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From Disparities Research toDisparities Interventions inDisaster Preparedness Lessons Learned and Thoughts About the Future David P. Eisenman, MD MSHS Associate Professor of Medicine David Geffen School of Medicine at UCLA
Mentors and Colleagues Steve Asch, MD, MPH Linda Bourque, PhD Jonathan Fielding, MD, MBA, MPH Lillian Gelberg, MD, MSHS Deborah Glik, ScD Dennis Mileti, PhD Martin Shapiro MD, PhD
Framework for eliminating disparities DETECTING UNDERSTANDING REDUCING Identify which Determine why Identify how disparities disparities occur disparities can be exist eliminatedKilbourne, et al. AJPH, 2006.
Framework for eliminating disparities DETECTING UNDERSTANDING REDUCING Identify which Determine why Identify how disparities disparities occur disparities can be exist eliminated Before: More likely to be under-prepared During: More likely to experience loss, injury, disease and death After: More likely to experience slower response and recoveryGraham, Office of Minority Health’s Agenda to Integrate Racial and Ethnic Communities into Emergency Preparedness”presented at Public Health Preparedness Summit, 2009
Research Gaps Survey research or case studies focused mainly on disparities between broad majority versus minority groups. Factors that cause disparities less understood – Contextual factors? – Barriers and promoters? Few outcome studies, fewer using prospective designs or theory-based interventions.
Lessons Learned… Vulnerable populations want to get prepared. Social networks influence disaster behaviors, for better and for worse. Culturally targeted programs can improve preparedness… …but only so much. Why?
How would vulnerable groups prepare after September 11th?Protection Action Decision Model(Lindell & Perry); ExtendedParallel Process Model (Witte)– Address how we process threats and taking protective actions– Link self-appraisal of personal vulnerability to protective actions. Threat severity (how severe will the effects be?); susceptibility (how likely it will happen to me?) Response efficacy (will recommended actions help me?); Self-efficacy
RDD telephone survey of the non-institutionalized adultpopulation in Los Angeles County;6 languages: English, Spanish, Chinese (Mandarin &Cantonese), Korean & VietnameseOver sampled Asian and African Americans59% cooperation rate“In the past year, has anyone in your household done anyof the following in response to the possibility of terrorism:1) purchased or maintained emergency supplies of food,water or clothing? 2) Developed an emergency plan for youand your family?”
Implications Vulnerable groups (ethnic minorities, disabled, immigrants) amenable to improving preparedness. Tailored and targeted programs may work for diverse population segments of Los Angeles
Literature on increasedprotective behaviors amongminority groups Eisenman, et al., AJPH, 2009 Uscher-Pines L, Am J Prev Med, 2009 Page, L., et al., Biosecur Bioterror, 2008 Rubin, GJ., et al., BMJ 2008
Reasons for non-evacuation Little known about low-income, urban, minority communities Transportation, shelter, historical experience cited in surveys Decision-making is multifactorial and socially embedded; surveys don’t address this. Qualitative research is needed
PurposeTo study the experience of Hurricane Katrina evacuees to understand evacuation decision- making in impoverished, urban, mainly minority communities.Participants describe factors affecting evacuation that are more complex than previously reported, interacted with one another, and were socially influenced. Eisenman, et al., AJPH, 2007
Quick response researchMon Tues Wed Thurs FriAug 29 30 31 Sept 1 2Katrina NOLA Astrodome Houstonlandfall evacuated opens shelters house 27KEisenmancamping trip5 6 7 8 9Labor Day NSF grant IRB Work in Recruitment submitted; fly shelter clinic; begins to Houston IRB approval
Major Themes: Social network Transportation Trust Risk Shelter perception Message Money, jobs, understanding property Health
TransportationI mean, if youve got 20 peopletrying to get in one car its notgoing to happen. So some people,you just stay because you have to.
ShelterReally truly, we had cars, but wedidnt know anybody to go to.They said go to Texas but I didntknow anybody in Texas.
Health I could have made it on my own, but it was just my aunt and my uncle. Every few steps he made…she forgot his walker…every few steps he made he was falling down.
Social networksMy plans were to leave. Unfortunately wereceived a call and we had to come backhome. My mother-in-law had called for us tocome back…. You know when they get acertain age they get confused.My mother-in-law wouldnt leave the house.My husband wouldnt leave her and Im notgoing to leave him.
Social networksLike my Mom said, shes been throughBetsy, Camille, all the hurricanes, themajor hurricanes and she just wasntevacuating. So I wasnt going to leave myMom to stay there by herself.I had a 90 year old mother that I wastaking care of and she would not leavethat house for hell or high water.
The influence of social networks:conclusions and recommendations Demonstrates interactions between factors influencing evacuation – Counterpart to Drabek’s finding “ families move as units and remain together, even at the cost of overriding dissenting opinions.” Broad networks hindered and facilitated evacuation – Stretched limited resources – Obligations to extended family, especially elderly who resisted evacuation or were frail, inhibited individuals and nuclear families Disaster research and policy must address social units not just individuals.
•Programa para Responder a Emergencias con Preparación.•A culturally-targeted, community-based program topromote disaster preparedness among low income Latinos•UCLA, Coalition for Community Health (CCH), LosAngeles County Department of Public Health
Preparedness in Los Angeles islow...Family Emergency Plan 39.3% 3 Days Food/Water 82.0%Battery-Powered Radio 93.6% First Aid Kit 70.8% Flashlight 76.2% Spare Batteries 77.4% 30% 40% 50% 60% 70% 80% 90% 100% * While most residents have each item, only 45% have all 5 items; <40% have plan.
Latinos less likely to have supplies (OR=0.73) andSpanish speakers less likely to have emergencyplan (OR=0.61)*60% 56.4% 47.4% 47.5% 42.5%45% 41.8% 40.8% 38.8% White Latino Africa American 32.2% APIs - Chinese30% APIs - Korean 22.5% 16.8%15% Disaster Supplies Emergency Plan * Controlled for age, gender, income, education, community, country of origin, health.
PromotoraLocal lay community residents trained in basichealth promotion skills working with fellowcommunity members who are under-served by thehealth care system.Use their cultural knowledge, social networks, andleadership role in the community to modelbehavior, overcome barriers, and create change.Provide connections between community andhealth care system including informal counseling,service assistance, education.Improved health care access, prenatal care, healthbehaviors.Not previously used in U.S. disaster preparedness
PREP logic modelPREP CAB Focus CAB Interven New Groups tion behavior CBPR CBPR CBPR CBPR CBPR HBM PADM HBM PADM SI
“Disaster Kit” Only half heard of term “disaster kit” or “emergency kit” – Whats the difference between a disaster kit and a first aid kit? – Storage, like when we buy something we say this is for storage – Emergency things Eisenman, et al., JHCPU, 2009
Communication Plan For most very fuzzy having the means to get communications from others during a disaster – A portable radio. – If there is no electricity you can’t ever charge your cell phone. – a little book with all the emergency phone numbers – walkie talkies Kind of like an emergency exit.
PREP Experiment:Overview Randomized, longitudinal two-group cohort design of a culturally-tailored, disaster preparedness program – ‘high-intensity’ vs ‘low-intensity’ groups Latino immigrant adults living in Los Angeles County, recruited using Respondent Driven Sampling – Eligibility: Latino, adult, domiciled in Los Angeles, 1 adult per household Baseline and 3-months post-intervention telephone assessments.
Theoretical ModelDemographic Milling/norms H1: Disaster suppliesCulture/Beliefs: Perceived benefits H2: Communication(fatalism, locus of planresponsibility, Perceivedliteracy) barriers Self-efficacy
Media Culturally tailored brochure Laminated shopping card Pre-printed/perforated communication cards
Platica Small group discussion, 1 hour Led by a trained promotora Held at community site. + Media materials N=25
Respondent Driven Sampling A type of chain referral sampling method that uses social network theory to gather a sample representative of the target “hidden” population. 7 seeds – Recruitment instructions, 4 coupons with unique codes, 5$ per eligible recruit – All persons who called the study number and presented a valid coupon were assessed for eligibility.
SummaryCulturally tailored materials did very well,often doubling proportions ofpreparedness.Significantly greater proportion ofparticipants in the platica arm reportedincreases in important outcomes.
Improving CommunicationPlans Nationally, fewer people have plans than supplies, even after media campaigns. Platicas led more participants to develop a written plan than media Is this due to social interaction resolving participants’ ambiguities? – Emergency communication plan requires discussion and agreement – Promotoras suited for clarifying uncertainties and misunderstandings
Perceived benefit of a planResponses to Pre- Post-“Having a plan for….is helpful.”Strongly 32 (17%) 79 (42.3%)disagreeMildly agree 3 (1.6%) 6 (3.2%)Neither agree 4 (2.1%) 1 (0.5%)or disagreeMildly agree 20 (10.7%) 9 (4.8%)Strongly agree 128 (68.5%) 92 (49%)
Emergency Plan perceived benefit of a planConfusion and fuzzy understanding– Do we need different plans for different emergencies? For different times of the day and week? Doesn’t it matter what the authorities say during the emergency? Is text better than telephone?
Emergency Plan Family emergency planning cannot totally be done in the family vacuum “Species-level” changes in communication Are we dubious about the benefit of a plan?
Emergency MedicationSupply Did not improve in PREP People in poor physical or mental health are less likely to be prepared. – Eisenman, DMPHP, 2009. Inflexible drug-dispensing policies prevent the public from building reserves – Carameli and Eisenman DMPHP, 2010.
“The fact that every family’s plan involves otherparts of the community is why I strongly believethat there needs to be one day in the yeardedicated to the emergency planning process. Ifwe as a nation feel it is really important for thepublic to develop emergency plans, it would befar more effective if everyone was doing that atthe same time — rather than asking individualsto do it on their own so the planning can beintegrated.” John Solomon, incaseofemergencyblog.com, 9/13/10