The final Phase of review (Phase 3) consisted of carefully reviewing each resource labeled an all-star in Phase 2, with the goals of identifying promising risk communication strategies and providing examples of these strategies drawn from this set of resources. At this stage, the goal was not to quantitatively evaluate each and every resource. Each all-star resource was rated on six dimensions using a scale ranging from poor to truly extraordinary, with relatively finer distinctions made at the high end of the scale, reflecting that these resources had already been identified as exemplary. Subsequent analysis focused on the dimensions upon which specific all-star resources were seen to excel. Table 1 displays the proportion of the 41 all-stars rated as truly extraordinary (the highest rating) on the six score sheet dimensions. The all-star score sheet is included in Appendix B4.
|TABLE 1. Proportion of All-Stars Rated Highest on Each Dimension
(N = 41)
| Objectives for the resource are clearly stated and addressed
| The risks associated with the public health emergency are clearly stated and addressed
| Resource reasonably covers issues salient to the specified vulnerable population(s)
| Resource provides specific guidance on how to act on the advice given (i.e., is easily actionable)
| Resource is clear and easy to understand
| Resource is engaging
Clarity and Understandability. The most often-cited point of excellence among the all-stars was clarity and understandability. Within this, three themes arose. First of all, providing concrete examples can dramatically increase clarity. Videos by Ready America (Documents #8 and #9 in the compendium) showed members of the vulnerable population and their caregiver acting out recommended actions, providing concrete models for recipients. A webcast (#77) by the Substance Abuse and Mental Health Services Administration (SAMHSA) ends with a mock counseling session, helping recipients to ground their expectations. An American Red Cross coloring book (#62) includes pictures of what children should be doing during an emergency. And a resource from the American Red Cross (#63) includes a letter written to seniors by seniors, conveying compelling, relevant experiences.
A second theme was that understanding may be facilitated by simply defining terminology and spelling out assumptions. Emergency preparedness communities often use language that may not be well-known to vulnerable populations, and hence need to be defined. For example, the Ready, Set, Prepare! children's activity book (#59), also from the American Red Cross, has a Words to Know section defining important words. Similarly, SAMHSAs Developing Cultural Competence in Disaster Mental Health Programs (#113) begins with a set of guiding assumptions which help set the stage for the rest of the resource.
Third, tailoring the format to the audience and situation can greatly impact clarity and understanding. Audio/visual and pictorial displays can have great impact. A simple but dramatic example is provided by the City of Los Angeles guide, Emergency Preparedness for People with Disabilities (#183), which contains a drawing of a dog holding a sign that says dont forget me. But whereas flashy can be good, simple can be better for specific audiences or situations. A set of tip cards for first responders from the Center for Development and Disability at the University of New Mexico (#4) consists of simple, bulleted information broken down by disability type. The effectiveness comes from the ability to quickly digest the key points in dynamic response environments. A very different example of formatting that facilitates use by different audiences is the Centers for Disease Control and Prevention Website, Index of Printable Hurricane and Flood Materials (#289), which provides risk communications in multiple languages in an easy-to-navigate matrix design. Another example of tailoring is the Masters of Disasters suite of material for earthquakes (#39). This set of materials offers lessons and examples tailored to multiple developmental stages, for use with children in different age groups. Other important aspects of tailoring the format include using appropriate reading levels and ensuring that availability matches the audience (e.g., because of modality or technology limitations).
Comprehensiveness. Coverage of issues relevant to vulnerable populations was also frequently noted in the review of these documents. Resources that were careful to acknowledge diversity within vulnerable populations stood out. For example, a factsheet from the U.S. Department of Veterans Affairs (#267) noted that children of different age ranges will likely have different reactions to terrorist attacks, and hence will require different caregiving strategies. The previously mentioned SAMHSA guide on cultural competency (#113) explicitly emphasizes this point.
Comprehensive coverage, however, does not mean uniform coverage. In particular, risk communicators may have the instinct to tell people what they should know, not recognizing that some of that information is obvious or widely known. Dwelling on such information could potentially damage credibility of the source. Instead, including and emphasizing crucial information that is less likely to be known can have a greater impact. In particular, such a strategy can lead to ah-ha moments with recipients, enhancing the perceived value of the resource. A straightforward example of this was noted in a brochure by the National Organization on Disability for animal owners (#180), noting that different resources (e.g., access to shelters) may be available to service animals than for pets in general. A brochure from the Community Emergency Preparedness Information Network on hurricane preparedness for the hearing- impaired (#143) suggested placing important papers in waterproof containers and putting refrigerators/freezers on their coldest settings to prepare for a potential power outage. These specific examples may not be news to some individuals, but were to the reviewers, and may also be to other individuals.
Action Orientation. Also frequently cited by reviewers was the action orientation of many all-star resources. An American Red Cross activity book (#59) encourages children to take an active role in preparing for emergencies, and a ready.gov scavenger hunt (#242) sends children in search of emergency kit items. The second section of the guide to cultural competency (#113) provides a framework for action. Additionally, checklists and self-assessments can help recipients tailor resources to their own needs. The booklet, Listen, Protect, and Connect: Psychological First Aid for Children and Parents, (#250) from the U.S. Department of Homeland Security (DHS), includes places to write in details, which helps to ground the risk communication in an individuals experiences. Finally, the credibility of calls to action may be enhanced by recognizing barriers to success. The NACCHO Advanced Practice Center Toolbox (#18) does this quite effectively, citing cost of preparedness (e.g., first-aid kit and battery-powered radio) and denial of risk as examples of barriers.
Ability to Engage the Audience. Another prominent theme was the ability of resources to engage their intended audience. Multi-modal approaches were noted by the reviewers as breaking monotony, grabbing attention, and providing different angles on a common message. For example, SAMHSAs substance use and trauma-related webcast (#77) combines an interview video with parallel PowerPoint slides (with the option of enabling closed captioning). Such approaches acknowledge both different learning styles and different communications needs. Embedding checklists, self-assessments, and other active segments can help to achieve some of the benefits of shorter resources, but within longer, more comprehensive resource packages. The Family Readiness Kit from the American Academy of Pediatrics (#125) was a particularly striking example of this, including checklists, childrens activities, and fact sheets within a larger kit. Similarly, in longer resources, and particularly those targeting providers, appendices can add crucial details without breaking up the overall flow of the main resource.
Clearly Stating and Addressing Objectives and Risks. Finally, reviewers also noted that stating the purpose of a resource early and clearly was helpful in grounding resources. For example, a preparedness manual from the American Red Cross (#1) for people with disabilities (PWD) was at the same time very tangible and very detailed--a combination facilitated by clearly spelling out objectives. A single-page SAMHSA handout entitled Alcohol, Medication, and Drug Use After Disaster (#92) very clearly and concisely spells out substance abuse risks after a disaster and provides strategies for managing these risks. Similarly, motivating recommended actions helps make them more compelling and relevant to the decisions that need to be made by the recipient. The tip cards for early responders (#4), in one specific instance, point out that every person and disability is unique, as a means of motivating responders to ask a person before attempting to assist them. Such motivations can serve to demystify recommendations by suggesting contextual considerations.