The larger literature on risk communication--beyond that which addresses public health emergencies and vulnerable populations--offers several recommendations for how to develop and deliver successful messages. Good risk communication has been described as decision-relevant, two-way, and interactive.[17, 18, 19] Effective risk communication can promote trust, awareness, understanding, and motivation to act.
The literature reviewed here, specific to public health emergency risk communication with vulnerable populations, echoed these general recommendations. Additionally, each of the reviewed references addressed the broad points that early and consistent risk communication is key in public health emergencies (See ) and that risk communication must take into account the special needs of vulnerable populations (See [10, 22]). Several themes emerged from the literature that highlight promising communication strategies for public health emergency risk communication with vulnerable populations. These themes are summarized below.
Offer Frequent Communication in Multiple Modes that are Locally and Personally Relevant
A major challenge in public health emergency risk communication is providing timely, accessible information that is locally and personally relevant about an event, which is often broad in scope and characterized by some degree of uncertainty. For vulnerable populations, there are additional considerations related to their special needs that must be taken into account when developing a messaging strategy.[22, 23] Several of the references in this review suggested that risk communication with vulnerable populations is most likely to succeed when messages are provided early, often, in multiple formats (e.g., television, print (verbal and pictorial), audio, Internet, interpersonal), and when the content of messages and their presentation are tailored to be locally and personally (including linguistically) relevant.[6, 7, 9, 13, 21, 24, 25, 26, 27, 28, 29, 30, 31, 32, 33, 34, 35, 36, 37, 38, 39, 40, 41] Thus, ideally, the information contained within public health emergency risk communication is presented to the public early and often, via multiple sources that individuals find trustworthy, accessible, and credible. This is true for the public generally (See ), and for vulnerable populations in particular, who may need additional time or specific accommodations to adequately follow emergency instructions.
This first theme represents an overarching conclusion of all the references we reviewed. Achieving timely, frequent, tailored risk communication presented in multiple formats and delivered by trusted sources requires considerable resources and organizational infrastructure. More specific themes regarding how to do this follow.
A Community-Based Participatory Approach is Promising
Several studies[7, 10, 12, 14, 29, 31, 35, 37, 41, 43, 44, 45, 46, 47] highlighted the potential of community-based participatory approaches to improving risk communication for vulnerable populations. Community-based participatory approaches are increasingly common in public health, with good evidence of success in intervention development and delivery. Further, in areas of public health outside of emergency preparedness, community-based strategies such as use of community or lay health advisors are increasingly used to motivate health behavior (See [50, 51]). The evidence suggests that community members want to be involved in PHEP, response, and recovery[7, 29, 47] and would therefore be amenable to participating in risk communication efforts for vulnerable populations. In many communities, local Citizen Corps programs may provide the infrastructure around which to organize community-based efforts.
Community involvement may help emergency risk communications overcome common barriers to success related to trust and available resources for communication dissemination.[31, 35, 37, 43] Further, with appropriate training, community-based risk communicators would be well positioned to provide information tailored to local cultural norms. This type of tailoring has been shown to be important to the success of risk communication with vulnerable populations, and may be especially useful for senior citizens, individuals from diverse cultures, and those living in geographically isolated or rural settings.[35, 45] Specific community-based risk communication approaches mentioned in the literature include use of churches, knowledge centers (hubs where one or two trained community members facilitate access to communication technology is available), and lay advisors to deliver neighborhood and peer-delivered communication.
Implications for Tasks 4 and 5: Continued work should determine whether available outreach and education materials have been developed in a community-based participatory way (Task 4), and to what degree community members are involved with the development and execution of public health emergency risk communication efforts, as recommended by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) (Task 5).
The Internet Is a Successful Delivery Method--for Those Who Have Access
The Internet is increasingly utilized in health care delivery and practice and has been demonstrated to be a successful communication tool in the aftermath of a public health emergency. For example, the faculty, students, and staff of Tulane Medical School benefited greatly from a “recovery website” that was created to facilitate communications in the days and weeks following Hurricane Katrina.
Would an Internet-based risk communication strategy for PHEP, response, and recovery be valuable to vulnerable populations? In fact, use of advanced communication technologies is a recommendation of the “Hurricane Katrina: Lessons Learned” report, and there is evidence to suggest that Internet-based communication strategies may be particularly useful, as features of Internet-based messaging are especially effective at overcoming communication barriers commonly encountered by vulnerable populations. For example, tailored health communications have been shown to be more effective than non-tailored messages at influencing behavior, and communications delivered via the Internet can be very easily and specifically tailored, increasing the chances for success with vulnerable populations.[9, 25, 34, 56] There are several ways that Internet-based risk communications can be tailored to accommodate the needs of vulnerable populations, including the language in which the information is presented (for non-English speaking populations), the accompanying images displayed (for cultural tailoring for diverse populations), the reading level and detail provided (for low-literate populations or children), and the format in which the information is presented (visual and/or audio). Further, Internet access to Electronic Health Records, where available, can facilitate communication critical to the medical needs of individuals with chronic illnesses. Finally, Internet-based messaging can also be frequently updated to reflect the often fast-changing circumstances surrounding a public health emergency.
In our review, very few studies addressed risk communication via the Internet for vulnerable populations.[24, 26, 34, 36, 56, 57, 58] The potential for Internet-based messaging to improve emergency communication with vulnerable populations is limited by Internet access,[3, 26, 57] and some vulnerable populations may be especially limited in their use of the Internet. For example, the PEW Internet and American Life Project found that only 26 percent of Americans age 65 and older are “on-line” using the Internet for email and other purposes, compared to 67 percent of Americans age 50-64. However, increased use of cell phones to access the Internet has widened the population of Internet users beyond those with computers and has made text messaging a viable option for widely disseminated risk communication. Additionally, there is evidence to suggest that some vulnerable populations may prefer to rely on social networks to receive information and to guide decision making during a public health emergency. Thus, if one member of the social network was able to access the Internet, the benefits would reach a larger audience.
Use of the Internet to disseminate communication regarding emergency preparedness may be problematic, given that several vulnerable populations are less likely to have easy access to the Internet or to be savvy Internet users. However, during response and recovery, Internet access could be offered to affected individuals as part of re-establishing the communication infrastructure. For example, resources such as the Federal Emergency Management Agency’s (FEMA) Mobile Emergency Response Support detachments could provide Internet access to evacuees with websites developed and managed remotely. In this way, vulnerable populations could receive Internet assistance from individuals aiding in response and recovery, thereby benefiting from the strengths of the Internet as a communication tool. As technologically based approaches to communication may not address the needs of all groups (e.g., senior citizens, mentally ill, cognitively disabled), the Internet cannot replace “old media” means of communication (e.g., radio, television, print media). However, the percentage of the population engaged with the Internet is steadily increasing, and given that employing multiple modes of communication increases the chances of reaching the hard-to-reach, adding the Internet to the public health emergency risk communication arsenal could increase the chances of adequately addressing the needs of some vulnerable populations. However, even for those with Internet access, these electronic systems often become unavailable for all populations during disasters that affect electrical supply during the immediate aftermath of emergencies. Thus, the Internet may be most effective for preparedness and recovery stages of public health emergencies.
Implications for Tasks 4 and 5: Continued work should examine whether Internet-based resources for vulnerable populations are available and offer good potential for success (Task 4), and site visits should include an assessment of wireless communication capability and how these modes are integrated in state and local plans (Task 5).
Translation Does Not Ensure Comprehension
While translation is an obvious first step towards effective risk communication with non-English speakers, several studies we reviewed indicated that translation is not enough. To successfully communicate public health emergency risks to non-English speaking and diverse populations in general, communication must be culturally competent.[9, 10, 24, 29, 38, 61] Clarification of key terms must be addressed (e.g., definition of “emergency”), linguistic barriers must be identified and remedied (e.g., the Spanish word for “chicken pox” is the same word for “smallpox”), and cultural beliefs about the causes of disasters must be addressed. Training plays a key role in preparing communicators to be culturally competent, and research is necessary to develop culturally competent educational materials. Volunteers from vulnerable populations may be especially valuable in these endeavors as part of a community-based participatory approach.
Implications for Tasks 4 and 5: Continued work should characterize the availability of outreach and educational materials that are offered in languages other than English and to what degree these materials also appear to be culturally competent (e.g., were they developed by members of the cultural group to whom they are targeted, do they contain culturally relevant images; Task 4). Efforts to address linguistic and cultural considerations should be examined in stakeholder interviews as part of the case studies (Task 5).
Vulnerability Assessments are a Critical Step in Program Development
Knowing the size and locations of vulnerable populations in a given jurisdiction facilitates effective outreach, including communication, during a public health emergency. Vulnerability assessments as a routine part of public health preparedness are critical to informing risk communication strategies.[10, 56, 62] Chapter 68 of U.S. Code Title 42 describes the use of multihazard maps to identify where natural disasters are likely to occur. Similarly, population vulnerabilities can be mapped using Geographic Information Systems (GIS). GIS maps are increasingly used in public health research to examine distributions of disease incidence and health-related knowledge and could also be purposed to develop effective communication campaigns for vulnerable populations. For example, GIS maps could be used to determine where vulnerable populations may cluster (e.g., locations of hospitals, nursing homes, low-income housing) and could use this information to target risk communication campaigns. With funding from the Office of the Assistant Secretary for Preparedness and Response, RAND is currently completing an interactive web-based GIS tool to be used by health departments for this purpose. The tool will allow health departments to geographically identify where the most vulnerable members of their communities live (e.g., individuals with disabilities, non-English speaking individuals).
Implications for Task 5: Continued work should determine the degree to which vulnerability assessments are a routine part of preparedness activities and whether GIS mapping is routinely conducted as a part of vulnerability assessments for emergency preparedness. In addition, the task should examine whether stakeholders perceive that these maps could result in added value for risk communication planning.
The Special Needs of Children
When children are affected by a public health emergency, their developmental levels and their psychological reactions must be taken into account regarding communication.[10, 65] Often, emergency risk communication and messaging strategies will reach children through their caregivers. For parents, emergency risk communication should be frequent and instructive, as parents of young children are likely to experience additional anxiety related to protecting their children.[28, 30, 46] School-based communication strategies offer an opportunity to reach both children and their caregivers; school curricula may be an effective venue in which to promote risk communication for children that is tailored to their developmental abilities, and school nurses are an important ally in emergency risk communication for children.
Implications for Tasks 4 and 5: Continued work should examine what materials are available for children and parents/caregivers regarding PHEP and whether there is an adequate range of developmentally tailored resources for older versus younger children (Task 4). Discussions with key informants should investigate whether school-based efforts or activities in other institutions in charge of children (e.g., child care centers) are a part of current emergency preparedness efforts in their jurisdiction (Task 5).
In Self-Contained Organizations, Leadership is Key to Communication Success
In addition to addressing vulnerable populations, three studies offered perspectives on successful communication strategies within self-contained organizations, such as hospitals, large office buildings, and schools. In these cases, clear leadership was identified as key to communication success. Leadership regarding who is in charge of formulating and disseminating risk communication is critical to timely execution of message delivery and to avoiding unclear or ambiguous messaging.
Implications for Tasks 5: Continued work should investigate the chain of command and leadership structure around the steps involved with risk communication (e.g., message formulation, message delivery), and whether communication with vulnerable populations is specified in an organization’s plan, and if leadership on this communication is designated to someone.
Meteorologists as a Trusted Source
In what appears to be two unrelated references, meteorologists were specifically mentioned as excellent points of communication delivery in public health emergencies, as they are seen as trusted and objective sources of information[69, 70] and appear most often on television, which may be a preferred risk communication medium. Though meteorologists were only mentioned twice, in a relatively small literature it is worth noting that two studies arrived at this same conclusion. Given the relevance of weather to several types of public health emergencies (e.g., natural disasters and any emergency with an airborne component), meteorologists would have frequent opportunities to be involved with public health emergency risk communication for vulnerable populations.
Implications for Tasks 4 and 5: Continued work should determine whether meteorologists are included within outreach materials (Task 4) and to what degree meteorologists or local weather departments are included within risk communication strategies (Task 5).
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