We draw a number of conclusions from our assessment of risk communication strategies and practices. First, the field, defined by the intersection of public health emergency risk communication and at-risk populations, is relatively new. Only a small proportion of the literature in this domain addresses at-risk populations within the context of public health risk communication (see Appendix A). Of the literature identified, most is descriptive in nature, suggesting a need for more rigorous evaluations of risk communication strategies that target at-risk populations. In her review of risk communication activities during public health emergencies, Glik (2007) also noted the need for systematic evaluations of the effectiveness of risk communication, particularly during actual events. We found that across states and risk communication activities, evaluation efforts range widely in terms of their methodology and rigor. More systematic evaluation to determine the impact of risk communication for at-risk populations would provide valuable information to guide the field in enhancing preparedness, response, and recovery.
A relatively wide range of risk communication resources was identified in the compendium search (see Appendix B). Among the subset of materials we judged to be “all-stars” and reviewed in greater depth, we confirmed many of the findings from the literature review.
For example, in the literature review, weather reporters were identified as a preferred risk communication messenger during emergencies. Accordingly, interviews in Oklahoma confirmed the importance of weather reporters as key communicators to the public because they are trusted community members and they provide essential weather-related information as well as reinforce messages about how viewers can protect themselves.
Our interviews also confirmed the literature review findings that children have special needs during disasters and therefore that school-based settings are an important venue for exercises and drills.
Finally, our literature review, compendium search, and interviews provided triangulating information about how risk communication for at-risk populations is used and highlighted those activities that are particularly innovative and that hold promise for broader use across states. As suggested by the results of the literature review, using community-based participatory approaches to designing and disseminating risk communication for at-risk populations, and offering messages in multiple modes that are locally and personally relevant, are promising practices that would have many benefits but are currently underutilized.
Table 3 summarizes the key factors of risk communication as they apply to at-risk populations organized within the five CDC guidance areas (rows) across each phase of an emergency event (columns). This table follows the form of a Haddon Matrix (Haddon, 1972, 1980). The matrix illustrates how particular features of effective risk communication map to the phase in terms of when certain activities should take place. Accordingly, our key conclusions and policy considerations are delineated by emergency phase (pre-event, event, and post-event), highlighting the risk communication strategies that are commonly used and suggesting which of these hold particular promise for future success. We also discuss implications for future PHEP.
|TABLE 3. Matrix for Organizing Risk Communication Practices for At-Risk Populations by Phase of Emergency and Risk Communication Practice Area|
|Risk Communication Practice Area||Event Phase|
|Plan Development||Establishing planning committees that include representatives of at-risk populations||N/A||N/A|
|Drills/Exercises||Strengthening training by directly addressing the needs of at-risk populations||N/A||Evaluate the impact of risk communication efforts|
|Coordination||Community involvement||Use new technology to enhance communication reach||Share lessons learned across organizations and geographic regions|
|Spokesperson Training||Present clear facts with actionable plans||Present clear facts with actionable plans||N/A|
|Translation Mechanisms||Tailor the risk communication to the unique needs of at-risk populations||Offer risk communication in multiple modes and multiple languages||Develop messaging for post-event risk communication|
|NOTE: N/A = not applicable for this phase.|
1. Risk Communication Pre-Event
State officials in public health and other agencies have made a number of advancements in risk communication, such as developing tool kits to guide local agencies and developing core messages for use with common types of disasters, particularly for natural disasters, as described in Section III (e.g., involving at-risk populations in the planning process and tailoring messages for Latinos). There has also been promising growth in activities designed specifically for at-risk populations, including the availability of messages in different languages and formats for those who do not speak English or who have disabilities, respectively.
However, as evidenced by our evaluation (including the literature review, the compendium, and our site visits), many barriers to effective risk communication remain, in part because of limited resources to enable specific tailoring to meet the needs of such a diversity of at-risk groups. Some possible solutions that may not be particularly resource-intensive may enhance public awareness and increase compliance with public health recommendations. These include the following activities before an event takes place:
Establish planning committees that include representatives of at-risk populations. Including representatives who are themselves at-risk in planning committees can inform the types of risk communication strategies as well as approaches for message dissemination. Even if some groups are not represented on committees, involving them in other preparation activities (e.g., including children in school-based drills or senior citizens in influenza vaccination clinic exercises) will provide valuable lessons for future disasters. In addition, involving these representatives in the development and review of communication materials can ensure that messages are appropriately crafted.
Strengthen training activities by directly addressing the needs of at-risk populations. One potential way to address public concerns is to strengthen educational activities by including CBOs, agencies, and other partners in the training itself. Enhanced training for those delivering messages regarding the special needs of at-risk populations may aid mutual learning, increase cultural competence, increase trust among members of the potentially at-risk population and strengthen health departments, agency, and CBO capacity. In addition, techniques such as message framing may be particularly useful. Specifically, framing messages to anticipate concerns expressed by at-risk populations (e.g., privacy and distrust) as well as by first responders (e.g., discomfort with PWD) that include points of resistance (Chapman and Lupton, 1994) may be particularly useful strategies for communicating risk to at-risk populations. Thus, trainings, drills, and exercises should incorporate the unique aspects of at-risk populations.
Tailor risk communication to the functional needs of at-risk populations. Risk communication should closely match the perspectives, technical abilities, and concerns of the intended audience (National Research Council, 1989). Having at-risk population representatives involved in planning will facilitate message development to meet the specific needs of different groups. In particular, including checklists and self-assessments as part of risk communication development can help the recipient customize the material to their personal needs. Social marketing strategies, such as creating specific messages for audiences from diverse backgrounds and with diverse needs, are a useful approach to enhancing communication and associated compliance (Andreason, 1995; Kotler, 1989; Manoff, 1985). Identifying in advance who is most in need of help can more precisely direct preparation and response efforts (Kasperson, 1986), including communication channels. In particular, it is important to consider the likelihood that certain factors need to be addressed for successful emergency risk communication. As an example, it is highly likely that PWD will be dependent on assistance from others given their limited independence and will also require different communication channels. Non-English speakers will require language translation and bilingual spokespersons with the appropriate social and cultural competencies and those from diverse cultures will also have a high likelihood of mistrusting authorities. Also, risk communication should be tailored to the developmental abilities of children and adapted for adults with intellectual disabilities. The use of data to identify characteristics of target audiences--such as through surveys, exploratory group sessions (focus groups), checklists, demographic profiles, and interviews--provides valuable information for guiding the design of risk communication messages and approaches to dissemination (Covello, McCallum, and Pavlova, 1989). In addition, embedding risk communication activities into other ongoing activities such as adding written materials to standard program or agency mailings using strategies that work in other community settings, may help engage individuals from at-risk populations to participate in preparedness.
2. Risk Communication During an Event
Dissemination of effective risk communication messages to at-risk populations during an emergency depends on the extent to which messages can be crafted so that they are “locally relevant and culturally competent” (Glik, 2007). Reynolds (2007) suggests considering three critical questions in determining how to communicate with at-risk populations during a crisis or emergency:
For which population during a crisis is a specialized message or communication product required, if any?
Are cultural differences among non-dominant group members of the United States significant when attempting to communicate health and safety information during a public health emergency?
Are communication messages from government authorities involved in the disaster response received differently by non-dominant groups?
Accordingly, local relevance and cultural competence can be more nuanced and therefore more challenging to address. Based on what we learned from this evaluation, the following strategies for use during an emergency hold the most promise and are supported by the literature:
Offer risk communications in multiple modes and multiple languages. “A picture is worth a thousand words” and pictorial media can effectively communicate across the majority of at-risk populations, excepting those with visual impairments, for whom alternative modes of communication are necessary. Most information designed for informing at-risk populations about risk in emergencies is made available only on the Internet, yet this mode of communication may not be accessible to many at-risk populations (Wingate et al., 2007). Other forms of communication, such as reliance on social networks in local communities, may be more effective for such groups (Eisenman et al., 2007). Further, translation of materials into other languages should ensure that proper dialectical differences and colloquialisms are used to increase reach and uptake by that population. In addition, crafting messages so that they can be most easily understood in whichever medium they are presented is critical. For example, speaking slowly and in an audible voice is necessary for television/radio messaging, presenting messages in large font and with appropriate color contrast is necessary for print messages, etc. Finally, the Internet was identified as a viable mode of risk communication but it is important to ensure that all individuals, including PWD, have access to that information on the websites. In fact, state and local government websites are legally obligated to provide equal access to information for PWD under the ADA (http://www.ada.gov/websites2.htm; http://www.section508.gov).
Present clear facts with actionable plans. Consistent with the risk communication literature (Lundgren, 1994; Mileti, Fitzpatrick, and Farhar, 1992; Renn and Levine, 1991; Sandman, 2003), a strong theme from the site visits was the importance for messages to deliver balanced facts that incorporate the most timely and accurate information. The facts about the risks should be accompanied by information about what individuals can do to protect themselves. Specifically, risk messages should allow recipients to access, confirm, and take direct action (Mileti and Sorensen, 1990). Further, these actions need to be presented in terms that populations at-risk can embrace. As an example, it is insufficient to recommend evacuation without qualifying how someone in a wheelchair might comply; they might need to be advised to ask for help. Therefore, training for spokespersons delivering risk communication messages should emphasize these principles. However, to enhance reach to at-risk populations, it will be important to broaden the number and types of professionals available and trained in risk communication beyond the health department PIO. Additionally, use of message mapping (Covello, 2008) is a useful tool to help address mental noise and focus practitioners on creation of clear, jargon-free messages.
Employ new technology to enhance communication reach. Recognizing that, for some states and localities, resources may limit the types of technologies that are available for enhancing risk communication, it is still important to use whatever methods are available. Thus, videophones, help lines, and mass phone alerts can significantly broaden the outreach of communications beyond what the print, Internet, radio, and television media can provide, particularly if some power sources are down. However, some older technologies such as phone trees, neighborhood watches, and bull horns may be the best option for reaching audiences that are unable to access the newer technologies.
Use strategies to identify and track at-risk populations. Our site visits also suggested that registries are a promising planning tool for identifying and communicating with at-risk populations and that the information in those registries can significantly improve the targeting of risk communication materials during an emergency. However, use of registries comes with a number of challenges. One concern is that such systems rely on PWD to register themselves, and the simple act of signing up for a registry may create a false sense of security; individuals will still need to be prepared, regardless of whether they are on a registry. Additionally, a registry is only as effective as the response capability. Thus, liability of emergency managers who maintain those registries is of concern. To address these barriers, site visit informants suggested that instead of implementing plans focused on knowing where to locate at-risk populations, emergency managers should integrate service providers from CBOs and local government agencies into a broader registry to address all phases of emergency management (planning, exercising, coordinating, training, and translation/cultural adaptation). In addition, a rapid assessment at the time of the event may uncover subtle cultural issues that need to be addressed either through changing the message, altering the channels, using a different spokesperson or engaging a community partner to help enhance credibility and trust (Quinn, 2008). Finally, as mentioned previously, GIS systems can be an effective tool for mapping the location of at-risk populations.
3. Risk Communication Post-Event
Following an emergency, the emphasis for communicating risk to at-risk populations is on learning how to address gaps that were identified in previous events and on how to minimize future problems. These are some of the themes revealed across our efforts pertaining to the recovery phase:
Develop messaging for post-event risk communication. In our review of existing risk communication practices, we identified relatively few risk communication materials intended for the post-event response. However, informants shared that this continues to be a gap area, as the recovery from a major event may require a set of long-term strategies that must be shared clearly with community members. As we summarized earlier, at-risk populations are not only at increased risk of poor consequences during an event; they often are more susceptible to challenges in establishing daily life after disaster. Risk communication efforts that include messages for these populations (e.g., how to access specialized resources; eligibility for specific social services) are critical.
Evaluate the impact of risk communication efforts. From our literature review and interviews, we learned that there is little formal evaluation of past efforts to inform communities about risk. Such evaluations, including after-action reports, may become more common as more experience is gained and as state governments face increasing disasters due to pandemic flu, bioterrorism, and other public health threats (Glik, 2007). Building a capacity for systematic evaluations to track messages, monitor media coverage, and survey recipients following emergencies accompanying responses will be key to identifying what works and what does not work to increase public awareness and compliance. Of course, evaluation is also important before an event and we learned that few of the practices we identified through site visits and interviews are being evaluated to determine their reach and/or effectiveness.
Share lessons learned across organizations and geographic regions. Once the acute stage of a disaster has subsided, communications can focus on after-action reports and other evaluation activities, including sharing experiences and lessons with other counties and states. Use of community forums and engagement of community partners in the evaluation will ultimately help to improve the capacity of agencies and their cultural competence with at-risk populations.
4. Implications for Future Public Health Emergency Activities
A key theme in our discussions with informants across sites was the importance of using “people first” language that does not inappropriately attribute a disability to those individuals. This feedback reaffirms a function-based approach, which focuses on individual capabilities rather than on labels or broad generalizations about populations, and is consistent with what we learned in the interviews. This suggests that most risk communication messages and dissemination strategies should be designed to match the abilities and resources of individuals, rather than their disabilities.
In addition, many aspects of communicating risks in the face of emergencies apply to all individuals, regardless of whether they are from an at-risk population. Further, most individuals at-risk are able to communicate in some common ways. For example, all groups except those with visual impairments have the ability to interpret pictorial material, particularly if it is simple and does not require translation to multiple languages. Supplementing imagery with audio messages is likely to address the needs of many at-risk populations.
However, we also learned that some content of emergency risk communication is specific to a particular at-risk group. Thus, consistent with implementing PAHPA with a functional-capabilities approach, message tailoring for particular groups should be based on functional areas, including independence, transportation, need for supervision, communication, and medical care needs. For example, individuals who need assistance with aspects of daily living may need information about how to involve their caregiver in preparing for and responding to disasters. Another example is that people who use wheelchairs need to know how to evacuate “on wheels.”
The results presented in this report could inform federal, state, tribal, territorial, and local emergency preparedness planning on how to address the unique needs of at-risk populations in existing emergency preparedness, response, and recovery plans. We have highlighted several risk communication practices that could be modified and adopted by others. We have also described some of challenges or barriers that others might encounter when attempting to plan and execute their own risk communication activities.
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