In tro d u c tio n ..# INTRODUCTION
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 workbook 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, 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 document describes 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 document, 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 Furthermore, Homeland Security Presidential Directive 21 (HSPD-21), signed in October 2007, establishes the National Strategy for Public Health and Medical Preparedness including, 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/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 document and the additional tools, templates, and materials included in the toolkit are some results of this effort 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 .

# PURPOSE
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

# C ategories Checklist
Look in the Resource G u id e fo r a ch e cklist o f p e o p le a n d g ro u p s th a t m ig h t fa ll in to e a ch c a te g o ry .
E c o n o m i c D i s a d v a n t a g e 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 .
L a n g u a g e a n d L i t e r a c y 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 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 - In urban a re a s , 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  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 Kentucky O utreach Information N etw  Defining at-risk populations will require investigation to build an understanding of the unique demographics represented in your community. You will need to learn about the spoken languages, cultural practices, belief systems, and the physical and mental limitations of the residents .

# Limited English Proficiency
In this first phase, you will identify the populations you consider at-risk and then initiate a dialogue and engage those who represent organizations and government agencies that can reach many people in your community. These organizations can provide a wealth of information about at-risk populations and their representatives . You will start building a network of collaborators and partners as you delve into the specific demographics that distinguish your community from others .
Step Step

#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 .

# Snapshots of Data for
Communities N ationw ide (SNAPS)   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 Your database does not have to be complex You can use a simple table in a word processor or spreadsheet 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 P h a s e 2 : L o c a t i n g A t -r i s k P o p u l a t i o n s
In most jurisdictions, a good approach to locating at-risk populations is to combine geographic information system (GIS) technology with information acquired through community collaboration, and networking in the data collection process
In this phase, you will map gathering places and trusted sources within your community Developing this system will help you get a visual representation of the network you are developing Eventually this will allow you to identify gaps in coverage This phase will also lead you through further engaging community members in this process In the Define phase, you started building your network through representatives of organizations You are now taking your COIN to the next level by engaging people who are on the front lines of providing service to the at-risk populations in your community, members of your identified groups, and their trusted leaders 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 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 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've 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 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 (CHW). 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   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 Step

#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:
- 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

# Step 3 -Analyze Data Gathered From the Surveys, 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

# American Sign Language Resources
The fo llo w in g resources ca n h elp y o u lo ca te fo re ig n la n g u a g e a n d A m e ric a n S ign L a n gu a g e (ASL) in te rp re tin g se rvice s a n d a d d itio n a l in fo rm a tio n th a t w ill be h elpful:
- 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 - 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:

# Getting Creative With Trusted M essengers
- 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 whom they consider to be the best person to disseminate messages to their community. Avoid making assumptions about whom 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 .
U pdate y o u r d ata b as e . 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 y o u r communication plan to reach a t-ris k 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 .

# Next Steps
In a community, this systematic process can be used by all emergency planners to work together to define, locate and reach at-risk populations . We hope that everyone exploring the process will work to connect with one another and to coordinate their activities . Now that the process is complete, you will need to continue strengthening the relationships that you have developed . - What elements worked as planned?
- Were community leaders of at-risk populations reached effectively?
- Was anyone left out?
- Who needs to be added to the COIN?
- What reactions and factors did we fail to anticipate?
- Where can we improve the plan?
These exercises should generate after-action reports that will outline the gaps in your emergency communications and preparedness plans Be sure to revise and update your preparedness plans based upon the after-action report findings

# Email Drill Template

# Principles of Community Engagement
Principles of Community Engagement (CDC, 1997) represents the first time that the relevant theory and practical experience of community engagement has been synthesized and presented as practical principles for this important work . It defines key concepts and insights from the literature that support and influence the activities of community engagement . This publication, available online at www. cdc . gov/phppo/pce, sets the standard and continues to be used nationally and internationally
Principles of Community Engagement provides a science base and practical guidelines for engaging the public in community decision-making and action for health promotion, health protection, and disease prevention . These guidelines can help public health professionals and community leaders improve communication, promote common understanding, and strengthen coordination, collaboration, and partnership efforts among themselves and community members and institutions Key principles forming the core of the document hold true across public health disciplines regardless of the initiating organizations:
- Be clear about the purposes or goals of the engagement effort and the populations and/or communities you want to engage .
- Become knowledgeable about the community in terms of its economic conditions, political structures, norms and values, demographic trends, history, and experience with engagement efforts . Learn about the community's perceptions of those initiating the engagement activities .
- Go into the community, establish relationships, build trust, work with the formal and informal leadership, and seek commitment from community organizations and leaders to create processes for mobilizing the community.
- Remember and accept that community self-determination is the responsibility and right of all people who comprise a community. You should not assume that you can bestow on a community the power to act in its own self-interest
- Partnering with the community is necessary to create change and improve health .
- You must recognize and respect community diversity. Awareness of the various cultures of a community and other factors of diversity must be paramount in designing and implementing community engagement approaches . (Engaging these diverse populations will require the use of multiple engagement strategies) .
- Community engagement can only be sustained by identifying and mobilizing community assets, and by developing capacities and resources for community decisions and action .
- You must be prepared to release control of actions or interventions to the community and be flexible enough to meet the changing needs of the community.

# Community collaboration requires long-term commitment on the part of the engaging organization and its partners .
To earn public trust and the trust of your partners:
- Be clear. People want direction .
- Be concise . Too much information is a barrier to understanding .
- Be correct. Check facts . Update frequently.
- Be connected . Know the people to reach in key communities and build relationships with them .
- Be confident-but don't confuse confidence with control . People trust the confidence shown by real leaders, not the control tactics of authority figures .
- Be transparent . Make your goals, values and priorities evident .
- Be a role model . Practice these principles as a model for your partners .

# Developing and Testing Messages for Cultural and Linguistic Competence
It is important to remember that your perception of the messages you develop might not be the same as your audience's While you want them to understand and respond to the information you provide, they are first listening to hear that 1) you respect them, 2) their needs have been considered, and 3) they are included in emergency plans .
Linguistic and cultural competence means understanding the most effective ways to convey information to members of diverse populations Often the main form of communicating public health information is through written materials, such as brochures, newsletters, and flyers If you are trying to reach a population or community with limited English proficiency, then materials might need to be translated into that community's native language or presented visually in a picture format Also consider that for those who are not literate in their native language, these written materials will not be effective, and recorded audio messages might be more appropriate Consider the cultural relevancy of photographs, images, and other visual features when creating messages and materials
You might need to consider the reading and comprehension level of your intended audience and use simple sentences, plain language, and avoid technical and medical terms Most successful communications to the general public are produced at a sixth grade reading level Studies show that even sophisticated readers are subjected to so much information in a day that they now require this level of simplicity for full comprehension, particularly during emergencies After you have worked with the community to develop sample messages and materials, you can conduct a series of focus groups with members of different at-risk populations Ask their opinion on the content, the presentation, whether the materials are sensitive toward their needs and culture, and if the message increases their awareness, changes their opinion and motivates them to change Work with them to make appropriate changes to these materials so that they meet these goals Culturally CAPABLE: A Mnemonic for Developing Culturally Capable MaterialsTM8
You can pose these questions to focus group members to ensure that the materials you are testing are appropriate for the audiences you are trying to reach

# Colors: Certain colors may convey different meanings for different groups, religions, cultures and communities
- Do the colors in the document have any cultural significance (positive or negative) for you or members of your community?
- Do you feel that the colors in this document should be changed?
Art: Certain images may or may not be appropriate for the target audience . Ideally, images should be used that are reflective of the readers .
- Are the pictures and artwork representative of your community?
- What message does this art/picture/logo send to you?
Paper: Some groups may have difficulty reading information on certain colors and holding certain paper types .
Some paper sizes and binding formats are also more or less common for specific groups .
- Is the paper easy to handle/read?
- Is the paper size appropriate for your community?
Access: Materials should be placed in locations that can be easily accessed, and at physical distribution points and height placement that will enable easy access for all members of a community.
- Where should we place these materials for ease of access?
- Should we make these materials available electronically, and if so, what is the best way to distribute them?
Buy-In: It may be helpful to have multiple members of the community review the materials to create buy-in and awareness . If the reviewers grant permission to be acknowledged on a final version of the material that has been reviewed by them, their status within the community may in turn increase the level of buy-in from the community at large
- Would other individuals/organizations be willing to review the materials?
- May we print an acknowledgement directly on the final version of the material, to enable other individuals from your community to see that you have supported us? Language: Words should be easy to read and understand, and the content should be written in a way that is most appropriate for the target community - Are the words easy to read, in a font size that the majority of readers will be able to read?
- Is the content easy to understand, appropriate for the community being served and written at a reading level that will be understood by the majority of readers?
Evaluation: To make a final assessment regarding materials, it is important to understand the impact of the changes proposed by the reviewers .
- What would be the consequences of the material being distributed "as is"?
- Would you be willing to evaluate the material again after changes have been implemented? - They might work under many labels, including CHWs, Community Health Advisor (CHA), Promotora, ayudante, and other locality-specific titles .
- CHWs help increase access to health services (particularly among racial and ethnic minority groups) .
- They contribute to broader social and community development .
- According to the National Rural Health Association, "the most significant commonalities of CHA programs are that: o they are focused on reaching at-risk populations;
- the workers usually are indigenous to the target population;
- their expertise is in knowing their communities rather than formal education" (National Rural Health Association, 2000).
- As "in-between people," CHWs "draw on their insider status and understanding to act as culture and language brokers between their own community and systems of care . "

# Delivery Channels
Channels for disseminating and delivering the messages are varied and your selection of which ones to use will depend on availability, access, and how well they reach your different populations Some methods to consider include:
- Television, in particular, is considered the preferred medium among all populations for receiving emergency information such as weather alerts and news about disease outbreaks and prevention
- The ethnic media community is usually underestimated . Few communication plans emphasize ethnic media, although one in four adults use ethnic media daily10 Even when members of an intended audience have access to the mainstream media, they are far more responsive to messages delivered by a person from a similar cultural or ethnic group Most organizational communication plans do not include in-depth use of ethnic media
- Internet access is an important source of information for many in America Even people who are homeless have access at public libraries and regularly use the Internet for information Many state government websites have been translated and are available in languages other than English For people who are deaf or hard of hearing, electronic messaging is an invaluable communication tool Blogging and other types of online bulletin boards with direct posting to an electronic network community at large provide additional dissemination of underutilized possibilities Also consider podcasting as an information dissemination channel for those who are visually impaired or those who prefer to listen to, rather than read, information
- The use of cell phone/text messaging technology has dramatically increased Text messaging is a main access point for young people and is a resource for the people in deaf and hard of hearing communities Newer cell phones also allow for Internet access
- Reverse 911 is a mechanized phone system technology that can dial and deliver a pre-recorded message to homes with phones in a particular jurisdiction Some form of it is currently used in many communities to give neighborhood announcements and crime alerts It is not available in all areas of the country - Telephone calling trees are effective ways to reach remote rural populations Often, these trees are self-initiated by residents of these areas During blizzards, for example, rural neighbors will call or use ham radios to check on each other
- 2-1-1 is an easy to remember telephone number that, where available, is answered by live operators and referral specialists who can connect people with important community services and volunteer opportunities . As the public becomes more and more familiar with using 2-1-1, they might think to call this number in an emergency. Both telephone 2-1-1 and the 2-1-1 website www. 211. org might be available to assist with providing public health information, tailored by location for your community. Services that are offered through 2-1-1 will vary from community to community, so contact your local 2-1-1 to see what capabilities are available in your jurisdiction .

# W h en M ainstream M e d ia is N ot an Option
Channels for delivering the messages are varied and will depend on availability, access, and how well they reach your populations . In certain emergencies, a loss of power will severely limit options .
Delivery channels, when the electricity has not been affected or limited, can include:
- Television/mass media (radio, newspaper)
- Ethnic media Plans for message delivery should be set up in advance of a disaster so that a telephone calling tree is available when disaster strikes
Other tactics for reaching at-risk populations include:
- Door-to-door information distribution including door hangers and pamphlets
- Information distribution to a pre-determined emergency information point (churches, libraries, grocery stores, post offices, schools, restaurants, markets)
- Peer ambassadors designated to help neighbors receive information

# Police alerts
Tools for reaching at-risk populations include:
- Picture books
- Braille and alternative language handouts
- Closed-captioned videos

# Audiotapes
O ffic e of Public Health P re p a re d n e ss a n d Response (OPHPR)

# Regional Councils and Metropolitan Planning Organizations
When local governments (city or county) work cooperatively to address problems or issues for a region, they often do so as part of a council of governments, metropolitan planning organization (MPO), or regional council .
Regional councils have state and locally defined boundaries They can deliver federal, state, and local programs and can function as planning organizations They are accountable to local units of government and typically work in transportation planning, economic development, workforce development, environmental planning, services for the elderly, and providing information via clearinghouses A MPO is an agency created by federal law to provide local input for urban transportation planning and to allocate federal transportation funds to cities with populations of greater than 50,000. According to the National Association of Regional Councils (NARC), nearly half of all MPOs operate as part of a Regional Council serving the same general geographic area Many Regional Councils and MPOs have sophisticated GIS that they use to map transportation and other planning activities . This data can be extremely valuable to you for community mapping .
3 0  We are currently working in the community to identify and reach at-risk populations to improve day-to-day communication and to be prepared to reach them in an emergency I've done some searching and I understand that your organization serves_______________________ in ______________________ .
PU
We want to improve our ability to communicate with at-risk populations in the community. Would someone in your organization be willing to assist us by answering some questions about your organization, the populations it serves, and its communication capabilities?
Sample Questions:
- What populations does your organization serve?
- What are your organization's outreach capabilities?
- How many people do you serve?
- Where is your organization located?
- What geographic areas does your organization serve? The purpose of a focus group is to reveal the in-depth attitudes, perceptions, and behaviors of at-risk populations in your community. This information can be used to augment the existing emergency communication plans . In-depth information can be obtained by asking leading questions such as:
- What sources do you usually use to get news and other information?
- Who gives you the most reliable information about health care and other health-related issues?
- What forms of communication are most effective (e . g . , door-to-door, face-to-face, or written materials)?
- 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 to you? Step 1 -Collect population information and data Use U . S . Census Bureau and other national data as well as data developed just for your community (studies conducted by area agencies or quasi-governmental organizations, such as a Metropolitan Planning Organization) .
Step 2 -Estimate the number of people in at-risk populations who live in your community Work with your health, emergency, and safety professionals, and other community partners to agree on the definitions you will use for at-risk populations in your community.
Step 3 -Identify overarching organizations/government agencies and the key contacts there that can help you Collect phone numbers, e-mail addresses, and postal addresses .
Step 4 -Facilitate discussions with key contacts Topics can include:
- The process of defining at-risk populations
- Long-term goals and objectives
- Other people who should be part of the discussion and their contact information

# Information about the populations under discussion
Step 5 -Stay in touch Keep your partners engaged . Ensure they remain updated on your activities and that you keep up-to-date on any turnover or staff transitions .
H o w to Use the Inform ation Develop a simple database that includes your partner contact information . This database will grow throughout the process

# A t-a-G lance: Locating A t-risk Populations
Step 1 -Assess existing departmental processes to locate at-risk populations
Step 2 -Choose digital mapping or alternate methods Use Census and other data previously collected to map locations where there are significant numbers of people who are members of at-risk populations . This will help provide a visual representation of where your populations are Consider working with partner organizations, such as a local Metropolitan Planning Organization (MPO) if departmental resources are not available for digital mapping programs . Also consider using colored pins or dots placed on a map of your community.
Step 3 -Locate and map gathering places for the at-risk populations you have identified . Create a map that shows the locations of community centers, missions, churches, or grocery stores that might be used by at-risk populations in an emergency
Step 4 -Identify and map trusted sources in the at-risk communities It is important to find contacts and service providers representing the at-risk population groups, and to know where they can be reached during an emergency
Step 5 -Facilitate discussions with representatives from community organizations connected with at-risk populations Talk with leaders and representatives from community organizations that are connected with at-risk populations .
Meeting face-to-face the first time will do a lot to build trust and build a solid foundation for an ongoing successful working partnership . Arrange roundtable meetings or conference calls . Discuss goals, objectives, roles, and common issues surrounding the challenges in accurately finding at-risk populations .
Step 6 -Expand your COIN to include service providers, businesses and others who work with, represent and belong to at-risk populations . Members of this network are your community collaborators and program partners . Maintain regular contact with the COIN members through a newsletter, conferences calls, or meetings .
- Expand your database by adding contact information for community collaborators and program partners
- Review the community organizations that helped you locate at-risk populations .
- Develop policies and procedures for the information you gather and maintain confidentiality of contact information for your COIN members At-a-G lance: Reaching A t-risk Populations
Step 1 -Survey agencies and organizations to learn about their successes and failures Learn about their successes and failures other departments have faced in reaching at-risk populations .
Step 2 -Conduct focus groups or community roundtables Focus groups or community roundtables with members of different at-risk population groups can identify their needs and barriers to communication
Step 3 -Analyze data gathered from the surveys, focus groups, and your previous assessment efforts
Step 4 -Collaborate with community organizations Work together with your partners to develop messages and materials that reach at-risk populations .
Step 5 -Identify appropriate, trusted messengers to deliver messages H o w to Use the Inform ation
- Update your database .
- Enhance your communication plan to reach at-risk populations .

# At-a-G lance: N e x t Steps
- Exercise your network with drills and preparedness exercises .
- Expand your scope .

# Q uick Reference Guide
The Categories As you start to locate and reach at-risk populations, you can focus on five broad, descriptive characteristics that put people at-risk:  Isolation (cultural, geographic, or social): includes those who are separated from mainstream society, either because of their culture (migrant workers), religious beliefs (Amish), or geographic location (farmers in rural areas) These people can be very difficult to reach in emergencies because they usually do not have access to traditional means of communication Age: Chronic health problems, limited mobility, blindness, deafness, social isolation, fear, and reduced income could put older adults at-risk . Infants and children under the age of 18 also can be at-risk, particularly if they are separated from their parents or guardians in an emergency Phase 1: Defining A t-risk Populations Defining at-risk populations will require investigation to build an understanding of the unique demographics represented in your particular community. You will need to learn about the spoken languages, cultural practices, belief systems, and the physical and mental limitations of the citizens .
Step 1 -Collect population information and data
Step 2 -Estimate the number of people in at-risk populations who live in your community
Step 3 -Identify overarching organizations/government agencies and the key contacts that can help you
Step 4 -Facilitate discussions with key contacts
Step 5 -Stay in touch

# Develop a Database
An electronic 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 such as: names, phone numbers, e-mail addresses, and postal addresses for key contacts at organizations and government agencies .

# Phase 2: Locating A t-risk Populations
The best approach to locate at-risk populations in your jurisdiction would be to combine Geographic Information System (GIS) technology with information acquired through community collaborations and networking .
Step 1 -Assess existing departmental processes to locate at-risk populations
Step 2 -Choose digital mapping or alternate methods
Step 3 -Locate and map gathering places for the at-risk populations you have identified
Step 4 -Identify and map trusted sources in the at-risk communities
Step 5 -Facilitate discussions with representatives from community organizations connected with at-risk populations
Step 6 -Expand your COIN to include service providers, businesses, and others who work with, represent, and belong to at-risk populations Phase 3: Reaching A t-risk Populations In an emergency, messages must not only inform and educate, but they must also mobilize people to follow public health directives
Step 1 -Survey agencies and organizations to learn about their successes and failures
Step 2 -Conduct focus groups or community roundtables
Step 3 -Analyze data gathered from the surveys, focus groups, and your previous assessment efforts
Step 4 -Collaborate with community organizations
Step
- American FactFinder www. factfinder, census . gov American FactFinder compiles data (at the sub-county/census tract level) on persons according to age and sex, origins and language, income, aging, poverty, veterans, disability, race and ethnicity, employment, and education .
- CensusScope: Your Portal to Census 2000 Data www. censusscope . org CensusScope is an easy-to-use tool for investigating U . S . demographic trends .
- MPOs and Regional Councils - They must be located in or serve a high need community, i . e . "medically underserved areas" or "medically underserved populations";
- They must provide comprehensive primary care services as well as supportive services such as translation and transportation services that promote access to health care;
- Their services must be available to all residents of their service areas, with fees adjusted upon patients' ability to pay;
- They must be governed by a community board with a majority of members health center patients; and,
- A major goal of the Privacy Rule is to assure that individuals' health information is properly protected while allowing the flow of health information needed to provide and promote high quality health care and to protect the public's health and well being . The rule strikes a balance that permits important uses of information, while protecting the privacy of people who seek care and healing . Given that the health care marketplace is diverse, the rule is designed to be flexible and comprehensive to cover the variety of uses and disclosures that need to be addressed . N a tio n a l V o lu n tary O rgan izations Active in Disaster (NVO AD) . nvoad . org NVOAD is an organization that coordinates planning efforts by many voluntary organizations responding to disaster. NVOAD is not itself a service delivery organization . Instead, it upholds the privilege of its members to independently provide relief and recovery services, while expecting them to do so cooperatively. NVOAD is committed to the idea that the best time to train, prepare, and become acquainted with each other is prior to the actual disaster response Organizations and agencies that wish to become NVOAD members go through an application process and need to demonstrate their capability to work within the parameters agreed to by the members of NVOAD . An approach to health and mental health to increase awareness and interest in health promotion and disease prevention programs targeting refugees, and provide information and tools to assist organizations in related activities and services . The overall objective of this initiative is to increase the health and well-being of high risk refugee populations in the United States .

# N e w Am erica M e d ia (N
Regional Councils . narc . org Regional Councils are multi-service entities with state and locally defined boundaries that may deliver federal, state, and local programs while functioning as planning organizations . They are accountable to local units of government and typically work in comprehensive and transportation planning, economic development, workforce development, the environment, services for the elderly, and clearinghouse functions According to the National Association of Regional Councils (NARC), nearly half of all MPOs operate as part of a Regional Council .   Team members involved will be:
The  will fulfill the following roles, and/ or provide the following services:
CDC's Office of Public Health Preparedness and Response (OPHPR) would like to thank all of the professionals who supported this project and generously shared their time, expertise, and insight Unfortunately, there are far too many contributors to allow formal acknowledgement of each and every person OPHPR hopes that in reading through this toolkit, those who contributed will recognize their work and be proud of the role that they played