Analysis of Risk Communication Strategies and Approaches with At-Risk Populations to Enhance Emergency Preparedness, Response, and Recovery: Final Report. A. Risk Communication Activities for At-Risk Populations


General findings. Our interviews with state and local informants revealed common themes regarding how communities are currently developing and implementing their risk communication strategies for at-risk populations. Across states, planning is initiated at the state level, but most message adaptation and strategy development for reaching specific at-risk populations is conducted at the local level. As an example, in California, officials approach risk communication using a top-down guidance approach. Specifically, lead state agencies within the California Department of Public Health, such as the Public Health Emergency Preparedness Office and the Office of Emergency Services, provide broad guidance to the local agencies on how to deal with emergency situations, and they monitor how the agencies follow those guidelines. The California Department of Aging serves in an intermediary role between the Office of Emergency Services and CBOs. Specifically, the Department receives incident information, communicates it to their representatives “on the ground,” and then sends information from the ground it back up the pipeline. This minimizes the burden on the front lines.

Oklahoma also uses a top-down approach to risk communication practices. For example, state legislation guides how the state responds and communicates in the event of an emergency. The Oklahoma Department of Emergency Management generally takes the lead in developing and disseminating most messages before, during, and after an emergency. The content of those messages may involve input from the Oklahoma Departments of Health and Rehabilitative Services or other state agencies, depending on the issues involved. In this state, the local/county governments adopt state messaging unchanged or adapt it/add to it as needed for their local communities.

At the state level, risk communication efforts are generally not specific with respect to different at-risk populations. Most state informants reported that the message content does not need to be tailored, but that there may be situations in which the method of message dissemination should be altered to meet the needs of at-risk populations (e.g., people with hearing impairments or those with limited English proficiency). This tailoring is generally performed at the CBO or agency level rather than by the state and is consistent with findings from the compendium, where we found that non-government organizations often specifically tailored message content to specific at-risk populations (e.g., transportation for those who are mobility impaired or sheltering for those with guide dogs).

Tailoring messages to each at-risk population is resource-intensive, and most state informants are not trained in messaging for each population. For example, in Florida and Oklahoma, the local/county governments use the state templates for messaging and then add messages that may be relevant to their local communities. Some county administrators manage multiple counties with limited staff (sometimes without a PIO) and may pass the messages on to their residents unchanged. Other counties have full or part-time PIOs and can tailor the messages more to the needs of the local community; however, this tailoring may be related to local emergency conditions and not the needs of specific local populations.

On the other hand, all states prioritized the translation of messages into multiple languages, depending on the need in the population. For example, the Oklahoma Department of Health regularly translates preparedness materials into Spanish but uses CDC-prepared materials translated into other languages spoken in the state. It is difficult to find the resources needed to translate into other languages that are spoken by smaller groups, especially when many of these groups are also proficient in English.

CBOs are important assets in serving as intermediaries in the process of communicating with different populations. Our literature review emphasized their importance in presenting messages from trusted members of the community. However, some states were more inclined to actively involve CBOs in the risk communication process than others. Nevertheless, these community partnership approaches are consistent with the priorities for risk communication in the CDC guidance.

States tend to develop some pre-planned, standardized messages around emergency events that are likely to occur every year in their state, such as heat waves, tornadoes, fires, or hurricanes. Many states have lists of sample key messages that are ready to disseminate. Informants also noted the importance of factors emphasized in the compendium report (Appendix B): Messages should be crisp and easily understandable, and include actionable recommendations. Messages should be empathetic, describe the scope of the problem, list how the health department (or other agencies) are responding, explain the risk to residents, and tell the intended audience what actions can/should be taken (e.g., be alert, seek medical treatment, where to go for more information).

In the compendium of risk communications, we found that when risk communications specified the type of emergency, it was most often a natural disaster. In each of the sites visited, this same pattern was found, with sites targeting the natural disasters most common to their specific locations. For example, in California, the key events are earthquakes, heat, and fires, though guidance also covers terrorism and bioterrorism events. In Oklahoma, the emphasis is on tornados and ice storms, with some attention to wildfires and floods. Florida is concerned primarily with hurricanes and flooding, and the Metropolitan Washington Area is focused on bioterrorism, hurricanes, electrical storms, and flooding. The Washington, DC, metro area in particular is poised to respond to threats of terrorism given the events of 9/11 and the subsequent anthrax attacks. In addition, given CDC and other federal funding and the priorities they set, there is also a significant focus on developing preparedness plans and messaging for pandemic influenza.

  1. Developing emergency response plans that include the media, public, partners, and stakeholders. We learned about several activities across states that involve partnering with key stakeholders, including community members, agencies, and other organizations, to develop emergency response plans. The desirability of such strategies is supported by the results of our literature review, which identified community-based participatory approaches to message development as especially promising. We highlight some examples:

    • Plans for local community partners to address at-risk populations. The California Department of Health Services developed a risk communication tool kit for use by local health departments in the state; the tool kit includes ideas about how to communicate with various populations but leaves the majority of content decisions to local planners. California is also working with community organizations, such as libraries, that can distribute guidebooks to their constituents. In addition, the state is partnering with Kaiser Permanente to develop three video public service announcements on seasonal and pandemic influenza. The state holds ethnic media roundtables where PIO staff meet with a wide variety of ethnic media organizations to discuss risk communication messages and to establish and maintain professional ties.

      In Miami-Dade, Florida, there is a database containing information on 10 percent of the persons at-risk in the county. The county uses this information to work with CBOs to meet the needs of at-risk populations. The information can be organized by evacuation zone, level of care, primary language, whether the person is bed-bound, and a variety of other characteristics. CBOs often inform clients about an emergency and develop disaster guides with the at-risk population they serve. This tool has high utility but because it is difficult to obtain such information for the majority of people at-risk, its reach is limited.

    • Plans for PWD. Together, the Florida health and disability agencies have developed a 12-page preparedness guide for PWD. The Florida Statewide Disability Coordinator: (1) works with the health department and the Centers for Independent Living to learn how best to communicate with consumers of those agencies; (2) establishes procedures to provide effective communication within shelters; and (3) works with each county to establish contact with ASL interpreters who could be available in shelters during an emergency. In addition, the Developmental Disabilities Council is creating a manual to help PWD prepare for disasters, know what to include in emergency packets, and know what to do in the event of a disaster.

    • Outreach for senior citizens. Oklahoma is in the process of developing the Push Partner Program. This is a plan for disseminating mass immunizations or prophylaxis in case of pandemic flu or other public health emergency. The state health department will partner with different organizations that have outreach to populations who might not otherwise be able to get to a central dispensing site. This includes older adults and people with disabilities. The state is developing a statewide memorandum of understanding with the Aging Services Division within the Oklahoma Department of Human Services be the conduit to the Area Agencies on Aging across the state to push information to older adults and others who are at-risk.

      Specific messages have not yet been developed; however, the Push Partner Program offers a unique opportunity for getting messages out to at-risk populations through a community partnership approach. Indeed, these extra efforts to reach senior citizens are especially valuable: our review of the literature suggests that this population is less likely to access sources of information, such as the Internet, that are becoming increasingly popular media for disseminating emergency risk communication. (The literature review also identified the Internet as a successful delivery method for those who do have access.)

    • Communication channels for the hearing-impaired. Oklahoma Weather Alert Remote Notification (OK-WARN) is a program developed in partnership with the Oklahoma Departments of Emergency Management and Rehabilitative Services, the National Weather Service, and other organizations to disseminate emergency messages via email and pagers to those who are deaf or hard-of-hearing. Interested individuals register themselves with this program and, in the event of a weather alert or an emergency, they are notified by the OK-WARN system. Message recipients must supply their own pager or other communication device, but the service is free. This strategy is consistent with findings from the literature review suggesting that risk communication needs to be locally relevant in order to achieve effectiveness. States generally create broad messages for the population as a whole, which local staff tailor for their specific populations.

    • Core messaging tools. Montgomery County in the Metropolitan Washington Area is using several strategies for developing plans and communicating with the major at-risk populations. The core approach relies on Plan 9 (Montgomery County, Maryland) or Be Ready DC (Washington, DC), a county-wide educational campaign and tool kit emphasizing preparing a disaster kit with nine essential items needed in the event of an emergency: water, food, clothes, medications, flashlight, can opener, radio, hygiene items, and first-aid. Plan 9 distills these nine essential tips to keep in mind during an emergency, which CBO leaders can use with their constituents to prepare them for an emergency. Another advantage of this approach is that the message is concrete and serves as a centralized messaging strategy that can be standardized on all preparedness plans and materials shared with the community. It also ensures that folks get the same types of information in an easy-to-use format. Community partners have enhanced this tool for use with specific at-risk populations, not by altering the content of Plan 9, but by adjusting the way this information is shared.

      Both Department of Health interview informants in Montgomery County and Washington, DC, are partnering with a local CBO to craft and disseminate the messages. For example, in Washington, DC, city agencies have worked together to create Be Ready DC: easy-to-use materials for creating a personal or family emergency plan. Unlike in Montgomery County, where many efforts are housed in the Maryland Department of Health, the DC Departments of Homeland Security and Emergency Management coordinate Be Ready DC efforts. Be Ready DC is a centralized place to obtain emergency updates as well. These practices are particularly action oriented, a clear principle identified from the compendium.

  2. Conducting trainings, drills, and exercises. We highlight two examples of training activities.

    • Communication exercises. In collaboration with the Sheriffs Department, the California Department of Health and Human Services, through its PIO, conducts periodic exercises to ensure that responders are properly trained for helping at-risk populations during a disaster. For example, one exercise involved training responders to provide rapid outreach to non-English speaking people from different cultures in different languages. As emphasized in the literature review, it is important that risk communication efforts for at-risk populations go beyond straight translation to also teach cultural competence (e.g., address linguistic barriers and incorporate cultural beliefs) to ensure comprehension.

    • Risk communication training. In Oklahoma, the PIO in the Oklahoma Department of Emergency Management provides regular training sessions and monthly opportunities for continuing education to PIOs across the state (including those who work for state and local government agencies as well as those who are responsible for messaging in private organizations). In addition to these efforts, the Oklahoma Department of Human Services provides risk communication training annually to PIOs, focusing on developing and disseminating emergency messages. A community disability organization is training advocates of PWD, and this training includes an emergency planning component. These approaches highlight the importance of cultural competency and participatory involvement of community members, as discussed in the results of the literature review.

  3. Coordinating risk communication planning with state and local agencies and non-government partners. We identified a number of ongoing activities involving coordination of risk communication at our study sites.

    • Training the public to address the needs of at-risk populations. The Red Cross Bay Area Chapter in California works with businesses and apartment managers to train residents on first-aid and cardiac pulmonary resuscitation, with a focus on the health aspects of disasters, including having extra medication available for people with chronic illness.

    • Training for PWD. The program is a coalition of local partners that includes risk communication to focus on PWD and non-English speakers, frail senior citizens, and recent immigrants to ensure that the needs and concerns of people at-risk are addressed in emergency preparedness and response. (“Secure your stuff” and “Have a disaster kit” are key messages.) Numerous materials on various types of disasters are available for download.

    • Contracting with disability organizations. One mechanism that facilitates dissemination of risk communication messages in California includes contracting with disability organizations to leverage resources. For example, one state accessed a large volunteer base of trained instructors and presenters who were skilled in different languages and were from different cultures. Their materials were also available in Braille. They also conduct grassroots activities in the community and work in collaboration with other agencies. Key messages they promote are to (1) make a plan with family; (2) have a disaster kit with basic supplies; and (3) be informed--get appropriate and correct information during a disaster. Often these messages need tailoring to at-risk populations, for example, providing large print for senior citizens, identifying lower-cost strategies for low-income residents to assemble a disaster kit, and developing school-based programs to help parents prepare with their children.

  4. Training key state and local public health spokespersons to communicate with at-risk populations. Several training activities with a focus on emergency preparedness and response for at-risk populations were notable across the sites.

    • Community health care and other providers as spokespersons. In California, guidelines for message development include attention to cultural sensitivity, the needs of multiple community stakeholders, and mental health considerations. Populations that are identified as needing tailored messages include those with limited literacy, the homeless, immigrants, individuals with limited or no proficiency with English, those with visual or hearing impairments; individuals with disabilities, senior citizens, and children. Informants in this state have also developed an inventory of messages for “confirmed” and “unconfirmed” events. In addition to the general public, health care and other community providers are often the target audience for risk communication that occurs prior to an event. Messages tailored to these providers often include strategies for contacting clients and developing plans for their clients to obtain care in an emergency. The state disseminates best practices to local health departments through complementary resources--the Crisis and Emergency Risk Communication (CERC) Tool kit that is based on CDCynergy (Covello, 2008) and the CDC’s CERC course ( How local departments train spokespersons varies by community.

    • Weather reporters as spokespersons. Oklahoma relies heavily on the community and the “Oklahoma Standard” (a high standard of civic behavior and generosity in helping others), encouraging residents to check on their neighbors following an emergency to ensure that they are okay, to help them if evacuation is ordered, or to determine their needs. Weather reporters are also key assets in the state in communicating messages in preparation for, during, and in the immediate aftermath of a disaster. They help to reinforce messages for safety during a tornado (where you should be, what you should have with you, and how to keep yourself safe) and are important communications conduits--widely watched and respected. The results of the literature review suggested that weather reporters are a particularly trusted source of emergency information; they are seen as non-political, objective messengers who appear on the easily accessed communication medium of television.

  5. Establishing mechanisms to translate emergency messages into priority languages. Informants at all the sites we visited indicated that they translated risk communication materials into multiple languages. In California, in response to the fires and extreme heat of summer 2008, several key risk communication messages were translated into priority languages. For example, a one-pager in multiple languages explained the N95 respirator and how to use it appropriately, and another provided summer heat tips, with information on preventing and treating heat related illness (translated in 12 languages). Cultural and social factors that may affect communication such as mistrust may also require different dissemination channels to increase the impact of messages. For example, we also learned about the importance of CBOs that are closely linked to non-English speaking populations in helping to ameliorate concerns of immigrants they will be reported to the immigration and naturalization service and mistrust of public health officials. As with training, messages and messengers must also be culturally competent in order for communication to be successful.

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