In emergencies, limited English-proficient (LEP) populations are some of the most vulnerable members of a community.1 Communicating effectively during emergencies can prove challenging due to language, cultural, technological, and logistical barriers.2 Identifying and overcoming barriers to effective preparedness and emergency response is one of the objectives for the Centers for Disease Control and Prevention's network of 14 Preparedness and Emergency Response Learning Centers (PERLCs)3 and 9 Preparedness and Response Research Centers (PERRCs).4 This report describes how a PERLC and a PERRC colocated at the Northwest Center for Public Health Practice (NWCPHP)5 responded to a request from the Los Angeles County Department of Public Health (DPH) Emergency Preparedness and Response Program6 (EPRP) to help them improve emergency communications with LEP communities.
Northwest Center for Public Health Practice
NWCPHP at the University of Washington, School of Public Health, is 1 of 5 universities with colocated PERRCs and PERLCs. Established in 1990, NWCPHP provides training, research, evaluation, and communication services to state, local, and tribal public health agencies and organizations. The colocation of both the Northwest Preparedness and Emergency Response Research Center (NWPERRC) and Northwest Preparedness and the Emergency Response Learning Center (NWPERLC) creates a unique environment where evidence-based strategies are translated into workforce development training, evaluation, resources, and tools. The NWCPHP team's expertise in communication and social media has informed NWPERRC's research in emergency communications. To improve outcomes during emergencies, NWPERRC communications research focuses on working to identify best practices for emergency communications, including research on LEP communities and uses of text messaging in emergencies. NWPERLC translates the findings into workforce training, practice toolkits, and communications resources to improve emergency preparedness and response.
LEP emergency communications and social media
The population of non–English-speaking immigrants in the United States has grown by 140% over the past 3 decades7; those belonging to LEP communities are disproportionately at risk during emergencies and disasters. Lack of emergency communications disseminated in languages other than English, health status and social disparities, low health literacy, cultural barriers, and lack of access to health care all contribute to excess morbidity and mortality among LEP populations.7
How well public health agencies communicate in emergencies, especially with LEP communities, directly impacts the rates of survival and injury prevention before, during, and after an event.8 An article by Wells et al.9 highlights the importance of community resilience (the ability to bounce back from adverse situations)10 as well as community engagement (involvement of multiple levels of the social environment)11 in preparedness and emergency response. While the importance of community resilience is readily acknowledged by local public health, the authors found a lack of working models throughout public health departments.
Social media is a communications tool that may facilitate improved public health communication during an emergency, although challenges in public health systems and policies may slow implementation.12 Staff support may not be available, or agencies may be waiting for more information regarding best practices for public health social media. Similarly, text messaging is another communication channel that has emerged as a means to provide credible, timely health information to the public. An article by Karasz et al.13 identifies text messaging as an especially useful form of communication since it is increasingly prevalent among all age groups and can be customized to meet individual needs. Text messages have been found to be valuable when they are perceived as “highly relevant, customized, and simple.” However, care must be taken when sending messages to individuals so as not to infringe upon any privacy or confidentiality issues, including the HIPAA rules protecting personal health information.13
LA County DPH
LA County DPH serves a diverse population of more than 9.8 million people and where more than 200 languages are spoken.14 The DPH EPRP is tasked with protecting the residents of LA County from the health consequences that result from natural or intentional emergencies through the use of threat assessment, planning, improved operational readiness, and timely response.
The DPH EPRP reviewed after action reports15 following the H1N1 pandemic and identified communication gaps, particularly among LEP communities. In 2011, the director of the DPH EPRP contacted NWCPHP because of its expertise in emergency preparedness research communications and translation to request assistance in improving DPH capacity to effectively engage and communicate with LA communities before and during public health emergencies. The overall goals included working to improve DPH staff/organizational capacity to engage LEP populations in emergency preparedness activities, utilizing social media in emergency preparedness communications, and conducting emergency translation activities.
The scope of this work with LA County DPH included a training needs assessment of the DPH preparedness workforce, a webinar series and an in-person training on evidence-based and best practice findings, and the development of a toolkit to improve emergency communications and community resilience.
NWPERLC developed a training needs assessment based on the Public Health Preparedness and Response Core Competency model16 and the Public Health Preparedness Capabilities: National Standards for State and Local Planning.17 The questionnaire was disseminated through the use of a Web-based survey to assess the knowledge, skills, and abilities of LA County staff in communicating and working with LEP communities to promote emergency preparedness. The assessment was designed to gather information on training needs with regard to LEP populations and emergency preparedness, emergency preparedness activities of staff, communication with LEP populations, training preferences, and access to training technologies. LA County community liaison staff, public health nurses, health educators, and emergency preparedness staff members were invited to participate in the assessment. To learn more about how LA County DPH staff communicate with LEP communities, they were asked about the frequency of communication with LEP populations, barriers to communicating with LEP populations, and the gaps that they have identified in the current LA County DPH protocols for communicating and working with LEP populations.
Community engagement and communication training series
On the basis of the communications research of NWPERRC and a literature review of best practices, NWPERLC developed a series of trainings for LA County DPH to improve preparedness communication strategies and tools with LEP populations. Training topics included the use of social media in emergency communication and the use of community engagement strategies to improve preparedness among LEP populations.
Part 1: Communicating with LEP populations
This 90-minute webinar looked at how to establish communication plans with LEP communities in advance of an emergency. NWPERLC instructor Missie Thurston examined methods of communication, including traditional media and social media, and provided case studies and sources for additional information. Participants learned how audience research improves communications planning, the benefits of using various forms of communication, including storytelling and pictorial communication, how to reach lower literacy and immigrant populations, and the use of social media as a tool to better understand and communicate with specific populations.
Part 2: Text messaging for public health emergencies
This 90-minute webinar familiarized participants with SMS (short message service) or “text messaging.” NWPERRC researchers Sharon Bogan, MPH, and Meredith Li-Vollmer, PhD, included findings from audience and industry research conducted and shared lessons learned from text messaging programs they have implemented. Learning objectives included the benefits and limitations of text messaging for public health emergencies, legal and logistical considerations with text messaging programs, and what specific audiences want in a public health texting program.
Part 3: Helping LEP communities prepare for emergencies
Best practices in adult education18 were used in all of the training activities. An interactive workshop was developed to introduce core concepts of community engagement and had participants working with instructors and colleagues to develop new approaches they could immediately apply to communications planning. The half-day in-person training workshop focused on tools and strategies used to engage communities with limited English proficiency. The workshop was interactive to provide real-life scenarios, provide useful information, and promote thoughtful discussion. Learning objectives included current challenges and barriers in assisting LEP communities, responding to and recovering from public health emergencies, and methods to assist LEP communities in preparing for responding to public health emergencies.
Self-reported confidence was used as an indicator of a participant's ability or capacity to understand and accomplish an articulated learning objective. Studies measuring self-reported confidence levels in the workplace found that behavior in the workplace was a function not only of knowledge but also of how certain the employee was of that knowledge.19 The trainings were evaluated using Kirkpatrick's20 level 1, 2 with a pre- and postdesign. The surveys were intended to gather the extent to which self-reported confidence levels changed on the basis of learning objectives for each training activity. The precourse survey collected demographic information and baseline data on self-reported preconfidence related to course-specific learning objectives. These results provided faculty with information to ensure that sessions were relevant to the training needs of participants. The postcourse survey gathered data on participants' self-reported confidence in their knowledge and skills upon completing the course. The questionnaires were administered electronically using a Web-based tool, SurveyMonkey.
Toolkit for emergency preparedness with LEP populations
Using the expertise of NWPERRC researchers, a review of the literature for preparedness and emergency response was conducted and a toolkit was developed. The final toolkit includes 35 resources on cultural competency, seminal academic articles, translational databases, guidelines, trainings, and best practices.
Training needs assessment
The training needs assessment consisted of a 45-question Web-based survey. LA County DPH provided e-mail addresses for 71 community liaison staff, public health nurses, health educators, and emergency preparedness staff members who were invited to participate in the online survey. A 52% response rate was achieved. The largest percentage of respondents (24.3%) also reported working in the emergency preparedness and response division of LA County DPH. When asked what their primary response role would be in an emergency, 32.4% reported they would fall under the operations. When asked about training, the top 2 identified needs were “Demonstrate the correct use of nonroutine equipment used for emergency communication” (45.9%) and “Use principles of crisis and risk communication.” Respondents were asked to identify any additional topic areas related to engaging LEP populations that they would be interested in receiving training in. Areas that respondents reported an interest for training included beginning and advanced language skills including Spanish, American sign language, and Tagalog, some basic phrases that would be helpful for use during an emergency, and training on cultural competency/cultural sensitivity. The training needs assessment provided important data to develop an effective workforce development plan to identify potential training and communications needs working with LEP populations in emergency preparedness and response.
Evaluation of community engagement and communication training series
Postcourse survey data from all 3 courses show that 53.9% to 63.7% of respondents rated the course they attended excellent/very good and 72.8% to 90.9% strongly agree/agree that they will be able to apply the content of the course to their work. All respondents reported that the courses were well organized, the slides were clear and easy to use, and that the webinar technology was straightforward and easy to use. The vast majority of respondents rated the length of their courses as about right (76%-90.9%) and reported the quantity of information as about right (69.2%-100%).
For every course, the percentage of participants who reported feeling very confident/confident about their knowledge and skills related to each learning objective increased from the precourse survey to the postcourse survey. For the LEP Communications Training, an additional 28.5% to 28.6% of respondents felt very confident/confident. For the Text Messaging for Public Health Emergencies, an additional 25% to 50% of respondents felt very confident/confident. An additional 20% to 50% of respondents felt very confident/confident after the Helping LEP Communities Prepare for Emergencies Workshop. The evaluation indicated some aspects of the courses that could be improved. Suggestions for improvement included more interaction with the social media technology, “concentrating on community engagement in the field,” and to “include more information about best practices in working with LEPs.” However, there were also comments that praised the 3-part series. One respondent wrote, “I think the training provided a great opportunity for participants to begin to really process through how much more we need to include LEP in our outreach on health issues as well as emergency preparedness messages.”
Toolkit for emergency preparedness with LEP populations
A toolkit was developed to provide a DPH a useful set of resources that could be adapted and tailored to meet specific communications needs in working with LEP communities. A review of the literature was conducted including 23 articles published by NWPERRC researchers.22 The search strategy for emergency preparedness for LEP populations, focused on the following: engagement of LEP populations in emergency preparedness; utilization of social media in emergency preparedness; and techniques for conducting emergency translation activities. While the literature review followed a systematic review strategy, it was not intended to be comprehensive. An additional 41 articles were reviewed and deemed relevant if they were published within the last 10 years and addressed at least 1 of the 3 focus areas. Both peer-reviewed and “gray literature” were included. Reviewers began with a PubMed23 key word search, including a review of all “related citations” for each search return. A similar review was conducted in Google Scholar,24 as well as a gray literature database maintained by Public Health–Seattle & King County.25 Reviewers also searched the National Library of Medicine–Outreach Activities & Resources.26 Findings were categorized using a framework adapted from Brownson and Fielding.27 All relevant findings were cataloged in an Excel workbook, organized into separate spreadsheets by topic. For easier use by practitioners, citations perceived by the reviewers to be most useful to this project were condensed into a practical toolkit. Reaching at-risk populations requires the use of multiple channels, formats, and tools. Many useful themes that emerged are as follows: define and locate LEP communities, get to know these communities through their community-based organizations, involve community liaisons in preparedness planning, build strong ties with ethnic media, make sure preparedness messages and official plans are culturally and contextually appropriate, translate emergency messages prior to an emergency, create a plan for professional translators and community members to translate in time of emergency, use members of the community and CBOs for outreach in time of emergency, medical interpreters and community health promoters are currently untrained in emergency preparedness/response but would be good resources, pictorial directions in emergency preparedness materials and in disaster announcements are good for many groups—including LEP communities.
NWCPHP's training expertise as a PERLC, combined with its PERRC with a focus on communications, provided the expertise to respond quickly and effectively to a request from LA County DPH to help them assess and improve emergency communications with limited English-speaking populations.
Colocation of a PERLC and PERRC at NWCPHP created an environment that facilitated rapid translation through a few different mechanisms: some NWCPHP faculty and staff members work on both PERLC and PERRC projects. Both attend seminars and brown bag sessions and have informal discussions on ways to translate research to practice.
The information obtained from the literature review, needs assessment, training evaluation, and toolkit was useful for further refining communications and training initiatives. As health departments across the country address the challenges of communications, LA County DPH was able to use the knowledge and lessons gained from the NWCPHP's assessment to inform, design, and prioritize education and training offerings to further develop its workforce and use NWCPHP trainings to improve DPH capacity to effectively engage and communicate with LA LEP communities before and during public health emergencies. NWCPHP designed the trainings to fit the needs of the public health practitioners. In addition, the trainings that were developed are applicable to local, state, and tribal health departments of various sizes. The complete suite of trainings included two 1½-hour webinars and one half-day in-person workshop and is available on the NWCPHP Web site at www.nwcphp.org.
The ability and expertise to translate research findings quickly into training and resources are strategic benefits to public health practice agencies working on emergency preparedness. Leveraging the faculty and staff capacity of the NWCPHP NWPERLC and NWPERRC programs uses personnel resources wisely and enables the support to respond quickly to the request and needs of one of the largest health departments in the country. The colocation of Centers for Disease Control and Prevention–funded PERRCs and PERLCs offered efficiencies and expertise to accomplish the multicomponent evidence-based request. Being able to translate research findings quickly is a strategic benefit to public health practice agencies working on emergency preparedness. Health departments are faced with having to make program decisions quickly and often in the absence of adequate data. This collaborative activity is an example of how in these times of diminishing resources, strategic placement of funds can meet the research, training, and best practice needs of health departments and advance important knowledge gains in communications that can ultimately save lives in emergencies.
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* The PERLC program is designed to address the preparedness and response training and education needs of the public health workforce. Supported by Federal funding (2010 to date), the program includes 14 centers in Council on Education for Public Health accredited Schools of Public Health. For additional information, see www.cdc.gov/phpr/perlc_factsheet.htm.