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.

Step 1: Collect Population Information and Data

Begin by investigating and analyzing available data gathered by others to shed light on different population groups in your community. You can use many sources of population statistics from the national level down to local agencies. This quantitative data, previously gathered by others, will help you begin the process and build a “snapshot” of your community. Some resources that are available to help you with creating this snapshot include:

• U.S. Census data
• Information provided by state/local health departments
• Snapshots of Data for Communities Nationwide (SNAPS)
• Chambers of Commerce
• United Way
• Public Health Foundation’s database on counties
• The National Public Health Performance Standards Program (NPHPSP)

Review the national (103KB/1 page) and state (252KB/1 page) information sources in the resource guide for more examples of resources that may be available to help you create this snapshot.

Step 2: Estimate the Number of People in At-risk Populations Living in Your Community

Once you have collected information, establish baseline criteria to define groups within your community. As you consider the data you are gathering, identify the categories that are significant to your community. You can then synthesize the data into a brief report to estimate the number of people in different population segments within your community. This will help you gain a greater understanding of the scope of the outreach required.

At first, you might want to only focus on a few populations that will give you access to the largest number of people. As your program grows and you establish more partnerships, you can then consider adding categories to your plan.

Review the national (103KB/1 page) and state (252KB/1 page) information sources in the eToolbox section for more examples of resources that may be available to help you create this snapshot.

Defining the groups and numbers within your region is one of the first steps to accessing the largest number of people possible during an emergency.

Step 3: Identify Overarching Organizations/Agencies and the Key Contacts That Can Help You

Many organizations and agencies in communities across the country have extensive knowledge about the needs of various at-risk populations. An overarching organization is the lead organization that might partner with or provide funding to many direct service providers. Overarching organizations that fund or partner with smaller, direct service providers are often the best place to start engaging your community. In many areas, this would be an organization such as the United Way.

Review the category checklist (165KB/3 pages) in the eToolbox section for more examples of overarching organizations/agencies and key contacts that may be available to help you.

These organizations provide a direct link to CBOs and FBOs that serve many different populations. These direct service providers and agencies have the know-how and “big picture” understanding that can be a valuable resource in planning for preparedness, response, and recovery activities. In Phase 2 of this process, you will work with your overarching organizations to identify these direct service providers and trusted leaders. Public libraries can also serve as excellent resources with information about community service providers, particularly in very small communities that do not have a community foundation or local United Way.

As you identify these organizations, determine the most appropriate representatives with whom you can work and the best approach (personal appointment, phone, mail, e-mail, etc.) to reach them. You might be working with the leader of the organization, the person who oversees community affairs, or a student intern. Whatever the level of authority, this person can become a valued resource.

Step 4: Facilitate Discussions With Key Contacts

This step establishes relationships and identifies other potential partners and collaborators. Make an appointment to meet the key contacts at the overarching organizations and agencies to introduce yourself and explain the critical role these organizations will play in the process of reaching at-risk populations during an emergency.

Offer reciprocal assistance to the organizations and agencies that you ask for help. You might be able to help these potential partners by offering to share information or resources. Remember that they may also have concerns about spreading resources too thin.

Arrange a time to meet with several key contacts at a location most convenient for the attendees. If time and travel constraints make face-to-face meetings impractical, consider alternative means of getting together, such as a conference call. Regardless of meeting format, your role will be to facilitate the discussions and brainstorming on topics such as:

• Sharing the results of data collection to identify at-risk populations
• Long-term goals and objectives
• Other people who should be part of this discussion and their contact information
• How partner organizations might contribute to reaching at-risk populations with critical information in a public health emergency

As you collaborate with your planning partners, be sure to address the terminology you will be using as descriptors, or definitions, for the at-risk populations you wish to include.

Step 5: Stay in Touch

Sustaining community engagement is as important as building relationships. It is important to stay in touch—not only to update your partners on your activities but also to stay updated on staff turnover and transitions in partner organizations. It is important to communicate with your contacts on a regular basis and build in a mechanism to maintain updated contact information. You might find it helpful at this stage to provide regular brief updates on the progress of your work through e-mail, mail, or telephone calls. Later, as resources allow, you might want to develop a newsletter (in print or electronic formats) to keep people in your network connected, informed, and responsive. Build opportunities into your communication and outreach activities for feedback from your partner organizations.

Regularly scheduled phone calls, newsletters, fliers around the community, and meetings can help you maintain and update your COIN network.

How to Use the Information

You have been collecting information that you will use throughout the process to locate and reach your community’s at-risk populations. You need to be able to manage the information in a way that can grow as you acquire new data, contacts, characteristics, and other details.

Develop a database. A database is one of the best ways to record information so you can track multiple factors, share data with others, and keep information current. Record specific demographic information about key contacts at organizations and government agencies including:

• Names
• Phone and fax numbers
• E-mail addresses
• Postal addresses

Your database does not have to be complex. You can use a simple table in word processing software to organize the information that you collect. If you want to plan for a more robust database and have information technology (IT) staff to help you develop, build, and plan for future growth of your database, including them now in your planning activities will be beneficial. If they are involved from the beginning and understand your goals, they will be better able to help you anticipate ways to organize the data so that it will be most useful as you expand your database.

Step 1: Assess Existing Processes to Locate At-risk Populations

You probably already know who some at-risk populations are and how to reach them because they are enrolled in programs and receive services from your agency. State and local public health departments, for example, know women who are connected through the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and generally know how to get in touch with them; or they know how to contact daycare providers who can help locate parents and guardians in an emergency.

To avoid duplicating efforts, you might find it helpful to conduct an inventory of your department’s current activities that include techniques and abilities to locate people. Interview others in your department or agency about the successes and barriers they have experienced in locating people who use their services. You might want to ask questions such as:

• Who are the at-risk populations served by the department?
• Where are their gathering places?
• What is the department’s process for locating these people? What data are available to use in the mapping efforts?
• How do at-risk populations receive information from the department?
• Who are their trusted sources?
• What other community and religious organizations serve these same groups?
• What other links do these at-risk population groups have to the community?
• What privacy rules could impact efforts to locate at-risk population groups?

This type of intra-departmental assessment can provide locating strategies as well as data that can be used in the mapping process. You might also consider asking your partners to gather this information from their networks.

Step 2: Choose Digital Mapping or Alternate Methods

Research indicates that about 80% of all government information has a geographic component.⁶ A GIS captures and stores data that are then displayed on a map for analysis. These systems can include a wide variety of information including geographic, social, political, environmental, and demographic data.

Although mapping technology is available in the United States, mapping of specific populations is sporadic. In many coastal communities, for example, mapping is used by fire departments and cities in evacuation planning. In other places, Area Agencies on Aging or county offices on elderly affairs have mapped older populations. Other local agencies might be using digital mapping techniques to display information ranging from neighborhood crime data to environmental information such as air quality and the amount of smog.

In addition, every state has a GIS coordinator who is familiar with the digital mapping activities in the state. In most states, resources to help update and interpret demographic data to map at-risk populations and track changing population dynamics are available at the state departments of public health, family services, transportation, commerce, economic development, ethnic affairs, or other similar offices.

When using GIS software to locate at-risk populations, you will bring the population data you collected to define populations into the mapping program. Some GIS mapping software comes with U.S. Census data embedded.

Remember that the timeframe between U.S. Census data updates and its reliance on self-reporting will require that you update your data periodically. Also, consider printing out the data at regular intervals so the information is accessible in emergencies should widespread power outages occur.

If you do not have access to or are unable to use GIS software, post a map of your community on a wall. Use the census and other data you have collected in the "define" phase and information gathered from community collaborators to determine where your at-risk populations might be found. Use pushpins or markers for a visual representation.

In small communities, mapping is often viewed as unnecessary because “everyone knows everyone else.” Yet, mapping—whether it is done with colored pins on a paper map or electronically—provides an exceptionally clear picture of where at-risk population groups might be found during an emergency. It is a time-saving benefit regardless of community size or diversity. Saving time is especially important when the people responding with emergency support come from outside a community and might be unfamiliar with the local demographics. The best planning efforts will incorporate both geographically mapping the populations with their gathering places and forming collaborations and partnerships to create additional lasting relationships with various groups and their trusted sources.

Mapping is a community-building process. You will collect information from sources at the local level and from those who know the community (e.g., police officers, public works crews, utility workers, tribal entities, social service providers, places of worship, barber shops, and schools).

This information will help you dig deeper into your community for information about neighborhoods and the people who live there, about community centers and the people who congregate there, and about the places and people to whom those most at-risk will turn in a time of crisis.

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⁶Geographic Information Systems: Challenges to effective data sharing. United States General Accounting Office. June 10, 2003. http://www.gao.gov/new.items/d03874t.pdf

Step 3: Locate and Map Gathering Places for the At-risk Populations You Have Identified

Collaborate with your partners to find the places where your identified populations gather. This will help you to locate individuals and groups within these populations. People who share important aspects of their lives gravitate socially and geographically to traditional gathering places or venues where they feel comfortable.

Obvious examples are soup kitchens for homeless populations or day-worker sites that attract undocumented immigrants. In very small communities, the post office may be a central point for daily information sharing and community updates, and the local postmaster is often a knowledgeable and trusted community resource. Commercial locations can be important gathering places. For example, people who live in remote rural areas gather at shopping locations on weekends. In many cases, employees at these stores will be trusted information sources because they are part of extended families in the area and are therefore excellent resources to find people and share health or emergency information.

Step 4: Identify and Map Trusted Sources in the At-risk Communities

People are more likely to receive information and act on it when the message comes from a trusted source they view as credible. Some examples of trusted sources or non-traditional leaders in your community may be the PTA president, local pastor, and respected school teacher. Spokespersons in authority are not always perceived as the credible, trusted sources we hope they will be in delivering information to the general public and might even be less credible for the at-risk populations you are trying to reach.

This lack of credibility underscores why it is so important to build your network, or COIN, of trusted spokespersons with whom your at-risk populations will identify and trust. These individuals might not serve in an official capacity or be known to public health and emergency providers yet, but they can serve as a channel of information and become a cadre of leaders in emergencies. The same qualities that make them leaders in their communities often make them willing to serve as a liaison between health professionals and at-risk populations before and during an emergency.

A COIN might also include members of the media, especially those who have closer connections to at-risk populations, such as the local ethnic media outlets. These media outlets can be a very powerful voice and provide a close connection to the populations they serve. Another trusted source might be the director of a multicultural community center or a community health worker. In addition to having the confidence of the people the center serves, this person might also have a good network already in place to reach community members through an e-mail listserv, telephone tree, mailing list, or simple word-of-mouth.

Include trusted sources in meetings and planning sessions with other community organizations and service providers. Add them to your database, capturing their contact information and how they prefer to be reached. As you build your network of trusted sources, map their locations in your community so you can begin to get a visual representation of the network you are developing.

Eventually you will be able to integrate this information in such a way that you can develop digital maps showing the locations of trusted sources, spokespersons and community resources coordinated with the populations that they serve. Later on, this graphic representation of your network and the populations that they serve will help you identify gaps in coverage for at-risk populations in your community.

Engaging community members in activities to locate at-risk populations requires collaboration, contribution, and commitment. You will be asking very busy people to share their time, energy, and information to help you disseminate emergency and public health information. You will be developing long-term relationships built on respect, credibility, and a shared concern that people in at-risk population groups are included in health and emergency planning, response, and recovery.

The process of identifying trusted leaders in your community is an ongoing process. You will want to continuously identify who is missing from the COIN. Your current COIN members may be a good resource in directing you to such non-traditional leaders.

Step 5: Facilitate Discussions With Representatives From Community Organizations Connected With At-risk Populations

Ongoing engagement of your partners and representatives from community organizations is important throughout each phase of this process. You can host a meeting or conference call with the representatives of community organizations that you have already identified to discuss the issues involved as you locate at-risk populations. Talking with representatives of community organizations that serve at-risk populations, including those that address human service needs as well as community needs, is essential to determine which organizations can help you the most. Not every community representative will have a role to play in the "locate" phase, but they can be valuable connections to reach groups and to disseminate health or emergency information. This dialogue will enable you to meet community collaborators who can help you learn where to locate at-risk population groups. Ask community collaborators to explain:

• The populations they serve
• How they distribute and receive information
• Their classification as an overarching organization or a direct service provider
• What their potential outreach could be—the number of organizations and/or individuals this collaborator or partner could reach with ordinary and crisis communications

Step 6: Expand Your COIN to Include Service Providers, Businesses, and Others Who Work With, Represent, and Belong to At-risk Populations

An overarching organization is the lead organization that might partner with or provide funding to many direct service providers. The service provider organizations are a more direct link to the populations they serve. You first contacted overarching organizations and government agencies in the “define” phase. These organizations can now serve as a link to service providers, providing detailed information and saving you time and resources.

If the overarching organization is unable to provide the requested information about its member organizations, you might have to contact the service providers directly to get the information you need. In such cases, an important way to build trust is to build upon existing relationships. Many CBOs and FBOs are already involved in public health initiatives to reach at-risk populations to eliminate health disparities. Reach out to these programs to enlist their help to reach the partners for your network.

At the local level, small FBOs such as missions, ministries, or individual congregations can provide informal community outreach through programs that visit sheltered-in populations or provide after-school mentoring. By asking general questions about such programs, you might locate some of the at-risk populations in your community.

As you expand your list of organizations and contacts, the following tips might be helpful:

• Many of these organizations are listed in telephone directories or can be found online through a keyword search on the Internet, using words such as “disability,” “blind,” “deaf,” “developmental disability,” and “mental health.”
• People might self-select into groups based on their particular disability or need:
• University students who have mobility impairments often form organizations that provide support and advocacy.
• People who belong to various cultural and ethnic groups might form close bonds with other individuals in the same groups.
• People who speak a common language, share a common country of origin, or a common religion might join together in informal ways. The church, the mosque, or other houses of worship are often the places where community needs, political opinions, and employment options are discussed. In some ethnic populations, community storefronts are the gathering and information centers.
• These groups might not show up on an official list as they do not have national charters or oversight and are usually informal and private, often without scheduled meetings or agendas. Leaders of these groups, whether they are the matriarch of the family, community elder, religious leader, or the club president, can provide pertinent information about the groups they represent. These leaders also serve as valuable links in the process of building a network of collaborators and sustaining community engagement.
• You might locate these affinity groups by asking the representatives of the overarching organizations if they are aware of any of these types of unofficial groups in your community. Be sure to ask for names and best ways to contact the leaders.
• If there is a college or university in your area, you can contact the student affairs department to ask for information. Often a person belonging to the group will be the best source of information.

After identifying those organizations most appropriate to locate at-risk populations, you can begin to discuss the roles of your department and the other network members to locate and reach everyone in your jurisdiction, regardless of individual or community barriers.

How to Use the Information

As you continue to build and develop the network, maintaining the trust and anticipating possible concerns of your members will ensure the future success of your COIN.

Develop policies and procedures for the information you gather and maintain confidentiality of contact information for your COIN members. As you continue building and updating your database, the information you collect will likely become very attractive to other partners (including federal and state agencies), and you might get requests to share contact information for your network members.

The success of your network is built upon trust. Demonstrate your commitment to COIN members by having clear policies for how contact information will be used and by clearly defining confidentiality issues at the start of your relationship with each member. As keeper of this important contact information, decide ahead of time if you would be willing to disseminate messages on behalf of other partners during normal, non-emergency times, and include policies and procedures for non-emergency communications.

Expand and update your database. You will want to continue expanding the database you created in the "define" phase by adding contact information for community collaborators and program partners. You might also want to add the places where you have been able to locate at-risk populations and their gathering spaces.

As the work to locate and reach at-risk populations continues over time, members of your COIN might change or their contact information might change. Keeping your database current will be extremely important as your work moves forward.

Step 1: Survey Agencies and Organizations to Learn About Their Successes and Failures

The best way to learn what works well is to ask people who are already in the business of reaching at-risk populations. You can conduct a simple interview or survey with people in and outside your agency who routinely communicate with members of at-risk populations. This might include professionals such as first responders (fire, police, and emergency medical services), people who are in charge of programs such as Meals on Wheels, tribal elders, instructors in English-as-a-second-language classes, ethnic media representatives, and health care practitioners at clinics.

You will be able to use this information to start planning appropriate ways to augment your existing communication plan to include at-risk population outreach. This survey interview can help you identify practices that succeed—some of which you might want to incorporate in your plan—and those that failed to accomplish any measurable objective.

Step 2: Conduct Focus Groups or Community Roundtables

An important next step is to use community assessment techniques (surveys and focus groups) to reveal in-depth details on the barriers and specific communication needs of at-risk populations in your community. Although these techniques can be the same used in research, you can use them for local program purposes not for creating general knowledge. Policies and procedures should be followed to ensure the privacy of the participants and the information collected.

Focus groups and community roundtables allow you to talk directly with members of the populations you want to reach. Your COIN members can help you in establishing and facilitating these focus groups. For example, their existing relationships could be beneficial to you as you recruit participants, pose appropriate questions, and gather information. This information can give you a better understanding of your at-risk populations by delving into topics such as:

• Barriers to receiving information based on past experiences
• Preferred methods of communication
• Key spokespersons and trusted sources for public health messages
• Media usage/habits
• Primary languages spoken
• Developing culturally competent messages

This information can be obtained by asking leading questions like:

• In the past, what types of barriers have kept you from receiving important information?
• What sources do you usually use to get news and other information?
• Whom do you trust to give you information about health care and other health-related issues?
• When there is an emergency, how do you get information?
• If there were a public health emergency, where would you go for information?
• How do you prefer information to be communicated (e.g., in what language, verbal, or written)?

Before you conduct focus groups or community roundtables, check with your COIN and within your own agency to determine if these have already been done. Also consider the best ways to access your intended population. For example, if your target demographic is the elderly, conducting a focus group might not be effective because elderly people might have transportation or mobility issues that prohibit them from attending a focus group. This population may also mistrust people they do not know and worry about their personal safety.⁷

In these instances, a telephone interview might be a more appropriate data collection method if trusted members of the community adequately prepare this population for such outreach. Telephone surveys are not without limitations and do not capture those without telephones, are possibly biased due to mobile phone use, and have a potentially low response rate because of caller identification and answering machines. As an alternative, a written survey delivered by a trusted source, such as a Meals on Wheels provider or a family member, could be an effective way to encourage participation.

A written survey, whether administered in-person or through the Internet, does not have the qualitative capability of assessing perceptions, attitudes, and behaviors through interpersonal communication and interaction. However, it can provide statistical data that reveal recurring themes, best communication methods and practices, media outlets used most often, and information sources that are trusted by the populations you are trying to reach.

If you plan focus groups for your intended population, schedule them at convenient times and at locations such as multi-cultural community centers, churches, schools, or senior centers that are easily accessible. You might need to arrange for interpreter services, depending on the specific population you are inviting.

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⁷ McKinlay, JB. (1991). Optimal survey research methods for studying health-related behaviors of older people. Vital Health Stat 5, 6, 81-92.

Step 3: Analyze Data Gathered From the Surveys, Focus Groups, and Your Focus Groups, and Your Previous Assessment Efforts

As you review your findings from the "define" and "locate" phases of this process, along with your recent focus groups and surveys, you might see common characteristics and needs that will enable you to create a list of key findings for each population. Look for common themes and emerging patterns that relate to reaching at-risk populations with messages they understand and to which they can respond.

Your findings might show that some cultural groups are less trustful of official government messages than the population as a whole and that they desire communication materials that are culturally relevant to their group. CBOs and FBOs can serve an important role in reinforcing and validating information for these groups who might receive information through mainstream channels first. The messages disseminated through these trusted sources will be consistent and reinforce the messages through the mainstream channels.

Step 4: Collaborate With Community Organizations

Your assessment provides the basis for understanding the cultural and linguistic characteristics of your community and the communication barriers faced by at-risk populations. Such findings will serve as the basis for developing communication strategies that overcome communication barriers and convey information that is understandable and relevant to members of the diverse populations.

Community collaborators who have become a part of your network will bring their experiences in implementing communication strategies to the process. Ask your collaborators to share their strategies. In an emergency, public information must meet the needs of at-risk populations to be effective. Some communication tactics include:

• Keep messages simple and concise by using short sentences and plain language to allow for easy translation of materials (consider using sixth grade reading level or lower).
• Provide written materials in bilingual or multi-lingual form.
• Include visual aids such as pictures and maps to reinforce key messages.
• Repeat key information.
• Include directions and phone numbers.
• Use large fonts.
• Identify preferred communication methods (face-to-face, door-to-door, word-of-mouth), and develop messages accordingly.
• Identify preferred media through which messages are delivered. Is it the local newspaper, ethnic radio station, or the church pastor?

As part of your ongoing efforts to strengthen your local community’s capacity to respond to a public health emergency, you can conduct workshops with representatives of at-risk populations and community leaders who are already committed to participating in your agency’s outreach work. The workshops:

• Help sustain relationships with members of your network.
• Provide an avenue for them to participate in decisions and actions that directly affect their communities and reinforce their sense of dignity.
• Increase their awareness of cultural and social diversity in your jurisdiction.
• Demonstrate your long-term commitment to the network.

Depending on the size of your jurisdiction, you might choose to have a series of workshops in different locations. Activities at these sessions might include:

• Viewing a basic “train-the-trainer” video on disaster-related communication, the leaders’ roles and responses, and techniques for conveying information quickly and accurately to members of the intended populations
• Reviewing materials produced specifically for at-risk population groups
• Gathering input on how existing materials can be adapted or new materials developed to better meet the needs of various populations

Collaborate with community organizations or bring COIN members to the planning table to address the needs of at-risk populations in your agency’s all-hazards emergency preparedness plan by:

• Asking them to identify the information needs of their community.
• Asking them for ideas about how best to reach them or address their needs in an emergency.
• Inviting them to review and make suggestions to the public health emergency preparedness plan that address specific strategies to use with at-risk populations.
• Working together to include this information in your preparedness plans and testing the plans in your preparedness exercises.
• Inviting them to participate in your exercises and including them in post-exercise evaluations and after-action reporting activities.
• Ensuring you complete the process by updating your preparedness plans based on what you learn from your exercises.

Step 5: Identify Appropriate, Trusted Messengers to Deliver Messages

At-risk populations might respond differently to a message depending on the messenger. For many groups, the person delivering the message is often better received if he or she is from a similar racial or ethnic group or is in a similar situation as the intended audience. Doors are more likely to open for peers who deliver health care messages to their neighbors than for someone from a different background who lives outside the neighborhood.

Even when members of an at-risk population group have access to the mainstream media, they might be more responsive (and therefore more willing to follow directions) if someone they know or trust delivers the message. For instance, elderly persons might watch television and listen to the radio, but might be more easily persuaded to take action if encouraged to do so by family or caregivers. For non-English speakers, a family member or representative of their faith community might have the most influence in delivering information.

People to consider as messengers include:

• Trusted persons within at-risk populations. Such persons are essential conduits of information to and from those groups. They must be identified, invited to the process, and their needs and concerns met so they are willing to be active participants in the emergency preparedness process prior to a public health emergency. The network you have been building throughout this process contains names of the community leaders considered credible by specific at-risk populations.
• Religious leaders, barbers, and hair stylists. Such persons can be trusted sources of information about health care and the community.
• Community and neighborhood leaders who are perceived as credible. Such persons are more likely to be believed by at-risk populations than official government spokespersons.
• Reporters, editors, announcers, and news directors in media outlets that serve your community. Such persons can be considered traditional messengers that will have a broad reach into most at-risk populations. Remember to include the ethnic media outlets as methods to disseminate your messages.
• The matriarch of a family. For many populations, the matriarch is the most respected and trusted source of information, while in other cultural groups, elders are the respected and trusted sources of information.

As you meet with community members to build your network, ask representatives from the different groups who they consider to be the best person to disseminate messages to their community. Avoid making assumptions about who the trusted person might be based upon your interactions with other groups.

How to Use the Information

As your COIN continues to grow, you will want to ensure that you keep in touch with the members and that you are incorporating their input into your existing communication and emergency operations plans.

Update your database. In your existing database, add vertical headings (such as barriers, channels, and messages) and enter the new information from your assessment on barriers for at-risk populations, preferred channels of communication, and the messages ranked most effective by your focus groups. This information will be an excellent resource and help you keep focused on the goals you have set.

Enhance your communication plan to reach at-risk populations. Using key findings from your surveys, focus groups, and other searches, along with the information in your database, you can enhance your existing communication plan to include at-risk population groups and to designate the appropriate, trusted spokespersons. Be sure to include members of the at-risk populations in your planning sessions. Encourage them to provide input so that your communication plan is feasible and appropriate.

Your plan could be a supplement to your organization’s existing crisis and emergency risk communication (CERC) plan, or it could be incorporated into the body of the CERC plan itself. Elements to address in your communication plan include:

• Identifying the roles played by state, local, and tribal officials and staff, public agencies and service providers, CBOs, and members of your COIN. This element is often overlooked in communication plans and can lead to confusion, duplication of effort, and turf issues
• Defining your at-risk population groups
• Finding these intended audiences and their gathering places
• Developing strategies to describe your approach to achieve your goals and objectives around reaching at-risk populations
• Developing specific tools and tactics to address gaps