Improved Knowledge of Disaster Preparedness in Underrepresented Secondary Students: A Quasi-Experimental Study

Disaster preparedness is a public health concern that applies to all health professions including medicine, nursing, emergency medical services, social work, and hospital administration, to name a few. Disasters are categorized as man-made, natural, or hybrid and their human and economic costs are significant.^1-3 Natural disasters, which include earthquakes, volcanoes, floods, tornadoes, hurricanes, and other geological events had a mean mortality of 60,000 per year globally from 2000 to 2019.^{2, 4} Pandemics also fall under the natural disaster category and carry the potential for high morbidity and mortality with accompanying social and economic consequences.^{5, 6} The SARS-CoV-2, known as COVID-19, pandemic has infected over 35 million people worldwide to date, with over one million deaths globally at time of writing.⁷ The widespread long-term effects of this crisis defy prediction. An especially devastating year for natural disasters was 2010, with the mortality rate spiking to 257,000^{4, 8} and a global economic cost of $222 billion.⁹ Another illustration of the economic impact of natural disaster is Hurricane Katrina, which cost an estimated $250 billion, with the US insurance companies only reimbursing $82.4 billion of the loss.^{4, 10} Man-made disasters, including terrorism, mass shootings, explosions, nuclear leaks, and chemical or biological events, have also demonstrated a large human and monetary impact.^{3, 11} A noteworthy example is the September 11, 2001 terrorist attacks that caused 2977 deaths and cost about $200 billion.^{11, 12} Hybrid disasters occur when natural and man-made forces combine, such as landslides caused by deforestation and heavy rainfall.³

Disaster preparedness is one facet of the disaster cycle, which occurs in four stages: mitigation, preparedness, response, and recovery.¹³ Mitigation covers prevention of disasters and reduction of potential risks, preparedness includes planning for emergencies, and response is the period after a disaster occurs when emergency personnel assists victims. Recovery occurs soon after the response stage and addresses the return to normal operations.¹³ Preparedness is one area that can be improved upon at any time through dissemination of information and resources, making it an ideal step in the cycle where an intervention can be implemented.

Disasters are difficult to predict, making adequate preparation paramount to sufficient response.⁶ The literature describes insufficient disaster response training for health professionals and a call for better preparation.^14-16 A major barrier to adequate training in the United States is the lack of funding for public health, which only garners 3 cents of every health dollar spent.¹⁷ Markenson et al.¹⁴ disaster preparedness experts at Columbia University, outlined disaster response core competencies for all health professions motivated by their belief that a unified and coordinated disaster response could only be executed when disaster training is consistent across health disciplines. The 4 core competency categories are “emergency management and preparedness, terrorism and public health emergency preparedness, public health surveillance and response, and patient care for disaster, terrorism and public health emergencies.”^{14 (p. 520)} For example, nursing plays a unique role in disaster preparedness with health care knowledge, large human capital, and presence in all intersections of the United States. However, nurses, like other health professionals have limited training specific to disaster preparedness. Disaster preparation has begun to be included in small amounts in nursing textbooks, but the topic is minimally covered in curricula.^{15, 16}

Emergency readiness training should not be limited to the health care sector because disaster response is not carried out by health care workers alone.⁶ Large-scale disaster response extends to all corners of a community, including governing bodies, agriculture, food and water supply, waste disposal, and educational institutions.⁶ Providing disaster preparedness training to secondary school students may prepare them to be active in community disaster response. Just as disaster training should increase for health professionals, the population should also be included in public education efforts. Secondary students are in an advantageous position to receive disaster training as a captive audience and source of information delivery to their family units.

A 2016 study that surveyed school nurses examined pandemic preparedness in public schools in Missouri and found that few schools were equipped to address a pandemic, with modest improvements in preparedness measures after an education intervention.¹⁸ One consideration to improve disaster preparedness in secondary education is to partner with established programs educating or pipelining secondary students into health-care professions. One such program is a KC HealthTracks. KC HealthTracks is a pipelining program established by the University of Missouri Kansas City (UMKC) and is funded through the National Workforce Development Program via the Office of Minority Health. KC HealthTracks is a health professions educational enrichment program for promising students from under-resourced high schools in the Kansas City area. The goal of the program is to increase the number of local high school students matriculating to health professions programs in higher education to grow a skilled, diverse workforce. A unique aspect of the secondary students recruited is their background and involvement with innovative programming. All students who are recruited are self-identified as interested in health professions as a future career. In addition, all students are recruited based on need, including low income, first-generation, and ethnically and racially diverse. The unique programming from the grant includes full access to the Project Lead the Way curriculum which has multiple tracks including a biomedical track. In addition to Project Lead the Way curriculum, students participate in interprofessional, hands-on experiences throughout the year to expand their knowledge and supplement their awareness of various health care professions.

Students who participate in the HealthTracks program are on tract and will likely become members of various health professions. Introducing disaster preparedness at this early stage in their education may inspire them to continue learning about this important field. Fuhrmann et al.¹⁹ neuroscience researchers at Cambridge, suggest that memories made between the ages of 10 and 30 are more easily recalled than memories from other periods in a person's life, making this window an ideal time to introduce important concepts. The students who participate in the KC HealthTracks program are in the idealized position to receive disaster education and are therefore prepared to activate in times of need.

Few studies investigate secondary students' knowledge of disaster response, creating a gap in knowledge.^20-22 Providing disaster preparedness training to secondary students could prompt a future interest in this much-needed specialty. Educating secondary students will benefit our preparation for future emergency preparedness models. The purpose of this study is to assess the effectiveness of a disaster preparedness education intervention on high school students who are interested in health professions. It is hypothesized that a hands-on educational intervention will be increased participants' familiarity with emergency preparedness.

METHODS

Instrumentation

We used a pre- and post-intervention survey to determine impact of a disaster preparedness education intervention on high school students. The tool utilized was the adapted Emergency Preparedness Information Questionnaire (EPIQ; Figure 1), validated by Garbutt et al.²³ to assess nurse's familiarity with emergency preparedness topics. The authors of the tool granted permission for its use in this study. The questionnaire contains 18 topics and begins with the prompt, “Please circle the number of your level of familiarity with the following topics.” It utilizes a Likert scale of 1 to 5, with 1 representing “I have never heard of this topic before” and 5 indicating “I am very familiar with this topic; I am an expert on this topic.” The adapted EPIQ tool scored a reading level of 16 on the Flesch–Kincaid scale. The investigators simplified the terminology on the adapted EPIQ tool to a Flesch–Kincaid level 10 for the purposes of this study. The adapted EPIQ tool was used for the pre- and post-tests in the control and experimental groups.

RESULTS

The demographics resulted in ethnically and racially diverse groups for both experimental and control groups as seen in Table 1. The average age was 16.1 years for the control group and 17.2 for the experimental group. There were more females (N = 22) than males (N = 3) in the control group, and more females (N = 23) than males (N = 8) in the experimental group. The distribution of grade level was consistent with the average age of the participants. The majority of the students in the control group were sophomores (N = 16) with some juniors (N = 6), and seniors (N = 3). The intervention group was comprised of mainly junior students (N = 29) and with 2 senior students.

The experiment yielded clinically and statistically significant results (Table 2). The pre-test showed no statistical difference between the 2 groups pre-intervention with a range of p = .061 to p = .711 for all the questions. This established that the control and experimental groups started with the same level of familiarity in emergency preparedness knowledge. Excluding question one (p = .088), all items postintervention were statistically significant between the groups (p range of .000 to .017). The subject for question one was “quick physical and mental assessment.” Within group statistics were also statistically significant, with range of p values from .000 to .018 for the 18 questions. Clinical significance improved from “I have heard of this topic but I don't know anything about it” to “I have heard of this topic and I know a few things about it” post-intervention.

DISCUSSION

These results indicate both a statistical and clinical improvement in knowledge based on the reported familiarity with disaster preparedness topics. Data analysis confirms our hypothesis that secondary level students provided disaster education will improve knowledge with active instruction and that these data support their readiness to receive this information. All students tested before the educational intervention lacked disaster preparedness knowledge. After the intervention, the experimental group improved in all areas except assessment. A traditional head-to-toe assessment was not included in the teaching, but rather a lesson on quickly differentiating minor versus major injury. Training for this skill could be included in future education.

In relation to the statistical significance, the clinical significance also improved. Clinical significance is important in this study because it demonstrates that familiarity with disaster concepts can be improved with a low cost, simple education intervention. This process provides an option for educating secondary students on disaster preparedness in a short period of time (1.5 hours) with an impact that may be beneficial for our communities.

There is a demand for adequate training in responding to disasters. The World Health Organization states that due to the gaps in knowledge and familiarity with disaster response, it is difficult to recruit and provide trained responders.²⁶ They further state that responders arrive out of moral obligation and with a willingness to help but without the benefit of training. These volunteers arrive with no understanding of their role becoming a burden and ultimately endangering the very people they wish to help by draining resources and time best spent on the survivors.²⁶ Targeting secondary students and instilling the need for training will prepare them to be situationally aware of the need for disaster training as they pursue their careers. In addition, it arms them with tools that enable them to volunteer and respond with knowledge before their formal health care professional training.

There is a limited body of knowledge in the literature regarding how secondary students are taught disaster education. Most disaster preparedness curriculum is written and delivered to secondary students with a very general subject matter, covering types of disasters, their impact on communities, and personal safety during disasters.^{20, 27, 28} Rahman²¹ conducted a survey of secondary students in Dhaka, Bangladesh regarding their knowledge of earthquake risk and safety and found that 74.3% of those surveyed were unprepared for this type of disaster, which is concerning as they live in an area at high risk for earthquakes. A study in Indonesia, another country at high risk for earthquakes, found that secondary students' knowledge improved with an education intervention including signs of natural disaster and safety measures.²²

In a large disaster event, it is common that all citizens capable of providing first aid are asked to assist. In the event that the supply of health care workers cannot meet the demand created by the disaster, community members need to become a part of the disaster response. The United States is embracing an “all hands on deck” mentality during the COVID-19 response, even instituting early graduation for health professions students which increases human capital and improves disaster response capacity.^{29, 30} Community members who received disaster preparedness training in secondary school may be more easily mobilized to assist health care workers during an emergency.

IMPLICATIONS FOR SCHOOL HEALTH AND EQUITY

The intervention found that secondary students who have expressed interest in pursuing health professions careers were receptive to education about disaster preparedness. The intervention yielded statistically significant increases in 17 of the 18 adapted EPIQ tool questions. Through these responses, it can be concluded clinically that the students' familiarity with emergency preparedness topics improved post-intervention, indicating the method of instruction was effective. The round-robin training stations utilized various active learning strategies; a methodology that is shown to be effective for secondary students.³¹ Schools and organizations that provide this training should consider this style of delivery. If these trainings are offered by an outside entity instead of one specific school, all schools in the area need to be invited to ensure equity. It is important for organizers of the training to offer the opportunity for under-resourced students to participate.

Disaster events impact the entire community, including children.³² While it may be adequate to focus on teaching younger minors only personal safety measures, students at the secondary level are capable of providing aid during a disaster and may desire to contribute to disaster responses. Being introduced to disaster preparedness topics at this level may prompt students to expect more information and guidance on this subject as they move through educational systems. This study demonstrates the capacity of secondary level students in emergency training and establishes that students are both interested and engaged in this topic.

This study was conducted before the start of the SARS-CoV-2 pandemic, so the original offering did not implement social distancing or special considerations for gatherings.^{33, 34} Disaster education is still an important addition to the secondary school curriculum and this offering can be adapted in a variety of ways to meet social distancing guidelines. This event could be held in person in the school gym, cafeteria, or other large space with a smaller number of participants. Students and educators would need to wear masks, sign in at the door and report if they have had any symptoms of Covid-19 to keep potentially contagious people out of the event and allow for contact tracing should anyone develop symptoms after the event.³⁴ To reduce numbers, the in-person option could be offered to a smaller subset of students, such as students in one course or students involved in a service club, however, this option has the potential to be less equitable because many will be excluded. To allow for a larger number of students while considering social distancing, the event could be held in a cycle of 1.5 hours per session, 15 minutes to reset and disinfect, and then another 1.5-hour session with a different group of students.³⁴ There could be up to 4 sessions offered in a standard 8-hour day with time allotted in between groups for cleaning and breaks.

Live video conferencing is an online delivery option that also considers the equitable distribution of this education. This option eliminates the need to consider room capacity limits, masking, social distancing, symptom screening, and contact tracing. It also opens the possibility for disaster management experts who do not live locally to provide the teaching in partnership with local educators. The major disadvantage of the online option is that it limits the hands-on instruction that was an integral part of the first aid and backboard station. Educators could demonstrate skills on camera, but return demonstration would be more difficult. One recommendation that could bridge this gap is a “make your own splint” assignment due after the event, where students would turn in a photo of a splint they made out of household items. This assignment would allow for practical application of the topic, including the supply limitations encountered in a real disaster.

Now more than ever, disaster training should be incorporated into the curriculum in collaboration with local public health officials or hospitals. The logistics may vary from school to school, especially considering the limitations incurred by the pandemic. Methods for adding disaster preparedness to the curriculum can be accomplished through in-person and online options. Based on the study results, it is recommended to provide an engaging, hands-on round-robin training that provides relevant skills in the classroom. This addition to the curriculum will need a faculty champion to lead the initiative. Any faculty member willing to collaborate with local health officials could fill this role, but potential candidates may be the school nurse or health teacher. The impact of this intervention demonstrates that secondary students are ready for disaster preparedness training.

ACKNOWLEDGEMENTS

The study was completed under the Curators of the University of Missouri on behalf of University of Missouri – Kansas City. The project title is KC HealthTracks. The programming is supported by the Office of Minority Health National Workforce Development Grant. Grant number 6 CPIMP151115-05-02 and program name Minority Health Community Programs to Improve Minority Health.