In 2011, more than 40 million people in the United States were 65 years of age or older,1 This number will nearly double in the next 20 years.2 When all 76 million of the baby-boom generation have reached age 65 (in 2030), they will represent 1 in every 5 Americans.2 This marked increase of older persons will concomitantly increase the demand on public health and emergency responders to mitigate the disproportionate effects of disasters, whether natural or human caused, on this population.
For all vulnerable populations, the formula by Arnold (ie, risk = hazard x vulnerability/manageability) becomes particularly pertinent.Reference Arnold3 Infants, pregnant women, persons with disabilities, the homeless, and those with severe mental health conditions will need assistance with sheltering in place or with evacuation during disasters or special attention due to decreased immune response or other limitations in functional capacity. Likewise, frailty—a widely recognized state of reduced physiologic reserve frequently occurring in elders—increases vulnerability to stressors in older populations, particularly resulting from the insults of disasters.Reference Bergman, Ferrucci and Guralnik4Reference Fried, Ferrucci, Darer, Williamson and Anderson5
Psychosocial characteristics associated with frailty also place older populations at greater risk in a disaster.Reference Bergman, Ferrucci and Guralnik4Reference Sternberg, Wershof Schwartz, Karunananthan, Bergman and Mark Clarfield6Reference Fernandez, Byard, Lin, Benson and Barbera7Reference Aldrich and Benson8 Problems with immobility, neurosensory, and cognitive impairments; other general age-related changes in hydration/thermoregulation; psychosocial issues such as place and type of residence, living alone; access to health care; fiscal resources; and ethnogeriatric, language, or other circumstances that limit effective communication all place older populations at increased risk of harm.Reference Fernandez, Byard, Lin, Benson and Barbera7Reference Aldrich and Benson8 The devastating 2005 Gulf Coast hurricane season highlighted these vulnerabilities: 74% of those who died were elderly adults, most were African American, and many died of the stress and accidents that occurred during evacuation.Reference Dyer, Regev, Burnett, Festa and Cloyd9 Many elderly persons were still experiencing posttraumatic stress disorder up to a year after being displaced, and many died a year later.Reference Sakauye, Streim and Kennedy10 More recently, in a manner similar to Hurricane Katrina in New Orleans, the great majority of those who died in the March 2011 tsunami in Japan constituted older persons who drowned or simply could not run up hillsides fast enough to escape.11
To prevent such disproportionate loss in disasters, all public health and emergency preparedness planners, front-line health care professionals, first responders, and first receivers need to know how frail elders respond differently via their altered presentation and homeostasis associated with advanced age.Reference Fried, Ferrucci, Darer, Williamson and Anderson5Reference Ahmed, Mandel and Fain12Reference Walston, Hadley and Ferrucci13 Frail elders are generally aged 85 years and older and are usually the most vulnerable for preparedness and response planning, although their needs may vary widely through the population. They have decreased functional abilities, atypical presentations, and increased dependence on others, which decreases their physiological capacity to respond to stressors caused by disasters.Reference Fernandez, Byard, Lin, Benson and Barbera7Reference Schuurmans, Steverink, Lindenberg, Frieswijk and Slaets14 Consequently, planners and responders need to know about frail elders' requirements for their specific conditions, eg, reliance on oxygen or complex medication regimens; whether they live alone, in assisted-living facilities, and/or in a high-rise building; and whether they receive informal care from family and/or direct care workers, as caregivers may also be affected by the disaster and cannot arrive in time to render usual care.Reference Aldrich and Benson8
Another issue of frailty is recognizing the fine distinction between frail and non-frail or robust elders based on functional abilities. A robust elder may have better cognitive and physical ability than a frail elder, but 60- and 70-year-old persons who have had recent surgery (eg, rotator cuff repair or knee or hip replacement) can become nearly as vulnerable as the frailest elder owing to mobility issues. Furthermore, persons living or working in high-rise buildings who experience power failure or isolation for extended periods of time can be affected similarly to frail and much older persons.Reference Fernandez, Byard, Lin, Benson and Barbera7Reference Aldrich and Benson8
To address the complex issues associated with aging and emergency preparedness, the Texas Consortium Geriatric Education Center (TCGEC) developed a didactic training program to increase awareness of health professionals, first responders, and first receivers of the unique needs of vulnerable elders. The TCGEC was one of a collaborative of member institutions of the National Association of Geriatric Education Centers that began its work after the October 2001 bioterrorism attacks using anthrax.Reference Perweiler, Roush and Tumosa15Reference Roush16 Geriatric emergency preparedness and response (GEPR) curricular content was developed from proceedings of consensus panels of (1) federal Health Resources and Service Administration grantees at New York University, University of Kentucky, Case Western University, St Louis University, Stanford University, and Baylor College of Medicine; (2) members of the Vulnerable Populations Collaborative Group, formed by the Association of Schools of Public Health and the Centers on Public Health Preparedness of the Centers for Disease Control and Prevention; and (3) attendees at invitational workshops hosted by the Canadian Division of Aging and Seniors. These expert working groups assessed the needs and limitations of older persons in disasters to develop a list of considerations planners and health officials could use when making all-hazards disaster plans.
An all-hazards approach that incorporates multilingual programs and culturally competent materials into preparedness planning further helps to mitigate disaster effects for elders from varying ethnic backgrounds whose facility to communicate effectively in English may affect their ability to follow directives to act quickly and appropriately. The Office of Minority Health, US Department of Health and Human Services, created the national standards for culturally and linguistically appropriate services in health care.17 The GEPR curriculum considers this and many other factors that may impede an elder's ability to receive, process, or follow preparedness recommendations. These broad categories of consideration include physical and medical, psychosocial, practical, and an area of overlapping considerations.11 GEPR training has reached several thousand health care professionals in Texas and throughout the country, promoting awareness of the vulnerabilities among older people and the planning necessary for disaster response and recovery.Reference Johnson, Howe and McBride18
During the summer of 2009, the Center for Biosecurity and Public Health Preparedness (CBPHP), University of Texas School of Public Health (UTSPH), Houston, funded 7 of TCGEC's 30 GEPR workshops and conducted a qualitative evaluation of this sample and a re-assessment of the training needs of the target workforce. The primary purpose of this analysis was to better understand participant learning and opinions about the usefulness of the course, whether participants believed their ability to apply the content had improved, and their intentions for application. Having attendees' views on these areas of utility was important to inform future developments in training health care and public health professionals about important considerations for use in older adults in disasters.
METHODS
The 7 workshops for this evaluation were conducted May through July in Chicago, Illinois; Anchorage, Alaska; San Antonio and Fort Worth, Texas; Texarkana, Arkansas; Norman, Oklahoma; and Asheville, North Carolina. Workshops consisted of a 1-hour slide presentation, followed by a 30-minute exercise using the format of the nominal group technique (NGT),Reference Delbecq and Van de Ven19 by which the audience was divided into small groups. Each group chose a recorder and reporter and spent 10 minutes discussing the top 3 things they would do to safeguard themselves and the residents at their long-term care (LTC) facility if an influenza-like illness spread from a neighboring LTC facility. (Slides used in the workshops are available at http://www.tcgecdistancelearning.org/ under Resource List/Bioterrorism and Emergency Preparedness/GEPR at Health Care Sites.) Attendees at each program were asked to complete evaluation and participant information forms. Although both forms were available to all participants, only those requesting continuing education credit were required to complete them.
For each program, the content presented, the presenter, and the duration of the workshops were the same. During the workshops, no marked differences were found among participants on matters such as quality of questions asked, apparent attendee interest, or modal responses to the NGT exercise. Also, the representation of professional fields among programs was highly similar: physicians, nurses, social workers, LTC administrators, and others.
Although the content and presentations were the same, no standardized evaluation instrument was used for all workshops, as organizers at each venue chose to conduct the evaluation using their own instruments. However, 2 of the questionnaires were exactly the same, providing 6 questionnaires for analysis instead of 7. One difference in the evaluation instruments was that the objectives were not always stated the same. The objectives for each of the questionnaires were as follows:
Questionnaires 1, 2, and 3
• Identify and describe the characteristics and reactions of frail elders that make them a vulnerable group affected disproportionately by disasters;
• Discuss effective interventions to assist this vulnerable population in the pre-event, event, and postevent phases of disasters;
• Describe emergency management methodology, including, but not limited to, mitigation, preparedness, response, or recovery.
Questionnaire 4
• List at least 3 factors associated with aging that predisposes older people to be more affected by a disaster than younger adults.
• List at least 3 actions individuals can take to be better prepared to render age-appropriate care to older persons involved in disasters.
Questionnaire 5
• Objectives 1, 2, and 3 are the same as in Questionnaires 1, 2, and 3, plus:
• Objective 4: List 6 Class A agents used by bioterrorists.
Questionnaire 6
• No questions regarding learning objectives
Some questionnaires shared some of the same questions, some shared similar questions with slight variations in phrasing, and some shared similar constructs but different interrogatory modes. Questions were multiple choice and open ended; and scales were employed for some. This variation in instruments, phrasing of questions and objectives, and number of workshop participants meant that a rigorous quantitative analysis would not be possible. However, qualitative analysis provides an effective method for the comparison and grouping of concepts into higher order concepts or categories and the identification of important themes to provide a better understanding of the impact and meaning of an event for the focal group.Reference Strauss and Corbin20Reference Creswell21
The phenomenological approach focuses primarily on what participants have in common to produce a description of the “universal essence.”Reference Creswell21 This method of qualitative analysis, with its paramount concern with meaning versus frequencies, was employed to allow GEPR program planners the opportunity to better understand how participants experienced the workshop, particularly as it relates to theories of evaluation, health behavior, and health education.Reference Kirk and Miller22Reference Miles and Huberman23Reference Glanz, Rimer and Lewis24Reference Kirkpatrick25Reference Kirkpatrick26 Data collected by the various instruments provided information for assessment at the first (reaction/satisfaction) and second (learning/knowledge increase) levels of Kirkpatrick's 4-level model for evaluating training programs.Reference Kirkpatrick25Reference Kirkpatrick26 In addition, participants' specific plans (intention) for the use or implementation of content learned was examined in lieu of behavior change (Kirkpatrick's level 3Reference Kirkpatrick25Reference Kirkpatrick26), based on the predictive success of the behavioral change theories—the theory of reasoned action (TRA) and the theory of planned behavior (TPB)—wherein behavioral intention is believed to be the best predictor for performance of a given behavior.Reference Montano, Kasprzyk, Glanz, Rimer and Lewis27Reference Ajzen28Reference Millstein29
Another construct of the TRA/TPB theories included in this analysis was the “evaluation” attitude, or the instrumental value placed on the information or behavior by the participant, for which a high rating is believed to be a contributing factor for behavioral intention.Reference Montano, Kasprzyk, Glanz, Rimer and Lewis27Reference Ajzen28Reference Millstein29Reference Ajzen, Czasch and Flood30Reference Ajzen, Cote, Crano and Prislin31 Self-assessed ability (perceived self-efficacy) is also included in this analysis, which has been shown to influence behavior, both directly and as a determinant of behavioral intention.Reference Bandura32Reference Janz, Champion, Strecher, Glanz, Rimer and Lewis33Reference Baronowski, Perry, Parcel, Glanz, Rimer and Lewis34
Based on the cited theoretical constructs, the 4 categories providing the framework for reporting the results of the data analysis are: (1) participant learning (knowledge), (2) participants' perceived usefulness of course content (evaluation attitude), (3) participants' plans for application of the information (intention), and (4) participants' self-assessed proficiency or ability (self-efficacy). Table 1 provides the questions and measures from the questionnaires that were used for these constructs. Also included was feedback from the general comments section of the evaluation instruments about how the training might be improved, because consistent trends in the responses provide information that is instructive and further elucidates the other findings.
TABLE 1 Evaluation Questions and Measures by Framework Constructs Used for Analysis
Finally, percentages are reported for questions in which a descriptive statistic provides additional detail. These statistics are based on the number of respondents for whom the question appeared on their questionnaire or, where appropriate, on the number of respondents who answered the question. The basis for the calculation of each descriptive statistic is stated in each instance.
RESULTS
Population
A total of 292 participants from 7 workshops completed evaluation forms. The greatest proportion of respondents (56%) was trained at the 3 workshops in Texas, followed by North Carolina (24%), Alaska (10%), and Illinois and Oklahoma combined (10%). Table 2 shows that the majority of workshop respondents held degrees for the provision of direct care to their patients/clients, with the greatest proportion represented by those with nursing degrees (35%). Those studying to become direct care providers accounted for 14%. Although the place of employment (not asked on all questionnaires) was unknown for 23% of the respondents, 50% reported working in places providing direct contact with older adults (Table 3). The largest single proportion of respondents worked in long-term care facilities.
TABLE 2 Participant Education
TABLE 3 Participant Employment
Participant Learning
Indicators of learning were derived from open-ended questions asking respondents to describe what they had learned, or to give an example of something learned that could be used immediately on return to their practice/classroom. Responses ranged from statements indicating raised awareness, such as “[the workshop] provided me with quite a new perspective, not only regarding elders, but my own lack of preparedness,” to statements that they had learned “much useable” information about disasters and preparedness, suggesting that they had learned more than they were interested in recording on the form.
Most often, respondents attempted to generalize their learning in some meaningful way. They reported that the workshop made them aware of the importance of including the needs of older persons in both their training and response planning and the need to “communicate early and often.” Respondents reported that they now understood the shortcomings of their emergency plans, but had learned specifically “how and what a community needs” to properly prepare for the needs of their elder populations, including available resources. Other respondents were more specific with their answers, demonstrating increased knowledge about diagnosing and treating transmissible diseases in older adults who present differently from other adults. They specifically reported learning about changes in immunity, homeostasis, and response to influenza vaccinations with aging, and that older people may be the community's sentinels.
Rating how well the workshop objectives had been met served as another proxy supporting respondents' beliefs that learning had occurred. For one group, 92% of respondents considered the objectives to have been met (8% did not answer). For 3 workshops, 100% of the respondents who answered thought that the objectives had been met, but 45% of the respondents from these groups failed to answer the question. In 3 other workshops, 91% of respondents in Texas and 69% of respondents in Alaska felt that the workshop had been effective in teaching the participants to identify and describe the characteristic reactions of vulnerable groups affected by disaster. Also, 82% in Texas and 69% in Alaska reported discussing effective interventions to assist this vulnerable population in the pre-event, event, and postevent phases of disasters. Moreover, 86% in Texas and 62% in Alaska felt that they could now accurately describe emergency management methodology, including, but not limited to, mitigation, preparedness, response, and recovery.
Usefulness of Course Content
In addition to clear indications that learning had occurred, a large majority of workshop participants believed that what they had learned was useful information. In the 2 workshops where participants were asked to rate the usefulness of the material in their practice/educational role, 80% found it useful, 12% did not find it useful, and 8% failed to answer. Rates were similar (73% found it useful, 10% did not, and 17% did not answer) in another workshop where participants were asked to rate the relevance and usefulness of course content. All of the respondents (100%) of another workshop reported that the workshop was useful in their professional activities.
Regarding overall usefulness of the course content, questionnaires used in 3 workshops asked participants about the specific sections of the GEPR curriculum believed to be most useful. The section of the curriculum that dealt with the need to increase emergency preparedness in all 3 phases of disaster planning was found by respondents to be the most useful (57%). Both the sections on older patients' history and clinical observations for increased vulnerability and the questions that can be asked of students, colleagues, patients, and their caregivers were thought to be the most useful by an equal proportion (27% each) of respondents; 14% thought the resource lists were most useful (responses do not total 100%, because respondents could choose more than one answer).
Workshop participants were also asked if there had been past event(s) when the information might have been useful. In 3 workshops, 64% of responding participants reported that there had been circumstances in their practice or private life in which the information might have been helpful, specifically disaster situations such as hurricanes, river flooding, earthquakes, tornadoes, and volcanoes, in both domestic and international settings (eg, Central America and Africa). They also reported on situations involving methicillin-resistant Staphylococcus aureus wound infection and several viral infections. Workshop participants further described situations in Red Cross shelters, senior centers, other care settings, and family settings in which the information would have been helpful. One respondent's statement, “If I’d had even a portion of this info, I could have personally been better prepared,” was similarly expressed by many participants.
Three workshop evaluation instruments asked for an example of the participant's learning that could be used immediately. Four themes arose from the many examples given: (1) educating students, coworkers, and organizational staff; (2) raising awareness among older adults and assisting them in developing individual plans; (3) assessing their organization's current response plans and making changes to improve their preparedness, particularly for H1N1 response; and (4) postdisaster clinical assessments (such as understanding the “difference between memory loss vs executive function loss,” evaluation in asymptomatic presentations, the lower thresholds for testing in elderly patients, and “psychological first aid”). Respondents also stated that the online resources would be immediately useful to them, particularly the websites regarding shelters/emergencies.
Plans for Application
In addition to examples of learning that could be used immediately, almost all participants were asked about specific plans for use of the information learned. Three groups were asked, “If you are thinking of using the GEPR program in your practice, or education setting, how do you envision using it?” Nine of every 10 respondents answered, with the largest proportion (68%) replying that they would “include portions of the content in courses for students, colleagues, and/or patients.” Another 14% would “have other staff members use it,” and 10% would use it “during patient office visits.” The remaining respondents (8%) wrote in various other plans.
The other groups were also asked about their plans for use of the information, although more generally (and in open-ended format) with the question, “How do you plan to use this information in your work setting?” Plans to apply the information fell into the same 4 areas as those for the usefulness of the information: (1) to use the information for training, (2) to assist patients/clients and their families with the development of individual plans, (3) to plan disaster preparedness for their organization, and (4) to conduct clinical assessments. Although most answers were similar to the earlier question regarding use of the information, this second question raised additional ideas, such as plans to prepare guidance documents for elders and their families; to ensure appropriate equipment and supplies are available for caring for residents in a disaster; to use the information for community outreach and in public relations with the media (eg, public interest spots on radio and TV); and to determine how the information would be applied in rural areas.
Self-Assessed Proficiency and Ability
Not only did survey respondents have specific plans to implement changes based on the information learned in the workshop, they also reported the belief that their proficiency and ability had improved. Participants at 1 workshop were asked about their proficiency in the subject before and after the workshop and whether their participation would benefit their work. Only 4% of the respondents failed to answer these questions. Ratings of 68% for low/no proficiency before the workshop were reduced to 20% after the workshop, while the 28% proficiency in the subject before the workshop increased to 76% after the workshop. From a work-related viewpoint, participation in the workshop was considered beneficial by 84% and not beneficial by 12%.
With regard to self-assessed ability, participants in 1 of the large workshops were asked to rate whether the workshop had improved their ability to provide care to older adults. Based on 6 dimensions of care, each of which was rated independently, a minimum of 77% of respondents clearly indicated a belief that their abilities had increased on each dimension of care (see Table 4). Although 1 question included a segment stating that “the instructor's presentation(s) positively impacted my ability to provide services to patients and/or clients,” the participants were also asked in the same question to assess the instructor's knowledge of the topic and ability to communicate it. Answers to this question were considered to be a marker of customer satisfaction and were not included in the analysis as participant ability.
TABLE 4 Self-Assessed Improved Ability
Instructive Comments on the Workshop
Workshop participants were asked about additional education needs, suggestions for the curriculum, and other input regarding the workshop or material presented. Respondents indicated that there was so much important information that only 1 approximately 90-minute workshop was not enough, and they often requested additional detailed information on specific ways to assist their elder clients in developing individual plans. It was suggested that the presentation be increased to a full day to give participants more time to learn and absorb the information. Respondents also thought it would be helpful to focus more of the workshop on local threats, such as earthquakes for Alaska or tornadoes for Oklahoma. This need was expressed most frequently by participants of the workshop in Alaska.
Finally, respondents made suggestions instructive to both trainers and health care organization leaders. They thought that it was important to train all staff within an organization; follow up the workshop with actual local emergency preparedness work sessions to draft emergency plans for their community or organization, including specific plans for older adults; and to hold periodic drills to assess the ability of the plans to provide appropriate care.
COMMENT
This report presents the results of a qualitative evaluation of a GEPR training program using 7 continuing education workshops funded by the UTSPH/CBPHP as a convenience sample of the 30 workshops presented by the TCGEC. Although selection bias is an important limitation, it was minimized somewhat in the protocols. The CBPHP did not select which of the 30 workshops would receive the funding support (and be included in the evaluation) and neither the trainer nor the TCGEC knew until after billing and payment at the conclusion of the workshops that year that a thorough qualitative evaluation would be conducted on this sample. Although fortuitous, the sites represented in the sample provided some geographical variation. Also, threats to the validity and reliability of this study were reduced further: (1) the transparency in the analysis decisions presented herein, and (2) the use of scientifically accepted theoretical constructs. The limitation most important to note was the small number of questions on each instrument from which conclusions could be drawn, which is typical of most postworkshop evaluation instruments.
Regardless of wording or interrogatory mode, responses for each construct were consistent with the exception of the difference between the 3 Texas workshops and the workshop in Alaska. The difference of 13 to 24 percentage points lower for Alaska on 3 proxy measures of learning regarding how well workshop objectives were met can likely be accounted for in this group's general comments regarding the need for tailoring the curriculum to the local context. In spite of the methodological limitations of the study, theory and qualitative analysis techniques provided systematic tools to analyze the data collected to better understand the reactions of participants to the GEPR curriculum and how their knowledge, attitudes, intentions, and self-efficacy may have been influenced.
The findings of this qualitative assessment are that the GEPR program was valued and that the workshops had a positive influence on the participants. A large majority of 292 respondents from Anchorage to Asheville were able to name specifics learned; give examples of applications for the information taught; share specific past situations in which the information learned would have been helpful; and give specific plans for use of the information learned or intentions for follow-up action. The ability of participants to apply the material to both past experiences and future possibilities provides more than an indication of learning; it also suggests successful integration of the new information within existing frameworks. The increase in self-reported proficiency in the subject or the ability to do one's job, along with high ratings for the usefulness of the information taught, suggests a positive attitude toward valued information and increased self-efficacy in the subject matter. Most importantly, the naming of specific plans for appropriate use of the material indicates positive behavioral intention, which, along with the integration of valued information and improvements in self-efficacy, suggests adoption and the potential for longer-term impact.
In addition to positive indications of curriculum adoption, information was garnered for program improvement. The pervasive theme among all of the suggestions for improvement was a request for more: additional detailed information, including tailoring to the local context, increased class time for learning; more help with plan development and exercises; and greater exposure of the curriculum to colleagues and coworkers. It is apparent that attendees of this training were motivated by the subject matter and desired deeper immersion to ensure that they were properly prepared. While the determination of the right length of time and level of detail to provide in a workshop can be difficult, making sure that participants have ample opportunity to study, absorb, and apply the information is not only desired but also may be crucial for translation into workplace behavior.
Moreover, developers and trainers of GEPR might apply the concepts of the training more specifically to the local context for each training venue and possibly include extended community or work group planning sessions. The need for municipal health agencies to be able to identify vulnerable elders and know where they are located in the community, for health care workers who are trained in how to deal with disasters and pandemics, and for institutions to have updated plans create fertile ground for GEPR training that offers an opportunity for extended planning sessions. Collaborations of subject matter experts with community groups who have a good understanding of the geographic setting and associated threats, and the local context (political, social, and cultural) could provide the most effective application of GEPR principles. Finally, the necessity of repeating response exercises/drills, assessing plans, and reassessing the population's needs must be emphasized using the circular aspects of postevent planning, training, and modification followed by more planning and training.
CONCLUSIONS
To the extent that the respondents in this study may be representative of their counterparts elsewhere, the results of this evaluation indicate that health care providers have a need to know more about how to care and vouchsafe for older adults in disasters and effectively discharge their ethical responsibilities to this vulnerable population. The potential for bioterrorism and the devastation of natural disasters on all vulnerable populations are clearly felt by all who have had the opportunity to participate in GEPR training. While its specifics may be unknown, the fact that a disaster will occur somewhere is a given, and that we have both a fiduciary and ethical responsibility to protect this vulnerable population. To fulfill this charge, all health care providers need training specifically in geriatric emergency preparedness and response.
Support and Funding: Funding for the presentation of the Geriatric Emergency Preparedness and Response workshops was provided by Centers for Disease Control and Prevention grant #5U90TP624246 for Centers for Public Health Preparedness.
