Introduction to the eTool

The capacity to reach every person in a community is one of the major goals for emergency preparedness and response. The goal of emergency health communication is to rapidly get the right information to the entire population so that they are able to make the right choices for their health and safety. To do this, a community must know what subgroups make up its population, where the people in these groups live and work, and how they best receive information. Although knowing this type of information might seem obvious, many jurisdictions have not yet begun the process to define or locate their at-risk populations.

To maintain consistency with the Pandemic and All-Hazards Preparedness Act (PAHPA), this eTool uses the term “at-risk populations” to describe individuals or groups whose needs are not fully addressed by traditional service providers or who feel they cannot comfortably or safely use the standard resources offered during preparedness, response, and recovery efforts. These groups include people who are physically or mentally disabled (e.g., blind; deaf or hard-of-hearing; have learning disabilities, mental illness or mobility limitations), people with limited English language skills, geographically or culturally isolated people, homeless people, senior citizens, and children.

Regardless of terminology, trust plays a critical role in reaching at-risk populations. Reaching people through trusted channels has shown to be much more effective than through mainstream channels. For some people, trusted information comes more readily from within their communities than from external sources.

This eTool guides the user through a process that will help planners to define, locate, and reach at-risk populations in an emergency. Additional tools are included to provide resources for more inclusive communication planning that will offer time-saving assistance for state, local, tribal, and territorial public health and emergency management planners in their efforts to reach at-risk populations in day-to-day communication and during emergency situations.

If you follow the process outlined in this eTool, you will begin to develop a community outreach information network (COIN)—a grassroots network of people and trusted leaders who can help with emergency response planning and delivering information to at-risk populations in emergencies. Building a strong network of individuals who are invested in their community’s well-being, who are prepared and willing to help, and who have the ability to respond in an emergency is just the start. You must also include network members in your emergency preparedness planning, test the capacity of your COIN to disseminate information through preparedness exercises, and make changes to your preparedness plans based on the evaluation of those exercises.

Purpose

One lesson learned from events since 2001, especially Hurricane Katrina in 2005, is that traditional methods of communicating health and emergency information often fall short of the goal of reaching everyone in a community. Although a great deal of work has been done, public engagement for emergency response planning remains low. Other reports and legislation have also acknowledged this challenge as indicated below.

In December 2008, the Trust for America’s Health released its sixth annual Ready or Not? Protecting the Public’s Health from Diseases, Disasters, and Bioterrorism report.¹ This report recommends that “risk communication and emergency planning activities need to include all segments of the population to ensure their voices are heard and incorporated.” The 2008 report further recommends that “federal, state, and local officials must design culturally competent risk communication campaigns that use respected, trusted, and culturally competent messengers.”

When enacted in December 2006, the Pandemic and All Hazards Preparedness Act required the U.S. Department of Health and Human Services (HHS) “to integrate the needs of at-risk individuals on all levels of emergency planning, ensuring the effective incorporation of at-risk populations into existing and future policy, planning, and programmatic documents.”² PAHPA singled out risk communication and public preparedness as essential public health security capabilities, and it made state and local preparedness awards contingent upon an explicit mechanism, such as an advisory committee to obtain public comment and input on emergency plans and their implementation.

Furthermore, Homeland Security Presidential Directive 21 (HSPD-21), signed in October 2007, established the National Strategy for Public Health and Medical Preparedness, which includes community resilience as a critical component along with bio-surveillance, countermeasure distribution, and mass casualty care.³ Community resilience is how community and personal characteristics facilitate the ability to “bounce back" from adversity. This resource assists the inclusion of at-risk populations communication needs to promote their resiliency.

The Centers for Disease Control and Prevention (CDC), with the assistance of many state and local government and non-governmental agencies, has responded by compiling and disseminating information and materials for public health and emergency preparedness planners to better communicate health and emergency information to at-risk populations for all-hazard events. The process outlined in this eTool and the additional templates and materials included in the eToolbox are some results of this effort.

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¹ Trust for America’s Health. Ready or Not? Protecting the Public’s Health from Diseases, Disasters, Bioterrorism. December 2008.
http://www.rwjf.org/files/research/3613.1208.readyornot.tfahrpt.pdf

² Pandemic and All-Hazards Preparedness Act Progress Report. Assistant Secretary for Preparedness and Response. U.S. Department of Health and Human Services. 2008.
http://www.phe.gov/Preparedness/legal/pahpa/Documents/pahpa-at-risk-report0901.pdf

³ Homeland Security Presidential Directive 21. October 18, 2007.
http://www.whitehouse.gov/administration/eop/ostp/nstc/biosecurity

The Categories

As planners and communities embark on the process of defining, locating, and reaching their at-risk populations, there are advantages to beginning with very broad categories. Working in broad categories can be an effective and manageable starting point. The key advantage of this approach is that it allows you to examine the nature of the vulnerability that might put someone at higher risk in an emergency.

For example, a plan to identify every language other than English spoken in a community will produce a very long list. On the other hand, a plan to identify demographically significant groups of individuals with no or limited English proficiency or those with very low literacy levels will yield one category: Language and Literacy.

Many sub-groups that make up broader categories of populations experience some of the same communication barriers. For instance, whether the intended audience speaks Spanish or Chinese or simply does not read or understand English well, the communication barrier is a language or literacy issue and many of the strategies for message adaptation can be the same. Instead of translating emergency messages into 126 languages spoken in a community, public health departments have initiated pilot efforts to convey crucial information in simple, picture-based messages that are easily understood by everyone.

As you start to define, locate, and reach at-risk populations, five broad, descriptive categories will help you group people who are at risk:

• Economic Disadvantage
• Language and Literacy
• Medical Issues and Disability (physical, mental, cognitive, or sensory)
• Isolation (cultural, geographic, or social)
• Age

Many individuals do not typically fall neatly into one category or population group or they might fall into more than one. In some cases, an individual might not fall into one of these categories but could have a family member who does. When this occurs, efforts to provide emergency services can be thwarted because family members do not want to be separated.

After a widespread emergency, people might find themselves stranded, displaced, destitute, homeless, or sick. They might experience challenges that leave them newly vulnerable or suddenly outside of mainstream communications in ways they did not experience before the emergency. These factors can create new at-risk populations.

Economic Disadvantage

Start with economic disadvantage. If resources permit a community to address only one at-risk population characteristic, using poverty as a criteria may help reach a large number of people.

Economic disadvantage does not necessarily impair the ability of an individual to receive information, but it can significantly affect his/her ability to follow a public health directive if the individual does not have the resources or means to do what is being asked (e.g., stockpile food, stay home from work and lose a day’s pay, evacuate and leave their home, or go to a point of dispensing).

Economic disadvantage is so broad because many people that fall into other categories also live at or below the federal poverty level. When individuals are placed at risk because of both limited language or literacy and economic disadvantage, their risk is compounded, and planning efforts should reflect that.

Language and Literacy

This category includes people who have a limited ability to read, speak, write or understand English, have low literacy skills, or who cannot read at all (in English or in their native language).

It is important to consider language and literacy when you develop public health messages. To ensure that everyone can understand the information and follow public health directives, information must be culturally and linguistically appropriate and accessible to everyone.

Medical Issues and Disability (physical, mental, cognitive, or sensory)

According to the Americans with Disabilities Act, a person has a disability “if he or she (1) has a physical or mental impairment that substantially limits a major life activity, (2) has a record of such an impairment, or (3) is regarded as having such an impairment.”⁴ The most easily recognized people in this category are those who are blind, deaf, and hard of hearing, as well as those with health conditions that limit mobility or make them dependent on electricity. As much as 14% of the population has hearing, vision, or mobility limitations.⁵

People with mental disabilities are thought by many health and emergency planners to be the most challenging at-risk population in widespread emergencies because people who cannot understand and follow directions could jeopardize others in addition to themselves. Mental disability is a population category that will require priority attention in some emergencies.

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⁴ Executive Summary: Compliance Manual Section 902, Definition of the Term “Disability.” March 2009. The U.S. Equal Employment Opportunity Commission. February 3, 2010.
http://www.eeoc.gov/policy/docs/902sum.html

⁵ Public Involvement Techniques for Transportation Decision-Making. December 1996. U.S. Department of Transportation Federal Highway Administration. April 2, 2008.
http://www.fhwa.dot.gov/reports/pittd/ada.htm.

Isolation (cultural, geographic, or social)

People can be isolated if they live in rural areas or in the middle of a densely populated urban core. There are many ways people might be considered isolated, including:

• Rural populations include ranchers, farmers, and people who live in sparsely populated communities. Rural areas can have special communication challenges, such as dependence on satellite television, which does not always provide local channels or news. Additionally, radio stations have moved to a canned commercial feed in many communities and might not be useful for dispensing local information in an emergency.
• In urban areas, people can be isolated because of language, lack of education, cultural practices, chronic health problems, fear, lack of transportation or access to public transit systems, unemployment, and other factors. Even if they have access to mass media, they might not have the means to respond to emergency directives.
• Temporary residents can be a major population for many communities, but there are big differences in the types of temporary residents: people living on a military base, students, tourists, or seasonal farm workers, for example.
• Undocumented immigrants are foreign-born persons who reside in the United States and have not yet achieved legal residency. These individuals might consciously avoid interaction with social and public agencies.
• Single parents and caregivers face challenges because they have no one to share their responsibilities to care for those who are dependent on them. This increased responsibility can impair their ability to plan for emergencies or carry out public health directives, and it can be emotionally overwhelming.
• Religious and cultural practices may reduce the likelihood of certain groups receiving emergency communications. For example, mass media communications would be ineffective for reaching Amish and Mennonite communities, which usually do not have televisions or radios.

Age

Although many elderly people are competent and able to access health care or provide for themselves in an emergency, chronic health problems, limited mobility, blindness, deafness, social isolation, fear, and reduced income put older adults at an increased risk during an emergency.

Infants and children under the age of 18 can also be at-risk, particularly if they are separated from their parents or guardians. They could be at school, in day care, or at a hospital or other institution—places where parents expect them to be cared for during the crisis. There are also increasing numbers of children who are home alone after school. Separation of family members can cause its own havoc in a crisis, as demonstrated during evacuations for the 2005 hurricane season when members of some families were separated and sent to separate shelters and even to different states.

Creating a COIN in Your Community

Every person who lives, works, or travels through your community should be able to access information in an emergency. To ensure that happens, regardless of the communication and other barriers, you must first know who is in your community at any given time and how best to reach them with messages that will motivate action.

Community engagement and collaboration is crucial to achieve truly inclusive emergency planning. Comprehensive preparedness is only possible when public health professionals integrate the knowledge and skills of governmental and local public service providers, community-based organizations (CBOs), faith-based organizations (FBOs), and public health toward a common goal of enhancing communication, response, and recovery efforts. Community organizations should be involved in emergency preparedness planning from the beginning and engaged at every step of the way.

The process to accomplish this mission is divided into three phases: define, locate, and reach. Each phase includes specific activities to help you create and maintain your own community outreach information network (COIN), a grassroots network of people and trusted leaders who can help with emergency planning and give information to at-risk populations during an emergency.

By following the steps in each of these phases, you will have laid a solid foundation for your network, and you will be more prepared to reach at-risk populations during an emergency.