Applying the Guide to Planning and Practice At any one or more points in time, it can be argued that everyone may be “at-risk” in public health emergencies; however, risks to groups unable to access resources and services are considered to be the result of existing vulnerabilities. Here, we define vulnerability as the characteristics of a person or group and their situation that influence their capacity to anticipate, cope with, resist and recover from the impact of an emergency. These groups include, but are not limited to, those who are physically or mentally disabled (blind, deaf, hard-of-hearing, cognitive disorders, mobility limitations), limited or non-English speaking, geographically or culturally isolated, medically or chemically dependent, homeless, frail/elderly, and children. Alignment with National Preparedness Goal and Framework The Guide is intended to help address and supports incorporation of the recent set of preparedness capabilities introduced under the National Preparedness Goal (PPD-8) associated with community preparedness and at-risk populations, including community partnerships, emergency public information and warning, and medical countermeasure dispensing. Specific capabilities and functions include the following:

Source: FEMA News Photo

Emergency Management and Homeland Security Core Capabilities http://www.fema.gov/core-capabilities Incorporate, in all plans, procedures, and protocols (including outreach, training and exercises, and volunteer opportunities), consideration for vulnerable and at-risk populations Develop and provide community preparedness public education program and materials for non-English speaking communities and special needs populations Integrate public outreach and non-governmental resources into emergency operations plans and exercises Provide education and training for the public in all mission areas Develop (or enhance) local public information and communication plans for needs of at-risk populations

Public Health Preparedness Public Health Emergency Preparedness Capabilities http://www.cdc.gov/phpr/coopagreement.htm Engage public and private organizations in preparedness activities that represent the functional needs of at-risk individuals as well as the cultural and socio-economic, demographic components of the community. (Capability 1, Function 1.) Identify those populations that may be at higher risk for adverse health outcomes. (Capability 1, Function 1.) Identify the potential hazards, vulnerabilities, and risks in the community that relate to the jurisdiction’s public health, medical, and mental/behavioral health systems. (Capability 1, Function 1.) Work with emergency management and community and faith-based partners to identify the public health, medical, and mental/behavioral health services. (Capability 1, Function 3.) Build community partnerships to support public health preparedness (Capability 1, Function 2.) Facilitate the collection of geographically-specific data (Capability 1, Function 1.)

Hospital Preparedness Hospital Preparedness Program Capabilities http://www.phe.gov/Preparedness/planning/hpp/reports/Documents/capabilities.pdf Identify populations with health vulnerabilities, limited access, reduced abilities, and/or those needs that may be exacerbated by chemical, biological, or radiological exposure. (Capability 1, Function 7.) Identify those populations that may be at higher risk for adverse health outcomes. (Capability 1, Function 7.) Engage public and private organizations in preparedness activities that represent the functional needs of at-risk individuals as well as the cultural and socio-economic, demographic components of the community. (Capability 1, Function 7.)

The Guide is designed primarily to address the training needs of individuals working in emergency management, local health departments, and hospitals who may find this information useful. This includes planners, preparedness coordinators, and public health personnel interested in identifying, engaging, communicating with, and providing services to vulnerable and at-risk populations during emergencies and disasters.

Relationship of Hazards & Risk

Risk is directly affected by the hazard and the degree of vulnerability experienced by exposed persons over a particular period of time and area. The generic formula of this relationship follows:

Risk = Hazard + Vulnerability

While this formula is certainly not new and actually finds its origins in risk analysis and safety engineering studies of frequency and severity exposure to risks, it is important to consider the relationship as you develop and implement your preparedness plans.

Most at-risk population planning initiatives will require more resources than any one agency or organization can provide. A comprehensive preparedness program for at-risk populations is the results of the coordination of a number of individuals and the agencies they represent around a set of common planning goals. Community engagement principles can be useful in providing guidance for planners wishing to embark on a new at-risk population project. This may require you to go into your community, establish relationships, build trust, work with formal and informal leadership, and seek commitment from community organizations and leaders to create processes for mobilizing the community.

• 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.
• Establish a “case” to persuade prospective partners of the benefits of disaster planning for at-risk populations. Such planning is often in the best interests of the organization.

Social Vulnerability Index (SVI)

One of the most challenging initial tasks when planning for at-risk groups is deciding how to define “at-risk.” As we mentioned previously, CDC defines at-risk populations as those groups whose needs are not fully addressed by traditional service providers or who feel they cannot comfortably or safely access and use the standard resources offered in disaster preparedness, relief, and recovery. Social vulnerability refers to the socioeconomic and demographic factors that affect the resilience of communities. Previous research and experience have demonstrated those more socially vulnerable populations are more likely to be adversely affected in emergencies and disaster events.  By effectively addressing social vulnerability, efforts decrease both human suffering and the economic loss related to providing social services and public assistance after an event. The Centers for Disease Control and Prevention, National Center for Environmental Health, Office of Terrorism Preparedness and Emergency Response (COTPER) collaborated with the Agency for Toxic Substances and Disease Registry’s Geospatial Research, Analysis, and Services Program (GRASP) to produce a social vulnerability index with the intention of helping state, local, and tribal disaster management officials identify the locations of their most vulnerable populations.

The Social Vulnerability Index (SVI) is intended to spatially identify socially vulnerable populations, to more completely understand the risk of hazards to these populations, and to aid in mitigating, preparing for, responding to, and recovering from that risk. This index is divided across four domains to calculate vulnerability measures within and across these domains at the census tract level:

(Income, Poverty, Employment, Education) The socioeconomic domain includes 1) percent individuals below poverty; 2) percent unemployed; 3) per capita income; and 4) percent persons with no high school diploma.	(Age, Dependency, Disability, Single-Parenting) The personal and household domain includes 1) percent persons 65 years of age or older; 2) percent persons 17 years of age or younger; 3) percent persons more than 5 years old with disability; and 4) percent households with male or female householder, no spouse present, with children under 18 years of age.
(Minority Status, Non-English Speaking) The race and ethnicity domain includes 1) percent minority; and 2) percent persons 5 years of age or older who speak English “less than well.”	(Housing, Crowding, Transportation) The housing and transportation domain includes 1) percent multi-unit structures; 2) percent mobile homes; 3) crowding; 4) no vehicle available; and 5) institutionalized population.

Background on SVI The Social Vulnerability Index (SVI) was designed to provide a framework to help decision-makers examine how people’s social circumstances, such as age, race, or socioeconomic status, contribute to their vulnerability and ability to recover from the effects of a public health, natural, or technological emergency event. The SVI is build upon four over-arching domains that are closely associated with varying vulnerability and risk to disasters. Combined, the four domains provide an overall summary of varying social vulnerability in a total composite value. The SVI data is presented at the census tract level. Each tract is ranked according to its level of vulnerability in comparison to the average across the state. Those areas with more vulnerable populations are indicated by the darker color and those less vulnerable (in compason to the state average) are lighter in color. The SVI can be used to help create a profile of your area’s most populated at-risk groups to help you move forward with your preparedness planning and activities. The Social Vulnerability Index is divided across four domains to calculate vulnerability within and across these domains at the tract level.

Overall Social Vulnerability and four Domains

The information contained in the SVI can help you identify hard-to-reach, underserved population groups in your service delivery area, their general location, and possible contact points in their communities. The following is an initial checklist to help you begin to identify, reach, and provide services to at-risk populations.

• Choose an underserved group to reach, basing your choice on reliable demographic and epidemiological data whenever possible. Involve a wide variety of groups (e.g., clients, funding sources, and staff) in this selection process.
• Work with community members and community organizations to carry out a rapid low-cost needs assessment and identify the group’s health needs.
• Identify potential working partners among the community-based groups, non-governmental organizations, religious leaders, private organizations, development projects, government ministries, and donors already working in the area.
• Work with the community to set qualitative and quantitative objectives for your program.
• Select a strategy or combination of strategies to attain your objectives, given your budget and other resources.
• Establish a system for receiving accurate and timely information on services, supplies, and activities so that you can identify problems as they arise and address them promptly.
• Integrate your services for underserved groups into your ongoing programs and activities.

Adapted from Management Sciences for Health, The Manager (http://erc.msh.org)

The SVI is one way of defining and identifying at-risk populations. Ultimately, your department must decide how to define at-risk populations for your own planning and response needs. You and your department should gather data and keep in mind that populations at risk may change depending on the threat (e.g. a particular infectious disease may affect children more than other groups). Be sure to also consult secondary data sources to obtain a profile of your county’s most populated at-risk groups that can be disseminated at your first multi-organizational planning committee meeting.

Overcoming Barriers & Building Community Partnerships

One of the most challenging elements of planning for at-risk populations is that some segments of the population are particularly hard to reach. Some groups may have barriers, such as mistrust of government, that require strategies to be adopted for the unique circumstances of each group and/or individual that cannot be reached by typical means. However, you and your department may also be concerned about working in partnership with organizations and entities outside your department/district. Many of the concerns that you may have noted are common weaknesses associated with partnerships. However, these concerns and potential barriers may also be countered by the following strengths:

• Working with partners will reduce the number of public health personnel needed to response to an incident
• Gaining access and building trust with groups and individuals through trusted community-based organizations
• Building upon previous experience, you may already have worked well with outside organizations on other preparedness activities, such as pandemic flu planning, conducting flu clinics, or other projects

While your department has an important role in leading at-risk populations initiatives, it must be recognized that you can’t do it alone. Hard-to-reach populations are not homogeneous and strategies must be adapted for the unique circumstances of each group and/or individual that cannot be reached by typical means. It is essential to know why certain groups have difficulty understanding or carrying out preparedness and response activities before developing any targeted intervention.Effective plans will need strong collaboration from stakeholder groups in your community.

The success of at-risk populations planning largely depends on the strength of partnerships with members of at-risk populations and the organizations that serve them. As you prepare and plan, building community partnerships may not be as difficult as you think. Here are a few of our partners that we work with to strengthen the mapping and resources to serve you:

North Carolina Public Health Preparedness & Response Eastern Band Cherokee Indians Seattle/King County Public Health Urban Area Security Initiative Region (King, Pierce, and Snohomish County) West Virginia Center for Threat Preparedness

WV Division of Homeland Security and Emergency Management New Mexico Department of Homeland Security Georgia Department of Public Health Georgia Emergency Management Agency

In addition, there are some additional points to keep in mind as you progress through the planning process with your community partners:

• They employ hard working personnel.
• They serve the same clients as you do – your community.
• They have the visibility and established community involvement that holds the community’s trust.
• They have access to the staffing and financial resources to pull this off.
• They already have a mindset for helping.
• Most partner agencies will have experience organizing and mobilizing volunteers to do work for the community.

Ultimately, you and your department must decide how to define, identify, contact, and prepare at-risk populations in your own community. The tips and resources contained in this guide are intended to support your planning and preparedness activities. This Guide is designed to help you and your department improve your preparedness planning by including vulnerable and at-risk populations. It is intended to provide some first steps to identifying and helping you to assess how your services may address populations in your community.