Given the uncertainty caused by inconsistent scientific information around radiation, the analyses of PHNs’ interactions with mothers and with their own peers have yielded insight into the challenges and corresponding strategies that PHNs face and can adopt for better communication of risks. This study provides community-based insights on the needs related to health communication and on the ways to improve risk communication following the Fukushima nuclear accident through the perspectives of PHNs, who live and work in, and interact regularly with the local community. This is the first study to delineate such information through a combination of data from PHNs and their interactions with mothers, and is thought to be instrumental to our general knowledge in disaster recovery interventions despite the context to be specific to the Fukushima Nuclear incident.
Mothers’ concerns
Many disaster studies lack baseline data [12]; in contrast, our review of records from routine services of parenting counseling provides this critical baseline, and enabled us to document the changing trends of community concerns before and after the disaster. Many of the post disaster concerns from Fukushima are similar to those documented in other disaster settings [18, 19]. The PHNs’ records of mothers’ reactions after the disaster were similar to those observed after the Chernobyl accident; parental anxiety at a subclinical level is expected according to previous research [18], and the mothers in our study have also raised similar concerns in the year of the Fukushima incident and in the following year. Another observation from the Chernobyl incident was the tendency for mothers to report somatic symptoms of their children despite no abnormalities in medical assessments [19], and our study has likewise observed an increase in consultations on children’s medical issues during health checkups in 2011.
Concerns about their children’s health further escalated, as evident from statements by mothers attending consultations in 2012 to question PHNs about technical information related to radiation and thyroid screening. Additional knowledge on radiation and its related health risks in PHNs is clearly warranted. Another finding from our study was how these mothers were also voicing conflicts of risk perceptions with their spouses. This resonates with findings from a recent study looking into risk communication after the Fukushima incident, which has shown a distinct higher proportion of mothers in Fukushima to have stronger levels of anxiety as opposed to fathers [20]. It is well known that risk perception differs between sexes, and perceived risk is generally higher among women than men [21]. In lieu of our findings, the strengthening of parenting support programs organized by the city currently is further recommended to address mothers’ persistent concerns on risk, and potential conflicts arising from differing risk perceptions within the family. This follows the Inter-Agency Standing Committee guidelines recommending strengthening of existing resources and capacities as one of core principles in mental health support in a disaster setting [22].
Empowering mothers
PHNs, when considering mothers’ distinctive concerns, perceived themselves as information channels in the community and recognized the importance of empowering residents with advice so as to allow them to make well-informed decisions. The nurses proposed the provision and use of radiation dosimeters as an empowerment tool, and an expansion of the current scope of consultations to provide residents more opportunities to ask questions pertaining to daily life. The radiation dosimeters became widely sold commercially after the disaster, at a cost of about 30 USD. The availability and usage of radiation dosimeters is an important component for the regain of a sense of control of one’s surroundings, as demonstrated by an initiative supported by the European Commission ten years after the Chernobyl accident to successfully improve mothers’ sense of control by recommending the measuring of radiation levels in their living environments, and discussing protective measures that can be taken at home [23, 24]. PHNs in Fukushima can therefore learn from these experiences and adopt similar activities in their local communities much earlier than the case of Chernobyl so as to better empower mothers and facilitate communication in radiation-related risks. Indeed, in line with recommendations by these post-Chernobyl studies [23, 24], Fukushima City has already initiated experience-based learning sessions in which participating residents learn to measure and interpret their own radiation exposure level.
Improving nurses’ health literacy skills
The PHNs also recognized their responsibilities and the need to improve their communication skills to better transfer scientific knowledge and information to the community. Previous research in health literacy has indicated that any information provided through parenting support and other city activities should be comprehensible to mothers and their family members [25]. Such access to information would allow residents to make informed lifestyle decisions. This might also relieve unnecessary distress in mothers and within the family. In times of crisis, high quality communication between lay people and healthcare workers is critical both in the relaying of clear and credible information and the engagement of intended audiences [26]. The National Action Plan to Improve Health Literacy has therefore been initiated in the US in 2010, with the goal of developing and disseminating health information that is accurate, accessible, and actionable [27]. Henceforth, increasing awareness of health literacy, a concept only introduced in Japan in the late 1990s [28], is an important step to further bolster quality communication between PHNs and community residents. Although no studies have been published on this front, Fukushima City and Fukushima Medical University are currently organizing and evaluating health literacy workshops for the PHNs.
Expanding city health services
Going beyond the individual capacity-building of residents and PHNs, the nurses have also, in their peer discussions, suggested an organizational upgrading of the provision of city health services to improve their communication with the community. Specific suggestions included expanding the frequency of community-based counseling services, and standardizing the provision of information (highlighting the need for systematic information especially with regards to thyroid cancer screening). The importance of improving communication between the community and the local government office, in which PHNs work, is supported by a previous study [29]. In their examination of determinants of people’s trust toward government and non-government organizations, they found that an important factor to facilitate government-community relations was the degree of “openness” of an organization attained via the bidirectional communication. In general, a challenge among PHNs working in Japan’s hierarchical local government system is the difficulty of initiating new activities that have not been endorsed by the upper levels of the government [30]. The disaster has however, increased the PHN’s decision-making power in the local government system, thus new programs such as a mental health support program for mothers at the 18-month child health checkups, regular lectures on radiation-related topics for residents, and epidemiological assessments of child growth have been implemented since the Fukushima nuclear incident [10].
Although human resource and budget constraints exist, and the differing interests among stakeholders (such as upper boards of prefectural government, municipal office and universities) will need to be taken into account, continuous efforts to improve services that can enhance communication with the residents are required to address the social distrust caused in part by how the Japanese government has communicated with people immediately after the disaster [31].
Study limitations and strengths
A major limitation of the present study was the limited amount of qualitative data extracted from the child health checkup files and workshop discussion notes. Each case contained only a few sentences that were often fragments. Another limitation was how samples were only collected within a specific time period of each year (between April and May). However, the qualitative analysis of both parenting counseling records and discussion notes from PHNs’ training workshops, although limited in amount and time-frame, can provide comprehensive information for PHNs and policy makers to understand community needs and to formulate appropriate strategies. Of note, a comparison between the present study and a previous study adopting a similar sampling strategy throughout a year in the sample city has indicated no differences in mothers and children’s basic characteristics [32].
On the other hand, a methodological strength of this paper was that it has demonstrated the usefulness of the combination of text mining and SCAT for the analysis of text data that are readily available and accessible via currently available healthcare services.