Emergency Health Risk Communication DURIN THE 2007

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Emergency Health Risk Communication

During the 2007 San Diego Wildfires:
Comprehension, Compliance, and Recall
a b a
David E. Sugerman , Jane M. Keir , Deborah L. Dee , Harvey
b b c
Lipman , Stephen H. Waterman , Michele Ginsberg & Daniel B.
b
Fishbein
a
Office of Workplace and Career Development , Centers for Disease
Control and Prevention , Atlanta , Georgia , USA
b
Division of Global Migration and Quarantine , National Center for
Preparedness, Detection, and Control of Infectious Diseases, Centers
for Disease Control and Prevention , Atlanta , Georgia , USA
c
Community Epidemiology Branch , County of San Diego Health and
Human Services Agency , San Diego , California , USA
Published online: 11 Apr 2012.
To cite this article: David E. Sugerman , Jane M. Keir , Deborah L. Dee , Harvey Lipman , Stephen
H. Waterman , Michele Ginsberg & Daniel B. Fishbein (2012) Emergency Health Risk Communication
During the 2007 San Diego Wildfires: Comprehension, Compliance, and Recall, Journal of Health
Communication: International Perspectives, 17:6, 698-712, DOI: 10.1080/10810730.2011.635777
To link to this article: http://dx.doi.org/10.1080/10810730.2011.635777
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Journal of Health Communication, 17:698–712, 2012
ISSN: 1081-0730 print/1087-0415 online
DOI: 10.1080/10810730.2011.635777
Emergency Health Risk Communication During

the 2007 San Diego Wildfires: Comprehension,
Compliance, and Recall
DAVID E. SUGERMAN
Office of Workplace and Career Development, Centers for Disease Control
and Prevention, Atlanta, Georgia, USA
JANE M. KEIR
Division of Global Migration and Quarantine, National Center for
Preparedness, Detection, and Control of Infectious Diseases, Centers for
Disease Control and Prevention, Atlanta, Georgia, USA
DEBORAH L. DEE
Office of Workplace and Career Development, Centers for Disease Control
and Prevention, Atlanta, Georgia, USA
HARVEY LIPMAN AND STEPHEN H. WATERMAN

MICHELE GINSBERG
Community Epidemiology Branch, County of San Diego Health and
Human Services Agency, San Diego, California, USA
This article is not subject to US copyright law.

The authors thank Cathy Cirina and Jeff Toor at the San Diego State Social Science and
Research Laboratory for their excellent work in administering the telephone survey; Jacqueline
Polder, Centers for Disease Control and Prevention Quarantine Officer at the Houston Airport,
for providing pandemic influenza expertise; and Gabrielle Benenson and Clive Brown, who
provided recommendations on the survey design.
Costs for the random digit dial survey and personnel were supported by a grant by the
Centers for Disease Control and Prevention.
The findings and conclusions in this report are those of the authors and do not necessarily
represent the views of the Centers for Disease Control and Prevention, U.S. Department of
Health and Human Services.
Address correspondence to David E. Sugerman, Centers for Disease Control Global
Immunization Division, 1600 Clifton Road NE, MS F-62, Atlanta, GA 30333, USA. E-mail:
ggi4@cdc.gov
698
Emergency Health Risk Communication 699
DANIEL B. FISHBEIN
In October 2007, wildfires burned nearly 300,000 acres in San Diego County, California.
Emergency risk communication messages were broadcast to reduce community
exposure to air pollution caused by the fires. The objective of this investigation was
to determine residents’ exposure to, understanding of, and compliance with these
messages. From March to June 2008, the authors surveyed San Diego County residents
using a 40-question instrument and random digit dialing. The 1,802 respondents
sampled were predominantly 35–64 years old (65.9%), White (65.5%), and educated
past high school (79.0%). Most (82.5%) lived more than 1 mile away from the fires,
although many were exposed to smoky air for 5–7 days (60.7%) inside and outside
their homes. Most persons surveyed reported hearing fire-related health messages
(87.9%) and nearly all (97.9%) understood the messages they heard. Respondents
complied with most to all of the nontechnical health messages, including staying inside
the home (58.7%), avoiding outdoor exercise (88.4%), keeping windows and doors
closed (75.8%), and wetting ash before cleanup (75.6%). In contrast, few (<5%)
recalled hearing technical messages to place air conditioners on recirculate, use High-
Efficiency Particulate Air filters, or use N-95 respirators during ash cleanup, and less
than 10% of all respondents followed these specific recommendations. The authors
found that nontechnical message recall, understanding, and compliance were high
during the wildfires, and reported recall and compliance with technical messages were
much lower. Future disaster health communication should further explore barriers to
recall and compliance with technical recommendations.
Global climate change, exponential population growth, and urbanization have resulted
in more frequent and deadly natural disasters (Lowrey et al., 2007). To inform the
public about their personal risk, emergency risk communication was developed as a
new communication model to convey information about issues that pose a threat to
health, safety, or the environment (Reynolds & Crouse Quinn, 2008). Appropriate risk
communication is critical to protecting populations and evaluating messages during
natural disasters is essential to improving disaster response. Risk communication
effectiveness is known to be influenced by message comprehension, the personalization
of risk, socioeconomic and cultural factors, and messenger trust (Glik, 2007). Risks that
are perceived to be familiar, voluntary, natural, or under an individual’s control are
more accepted than risks perceived to be unfamiliar, involuntary, or exotic (Fischhoff,
Lichtenstein, Slovic, & Keeney, 1981), and there is a decrease in public perceptions of
trust and credibility in government communication activities (Slovic, 1999).
To learn how to improve communication during future wildfire disasters, we
conducted an evaluation of the 2007 San Diego wildfire risk messages. Beginning on
October 21, 2007, San Diego County experienced one of the largest wildfires in California
history. By the time the fires were extinguished, 15% of the county’s total land area had
burned. The fires caused local particulate matter levels, measured at 10 microns (PM
10), to exceed the Environmental Protection Agency’s “unhealthy” limit (150 μg/dL for
7 consecutive days). In certain areas, particulate matter approached “hazardous levels”
(500 μg/dL). County emergency department syndromic surveillance data showed that
daily hospital visits for shortness of breath increased 25%, with a doubling of hospital
visits for asthma during October 21–26, 2007, compared with the previous 21-day average
(Centers for Disease Control and Prevention, 2008). Epidemiologic studies indicate that
cardiopulmonary morbidity and mortality are increased during, or just after, periods of
700 D. E. Sugerman et al.
elevated particulate matter (Pope, Schwartz, & Ransom, 1992; Schwartz, 1994; Schwartz,
Dockery, & Neas, 1996). Community smoke exposures resulting from wildland forest
fires have been associated with increased emergency department and hospital admissions
for chronic obstructive pulmonary disease, bronchitis, asthma, and chest pain (Duclos,
Sanderson, & Lipsett, 1990; Shusterman, Kaplan, & Canabarro, 1993). To mitigate
the health effects of the fires, the San Diego County Health and Human Services
Agency, together with the American Heart and Lung Associations, distributed health
recommendations through mass media messages. These recommendations were delivered
via television, AM/FM radio, newspaper, and the Internet during 3 weeks of emergency
broadcasting. Most messages focused on protection from smoke inhalation among those
in affected areas. An important part of any messaging is the development and timely
release of effective health risk communication to encourage behaviors to limit negative
health impacts (Vaughan & Tinker, 2009), especially among vulnerable populations
(Blumenshine et al., 2008; Vlahov, Coady, Ompad, & Galea, 2007). Few previous studies
have looked at effective risk communication during wildfires or analyzed the effect of
technical message content, especially among vulnerable groups.
Method
Our 2007 Wildfire Survey was adapted from a previous study conducted after
another southern California wildfire (Künzli et al., 2006). The survey was designed to
elicit differences in recall, comprehension, and compliance by message type (i.e., technical
vs. nontechnical) and by respondent demographics (e.g., age, sex, income). We defined
technical messages as those referencing specific products or detailed actions: “use of N95
respirators during cleanup,” “use an indoor HEPA filter,” and “run air conditioners
on recirculate.” All other messages were classified as nontechnical. Respondents were
first asked to recall all messages they saw or heard during the week of fire emergency
broadcasting. Message recall was assessed using the following questions: “During the
week of the fires, did you see or hear any health messages related to the fires?” and “Where
did you see or hear the majority of these health announcements?” Without prompting,
interviewers then asked, “What were some of the specific health messages you saw or
heard?” and recorded all mentioned responses from a provided list of aired messages:
•• stay indoors
•• drive with all windows closed
•• run air conditioners on recirculate
•• keep home windows closed
•• use HEPA air filters
•• only exercise indoors
•• west ash before cleanup
•• use N95 respirators during cleanup
•• limit activities to what is absolutely necessary
•• boil tap water before drinking
•• drink bottled water
Respondents were then prompted by reading from a list of health messages broadcast
during the fires and asked whether they remembered hearing the specific messages.
Message comprehension was assessed using the question: “If you saw or heard
any message: “Did you understand each of the health messages that you saw or
heard?” and if no, “Can you tell me why you didn’t understand some the message(s)?”
with the following response options:
•• not in primary language

•• information was too technical
•• something else about the message made it difficult to understand
•• don’t know
•• refuse
Last, we measured message compliance with a general question:
Thinking now about all of the messages that you saw or heard during the
week of the fires and that applied to you, would you say you followed all
of those messages, most of those messages, some of those messages, or
none of those messages?
We also asked several specific questions:
•• When you cleaned up, did you wet areas that had heavy dust or ash?
•• Did you wear a mask during cleanup?
•• If yes, what type of mask was it? Was it a fitted N95 mask with an N95 logo on
the mask or packaging, was it a dust, surgical, or painting mask, a bandanna or
cloth, or some other kind of mask.
We then asked the following, in terms of how many days (from 0 to 7 days):
•• Did you keep all windows and doors completely closed?

•• Did you use air conditioning when you were at home?
•• Did you use a HEPA air filtration system when you were at home?
•• Did you stay inside most of the day except for essential activities?
•• Did you spend less time outdoors than usual?
•• Did you participate in outdoor athletic activities?
•• Did you wear a mask?
The survey was determined to be exempt from institutional review board review
by the institutional review board at the Centers for Disease Control and Prevention
because the survey was a program evaluation and public health response. Participation
was voluntary, and all participants gave verbal consent.
The San Diego State University Social Sciences and Research Lab purchased 24,000
random digit dialing sample records for San Diego County from Scientific Telephone
Samples (Foothill Ranch, CA) to reach a sample of 1,800 persons. Up to eight attempts
were made to contact each respondent. Interviews were conducted in Spanish and
English, 7 days a week, for 16 weeks. To participate in the interview, respondents had
to meet the following criteria: (a) be 18 years of age or older and (b) have been present in
San Diego County during October 21–28, 2007—the most intense burn period with the
highest concentrations of particulate matter. The instrument was first pilot-tested with
78 respondents before full-scale data collection to revise questions and work out coding
errors. From May to June, 2008, 18,687 calls were placed with 7,706 ineligible numbers
(fax/model, disconnected, page/cell, business/government, not qualified because individual
was younger than 18 years of age or not present in the county during the fires, over quota),
9,052 numbers of unknown eligibility (busy, no answer, answering machine, unqualified
refusal, language barrier, call back, and Spanish call back), and 1,929 eligible numbers
(1,802 completed the interview, 95 terminated, and 32 partially completed the interview).
Response and cooperation rates were calculated using the American Association for
Public Opinion Research (AAPOR) Outcome Rate Calculator, version 2.1.
Response Rate = Completes/[Eligible + e* (Unknown Eligibility)]
*Estimate of e is based on proportion of eligible households among all

numbers for which a definitive determination of status was obtained.
Cooperation Rate = Completes/Eligible
Data were retrieved from SPSS and entered into SAS at the Centers for Disease
Control and Prevention. Respondent demographics were compared with San Diego
County census data. San Diego County 2007 census projections for those 18 years of age
or older were obtained from the U.S. Census Bureau 2005–2007 American Community
Survey 3-Year Estimates and 2008 estimates from the San Diego Association of
Governments. We analyzed differences in health message recall, comprehension, and
compliance by demographic, smoke/fire exposure, and medical history variables. We
examined the mean number of complied-with messages (of a total of 10) for age, sex,
education, employment, income, major statistical area of residence, medical history,
and reported smoke/fire exposure). Smoke exposure was captured by asking respondent
about the number of days they were exposed to “smoky air.”
For these comparisons, we used Fisher’s exact test for categorical variables and
Wilcoxon rank-sum test for continuous variables. All variables were subsequently
analyzed by multivariate linear regression. Significance was defined as p < .05. We
defined vulnerable groups as those older than 65 years of age, with high school or
lower education, with annual incomes less than $50,000, not employed full time, or
who did not speak English as their primary language.
Results
Participation and Respondent Demographics
The calculated response rate was 48%, and the cooperation rate was 93%. The
average interview lasted 17 minutes; 10% of interviews were conducted in Spanish. Of
respondents, 50% were male, and most were middle aged (35–64 years), non-Hispanic
White, educated past high school, employed full time, and spoke English as their primary
language (Table 1). Compared with San Diego County census data, the respondents were
older (less often 18–24 years of age [3.7% vs. 15.3%] and more often 45–64 years of age
[46.2% vs. 30.4%]), more often non-Hispanic White (65.3% vs. 53.9%), had household
incomes greater than $50,000 (60.5% vs. 58.6%), and were more highly educated, college
graduate or higher (44.6% vs. 28.4%), than other county residents.
Smoke Exposure, Health Conditions, and School Closure Effect

A majority of respondents (60.4%) reported smoke exposure for at least 5–7
days. Most (82.5%) respondents said the fire was more than 1 mile away from their
Table 1. Comparison of characteristics of respondents (N = 1,802) and San Diego

County residents (N = 2,214,244)
Survey respondents San Diego County residents†

Characteristics N (%) N (%)
Age (years) 1,689 2,214,244
18–24 63 (3.7) 339,022 (15.3)
25–34 203 (12.1) 435,071 (19.6)
35–44 339 (20.1) 440,590 (19.9)
45–54 446 (26.4) 405,082 (18.3)
55–64 334 (18.8) 267,263 (12.1)
65+ 304 (18.0) 327,216 (14.8)
Gender 1,724 2,214,244

Male 869 (50.4) 1,104,628 (49.9)
Female 855 (49.6) 1,109,616 (50.1)
Race/ethnicity§ 1,669 2,365,297
Non-Hispanic White 1090 (65.3) 1,275,451 (53.9)
Hispanic 369 (22.1) 630,736 (26.7)
Asian 84 (5.0) 256,503 (10.8)
Non-Hispanic Black 68 (4.1) 120,605 (5.1)
Other 58 (3.5) 82,002 (3.5)
Primary language* 1,713 2,993,126
English 1422 (83.0) 1,866,706 (83.5)
Spanish 224 (13.1) 255,860 (11.5)
Other 67 (3.9) 110,888 (5.0)
Education 1,714 2,233,454
High school or less 359 (20.9) 838,731 (37.6)
Some college 591 (34.5) 732,735 (32.8)
College graduate 374 (21.8) 400,873 (18.0)
Past college 390 (22.8) 232,291 (10.4)
Employment 1,713 2,298,030
Full time 913 (53.3) —
Retired 331 (19.3) —
Part time 183 (10.7) —
Homemaker 160 (9.3) —
Disabled 62 (3.6) —
Unemployed/student 64 (3.7) 80,842 (3.5)
Household income** 1,449 1,041,790
$0–$10,000 59 (4.1) 51,240 (4.9)
$10,000–$30,000 252 (17.4) —
$30,000–$50,000 262 (18.1) —
$50,000–$100,000 471 (32.5) 331,156 (31.8)
$100,000+ 405 (28.0) 57,935 (26.8)
†2005–2007 American Community Survey 3-Year Estimates.
§Source: 2008 San Diego Association of Governments.
*For census data, English if only spoke English or spoke another language and English
“very well,” Spanish if spoke Spanish and English “well” or less, and Other if spoke any other
language and English “well” or less.
**For census data, household income reported in real 2007 dollars adjusted for inflation for
those 16 years or older.
home. Three percent reported their primary residence was fire damaged. Seventy-two
percent smelled smoke outside their homes for more than 4 days, and 29% smelled
smoke inside their home for more than 4 days.
A number of respondents reported chronic medical conditions, including
hypertension (31.1%), asthma (15.1%), chronic obstructive pulmonary disease (2.7%),
congestive heart failure (2.9%), and angina (4.5%). Of those with underlying asthma,
31.5% increased the frequency of use of metered dose inhaler; while 41.3% of those
with chronic obstructive pulmonary disease increased metered dose inhaler frequency,
and 23.7% increased home oxygen flow rates (Table 2).
Compared with other respondents, persons who reported increasing inhaler
or oxygen use were over twice as likely to wear N95 respirators during cleanup
(prevalence ratio = 2.6, 95% CI [1.2, 4.9]) and nearly five times more likely to visit
a physician (prevalence ratio = 4.7, 95% CI [2.3, 9.2]). Persons reporting limited
visibility because of smoke for 1–7 days were more than twice as likely to seek
medical care (prevalence ratio = 2.4, 95% CI [1.2, 4.8]) than were those not reporting
limited visibility. Reported physical and mental health conditions were positively
correlated with seeking medical care, including chronic obstructive pulmonary
disease (prevalence ratio = 8.0, 95% CI [4.5, 13.2]), angina (prevalence ratio = 6.2,
95% CI [3.6, 10.2]), congestive heart failure (PR = 6.1, 95% CI [3.3, 10.7]), reported
depression or apathy during the fires (prevalence ratio = 3.8, 95% CI [2.3, 9.6]), and
asthma (prevalence ratio = 4.0, 95% CI [2.5, 6.5]). In a logistic regression model
using the variables determined to be significant in the univariate analysis (p < .05),
the decision to seek medical care was higher among respondents with congestive
heart failure and/or angina (adjusted odds ratio = 9.36, 95% CI [2.36, 37.02])
increased inhaler or oxygen use (adjusted odds ratio = 4.4, 95% CI [1.70, 11.42]),
and reported depression or apathy during the fires (adjusted odds ratio = 3.1, 95%
CI [1.15, 8.25]).
Nearly half the respondents had a child living at home during the wildfires, and
90.5% reported that the child’s school was closed for 1 day or more during the wildfires.
Of these parents, 21.6% missed work to provide childcare, with 62.2% reporting lost
income because of lost work hours (Table 2).
Message Delivery, Recall, Comprehension, and Compliance

Most respondents recalled hearing emergency messages (Table 3). Television
was reported to be the primary message source by 77% of respondents. Nearly
all (97.8%) reported understanding the messages they saw or heard. Without
prompting, staying indoors was the main message respondents recalled.
Nontechnical messages such as “stay indoors,” “keep windows and doors closed,”
and “only exercise indoors” were more often remembered than were messages
using technical terminology such as “use N95 respirators during cleanup,” “use
HEPA air filters,” and “run air conditioners on recirculate.” Most respondents
reported taking multiple actions to prevent additional exposure to smoke during
5 or more days of elevated PM10 levels, from October 21 to 28, 2007. They
stayed inside their homes most of the day (58.7%), kept all windows and doors
closed (75.8%), did not participate in outdoor sports (88.4%), and wet ash with
water before and during home cleanup (75.6%). Fewer persons used home air
conditioning (15.5%), HEPA air filtration (10.3%), or donned N95 respirators
during ash cleanup (8.1%).
Table 2. Reported exposure to smoke/fire, past health conditions, and actions taken
during the 2007 San Diego wildfires (N = 1,802)
Exposure n (%)
Smoke exposure (days)
0 133 (7.8)
1–2 230 (13.6)
3–4 309 (18.2)
5–7 1025 (60.4)
Smelled smoke inside the home (days)
0 626 (35.9)
1–2 341 (19.6)
3–4 279 (16.0)

5–7 498 (28.6)
Smelled smoke outside the home (days)
0 70 (4.0)
1–2 152 (8.6)
3–4 268 (15.2)
5–7 1268 (72.1)
Fire proximity to location of home
1 mile or less 312 (17.5)
More than 1 mile 1469 (82.5)
Primary residence was fire damaged 48 (2.7)
Past health conditions
Asthma 272 (15.1)
Chronic obstructive pulmonary disease or emphysema 48 (2.7)
Hypertension 558 (31.1)
Diabetes 152 (8.5)
Congestive heart failure 53 (2.9)
Angina 81 (4.5)
Fire health effects
Asthmatics with increased inhaler use (n = 272) 84 (31.5)
Chronic obstructive pulmonary disease with increased inhaler use
(n = 48) 19 (41.3)
Chronic obstructive pulmonary disease with increased home
oxygen use (n = 48) 9 (23.7)
Sought medical care during/after fires 69 (4.0)
Depressed during fires 365 (20.4)
School closure
School or preschool closed during the fires 773 (90.5)
Household member missed work for childcare 167 (21.6)
Income lost from missed work for childcare 104 (62.2)
Actions taken during the fire
Nontechnical
Stayed inside most of the day (5 days or more) 1047 (58.7)
Kept all windows and doors closed (5 days or more) 1339 (75.8)
Participated in outdoor sports (0 days) 1580 (88.4)
Wet ash during cleanup (n = 925) 693 (75.6)
(Continued)
Table 2. Continued
Exposure n (%)
Technical
Used home air conditioning (5 days or more) 267 (15.5)
Used High-Efficiency Particulate Air filtration (5 days or more) 181 (10.3)
Wore N95 mask during ash cleanup (n = 925) 75 (8.1)
Table 3. Message delivery, recall, comprehension, and compliance during the 2007
San Diego wildfires (N = 1,802)
Message delivery n (%)

Saw or heard health messages 1489 (88.1)
Delivery source
TV 1146 (77.1)
Radio 96 (6.5)
Internet 20 (1.3)
Other 224 (15.1)
Content source
San Diego Department of Health 757 (47.0)
American Heart Association 446 (27.5)
American Lung Association 683 (42.0)
Local or national hospital physicians 425 (25.6)
Healthcare provider 162 (9.8)
Message recall*
Stay indoors 1048 (67.5)
Drive with windows closed 15 (1.0)
Keep home windows closed 279 (18.0)
Only exercise indoors 166 (10.7)
Boil tap water 42 (2.7)
Wet ash before cleanup 20 (1.3)
Run air conditioning on re-circulate 70 (4.5)
Use High-Efficiency Particulate Air filtration 30 (1.9)
Use N95 respirators during cleanup 26 (1.7)
Keep a sufficient supply of medication (among those with asthma
and chronic obstructive pulmonary disease) 0 (0.0)
Avoid fire cleanup if have asthma (among those with asthma and
chronic obstructive pulmonary disease) 3 (1.0)
Message comprehension
Did not understand all heard messages 32 (2.2)
Reasons not understood
Not in primary language 7 (21.9)
Information too technical 3 (9.4)
Other 22 (68.7)
(Continued)
Table 3. Continued
Message delivery n (%)

Global message compliance**
All 444 (26.8)
Most 887 (53.6)
Some 221 (13.3)
Very few 73 (4.4)
None 31 (1.9)
*Without prompting.
**Persons were asked the degree of message compliance among all messages heard, saw,
understood, and applicable to them during the week of the fires.
Factors Related to Message Compliance

In univariate analysis, compliance with most to all messages was higher among
persons who were female, spoke English as their primary language, were educated
beyond high school, and earned incomes of $50,000 or more (p < .05). Higher exposure
to smoky air (more than 2 days), a history of asthma or chronic obstructive pulmonary
disease, reporting depression, and visiting a doctor during the fires (p < .05) were
also associated with higher mean message compliance (Table 4). In multivariate linear
regression, being female, primarily English speaking, educated beyond high school,
having asthma or chronic obstructive pulmonary disease, and reporting depression or
apathy during the fires remained significant (p < .05).
The mean number of messages complied with (for nontechnical, technical, and
total messages) was significantly higher, by univariate linear regression, for persons
in the 18–64 year-old age group, persons employed full time, those with more
than 2 days of exposure to smoky air, those with asthma or chronic obstructive
pulmonary disease, persons reporting increased oxygen or inhaler use, and those
reporting depression during the fires (Table 5). When only technical messages were
analyzed, compliance was higher among those aged 18–64 years, who spoke English
as their primary language, were educated beyond high school, were employed full
time, had incomes of $50,000 or more, were exposed to more than 2 days of smoky
air, reported feeling depressed at some point during the fires, reported a history of
asthma, chronic obstructive pulmonary disease, angina, or congestive heart failure,
reported increased home oxygen or inhaler use, and reported seeing a doctor during
the fires.
Discussion
Before survey initiation, we hypothesized that most people recalled,
comprehended, and complied with nontechnical emergency health risk messages
and that vulnerable groups (i.e., elderly adults, those who are unemployed, less
educated, poorer, or racial/ethnic minorities) would demonstrate reduced recall,
comprehension, and compliance. The majority of respondents reported significant
exposure to wildfire smoke for at least 4 days. From the first days of the fires,
respondents generally adhered to nontechnical messages, despite recalling only
one nontechnical message without prompting—to stay indoors. Few respondents
Table 4. Compliance with most to all messages by demographic, health state, smoke
exposure, and health exacerbation variables during the 2007 San Diego wildfires
Complied with most to

Variable all messages* n (%) p
Age (years)
18–64 1094/1348 (81.2%)
65+ 210/274 (76.6%) .095
Gender
Male 634/826 (76.8%)
Female 697/830 (84.0%) <.001
Race/ethnicity
Non-Hispanic White 852/1041 (81.8%)

Hispanic 278/363 (76.6%)
Other 159/199 (79.9%) .093
Primary language
English 1113/1360 (81.8%)
Spanish or other 211/286 (73.8%) .003
Education
High school or less 261/348 (75.0%)
More than high school 1061/1298 (81.7%) .006
Employment
Full time 718/886 (81.0%)
Less than full time 604/759 (79.6%) .49
Income
<$50,000 419/549 (76.3%)
≥$50,000 704/842 (83.6%) <.001
Smoke exposure
0–2 days 255/336 (75.9%)
3–7 days 1056/1296 (81.5%) .025
Asthma or chronic obstructive
pulmonary disease
Yes 231/272 (84.9%)
No 1100/1384 (79.5%) .045
Increased inhaler or oxygen use
Yes 73/85 (85.9%)
No 1258/1571 (80.1%) .21
Heart failure or angina
Yes 74/93 (79.6%)
No 1257/1563 (80.4%) .79
Depressed during the fires
Yes 370/439 (84.3%)
No 961/1217 (79.0%) .017
Saw doctor during the fires
Yes 53/68 (77.9%)
No 1274/1581 (80.6%) .64
Table 5. Mean number of fire-related nontechnical, technical, and total health mes-
sages complied with by demographic, health state, health exacerbation, and smoke
exposure variables during the 2007 San Diego wildfires
Nontechnical Technical
messages messages Total messages
M p* M p M p
Age (years)
18–64 2.0 0.9 2.9
65+ 1.7 <.001 0.7 <.001 2.3 <.001
Gender
Male 1.8 0.9 2.6

Female 2.1 <.001 0.9 .57 3.0 <.001
Race/ethnicity
Non-Hispanic White 1.9 0.9 2.8
Hispanic 2.0 0.8 2.8
Other 2.0 .90 0.9 .063 2.9 .30
Primary language
English 2.0 0.9 2.9
Spanish or other 1.9 .26 0.7 .001 2.7 .007
Education
High school or less 1.9 0.8 2.7
More than high school 2.0 .23 0.9 .011 2.9 .013
Employment
Full time 2.0 0.9 2.9
Not full time 1.9 .048 0.8 .001 2.7 .001
Income
Less than $50,000 1.9 0.8 2.7
$50,000 or more 2.0 .074 0.9 <.001 2.9 <.001
Smoke exposure
0–2 days 1.6 0.2 1.8
3–7 days 2.2 <.001 1.8 <.001 3.5 <.001
Asthma or chronic
obstructive pulmonary
disease
Yes 2.1 1.0 3.2
No 1.9 .002 0.8 <.001 2.7 <.001
Heart failure or angina
Yes 2.1 1.0 3.1
No 2.0 .30 0.8 .028 2.8 .048
Depressed during the
fires
Yes 2.2 1.0 3.2
No 1.9 <.001 0.8 <.001 2.7 <.001
Increased inhaler or
oxygen use
Yes 2.3 1.2 3.4
No 1.9 .013 0.8 <.001 2.8 <.001
(Continued)
Table 5. Continued
Nontechnical Technical
messages messages Total messages
M p* M p M p
Saw doctor during the
fires
Yes 2.2 1.2 3.4
No 2.0 .072 0.8 <.001 2.8 .001
*Signed rank (Wilcoxon or Kruskal-Wallis).
adhered to or recalled hearing technical messages. However, nearly all (97.8%)

persons reported comprehending recalled messages, and only 3 respondents cited
technical language as a barrier.
The goal of health and safety messaging during a crisis is to empower the
public to take action and reduce risks of injury and illness, while also mitigating
fear and anxiety (Glik, 2007). This health message evaluation demonstrated higher
compliance with nontechnical messages to stay indoors with windows and doors
closed, and among those with underlying medical problems and smoke exposure.
Persons with underlying health conditions and direct exposure to the threat have
been found to perceive greater personal risk and may be more likely to adhere to
emergency risk communication (Glik, 2007). Lower compliance was observed with
technical messages regarding air conditioning, HEPA filters, and N95 respirators,
and among vulnerable populations —those who were older than 65 years of age,
less educated, with lower income, not employed full time, and who did not speak
English as their primary language. Consistent with communication evaluations
during past disasters (Andrulis, Siddiqui, & Gantner, 2007; Eisenman, Cordasco,
Asch, Golden, & Glik, 2007), we found increased health risks and lower message
compliance among vulnerable populations, the elderly, less educated, minorities,
and those of low income.
Multiple factors influence a person’s exposure to, comprehension of, and
compliance with public health messages, such as work and family obligations;
language barriers; access to TV, radio, newspaper; perceived credibility of sources;
transportation resources; social network influences; and personal experiences with
past disasters (Crouse Quinn, 2008). Members of ethnic and racial minority groups
have been found to be heavily influenced by extended social networks and are often
distrustful of the media. For example, messages aired during Hurricane Katrina were
often perceived by vulnerable populations as ambiguous, many times leading them to
defer to the advice of their social networks (Eisenman et al., 2007). Vulnerable groups
may more often trust new information received from their social network (i.e., church
or friends) than from outside sources (i.e., media, government authority figures).
The study was limited by possible recall bias, with phone interviews occurring
5–8 months after the fires ended. We could not calculate the quantity of messages that
people were exposed to, so differences in recall may also have been related to differences
in exposure. There was also potential selection bias with a 52% response rate. The
respondents from our survey differed from county residents in that respondents were
more often older, non-Hispanic White, and higher educated. Because of cost limitations,
we did not purchase a cell phone log and were thus unable to include cell phone–only
households in our survey. In addition, by prompting respondents with aired messages
at the beginning of the survey, we may have influenced the response to the questions
that followed. While statistically significant in our multivariate analysis, there were small
numerical differences in the mean number of messages with which respondents complied.
Despite these limitations, this survey demonstrated reduced message recall and
compliance among vulnerable populations, as well as lower recall and compliance
with messages that included technical language or required purchasing recommended
interventions (i.e., N95 respirators or HEPA filters). An evaluation of a large wildfire
on the Hoopa Indian Reservation in Northwestern California (Mott, Meyer, Mannino,
& Redd, 1999) revealed poor recall of public health messages, except for the message
to stay indoors. The same study also found that recall was higher among those with
medical conditions and lower among the poor.

Published reports also support our findings that most people have difficulty
recalling more than three messages (Solso, 2001) and that recall of technical messages
is generally poor (Glik, 2007). Thus, we recommend in future disaster situations
reducing the number of total messages delivered while improving messaging targeted to
vulnerable groups. The public needs to be provided with facts about the crisis without
being overwhelmed. Technical messages may be made easier to follow for the public
if the county health department encourages stores to clearly label recommended items
such as HEPA air filters and N95 respirators during firestorms. Improved clarity in
the communication of risk content, including videos, personal testimony from older
community members (Pennings & Grossman, 2008), easy-to-read materials, and easily
understandable messages (eighth grade or less) with pictures and graphics to illustrate
concepts and actions (Eysenbach & Köhler, 2002) could also improve compliance. In
conjunction with these efforts, county health departments can disseminate messages
by using automated calling systems and conducting site visits to reach vulnerable
populations. The importance of health communications that are simple, short, and
tailored to vulnerable groups cannot be overstated.
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Emergency Health Risk Communication DURIN THE 2007

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On: 19 November 2014, At: 05:19

Journal of Health Communication:

Emergency Health Risk Communication

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Emergency Health Risk Communication During

HARVEY LIPMAN AND STEPHEN H. WATERMAN

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•• not in primary language

Last, we measured message compliance with a general question:

We also asked several specific questions:

•• Did you keep all windows and doors completely closed?

Response Rate = Completes/[Eligible + e* (Unknown Eligibility)]

*Estimate of e is based on proportion of eligible households among all

Cooperation Rate = Completes/Eligible

Smoke Exposure, Health Conditions, and School Closure Effect

Table 1. Comparison of characteristics of respondents (N = 1,802) and San Diego

Survey respondents San Diego County residents†

Gender 1,724 2,214,244

Message Delivery, Recall, Comprehension, and Compliance

3–4 279 (16.0)

Message delivery n (%)

Message delivery n (%)

Factors Related to Message Compliance

Complied with most to

Non-Hispanic White 852/1041 (81.8%)

Male 1.8 0.9 2.6

adhered to or recalled hearing technical messages. However, nearly all (97.8%)

medical conditions and lower among the poor.

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