1. From Disparities Research to
Disparities Interventions in
Disaster Preparedness
Lessons Learned and Thoughts
About the Future
David P. Eisenman, MD MSHS
Associate Professor of Medicine
David Geffen School of Medicine at UCLA

3. 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

4. Framework for eliminating
disparities
DETECTING UNDERSTANDING REDUCING
Identify which Determine why Identify how
disparities disparities occur disparities can be
exist eliminated
Kilbourne, et al. AJPH, 2006.

5. 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 recovery
Graham, Office of Minority Health’s Agenda to Integrate Racial and Ethnic Communities into Emergency Preparedness”
presented at Public Health Preparedness Summit, 2009

6. 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.

7. 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?

8. How would vulnerable
groups prepare after
September 11th?
Protection Action Decision Model
(Lindell & Perry); Extended
Parallel 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

9. RDD telephone survey of the non-institutionalized adult
population in Los Angeles County;
6 languages: English, Spanish, Chinese (Mandarin &
Cantonese), Korean & Vietnamese
Over sampled Asian and African Americans
59% cooperation rate
“In the past year, has anyone in your household done any
of 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 you
and your family?”

11. Implications
Vulnerable groups (ethnic minorities,
disabled, immigrants) amenable to
improving preparedness.
Tailored and targeted programs may
work for diverse population
segments of Los Angeles

12. Literature on increased
protective behaviors among
minority 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

14. 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

15. Purpose
To 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

16. Quick response research
Mon Tues Wed Thurs Fri
Aug 29 30 31 Sept 1 2
Katrina NOLA Astrodome Houston
landfall evacuated opens shelters
house 27K
Eisenman
camping trip
5 6 7 8 9
Labor Day NSF grant IRB Work in Recruitment
submitted; fly shelter clinic; begins
to Houston IRB approval

18. Major Themes:
Social network
Transportation Trust
Risk
Shelter perception
Message
Money, jobs,
understanding
property
Health

19. Transportation
I mean, if you've got 20 people
trying to get in one car it's not
going to happen. So some people,
you just stay because you have to.

20. Shelter
Really truly, we had cars, but we
didn't know anybody to go to.
They said go to Texas but I didn't
know anybody in Texas.

21. 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.

22. Social networks
My plans were to leave. Unfortunately we
received a call and we had to come back
home. My mother-in-law had called for us to
come back…. You know when they get a
certain age they get confused.
My mother-in-law wouldn't leave the house.
My husband wouldn't leave her and I'm not
going to leave him.

23. Social networks
Like my Mom said, she's been through
Betsy, Camille, all the hurricanes, the
major hurricanes and she just wasn't
evacuating. So I wasn't going to leave my
Mom to stay there by herself.
I had a 90 year old mother that I was
taking care of and she would not leave
that house for hell or high water.

24. 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.

26. •Programa para Responder a Emergencias con Preparación.
•A culturally-targeted, community-based program to
promote disaster preparedness among low income Latinos
•UCLA, Coalition for Community Health (CCH), Los
Angeles County Department of Public Health

27. Preparedness in Los Angeles is
low...
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.

28. Latinos less likely to have supplies (OR=0.73) and
Spanish speakers less likely to have emergency
plan (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 - Chinese
30%
APIs - Korean
22.5%
16.8%
15%
Disaster Supplies Emergency Plan
* Controlled for age, gender, income, education, community, country of
origin, health.

29. Promotora
Local lay community residents trained in basic
health promotion skills working with fellow
community members who are under-served by the
health care system.
Use their cultural knowledge, social networks, and
leadership role in the community to model
behavior, overcome barriers, and create change.
Provide connections between community and
health care system including informal counseling,
service assistance, education.
Improved health care access, prenatal care, health
behaviors.
Not previously used in U.S. disaster preparedness

30. PREP logic model
PREP CAB Focus CAB Interven New
Groups tion behavior
CBPR
CBPR CBPR CBPR
CBPR
HBM
PADM HBM
PADM
SI

31. “Disaster Kit”
Only half heard of term “disaster kit”
or “emergency kit”
– What's 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

33. 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.

35. 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.

36. Theoretical Model
Demographic Milling/norms H1: Disaster
supplies
Culture/Beliefs: Perceived
benefits H2: Communication
(fatalism, locus of
plan
responsibility, Perceived
literacy) barriers
Self-efficacy

37. Media
Culturally tailored
brochure
Laminated shopping card
Pre-printed/perforated
communication cards

38. Platica
Small group
discussion, 1 hour
Led by a trained
promotora
Held at community
site.
+ Media materials
N=25

39. 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.

41. RDS results

42. Eisenman, et al., Am J Prev Med, 2009

43. Summary
Culturally tailored materials did very well,
often doubling proportions of
preparedness.
Significantly greater proportion of
participants in the platica arm reported
increases in important outcomes.

44. Improving Communication
Plans
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

45. Perceived benefit of a plan
Responses to Pre- Post-
“Having a plan for
….is helpful.”
Strongly 32 (17%) 79 (42.3%)
disagree
Mildly agree 3 (1.6%) 6 (3.2%)
Neither agree 4 (2.1%) 1 (0.5%)
or disagree
Mildly agree 20 (10.7%) 9 (4.8%)
Strongly agree 128 (68.5%) 92 (49%)

46. Emergency Plan
perceived benefit of a plan
Confusion 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?

47. 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?

55. Emergency Medication
Supply
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.

56. “The fact that every family’s plan involves other
parts of the community is why I strongly believe
that there needs to be one day in the year
dedicated to the emergency planning process. If
we as a nation feel it is really important for the
public to develop emergency plans, it would be
far more effective if everyone was doing that at
the same time — rather than asking individuals
to do it on their own so the planning can be
integrated.”
John Solomon, incaseofemergencyblog.com, 9/13/10

57. Thank you