that does that and old age being a bi g one, and multiple chronic diseases being another one, and certain medications. Interviewer 1: What steps do you think could be taken to help such patients immediately after those kinds of events? Respondent: There'd definitely decontamin ation stuff, HAZMAT time. I don't know what to do for any of that. Interviewer 1: What kinds of things can get in the way of accessing medical care for people served here? You men tioned distance, but are there other things, say for people with chronic conditions? Respondent: I think finances become bigger, because they're willi ng to do it, but they may have a harder time affording it. Taking the costs of medicine becomes a problem. That is a problem with psychiatric medicines, too, but it's a bigger problem with physical ones. Easy access to specialists causes some pr oblem there, but it's not nearly as big as the other. Interviewer 1: How do you think these barriers might change following a terrorist attack? Respondent: I doubt they'd change much. Interviewer 1: How would you monitor patien t's medical care in the months or weeks following a terrorist attack? Respondent: Well, you'd have a whole new list of things to keep an eye out for.

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202 APPENDIX D DOCTOR SMITH INTERVIEW TRANSCRIPT Interviewer 1: If you could de scribe your position here. Respondent: My position is I am the medi cal executive director of the Health Department. Having that title, what I do here ninety percent of the time is see patients. About ten percent of the time I do administrative stuff. Interviewer 1: What types of mental diso rders do you think you would likely see in patients following such events? Respondent: Well, I gained practice here in Ju ne 2001. So, it was after that, that we had 9/11. I saw a lot of anxiety. I saw people who were stable on medication for anxiety and depression coming in with exacerbations of illness. A lot of people had someone affected on that day or knew someone that was affected on that day or subsequently had somebody in the military. There was a family member whose career was affected by that day. I saw people who were diagnosed previously having an exacerbation and I also had some new patients coming and people complaining of insomnia, cannot sleep, very nervous thinking that the world is going to end. I saw those kinds of things. Mostly anxiety and depression were the two thi ngs that I saw the most. Interviewer 2: How much of an increas e do you think that you saw from what you usually see? Respondent: Its strictly goi ng to be like a gut level. I think off the cuff, I would guess probably a ten to twenty pe rcent increase, very rough. Interviewer 1: Are you aware of any risk f actors for developing mental illness following these kinds of events? Respondent: I think that there are risk factors. I cant quote an article. The thing that was between my ears any time first of all is anyone who has a pre-existing mental illness. There is no question that an event like that is going to impact on their consciousness and could make things worse. I think also, although, I cant write an article on it, but I think that people who do not have a good support system through communication. People who are more isolated would tend to have mo re trouble coping with something like that because they are not able to talk about that as much with others and those kinds of things. I was thinking about it and people in rural areas

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203 would have more difficulties with those things. I think its a little better for some because of the internet and co mmunication, but a lot of my patients dont even have telephones. They just s ee what is in the papers or may be what they see on the T.V. It is a lot of gloom and doom that makes news and that is upsetting a lot of people. Interviewer 1: What steps do you think could be taken to help these patients immediately after that kind of event? Respondent: Well, I can suggest things and I can also see immediate ba rriers. I can say, well, we can have an open house to ta lk about it, have a group therapy. My patients cannot get transportation. They have a doctors appointment two months in advance and then thei r ride falls through and they cannot make it. Actually reaching them unless some mass transit system is brought in for which it is feasible it is difficult to reach them. Okay, what are the other methods of communicatio n? Talking on the telephone that might work. Sending letters to the on es, but some cannot read and some cannot read well. So thats going to be a problem. The only thing that I tried to do in the time after 9/11 occurred and we have had only a few days after the white powder scare and someth ing like that is when they come out to talk about it to try to make sure that they are knowledgeable about whats happening. And, if they have lots of fact its going to ease their mind and then we try and answer th eir questions. How do you do that on a mass level? I dont know how to do that I dont have a solution for you if you are asking for one. I dont know how to do it. In rural areas there is lots more isolation, lots more barriers to communication. One person communicating to a mass audience is ve ry difficult. It is not one-on-one. It is not real feasible. Interviewer 1: So, it sounds like there are sign ificant barriers that you mentioned transportation and such. What about stigma in terms of mental health? Respondent: Well, there is some stigma. There is not so much in this county of the health department. I think, for inst ance, I worked in other county health departments. In a bigger county, for example, because people are assuming in the bigger county they are assuming you are walking in there and that you have a terrible disease that you probably contracted sexually and that is why you have to go there. This health department has an advantage over that because it is ru ral and out of the way. For many years, there was little to no medical infr astructure in this county. It was seen as a clinic or as a place you go fo r sore throats and for rashes and not just for sexually transmitted diseases for HIV and AIDS care. So, I dont think there is a big stigma walking through the door here. As far as receiving mental healthcare, no one knows when you are walking in what you are going to get. I dont think that there is a huge barrier, but it would

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204 be in other counties. If I was sitt ing in a different county and you were asking me that question I would talk a bit more about the stigma because there is a little stigma in other counties. Interviewer 1: Are there any other barriers besides those that you mentioned to people receiving care for mental health? Respondent: We covered money; we covered transportation, some of the barriers in communication. I am not a mental h ealth professional trained to do this, but you cant use really big words sometimes. I have had some complaints from patients about them not getting it, but not many. Most people get with the program and kind of get through it better. It is real important for them not to feel like someone is looking down at them and any good therapist should be able to pick up on them. I dont think it is big barrier out here. But off the top of my head, no I cannot think of anything else. Interviewer 1: How do you think a bio-terrorist attack or ot her public health emergency would change how you monitor patient s mental healthcare in the weeks or months following such an event? Respondent: Well, the big difference that I see is having a kind of active monitoring system or something like that. I dont have one. What I did do when things occurred back in 9/11 and in anthrax and in all that, the people who were coming in, I am asking how are you doing? There are a lot of things going on right now. I would try to, le t me see the right word, I guess validate the fact that they could feel bad about that. They could talk to me and discuss with me how they were doi ng. I would try to put it in that context of the feelings that they could be having. It could be some kind of exacerbation of illness and what it woul d be like under those conditions. Interviewer 1: Have you had any sort of staff education or in-services about bioterrorism or other public health emergencies? Respondent: I know it seems to me [someone in the office staff] could tell you the answer to this. I know th at at one point, although I didnt get to attend, there was a presentation here. I did not see it myself. I think that may have happened and may have been sp ecifically about bioterrorism in general. So, if I had to give something on bioterrorism that we were involved with the smallpox vaccination campaign. We had to make a presentation to the community, to the police, and to the emergency operations center. We had to do several of those. I attended some of their web meetings for the Department of Health put on regarding smallpox and bioterrorism. It has come up in semina rs that I have been to for medical education in the last couple years. Things like that. As far as right here,

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205 something I know of other than the In ternet and satellite based stuff, I think they may have done one pres entation, but I did not see it. Interviewer 2: Just a quick follow up, have there been any discussions about chemical attacks or chemical weapons or a tanker spill or something? Respondent: In this county, they got going on a kind of HAZMAT type of squad that works. They have some suits. We got some of that funding that came down after 9/11 for the biological the cl ass A stuff. Yes, there has been some discussion. They have had a c ouple of exercises with hazmat teams on how to handle those things. We dont have anything here except the personal protection pack.

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206 APPENDIX E DOCTOR DAVIS INTERVIEW TRANSCRIPT Interviewer 1: Could you fill me in on your role and activities? Respondent: I am the emergency room direct or. I am also in charge of medical direction for four counties. Interviewer 1: What is the si ze of your active patient load? Respondent: It is hard to say because I work a lot with rescue and pre-hospital stuff. So, my shifts in the E.R. are lim ited to four or five a month. Interviewer 1: What types of mental diso rders do you think you would see in patients following a terrorist attack, like the at tack on the World Trade Center or a disease outbreak? Respondent: I think that you would see the anxi ous people. The people that think they are infected. The person who is sn eezing and knows it is Anthrax instead of the flu. Those that have a stom ach virus and think it is botulism or salmonella poisoning. You will see depression. It depends on how big the event is and how many people are involve d. I imagine that some of the schizophrenics, some of the people that have psychosis, will probably need a little bit of understandi ng and help in dealing also. Interviewer 1: Do you have any ideas on how you would deal with it in the E.R., this influx of people who think they are infected? Respondent: I would imagine that we would get public health involved in some way. It depends on the size of the event and the type of the event. We would need counselors and places that we could put people. For an acute event where we were overrun, my guess is we would rely on some of the hospitals to offer us support in some way. It depends on the size. Interviewer 1: How do you think you would identify people with a mental condition versus some kind of direct exposure? Respondent: It might be tough, but by admission or transfer. If you had a fifty-year-old gentleman that complained of chest pain; it may turn out that he has a mental condition. People will have to be admitted. People with headache or diarrhea will have to be ruled ou t from physical causes in addition to the mental aspects.

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207 Interviewer 1: What do you think are the best treatment options for people that might develop mental disorders af ter these kinds of events? Respondent: Again, it depends on the event. Some of them will need one-on-one counseling. Some of them may need medication adjustment. Some of them will do well in a group setting. Y ou have stress de-briefers, but there is controversy over that being the ap propriate treatment. I think that everybody needs to have whatever he or she needs to deal with it. Some people may say that they will handle it themselves. There is no standard on how to react when someone dies. Some families want to be right there when they die. Some family members need a minute. Some people dont want to see them until they get to the funeral home. Interviewer 1: Are you aware of any risk factors for developi ng mental disorders following these kinds of events? Respondent: I know that depression will be. It will go back to the type of event, how closely it hit home, family or wor kplace. It will vary for everybody involved. Interviewer 1: Any types of pa tients or demographic aspects th at might increase the risk of developing a mental disorder? Respondent: I think it depends on peoples background. Interviewer 1: How do you thi nk a bioterrorist event would change how you assess, treat, or monitor people for mental health? Respondent: If an event occurred, then the pe ople that we see in th e E.R., unless we can specifically attach a broken bone, we would need to look at why the event occurred. Chest pain, nausea, and he adaches those would have to be looked at in a different light. You just dont know where that is coming from. We would rely heav ily on family practices in the area. An initial screen might be a little suspicious so we refer them back. We see a lot of people that may have wor krelated injuries. They may not be sleeping well. We would see more domestic violence and more accidents due to the event. Interviewer 1: Do you see patients now who pr esent with chest pain or shortness of breath and it is just anxiety? Respondent: Yes. They come to us and we ha ve to do a fair amount of screening. A lot of times, they might just want a gene ral reassurance. But, we have to assume that it is the worst of the things. Someone who comes to the emergency room with chest pain will be treated as if they have underlying

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208 coronary disease or lung disease or GI disease until we can prove otherwise. Unfortunately, a lot of an xiety, depression the minor neuroses are included in that. You will probably see a lot more alcoholics too. A lot more people will drink when they are pressured. Interviewer 2: Have you been offered or gone to any in-services or other training about bioterrorism? Respondent: Lots of them. Interviewer 2: Have you gone to any of them? Respondent: Piles of them. Interviewer 2: In terms of these types of in -services or other disc ussions that you have had about bioterrorism, have you had inte ractions with family practitioners or others from the community, who arent necessarily affiliated with the hospital? Respondent: We have met with the county em ergency management director. We have talked with the fire department. Ju st talking about it and planning. We have done some drills. My position a llows me to attend a fair amount of the meetings. The state E.M.S. meeti ngs educate me there. The [local] county puts a fair number of classes on. From a bioterrorism standpoint about mechanics of Hazmat, we have ha d classes here and there. I will get our people prepared to handle the actual event itself. There are small group discussions. Theres a lot of as king what if, how do we handle such and such? The first wave of people that we will see will be the mental health people. The people who truly have an exposure to the event will probably remain on scene. The people that show up at our door will get in their car and drive here and will ab solutely know that they have had exposure. A year ago October we had a continuing education program. Mr. D. was here from [the nei ghboring county]. We did a physician continuing education day. A lot of it was for the required stuff for licensing. Mr. D touched on a fair amount of the bi oterrorism stuff. We were talking about smallpox and anthra x, and he covered them. We had ninety-five physicians out ther e. So we hit it all. Interviewer 2: Are there any particular barriers to accessing car e that your patients confront either the E.R. or the clinic? Respondent: I hope not. Insurance status is not we take everything. We pride ourselves on having good access. Interviewer 2: What about be ing able to get medications for patients? Are there any particular barriers for getting medicati ons for patients without insurance?

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209 Respondent: Not really. Im sure we try to get them samples. Some things you cant get in samples. Until it goes into generic, you cant get them. The majority of them you can get. In the emergency room, we may prescribe something. But, we give them a limited supply and an order to see someone else. You can go to the health department. There is a relationship between them and Eckerds to get medications at a reduced rate. Interviewer 2: How important do you think it is for healthcare providers to receive training about bio-terrorism or public health emergencies relative to other things they have to deal with (scale of 1-10)? Respondent: I am a gray person. I would expe ct that our E.R. peopl e would be a nine. Certainly our family practice stuff woul d be a three. Do I ask some of them to come and help with triage in an emergency if we are overwhelmed? That would be probably a five or six for him. Do I expect the surgeon to know? That is probably a two or three for him. Its not what he deals with. The E.R. nurses will be a nine or ten. The nurses on the floor will be a three to a four. They may need to do stuff in the office with coordination of patients. She can place things together better than me. People upstairs may not see what we are seeing. If there are four, one of them might pick up on it. Yes, th ey need a level of awareness, but are they going to treat it initially, probabl y not, especially with a known event. FOOTNOTE: Interviewer 2: Just one quick comment. At th e end, I asked if the participant is from the local community. He lives in the area.

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210 APPENDIX F DOCTOR JONES INTERVIEW TRANSCRIPT Interviewer 1: What is your position here? Respondent: Medical director. Interviewer 1: You also are i nvolved in direct patient care? Respondent: Yes. Interviewer 1: About how many pa tients would you see in a week? Respondent: We average from eighteen to nine teen a day in the summer and twenty-two to twenty-three a day in the winter. Interviewer 1: How many would you personally see in a week? Respondent: About one hundred to one hundred and ten. Our biggest barrier to specialized care is being able to get people in. Any specialty careinsurance is a hurdle. We get thi ngs back from Hospital X saying that they do not have the capacity to take care of them in a timely fashion. That is understandable because they are the referral center for everywhere. You get letters from Medicaid saying that they will not serve certain counties. If you are on Me dicaid, you need to move to this county because you wont get specialty care in this c ounty. We have some providers, but it is a stumbling block. Interviewer 1: What kinds of things do you th ink you would be likely to see in patients after bioterrorist events? Respondent: You will have an exacerbation of most peoples anxieties. Depending on what kind of bioterrorism you are talk ing about, you might need to deal with post-traumatic stress disorders. It may not be long-term. There will be a component of stress and shock. Going through that type of situation or being in fear will wear on them. If you look, we all noticed that after 9/11. There was an increase in people in the E.R. They came in and asked if there was exposure or whether they could be tested for things. Interviewer 1: What do you think the best tr eatment options are fo r people that develop mental disorders after a bioterrorist attack?

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211 Respondent: I think counseling is our only choice. You will have depression and anxiety after an attack. I would put those under adjustment disorders. Interviewer 1: Are you aware of any risk f actors for developing me ntal health problems after these kinds of events? Do you think there are certain kinds of patients that are more likely to develop something? Respondent: If you have anxiety, you will ha ve problems with anxiety. If you have depression, you will have problems with depression. A.D.H.D. will be complicated. All of them will be complicated. I think that the people that already have a diagnosis will be at risk for worsening. Interviewer 1: You mentioned that barriers can get in the way of accessing healthcare in general. Are there other things that get in the way? Respondent: Yes, economic barriers and transpor tation. We are seeing that more with the cost of gas. A lot of families only have one vehicle. If dad is at work, the mom may have the child, but there is no way to get here. For people on fixed incomes we feel it, but it wont stop us from getting to our job or appointment. If you are making substant ially less than that, it is a big increase in your budget. A lot of people around here also have cars that are older and less efficient. Interviewer 1: Do you think that these ba rriers might change following an event? Respondent: Yes. It depends on what kind of event we are talking about. If you have a major event, everything becomes more costly. I think that the resources and specialty care supply will go down. Interviewer 1: What do you think could be done to get rid of some of these barriers? Respondent: If you look at [a nother county], they are l ooking at a transportation service. I think that you will begin to see certain organizations provide services for people who do ha ve Medicare/Medicaid and use transportation services. They are relatively affordable. Local and larger government agencies will look at that There is no mystery to everybody that prevention is less expensive than treatment in the long run. The only problem is that it costs and the govern ment only has so many resources. Do I think there will ever be a day where we will have socialized medicine? I do not think it will happen in the next twenty years. It may, but we will have to be good leaders of the programs we are in charge of. We need to minimize the hurdles. Interviewer 1: How do you think a bioterro rist attack might change how you monitor patients mental healthcare?

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212 Respondent: You just have to move it to the front. It has to be on the forefront. You have to have a screening question. I think the majority of people would look at a list of differentials. Y ou have to look at blood sugar, blood pressure, anxiety, and depression. It will worsen all of them. Stress itself is not healthy for the body. Interviewer 1: What kind of physical hea lth problems do you think you might encounter following a terrorist or bioterrorist attack? Respondent: It would depend on what the attack entailed. If we are looking at someone running into the fertilize r plant, then you are l ooking at respiratory problems. If we are crop dusted wi th Anthrax, you look for respiratory problems. It would depend on the event. Here it is a little harder because we are not as concentrated. You will have all of the symptoms, whether they are real or thought up. If you l ook at Anthrax, you get a fever, cold, and cough. How many people do we have that have that? For a lot of the airborne stuff, the early symptoms are similar to the common cold. It depends on what it is. Those symptoms will explode. You need a way to triage them and move them on. Interviewer 2: Are there any different barri ers to accessing medical care for infectious diseases? Respondent: The majority of them will be financial. It depends on if you have a payer. Next will be transportation. T hose are the two biggest ones. Interviewer 2: Have you had any opportunities or in-services to lear n about bioterrorist agents? Respondent: Yes we have had opportunities. But, have we taken advantage of the opportunities? No. Interviewer 1: How important do you think it is for healthcare providers to receive training for bioterrorism or othe r public health emergencies? Respondent: It is important. I would say that relative to th e other things, a five or a seven. Some people will ask why not a ten. Bioterrorist acts may happen and can happen, but the everyday re alities of dealing with peoples problems happen every day. You have so many hurdles to get there that you need to make choices. You need to decide if you are going to train on mental health or the in-services you n eed. We need and are prepared. Interviewer 1: We can close out by asking if there is anyt hing else you would like to tell us? Respondent: The biggest hurdles we face are financial and transportation. They go together. Specialty care is also a hurdle It is a big hurdle. It is easy for

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213 us to allow bioterrorism to drift back on the priority plate. It is good for people to bring it forward because it can happen. I think we will look at more of a natural disaster or expl osion here. Somebody could always do something crazy at one of the high school events. We have done some kinds of discussion with th e health departments about the disaster plan. If you could fix those barriers, that would be great. Footnotes: Interviewer 2: The physician who we intervie wed was the first person to openly express concern about being taped. He indica ted that it might impact the way he responded. I do not think th at was the case. He seemed pretty open to me.

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214 APPENDIX G DOCTOR BROWN INTERVIEW TRANSCRIPT Interviewer 1: What types of mental disord ers do you think you woul d be likely to see following bioterrorist or terrorist attacks? Respondent: Most of the time when you think of bioterrorism, you think of agents that are physically capable of morbidity and mortality. For instance, conditions affecting skin and mucous membranes, gastrointestinal, and airborne or respir atory kinds of things. It can also create hysteria and anxiety. Depending on how it is handled it can turn an individual into a depressive type with feelings like hopelessness, helplessness, and a what am I to do type of environment. That would be the same as any other type of disaster scenario. Interviewer 1: How would you manage patient s that you suspected might have a mental disorder following these kinds of events? Respondent: The first is education. We have monthly provider mee tings. I do not care if it is anthrax or smallpox. We do vaccinate against smallpox. We get updates from the Department of Hea lth. We talk about our disaster preparedness. We have our own clinical plan that would come into play. We plan for resources. Interviewer 1: What do you think are the best treatment options for people who develop mental disorders following these kinds of events? Respondent: The best would be one-to-one and group counseling. Access to mental health counseling is extremely importa nt; dove tailing that with discussion with and treatment by their primary car e physician is also very important or integration of their primary car e provider with the counseling. Someone or an organization that they tr ust. The first step is reassurance that this is what is going on and that there are some stable things here. I think that medication can be important. On a larger scale, I remember the bioterrorism in Dallas with those pe ople getting Salmonella poisoning. Also, it has been ten years since the train in Japan and since those people had the gas. It is all different types. 9/11 affected everybody here. Interviewer 1: What kinds of things can ge t in the way of accessing healthcare for people served at this clinic?

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215 Respondent: There are so many blocks to acce ss of care. Transpor tation is certainly one. Funding is a big one. Interviewer 1: Are you aware of any risk f actors for developing me ntal health problems following a bioterrorism or terrorism event? Respondent: No, I think using some common se nse that past history of post-traumatic stress disorder or any type of invol vement in war, criminal, and stressrelated issues that come from senses of loss of control and co-morbidities, like anxiety and depression. Interviewer 1: How do you think a bioterro rist attack change how you would monitor patients mental healthcare in the weeks or months following the event? Respondent: We would first identify that it is an issue by educating providers and the staff. That would be number one. Then, rearranging schedules for our mental health counselors that are in the community and the three centers by making them more available, in creasing awareness, preparing for different schedules, after hours, and ex tended hours. We are lucky to have a pharmacy here. And because of the a ssociation with the other healthcare providers in the area, if we needed more intensive care we would include the hospital as well. The communicati on between us and [other clinics] would also be involved. Interviewer 2: How important do you think it is for healthcare providers to receive training about bioterrorism or hea lth emergencies re lative about other things they may get educated or trained about? Respondent: I think that it is certainly a place for it. We all recognize that. It was lower in the list before 9/11. It is the world in which we live in. I think that we all recognize that. Do we s ee Anthrax everyday? No, but it does come up. I have never seen a case of smallpox. But, nonetheless we know what it looks like. Is it somethi ng that we have studied? No, but, we are all aware of it. The way th at we present the updates from the department of health to the providers probably goes in one ear and out the other. But, I think that enough is reta ined. Recognizing trends in patterns is talked about. Interviewer 1: Is there anything else that you think we should talk about that we have not had a chance to bring up today? Respondent: No.

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216 APPENDIX H DOCTOR PHILLIPS INTERVIEW TRANSCRIPT Interviewer 1: If we could just ask a few questions about your position here. What is your position here and what kinds of activities are you involved in? Respondent: I am a senior physician. I am ma inly a clinical doctor. I do pediatrics here. I see patients; really hands on tr eating them. I treat them five days a week. Interviewer 1: How would you estimate the si ze of your active patient load right now? Respondent: I can give you a ballpark. If you base it on the number of patients a day, it depends on the season. But maybe, I would say twenty, at least twenty a day. Interviewer 1: What types of mental disorder s do you think you would be likely to see in your patients following such an event that is bioterrorism? Respondent: Panic attack, anxiety diso rders, and generalized anxiety. Interviewer 1: What do you think are the best treatment options for children who develop mental problems after th ese kinds of events? Respondent: Counseling on a long-term basis. It depends on how much understanding you have about the situation. Interviewer 1: Are you aware of any risk f actors for developing me ntal health problems after these kinds of events? Respondent: No, and yes, depending on how th ey were before. There are a lot of situations in life and how they react to that one. Past experience can tell me if its going to be a bad reaction ag ain this time. Family history is important also. Some teenagers, especially, they mimic what the parent does. If it runs in the family, there is a high probability that the children will have similar symptoms. Interviewer 1: How do you think a bioterro rist attack might change how you monitor patients mental healthcare in the weeks or months following the event? Respondent: How do I think it would affect me?

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217 Interviewer 1: How would it change how you w ould monitor patients mental healthcare? Interviewer 2: Would you do a nything different perhaps? Respondent: Yes. It depends on what kind of bi oterrorism attack is there. A lot of it will be reassurance, Interviewer 1: So, you would be more inc lined to use some kinds of psychological education or reassurance? Respondent: Psychological and medical, in term s of these are the kinds of things to look for. A lot of them w ill have a fear of dying. Interviewer 1: What type of medical conditions would you be on the lookout for following these kinds of events? Respondent: It depends on the kind of event. If it were a respirat ory event, we would look for respiratory symptoms, so it is dependent. Interviewer 1: What about with smallpox? Respondent: We would look for a rash and a fever. Interviewer 1: Have you had any opportunities to learn about bioterrorism? Have you had in-services and training? Respondent: Yes. Interviewer 1: Have you done any reading on your own? Respondent: Yes, the journals, the medical journals. A lot of time reading them, depending on what the situation or crisis is. They will have issues or discussions about them. It is not co ming from the public health point of view. It is coming from the Ameri can Academy of Pediatrics, what you have to do as a private practitioner. It is more on that aspect rather than on the public health point of view. Interviewer 1: Do you think it is important fo r healthcare providers to receive training for bioterrorism or public health? Respondent: Yes, as the public gets informati on, if they want information, I am sure they will be directed to the health department. It is important for our people to know what information and an swers to give. They need to be consistent in information.

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218 Interviewer 1: Is there anything else that you would like to tell us about physical, mental health conditions in relation to bioterrorism? Respondent: I am just curious what will th is research end up producing. They are cutting down the existing resources. The doctors are so overwhelmed. The number of cases has increased, but the number of providers has not.

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235 United States Census Bureau: State and County Quick Facts. Data Derived from Population Estimates, 2000 Census of Popul ation and Housing. Available at http://quickfacts.census.gov/qfd/states/12000.html Accessed on July 13, 2006. United States Federal Emergency Management Agency. Emergency Preparedness. 2003. Available at http://www.fema.gov/ Accessed on November 30, 2005. United States Government Accountability O ffice, Bioterrorism: Preparedness Varied across State and Local Jurisdicti ons. Washington, DC: April 2002. United States Government Account ability Office. Available at http://www.gao.gov/ Accessed on October, 22, 2005. Washington, DC: 2003. United States Government Accountability O ffice. Hospital Preparedness: Most Urban Hospitals Have Emergency Plans but Lack Certain Capacities for Bioterrorism Response GAO-03-924 Available at http://www.gao.gov/docdblite/summary .php?rptno=GAO-03-924&accno=A07875. Accessed on October, 27, 2005. Varkey P, Poland GA, Cockerill FR, Smith TF, Hagen PT. Confr onting Bioterrorism: Physicians on the Front Line. Mayo Clinic Proceedings 2002; 77(7): 661-672. Waeckerle JF. Disaster Planning and Response. The New England Journal of Medicine 1991; 324 (12), 815-821. Wallace R, Grindeanu LA, Cirillo DJ. Critical Issues in Rural Healthcare. Chapter 2: Rural/Urban Contrasts in Population Morbidity Status Blackwell Publishing, Ames, IA, 2004, 22-23. Websters Ninth New Collegiate Dictionary. 1984. Merriam-Webster, Springfield, MA. Weiss RS. 1994. Learning from Strange rs: The Art and Method of Qualitative Interviewing. Free Press, New York, NY, 17. Wetter DC, Daniell WE, Creser CD. Hsopital Preparedness for Victims of Chemical and Biological Terrorism. American Journal of Public Health 2001; 91: 710-716. Wild J. 1955. The Challenge of Existentiali sm. Indiana University Press, Bloomington, IN. Wolcott HF. 1990. On Seeking-and RejectingValidity in Qualitative Research. In E.W. Eisner & A. Peshkin (Edito rs), Qualitative Inquiry in Education: Continuing the Debate. Teachers College Press, New York, NY. Wolcott HF. 1995. The Art of Fieldwork. AltaMira Press, Walnut Creek, CA. Wolff KH. Surrender-and-Catch and Phenomenology. Human Studies 1984; 7 (2), 191210.

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236 Wolper L, Gans D, Peterson T. Bioterrorism Visits the Physicians Office. 2003. In J Blair, M Fottler & A Zapanta (Editors), Bioterrorism, Preparedness, Attack and Response: Advances in Healthcare Mana gement. JAI Press/Elsevier, London, UK, 3-24. Yin RK. 1994. Case Study Research: Desi gn and Methods. Second Edition. Sage Publications, Thousand Oaks, CA.

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237 BIOGRAPHICAL SKETCH As a health services researcher enga ging in a constructivist study of rural physicians and healthcare provi ders perceptions of emer gency preparedness and the barriers to preparedness, I have personal experiences as a phys ician and at times in rural settings. I am a native Floridian, who returned to the state of Florid a four years ago. In addition to residing in the state where the primary data have been collected, I have practiced medicine in the state, albeit not in an area that would be classified as rural. Prior to beginning the doctoral program at the University of Florida several years ago in the Department of Health Services Research, Management and Policy, I practiced primary care medicine and have been a healthcar e consultant. In those roles, I have been responsible for coordinated acu te and chronic patient care in volving general internal and family medicine, and emergency medicine in the hospital, nursing homes, and outpatient settings. I also have experience in creati ng and instituting disease protocols in chronic disease management and conducting other hea lthcare consulting research serving as a medical editor for an alternative and complementary medicine firm. In addition to clinical ex perience as a physician and as a healthcare consultant, while at Harvard University, I was formally educated on disaster management through didactic courses and seminars. While at Harvard, I created with the assistance of another physician colleague a public health/bioterrori sm website on Nuclear Disaster Management entitled Chernobyl: Anatomy of a Disaster. Recently, as an adjunct faculty member at the University of Central Florida, I created and currently instruct a

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238 course entitled Health Issues in Disaster Preparedness. This course focuses on disaster preparedness and the related mental and physic al health issues fo r natural catastrophic eventssuch as hurricanes and earthquakesas well as human-caused disasterssuch as bioterrorism. Beyond professional activities, I have pers onal life experiences that are noteworthy and related to disasters. I, unfortunately, lost a colleague and more importantly a dear friend with whom I worked at the United States Department of Health and Human Services. He was present on one of the airp lanes that departed from Washington, D.C., on the morning of September 11, 2001, and was subsequently hijacked and crashed.


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PERCEIVED BIOTERRORISM PREPAREDNESS AND THE IMPEDIMENTS TO
BIOTERRORISM PREPAREDNESS OF RURAL PHYSICIANS















By

GAVIN JOSEPH PUTZER


A DISSERTATION PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF
DOCTOR OF PHILOSOPHY

UNIVERSITY OF FLORIDA


2006

































Copyright 2006

by

Gavin Joseph Putzer, MD, MPH

































This document is dedicated to Mom and Tricia.















ACKNOWLEDGMENTS

I thank my Mom for her constant and unremitting emotional support, guidance, and

love.

I thank Tricia for her unending emotional support and love.

I thank my health services research and policy mentor, Paul, for his expertise,

guidance, and support.

I thank my qualitative research mentor, Mirka, for her research methodology

expertise and insight, advice, and support.

I thank my other committee members for their insight and support.
















TABLE OF CONTENTS


A C K N O W L E D G M E N T S ................................................................................................. iv

LIST OF TABLES ............ .................. .... .............. ............ ........... .. viii

LIST OF FIGURES ......... ........................................... ............ ix

A B STR A C T ................................................. ..................................... .. x

CHAPTER

1 IN T R O D U C T IO N ............................................................................. .............. ...

2 BACKGROUND AND LITERATURE REVIEW ..............................................12

B ackgrou n d of D isasters.................................................................. ..................... 12
Terrorism H history and Perceived Threat ........................................ .....................15
N national Preparedness Efforts ............................................................................. 17
Rural Areas and Vulnerability to Bioterrorism .................................. ............... 20
Local Preparedness Efforts and Public Health ........................ .......................... 22
Physician Perceptions of Bioterrorism Preparedness: A Review of the Literature
R regarding N national Studies.................. ..... ...... ....... ................. ...25
The Public Health System and Primary Care Physicians Perceptions of
Bioterrorism and National Bioterrorism Preparedness .......................................37
Physician Perceptions and Knowledge of Bioterrorism Preparedness: A Review
of the Literature Regarding Local Studies ....................................... 52
Specific Research Questions and Contribution to the Literature.............................. 62

3 EPISTEMOLOGY, THEORETICAL PERSPECTIVE & RESEARCH
M E T H O D S ......................................................... ................ 6 7

Ontological and Epistemological Considerations.....................................................70
Theoretical Perspective: Constructivism ........................................ ............... 73
M e th o d s ........................................................................... 7 6
P a rtic ip a n ts .............. .. ............................................................... .............. 7 7
Selection C riteria and Sam pling ................................... .................................... 77
D em graphic Inform ation ............................................................................80
D ata Collection ......................................... ... .............................................. 82
My Role in the AHRQ 1 UO1 HS14355-01 Grant ............................................82
In te rv ie w s ...................................................................... 8 3









D ata A nalysis................................................... 86
C oding and M em os........... ....... ..................................................... .... .... .... .. 89
Constant Com parative M ethod ................................... ................................... 92
T h eory B u ilding ........... ........................................................ .... ............ .. 92
V alidity and C consistency ................................................... ........................ .93
Subjectivity Statem ent .................. ............................ .... .. .. .. ........ .... 101
L im stations ..................................................................................................... 103

4 FINDINGS ....................................................................... ........ 108

Physician Professional Preparedness and its Associated Elements: Cognitive
Preparedness, Clinical Preparedness, and Expectation Preparedness..............115
M ental and Em otional H health ........................................................ ............. ..117
P hy sical H health ......................... ......... ............................... ............... 12 1
Risk Factors for M ental Illness or Physical Illness ...............................................124
Physician Professional Preparedness and its Associated Elements: Simulation
Preparedness, Expectation Preparedness and Resource Preparedness................ 129
Physician-Patient R elated B barriers ........................................ ........ ............... 134
Access Barriers .................................... .....................................135
Com m unication Barriers .............................................................................139
K now ledge B barriers ..................................... ...... .. ...... .. .......... .. 141
M medical Interventions .................. ............................ .... .... ... ........ .... 144
M mental H health Interventions ................................................... ................. 145
M ental and Physical H health Interventions....................................................... 147
Physical H health Interventions...................................................................... 149

5 DISCUSSION AND CONCLUSIONS ...........................................................152

Salient P points for D discussion ................................................... ........... ................ ... 152
Key Findings Regarding Rural Physicians' Professional Preparedness................. 154
Health Policy Options & Implications Regarding Physician Preparedness ............159
Key Findings Regarding the Rural Healthcare System's Preparedness................. 162
Health Policy Options & Implications Regarding System Preparedness...............64
Key Findings Regarding Physician Perceptions of Rural Patient Factors..............167
Health Policy Options & Implications Related to Patient Factors .........................171
Future R research Q questions ............................................... ............................ 173
Conclusion ..................................... ................................. ......... 175

APPENDIX

A IN TER V IEW Q U E STIO N S .....................................................................................176

B QUALITATIVE INTERVIEW CODING CHART .............. ................177

C DOCTOR WILLIAMS INTERVIEW TRANSCRIPT ................. .................. 199

D DOCTOR SMITH INTERVIEW TRANSCRIPT............... ................ 202









E DOCTOR DAVIS INTERVIEW TRANSCRIPT ............ ...............206

F DOCTOR JONES INTERVIEW TRANSCRIPT ..............................................210

G DOCTOR BROWN INTERVIEW TRANSCRIPT .............. ...............214

H DOCTOR PHILLIPS INTERVIEW TRANSCRIPT .............. ...............216

L IST O F R E FE R E N C E S ................... ............... ..........................................................2 19

B IO G R A PH IC A L SK E T C H ........................................... ...........................................237
















LIST OF TABLES

Table Page

2-1 Knowledge, Attitudes and Beliefs Regarding Smallpox and Smallpox
V vaccination .................................................................................................... ......32

3-1 Participant Demographic Information....................................... 83

3-2 Clinical Background Inform ation....................................... .......................... 83
















LIST OF FIGURES

Figure Page

1-1 Actual Versus Perceived Bioterrorism Preparedness........ ...... ....... ............11

2-1 O overview of D disasters ....................................................................... 13

3-1 Qualitative M ethod Process .................................. .....................................69

3-2 D detailed Qualitative M methods Process ........................................ .....................77

4-1 Rural Physician-Patient Bioterrorism Preparedness 109









Abstract of Dissertation Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Doctor of Philosophy

PERCEIVED BIOTERRORISM PREPAREDNESS AND THE IMPEDIMENTS TO
BIOTERRORISM PREPAREDNESS OF RURAL PHYSICIANS

By

Gavin Joseph Putzer

August 2006

Chair: R. Paul Duncan
Cochair: Neale R. Chumbler
Major Department: Health Services Research, Management, and Policy

Recent public health emergencies such as the September 11, 2001, terrorist attacks

on the World Trade Center in New York City, the use of anthrax as a bioterrorist tool

against citizens, and other natural disasters in the United States have increased awareness

of the nation's vulnerability to large-scale emergencies. To moderate the risks and

magnitude of public health emergencies deriving from such events, the United States has

made emergency preparedness a priority for public health advocates and physicians. In

particular, scant attention has been given to preparing physicians and other health care

providers in the United States' sparsely populated areas for public health emergencies

such as bioterrorist events. Yet emergency preparedness in rural communities is a

significant issue for the nation given that roughly 80% of United States land is classified

as rural and one-fourth of the United States' population lives in rural areas.

The study utilized the interview data transcripts from six rural physicians as the

primary data with which to explain the state of emergency preparedness of rural

physicians and to explain and better understand the barriers to preparedness encountered

by these rural health care providers. The principal objectives of this study were to









provide a greater description and understanding of rural physicians' perceived

preparedness regarding public health emergencies such as bioterrorist events.

Physician participants expressed a lack of bioterrorism preparedness in five facets:

cognitive, clinical, expectation, simulation and resource preparedness. In essence, rural

physicians were unaware of the pertinent signs and symptoms of bioterrorist-inducing

agents, the relevant risk factors, and the appropriate therapeutic treatments. Additionally,

rural physicians described their expectation preparedness as low. Physicians explained

that although simulation exercises and corresponding training opportunities existed, many

of them had not availed themselves to these endeavors. A dearth of resources,

specifically a lack of specialty physicians, was also cited. Thus, rural physicians felt less

than fully prepared both intellectually and professionally for a bioterrorist event.

This study discovered that, although there are knowledge gaps in physician's

bioterrorism education and training, these gaps appear to be the result of personal choice

and discretion. This study substantiates that there appears to be a significant need to take

additional decisive steps to encourage rural physicians to attend bioterrorism

preparedness seminars. Furthermore, it appears there is a compelling need for improved

preparedness regarding bioterrorism knowledge surrounding the associated important risk

factors and therapeutic medical interventions for bioterrorist infectious agents.

Furthermore, it appears from this study that if rural physicians are provided with a greater

number of resources financial, educational and technological -they will inevitably feel

better prepared and perceive more auspicious health outcomes for their patients. Thus,

strategically implemented health policy objectives can have a tangible impact on the

impediments identified in this study which have hindered rural physician preparedness.














CHAPTER 1
INTRODUCTION

Natural disasters such as earthquakes, tropical cyclones, floods, and volcanic

eruptions have claimed approximately three million lives worldwide during the past 20

years, have adversely affected the lives of at least 800 million more people, and have

caused more than $50 billion in property damage (Office of US Foreign Disaster

Assistance, 1995; National Academy Press, 1987). Worldwide, a major disaster occurs

almost daily, and natural disasters that require international assistance for affected

populations occur weekly (Binder & Sanderson, 1987).

Today, with increasing frequency, the global community is witnessing complex

human-induced disasters such as terrorist attacks resulting from the breakdown of

traditional state structures, armed conflict, and the upsurge of ethnicity and

micronationalism (Noji, 1997). The cause of these human-induced emergencies as well

as the assistance provided to the afflicted is influenced by intense levels of complex

political, social, and economic considerations (Noji, 1997). The number of refugees

affected by a combination of natural and human-induced disasters has increased

significantly over the last two decades to an estimated 17 million, and the number of

persons displaced through other causes, though difficult to estimate, is probably just as

large (Noji, 1997). With both human-induced disasters and the number of their victims

increasing, disasters constitute a major public health problem. According to a United

States Centers for Disease Control and Prevention (CDC) study, the economic impact of

a bioterrorist attack scenario with anthrax as the agent per 100,000 citizens exposed









would be approximately $26.2 billion (Kaufman et al., 1997). In the absence of an

intervention preparedness program for the 100,000 persons exposed, the anthrax cloud

would result in 50,000 cases of inhalation anthrax, with 32,875 deaths (Kaufman et al.,

1997). Although a large-scale bioterrorist attack of that magnitude has not yet occurred

in the United States, the brush with anthrax in October 2001 filled every American with a

sense of fear and foreboding (Fottler, Scharoun, and Oetjen, 2004).

The widespread national media attention belied the fact that only five mortalities

and 22 persons were actually contaminated from the anthrax bioterrorist attack. Yet our

initial response to the anthrax attacks was marred by misinformation, confusion, and

widespread public alarm which predominantly flowed from the lack bioterrorism

preparedness. The fear of the unknown gripped Americans as individuals flocked to

doctor's offices and emergency departments worried that they might have come in

contact with anthrax. They demanded screening and testing for exposure to anthrax, and

begged for prescriptions for antibiotics deemed effective for treating anthrax exposure.

Although only 22 individuals were infected, more than 10,000 people took antibiotics as

a precautionary measure (CDC, 2005). Alarmingly, as panicked as the American public

was with this anthrax scare, a full-blown release of a biological agent could cause

immeasurably greater levels of chaos, panic, and mass hysteria (Fottler et al., 2004).

Consequently, it is particularly important that front-line healthcare responders such as

primary care physicians are well trained and educated regarding bioterrorism agents in

order to present clear information to allay the fears of patients and the general public.

The recent public health emergencies such as the September 11, 2001, terrorist

attacks on the World Trade Center (WTC) in New York City and the use of anthrax as a









bioterrorist tool against citizens in the United States have increased awareness of the

nation's vulnerability to large-scale emergencies. Bioterrorism is now perceived as a real

threat to public health. Many healthcare facilities have created emergency operations

plans, but it is very questionable if all of our healthcare facilities can effectively respond

to a bioterrorist attack (Fauci, 2002; Grow & Rubinson, 2003; Leavitt, 2003; Macintyre

& Deatley, 2001). A number of reports have continued to show that public health,

healthcare facilities, and local and state governments are not ready for a bioterrorist event

(Blair et al., 2004). For example, the most recent one on hospital preparedness by the

U.S. Government Accountability Office (2003) came to that conclusion regarding urban

hospitals. One may expect even less preparedness from rural hospitals (Blair, Fottler, and

Zapanta, 2004). Perhaps the most disturbing information is that hospitals may be more

prepared than before, but physicians' offices and ambulatory clinics are not (Wolper et

al., 2003). This is particularly problematic because most biological agents result in flu-

like symptoms. Thus, it is far more likely that in the early stages for infected or

contaminated patients in the early stages to visit their family primary care physicians than

to frequent the emergency department of a hospital.

To moderate the risks and magnitude of public health emergencies deriving from

such events, the United States has made emergency preparedness a priority for

government and military agencies, public health advocates, law enforcement, physicians,

and other first responders. Although much of the aftermath of these events has resulted

in an increased focus on agencies in urban areas (McHugh, Staiti, and Felland, 2004), it

has also become clear that such a focus is necessary in rural areas. Rural areas are

especially vulnerable to bioterrorism for a number of reasons (Stamm, 2002; Office of









Rural Health Policy, 2002). National energy sites, nuclear sites, and hazardous materials

manufacturers are often located in rural areas. In the advent of a bioterrorist event, rural

communities may encounter a mass exodus of many urban residents to neighboring rural

areas. Such an event could conceivably overwhelm the existing rural health

infrastructure. Additionally, many rural communities are less well defended with respect

to urban areas making them easier targets to release bioterrorist agents. Yet little

attention has been given to preparing physicians in America's sparsely populated areas

for public health emergencies such as bioterrorist events, even though experts warn the

risks such incidents would pose to human health appear equally great in rural and urban

areas (Stamm, 2002; Wetter, Daniell, and Creser, 2001; Treat et al., 2001).

Unfortunately, there are few data to quantify emergency preparedness in rural

communities (Clawson & Brooks, 2003; Stamm, 2002; Office of Rural Health Policy,

2002). If emergency-related resources in rural areas are lacking, rural readiness for

future emergencies may be compromised (Clawson & Brooks, 2003).

Emergency preparedness in rural communities is a significant issue for the nation

given that roughly 80% of United States land is classified as rural (Office of Rural Health

Policy, 2002). One-fourth of the United States' population lives in rural areas. Rural

communities are found in all states, and 65 million Americans live in these communities

(Glasgow, Morton, and Johnson, 2004). Adequate emergency preparedness in rural

communities depends on coordinated efforts among public health departments,

community health centers, hospitals, and physicians. However, rural public health

departments tend to have less capacity and resources as well as less epidemiological

surveillance capacity than their urban counterparts. For example, physicians and mental









health providers are much less common on a per capital basis in rural settings than in

metropolitan or urban settings (Office of Rural Health Policy, 2003; Wallace, Grindeanu,

and Cirillo, 2004). Further, in comparison to urban communities which typically have

several hospitals, in many rural communities a single hospital may be the only nucleus of

health planning, activity, and resources for the entire community (Office of Rural Health

Policy, 2002). However, national policy changes have encouraged hospitals to downsize

bed capacity in an effort to contain costs and, as a result, rural hospitals lack surge

capacity for personnel and beds (Office of Rural Health Policy, 2002). Rural physicians,

similar to urban physicians, may lack the training and resources to respond to a public

health emergency such as a bioterrorist event. Rural physicians are also more likely to

provide care outside their specialty areas and do so more often than their counterparts in

urban areas (Office of Rural Health Policy, 2003; Wallace et al., 2004).

Even within the community of rural physicians there is variation in emergency

preparedness for bioterrorist events. Some rural community physicians are completely

unprepared, others are somewhat prepared, and some are taking active steps to achieve a

level of preparedness that is consistent with the inherent unpredictability of these events.

Quite apart from their actual preparedness, physicians have highly variable perceptions of

their preparation. It may be that some are well prepared but perceive themselves as ill-

equipped, whereas others may have misplaced confidence in their degree of

preparedness.

Barriers to improved preparedness have been well documented and must be

overcome in order for physicians to be prepared (McHugh et al., 2004; Blair et al., 2004;

Fottler et al., 2004; United States Government Accountability Office, 2002). These









barriers include but are not limited to a dearth of applicable knowledge and education, a

lack of finances, geographical isolation, a lack of communication or coordination, and a

lack of access. However, we do not know which barriers are most important in impeding

rural physicians' emergency preparedness for bioterrorist events and if rural physicians

are not prepared for public health emergencies such as bioterrorist events because of

these barriers. Thus, we do not know which of these impediments that rural physicians

face are the most important to overcome in attempting to become better prepared for rural

bioterrorist events. Thus, the purpose of this study is to describe and understand the

variation in emergency preparedness for bioterrorist events of physicians within the rural

settings. An additional purpose is to attempt to explain the reasons why rural settings and

rural physicians are unprepared or less prepared than they should be. The final purpose

of this study is to identify barriers to preparedness, thereby elucidating who is better

prepared and why are they perceived as better prepared.

Figure 1-1 illustrates a graphical representation of the four principal spheres of

inquiry that this study will examine. Of the four spheres, the central focus of the research

questions will be to examine the two spheres of perception.

An important distinction needs to be made between actual preparedness and

perceived preparedness. This distinction is salient because actual emergency

bioterrorism preparedness may or may not be synonymous with or equal to perceived

preparedness. Actual preparedness involves tangible experiences such as medical

education and training in identifying bioterrorism agents and the corresponding infectious

diseases. Perceived preparedness involves those very same elements as well as the

individual physician's perception of his/her preparedness. A physician may have had









actual training and education and yet still not perceive himself/herself as being prepared.

For instance, a physician may have learned of the signs and symptoms and how to

identify a bioterrorist incident, but not perceive himself/herself as being prepared because

of the lack of a tangible real-life experience. Thus, one of the spheres reflects actual

emergency bioterrorism preparedness (upper sphere) among rural physicians and the

other reflects perceived emergency bioterrorism preparedness (left sphere).

This same distinction may be made between actual barriers to preparedness and the

perceived barriers to preparedness. A physician may be able to identify actual barriers to

preparedness and these barriers may be rectified a priori to an event. Yet this

amelioration of actual or tangible barriers to preparedness may not even dispel an

individual's perception of barriers to preparedness. This is because individuals may feel

that increased resources, education, or training may assist in mitigating barriers, but may

not completely resolve what is being perceived as a barrier. Thus, the resolution of

perceived barriers may not be possible. Nevertheless, the identification of these

individual perceptions is important because perception is a powerful arbiter of actions

that might influence preparedness. So one of the spheres reflects actual barriers to

emergency bioterrorism preparedness (right sphere) among rural physicians and the other

reflects perceived barriers to emergency bioterrorism preparedness (lower sphere).

This study is extracted from primary data of a larger study funded by the Agency

for Healthcare Research and Quality (AHRQ). This larger study is an AHRQ 1 UO1

HS14355-01 grant entitled "Bioterrorism Preparedness among Rural Florida

Communities." The project is a two-year federally funded project to evaluate









bioterrorism preparedness and health needs in rural North Central Florida and the Florida

Panhandle.

Florida is an important state to examine regarding bioterrorism preparedness for a

number of reasons. As of 2005, it is the fourth most populated state in the nation with an

estimated population of almost 18 million (U.S. Census Bureau). Florida contains 67

counties and 37 are designated as rural counties (U.S. Census Bureau). These rural

counties possess similar attributes, impediments and socio-cultural characteristics that

define rural areas across the United States. Florida's annual tourist population is

estimated to be between one million and four million persons (Clawson & Brooks, 2003).

This includes a significant portion of international visitors, as well as transient tourists

who number over 40 million during any given year (Clawson & Brooks, 2003). Thus, the

implications for preparedness involving rural settings in Florida may be generalizable and

therefore valuable from a policy perspective.

The AHRQ grant project's principal objective is to gain a better understanding of

the treatment of rural residents following the aftermath of bioterrorist and other public

health emergencies. The aim of the project is to promote public health emergency

preparedness, including needs for long-term care, rehabilitation services, chronic physical

ailments, and mental healthcare. Interviews were conducted with key organizations and

individuals across the state of Florida to assess existing resources and response

mechanisms in rural communities to meet anticipated health needs arising from

bioterrorist events. The information obtained from these assessments may serve as the

basis for recommendations to policymakers to improve bioterrorism preparedness in rural

communities across the nation. The assessments will highlight special concerns of









certain priority populations, including women, children and families, and senior citizens.

The project will also develop an intervention to educate primary healthcare providers

concerning important aspects of mental healthcare.

The interviews included questions regarding the organization, annual budgets and

funding sources, services provided at the clinic, and patient socio-economic

demographics. Questions were posed regarding medical and mental heath conditions

commonly encountered at the clinic. Additionally, questions were asked regarding

policies concerning the various medical conditions and training/policies regarding

infectious diseases and other agents that may be used in bioterrorist events.

My research interests combined with my intellectual curiosity and my professional

background within public health and as a physician have fostered unique yet related

research questions to augment the larger federally funded project's objectives. This

study's principal objectives are to describe and explain physicians' perceived

bioterrorism preparedness and the individual perceived impediments affecting

physicians' preparedness. The evidence obtained from this research is intended to serve

as an addition to the core project. It will serve as the basis for policy and clinical

recommendations and possible tools to assist physicians and other healthcare providers to

improve bioterrorism preparedness at medical sites and within health systems.

Thus, this qualitative study will describe the observed state of emergency

preparedness and barriers impeding preparedness from the rural healthcare providers'

perspective. The interviewed healthcare providers were selectively sampled from sites in

rural North Central Florida and the Florida Panhandle and include individual healthcare

professionals who work in rural community health centers (CHC), rural county









Departments of Health (DOH), rural healthcare clinics, and rural private medical offices.

The study will use the interview data transcripts from these sites and six rural physicians

as the primary data with which to explain the perceived state of emergency preparedness

of clinicians and to explain and better understand the barriers to preparedness

encountered by these rural physicians. This study will not focus on empirical testing, but

instead will qualitatively explore the variation or degree to which rural physicians

consider themselves to be prepared for bioterrorist events. In summary, this study will

address two research questions:

What is the perceived bioterrorism preparedness among rural physicians?

How do the perceived impediments hinder rural physicians' preparedness?





































Perceived Barriers to
Emergency
Bioterrorism
Preparedness


Figure 1-1: Actual Versus Perceived Bioterrorism Preparedness














CHAPTER 2
BACKGROUND AND LITERATURE REVIEW

Background of Disasters

A disaster by definition is a calamitous event, especially one occurring suddenly

and causing great loss of life, damage, or hardship (Webster's Dictionary, 1984). A

disaster from a healthcare perspective may be defined as "a catastrophic event which,

relative to the manpower and resources available, overwhelms a healthcare facility and

usually occurs in a short period of time" (Betts-Symonds, 1994). Thus, disasters are

tragedies that overwhelm our communities, destroy our property, and harm our

populations (Waeckerle, 1991).

Disasters in general may be divided into either natural disasters or human-caused

disasters (Figure 2-1). Natural disasters include events such as hurricanes, earthquakes,

and tornadoes. The numbers of natural disasters, the people affected by them, and the

economic costs associated with them have been steadily increasing since the mid-

twentieth century (FEMA, 2003; Alexander, 1997; Berz, 1994; Berz, 1991). The number

of people affected by natural disasters in the last 50 years equals about two-thirds of the

world's population (FEMA, 2003). These natural disasters have claimed approximately

three million lives worldwide during the past 20 years, and have adversely affected the

lives of at least 800 million more people, and have caused more than $50 billion in

property damage (Noji, 1997).














Disasters


Induced Disasters Natural
(Human-Caused) Disasters


Intentional Unintentional

I I
Bioterrorism Other forms of Terrorism








Figure 2-1: Overview of Disasters

In the United States, presidential disaster declarations averaged 35 per year from

1976 to 2002 and were routinely sought for events that exceeded state capabilities

(FEMA, 2003). With both disasters and the number of their victims increasing, disasters

are now recognized as a major public health problem. Every state and territory in the

United States has communities that are at risk from one or more natural hazards (Hays,

1990). The CDC has a principal responsibility to nationally prepare for and respond to

public health emergencies such as disasters, as well as to conduct investigations into the

health effects and medical consequences of disasters (Noji, 1997).

A disaster may also be induced or caused by humans, and this category includes

both unintentional and intentional disasters. An unintentional induced disaster includes

events such as the fire in one of the reactors at Windscale in Great Britain in 1957, the

nuclear explosion at Chernobyl in 1986, or the mechanical failures that led to the release

of volatile radioactive materials in Pennsylvania at Three Mile Island in 1978, whereas an









intentional induced disaster is one in which the principal direct causes are identifiable

deliberate human actions. The global community is witnessing an ever-increasing

number of complex emergencies resulting from the breakdown of traditional state

structures, armed conflict, and the upsurge of ethnicity and micronationalism, including

examples such as Bosnia, Somalia, and Rwanda (Noji, 1997). The numbers of refugees

affected by both natural disasters and human-caused disasters have increased to an

estimated 17 million (Noji, 1997). Another subset of these human-caused intentional

disasters includes acts of terrorism accomplished through the use of biological or

chemical agents, explosives, or radiation.

This study will focus on intentional domestic disasters, or more specifically,

bioterrorist events. Terrorism may be further subdivided into biological terrorism or

other forms of terrorism. Bioterrorism may be defined as the intentional release of

potentially deadly bacteria and/or viruses into the air, food, or water supply (Frist, 2002;

Karwa, Currie and Kvetan, 2005). With the events on September 11, 2001, and the

subsequent anthrax attacks, the once seemingly remote threat of a bioterrorist attack in

the United States is now a reality (CDC, 2001; Borio et al., 2001; Mayer, Bersoff-

Matcha, and Murphy, 2001, Cherry, Kainer, and Ruff, 2003; Jernigan, Stephens, and

Ashford, 2001; Tucker, 1999; Trumbull & Abhayaratne, 2004). The terrorist attacks of

September 11, 2001, demonstrated that the United States is no longer isolated from a

dangerous world or protected by its geography.

The other forms of terrorism include the use of explosives, chemicals, nuclear

weapons, and radiation as instruments of mass destruction. Previous research related to

terrorism such as the WTC disaster on September 11, 2001, will be included and









reviewed as it relates to bioterrorism in general, but the central thrust of this study is to

examine rural physicians' perceived emergency preparedness for terrorism, specifically

bioterrorism, although also chemical and radiation terrorism in the United States post

September 11, 2001. Thus, the emphasis is very contemporary, i.e., late 20th century and

early 21st century.

Terrorism History and Perceived Threat

Historically, there have been relatively few instances of the use of bioterrorist

agents, but recently their use has escalated and the threat of a large-scale bioterrorist

attack has become quite real (Jernigan et al., 2001; Inglesby, Grossman, and O'Toole,

2001). A recent report by the Monterey Institute for International Studies found a total of

121 bioterrorist agent crimes have been committed since 1960, with a reported sharp rise

in them since 1995 (Tucker, 1999). In 1999, there were a total of 175 incidents

accounting for 25% of the total number since 1900. This was followed by a dramatic

peak in 2001 of 629 incidents, although 603 were hoaxes (Trumbull & Abhayaratne,

2004). Although the number of terrorist incidents may have been small by percentage in

2001, the increasingly omnipresent threat and perception of a possible bioterrorist event

and the subsequent hysteria that is produced can be quite disruptive.

Bioterrorism may be defined as the intentional release of biological infectious

agents, including microbes such as Bacillus uambi/ a i% (anthrax), Variola major

(smallpox), Yersiniapestis (plague), or Clostridium botulinum toxin. Bioterrorism in the

United States was seen with the use of Salmonella by the Rajneesh Sect in 1984. This

was a bioterrorist event that resulted in 750 cases of salmonellosis with 45

hospitalizations and zero fatalities (Torok, Tauxe, and Wise, 1997; Tucker, 1999).

Internationally, there were multiple failed bioterrorist attempts by the Aum Shunrikyo









sect in Japan between the years of 1990 through 1995. The sect's failed attempts

consisted of the use of aerosolized anthrax and botulinum toxin with no reported

casualties (Tucker, 1999; Henderson, 1999). And there was a bioterrorist event as

recently as of October 2001 in the United States with the dissemination of anthrax spores

through the United States Postal Service.

Today oceans and borders are readily crossed, making the United States as

vulnerable as other nations to acts of terrorism. International unrest and terrorism have

become all too familiar to Americans. Although the predominant weapons of

international terrorism continue to be improvised explosive devices, as evidenced by the

bombings in London in July 2005 and Madrid in March 2004, acts of biological terrorism

are a potential threat that could have serious immediate and long-term consequences.

Bioterrorist agents could cause mass casualties, resulting in significant morbidity and

mortality, societal disruption, and long-term human and economic hardship (Danzig,

2003; Inglesby et al., 2000). The strain that such events would impose on the medical

infrastructure-from hospital beds and pharmaceutical supplies to emergency departments,

primary care medical offices, and clinics-would probably be unprecedented, especially

given the fact that an attack with biological weapons would not be known in advance

(Karwa, Bronzert, and Kvetan, 2003; Inglesby et al., 2001; Borio et al., 2001; O'Toole,

1999). The scientific advances in the field of microbial genomics, proteonomics, and

related technologies further contribute to the fear of biological weapons use with

potentially devastating results. With the dissolution of state-sponsored biological

weapons programs, the security surrounding this vast intellectual property is questioned,

theoretically making it easier for a rogue nation or radical extremists to buy or steal it for









use in terrorist activities (Karwa et al., 2005). Thus, despite few historical precedents, the

possibility of a large catastrophic bioterrorist attack is quite possible.

National Preparedness Efforts

Prior to the WTC Disaster on September 11, 2001, the CDC was designated by the

United States Department of Health and Human Services to coordinate and lead an

overall planning to upgrade national public health infrastructure and preparedness

capabilities at the local, state, and federal levels to respond to biological and chemical

terrorism (CDC, 2000; Lillibridge, Bell, and Roman, 2000). Examples of this planning

were Project Topoff and Operation Dark Winter, which took place in May and June 2001,

respectively, in the United States. Operation Dark Winter was a role-playing exercise

developed and produced by the Center for Strategic and International Studies, Johns

Hopkins Center for Civilian Biodefense Studies, and ANSER (Analytical Services)

Institute for Homeland Security to test the ability of the federal, state, and local

governments to respond to mass-casualty incidents of biological terrorism (Inglesby et

al., 2001). In the mock disaster, former senior government officials played the roles of

salient leaders as a way of testing the government's communication procedures and other

processes that would be crucial to making decisions about responses regarding a

smallpox attack. During a period of two weeks, the smallpox epidemic dispersed to more

than 20 states and 10 countries, with 16,000 reported cases and 1,000 mortalities (Frist,

2002). The Dark Winter disaster exercise revealed a number of vulnerabilities in

emergency bioterrorism preparedness. Operation Dark Winter suggested that the United

States does not have adequate supplies, effective organizational systems, or the

communication networks necessary to deal with such an attack (Frist, 2002; Inglesby et









al., 2001). The exercise also revealed that the public health system and hospitals would

be rapidly overwhelmed by the enormous increase in patient demand.

Shortly after 9/11, in October of 2001, the anthrax attacks occurred and imposed

enormous burdens on already strained public health systems. Public health

responsibilities after the anthrax attacks included providing expert consultative advice

regarding the appropriate care to anthrax patients, investigating possible contamination

sites, testing of numerous suspected materials, hospital surveillance for new cases,

administration of antibiotic prophylaxis to tens of thousands of at-risk individuals, and

providing risk communication to the public (Gershon et al., 2004). These responsibilities

were in addition to the routine delivery of essential services and affected nearly every

sector of the public health infrastructure, including hospitals, clinics, pharmacies, and

medical practices, all of whom reported a significant rise in the number of patients with

psychosomatic complaints and antibiotic requests (Gershon et al., 2004).

The response to the anthrax attack was a multi-disciplinary effort involving

epidemiologists, public health officials, law-enforcement personnel, government

agencies, laboratory staff, media organizations, health professionals, and others. The

scale of this response exemplifies the resources and planning needed for emergency

bioterrorism preparedness in the United States. Yet no amount of planning could have

produced a good outcome without an astute physician who suspected and diagnosed the

first case and immediately notified the appropriate authorities (Gerberding et al., 2002).

Previous research has shown that optimal preparedness for an epidemic of any infectious

disease requires a multidisciplinary approach (Inglesby et al., 2000; Osterholm, 2001).

This multidisciplinary approach to preparedness includes a coordinated response from









physicians, governments, law enforcement, and civilian authorities (Inglesby et al., 2000;

Osterholm, 2001; Schoch-Spana, 2000; Waeckerle, 1991).

This is equally important in preparing for an event of bioterrorism-the deliberate

release of an infectious agent or toxin-as it is for naturally occurring outbreaks.

Bioterrorism preparedness requires physicians to be aware of the possibility of

bioterrorism at any time (Gerberding et al., 2002, Inglesby et al., 2000). Plans can only

be implemented effectively if physicians are aware of the possibility of bioterrorism,

suspect and recognize an event when it occurs, notify public health authorities promptly

upon suspicion of such an event, and institute appropriate management. Broader public

health aspects of bioterrorism preparedness, including primary prevention measures, are

also important areas for informed action by physicians. Medical education and training

curricula must include information on key potential agents of bioterrorism, and medical

staffs, especially those, such as primary care physicians, who are most likely to see

patients affected by a biological weapon, require continuous education in this area.

Moreover, physicians from other specialties may need sufficient knowledge of the likely

clinical features of potential biological agents in order to recognize patients presenting

with a compatible illness (Gerberding et al., 2002; Karwa et al., 2003, Karwa et al.,

2005).

Today, in the aftermath of these attacks, additional efforts have been undertaken to

enhance the United States' preparedness against biological agents. Proper preparedness

suggests the ability to respond to a threat and prevent morbidity or mortality. The CDC

identified five key components for a comprehensive public health response to an incident

of terrorism: detection (surveillance), rapid laboratory detection, epidemiological









investigation and implementation of control measures, communication, and preparedness

planning (Rose & Larrimore, 2002, Gerberding et al., 2002).

Rural Areas and Vulnerability to Bioterrorism

Rural communities are found in all states and 65 million Americans live in these

communities (Rosenthal, 2003). The lack of a perceived threat to rural communities

often leads to less bioterrorism preparedness (Sterling et al., 2005; Shadel, Rebmann,

Clements, Chen, Evans, 2003; McFee et al., 2004). However, given that 65 million

Americans live in rural locations, many in close proximity to potential military or

economic targets, it is critical that these areas prepare to respond in the event of a

bioterrorist attack (Office of Rural Health Policy, 2002).

Rural areas are especially vulnerable to bioterrorism for a number of reasons

(Clawson & Brooks, 2003; Office of Rural Health Policy, 2002; Rosenthal, 2003; Stamm,

2002). Rural areas comprise the source of most food and farming distribution, so

localized bioterrorism against agriculture could threaten significant portions of the

country. Many cities obtain their drinking water from rural reservoirs with limited

security. Many national energy sites, nuclear sites, and hazardous materials

manufacturers are located in rural areas. Contaminants could be dispersed to cities by

crop duster aircraft originating from rural airports (Stamm, 2002). Although rural areas

are not high profile targets such as the WTC or the Pentagon, they are easier targets

because of limited supervision and security.

Bioterrorism involves the spread of various infectious disease agents in order to

inflict harm or kill others. These agents are a likely choice of weapons by terrorists

because they are easy to conceal and disperse among a population. Bioterrorist agents do









not differentiate between individuals or geographical areas. The use of such agents could

spread through a population rapidly, thus causing implications to the healthcare system.

The anthrax incident in late 2001 exposed some of the public health ramifications

of bioterrorism. The fear of the unknown gripped Americans as individuals inundated

physicians' offices and emergency departments worried that they might have been

exposed to anthrax. Many patients demanded screening and testing for exposure to

anthrax and begged for antibiotics deemed effective for treating anthrax exposure. Thus,

access to care was severely affected during this crisis.

Access to care describes the fit between the patient and the healthcare system.

Penchansky (1981) defines access as a set of five specific dimensions. The specific

dimensions are availability, accessibility, accommodation, affordability, and

acceptability. According to Penchansky (1981), problems with access to care, or more

specifically with any of the component dimensions of access are presumed to influence

patients and the healthcare system in three measurable ways. The first is that utilization

of services, particularly entry use, will be lower. Second, clients will be less satisfied

with the system and/or the services they receive. Third, physician practice patterns may

be affected. For instance, inadequate supply resources may cause physicians to curtail

services, devote less than appropriate amounts of time to each of their patients, or use the

hospital as a substitute for their short supply. The anthrax incident described in great

detail above illustrated and highlighted each of these effects.

A bioterrorist event in an urban area may also result in a mass exodus to a rural

area, overwhelming rural physicians with ill and contaminated individuals (Clawson &

Brooks, 2003). In a study conducted by Rosenthal (2003), it was found that, due to









lack of funding and complacency, many local health departments were unprepared for the

burden of responding to a bioterrorist attack. The Rosenthal study notes that health

departments in rural communities, in particular, are unequipped to provide 24-hour

emergency response. Rosenthal (2003) also explained that nearly 20% of rural health

departments have no Internet access and 10% do not have e-mail, all of which are critical

for instant communication and information. Further, exacerbating rural areas

vulnerability to bioterrorism is the fact that the number of physicians and other healthcare

providers in rural areas is often limited (Clawson & Brooks, 2003). So in the event of a

bioterrorist attack, rural communities may become overwhelmed and not be able to

provide ancillary support for urban communities (Florida Department of Health, 2002).

Moreover, augmenting these vulnerabilities, many rural community physicians do not

feel immediately threatened by a bioterrorist attack, which often results in less

professional preparation (Bartlett, 2001; Chen, Hickner, Fink, Galliher, and Burstin,

2002; Office of Rural Health Policy, 2002; Shadel et al., 2003; Sterling et al., 2005).

Local Preparedness Efforts and Public Health

Achieving local preparedness requires the translation of national policy initiatives

into the implementation of local programs (McFee et al., 2004). Today, an urgent need

exists to take decisive steps to improve bioterrorism preparedness especially among

healthcare professionals (Rose & Larrimore, 2002). Rose and Larrimore (2002) explain

that the current generation of physicians and nurses feel unprepared in both their

knowledge base and confidence levels to deal with potential biological terrorism and its

consequence. Previous research has underscored this point by showing that community

clinicians often are the first to identify potential bioweapon victims yet remain

inadequately prepared clinically to address such events (McFee, 2002; Pesik, Keim, and









Sampson, 1999; Sniffen & Nadler, 1999). Consequently, it has become clear that there is

a pressing need to rapidly educate and train medical personnel on the signs and symptoms

and reporting mechanisms of bioterrorism-related diseases (Gershon et al., 2004). Few

studies have examined bioterrorism preparedness (Gershon et al., 2004), and several

published reports provide evidence of both knowledge gaps and high levels of interest in

bioterrorism-related training among physicians (American Medical Association [AMA],

2005; Heun, 2002; Sigmon & Larson, 2002).

In order to contribute meaningfully to the scholarly literature, we need to better

understand perceptions, awareness, and the extent of emergency bioterrorism

preparedness among physicians. This study will attempt to bridge those gaps and

examine physicians' perceptions of their bioterrorism preparedness and their perceptions

of the barriers to their emergency bioterrorism preparedness. This will provide an

important link in understanding the context under which the research questions for this

study were formulated.

Preparedness is a state of readiness to respond to a disaster, crisis, or any other type

of emergency situation. The Federal Emergency Management Agency further defines it

as "the leadership, training, readiness and exercise support, and technical and financial

assistance to strengthen citizens, communities, state, local and tribal governments, and

provisional emergency workers as they prepare for disasters, mitigate the effects of

disasters, respond to community needs after a disaster and launch effective recovery

efforts" (Bullock, Haddow, Coppola, Ergin, Westerman, and Yeletaysi, 2004). The CDC

has implemented a national network of education and training resources between colleges

and universities known as the Centers for Public Health Preparedness (CPHP) program.









According to this program (CDC, 2005), public health preparedness involves

strengthening the public health workforce readiness through implementation of programs

for life-long learning, strengthening capacity at state and local levels for terrorism

preparedness and emergency public health response, and developing a network of

academic-based programs contributing to national terrorism preparedness and emergency

response, by sharing expertise and resources across state and local jurisdictions.

A 2003 report from the United States Government Accountability Office (GAO)

states that four of five hospitals (81%) have a written emergency response plan that

specifically addresses bioterrorism, and that 18% are developing one (United States

Government Accountability Office [USGAO], 2003). Planning and preparing for

bioterrorism is different for healthcare professionals than for other natural disasters

principally because of the lack of experience and knowledge regarding bioterrorist agents

and although the probability in any one city or town may be low, the risks nationwide are

incredibly high (Jernigan et al., 2001; McGlown, 2004; Trumbull & Abhayaratne, 2004;

Tucker, 1999). The more common weapons of terrorism (e.g., explosives) are visible;

however, biological terrorism is an invisible enemy (McGlown, 2004). The bacteria and

viruses unleashed may not be the same ones physicians deal with daily. Most medical

providers have never seen a patient with anthrax or tularemia; caregivers do not know

how these diseases present in patients or how to appropriately protect themselves or

others. These are unknown entities to medical providers and thus are easily dismissed.

Further, the mere existence of institutional or clinical guidelines regarding bioterrorism

preparedness plans does not assure that a physician actually perceives himself/herself as

being personally prepared. Among other things, bioterrorism preparedness plans are only









as effective as the assumptions on which they are based. As with most disasters, it has

been suggested that the threat "must hit close to home" and affect one's community

directly before action is taken (McGlown, 2004). Thus, the current literature regarding

physician and medical providers' perceptions of preparedness for bioterrorism will be

reviewed. So what follows is an intensive review beginning with the quantitative

literature regarding physician perceptions of their bioterrorism preparedness and their

perceived barriers followed by a review of the one qualitative study performed on this

topic.

Physician Perceptions of Bioterrorism Preparedness: A Review of the Literature
Regarding National Studies

A study conducted by Alexander and Wynia in 2003 shows that there is minimal

information about contemporary physicians' sense of preparedness for bioterrorism,

willingness to treat patients despite personal risk, or belief in the professional duty to

treat during epidemics (Alexander & Wynia, 2003). Few physicians reported in this

study that they or their practice are "well prepared" for public health emergencies. This

study explored physicians' willingness to address potential acts of bioterrorism by

conducting a national random mail survey of a sample of 526 physicians involved in

direct patient care. The survey focused on physicians' perceived personal and workplace

preparedness for bioterrorist attacks. The survey asked physicians if their primary site of

clinical practice was well prepared to play a role in handling a bioterrorist event.

Twenty-two percent responded that they or their primary site of clinical practice (private

practice or a hospital setting) was well prepared to play a role in responding to a

bioterrorist attack. Personal and organizational preparedness were modestly correlated (r

= 0.27). Physicians in primary care specialties were significantly more likely than those









not in primary care to report a willingness to treat, as were those who reported being

more religious, being personally prepared, having "learned a lot about physicians' roles

in responding to bioterrorism post 9/11" and agreeing that physicians have a professional

duty to care for patients in epidemics or with the Human Immunodeficiency Virus (HIV).

On multivariate analysis, greater willingness to treat was associated with a belief in a

professional duty to treat patients in epidemics, feeling personally prepared, and being in

a primary care practice. The Alexander and Wynia (2003) study has a few potential

limitations. The study may have been influenced by bias having been a mail survey,

which relied on self-reporting. The type of bias distorting this study may have been what

is known as socially desirable response bias. This type of bias occurs when respondents

reply with a response that the respondents believe is acceptable both politically and

socially.

These findings have several implications for healthcare providers and

policymakers. First, they support concerns regarding bioterrorism preparedness among

physicians. In 2002, Chen, Hickner, Fink, Galliher, and Burstin studied family

physicians during a similar time period and found that only one-quarter felt prepared to

respond to a bioterrorist event and that receipt of response training were associated with

preparedness. Competing priorities and the perceived low likelihood of a local attack

may reduce physicians' preparedness (Bartlett, 2001). Chen et al. also noted that there

are no published validated measures of bioterrorism preparedness and limited data on the

effectiveness of specific educational programs. The Alexander and Wynia (2003) study

found that one's sense of personal preparedness correlated with having learned a

significant amount about bioterrorism since September 11, 2001 (correlation coefficient









of 0.50). So, efforts to provide physicians with instructions for a general early response

to medical disasters (such as where to report in an emergency situation) might foster a

greater sense of readiness.

In 2003, the Alexander and Wynia study showed temporal trends that were

noteworthy and yet also alarming. Both preparedness and the sense of professional

obligation to treat during epidemics are declining according to a study conducted by

Croasdale in 2002. These trends mirror the substantial decrease in physicians' use of

online bioterrorism training programs throughout 2002 and the years thereafter. Changes

in these areas are not unprecedented. In a similar fashion, early in the HIV epidemic,

physicians contentiously debated the duty to treat (Emanuel, 1988). Arguments

supporting a professional duty to treat in the face of uncertainty and risk have been based

on multiple ethical and pragmatic grounds, including appeals to virtue, beneficence,

patients' rights, the contract between physicians and society, and social utility (Bayer,

1988). Furthermore, W.D. Ross's seven prima facie duties are generally accepted to

comprise the central tenets of both professional duty and modern Western healthcare

ethics today. The Alexander and Wynia study reported that 79% of physicians today

perceive an obligation to care for the HIV-infected person. Although the reasons for

greater consensus of agreement today are complex, they are likely to include improved

knowledge of medical transmission, medical societies' position statements, legal

standards, and changing societal values. Risk has traditionally been part of medical care

and there have long been statements in the American Medical Association professional

codes of ethics as well as other medical academies' professional code of ethics

supporting the duty to treat (AMA, 2005). The Alexander and Wynia study reinforces









this consensus view, but not without reservations. In the Alexander and Wynia study,

80% of physicians reported a willingness to treat patients without a priori knowledge of

the level of risk while 20% refused to treat such patients. The study further states that

only 55% agreed that "physicians have an obligation to care for patients in epidemics

even if doing so endangers the physician's health" (Alexander & Wynia, 2003).

According to the Alexander and Wynia study, physicians who believe in a profession-

wide duty to treat have more than four-fold higher odds of reporting a willingness to treat

during an outbreak involving an unknown initial level of risk. The study concludes that

although the validity of reports about future behavior cannot be ensured, physicians who

deny an obligation to treat under conditions of risk are probably less likely to treat

patients in an actual incident. The results suggest that efforts to ensure physicians'

readiness to address bioterrorist events should include a renewed emphasis on this long-

standing professional obligation. This is especially important because physicians would

be called on to be one of the frontline responders' in a post-catastrophic event such as a

bioterrorist event. Thus, physicians must be prepared ethically, intellectually,

emotionally, and socially for such an event. Physicians and possibly other healthcare

personnel need to be trained in identifying rare infectious diseases, surveillance

techniques, and epidemiology and quarantining procedures. According to the Alexander

and Wynia study, "Preparing physicians for bioterrorism should entail providing practical

knowledge, preventive steps to minimize risk, and reinforcement of the profession's

ethical duty to treat." Similar factors should be considered in encouraging the duty to

treat in future epidemics or public health emergencies such as a bioterrorist event.









Another study conducted by Cowan, Ching, Clark, and Kemper (2005) shows the

willingness of private physicians to be involved in smallpox preparedness and response

activities. The United States' federal, state and local governments have implemented a

program known as the National Smallpox Vaccination Program (NSVP) to ensure that

the public health system is prepared to respond quickly to a smallpox outbreak (Bush,

2002). This study exposes that it is unclear whether the capacity, specifically the surge

capacity of the public health system, is sufficient to meet demand for vaccination in the

event of a public health emergency such as the release of a bioterrorist agent like anthrax

or smallpox.

An important aspect of bioterrorism preparedness is surge capacity. Surge capacity

is a healthcare system's ability to rapidly expand beyond normal services to meet the

increased demand for qualified personnel, medical care, and public health in the event of

bioterrorism or other large-scale public health emergencies (AHRQ, 2005). The study

expressed that to assure there is adequate capacity for various smallpox vaccinations,

public health officials may seek the help of other healthcare professionals such as

primary care physicians engaged in private practice settings. Previous research has

shown that individuals would seek care from their primary care physician first in the

event of a public health emergency over a hospital or a department of health, if they

thought they had contracted smallpox disease (Blendon et al., 2003; Green, Fryer, Yawn,

Lanier, and Dovey, 2001; Lane & Fauci, 2001).

The Cowan et al. (2005) study was a national random sample of 750 office-based

direct patient care internal medicine physicians and 750 family practice physicians drawn

from an American Medical Association Masterfile. The survey used was a 23-item









questionnaire exploring the willingness of private physicians to participate in pre-event

and post-event smallpox vaccination activities. The study explored factors associated

with this participation such as knowledge, attitudes, and beliefs about smallpox

vaccination; sources of information about smallpox vaccination; and physician

demographics and practice characteristics. In the Cowan et al. study, physicians were

asked to consider a pre-event scenario in which interested adult members of the general

public could voluntarily receive smallpox vaccinations. Under this scenario, 61% of the

physician respondents felt that vaccine should be administered in both a public health

setting and in a private office clinical setting versus exclusively in one setting or the

other. Thirty percent of physician respondents would be "somewhat willing" or "very

willing" to offer smallpox vaccination to interested patients in their practice (Cowan et

al., 2005). However, most physician respondents were "not very willing" or "not willing

at all" to offer the smallpox vaccination at their private offices (Cowan et al., 2005). The

most likely reason according to the study as to why most physician respondents were not

very willing or not willing at all to offer a smallpox vaccination at their private offices

was because of a possible vaccination adverse event (68% of respondents). Other reasons

included a possible smallpox outbreak (53%) and the risk of transmission of smallpox

vaccine virus (52%) to others. Many physician respondents cited necessary factors

before providing vaccination such as liability protection (95%), and guidance on program

logistics (92%).

Physicians were also asked in the Cowan et al. (2005) study if they would be

willing to participate in certain other pre-event vaccination activities if they received

proper training, liability protection, and compensation, and if capacity in their community









to vaccinate interested members of the general public was otherwise insufficient. Fifty-

nine percent reported that they would be willing to offer vaccinations in their practice to

first responders such as police, 28% would be willing to offer vaccination to interested

community members, and only 26% would be a vaccinator at a public health clinic. In

addition, the Cowan et al. study shows that 68% of physicians would be "somewhat

willing" or "very willing" to evaluate their patients with suspected mild to moderate

adverse reactions to smallpox vaccination, regardless of at which location these patients

had received their pre-event vaccination (Cowan et al., 2005). However, 14% of

physician respondents were neutral and 18% would be "not very willing" or "not willing

at all" to even evaluate their own patients (Cowan et al., 2005). This implies that the

majority of physicians would be willing to vaccinate first responders such as police, but

are more reluctant to vaccinate the general public. This is possibly due to similar reasons

as stated previously of possible adverse side effects and litigation.

Among physician respondents, 59% would be willing to provide contact

information for their practice to a federal registry of emergency smallpox vaccinators to

facilitate rapid community response to a smallpox outbreak (Cowan et al., 2005). The

study further stated that in preparation for responding to a possible outbreak, respondents

would need training in recognizing smallpox (87%), vaccine handling and administration

(97%), and recognizing and treating vaccine adverse events (98%). This implies that

many physicians perceive themselves as unprepared and realize the need for education

and training.

The Cowan et al. (2005) study also questioned physician primary care respondents

under the scenario that the public health system may not have sufficient capacity to meet









the demand for vaccination in the event of a smallpox outbreak. Respondents were asked

whether they would be willing to participate in certain post-event activities. Eight-nine

percent responded that they would be willing to offer vaccination in their practice to their

patients. Sixty-four percent would be willing to offer vaccination in their practice to

members of their community who may not be their patients, but only 44% would be

willing to be a vaccinator at a public health clinic.

The survey also attempted to assess physicians' knowledge, attitudes, and

perceptions regarding smallpox vaccination and smallpox in general. It asked the

respondents to assess the extent to which they agreed with five statements in the table

below.

Table 2-1: Knowledge, Attitudes, and Beliefs Regarding Smallpox and Smallpox
Vaccination
Statement Agree Neutral Disagree
In the next five 13% 26% 61%
years, a smallpox
outbreak or attack is
likely in the United
States
Vaccination is 88% 7% 5%
effective in
preventing smallpox
disease.
Overall, the 35% 27% 38%
smallpox vaccine is
safe.
I am confident in 45% 22% 33%
my ability to
recognize symptoms
of smallpox.
I am confident in 44% 21% 35%
my level of
knowledge
regarding the
smallpox vaccine.









Although few respondents perceived the risk of a smallpox outbreak to be high

(13%), the differences in perceived risk of an outbreak did not affect physicians'

willingness to offer vaccination in their practice under a pre-event smallpox vaccination

program for the general public. Forty-five percent of primary care physicians felt that

they could recognize the symptoms of smallpox and 44% were confident in their

knowledge of the vaccine. Thus, many primary care physicians demonstrated a

willingness to be involved in post-event activities and to participate in a system to plan

for such a contingency.

There are two main limitations in this study: the first is the validity of physicians'

predicted behavior based on hypothetical scenarios is unknown. Secondly, the low

response rates (less than 25% of surveys completed and returned) limit the external

validity or the generalizability of the findings to other physicians in other settings.

However, the results of this study suggest that there is a subset of primary care physicians

in private practice that would be willing to assist public health officials in their smallpox

preparedness and response efforts. Physicians in the study were reluctant to be self-

vaccinated and this has been shown to be consistent with other studies involving hospital-

based smallpox vaccination response teams in the first stage of the NSVP (Benin,

Dembry, Shapiro, and Holmboe, 2004; Everett, Coffin, Zaoutis, Halpern, and Strom,

2003; Everett, Zaoutis, Halpern, Strom, and Coffin, 2004) and are also consistent with the

low influenza vaccination rates of healthcare workers in general (CDC, 2004).

The physicians' lack of interest in pre-event vaccination has implications for

potential plans for a voluntary, pre-event smallpox vaccination for the general public.

The capacity required to implement such a program would depend in part on the level of









interest of the general public in being vaccinated. Although the public's interest has

previously been shown to be relatively high, it is also greatly influenced by the

vaccination decisions of practicing physicians (Blendon et al., 2003). In the Cowan et al.

(2005) study, despite physicians' reluctance to be vaccinated they did express some

willingness to participate in pre-event smallpox activities. The study explains that private

physicians are an option for expanding the capacity to vaccinate first responders, which is

the second stage of the NSVP. It explains that public health officials would need to

establish contact with the primary care physicians in their community to ascertain who is

willing to help and how best logistically to incorporate them into vaccination plans. The

study also states that private physicians are not as willing to participate in efforts outside

their own practice. Therefore, if there is a need to increase the number of available

vaccinators for public health clinics, planners will likely need to consider other health

professionals, such as school nurses (Gullion, 2004). According to the Cowan study,

private physicians seem willing to vaccinate their own patients in the event of an

outbreak scenario, but less willing to vaccinate the public in general. Thus, public health

officials should ensure that these physicians are included in response planning efforts and

determine how best to integrate their participation with that of other healthcare

professionals.

In numerous studies it has been indicated that physicians would need additional

training in order to assist with bioterrorism response efforts (Alexander & Wynia, 2003;

Chen et al., 2002; Cowan et al., 2005; AMA, 2005; Heun, 2002; Sigmon & Larson,

2002). Providing appropriate guidance and training not only helps to assure that

physicians feel prepared, but also increases the chances that physicians will participate in









response efforts and that the efforts will be successful (Alexander & Wynia, 2003;

Gerberding, Hughes, and Koplan, 2002).

A study conducted by Chen et al. (2002) showed that 95% of family physicians

agree that a bioterrorist attack is a real threat in the United States. This study used a 37-

item questionnaire with a 3-category Likert scale, ranging from "strongly agree" or

"agree" to "neutral" to "disagree" or "strongly disagree" to measure physicians'

assessments of bioterrorist risk and preparedness, specific clinical competencies,

capabilities in bioterrorism response, and their prior level of interaction with the public

health system. Physicians were also asked regarding four biological agents they perceive

may be used in a terrorist attack. In this study, physicians were categorized according to

a self-reported location of rural, urban, or suburban, and respondents were also asked to

describe the size of the population in their area.

Two survey items were the main outcomes of the Chen et al. study because they

were believed to represent the key features of family physician preparedness: (1)

"knowing what to do as a doctor in the event of a suspected bioterrorist attack in my

community," (2) "knowing where to call to report a suspected bioterrorist attack," (Chen

et al., 2002). Student's t-test and Pearson's chi square test were used to assess the

statistical significance of the bivariate analysis. Multivariate logistic regression was

performed to assess the effects of age, sex, geographic location, risk assessment, ability

to gather information, and previous training in bioterrorism preparedness on the main

outcomes of interest.

Ninety-five percent of family physicians believed that a bioterrorist attack is a real

threat in the United States and 39% of family physicians believed a bioterrorist attack are









real threat to their local community yet only 19% believed that their local medical

community could respond effectively. Furthermore, only 27% believed that the United

States healthcare system could respond effectively to a bioterrorist attack and fewer

(21%) believed that their local hospital or their local medical communities (19%) could

respond effectively to an attack according to a random national survey of 614 family

physicians (Chen et al., 2002). The Chen et al. study has both similarities and salient

differences from the Cowan et al. (2005) and the Alexander and Wynia (2003) studies.

All three studies explain that physicians do not feel personally prepared to respond to

bioterrorist events. However, the Chen et al. study reports that 95% of physicians

perceive that a bioterrorist attack is both real and imminent while in the Cowan et al.

study 13% of physicians perceive a bioterrorist attack with smallpox as an agent is likely

either now or in the next five years. According to the Chen et al. study 26% of

physicians reported that they could respond effectively in the event of a bioterrorist

attack. In contrast, when asked if they could respond effectively to natural disasters or

infectious disease outbreaks, a significantly higher percentage of physicians responded

that they would know how to respond to these other public health emergencies. Sixty-

five percent of physicians responded that they could respond effectively and would know

what to do (p < .001) in the event of a natural disaster and 66% of physicians responded

that they could respond effectively (p < .001) in the event of an infectious disease

outbreak.

After they combined responses for local hospitals and community preparedness,

only 17% of physicians believed that both their local hospitals and their medical

communities could respond effectively to a bioterrorist attack, compared with 60% (p <









.001) for a natural disaster and 56% (p < .001) for an infectious disease outbreak (Chen et

al., 2002). So significantly fewer family physicians feel they are personally prepared as

well as their local medical community and their local hospitals for a bioterrorist event

than for a natural disaster or an infectious disease outbreak. Yet there are similarities

between bioterrorist events and natural disasters and infectious disease outbreaks in that

early detection and reporting are also critical to a timely and effective response to a

bioterrorist event (CDC, 2000; Franz et al., 1997; Kahn, Morse, and Lillibridge, 2000;

National Academy Press, 1999;).

The Public Health System and Primary Care Physicians' Perceptions of
Bioterrorism and National Bioterrorism Preparedness

For most Americans, their first point of contact with the healthcare system is the

primary care physician, who is therefore on the frontline in this new era of bioterrorism

(Green et al., 2001; Lane & Fauci, 2001). Many victims of a bioterrorist attack may not

know they have been affected, and because the symptoms caused by many bioterrorist-

related agents mimic those of common conditions, primary care physicians will likely be

in the position of diagnosing and managing initial cases of bioterrorist-related illnesses

(Gourlay & Siwek, 2001). Thus, a primary care physician's ability to identify cases and

activate the public health system is a crucial step in effectively responding to a

bioterrorist attack (Franz et al., 1997; Gordon, 1999; Haines, Pitts, and Crutcher, 2000).

Several recent studies have concluded that the preparedness and infrastructure of

the public health system are inadequate to deal with a bioterrorist attack and need

improvement (CDC, 2000; Garrett, Magruder, and Molgard, 2000; Inglesby et al., 2001;

Kahn et al., 2000; Rosen, 2000). One survey found that fewer than 20% of emergency

departments in the Pacific Northwest had plans for responding to a bioterrorist event









(Wetter et al., 2001). However, these studies, although examining the public health

system, failed to discuss the critical role of primary care providers in responding to

bioterrorism (Henretig, 2001; Sidel, 2001). Other studies have found that many local

health departments are unprepared to respond to a bioterrorist attack (Rosenthal, 2003;

USGAO, 2003).

According to the Chen et al. (2002) study, physicians felt more comfortable

responding to other types of public health emergencies, such as natural disasters or

infectious disease outbreaks. This may be in part due to their personal experiences in

dealing with these events, or may reflect the formalized training in public health response

that is part of the medical school curricula. The reporting and response skills physicians

would use in dealing with the public health system during a bioterrorist event are similar

to the ones that they would use during natural disasters and infectious disease outbreaks.

Naturally, physicians' experiences with the public health system in responding to and

managing natural disasters and infectious disease outbreaks are helpful, but a bioterrorist

attack has unique features that require primary care physicians to be able to obtain and

use information from public health sources and intelligence sources (National Academy

Press, 1999). The Chen et al. study (2002) was the first to assess primary care

physicians' personal sense of preparedness for responding to a bioterrorist event.

According to the Chen et al. (2002) study, biological agents physicians consider

most likely to be used in a bioterrorist attack include anthrax (96%), smallpox (82%),

plague (28%), botulism (22%), ebola (16%), nerve gas (14%), tularemia (11%), E. coli

(7%), Salmonella (5%), and influenza (4%). The study performed by Chen et al. also

found that only 24% of the family physicians surveyed believed they could recognize









signs and symptoms of an illness in their patients due to bioterrorism, and 38% rated their

current knowledge of the diagnosis and management of bioterrorism-related illness as

poor. Furthermore, the Chen et al. study stated that only 18% of physicians had received

previous training in bioterrorism preparedness. Physicians who felt prepared for natural

disasters were four times more likely than other doctors to know how to respond to a

bioterrorist attack (36% versus 9%, p < .001). Physicians who felt prepared for infectious

disease outbreaks were 6 times more likely than other doctors to know how to respond to

a bioterrorist attack (37% versus 6%, p < .001). Physicians felt better prepared for a

bioterrorist attack if they had training in bioterrorism preparedness. Physicians who had

received training were 3 times more likely than other doctors to know how to respond to

a bioterrorist attack (55% versus 20%, p < .001). Moreover, 98% thought it was

important for them to be trained to identify a bioterrorist attack, and 93% of physicians

said they would like such training.

The Chen et al. study demonstrated that familiarity with the public health system

was not necessarily associated with physicians' preparedness for bioterrorism. Ninety-

three percent of physicians report notifiable infectious disease cases to the health

department, only 57% (p < .001) reported knowing whom to call to report a suspected

bioterrorist attack and only 56% of physicians reported knowing how to get information

if they suspected an attack in their community (Chen et al., 2002). In the multivariate

model, having received training in bioterrorism preparedness (odds ratio (OR) 3.9 [95%

CI 2.4-6.3]), and knowing how to obtain information in the event of a bioterrorist attack

(OR 6.4 [95% CI 3.9-10.6]) were significantly associated with physicians' knowing what

to do in the event of an attack. Believing that bioterrorism was a real threat to their









communities was also significantly associated with a physician's ability to recognize

signs and symptoms of a bioterrorism-related illness (OR 1.9 [95% CI 1.2-2.9]). In the

Chen et al. study, physicians' preparedness was not associated with geographic location,

residence (rural, urban or suburban), age, or gender.

One limitation of the Chen et al. (2002) study was that the survey instrument did

not define bioterrorism, but relied on the respondents' personal perceived definitions of

bioterrorism. Although the timing of the survey coincided with national media attention

on the anthrax cases, there was not a high level of confidence or knowledge in dealing

with bioterrorism.

In a study conducted in 2005 by David Sterling and colleagues, the issue of a

possible bioterrorist event occurring at the workplace is examined. The rationale for

most preparedness training of healthcare professionals is based on the assumption that

most persons infected following a bioterrorism incident will present first to emergency

departments of acute care facilities or to ambulatory settings such as private physician

offices, and such incidences would be recognized, appropriately treated, and reported to

the local health departments (Sterling et al., 2005). The Sterling et al. study explains that

an alternative first point of contact is industry, a location where workers gather and

disperse on a regular and documented basis, and require healthcare. Sterling et al. further

explains that in industry there are health professionals responsible for the health, safety,

and on-site well-being of the workforce and surrounding community; these professionals

are in a position for early recognition, surveillance, and isolation. It is the belief of the

authors of this study that targeted education, therefore, must be provided to these health

professionals. Several studies have asserted that no United States' asset is considered









safe from terrorist actions and large cities are not the only targets (Gwerder, Beaton, and

Daniell, 2001; Sterling et al., 2005). In addition, the lack of a publicized threat to

industry may impact the risk perceptions of occupational health professionals and

downplay the need for increased awareness, preparedness, and response at industrial

settings (Sterling et al., 2005). This lack of awareness and preparedness at the workplace

would probably diminish the contribution that occupational health professionals can

make to bioterrorism preparedness. A limitation of the Sterling et al. study is that it does

not state which types of workplaces (i.e., industrial, financial, or others) are involved and

87% of the workplaces examined are in the five Midwestern states of Missouri, Indiana,

Michigan, Wisconsin, and Illinois.

To address perceptions of preparedness and risk as well as preferred educational

delivery methods for bioterrorism and emerging infections-related materials, a survey of

occupational physicians was performed during the spring of 2001. Within the two months

following the September 11, 2001, terrorist attack and subsequent anthrax bioterrorism

event, and before release of any results from the first survey, a follow-up mail survey was

initiated in November 2001. Previous studies have corroborated this study and concluded

that the risk of a possible bioterrorist event is increasing and that physicians need to be

prepared and educated (Henderson, 1999; Tucker, 1999; Jernigan et al., 2001; Rose &

Larrimore, 2002; Trumbell, 2004; Sterling et al., 2005).

The survey instrument used was modified from a previous national survey of

physicians (Shadel et al., 2003) to examine occupational physicians' preparedness. The

instrument assessed several factors: the perceived threat of bioterrorism, past training,

barriers to training, access to instructional technology, and preferred medium for









education and training. Perception questions were based on a standard Likert scale of 1-5

or important to not important. The survey was disseminated at a 2001 spring conference,

Central States Occupational Medicine Association, for occupational physicians and then

collected. Following September 11, 2001, the survey was modified and a follow-up

survey was mailed to all physician participants from the conference.

Response rates to the pre-September 11 and post-September 11 survey were 58%

(n = 56) and 33% (n = 33), respectively. No significant demographic differences were

observed between the respondents of the pre-survey and the post-survey. Eighty-eight

percent considered themselves to be computer proficient and the assumption was that

computer proficiency does not change considerably over a brief six month period of time.

In each survey more than 80% were located in urban or suburban locations. There were

statistical differences noted during the pre-survey based on both the city involved (p =

.023) and the size of the facility (p = .004), regarding the likelihood of the public health

surveillance system to detect a bioterrorist event. The study found that the smaller the

city and the larger the facility, the greater the perception that an event would be

recognized. It also found that the larger the city then the greater the perception among

physicians that a bioterrorist attack would occur near their place of work (p = .019).

Naturally, perceptions of likelihood of another bioterrorism event increased

between the pre-September 11 and the post-September 11 survey. In the pre-survey, 61%

of respondents felt it would happen in the United States, 21% expected that it would

happen near their place of work, and 42% had received bioterrorism training. In the post-

survey following September 11, 2001, 94% believed another event was likely to occur in

the next five years, only 45% believed it would occur near them, and over 90% had









received some training. When participants were asked if another bioterrorist attack

would occur over the next five years, a statistically significant difference emerged

between the pre-survey and the post-survey respondents' perceptions (p < .001). The

statistically significant increase in perceived risk between the surveys was notable for a

local occurrence, i.e., expecting it to happen near their place of work (p = .012). When

participants were asked how likely they would be to seek information regarding

bioterrorism preparedness in the pre-September 11 surveys, 60.7% responded very to

somewhat likely. Whereas when the same question was posed in the post-September 11

survey, 93.8% responded very to somewhat likely. This difference was also statistically

significant (p < .001). Participants who had received bioterrorism training prior to the

pre-survey did not differ significantly in their responses to the survey than those who had

not received any training, although they were even less likely to believe that a bioterrorist

attack would occur near their work (13%). This poses an interesting question, one which

this study will attempt to clarify through examining the perceptions of preparedness of

rural physicians regarding bioterrorist events. Fifty-eight percent of the participants

indicated that they had not received any bioterrorism training prior to the pre-survey.

These participants listed four similar barriers as the most common: no training available

(59.4%, 53.6%), no continuing medical education training credits as part of their training

(37.5%, 32.1%), not part of their responsibility (25%, 42.9%), and no time dedicated

(21.9%, 25%). Occupational physicians noted that their first notifications for a suspected

bioterrorist event would be the local health department (70.9%), followed by the state

health department (65.5%), CDC (61.5%), an in-house infectious disease physicians

(58.2%). The post-September 11 surveys showed a significant increase in notification for









a bioterrorist event to the local health department (96.8%, p =.004) and a decrease in

notification to the state health department and the CDC. The responses for those with

prior bioterrorism training during the pre-survey were similar to the overall post-survey

results.

During a bioterrorist event, timely access to information is essential. The preferred

information sources to contact during a crisis were the CDC, state and local health

departments, and in-house infectious disease physicians. The preferences did not change

following September 11, but their rank order changed. The use of in-house infectious

disease physicians increased from 43.6% to 53.3% and the local health department from

40% to 53.3%. The use of poison control hotline decreased by a statistically significant

factor of four (p < .05).

A comparison was performed of the preferred method of receiving education and

training. The preferred methods of the pre-survey were professional meetings (69.6%),

followed by Internet access (35.7%), journal review (30.4%), and CD-ROM (23.2%). In

the post-survey following September 11, professional meetings were still most preferred

(64.5%) but the use of video (35.5%, p < .05) and grand rounds (19.4%, p < .05) were

statistically significant for preferred methods.

There were a few limitations in this study. The study was a small study with 56

respondents in the pre-survey and only 33 respondents in the post-survey. The study was

national, yet a few different states were represented in the pre and post surveys although

the authors note that they were demographically similar thus making it less generalizable.

Another limitation is that the first survey was performed at a conference and the second

study was a mail survey, which has its own inherent limitations.









Even though over 90% of the physicians had received immediate training following

September 11, additional training/education needs were demonstrated (Sterling et al.,

2005). Previous research corroborates this finding (Alexander & Wynia, 2003; AMA,

2005; Chen et al., 2002; Cowan et al., 2005; Heun, 2002; Sigmon & Larson, 2002).

Although training and education modules can be designed without information based on

the population that can be on the receiving end, it then rarely accomplishes its goal.

Results from this survey can serve as a basis for designing various levels of targeted

training and educational material specific to the perceived need, method of obtaining

information, and the format considered to be most conducive for learning (Sterling et al.,

2005). Sterling et al. further notes that the potential consequences from lack of

bioterrorism preparedness due to low perception of need and threat awareness need to be

addressed.

In sum, the previously conducted studies suggest that physicians studied in this

literature review may not be prepared for bioterrorist events. The majority of physicians

interviewed acknowledged that post September 11, 2001, the threat of a bioterrorist event

was heightened. Many of the respondents also reported that they had received

bioterrorism training because of the heightened threat. Yet, despite the training,

physicians expressed an even greater need for additional bioterrorism training and

education.

Continuing medical education (CME) is an evolving process of education for

physicians that foster the individual's commitment to lifelong learning, optimal

development, and maintenance of medical knowledge and skills. CME is also intended

to enhance the ability of physicians and healthcare professionals to provide excellence in









patient care, health maintenance, and disease prevention with resultant improved

outcomes of care of their patient population.

Physicians have been confronted with the need to keep their knowledge current for

many hundreds of years. Ell (1984) describes CME that was practiced in Venice from

1300 to 1800. Practitioners were required to attend a yearly refresher course in anatomy

in order to renew their licenses. In the United States, no formal attempts at requiring

CME were required until 1932, when the American Association of Medical Colleges first

proposed mandatory CME. After several decades of discussion and debate, in 1947 the

American Academy of General Practice began to require 150 hours of CME every three

years as a condition of membership (AMA, 1999). In 1975, the Accreditation Council

for Continuing Medical Education (ACCME) was formed as a consortium of seven

organizations which all have interests in CME (ACCME, 1999). Since that time, the

AMA and the ACCME have played principal roles in the development and accreditation

of CME. In a survey conducted in 1995, the AMA found that thirty-one states required

proof of CME for re-licensure, and by 1997, twenty-four specialty boards had made CME

a requirement for certification or re-certification (AMA, 1999). These requirements have

led to a burgeoning of formal continuing medical education programs.

Traditional continuing medical education consists of physicians attending a

meeting at their local hospital. The meeting ordinarily contains a lecture regarding a

medical condition or a procedure. Sometimes the lecture may be based on a real or

simulated case. This is often known as grand rounds. Typically the lecturer speaks for

40-45 minutes and leaves time for a five to ten minute question and answer period at the

end. A lecturer ordinarily presents the information with computer generated slides and a









handout of salient points is distributed. There is generally no pre-lecture or post-lecture

test of knowledge. Physicians earn credit by placing their name on a sign-in sheet.

This formatted lecture remains the dominant form of CME, although it has been

difficult to prove if continuing medical education results in any change in the physician's

practice behavior (Davis et al., 1999). Yet despite the reservations, there are important

non-academic advantages to continuing medical education lectures. The individual

physicians attending such CME lectures may learn that the lecturer, who is often also a

physician, may practice in the same community or a nearby community and accepts

patients with the conditions discussed or requiring the discussed procedures.

Furthermore, although anecdotal, it appears advantageous from a collegial or social

atmosphere. The CME meetings allow physicians to encounter other physicians and

learn what is new in the hospitals, among other physicians, and in the local medical

community.

Merriam (1996), in a review of adult learning theories, finds a number of

implications for the education of health professionals. The first, she explains, is to

develop self-directed learners. Merriam (1996) explains that no amount of academic

preparation, undergraduate or graduate, or continuing professional education will be able

to keep pace with changes in the health field. Professionals must take it upon themselves

to be lifelong learners and to engage in learning projects to remain current. Merriam

(1996) also explains that a second implication is that the more significant learning is that

which is situated in the context of adult life or in actual activity. She further explains that

some of these activities include lectures, internships, apprenticeships, mentorships, and

case-study instructional methodologies. Thus, continuing medical education seminars









offer opportunities for physicians to engage professionally, intellectually, and socially

with advances in medicine and public health.

In 2003, Shadel and colleagues performed a national needs assessment survey,

which measured infection control practitioners' perception of the risk of bioterrorism in

the United States and in their community. The needs assessment study also examined the

proportion of infection control practitioners' with prior training in bioterrorism

preparedness, and the barriers to receipt of such bioterrorism education (Shadel et al.,

2003). The study used an SPSS software package to randomly identify 4000 infection

control practitioners from a membership list of the Association for Professionals of

Infection Control and Epidemiology. Shadel and colleagues mailed a 35-question survey

to measure these factors (Shadel et al., 2003). The survey instrument was pre-tested for

format and content. The healthcare professionals involved in the pilot testing were

excluded from the random sampling. The questions were evaluated in 20 qualitative

telephone interviews with healthcare professionals.

The instrument assessed the perceived threat of bioterrorism, the extent of the

respondents' past bioterrorism training, and the perceived barriers to bioterrorism

training. The questionnaire also addressed access to technology and the preferred

instructional design and medium for delivery of educational opportunities and reference

materials. The survey questions regarding perceptions of risk were evaluated using a 1-5

Likert scale (1 being very likely and 5 being very unlikely). Thirty-one and one-half

percent or 1260 respondents from the original sample of 4000 participated in the mail

survey. Approximately half of the respondents described themselves as working in direct









patient care with most describing their work environment as an inpatient care facility. In

this national survey, 450 participants or 36.6% worked in rural areas.

The perceptions of risk regarding the intentional release of a bioterrorist agent in

the United States in the next five years (p = .475) or in the infection control practitioners'

work community (p = .199) did not differ by type of occupational setting (patient care,

public health, or administration). The likelihood that a respondent would seek more

information about bioterrorism preparedness was affected by the respondent's

occupational setting (p < .01), with significant differences between those working in

administration and patient care (p < .01). A smaller proportion of those respondents

working in administration (40.9%) were likely to seek out bioterrorism information

compared with those working in direct patient care (50.2%).

The study found significant differences between regions of the country when they

assessed the perceived potential threat of a bioterrorist event occurring in the next five

years in the United States (p = .022), and in the infection control practitioners' work

community (p < .01). Infection control practitioners in the South were more likely to

believe a terrorist attack would occur in the next five years in the US compared to those

in the Midwest (p = .13). Also, infection control practitioners in the South (86.6%) were

more likely to seek out bioterrorism preparedness information compared to those

practitioners in the Midwest (79.5%; p = .45). Eighty percent of the infection control

practitioners from the South believed that a bioterrorist attack was very likely to

somewhat likely in the US compared with the Northeast (74.3 %), the Midwest (71.8%),

and the West (71.4%). Approximately one-third (32.2%) of all infection control

practitioners believed that a bioterrorist attack was likely or somewhat likely in the next









five years in their community. There were no statistically significant differences by

community size (urban or rural) when infection control practitioners ranked the perceived

risk of a bioterrorist event in the next five years (p =.923). Yet the responses differed

when participants assessed the risk regarding their own community (p < .01).

Participants were more likely to believe that a bioterrorist event was very likely to

somewhat likely to occur in the United States during the next five years than in their own

community (74.4% versus 32%). Interestingly, how likely (i.e., very likely to somewhat

likely) those participants believed that a bioterrorist event would occur in their

community in the next five years differed significantly (p < .001), between communities

of different sizes: rural (16.1%), suburban (40.1%) and urban (42.0%). Differences

were also found between rural, suburban, and urban communities regarding how likely

they would be to seek information on bioterrorism preparedness (p < .01). Fewer than

half (41.7%) from a rural community reported that they were very likely to seek out more

information. This study's intent is to contribute information to the literature to help

clarify and possibly explain rural physicians' perceived bioterrorism preparedness. It is

also the intent of this study to examine how the barriers rural physicians encounter may

pose impediments to garnering educational training or information and thereby possibly

explain rural physicians' perceived behaviors and practice patterns

Only 56% of the respondents reported prior training in bioterrorism preparedness.

Those who reported prior bioterrorism training were more likely to believe that a

bioterrorist attack would occur in the next five years in the United States (p < .001).

Most of the respondents who reported prior bioterrorism training (51.8%) were involved

in direct patient care. Respondents reported that the two most common barriers to









receiving training were no training opportunities (70.2%) and no dedicated work time for

training (19.4%). Among those who had prior bioterrorism training, most had attended a

session on bioterrorism at a professional meeting (56%), obtained information through a

journal article (54.5%), or attended an in-service lecture (33.4%). The three preferred

training methods were the following: lecture at a professional meeting (59.6%), training

video (32.3%), and satellite teleconference (29.2%). A larger proportion of members

from rural areas selected videos (38.6%) or CD-ROM (17.4%) as the preferred method

for education delivery than those in urban (27.6%, 13%) and suburban areas (30.2%,

11.8%) respectively.

This study has a limitation in that the participants surveyed were all members of the

Association for Professionals of Infection Control and Epidemiology so one may

conclude that they may have perhaps been better prepared than other physicians. This

study was a randomly selected national sample, which provided the opportunity to

evaluate regional differences and community size differences. This study showed that

healthcare professionals in rural areas were the least likely to report that a bioterrorist

event might occur in their community. Moreover, fewer than half of healthcare

professionals from rural communities were likely to seek out additional information

regarding bioterrorism preparedness. Thus, increased attention and vigilance is needed to

increase the awareness of rural healthcare professionals who may not believe that they

are at risk to ensure that these rural physicians are prepared for a possible bioterrorism

event. Satellite teleconferences as an educational training method is particularly

interesting for rural community physicians because of their remote locations and limited

access. According to the Shadel et al. (2003) study, the satellite teleconference was









considered a preferred method of training; although in a study conducted on a national

sample of physicians (Shadel et al., 2001) it was one of the least preferred methods.

Physician Perceptions and Knowledge of Bioterrorism Preparedness: A Review of
the Literature Regarding Local Studies

In 2004, a study conducted by Gershon and colleagues showed the knowledge,

attitudes, and intended behaviors of New York City clinicians regarding bioterrorism-

related diseases. Data on urban clinicians' knowledge and attitudes toward bioterrorism

and related diseases were collected using a self-administered questionnaire after a 3.5-

hour educational intervention program was performed with presentations regarding up-to-

date case information as well as information on the New York City Department of Health

bioterrorism preparedness procedures. The lectures were supplemented with printed

literature and handouts, including a copy of the slide presentations, rolodex card with

New York State and New York City Health Department contact and reporting numbers,

and seminal journal articles on clinical presentation of bioterrorism.

The Gershon et al. (2004) study administered a post-presentation questionnaire

consisting of 37-items designed to evaluate their knowledge, beliefs, and confidence

regarding their ability to diagnose, treat, and report certain diseases of bioterrorism such

as anthrax, smallpox, tularemia, plague, and botulism. The questionnaire also evaluated

their own concerns and fears regarding the contagious nature of the bioterrorist agents.

They asked questions related to clinicians' degree of exposure to the WTC disaster (e.g.,

witnessing the event at the time it happened either in person or on television or having re-

exposure through television broadcasts) to determine the impact, if any, this had on their

bioterrorism attitudes and behavioral intentions. Items related to physicians' emergency

preparedness and response were also included in the questionnaire. Statistical analyses









were conducted to measure knowledge, confidence, concerns, infection control

intentions, and educational needs.

A total of 377 practitioners attended the program; of these, 310 completed the

questionnaire (82% response rate). Most of the survey respondents were male physicians

(55.2%) with a mean age of 52.9 years. The mean years of practicing medicine was 23.3

years and 36% were internal medicine specialists. After the three and one-half hour

educational seminar, on a set of five basic knowledge questions, 69.6% of the participants

had correct responses for reporting requirements although in other areas of knowledge

such as appropriate diagnostic testing (65.2%) and differential diagnoses (41.6%) the

correct responses was not particularly high even after the educational intervention

program.

Many participants reported increased confidence in bioterrorism preparedness with

regard to recognizing diseases of bioterrorism (88.6%), the ability to address patient

concerns (83.2%), the ability to treat bioterrorism diseases (74.6%), the ability to report

bioterrorism diseases (72.6%), and the ability to adopt appropriate infection control

procedures (68.7%). Almost 38% reported increased confidence in the United States

government's ability to protect the public's health during a bioterrorist attack and 13.9%

reported increased confidence in the United States government's preparedness for a

bioterrorist event.

Physicians reported overall concern about future bioterrorist attacks (77.4%) and

specifically concern about anthrax (58.4%) and smallpox (61%). They also reported high

levels of concern regarding bioterrorism among their patients; 90.5% of clinicians

reported that they provided care to patients with complaints related to fears of









bioterrorism during a two month period before training program. There was no

significant correlation found between clinicians' media exposure to WTC disaster and

their bioterrorist-related concerns. Yet clinicians who reported high degrees of television

exposure to the WTC disaster were 2.4 times more likely to volunteer in the disaster

relief efforts (e.g., assist in rescue centers, emergency rooms, outpatient settings, or

donate money and supplies) with an odds ratio of 2.45 (95% confidence interval [CI] =

1.12-5.35) than those who had limited exposure. Also, regarding the clinicians concerns,

61% were personally concerned about the risk of contracting smallpox and 58.4% were

personally concerned about the risk of contracting anthrax as a result of bioterrorism.

This may be in part due to the fact that the federal government, the media, and the

medical societies placed an emphasis on bioterrorism and its related issues.

The clinicians expressed interest in additional training on clinical diagnosis of

bioterrorism diseases (84.2%), infection control aspects of bioterrorism (81.9%),

treatment aspects of bioterrorism diseases (81.6%), and psychological aspects of

bioterrorism (74.5%). Training needs did not differ based on experience in treating

patients at risk for exposure to anthrax.

One limitation of the Gershon et al. (2004) study was the use of a single

questionnaire, which precludes the ability to evaluate the effectiveness of the program in

terms of its impact on the baseline knowledge and attitudes of clinicians. Another

potential limitation is that the sample is of participants limited to the greater New York

City area, and may therefore be difficult to generalize these findings to clinicians from

other parts of the country.









Rose and Larrimore performed a study in late 2002 to examine knowledge and

awareness concerning chemical and biological terrorism among clinicians. This survey

was used to assess the knowledge base of healthcare providers at an urban medical center

in preparation for developing a workshop on domestic terrorism preparedness. Rose and

Larrimore then conducted a second survey assessing domestic terrorism preparedness

among infection control personnel and nurse educators.

This study reports results of a knowledge and awareness survey on bioterrorism

agents prior to September 11, 2001. A possible limitation is that both surveys were

conducted in the northeastern United States because the Gershon et al. (2004) found that

geography may matter and the surveys were conducted prior to September 11, 2001.

During the year of 2000, a total of 291 healthcare professionals (e.g., nurses, physicians)

completed the survey on knowledge and awareness of chemical and biological terrorism.

The knowledge scores for all respondents were low, with less than one-fourth answering

the questions correctly. Few respondents had ever used respiratory protective equipment

(32.6%), Hazmat level protective clothing (10.3%), or used decontamination showers

(5.2%). Additionally, almost half of the respondents indicated that they were not certain

they would report to work in the event of a domestic terrorism attack (46.7%). Less than

23% of the respondents reported confidence in providing healthcare related to a

hypothetical terrorism event. The difference in scores among healthcare providers,

specialty groups, and gender were not statistically significant.

A study conducted in mid-2001 by Lanzilolti and colleagues, examined Hawaiian

medical professionals. The intent of the Lanzilolti and colleagues study was to assess the

availability of doctors and nurses to staff non-hospital medical facilities for mass casualty









incidents resulting from the use of weapons of mass destruction or other terrorist events.

The study also examined the level of knowledge and skills that these medical

professionals possessed as related to the treatment of victims involved in terrorist

incidents. This study consisted of a large-scale mail survey administered to medical and

nursing professionals residing and working in the state of Hawaii (Lanzilolti, Galanis,

and Leoni, 2002). This study examined the availability and capability of medical

professionals to respond to casualties caused by weapons of mass destruction. Although

this study had a low response rate (23%, n = 3386 for physicians; and 22.4%, n = 2775

for nurses), the findings yielded similar results to other studies reported in this literature

review (Alexander & Wynia, 2003; Chen et al., 2002; Gerberding et al., 2002; Gershon et

al., 2004). As in other studies discussed in this literature review exploring these issues,

the investigators found that both physicians and nurses reported having low knowledge

levels regarding bioterrorism agents such as smallpox, anthrax, tularemia, plague, and

botulism. Also as in previous studies mentioned above, the investigators found that both

the physicians and the nurses had a perceived inability to recognize and treat patients

with diseases of bioterrorism. The Lanzilolti et al. study also reported that less than 10%

of the physicians in the sample consider themselves able to treat victims of bioterrorist

incidents. In contrast, the respondents in the study reported generally high levels of

willingness to report to duty during a bioterrorism incident, with a positive correlation

seen between high levels of self-reported knowledge, awareness, and willingness to

respond. Thus, the study concludes that it may be possible to increase clinicians'

willingness to respond to a bioterrorist emergency through physicians' education and

training. This conclusion has been supported by several other studies examined within









this literature review (Alexander & Wynia, 2003; Chen et al., 2002; Cherry et al., 2003;

Croasdale, 2002; Gerberding et al., 2002; Gershon et al., 2004).

The limitations of the Lanzilolti et al. (2002) study include the low response rate of

only 23%, which may not accurately reflect many of the physicians' perceptions.

Another limitation in the study is the possibility of set response bias, which may lead to

biased results. Set response bias often occurs with large-scale written or mailed surveys

when respondents reply by marking the same response repeatedly to facilitate completion

of the survey. My study will attempt to contribute to the literature in a novel fashion by

examining physicians from a rural region in Florida from a qualitative perspective using

semi-structured interviews rather than surveys to examine their perceptions to

bioterrorism preparedness. Another potential limitation with the Lanzilolti and

colleagues study is that the sample consists of participants limited to Hawaii, and it may

therefore be more difficult to generalize these findings to clinicians from other parts of

the country.

A small study by Rico, Trepka, and Guoyan entitled Knowledge and Attitudes

about Bioterrorism and Smallpox: a Survey of Physicians and Nurses, was performed in

2002. This study surveyed licensed physicians (n = 134) and nurses (n = 121) in Miami-

Dade County. The investigators found that 97% of physicians and 92% of nurses were

interested in receiving bioterrorism training (Rico et al., 2002). The interest among both

physicians and nurses was especially keen for training on the recognition of potential

bioterrorist events and on the overall public health response to these emergencies. Only

21% of physicians and 7% of nurses in the sample of participants believed that they had

updated knowledge on the signs, symptoms, treatment, modes of transmission, and









communicability of class A bioterrorist agents (e.g., smallpox, anthrax, tularemia, plague,

and botulism). This study also confirms other studies pertinent to this literature review,

which explain that most clinicians perceive themselves as unprepared to effectively deal

with bioterrorism (Alexander & Wynia, 2003; Chen et al., 2002; Heun, 2002; Sigmon &

Larson, 2002).

A limitation of this study is the small sample size of 134 physician participants. A

small sample size may not accurately represent or depict the perceptions of a population.

Another limitation of the study is the set response bias with survey methodology.

Another potential limitation is that the sample is of participants limited to the Miami,

Florida or the Dade County area and it is therefore difficult to generalize these findings to

clinicians from other parts of the country.

A study performed by Alder, Clark, White, Talboys, and Mottice in 2004 examined

physician preparedness for bioterrorism recognition and response. A survey was

performed that included 30 rural and urban physicians in Utah. The survey included a

needs assessment regarding roles, current levels of preparedness, interest in further

training, and preference for training methods. The physicians were from various

specialties: four family medicine physicians, five general internists, five pediatricians, six

emergency medicine physicians, five infectious disease specialists, three dermatologists,

and two radiologists, and were grouped as primary care (i.e., family medicine, general

internist, and pediatricians), emergency care (i.e., emergency medicine physicians) or

specialty care (e.g., infectious disease specialists, dermatologists, and radiologists).

This qualitative study assessed the attitudes and assumptions of practicing

physicians regarding bioterrorism preparedness by using individual and small group









semi-structured interviews. Participants were asked about their perceived risk of

bioterrorism, current roles and ability to detect and respond to events, interest levels in

bioterrorism training, and preferences for educational offerings. Quota sampling, based

on physician specialty and community or tertiary/academic practice was used to select

participants.

Primary care physicians estimated that a direct local attack is unlikely, yet possible.

Emergency medicine and infectious disease specialists had similar responses. They both

felt that a national bioterrorist attack was more imminent than a local attack, yet a

national attack may have local consequences. Infectious disease specialists,

dermatologists, and radiologists stated that the likelihood of a local attack was extremely

unlikely.

The physician's perceived role for detecting and responding to bioterrorism was

found to be related to their type of practice. Both primary care and infectious disease

physicians felt that in the event of a bioterrorist attack they would be expected to link into

the public health infrastructure and notify emergency personnel. Primary care physicians

felt, because of their ongoing relationships with pre-existing patients, that they would be

able to detect unusual disease patterns and link the patients to medical specialists.

Primary care physicians also admitted that they are not adequately prepared to recognize

and treat bioterrorism related diseases. One primary care physician stated, "I could see

patients today whose symptoms could be attributable to any one of the biological agents.

I'm not going to be thinking about that because, number one, I can't distinguish the usual

from the unusual right now," (Alder et al., 2004, p 70). Emergency care physicians felt

that they would identify the index case and act as the primary medical respondent









because they are familiar with diseases caused by bioterrorism agents. One emergency

physician stated, "I think there's a good chance we would be one of the first people to

identify it if there was actually an event," (Alder et al., 2004, p 72). Infectious disease

physicians felt confident in their ability to recognize and respond to uncommon diseases,

including those caused by bioterrorism agents. Their confidence was partly due to an

increased emphasis on bioterrorism-focused continuing medical education. One

respondent stated, "I think one thing that maybe the anthrax case taught us was that if

you're not thinking about it, you're not going to catch it," (Alder et al., 2004, p 72). Both

dermatologists and radiologists felt that their primary role would be to support primary

care physicians.

Respondents cited time constraint and other competing demands as the primary

reasons for not being able to spend more time dedicated to bioterrorism preparedness.

One family practitioner stated, "You have to think of a disorder in order to ask the right

questions or to do the right physical exam. It's not seeing is believing, it's believing is

seeing. You have to have that mental model," (Alder et al., 2004, p 72). Most family

practice physicians wanted general information about disease processes and a better

understanding of how to link into the medical specialist's hierarchy, which could assist

with patients with bioterrorism diseases. One family practice physician explained, "I

wouldn't expect most family physicians to be able to say here are the diagnostic criteria

for anthrax. How important is it that I know the diagnostic criteria? Again, there is a

certain amount of information I know I can look up anywhere," (Alder et al., 2004, p 72).

Infectious disease physicians felt that all physicians should have a basic understanding of

diseases consistent with bioterrorism. One participant stated, "I think their most









important preparation is recognition of diseases, and they ought to have some inclination

or readiness with regards of how to prevent spread," (Alder et al., 2004, p 73). Another

participant pointed out that if primary care physicians are involved in surveillance, the

level of general bioterrorism preparedness would increase.

Preferences also varied according to medical specialty regarding which methods are

preferred for training and continuing education. Primary care physicians requested

training from health department personnel, fellow primary care physicians, or infectious

disease specialists with expertise in bioterrorism recognition and response. Primary care

physicians wanted to incorporate training into existing activities, such as CME activities

or professional meetings. In addition, they wanted to be provided with quick reference

materials. Emergency physicians wanted Web-based training activities, disaster training

drills, and exercises that include information regarding bioterrorism agents. All

physician specialists suggested grand rounds and physician meetings as valuable to

provide education and training.

One possible limitation with the Alder et al. study includes the use of a "small

focus" group, which may bias results. Several of the interviews only included a few

respondents representing large medical specialty groups. Although the study includes a

sample of participants limited to the one state, Utah, it is a well-conducted qualitative

study. Qualitative studies are less concerned with quantitative external validity or

generalizability across studies and are rather more concerned with what is known as

internal generalizability. This is because qualitative researchers study a single setting or

a small number of individuals or sites, using purposeful sampling rather than probability

sampling, and they rarely make explicit claims about the generalizability of their









accounts (Maxwell, 2005). Thus, the objective of qualitative research is to understand

the particular in depth rather than finding out what is generally true of many.

Specific Research Questions and Contribution to the Literature

Any bioterrorism event or threat of an event is a public health and community issue

in which the medical community has a major leadership role. Physicians have a dual

responsibility to educate the community and prepare for any event. Although only a few

physicians would likely recognize the sentinel case in a bioterrorist event, the overall

public health management would involve every physician. Consequently, physicians

must be knowledgeable to accurately address questions from patients, friends, and

acquaintances. Furthermore, every physician must be prepared to take an active role

should a bioterrorist event surface in his/her community. Thus, each physician has a

significant role to assume in our nation's defense against bioterrorism.

The intent of this literature review was to expose the need for rural physicians to be

prepared for public health emergencies such as bioterrorist events. This literature review

has shown that physicians feel better prepared to respond to other disasters such as

natural disasters and infectious disease outbreaks than bioterrorist events (Alexander &

Wynia, 2003; Chen et al., 2002). It has shown that physicians need and request

additional training and CME regarding bioterrorism (Alexander & Wynia, 2003; Chen et

al., 2002; Heun, 2002; Sigmon & Larson, 2002). It has further been demonstrated that

when physicians are provided continuing medical education and training regarding

bioterrorism, they perceive themselves as better prepared to respond to a public health

emergency such as a bioterrorist attack (Alexander & Wynia, 2003; Chen et al., 2002;

Cherry et al., 2003; Croasdale, 2002; Gerberding et al., 2002; Gershon et al., 2004). With

improved training and continuing medical education, physicians also perceive fewer









barriers to delivering patient care because they feel better prepared (Alder et al., 2004;

Cherry et al., 2003; Cowan et al., 2005; Sterling et al., 2005).

Bioterrorist agents can cause a vast array of constitutional symptoms such as fever,

chills, headache, nausea, vomiting, and diarrhea. Bioterrorist agents can also cause more

severe physical symptoms such as chest pain, pneumonia, convulsions, paralysis, and

mortality. Bioterrorist agents also impact mental health in that they invoke or exacerbate

fear, anxiety, acute stress disorder, depression, and other mental health conditions. Thus,

rural physicians' preparedness for organic and mental health conditions related to

bioterrorism is vitally important so when they encounter such signs and symptoms in

patients they can discern and diagnose the condition expediently. Bioterrorism

preparedness requires physicians to be aware of the possibility of bioterrorism at any time

(Gerberding et al., 2002, Inglesby et al., 2000). Plans can only be implemented

effectively if physicians are aware of the possibility of bioterrorism, suspect and

recognize an event when it occurs, notify authorities promptly upon suspicion of such an

event, and institute appropriate management.

Broader public health aspects of bioterrorism preparedness, including primary

prevention measures, are also important areas for informed action by physicians.

Medical education and training curricula must include information on key potential

agents of bioterrorism, and medical professionals require continuous education in this

area, especially those, such as primary care physicians, who are most likely to see

patients affected by a biological weapon. Moreover, physicians from other specialties

may need sufficient knowledge of the likely clinical features of potential biological









agents in order to recognize patients presenting with a compatible illness (Gerberding et

al., 2002; Karwa et al., 2003, Karwa et al., 2005).

This study exposes the need that exists to take decisive steps to improve

bioterrorism preparedness among physicians. Yet as previously stated in this literature

review (Rose & Larrimore, 2002), the current generation of physicians perceive

themselves as unprepared in both their knowledge base and confidence levels to deal with

potential biological terrorism and its consequences. Previous research has underscored

this point by showing that community clinicians often are the first to identify potential

bioweapon victims yet remain inadequately prepared clinically to address such events

(McFee, 2002; Pesik et al., 1999; Sniffen & Nadler, 1999; Varkey, Poland, Cockerill,

Smith, and Hagen, 2002). Consequently, it has become clear that there is a pressing need

to rapidly educate and train medical personnel on the signs and symptoms and reporting

mechanisms of bioterrorism-related diseases (Gershon et al., 2004). Few studies have

examined bioterrorism preparedness (Gershon et al., 2004), and several published reports

provide evidence of both knowledge gaps and high levels of interest in bioterrorism-

related training among physicians (AMA, 2005; Heun, 2002; Sigmon & Larson, 2002).

So, while the previous literature is both pertinent and valuable, there still remains a

void in the literature on the understanding of public health emergency preparedness and

especially of bioterrorism preparedness. Based on this literature review, there also has

not been a significant amount of attention devoted to rural areas. Consequently, there

remain gaps in the perceptions of preparedness among rural physicians. Furthermore,

most of the studies that do exist address the issue exclusively from a quantitative

perspective (Alexander & Wynia, 2003; Chen et al., 2002; Shadel et al., 2003; Sterling et









al., 2005). With the exception of the Alder et al. study (2004), there is not an in-depth

qualitative examination of physicians' perceived emergency preparedness for

bioterrorism. Thus, the topic could benefit tremendously from further qualitative

exploration.

The Alder study exposed physicians' attitudes and assumptions regarding

bioterrorism preparedness in the state of Utah. This study will further contribute to the

literature regarding bioterrorism preparedness by providing an informative qualitative

inquiry. This study has three principal distinctions from the Alder study. First, there is a

focus on perceptions of physicians from rurally designated areas in the state of Florida.

Florida occupies an especially important place regarding bioterrorism. It has the largest

coastline of the 48 contiguous states, which could serve as a major route of access for

bioterrorism. It also has a large rural population with 37 designated rural counties.

Moreover, Florida has a diverse ethnic population along with numerous national and

international tourists exceeding more than 40 million during any given year (Clawson &

Brooks, 2003). Second, this study focuses exclusively on primary care community

physicians in rural healthcare settings. Rural healthcare settings have few primary care

community physicians and often lack specialty physicians altogether. Several previous

studies have shown that primary care community physicians (McFee, 2002; Pesik et al.,

1999; Sniffen & Nadler, 1999; Varkey et al., 2002) will most likely be the first to

encounter sentinel bioterrorist events. Thus, this study is particularly relevant to rural

healthcare settings with primary care community physicians. Third, this study will focus

on the perceived barriers that prevent ample professional preparedness among rural

physicians.









I propose an intensive qualitative study of key informant physicians from rural

counties in North Central Florida. Rural physicians from these counties are hypothesized

to vary in their bioterrorism preparedness because of diverse professional and pragmatic

experiences, their varying degrees of training and education regarding bioterrorism, and

the variation of impediments or barriers to delivering medical care.

The study will use the interview data transcripts from six rural physicians as the

primary data with which to explain the state of emergency preparedness of physicians

and to explain and better understand the barriers to preparedness encountered by these

rural healthcare providers. This study will not focus on empirical testing, but instead will

qualitatively explore the variation or degree to which rural healthcare providers consider

themselves to be prepared for bioterrorist events. Thus, this study will address two

principle research objectives. The first objective is to describe and understand how rural

physicians perceive and explain their state of emergency preparedness particularly for a

bioterrorist event. The second research objective is to describe and understand how the

barriers that these rural physicians perceive to be operative affect their emergency

bioterrorism preparedness.

The long-term objective of this study is to provide a greater description and

understanding of rural physicians' perceived preparedness regarding public health

emergencies such as bioterrorist events. The principal objectives of this study are to

expose the current state of rural bioterrorism preparedness and to provide policy options

to improve the rural healthcare system's bioterrorism preparedness. Thus, the findings of

the proposed study should be relevant to researchers in the disciplines of public health

and rural medicine, as well as practitioners in health policy.














CHAPTER 3
EPISTEMOLOGY, THEORETICAL PERSPECTIVE & RESEARCH METHODS

This chapter begins by providing a brief description of the epistemology and

proceeds to explain constructivism as a theoretical perspective. The conventional

qualitative inquiry format of epistemology followed by the theoretical perspective is

followed (Figure 1). Although it should be noted that the epistemology and the

theoretical perspective are inextricably integrated and intertwined (Crotty, 2003) and may

have on occasion arrows pointing in both the reverse as well as the forward direction.

Chapter three begins with the methods of semi-structured interviews and

constructivist grounded theory (Charmaz, 2004, 2005). Next, participant selection,

participant demographics, and interviews are discussed. This is followed by grounded

theory and data analysis. The chapter continues with an explanation of how validity is

defined from both a quantitative and a qualitative perspective and the qualitative validity

measures employed in this study. The chapter concludes with the limitations of the study

and a subjectivity statement that describes my professional and personal experiences as a

physician, related to physicians and emergency preparedness.

Quantitative and qualitative researchers use similar elements in their work. They

state a purpose, pose a problem or raise a question, define a research population, develop

a time frame, collect and analyze data, and present outcomes (Glesne, 1999). Yet

qualitative research also has salient differences from quantitative research. Quantitative

researchers assume a fixed, measurable reality exists which is external to people. In

contrast, qualitative researchers are generally supported by the interpretivist paradigm,






68


which portrays a world in which reality is socially constructed, complex, and ever-

changing. The belief for constructivists is that social realities are constructed by

participants in social settings. To understand the nature of constructed realities,

qualitative researchers interact and talk with participants about their perceptions. So

qualitative researchers regard their research task as coming to understand and interpret

how the various participants in a social setting construct the world around them (Glesne,

1999).



Epistemology





Theoretical
Perspective





Methods


Figure 3-1: Qualitative Method Process

In qualitative research study, "research design should be a reflexive process

operating through every stage of a project" (Hammersley & Atkinson, 1995, p 24). The

activities of collecting and analyzing data, developing and modifying theory, and

addressing validity threats are usually all occurring at the same time, each influencing all

of the others (Maxwell, 2005). Qualitative research studies have become more prevalent

in health services research and particularly the medical community (Crabtree & Miller,

1999; Frankel, 1999). For example, two prominent qualitative researchers, Miller and









Crabtree, developed a document for the Information Mastery Working Group to identify

qualitative articles worthy of review for the medical journal, The Journal of Family

Practice and Evidence-Based Practice (Crabtree & Miller, 1999). The Journal of Family

Practice and Evidence-Based Practice has a web page in which supplementary materials

for published articles can be placed. Crabtree and Miller (1999) explain this is akin to an

external audit.

Qualitative research rests on assumptions that reality is socially constructed and

variables are complex, interwoven, and difficult to measure. To understand the nature of

constructed realities, qualitative researchers interact and talk with relevant participants

about their perceptions. The research approach is descriptive and inductive in nature,

searches for patterns, and may result in the formulation of hypotheses and theory.

Qualitative research has the principal purposes of understanding and interpretation

(Maxwell, 2005). According to Crotty (2003) and other qualitative researchers

(LeCompte & Preissle, 1993; Miles & Huberman, 1994; Robson, 2002; Rudestam &

Newton, 1992, p 5), the following components are important in research design: the

research questions, methods and validity. There are three principal elements of the

methodological research process (Crotty, 2003). This chapter will examine these

important elements by addressing the following three questions: What methods will be

used?, What theoretical perspective lies behind the methodology in question?, and What

epistemology informs this theoretical perspective? Thus, what follows is an explanation

to each question beginning with the epistemology, followed by the theoretical perspective

and then the methods themselves.









Ontological and Epistemological Considerations

Prior to embarking on any kind of qualitative research, it is important for a

qualitative researcher to consider and then identify assumptions regarding what

constitutes valuable knowledge (Crotty, 1998). The epistemology that the researcher

finds to be the most suitable should serve as the foundation on which research

methodology selection and implementation will be grounded (Crotty, 1998).

According to Maxwell (2005), ontology is a set of general philosophical

assumptions about the nature of the world and epistemology is how one can understand

it. Epistemology is the theory of knowledge embedded in the theoretical perspective and

thereby in the methodology (Crotty, 2003). So, an epistemology is a way of

understanding and explaining how one knows what one knows (Crotty, 2003).

Epistemology deals with the nature of knowledge, its possibility, scope, and general basis

(Hamlyn, 1995). According to Maynard (1994), epistemology is concerned with

providing a philosophical grounding for deciding what kinds of knowledge are possible

and how a person can ensure that their knowledge is both adequate and legitimate. In

essence, there is a need to identify, explain, and justify the epistemological stance. As

participants in this study, the rural physicians share their perceptions and thereby inform

the interviewers what knowledge is and the reality is what is reported in the study.

There are several types of epistemologies: objectivism, constructionism and

subjectivism. An objectivist epistemology holds that meaning, and therefore meaningful

reality, exists as such apart from the operation of any consciousness. An illustration of

objectivism is that a tree in the forest is a tree, regardless of whether anyone is aware of

its existence or not. As an object of that kind (objectively, therefore), it carries the

intrinsic meaning of "tree-ness" (Crotty, 2003, p 8). Crotty further explains that when









human beings recognize a tree, they are simply discovering a meaning that has been lying

there in wait for them all along.

Constructionism is another type of epistemology which rejects this view of human

knowledge. According to constructionism, there is no objective truth waiting for us to

discover it. Truth, or meaning, comes into existence in and out of our engagement with

the realities in our world. There is no meaning without a mind. Meaning is not

discovered, but constructed. According to Crotty, in this understanding of knowledge, it

is clear that different people may construct meaning in different ways, even in relation to

the same phenomenon. Crotty (2003) argues that this is precisely what one finds when

one moves from one era to another or from one culture to another. In this view of things,

subject and object emerge as partners in the generation of meaning (Crotty, 2003).

This study embraces constructionism as its principal epistemological stance.

Constructionism is the view that all knowledge, and therefore all meaningful reality as

such, is contingent upon human practices, being constructed in and out of interaction

between human beings and their world, and developed and transmitted within an

essentially social context (Crotty, 2003). According to constructionism, one does not

create meaning, but one constructs meaning. Human beings construct meanings as they

engage with the world they are interpreting. As Crotty explains, the world is always

already present, and although the world and the objects in the world may be in

themselves meaningless, they are partners in the generation of meaning. Thus,

constructionism brings the interaction between subject and object to the forefront. Crotty

(2003) explains that the image evoked from this interaction is the subject or humans

engaging with their object or the world. Thus, constructionism brings objectivity and









subjectivity together and unites them and it is in and out of this interplay that meaning is

born.

Subjectivism is another type of epistemology. In subjectivism, meaning does not

come only from the interplay between subject and object, but is imposed on the object by

the subject (Crotty, 2003). According to Crotty, in subjectivism one makes meaning out

of something or one imports meaning from somewhere else. The meaning ascribed to the

object may come from one's beliefs, or from one's professional experience, or from one's

personal experiences, or from one's educational background, or from religious beliefs, or

from primordial archetypes located within a collective unconscious, or from other realms.

So, meaning comes from more than an interaction between the subject and the object to

which it is ascribed (Crotty, 2003).

To be consistently subjective means to distinguish scientifically-established

objective meanings from subjective meanings that people hold in everyday fashion and

that "reflect" or "appear or perceive" or "mirror" objective meanings. Subjective

meanings are very important within an individual's life to ascertain an individual's

meaning making, perceptions, and reflections. Thus, subjectivism is an effort to identify,

understand, describe, and maintain the subjective experiences of the respondents.

In essence with this context, the epistemological stance of constructionism is in

search of the individual rural physicians' subjective experiences and constructed

meanings, perceptions, and understandings of emergency bioterrorism preparedness, and

the impediments preventing their preparedness. The rural physicians' perceptions and

their individual meaning-making processes produce the source of information, truth, and

knowledge.









Theoretical Perspective: Constructivism

Epistemology provides a philosophical background for deciding what kinds of

knowledge are legitimate and adequate. Epistemology is the theory of knowledge

embedded in the theoretical perspective. The theoretical perspective is the philosophical

stance that shapes our methodologies, providing a context for the process and grounding

its logic and criteria. The theoretical perspective is a statement of the assumptions

brought to the research task and reflected in the methodology as one understands and

employs it (Crotty, 2003). Thus, the theoretical perspective is a way of looking at the

world and making sense of it. It, too, involves knowledge and embodies a certain

understanding of what is entailed in knowing, that is, how one knows what one knows

(Crotty, 2003), although, as has been previously stated, knowledge is generally

considered more the realm of the epistemology, but there is overlap (Crotty, 2003). In

this study, the form of inquiry and data collection employed involves selective sampling

with semi-structured interviews. By the very nature of the interviews, some of the

assumptions relate to matters of language and issues of subjectivity and communication.

To account for these assumptions and justify them requires an explanation of the

theoretical perspective. Consequently, the theoretical perspective is an elaboration of our

view of the human world and social life within that world, wherein such assumptions are

grounded.

Research in the constructivist vein requires that one does not remain straitjacketed

by the conventional meanings that one has been taught to associate with the object.

Instead, such research invites one to approach the object in a radical spirit of openness to

its potential for new or richer meaning (Crotty, 2003). Constructivists believe that the

social "constructions of individuals and groups are not more or less 'true' in an absolute









sense, but, simply more or less informed and/or sophisticated" (Lincoln & Guba, 1985, p

111). Constructivism asserts that nothing represents a neutral perspective, that is,

nothing exists before consciousness shapes it into something perceptible (Kincheloe,

2005).

In constructivist theory, different individuals coming from diverse backgrounds

will perceive and see the world in different ways. The backgrounds and expectations of

the observer will also shape perception (Kincheloe, 2005). Constructivist theory defines

shared constructs and meanings as "situated"; that is, they are located in or affected by

the social, political, cultural, economic, ethnic, age, gender, and other contextual

characteristics of those who espouse them (LeCompte & Schensul, 1997). These

characteristics influence how individuals think, believe, and present themselves. Thus,

interpretations cannot be separated from the interpreter's location in the web of reality.

One's interpretive facility involves understanding how historical, social, cultural,

economic and political contexts construct one's perspectives on the world, self, and

others (Kincheloe, 2005).

The knowledge that constructivist research produces is grounded on the assumption

that the world is shaped by a complicated, web-like configuration of interacting forces.

Knowledge producers, like everyone else, are inside, not outside, the web. The knower

and the known are inseparable-they are both a part of the complex web of reality. No

one in this web-like configuration can totally escape the web and look back at it from

afar. Indeed, one must confess his/her subjectivity and one must recognize his/her

limited vantage points (Kincheloe, 2005).









To recognize how one's particular view of the web shapes the conception of social,

psychological, and educational reality, one also needs to understand the historical

location. According to Kincheloe (2005), the world is socially constructed, that is, what

one knows about the world always involves a knower and that which is to be known.

Kincheloe states that how the knower constructs the known is principally through

perceptions and reflections which constitutes what one thinks of as reality. He explains

that all knowers are both historical and social subjects. Each person is from

"somewhere", which is located in a particular historical time frame. These spatial and

temporal settings always shape the nature of our constructions of the world. Not only is

the world historically and socially constructed, but so also are people and the knowledge

people possess. He explains that individuals create themselves with the cultural tools at

hand. A person operates and constructs the world and his/her life on a particular social,

cultural, and historical playing field (Kincheloe, 2005).

Schwandt states that constructivists "are deeply committed to the contrary view that

what one takes to be objective knowledge and truth is the result of perspective"

(Schwandt, 1994, p 125). Constructivists "emphasize the instrumental and practical

function of theory construction and knowing" (Schwandt, 1994, p 125). Constructivism

is primarily focused on an understanding of an individual in the context of the social. It

involves the meaning-making activity of the individual mind (Crotty, 2003; Schwandt,

1994), and further explains the unique experience of each of us. It suggests that each

one's way of making sense of the world is valid and worthy of respect as any other,

thereby tending to ameliorate any innuendo of a critical spirit. The role of perceptions

and reflections are the essential components in the formulation of individual meaning-









making and understanding. Therefore, constructivism describes the individual human

subject engaging with objects in the world and making sense of them (Crotty, 2003).

Constructivism as a theoretical perspective facilitates individual meaning-making,

perceptions, and reflections as crucial elements. This theoretical perspective will assist in

understanding rural physicians' perceptions of their own perceptions to emergency

bioterrorism preparedness. It also assists in understanding the barriers rural physicians

perceive as impediments to emergency bioterrorism preparedness. Constructivism as a

theoretical perspective guides the study research inquiries and the purposes of the study

to understand the perceptions and reflections of rural physicians' preparedness for a

bioterrorism event.


Epistemology Theoretical Methods
Perspective
Semi-structured
Constructionism Constructivism Interviews
Grounded Theory






Figure 3-2: Detailed Qualitative Methods Process

Methods

This section describes the strategies that were used to recruit participants and

collect data, as well as the analysis procedures employed. This study uses qualitative

methodology to describe and understand rural physicians' and healthcare providers'

perceptions regarding emergency bioterrorism preparedness and the perceived barriers

encountered in preparedness. The detailed description of the methods used for this

inquiry is presented for the reader to be able to adequately evaluate the rigor of the

research process and findings.









Participants

Selection Criteria and Sampling

Crabtree and Miller (1999) ask how researchers select a sample from a larger pool

for closer scrutiny. They further ask how can one feel confident that the sample chosen is

appropriate and adequate (Crabtree & Miller, 1999). In such qualitative data collection, a

challenge involves determining when one has exhausted new information or reached a

saturation point. My qualitative study declares based on the rich content of the interview

participants that new data would not emerge with additional interviews. Thus, additional

data collection would merely result in repetitive data thereby suggesting data saturation.

Patton suggests that qualitative research "typically focuses in depth on relatively small

sample sizes, even single cases (n =1), selected purposefully" (Patton, 1990, p 168).

Patton contrasts this with quantitative research designs, which "typically depend on larger

samples selected randomly" (Patton, 1990, p 169). Qualitative research uses field or

documentary/historical research styles, and the sampling is driven not by a need to

generalize or predict, but rather by a need to create and test new interpretations (Crabtree

& Miller, 1999). Typically, the investigator intends to increase the scope or range of the

data to reveal multiple realities and/or create a deeper understanding (Crabtree & Miller,

1999). This is what McWhinney refers to as "an acquaintance with particulars"

(McWhinney, 1989). It allows for the development of theory that takes into account local

conditions (Bogdan & Biklen, 1982; Glaser & Strauss, 1967; Guba & Lincoln, 1989;

Lincoln & Guba, 1985; Patton, 1990). Thus, in field or documentary/historical research,

sampling strategies strive for information richness (Patton, 1990).

There are several possible goals of purposeful selection according to qualitative

researchers (Creswell, 2002; Guba & Lincoln, 1989; Maxwell, 2005). Purposeful









sampling is also known as criterion-based selection (LeCompte & Preissle, 1993; Patton,

1990). This study employs purposeful sampling, which is conventionally used in

grounded theory research (Glaser & Strauss, 1967; Strauss & Corbin, 1990). The goal of

using purposeful sampling in this qualitative study was to ascertain the representativeness

or typicality of the rural settings and the individuals. An additional objective was to

compare the settings and individuals.

Purposeful sampling is a strategy in which particular settings, persons, or activities

are selected deliberately in order to provide information that cannot be gotten as well

from other choices. This study used what Weiss (1994, p 17) explains as the use of

panels-"people who are uniquely able to be informative because they are expert in an area

or were privileged witness to an event." In this study, physicians were selected

purposefully from rural counties in North Central Florida to explain their current

perceived emergency preparedness and the perceived impediments to bioterrorism

preparedness. This purposeful sampling was performed to aid the grounded theory

development and the grounded theory coding process or as, Strauss and Corbin (1990)

state: "for verifying the story line, relationships between categories, and for filling in

poorly defined categories" (p 187).

Physician participants were recruited from several rural counties in North Central

Florida. The counties included were Levy County, Gilchrist County, Dixie County,

Bradford County, and Putnam County. This was done to select cases that illustrate or

highlight diverse variations and to identify what is typical, normal and common regarding

rural physicians' perceptions of emergency bioterrorism preparedness and the perceived

barriers. Although the degree of experience and medical specialty varied, each









participant selected to participate in this inquiry was a physician from a rural county

practicing medicine in a rural setting in North Central Florida. These physicians were

selected from county departments of health, medical clinics, and community health

centers. All of the participant physicians were from federally-designated metropolitan

statistical areas that were classified as rural in 2003 and 2004.

The educational background and, more importantly, the particular professional

specialty of the participants are important because the main purpose of this research is to

describe and understand the perceptions of physicians' emergency bioterrorism

preparedness. Additionally, the fact that these physicians were from rurally designated

areas is important. Physicians in rural communities play an essential role in the safety net

in the event of a bioterrorist attack (Office of Rural Health Policy, 2002). If a bioterrorist

attack were to occur in an urban area, the evacuation of the urban area could result in a

mass exodus of people migrating into the rural communities, with many needing medical

care. Also, the converse is true as rural health providers may be called upon to enter the

urban areas to lend support to the physicians there in order to meet all the needs of the

victims. Thus, it is essential that physicians practicing in hospitals, and also those in

private practice, be well trained and able to respond in the event of a bioterrorist attack

(Gerberding et al., 2002). In prior research studies in which physicians were interviewed

to gain information regarding their emergency bioterrorism preparedness, the data

generated revealed that physicians felt more prepared to deal with infectious disease

outbreaks and natural disasters than emergency bioterrorism events (Alexander & Wynia,

2003; Chen et al., 2002).









Participants were interviewed at their place of employment. Each participant had

either a medical doctorate (M.D.) or a doctorate of osteopathic medicine (D.O.) and had

practiced medicine prior to September 11, 2001 and five of the six had practiced

medicine at the same site prior to September 11, 2001. Physician participants were from

primary care specialties including family medicine, internal medicine, pediatrics, and

emergency medicine. This was done for several reasons. It was performed because in

many of these rural areas there was only one physician and it was also employed to

identify and search for important common patterns across diverse variations.

Demographic Information

Six physicians from the rural North Central Florida counties of Levy, Gilchrist,

Dixie, Bradford and Putnam Counties were recruited to participate in this study. This

number of participants has been successful in previous qualitative research examining

family physicians and patients' perceptions and personal experiences with pain (Miller,

Crabtree, Addison, Gilchrist, and Kuzel, 1994). This number of participants allows the

researcher to gather an ample amount of data to obtain validity, while at the same time

limiting the amount of data generated so that the researcher can provide in-depth

descriptions of the participants' perceptions (Crabtree & Miller, 1999; Merriam, 1995;

Patton, 1990). Patton (1990, p 185) further states "the validity, meaningfulness, and

insights generated from qualitative inquiry have more to do with the information-richness

of the cases selected and the analytical capabilities of the researcher than with sample

size." Of the six participants, five had a M.D. degree and one had a D.O. degree. Two

participants were from county Departments of Health (Levy and Dixie), and the others

were from rural health clinics (Fanning Springs, Shands at Starke, Trenton Medical

Center, and Putnam Family Medical and Dental). Three physicians were trained and









practiced as family practitioners, one was trained and practiced as an internal medicine

physician, one was trained and practiced as a pediatrician, and one was trained as a

preventive medicine or public health physician and also practiced emergency medicine.

Background information describing each of the participants was important when

seeking their perception of emergency bioterrorism preparedness and barriers to

emergency bioterrorism preparedness because any similarities or differences between

participants may have influenced how they viewed the world. Background information

was collected from each participant during the interview (See Appendix A: Interview

Questions). Table 3-1 shows basic demographic information from each of the

participants. Each of the physicians had unique medical experiences with bioterrorism

emergency preparedness. Each physician, save one, was employed and practicing

medicine at the site prior to September 11, 2001, and prior to the bioterrorism anthrax

attacks in October of 2001. One physician was practicing medicine, but at a different

location. Table 3-2 shows clinical background information for each physician, including

degree, specialty, years practicing medicine, years practicing medicine at the facility, and

rural county. Pseudonyms were used for each physician participant to protect their

identity (Table 3-1 and Table 3-2 contain the pseudonyms).









TABLE 3-1: Participant Demographic Information

Participant Age Gender Ethnicity County

Doctor Williams 46 Male Caucasian Gilchrist/Levy
Doctor Smith 42 Male Caucasian Levy
Doctor Davis 48 Male Caucasian Bradford
Doctor Jones 35 Male Caucasian Gilchrist
Doctor Brown 49 Male Caucasian Putnam
Doctor Phillips 38 Female Asian- Dixie
American

TABLE 3-2: Clinical Background Information

Participant Degree Specialty Years in Years at
Medical Medical Site
Field

Doctor M.D. Family Medicine 12 12
Williams
Doctor Smith D.O. Internal Medicine 16 3
Doctor Davis M.D. Public Health/ 21 21
Preventive
Medicine and
Emergency
Medicine
Doctor Jones M.D. Family Medicine 9 2
Doctor Brown M.D. Family Medicine 23 4
Doctor Phillips M.D. Pediatrics 12 4

Data Collection

Data collection consisted of participant semi-structured interviews. The specific

strategies used to collect data through these means are described in the following section.

My Role in the AHRQ 1 U01 HS14355-01 Grant

I became a member of the research team when asked to participate by the principal

investigator in early 2004. One of my roles was to assist with the interviewing of key

participant respondents. My other role in the research project was to assist with the

coding of the participant transcripts using the software program ATLAS.









I chose to compose this study using this data because of my interest in both

physician emergency preparedness and because of the loss of a friend and physician

colleague as a result of the September 11, 2001, terrorist events. Further, as a physician,

I am naturally interested in how physicians perceive their preparedness regarding public

health emergencies.

Interviews

The methods selected for data collection should take into consideration the fact that

it is not the researcher's perception that is of interest (Moustakas, 1994; Seidman, 1991).

In qualitative research, a common approach is to use open-ended semi-structured

interviews to gather data from participants (Kvale, 1996; Moustakas, 1994; Seidman,

1991). Interviews are the primary source of data in constructivist research because, if

structured properly, they allow the researcher to gather data while simultaneously

reducing the influence of researcher bias (Moustakas, 1994; Seidman, 1991).

Research interviews vary on a series of dimensions. This study employs a semi-

structured interview format. Such a format facilitates an a priori sequence of interview

question formulations, yet also embraces flexibility during the interview session to focus

on topics of importance for the participants. According to Kvale (1996), interviews also

differ in their openness of purpose. In this qualitative study, the interviewers explained

the purpose and posed direct questions from the inception of the interview.

The interview questions asked of each participant were brief and simple. Many of

the types of questions that are considered useful by qualitative researchers (Kvale, 1996;

Seidman, 1991) in semi-structured interviews were included. For instance, the types of

interview questions asked included introducing questions, probing questions, specifying

questions, structuring questions, direct questions, and indirect questions (Kvale, 1996).









The interview objective was to elicit a physician's perceptions of preparedness by

asking the types of organic and mental health conditions likely to be encountered

following a bioterrorist event and the risk factors associated with developing medical or

mental health conditions. The interview questions also elicited the perceived

impediments a rural physician or the physician's patients may encounter in accessing

healthcare and whether these would be exacerbated during or following a bioterrorist

attack. The questions probed into the level of perceived education and training that is

important and appropriate regarding bioterrorism agents and preparedness.

Representative interview questions included (1) What types of physical conditions do you

think you would be likely to see in patients following a terrorist attack? (2) What types of

mental health disorders do you think you would be likely to see in patients following a

terrorist attack? (3) Are you aware of any risk factors for developing medical problems

following a bioterrorist attack? (4) Are you aware of any risk factors for developing

mental health problems following a bioterrorist attack? (5) What kinds of things can get

in the way of accessing healthcare for people served at this clinic? and (6) How important

is it for healthcare providers to receive training for bioterrorism? Appendix A contains

the complete list of interview questions.

Prior to each interview a one page summary of the intent and objectives of the grant

awarded from the Agency for Healthcare Quality and Research was mailed to each of the

clinic's administrators. Two academic faculty members conducted each interview, with

one member asking questions and the other member recording field notes and reflections.

To help the participants feel comfortable, each interview was conducted at the clinic in

the physician's personal office. One of the interviews was conducted at a physician's









office which was not located on the physical clinical site. Two of the interviews were

conducted with two respondents, a physician and a healthcare administrator, present

during the interview; while the other interviews were conducted with only a physician

respondent. Each interview was audio recorded and transcribed verbatim by a

transcriptionist. After, the transcriptions were completed the researcher compared

samples of the interview transcriptions with the audio recordings side-by-side to assess

accuracy.

The interviewers began each interview, prior to the audio recording, with a briefing

or verbal explanation of the intent and research objectives of the study. This was

performed not only to explain the intent of the interview and the project but also to

develop rapport with each respondent prior to engaging in the interview. Each candidate

agreed to participate in the study voluntarily, potential benefits and anticipated risks were

explained, and each signed an informed consent form. Each respondent was assured that

the interview would remain confidential. Monetary compensation of twenty-five dollars

was provided to each participant's clinic or health center. This was provided as a token

of appreciation and was not viewed as payment for participating. The University of

Florida Institutional Review Board granted approval for the study.

The interviews ranged from forty-five minutes to one hour in duration, which is

within the 60 minute duration suggested by Seidman (1991). The duration is suggested

for two reasons. First, if the interview is too long the participant and/or the researchers

may tire and become inattentive. Second, the duration enabled the busy physicians to

schedule a reasonable amount of time. The intent was for each research interview to

proceed like a normal conversation yet have a specific purpose and structure (Kvale,









1996). Each participant was asked at the conclusion of the interview session if there were

any additional information that the respondent would like to add to the interview. Several

of the physician respondents asked how the research data would be utilized. In general,

the respondents were engaging and eager to discuss preparedness and their previous

experiences.

Data Analysis

This section describes the specific strategies that were employed to analyze the data

collected through the semi-structured interviews. This study uses grounded theory to

analyze the relationships between rural physicians and their social structure that pose

theoretical and practical concerns with respect to their perceptions of bioterrorism

preparedness.

Grounded theory method is a set of flexible analytic guidelines that enable

researchers to focus their data collection and to build inductive middle range theories

through successive levels of data analysis and conceptual development (Charmaz, 2005).

Grounded theory studies emerge from wrestling with data, noting similarities, making

comparisons, developing categories, and integrating an analysis (Charmaz, 2005).

Grounded theory entails developing increasingly abstract ideas about research

participants' meanings, actions, and their world, as well as seeking specific data to fill

out, refine, and check the emerging conceptual categories (Charmaz, 2005). Data and

ideas are not merely objects that one passively observes and compiles (Holstein &

Gubrium, 1995). Rather, data results from an analytic interpretation of a participant's

world and from the processes constituting how this world is constructed (Charmaz,

2005).









Charmaz (2005) explains that the entire research process is interactive because one

brings past interactions and current interests into the research and one interacts with

his/her empirical materials and emerging ideas. Grounded theory methods locate

subjective and collective experience into larger structures and increase understandings of

how these structures work (Clarke, 2003, 2004; Maines, 2001, 2003). Thus, grounded

theory method offers integrated theoretical statements that ultimately will lead to an

increased understanding of how rural physicians' perceived bioterrorism preparedness

develops, changes, or continues.

Glaser (2002) treats data as something separate from the researcher and implies that

data are untouched by a competent researcher's interpretations. If researchers interpret

their data, then according to Glaser (2002), these data are rendered objective by looking

at several cases. However, a limitation of both qualitative and quantitative research is

that no analysis is neutral because researchers do not come to their studies uninitiated

(Denzin, 1994; Morse, 1999; Schwandt, 1994, 2000). Charmaz (2005) argues what one

knows shapes, but does not necessarily determine, what one finds.

A constructivist grounded theory (Charmaz, 1990, 2000, 2003; Charmaz &

Mitchell, 2001) adopts grounded theory guidelines as tools but does not subscribe to

objectivist or positivist assumptions. Positivism can be characterized as a world

composed of observable, measurable facts and it implies that measurable reality exists

external to people (Glesne, 1999). Constructivists, instead, portray a world in which

reality is socially constructed, complex, and ever-changing (Glesne, 1999). So, a

constructivist approach emphasizes the studied phenomenon rather than the methods of

studying it and close attention is given to empirical realities and our collected renderings









of them as well as locating oneself in these realities (Charmaz, 2005). Charmaz (2005)

explains that it does not assume that data simply await discovery in an external world or

that methodological procedures will correct limited views of the studied world. Charmaz

further explains that it does not assume that impartial observers enter the research scene

without an interpretive frame of reference. Rather, what observers see and hear depends

upon their prior interpretive frames, biographies, and interests as well as the research

context, their relationships with research participants, and modes of generating and

recording empirical materials (Charmaz, 2005). Thus, constructivist grounded theory

places an emphasis on participants' experiences. In this view, subjective meanings

emerge from experience, and they change as experience changes (Reynolds, 2003).

Charmaz (2005) explains that no qualitative method rests on pure induction rather the

questions that are asked of the empirical world frame what one knows and one shares in

constructing what one defines as data. In a similar fashion, the conceptual categories

arise through our interpretations of data rather than from them or from our

methodological practices (Glaser, 2002). Thus, the theoretical analyses are interpretive

renderings of a reality, and not merely an objective reporting of it (Charmaz, 2005).

In this study, constructivist grounded theory offers a systematic approach to health

services research that fosters integrating subjective experience with social conditions in

the analyses. An interest in health services research and, more specifically, bioterrorism

preparedness and barriers facing rural physicians and their patients means attentiveness to

ideas and actions concerning perceptions of preparedness, perceptions of barriers to being

prepared for bioterrorism, education and training, and previous experience with disasters.

It signifies thinking about rural areas, scarce resources and healthcare personnel, and the









threats posed to rural healthcare settings. It prompts an assessment and a reassessment of

the preparedness perceptions and roles of physicians in rural healthcare settings. Thus, it

requires looking at both perceptions and realities. Therefore, contested meanings of

shouldd" and "oughts" come into play (Charmaz, 2005). Unlike positivists,

constructivists openly bring their should and oughts into the discourse of inquiry

(Charmaz, 2005).

Coding and Memos

Coding is the first step in taking an analytic stance toward the data in grounded

theory. The initial coding phase in grounded theory forces the researcher to define the

action in the data statement (Charmaz, 2005). Standard grounded theory practice uses

active, immediate, and short codes focusing on defining action, explicating implicit

assumptions, and seeing processes (Charmaz, 2005). By engaging in line-by-line coding,

the researcher makes a close study of the data and lays the foundation for synthesizing it

(Charmaz, 2005). This is what was performed in this study on each of the participants.

Charmaz (2005) explains that coding gives a researcher analytic scaffolding on which to

build. So each interview can inform earlier data. This means in essence that a researcher

can discover a lead through developing a code in one interview and can then go back

through earlier interviews and take a fresh look as to whether this code sheds light on

earlier data (Charmaz, 2005). This was performed on each interview in this study and

consequently ensures the data has multiple readings and renderings.

According to Glaser (1978, p 55), "Coding gets the analyst off the empirical level

of fracturing the data, then conceptually grouping it into codes that then become the

theory which explains what is happening in the data." The coding practices will help to

uncover our assumptions, as well as those of our research participants (Charmaz, 2005).