In addition to a qualitative synthesis of the existing peer-reviewed literature, we also examined data collected by the DAF to provide a general summary of the quality and content of the existing literature on public health emergency risk communication with vulnerable populations, including the main issues addressed by relevant statutes, regulations, and other related government or organizational reports. This summary includes descriptions of the types of vulnerable populations; the stages of emergency preparedness, response, and recovery; the types of public health emergencies; the functional areas; and the barriers to risk communication addressed in the literature to date.
A wide range of vulnerable populations were addressed in the review. Individuals from diverse cultures (including racial/ethnic minorities) were most commonly represented in the literature,[7, 23, 24, 26, 27, 28, 29, 32, 34, 37, 38, 41, 43, 47, 69, 70, 71, 72] followed by low-income populations[7, 25, 26, 28, 32, 34, 38, 39, 40, 43, 47, 56] and those with chronic medical disorders.[7, 22, 26, 28, 36, 39, 44, 47, 67, 68, 71] Additionally, several studies addressed children,[7, 30, 33, 41, 46, 56, 62, 65, 68, 71] individuals with little or no English proficiency,[7, 29, 33, 34, 37, 38, 62, 70] those who are transportation disadvantaged,[7, 26, 28, 32, 34, 39, 43, 71] the elderly,[7, 36, 37, 39, 47, 56, 62] and disabled individuals.[7, 23, 40, 44, 56] Only a few citations (less than five) were identified that addressed those who live in institutional settings[36, 39, 58, 71] or individuals with pharmacological dependency.[7, 71] There were no citations that addressed public health emergency risk communication for pregnant women.
Stages of Emergency Preparedness, Response, and Recovery
Studies addressed risk communication in the context of response to public health emergencies most often[21, 22, 23, 25, 26, 28, 32, 33, 35, 36, 38, 39, 40, 41, 43, 44, 47, 58, 61, 62, 66, 67, 69, 70, 72] (Figure 1), followed by preparedness,[7, 24, 26, 29, 31, 32, 34, 35, 36, 38, 39, 40, 41, 45, 47, 56, 57, 61, 62, 66, 67, 68] and recovery.[26, 27, 30, 35, 40, 41, 46, 47, 56, 61, 62, 65, 66, 67, 71] In one study, stage was not specified and in another, the focus was broadly on threat, warning, impact, reconstruction, and resilience.
We examined what stages of emergency were addressed by the type of vulnerable population. For individuals from diverse cultures, low-income backgrounds, and with chronic medical conditions (the top three vulnerable populations represented in the literature), we found that emergency response (e.g., evacuation) was most frequently addressed (Figure 1). However, for children, emergency recovery (e.g., mental health issues) was most often the focus of study, whereas for those with limited English proficiency, emergency preparedness (e.g., education to raise awareness) was most commonly addressed.
|FIGURE 1. Stages of Emergency Addressed within Different Vulnerable Populations|
Regarding types of emergencies (Figure 2), natural disasters (e.g., hurricane, tsunami) were the topic most often in the literature on risk communication with vulnerable populations[22, 25, 26, 27, 28, 29, 31, 32, 35, 37, 38, 39, 40, 41, 43, 56, 58, 61, 65, 66, 67, 68, 71] followed by terrorist threats or incidents.[7, 23, 29, 31, 38, 44, 45, 46, 57, 62, 67, 68, 69, 70, 72] Infectious disease outbreaks were addressed in several citations[29, 30, 31, 33, 57, 67, 68] while infectious disease pandemics[21, 67, 68] and man-made disasters[38, 67, 68] were each addressed less frequently. The remaining studies addressed another type of emergency, including agricultural, any trauma, flood or dam failures,[ 39] heat waves,[29, 36] power outage, school violence, or the type of emergency was not specified.[24, 34, 47, 65]
|FIGURE 2. Types of Emergencies Addressed in the Review|
As our working definition of risk communication highlights the importance of “actionable information,” we examined citations for whether specific functional areas were addressed in the context of risk communication (i.e., did the communication provide actionable information or instruction related to specific functional areas). Five functional areas relevant to the needs of vulnerable populations were considered: maintaining independence (e.g., communication regarding the securing of back-up medical supplies for the chronically ill), communication (e.g., communication regarding how to get needed information for individuals with hearing or sight-related disabilities), transportation (e.g., where evacuation transportation can be located for the transportation disadvantaged), supervision (e.g., how those who require supervision, such as children or institutionalized individuals, can obtain it during an emergency), and medical care (e.g., how those who require medical care can obtain it during an emergency). Communication was the functional area was most commonly addressed in the literature,[7, 21, 22, 24, 25, 26, 27, 29, 30, 32, 33, 34, 35, 36, 37, 38, 40, 41, 44, 45, 46, 47, 57, 58, 61, 65, 66, 67, 68, 69, 70, 71, 72] followed by medical care,[21, 22, 23, 28, 30, 33, 35, 37, 39, 47, 58, 66, 67, 68, 71] transportation,[31, 32, 34, 35, 37, 39, 47] maintaining independence,[27, 31, 71] and supervision. Several citations addressed an additional functional area, such as mental health[38, 46, 62, 65] or evacuation.[40, 43, 44]
Table 1 shows the functional areas addressed by type of vulnerable populations represented, where an X indicates that at least one reference addressed both the vulnerable population and the functional area. For the most part, functional areas were well distributed across types of vulnerable populations. However, there are some notable exceptions; for example, none of the literature we reviewed described emergency communication regarding maintaining independence, transportation, or supervision for individuals with disabilities. Similarly, emergency communication regarding supervision was missing from the literature on the elderly, and as no citations addressed pregnant women, functional areas relevant to this group in the context of public health emergencies (e.g., communication, medical care) were not addressed.
|TABLE 1. Functional Areas Addressed within Different Vulnerable Populations|
|Vulnerable Population||Functional Area Addressed|
|Maintaining Independence||Communication||Transportation||Supervision||Medical Care|
|Chronic medical condition||X||X||X||X||X|
|Limited/no English proficiency||X||X||X||X|
Finally, we examined the literature for barriers identified to communication success including emotional interference (e.g., fear, anxiety), trust, resources to disseminate communication, inconsistent or ambiguous messaging, and preconceived assumptions based on prior experiences with the type of emergency addressed. All but one study addressed the issue of barriers; of the categories included on the DAF (Appendix A1), barriers related to trust were addressed most often,[7, 23, 24, 28, 29, 30, 31, 32, 37, 38, 39, 43, 56, 69, 70, 72] followed by inadequate resources to disseminate communication.[24, 26, 28, 31, 32, 34, 35, 44, 56, 61, 66, 68, 70, 71] For example, Meredith et al. found that African American focus group participants had significant trust concerns related to government officials communicating truthful information in the event of a terrorist attack. Inconsistent or ambiguous messaging,[7, 21, 22, 23, 26, 28, 29, 33, 44, 57, 69, 72] emotional interference,[30, 32, 33, 37, 38, 46, 62, 65, 67, 69] and incorrect assumptions[7, 23, 28, 29, 31, 32, 72] were addressed in several citations as well. For example, Eisenman and colleagues found that one barrier to successful risk communication aimed at preparing vulnerable populations living in New Orleans for Hurricane Katrina was the incorrect assumption among some residents that the severity of Katrina would be similar to previous hurricanes that were far less devastating. In over half of citations there were barriers mentioned that did not fall within the categories we used on the DAF. These included (but were not limited to) barriers related to the specific characteristics of vulnerable populations, such as cultural beliefs, interpretations, or language barriers,[24, 28, 61, 70] literacy,[34, 35] and specific issues related to disabilities, such as provision of written information for the hearing-impaired.Figure 3 represents the distribution of barriers addressed.
|FIGURE 3. Barriers to Communication Success|
Statutes and Regulations
The DAF was used to extract data, where applicable, from the statutes and regulations included in the review. However, given the relatively small sample of statutes, regulations, and related reports deemed relevant for inclusion and the limited applicability of the DAF in characterizing these references (e.g., items such as Type of Study, Sample Size do not apply), rather than present aggregate data on DAF items we will briefly summarize the content relevant to emergency risk communication for vulnerable populations from each citation below. A table summarizing the vulnerable populations and stages of emergency addressed as well as key messages are displayed at the end of the section in Table 2.
The NRP: The NRP from the DHS describes a comprehensive framework for response to all hazards. As such, the NRP addresses emergency preparedness, response, and recovery, but also prevention. The NRP was the only citation included in this review that addressed public health emergency prevention as a specific emergency stage.
Communication plays a significant role in the NRP. One of the plan’s “key concepts” is the provision of coordinated communication between federal, state, and local government, as well as between members of the public and private sectors, in response to a public health emergency (generally referred to as Incidents of National Significance). Communication with vulnerable populations is not specifically addressed in the NRP.
Updated in 2006, the NRP details the development of a Joint Field Office (JFO) in response to an Incident of National Significance, the particular structure of which is determined by the type of emergency involved. In the JFO, primary responsibility for risk communication with vulnerable populations would fall to the External Affairs Officer (EAO). The EAO would work through the federal Joint Information Center and within the Logistics Section of the JFO. In its section on Incident Action Special Considerations, the NRP details three message considerations that would likely be impacted by an Incident of National Significance: message development, message delivery, and message receipt. Thus, the NRP acknowledges that there are significant challenges to successful risk communication in public health emergencies. These challenges are often exaggerated for members of vulnerable populations.
Finally, the NRP highlights the importance of citizens in all stages of emergencies, and describes the U.S. Citizen Corps, a community-based network that works to improve emergency preparedness, response, and recovery, by providing services that include “targeted outreach for special needs groups.”
Title 42, The Public Health and Welfare, Chapter 68, Disaster Relief: Overall, Chapter 68 emphasizes that disaster relief must be non-discriminatory. Specifically, in Section 5151, the code states “provisions for insuring that the distribution of supplies, the processing of applications, and other relief and assistance activities shall be accomplished in an equitable and impartial manner, without discrimination on the grounds of race, color, religion, nationality, sex, age, or economic status.”
All vulnerable populations included in the PAHPA definition are not included in Chapter 68 of Title 42. Vulnerable populations specifically mentioned in the code are individuals from diverse cultures, low-income backgrounds, seasonal farm workers, and “small impoverished communities,” defined as low-income areas of less than 3000 persons. Emergency preparedness, response, and recovery are addressed in Chapter 68, and details are provided regarding associated communication between federal, state, and local government.
Chapter 68 primarily serves to legislate the duties of the Federal Government in responding to national emergencies and disasters. As such, the code does not provide specific recommendations regarding outreach to vulnerable populations beyond specifying that disaster relief be non-discriminatory. However, in Section 5197h, the Minority Emergency Preparedness Demonstration Program is described. This program is intended to support research that: (1) examines the preparedness and response capacities of diverse populations; and (2) that promotes effective communication regarding public health emergencies to racial/ethnic minority groups. Relevant to the peer-reviewed literature that addresses diverse populations and populations with limited English proficiency, the Minority Emergency Preparedness Demonstration program places an emphasis on the development of public health emergency education that is culturally competent. However, details on what defines culturally competent communication or education are not specified.
The Federal Response to Hurricane Katrina: Lessons Learned: The publicly available Hurricane Katrina: Lessons Learned report follows a timeline beginning before Katrina’s landfall and ending with the continuing recovery efforts in the Gulf States. Emergency preparedness, response, and recovery are addressed for the vulnerable populations affected by the storm.
One hundred and twenty-five recommendations are made at the end of the report, organized within 17 “Critical Challenges.” One of the Challenges is Public Communications, which includes five recommendations specific to risk communication. The recommendations (summarized below) address several barriers to risk communication success identified in the peer-reviewed literature, including trust in risk communication sources, resources to disseminate messaging, and clarity and consistency of risk communication. However, none of the barriers identified in the peer-reviewed literature that specifically relate to vulnerable populations are referenced (e.g., cultural beliefs, interpretations, or language barriers,[24, 38, 61, 70] literacy,[34, 35] and specific issues related to disabilities, such as provision of written information for the hearing-impaired).
Recommendation #73: The NRP should detail the ways in which clear and consistent communication will occur between officials from federal, state, and local governments.
Recommendation #74: DHS should train and provide rapidly deployable Public Affairs teams.
Recommendation #75: Communication-related training should be provided to personnel in federal, state, and local governments.
Recommendation #76: Credible spokespersons for risk communication should be identified and coordinated as part of White House crisis communications efforts.
Recommendation #78: DHS should develop an integrated emergency alert system that leverages advanced technologies.
Post-Katrina Emergency Management Reform Act of 2006: The Post-Katrina Emergency Management Reform Act of 2006 outlines several actions to be taken by FEMA to address the needs of vulnerable populations before, during, and after public health emergencies.
Relevant to this review, the Reform Act recommends an Office of Emergency Communication within FEMA and designates an Administrator to create and oversee guidelines that address communication-related and other needs of individuals with disabilities, other vulnerable populations, and their caregivers. These guidelines will include provisions related to communication and accessibility both in shelters and more broadly during public health emergency response and recovery. Additionally, the Reform Act appoints a Disability Coordinator and establishes the National Emergency Child Locator Center (NECLC) within the National Center for Missing and Exploited Children. The NECLC is intended to facilitate communication aimed at reuniting families separated during a public health emergency via phone and Internet-based media; for example, the NECLC is required to establish a toll-free hotline to receive reports of displaced persons and to manage a website that tracks information about displaced children.
The National Organization on Disability’s Report on SNAKE Project: The National Organization on Disability's SNAKE project report describes the impact of Hurricane Katrina on vulnerable populations; specifically, individuals with “special needs” defined to include the elderly and those with physical, emotional, or cognitive disabilities. The SNAKE team evaluated shelter response in the aftermath of Hurricane Katrina using a survey that assessed shelter conditions, management, resources, and involvement of community-based organizations.
Among several recommendations made for how to better support vulnerable populations throughout emergency preparedness, response, and recovery, the SNAKE report offers specific guidance on how to present risk communication in accessible formats. Individuals who are deaf or hard-of-hearing were identified as the “most underserved” group with respect to communication needs. Accordingly, the SNAKE report suggests that the Federal Communications Commission remind purveyors of emergency information that emergency communications must be accessible to individuals with visual and hearing disabilities. The report goes on to emphasize that while accessible communication is critical during response to public health emergencies, communication must continue to be accessible during the recovery period as well; thus, any actions taken to increase the accessibility of emergency communications must extend beyond the area immediately affected by a public health emergency to include surrounding areas and states that will receive evacuees.
Trust for America’s Health: “Ready or Not? Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism”: The Trust for Americas Health Ready or Not? 2007 report aims to describe the nation’s progress toward achieving successful emergency preparedness (all hazards). Several preparedness indicators are examined state-by-state; however, none of the indicators included in “Ready or Not?” are specific to communication.
The report does address vulnerable populations in a section on “Additional Issues and Concerns.” Here, the report references another citation included in this review and echoes the main points it contains, including the need to tailor risk communication to the needs of vulnerable populations and to deliver information through a trusted source, to increase communication-related training opportunities for emergency responders, and to involve members of vulnerable populations in community-based efforts to prepare for, respond to, and recover from public health emergencies.
The Joint Commission’s “Standing Together: An Emergency Planning Guide for America’s Communities”: The Emergency Planning Guide from JCAHO outlines 13 components of emergency planning for communities (rural and suburban) that are to be executed in a participatory fashion. “Ensure thorough communication planning” and “ensure thorough planning related to vulnerable populations” are specified as two of the 13 essential components.
The JCAHO Guide offers recommendations for emergency preparedness, response, and recovery for several vulnerable populations, including those who have disabilities, who live in institutional settings, who are elderly, who are from diverse cultures, who have limited English proficiency, who are children, who have chronic medical disorders, who have pharmacological dependency, and who are geographically isolated. Regarding communication planning, the Guide recommends 15 strategies, three of which are particularly relevant to this review: planners are encouraged to identify credible, trusted sources to disseminate risk communication to the public; to determine how messages can be disseminated in multiple forms so that all community members can receive the communication (e.g., offer information in multiple languages, in print and audio formats); and to craft culturally competent messages such that cultural and linguistic factors are taken into account.
Regarding vulnerable populations, the Guide suggests that emergency planners conduct needs assessments to identify vulnerable populations and to enlist members of vulnerable populations in planning and response activities, including drills and exercises. The developmental and cognitive limitations of children regarding emergency risk communication are discussed; in particular, the Guide highlights children’s increased psychological vulnerability related to traumatic incidents associated with disasters and their limited cognitive resources with which to interpret relevant information. Educational settings are stressed as an important venue in public health preparedness: school nurses are identified as important partners for addressing the communication needs of children, and high school and college students are identified as potential participants in emergency planning and response.
Individuals with Disabilities in Emergency Preparedness (Executive Order 13347): Executive Order 13347, Individuals with Disabilities in Emergency Preparedness created the Interagency Coordinating Council on Emergency Preparedness and Individuals with Disabilities. The Council is chaired by the Secretary of Homeland Security and functions to ensure that the needs of disabled individuals are considered during the conception and implementation of emergency preparedness plans for all hazards.
CARF's “CARF Guide to Accessibility”: The CARF Guide to Accessibility details the requirements that organizations must meet to successfully provide an environment that is accessible to individuals with disabilities. Though specific emergency stages are not addressed in this publication, issues regarding accessibility in the context of public health emergencies generally are addressed.
|TABLE 2. Summary of Reviewed Statutes, Regulations, and Related Reports|
|Statute/Regulation||Vulnerable Populations Addressed||Stages of Emergency Addressed||Key Message|
|The National Response Plan||Not specified||Prevention, preparedness, response, and recovery||Highlights the importance of citizens in all stages of emergencies and describes where communication procedures are housed in a JFO.|
|Title 42, Chapter 68||Diverse cultures, low-income, seasonal farm workers||Preparedness, response, and recovery||Details the disaster responsibilities of federal departments; disaster relief must be non-discriminatory.|
|The Federal Response to Hurricane Katrina||Institutionalized individuals, elderly, diverse cultures, children, transportation disadvantaged, chronically ill, pharmacologically dependent, low-income||Preparedness, response, and recovery||Follows the timeline of events leading up to Hurricane Katrina’s landfall through the recovery phase and offers 125 recommendations based on “lessons learned.”|
|The Post-Katrina Emergency Management Reform Act of 2006||Individuals with disabilities, elderly, children, low-income, homeless, individuals with special needs and their caregivers||Mitigation, preparedness, response, and recovery||Recommends an Office of Emergency Communication within FEMA, a Disability Coordinator, and guidelines to ensure successful communication and accessibility for vulnerable populations.|
|National Organization on Disability’s SNAKE Project||Individuals with disabilities, elderly||Preparedness, response, and recovery||Describes the impact of Hurricane Katrina shelter conditions on individuals with special needs; the deaf and hard-of-hearing are identified as the most underserved.|
|Trust for America’s Health “Ready or Not?”||Individuals with disabilities, elderly, limited English proficiency, children, transportation disadvantaged, pharmacologically dependent, low-income, geographically isolated, homeless||Preparedness, response, and recovery||Reports progress on indicators of preparedness state-by-state. Cites regarding communication strategies with vulnerable populations.|
|JCAHO’s “Standing Together”||Individuals with disabilities, institutionalized individuals, elderly, diverse cultures, limited English proficiency, children, chronically ill, pharmacologically dependent, geographically isolated||Preparedness, response, and recovery||Outlines 13 components of emergency planning for rural and suburban communities. Recommends needs assessments to identify vulnerable populations and to enlist them planning and response activities.|
|Individuals with Disabilities in Emergency Preparedness (Executive Order 13347)||Individuals with disabilities||Preparedness||Established the Interagency Coordinating Council on Emergency Preparedness and Individuals with Disabilities.|
|CARF Guide to Accessibility||Individuals with disabilities||Not specified||Offers guidance to assure that risk communication can be accessible to and acted upon by disabled persons.|
|Administration on Aging’s “Just in Case”||Elderly, caregivers for the elderly||Preparedness, response, recovery||Brief set of guidelines and resources addressing functional areas of maintaining independence, communication, transportation, and medical care during public health emergencies.|
In Chapter 3 (and Checklist 4 of Appendix C), the Guide outlines numerous barriers to successful communication with disabled persons and specifies services that can be provided to overcome these barriers. Given the associated high-stress, it seems likely that the communication barriers identified by the CARF guide would only be exacerbated in the event of a public health emergency, thus underscoring the importance of following the guidelines to ensure communication accessibility for individuals with disabilities.
Visual, acoustic, and physical barriers to communication are included in the guide, such as inadequate lighting that interferes with lip reading or sign viewing, lack of signage and accessibility symbols, and high noise levels. Suggestions to overcome these barriers and to achieve successful risk communication with people with disabilities (PWD) include installing sound buffers, flashing alarms, appropriate signage posted at heights accessible to individuals in wheelchairs, offering a large print option for printed materials, provision of assisted listening devices, and allowance of service animals.
The Administration on Aging’s “Just in Case: Emergency Readiness for Older Adults and Caregivers”: Just in Case is a brief set of guidelines for the elderly and their caregivers addressing the functional areas of maintaining independence, communication, transportation, and medical care for emergency preparedness, response, and recovery. The guidelines are organized around three steps: Know the Basics, Have Your Emergency Supplies Ready, and Make a Personal Plan.
Communication is highlighted within the Personal Plan section; specifically, elderly individuals are encouraged to communicate with family, neighbors, and home health workers regarding a plan for staying safe during a public health emergency. Finally, Just in Case directs readers to several related websites, a readiness checklist, and a template to record emergency contact numbers and health conditions.
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