From Disparities Research to From Disparities Research to Disparities Interventions in Disparities Interventions in Disaster Preparedness Disaster Preparedness

Lessons Learned and Thoughts Lessons Learned and Thoughts About the FutureAbout the Future

David P. David P. EisenmanEisenman, MD MSHS, MD MSHSAssociate Professor of MedicineAssociate Professor of MedicineDavid Geffen School of Medicine at UCLADavid Geffen School of Medicine at UCLA

Mentors and ColleaguesMentors and ColleaguesSteve Asch, MD, MPH Steve Asch, MD, MPH Linda Bourque, PhD Linda Bourque, PhD Jonathan Fielding, MD, MBA, MPHJonathan Fielding, MD, MBA, MPHLillian Lillian GelbergGelberg, MD, MSHS , MD, MSHS Deborah Deborah GlikGlik, ScD, ScDDennis Dennis MiletiMileti, PhD, PhDMartin Shapiro MD, PhDMartin Shapiro MD, PhD

Framework for eliminating Framework for eliminating disparitiesdisparities

DETECTING

Identify which disparities

exist

UNDERSTANDING

Determine why disparities occur

REDUCING

Identify howdisparities can be

eliminated

Kilbourne, et al. AJPH, 2006.

Framework for eliminating Framework for eliminating disparitiesdisparities

DETECTING

Identify which disparities

exist

UNDERSTANDING

Determine why disparities occur

REDUCING

Identify howdisparities can be

eliminated

Before:More likely to be under-preparedDuring: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

Research GapsResearch Gaps

Survey research or case studies focused Survey research or case studies focused mainly on disparities between broad mainly on disparities between broad majority versus minority groups.majority versus minority groups.Factors that cause disparities less Factors that cause disparities less understoodunderstood–– Contextual factors?Contextual factors?–– Barriers and promoters?Barriers and promoters?

Few outcome studies, fewer using Few outcome studies, fewer using prospective designs or theoryprospective designs or theory--based based interventions.interventions.

Lessons LearnedLessons Learned……

Vulnerable populations Vulnerable populations wantwant to get to get prepared.prepared.Social networks influence disaster Social networks influence disaster behaviors, for better and for worse.behaviors, for better and for worse.Culturally targeted programs can Culturally targeted programs can improve preparednessimprove preparedness…………but only so much. Why?but only so much. Why?

How would vulnerable How would vulnerable groups prepare after groups prepare after September 11September 11thth??

Protection Action Decision Model Protection Action Decision Model ((LindellLindell & Perry); Extended & Perry); Extended Parallel Process Model (Witte)Parallel Process Model (Witte)–– Address how we process threats and Address how we process threats and

taking protective actionstaking protective actions–– Link selfLink self--appraisal of personal appraisal of personal

vulnerability to protective actions.vulnerability to protective actions.Threat severity (how severe will the Threat severity (how severe will the effects be?); susceptibility (how likely effects be?); susceptibility (how likely it will happen to me?)it will happen to me?)Response efficacy (will recommended Response efficacy (will recommended actions help me?); Selfactions help me?); Self--efficacy efficacy

RDD telephone survey of the nonRDD telephone survey of the non--institutionalized adult institutionalized adult population in Los Angeles County; population in Los Angeles County; 6 languages: 6 languages: English, Spanish, Chinese (Mandarin & English, Spanish, Chinese (Mandarin & Cantonese), Korean & VietnameseCantonese), Korean & VietnameseOver sampled Asian and African AmericansOver sampled Asian and African Americans59% cooperation rate59% cooperation rate““In the past year, has anyone in your household done any In the past year, has anyone in your household done any of the following in response to the possibility of terrorism: of the following in response to the possibility of terrorism: 1) purchased or maintained emergency supplies of food, 1) purchased or maintained emergency supplies of food, water or clothing? 2) Developed an emergency plan for you water or clothing? 2) Developed an emergency plan for you and your family?and your family?””

ImplicationsImplications

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

Literature on increased Literature on increased protective behaviors among protective behaviors among minority groupsminority groups

EisenmanEisenman, et al., AJPH, 2009, et al., AJPH, 2009UscherUscher--Pines LPines L, , Am J Am J PrevPrev Med, 2009Med, 2009Page, L., et al., Page, L., et al., BiosecurBiosecur BioterrorBioterror, 2008, 2008Rubin, GJ., et al., BMJ 2008Rubin, GJ., et al., BMJ 2008

Reasons for nonReasons for non--evacuationevacuation

Little known about lowLittle known about low--income, income, urban, minority communitiesurban, minority communitiesTransportation, shelter, historical Transportation, shelter, historical experience cited in surveys experience cited in surveys DecisionDecision--making is multifactorial making is multifactorial and socially embedded; surveys and socially embedded; surveys dondon’’t address this.t address this.Qualitative research is neededQualitative research is needed

PurposePurposeTo study the experience of Hurricane Katrina To study the experience of Hurricane Katrina

evacuees to understand evacuation decisionevacuees to understand evacuation decision-- making in impoverished, urban, mainly minority making in impoverished, urban, mainly minority communities.communities.

Participants describe factors affecting evacuation Participants describe factors affecting evacuation that are more complex than previously that are more complex than previously reported, interacted with one another, and reported, interacted with one another, and were socially influenced.were socially influenced.

EisenmanEisenman, et al., AJPH, 2007, et al., AJPH, 2007

Quick response research

9Recruitment begins

8Work in shelter clinic; IRB approval

7IRB submitted; fly to Houston

6 NSF grant

5Labor Day

2Sept 1Houston shelters house 27K

31Astrodome opens

30NOLA evacuated

Aug 29Katrina landfall

Eisenman camping trip

FriThursWedTuesMon

Major Themes:Major Themes:

Message Message understandingunderstanding

HealthHealth

TransportationTransportation

ShelterShelter

TrustTrust

Money, jobs, Money, jobs, propertyproperty

Risk Risk perceptionperception

Social networkSocial network

TransportationTransportation

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

ShelterShelter

Really truly, we had cars, but we Really truly, we had cars, but we didn't know anybody to go to.didn't know anybody to go to.

They said go to Texas but I didn't They said go to Texas but I didn't know anybody in Texas.know anybody in Texas.

HealthHealth

I could have made it on I could have made it on my own, but it was just my own, but it was just my aunt and my uncle. my aunt and my uncle. Every few steps he Every few steps he mademade……she forgot his she forgot his walkerwalker……every few steps every few steps he made he was falling he made he was falling down.down.

Social networksSocial networksMy plans were to leave. Unfortunately we My plans were to leave. Unfortunately we received a call and we had to come back received a call and we had to come back home. My motherhome. My mother--inin--law had called for us to law had called for us to come backcome back……. You know when they get a . You know when they get a certain age they get confused.certain age they get confused.

My motherMy mother--inin--law wouldn't leave the house. law wouldn't leave the house. My husband wouldn't leave her and I'm not My husband wouldn't leave her and I'm not going to leave him.going to leave him.

Social networksSocial networksLike my Mom said, she's been through Like my Mom said, she's been through Betsy, Camille, all the hurricanes, the Betsy, Camille, all the hurricanes, the major hurricanes and she just wasn't major hurricanes and she just wasn't evacuating. So I wasn't going to leave my evacuating. So I wasn't going to leave my Mom to stay there by herself.Mom to stay there by herself.

I had a 90 year old mother that I was I had a 90 year old mother that I was taking care of and she would not leave taking care of and she would not leave that house for hell or high water.that house for hell or high water.

The influence of social networks: The influence of social networks: conclusions and recommendationsconclusions and recommendations

Demonstrates interactions between factors Demonstrates interactions between factors influencing evacuationinfluencing evacuation–– Counterpart to Counterpart to DrabekDrabek’’ss finding finding ““ families move as families move as

units and remain together, even at the cost of units and remain together, even at the cost of overriding dissenting opinions.overriding dissenting opinions.””

Broad networks hindered and facilitated Broad networks hindered and facilitated evacuation evacuation –– Stretched limited resources Stretched limited resources –– Obligations to extended family, especially elderly Obligations to extended family, especially elderly

who resisted evacuation or were frail, inhibited who resisted evacuation or were frail, inhibited individuals and nuclear families 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 to promote disaster preparedness among low income Latinos

•UCLA, Coalition for Community Health (CCH), Los Angeles County Department of Public Health

* While most residents have each item, only 45% have all 5 items; <40% have plan.

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

70.8%

93.6%

82.0%

77.4%

76.2%

39.3%

30% 40% 50% 60% 70% 80% 90% 100%

Family Emergency Plan

3 Days Food/Water

Battery-Powered Radio

First Aid Kit

Flashlight

Spare Batteries

* Controlled for age, gender, income, education, community, country of origin, health.

Latinos Latinos less likely to have supplies (OR=0.73) and Spanish speakers less likely to have emergency plan (OR=0.61)*

56.4%

41.8%

47.4%

40.8%

22.5%

42.5%

38.8%

47.5%

32.2%

16.8%15%

30%

45%

60%

Disaster Supplies Emergency Plan

WhiteLatinoAfrica AmericanAPIs - ChineseAPIs - Korean

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

PREP logic modelPREP logic model

PREPPREP CABCAB Focus Focus GroupsGroups

CABCAB IntervenInterven tiontion

New New behaviorbehavior

CBPR CBPRHBMPADM

CBPR CBPRCBPR

HBM

PADM

SI

““Disaster KitDisaster Kit””

Only half heard of term Only half heard of term ““disaster kitdisaster kit””or or ““emergency kitemergency kit””–– What's the difference between a disaster What's the difference between a disaster

kit and a first aid kit?kit and a first aid kit?–– Storage, like when we buy something we Storage, like when we buy something we

say this is for storagesay this is for storage–– Emergency thingsEmergency things

Eisenman, et al., JHCPU, 2009

Communication PlanCommunication Plan

For most very fuzzyFor most very fuzzyhaving the means to get communications having the means to get communications from others during a disaster from others during a disaster –– A portable radio.A portable radio.–– If there is no electricity you canIf there is no electricity you can’’t ever charge t ever charge

your cell phone.your cell phone.–– a little book with all the emergency phone a little book with all the emergency phone

numbersnumbers–– walkiewalkie talkies talkies

Kind of like an emergency exit.Kind of like an emergency exit.

PREP Experiment: PREP Experiment: OverviewOverview

Randomized, longitudinal twoRandomized, longitudinal two--group cohort group cohort design design of a culturallyof a culturally--tailored, disaster tailored, disaster preparedness program preparedness program –– ‘‘highhigh--intensityintensity’’ vsvs ‘‘lowlow--intensityintensity’’ groupsgroups

Latino immigrant adults living in Los Angeles Latino immigrant adults living in Los Angeles County, recruited using Respondent Driven County, recruited using Respondent Driven Sampling Sampling –– Eligibility: Latino, adult, domiciled in Los Angeles, 1 Eligibility: Latino, adult, domiciled in Los Angeles, 1

adult per householdadult per householdBaseline and 3Baseline and 3--months postmonths post--intervention intervention telephone assessments.telephone assessments.

Demographic

Culture/Beliefs:

(fatalism, locus of responsibility, literacy)

Milling/norms

Perceived benefits

Perceived barriers

Self-efficacy

H1: Disaster supplies

H2: Communication plan

Theoretical ModelTheoretical Model

Culturally tailored Culturally tailored brochurebrochureLaminated shopping cardLaminated shopping cardPrePre--printed/perforated printed/perforated communication cardscommunication cards

MediaMedia

PlaticaPlaticaSmall group Small group discussion, 1 hourdiscussion, 1 hourLed by a trained Led by a trained promotorapromotoraHeld at community Held at community site. site. + Media materials+ Media materialsN=25N=25

Respondent Driven SamplingRespondent Driven Sampling

A type of chain referral sampling method A type of chain referral sampling method that uses social network theory to gather that uses social network theory to gather a sample representative of the target a sample representative of the target ““hiddenhidden”” population.population.7 seeds 7 seeds –– Recruitment instructions, 4 coupons with Recruitment instructions, 4 coupons with

unique codes, 5$ per eligible recruitunique codes, 5$ per eligible recruit–– All persons who called the study number and All persons who called the study number and

presented a valid coupon were assessed for presented a valid coupon were assessed for eligibility.eligibility.

RDS resultsRDS results

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

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

Improving Communication Improving Communication PlansPlans

Nationally, fewer people have plans than Nationally, fewer people have plans than supplies, even after media campaigns. supplies, even after media campaigns. PlaticasPlaticas led more participants to develop a led more participants to develop a written plan than media written plan than media Is this due to social interaction resolving Is this due to social interaction resolving participantsparticipants’’ ambiguities?ambiguities?–– Emergency communication plan requires Emergency communication plan requires

discussion and agreementdiscussion and agreement–– PromotorasPromotoras suited for clarifying uncertainties suited for clarifying uncertainties

and misunderstandings and misunderstandings

Perceived benefit of a planPerceived benefit of a planResponses to Responses to ““Having a plan for Having a plan for …….is helpful..is helpful.””

PrePre-- PostPost--

Strongly Strongly disagreedisagree

32 (17%)32 (17%) 79 (42.3%)79 (42.3%)

Mildly agreeMildly agree 3 (1.6%)3 (1.6%) 6 (3.2%)6 (3.2%)

Neither agree Neither agree or disagreeor disagree

4 (2.1%)4 (2.1%) 1 (0.5%)1 (0.5%)

Mildly agreeMildly agree 20 (10.7%)20 (10.7%) 9 (4.8%)9 (4.8%)

Strongly agreeStrongly agree 128 (68.5%)128 (68.5%) 92 (49%)92 (49%)

Emergency PlanEmergency Planperceived benefit of a planperceived benefit of a plan

Confusion and fuzzy understandingConfusion and fuzzy understanding–– Do we need different plans for different Do we need different plans for different

emergencies? For different times of the day emergencies? For different times of the day and week? Doesnand week? Doesn’’t it matter what the t it matter what the authorities say during the emergency? Is text authorities say during the emergency? Is text better than telephone?better than telephone?

Emergency PlanEmergency Plan

Family emergency planning cannot Family emergency planning cannot totally be done in the family vacuum totally be done in the family vacuum ““SpeciesSpecies--levellevel”” changes in changes in communicationcommunicationAre we dubious about the benefit of a Are we dubious about the benefit of a plan?plan?

Emergency Medication Emergency Medication SupplySupply

Did not improve in PREPDid not improve in PREPPeople in poor physical or mental People in poor physical or mental health are less likely to be prepared. health are less likely to be prepared.

–– EisenmanEisenman, , DMPHP,DMPHP, 2009. 2009.

Inflexible drugInflexible drug--dispensing policies dispensing policies prevent the public from building prevent the public from building reserves reserves

–– CarameliCarameli and and EisenmanEisenman DMPHPDMPHP, 2010. , 2010.

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

John Solomon, incaseofemergencyblog.com, 9/13/10

Thank you