Disability and Disasters: The Role of Self-Efficacy in Emergency Preparedness and Psychological Symptoms
by Jennifer E. Marceron
B.A. in Psychology, May 2009, The University of Virginia M.Phil. in Clinical Psychology, August 2014, The George Washington University
A Dissertation submitted to
The Faculty of The Columbian College of Arts and Sciences of The George Washington University in partial fulfillment of the requirements for the degree of Doctor of Philosophy
August 31, 2016
Cynthia A. Rohrbeck Associate Professor of Psychology
The Columbian College of Arts and Sciences of The George Washington University certifies that Jennifer E. Marceron has passed the Final Examination for the degree of
Doctor of Philosophy as of March 25, 2016. This is the final and approved form of the dissertation.
Disability and Disasters: The Role of Self-Efficacy in Emergency Preparedness and Psychological Symptoms
Jennifer E. Marceron
Dissertation Research Committee:
Cynthia A. Rohrbeck, Associate Professor of Psychology, Dissertation Director.
Philip J. Moore, Associate Professor of Psychology, Committee Member.
Maria Cecilia Zea, Professor of Psychology, Committee Member.
ii Dedication
I dedicate this work to people with physical disabilities who have suffered from natural and human-made disaster events, across the United States and internationally.
iii Acknowledgements
First and foremost, I would like to thank my parents, Ken and Theresa Marceron, and my brother, Michael Marceron, for providing love, encouragement and invaluable support throughout this program. Thank you for instilling in me the passion for learning and the confidence and persistence to strive for my dreams.
Secondly, I would like to thank my graduate advisor, Dr. Cynthia Rohrbeck, for her support as a researcher, teacher, clinician and mentor. I am grateful for her time and dedication to my personal and professional goals.
Thank you to my grandparents, Marvin and Patricia Marceron and Sharlene
Olson, for your love and support.
I am also grateful to my dear friends Barbara Simpson, Lauren DePompeo,
Camille Weaver, Margaret Anton, Desiré Moses, Joanna Church, Theresa Gentile and
Douglas Grosvenor for providing support, encouragement and laughter all along the way.
I would like to thank my colleagues, lab mates and friends, Katherine Burns,
Michelle Garvin, Laura Shaffner-Gray, Meagan Sweeney, Catherine Coogan, Hannah
Snyder, Courtney Wallin, Gina Raciti, Devin English, Teddi Zuckerman and Laura
Mlynarski for consultation, collaboration and, at times, commiseration.
Finally, I greatly appreciate the financial support for my dissertation research provided by the Society for Community Research and Action Student Dissertation
Award, APAGS Ellin Bloch and Pierre Ritchie Diversity Dissertation Grant, The Society for the Psychological Study of Social Issues - Grants-in-Aid Award, and the George
Washington University Summer Dissertation Fellowship.
iv Abstract
Disability and Disasters: The Role of Self-Efficacy in Emergency Preparedness and Psychological Symptoms
This study examined the moderating role of emergency preparedness self-efficacy on the relationships between the perception of threat associated with natural and human- made disasters and outcomes, including behaviors (emergency preparedness) and psychological symptoms (anxiety and distress), for adults with physical disabilities. This study was designed to address gaps in preparedness research for individuals with physical disabilities and to gain information about strengthening preparedness for that population, information that may ultimately strengthen resiliency of the population at large. The hypotheses were based on the integration of two theories—Protection Motivation Theory
(PMT; Maddux & Rogers, 1983), which describes how exposure, threat, and preventive behavioral outcomes interact, and the Risk Perception Attitude framework (RPA; Rimal
& Real, 2003), which adds specific predictions about how efficacy beliefs influence the impact of perceived threat on related behaviors. Adults with physical disabilities (N =
294) completed an internet-based survey including measures of perceived threat of disasters, emergency preparedness-self efficacy, emergency-preparedness behaviors, and symptoms of anxiety and distress. Most participants completed the survey independently online with a subgroup completing it by telephone interview.
The hypotheses were tested using analysis of covariance (ANCOVA) with relevant covariates. As expected, emergency preparedness self-efficacy moderated the relationship between perceived threat and emergency preparedness behaviors.
Specifically, there was a stronger relationship between threat and emergency preparedness for those individuals higher in self-efficacy, compared to individuals lower
v in self-efficacy. In contrast, emergency preparedness self-efficacy did not moderate the relationships between perceived threat and symptoms of anxiety and distress. Given the lack of significant interactions for those psychological outcomes, potential main effects between perceived threat and emergency preparedness self-efficacy with symptoms were examined. Perceived threat was significantly related to symptoms of anxiety but not significantly related to symptoms of distress. Emergency preparedness self-efficacy was not related to symptoms of either anxiety or distress.
These findings suggest that the interaction between threat and emergency preparedness self-efficacy could be a potential target for interventions designed to increase emergency preparedness among individuals with physical disabilities. It is particularly important to increase emergency preparedness self-efficacy for those who perceive more threat. Limitations of the study are acknowledged and recommendations are made for future research.
Keywords: disasters; anxiety, distress, emergency preparedness; self- efficacy;
vi Table of Contents
Dedication ...... iii
Acknowledgments ...... iv
Abstract of Dissertation ...... v
List of Figures ...... viii
List of Tables ...... ix
Chapter 1: Introduction ...... 1
Chapter 2: Literature Review ...... 4
Chapter 3: Method ...... 32
Chapter 4: Results ...... 42
Chapter 5: Discussion ...... 46
References ...... 70
Appendices ...... 84
vii List of Figures
Figure 1……………………………………………………………………………..…….69
Figure 2……………………………………………………………………………..…….69
viii List of Tables
Table 1…………………………………….………………………………………….….61
Table 2…………..……………………………………………………………………….62
Table 3…………...……………………………………………………………………….63
Table 4…………...……………………………………………………………………….64
Table 5…………...……………………………………………………………………….65
Table 6…………...……………………………………………………………………….66
Table 7…………...……………………………………………………………………….67
Table 8…………...……………………………………………………………………….68
ix Introduction
Disasters and emergency situations often arise with little notice and their consequences, including loss of life, loss of property and psychological effects (National
Consortium for the Study of Terrorism and Responses to Terrorism, 2014; United
Nations International Strategy for Disaster Reduction, 2014) can be devastating to individuals and communities. Preparing for disasters by engaging in emergency preparedness behaviors is crucial to mitigate the effects of these events.
Despite the benefits of preparing for disasters, many people living in the United
States are not well prepared. Therefore, it is important to understand why that discrepancy occurs. Various individual characteristics, including social support, resources, knowledge of disasters, information seeking, and demographics, have been examined in an effort to identify attributes associated with preparedness, and ultimately, increased positive outcomes and decreased negative outcomes following disasters
(Bourque et al., 2012). Emergency preparedness self-efficacy is one such characteristic of increasing interest.
Emergency preparedness self-efficacy (i.e., an individual’s belief in his or her ability to engage in emergency preparedness behaviors and respond appropriately to large-scale emergencies) has been positively related to emergency preparedness and inversely related to psychological symptoms (Burns, Rohrbeck, Moore, & Peterson,
2014a; Marceron & Rohrbeck, 2013). Because emergency preparedness self-efficacy is said to be malleable (Gist & Mitchell, 1992), it could be targeted in interventions to both increase emergency preparedness behaviors and decrease psychological symptoms
(Bandura, 1977; Bandura, 2001).
1 Protection Motivation Theory (PMT; Maddux & Rogers, 1983) provides a model to explain how exposure, threat, and various outcomes interact. In this theory, appraisal of threat (including its severity and probability) and appraisal of coping (including response efficacy and self-efficacy) predicts motivation to protect oneself. Integrating the
Risk Perception Attitude framework (RPA; Rimal & Real, 2003) with PMT, provides specific predictions about how self-efficacy beliefs interact with perceived threat when predicting behaviors. RPA predicts both an interaction between self-efficacy and perceived threat on behaviors and a direct effect of self-efficacy on behaviors as well.
This model suggests that those lacking in self-efficacy are likely to interpret potential risks or threat more fatalistically, and, as a result, are less likely to engage in risk- reducing behaviors (Rimal & Real, 2003).
The literature on the importance of emergency preparedness self-efficacy is growing. We do not know, however, if existing measures of emergency preparedness self-efficacy, including our own (the Emergency Preparedness Self-Efficacy scale, or
EPSE), predict emergency preparedness behaviors and/or psychological symptoms for a particularly vulnerable population—individuals with physical disabilities—as they have in samples from other populations, i.e., college students and community members (Burns et al., 2014a; Marceron & Rohrbeck, 2013).
Natural and human-made disasters (e.g., hurricanes, earthquakes, terrorist attacks, radiation leaks) disproportionately affect people with physical disabilities (Fox, White,
Rooney, & Rowland, 2007). For example, communities are less likely to provide emergency services for individuals with physical disabilities and, when those services are in place, individuals with physical disabilities often experience difficulty accessing those
2 services. Previous research on the effects of disasters on those individuals has been limited to studies of direct exposure, consequences, and recovery (all post-disaster) with little focus on preparedness for disasters or adjustment to the threat of disasters
(Eisenman et al., 2009b; Smith & Notaro, 2009). As in other populations, to better understand and improve emergency preparedness, it is important to examine preparedness before disasters occur, as individuals are coping with the ongoing threat of potential disasters.
The current study examined whether emergency-preparedness self-efficacy bolstered the relationship between perceived threat of disasters & emergency preparedness or the relationship between perceived threat of disasters and psychological outcomes based on the PMT and RPA frameworks (Maddux & Rogers, 1983; Rimal &
Real, 2003). These effects have been found in previous research with general populations not identified as having physical disabilities (Burns et al., 2014a; Marceron & Rohrbeck,
2013). The current study will add to our understanding of how models of disaster outcomes apply to individuals with physical disabilities, and what might be unique about that population.
This study used an Internet-based survey to collect data on approximately 300 adults with physical disabilities. It included measures of past exposure to disasters, perceived threat of disasters, emergency preparedness self-efficacy, emergency preparedness, and psychological symptoms (anxiety and distress). It was hypothesized that perceived threat and emergency preparedness self-efficacy would interact with perceived threat of disasters to predict emergency preparedness for individuals with physical disabilities. Similarly, it was hypothesized that perceived threat and emergency
3 preparedness self-efficacy would interact with perceived threat of disasters to predict psychological symptoms (anxiety and distress) for individuals with physical disabilities.
The results of this study suggest that emergency-preparedness self-efficacy beliefs and threat interact when predicting emergency preparedness. By understanding this interaction, it may be possible to increase emergency preparedness for individuals with physical disabilities, thus reducing risk and increasing resiliency for themselves and the greater population.
Literature Review
Disasters, whether they are natural, human-made or a combination of the two
(e.g., Fukushima Daiichi nuclear power plant accident), have resulted in significant loss of life and property damage. The CDC defines disasters as “a serious disruption of the functioning of society, causing widespread human, material or environmental losses, that exceeds the local capacity to respond, and calls for external assistance. Based on this definition, disasters could be any emergency (man-made or natural) that exceed local capacity to respond; so what may be a disaster in one jurisdiction might not be in another” (CDC, 2012a). Between 1970 and 2012, there were more than 2,600 terrorist attacks in the United States, resulting in more than 3,500 casualties (National Consortium for the Study of Terrorism and Responses to Terrorism, 2014). In the United States alone, natural disasters caused 12,366 deaths and 17.5 billion dollars in economic damage between 1980 and 2010, affecting about 27 million people (United Nations International
Strategy for Disaster Reduction, 2014). These disasters affect a large number of individuals; in a national survey of adults in the United States, 50 percent of adults reported past exposure to disasters at some point in their lifetime (Kilpatrick et al., 2013).
4 Such disasters can have devastating, long-term psychological effects for individuals who are either directly or indirectly exposed (Marshall et al., 2007). Increases in negative psychological outcomes associated with exposure to disasters and the perceived threat of disasters include symptoms of anxiety and distress, depression and post-traumatic stress disorder (Lee, Lemyre, & Krewski, 2010; Schuster et al., 2001;
Silver et al., 2013, Swenson & Henkel-Johnson, 2003).
Clearly there is a need for preventing such negative outcomes through strengthening beliefs and increasing behaviors surrounding emergency preparedness, particularly for high-risk groups (Levac et al., 2012). Demographic characteristics such as disability status, gender, residential community type, race/ethnicity, income, education and age impact preparedness, putting many of these groups at increased risk (FEMA,
2009). Because disasters are a subset of emergencies, disaster preparedness is often referred to as “emergency preparedness.” For example, the Federal Emergency
Management Agency (FEMA) refers to “planning considerations for specific functions, hazards, and threats” as “emergency planning” (FEMA, 2010, p. i). Given the multiple types of disasters, similar negative outcomes, and difficulty predicting which disasters will occur in a particular area, many emergency preparedness organizations such as the
Federal Emergency Management Agency (FEMA), the Red Cross, and the Centers for
Disease Control and Prevention (CDC), have shifted towards an “all hazards” approach to preparedness. The all hazards approach suggests focusing on emergency preparedness behaviors that will be effective across multiple disaster types (FEMA, 2010). For example, certain behaviors, such as evacuation plans or sheltering in place supplies, may be needed in most disasters and can be executed in the same way.
5 Although disasters occur frequently in the United States, emergency preparedness levels across the country remain low (FEMA, 2009). According to a nation-wide evaluation of emergency preparedness in the United States, 57% of respondents endorsed having “supplies set aside in their home to be used only in the case of a disaster” and
44% of respondents reported “having a household emergency plan ‘that included instructions for household members about where to go and what to do in the event of a disaster’” (FEMA, 2009, p. 1). As emergency preparedness is often measured by self- report, responses may be inflated by social desirability and actual rates may be lower.
While there is a growing body of research on this topic, little is known about individuals with physical disabilities as this population has often been overlooked in emergency preparedness planning and intervention (Smith & Notaro, 2009). Natural and human-made disasters disproportionately affect those who are physically unable to evacuate and/or have medical needs that make it difficult to shelter in place during an emergency or disaster (Fox et al., 2007). For example, households with family members with physical disabilities are less likely to evacuate during hurricanes than households without members with physical disabilities. Individuals using wheelchairs or other assistive devices may have significant problems engaging in emergency response plans such as sheltering in place during hurricanes (Rahimi, 1993). Further, during seismic events, physically handicapped individuals may be forced to take more dangerous means of escape (e.g., elevators), or have others individuals carry them out (Kelman & Stough,
2015). During the terrorist attacks of September 11, 2001, for example, many people with physical disabilities were instructed to “wait for help” (Kelman & Stough, 2015). Many
6 individuals who used wheelchairs or walkers perished when the building collapsed because they were waiting to be rescued (National Council on Disability, 2005).
While individuals with physical disabilities are disproportionately affected and more likely to be harmed during disasters, they are also less resilient in the wake of these traumatic events. For example, one year after a severe hurricane, 18% of households with members with physical disabilities reported that their lives were “very” or “a bit” disrupted in comparison to 9% of households without members with physical disabilities
(Van Willigen, Edwards, Edwards, & Hessee, 2002). Individuals with physical disabilities are also less prepared to provide for themselves in the aftermath of a disaster and their vulnerability increases in the absence of emergency supplies and communication plans (Eisenman et al., 2009b). Additional problems arise among individuals with physical disabilities who have lower socio-economic status as they may live in housing more vulnerable to damage, have fewer resources to prepare for disasters, and take financial burdens into account when making evacuation decisions. These factors compound preparedness and response behaviors for this population (Van Willigen,
Edwards, Edwards, & Hessee, 2002).
While studies have been conducted soon after significant exposure to disaster and have addressed direct effects of disasters and one’s perceived ability to cope with the aftermath of disasters (Benight & Bandura, 2004; Eisenman et al., 2009b; Smith &
Notaro, 2009), little research has been done pre-disaster, either on preparedness for disasters or adjusting to the threat of disasters, specifically with this population. The resilience of the entire community is strengthened when emergency preparedness is increased for vulnerable sub-groups of the population, such as individuals with physical
7 disabilities (Levac et al., 2012). Further, increased emergency preparedness has a greater potential to save the lives of individuals in this population. Therefore, by strengthening preparedness for individuals with physical disabilities, we may reduce the negative economic and psychological impacts of disasters for this sub-group and the general population. Strengthening emergency preparedness and planning for individuals with physical disabilities may reduce the additional load for families and communities with whom these individuals reside. For example, families or neighbors of individuals with physical disabilities may be more likely to evacuate when necessary rather than stay behind and risk injury if an emergency evacuation plan including the needs of the individual with a disability is in place.
The Impact of Disasters on Individuals with Physical Disabilities
Individuals with disabilities represent a heterogeneous group. The World Health
Organization (WHO) and the International Classification of Functioning, Disability and
Health (ICF) define disability as “an umbrella term for impairments, activity limitations, and participation restrictions” (WHO, 2011, p. 7). Similarly, the Americans with
Disabilities Act defines “disability” as: “a physical or mental impairment that substantially limits one or more of the major life activities, a record of such an impairment, and/or being regarded as having such an impairment” (Americans with
Disabilities Act of 1990). According to WHO (and NIDRR), disability refers to the
“negative aspects of the interaction between individuals with a health condition (such as cerebral palsy, Down syndrome, depression) and personal and environmental factors
(such as negative attitudes, inaccessible transportation and public buildings, and limited social supports)” (WHO, 2011, p. 7). Disability, as a construct, is on a continuum from
8 enablement to disablement (NIDRR, 2014). Due to the heterogeneity of this population, identifying sub-groups of this population may be important for understanding within group differences.
In 2013, about fifty-three million adults living in the United States reported some type of physical disability (Courtney-Long et al., 2015). The most frequently reported type of disability was in mobility (13.0%), followed by disability in cognition (10.6%), independent living (6.5%), vision (4.6%), and self-care (3.6%). The top two causes of disability, arthritis and back/spine problems, are associated with mobility or physical limitations and account for 35% of all disability. Further, prevalence of disability ranged across the US. For example, disability in mobility ranged from 8.5% in Minnesota to
20.7% in Mississippi and disability in independent living ranged from 4.2% in Nebraska and Utah to 10.8% in Mississippi. Generally, states with higher disability prevalences were in the South and states with lower disability prevalences were in the West or
Midwest. In one emergency preparedness survey, 15 percent of respondents endorsed having a disability that “would affect their capacity to respond to an emergency situation”
(FEMA, 2009). Due to recent CDC findings, this percentage may be an underestimation of the population of individuals who fit this criterion (Courtney-Long et al., 2015).
This subgroup—individuals with physical disabilities that might impact one’s capacity to respond to an emergency situation—is large, including about approximately
30 million people at least fifteen years old with “limitations associated with ambulatory activities of the lower body including difficulty walking, climbing stairs, or using a wheelchair, cane, crutches, or walker” (Brault, 2010, p. 8), and about 20 million people who had difficulty with “physical tasks relating to upper body functioning, including
9 difficulty lifting and grasping” (Brault, 2010, p. 8). To date, models that attempt to explain the interactions among disaster exposure, perceived threat of disasters, emergency preparedness self-efficacy, and outcomes (emergency preparedness and symptoms of anxiety and distress) have been based on studies using community or college student samples (e.g., Burns et al., 2014a; Marceron & Rohrbeck, 2013).
Understanding how these models apply to vulnerable community populations such as individuals with physical disabilities is crucial as these groups face more barriers to preparedness and emergency response behaviors than the general population.
Other individual differences may interact with disability status and lead to increased negative psychological and physical health outcomes when facing disasters.
For individuals and families, racial and ethnic minority status, gender, language, socioeconomic status, age and physical ability have been identified as factors contributing to the likelihood of taking action to prepare for emergencies (Kohn et al.,
2012; Levac et al., 2012; Mileti, 1999).
Disaster Exposure
Exposure to natural and/or human-made disasters is associated with increased perceived threat of disasters (Plapp & Werner, 2006) and psychological symptoms
(Harville, Jacobs & Boynton-Jarrett, 2015). Differences in the impact of disasters on individuals with physical disabilities may be explained by both differences in exposure as well as vulnerability (Perilla, Norris, & Lavizzo, 2002). In this context, differential exposure refers to differences in the extent to which individuals in vulnerable groups (i.e. individuals with disabilities, low SES, racial/ethnic minorities) are exposed to more traumatic aspects of disasters, such as living in more vulnerable homes. Differential
10 vulnerability implies that vulnerable groups are more affected by stressors, regardless of degree of exposure, meaning the context for which life events occur is critical in understanding reactions to stressful events (Perilla et al., 2002).
In addition to causing negative psychological outcomes, continued exposure to disasters and reminders of disasters (i.e. media coverage after a disaster) can also have a positive effect —they can motivate individuals to prepare for future emergencies. For example, increased emergency preparedness (e.g., improved hurricane preparedness following exposure to a hurricane) is one example of a positive behavioral outcome of disaster exposure (Sattler, Kaiser, & Hittner, 2000).
Perceived Threat of Disasters
Continued reminders of the possibility and likelihood of disasters (transportation security screenings, disaster watches and warnings, television and social media announcements, etc.) have been conceptualized as “ongoing threat” (Marshall et al.,
2007). Research on perceived threat of disasters has included multiple aspects, for example, the likelihood of a threatening event’s occurrence, its possible severity or adverse consequences, and worry or dread of the event (Slovic, Finucane, Peters, &
MacGregor, 2004). Continued reminders of the possibility and likelihood of disasters
(e.g., transportation security screenings, disaster watches and warnings, etc.) contribute to that perceived threat (Marshall et al., 2007).
Perceived threat is influenced by characteristics of an impending disaster and an individual’s knowledge and experience with that type of disaster (Villegas et al., 2013).
For example, individuals who face an impending hurricane evaluate personal threat based on hurricane characteristics (i.e. category at landfall) and prior knowledge and experience
11 with hurricanes (Villegas et al., 2013). Perceptions can be cognitive and affective (Chan
& Rhodes, 2014; Fischhoff, Slovic, Lichtenstein, Read, & Combs, 1978; Slovic, 2002).
The anticipation of a stressful event may also generate as much anxiety as the actual occurrence of an event (Mantler, Matejicek, Matheson, & Anisman, 2005), and regardless of whether or not an individual is at risk, mere perception of threat can impact behavior
(Kasperson et al., 1988; Slovic, 2002). Personal threat and fear caused by the potential for physical harm (as may occur in disasters) frequently leads to changes in personal behavior with the goal of minimizing exposure to risk (Huddy, Feldman, Capelos, &
Provost, 2002; Villegas et al., 2013). For example, perceived threat is strongly associated with likelihood of evacuating during a hurricane (Villegas et al., 2013). Individuals are therefore more likely to prepare for emergencies as perceived threat of disasters increases. This suggests that some degree of perceived threat is necessary to lead to changes in personal behavior. The problems associated with long-term, heightened risk appraisal in a chronically threatening environment (i.e. psychological symptoms) demonstrate the need for interventions to mitigate the impact of disaster threat on symptoms while also increasing emergency preparedness.
Self-efficacy
Self-efficacy has been defined as the belief in one’s ability to generate the motivation and resources to overcome obstacles, maintain personal functioning, and attain favorable outcomes among stressors associated with an event (Benight & Bandura,
2004). Four types of experience are involved in the development of self-efficacy: enactive mastery (personal attainments), vicarious experience (modeling), verbal persuasion, and psychological arousal (anxiety). Ultimately it is the individual’s cognitive
12 appraisal and integration of these experiences that determines an individual’s self- efficacy. As experience with a task increases, judgments about self-efficacy become more automatic (Gist & Mitchell, 1992). Generation of positive outcomes occurs though self- regulation of thought, emotion, and behavior and advantageous responses further increase self-efficacy (Bandura, 1997; Hobfoll, 2007). Individuals’ self-efficacy beliefs influence the choices they make, such that most individuals choose an action they feel competent in completing rather than one that they do not (Amtmann et al., 2012). Without the belief that they can produce desired effects and prevent undesired effects based on their actions, individuals have little motivation or incentive to act (Bandura, 2001). Previous research has shown that self-efficacy predicts health behaviors and can also moderate the relationship between stressors and health outcomes (Amtmann et al., 2012; Rigby,
Domenech, Thornton, Tedman, & Young, 2003). Benight and Bandura explain that
“masterly action transforms the threateningness of the environment,” suggesting that people who are more self-efficacious tend to take more control of their environments therefore reducing negative psychological reactions (2004, p. 1132).
Researchers have examined how individual characteristics such as social support, resources, knowledge of disasters, information seeking, and personality traits relate to outcomes following large-scale emergencies in an effort to identify those associated with increased positive outcomes and those associated with better outcomes (Bourque et al.
2012). Self-efficacy, or an individual’s perceived ability to respond as needed to certain situations when they arise (including disasters), is one such characteristic included in disaster preparedness models (Paton, 2003). Social learning theory supports self-efficacy as a malleable and dynamic characteristic, making it a particularly important
13 characteristic to include in models of emergency preparedness (Bandura, 1977; Bandura,
2001) that are designed to inform interventions. Self-efficacy can be conceptualized and assessed at different levels of specificity (ranging from general self-efficacy, the broadest conceptualization, to domain or context-specific, narrower conceptualizations, e.g., mathematics self-efficacy, artistic self-efficacy). While some experiences create a more generalized sense of self-efficacy, some produce mastery in a particular domain
(Bandura, 1977). Because self-efficacy can be context-specific, it is important to identify the degree of specificity required for measuring self-efficacy in disasters.
According to Benight and Bandura (2004), coping self-efficacy, which falls on the general end of the continuum, consists of an individual’s beliefs in his or her ability to cope with the demands of a posttraumatic environment and manage his or her reactions to severe stress. Benight and his colleagues have used coping self-efficacy measures (from 7 to over 30 items) to measure perceived self-efficacy beliefs about recovering from different types of traumatic experiences, including domestic violence (Benight, Harding-
Taylor, Midboe, & Durham, 2004) and various types of natural disasters (e.g., Benight,
Ironson, & Durham, 1999; Benight, Freyaldenhoven, Hughes, Ruiz, & Zoschke, 2000;
Benight, Swift, Sanger, Smith, & Zeppelin, 1999). When used in studies on disasters, the construct of coping self-efficacy (post disaster thoughts and behaviors that minimize damage, costs and harm) has usually been measured within a specific context, for example after a hurricane or a flood, with items referring to that type of disaster. Those studies have resulted in a proliferation of context-specific disaster coping scales that prevent easy comparisons of self-efficacy across disaster types.
14 In contrast, another approach is to include items assessing similar self-efficacy beliefs about emergency preparedness beliefs that would apply to all disasters, and could be assessed pre-disaster (a priori beliefs about one’s ability to minimize damage, costs and harm). This is how the Emergency Preparedness Self-Efficacy (EPSE) scale was developed (Burns et al., 2014a). The EPSE does not measure specific disaster or general post-disaster coping self-efficacy; rather, it measures pre-disaster emergency preparedness self-efficacy beliefs that can be applied to all disaster or public emergency situations. This level of measurement is consistent with the all hazards approach to disaster preparedness as promoted by FEMA, the Red Cross, and the CDC. The all hazards approach suggests focusing on emergency preparedness behaviors that will be effective across multiple disaster types (FEMA, 2010).
Some of the determinants of self-efficacy, including effort, ability, luck and task difficulty, likely interact by disability severity (Gist & Mitchell, 1992). To date, however, there is little research to suggest how self-efficacy would predict outcomes for individuals with physical disabilities. There is evidence, however, that individuals with physical disabilities report lower self-efficacy in some areas. For example, individuals with cerebral palsy reported lower scores on measures of general self-efficacy and specific health promotion self-efficacy as compared to individuals without physical disabilities (Becker & Shaller, 1995). In that study, individuals who required mechanical assistance had higher ratings of self-efficacy than those who required personal assistance, suggesting that perhaps those who have the ability to operate assistive devices tend to have higher self-efficacy than those who must rely on others for assistance (Becker &
Schaller, 1995). Higher levels of self-efficacy may also be related to better quality of life,
15 fewer symptoms of depression, and better mobility functioning as reported by individuals with multiple sclerosis (Schmitt, Groverover, DeLuca, & Chiaravalloti, 2014).
Individuals with the same degree of neurological impairment who had higher levels of self-efficacy reported better functional outcomes (i.e. walking and climbing stairs) than individuals who had lower self-efficacy. In this case, self-efficacy moderated the relationship between neurological impairment and functional outcomes (Schmitt et al.,
2014). As such, varying types and severity of physical disability may influence barriers and/or other predictors of emergency preparedness.
Self-efficacy is positively related to financial, educational, and functional status
(i.e. an individual’s ability to perform normal daily activities required to meet basic needs) (Becker & Schaller, 1995), characteristics typically negatively associated with physical disability (Van Willigen et al., 2002). In addition, people with physical disabilities face many barriers to improvement in their mental and physical health, including discrimination and misperceptions from healthcare providers, institutional bias, limited provision of personal assistance services, and difficulty with access to emergency services (Becker & Schaller, 1995). These factors may well diminish one’s ability to develop self-efficacy. Given the importance of self-efficacy as a malleable predictor for important outcomes, it is important to understand how individual differences affect the formation of self-efficacy beliefs. As they do in other areas, individuals with physical disabilities may have lower self-efficacy regarding emergency preparedness, and low emergency preparedness self-efficacy may lead to poorer emergency preparedness.
16 Emergency Preparedness
Natural and human-made disasters can have devastating effects on victims, particularly those who are not well prepared for these events. In addition to psychological outcomes, disasters can lead to personal injury, death and/or property damage. The concept of emergency preparedness arises from the “hazard cycle” including four distinct and time-sensitive stages: mitigation, preparedness, response and recovery (Fox et al.,
2007). Household emergency preparedness is one of the most effective ways to mitigate the effects of disasters (Levac et al., 2012). Emergency preparedness includes understanding the risks for a particular community, having emergency plans for evacuation and sheltering in place, practicing those plans, and having necessary emergency supplies (Levac et al., 2012). Generally, emergency preparedness refers to
“all actions taken before the disaster by responders and those directly affected that enable proactive engagement of social units when the disaster occurs” (Fox et al., 2007, p. 197).
Further, emergency preparedness is dynamic in nature, and it requires modification as social contexts or individual characteristics change, including becoming physically disabled (Levac et al., 2012).
Previous research found that coping self-efficacy is positively related to individual emergency preparedness (Lee & Lemyre, 2009). Additionally, research has shown that those who engaged in emergency preparedness were less likely to engage in avoidance behaviors associated with human-made disasters such as avoiding public places, avoiding news coverage on terrorism issues, and feeling nervous around certain people (Lee & Lemyre, 2009). Several stress and coping models imply that exposure to stressful or threatening circumstances may strain an individual’s coping resources to a
17 certain point at which he or she becomes motivated enough to actively reduce stress
(Epstein, 1993; Lazarus & Folkman, 1991). On the other hand, if coping resources are strained beyond means and the individual does not behave in a way that reduces stress, he or she may be at a greater risk for psychological symptoms (anxiety, distress; Lazarus &
Folkman, 1991). Being prepared for an emergency may also reduce general anxiety so that when a stressor occurs, the impact is less significant (Lee et al., 2009).
The inclination and ability to prepare for disasters may also depend on one’s degree of disability. Disability status is a contributing factor to low emergency preparedness (Levac et al., 2012). For example, individuals reporting physical limitations were less likely to have essential emergency preparedness items or have an emergency evacuation plan in comparison to individuals who did not report such limitations (Bethel,
Foreman, & Burke, 2011). Further, individuals with a health problem requiring the use of special equipment were also less likely to have essential emergency preparedness items than their able-bodied counterparts. Just as emergency preparedness is typically a low priority for the general population, for many individuals with disabilities, emergency preparedness may be “another task in a long list of needs that must be met” (National
Council on Disability, 2009). These findings suggest the need for public health programs to consider the role of physical disabilities and target individuals with such vulnerabilities to increase overall emergency preparedness behaviors essential for mitigating the effects of disasters (Bethel et al., 2011).
Results from the first global survey of how persons living with disabilities cope with disasters suggest “the key reason why a disproportionate number of disabled persons suffer and die in disasters is because their needs are ignored and neglected by the official
18 planning process in the majority of situations. They are often left totally reliant on the kindness of family, friends and neighbors for their survival and safety” (United Nations
Office for Disaster Risk Reduction (UNISDR), 2013, p. 1). Even when disaster-related services are available, they are often unprepared for the needs of individuals with disabilities (Fox et al., 2007). Emergency preparedness and response systems are typically “designed for people without disabilities, for whom escape or rescue involves walking, running, driving, seeing, hearing, and quickly responding to instructions, alerts, and evacuation announcements” (National Council on Disability, 2005, p. 12). In a study on preparedness across the United States for people with mobility disabilities, only 27 percent of emergency managers reported completing federal training on the needs of people with disabilities and 20 percent of emergency managers reported having guidelines for people with disabilities in place (Fox et al., 2007). In a study on hurricane evacuation, those with physical disabilities reported a lack of access or perceived lack of access to services and assistance as the reasons for not evacuating or as barriers to recovery after the event (Stough, Sharp, Decker, & Wilker, 2010; Van Willigen et al.,
2002).
Anxiety and Distress
Exposure to disasters, both directly and indirectly, is associated with negative psychological outcomes, including increased symptoms of anxiety and distress (Maclean,
Popovici, & French, 2016; Marshall et al., 2007; Neria, Nandi, & Galea, 2008; Sederer,
2012; van den Berg, Wong, van der Velden, Boshuizen, & Grievink, 2012). Degree of exposure to disaster is related to risk, with direct victims at the greatest risk for developing psychological symptoms, followed by emergency response workers, and
19 finally, the general population (Sederer, 2012). Further, degree of direct exposure to disaster is positively related to symptoms of anxiety and post-traumatic stress disorder over time (van den Berg et al., 2012). Disaster events experienced during childhood may lead to increased risk of psychological disorders, particularly anxiety disorders, in adulthood (Maclean et al., 2016). Although studies have shown positive relationships between direct exposure and proximity to the disaster and psychological symptoms
(PTSD), studies have also shown that mental health consequences of disasters are not limited to those who are directly exposed; those who are indirectly exposed to disasters may have psychological symptoms, sometimes exceeding those who are directly exposed
(Marshall et al., 2007; Neria et al., 2008).
For example, individuals exposed to media messages regarding human-made disasters, specifically terrorist attacks, and those who experienced other indirect exposure also have shown considerable symptoms of anxiety (Marshall et al., 2007; Silver et al.,
2013; Swenson & Henkel-Johnson, 2003). A national survey conducted several days after the September 11th attacks demonstrated that 44 percent of adults living in the United
States were experiencing one or more significant symptoms of distress. As most adults living in the United States did not experience direct exposure to the attacks, these findings suggest that indirect exposure to human-made disasters is also associated with considerable distress (Schuster et al., 2001). Exposure to natural disasters has also been associated with increases in symptoms of anxiety and distress. For example, exposure to floods (Mason, Andrews, & Upton, 2010), earthquakes (Bland, O’Leary, Farinaro, Jossa,
& Trevisan, 1996), and hurricanes (Acierno et al., 2007) resulted in higher levels of anxiety, distress, and post-traumatic stress symptoms.
20 In addition to previously reported evidence that individuals with disabilities are impacted more severely in disasters, such as difficulty or inability to escape during a disaster, there is also evidence that individuals with disabilities may experience higher levels of anxiety and distress as compared to those without disabilities. Although disability did not moderate the impact of hurricane season on psychological distress in a study on ongoing threat of hurricanes, individuals with disabilities reported higher levels of distress than those without disabilities (Zeinomar, Caracciolo, Andresen, Brumback, &
Defries, 2007). Further, disability severity is a predictor of symptoms of anxiety (Jones et al., 2014).
Explanatory Models of Disaster Outcomes
There are several theories that would predict how the previously mentioned constructs—disasters, threat, self-efficacy, preparedness and psychological symptoms— would interact. This study is based on an integration of two theories. In Protection
Motivation Theory (Maddux & Rogers, 1983), threats of personal harm initiate a cognitive appraisal process by which the individual evaluates 1) the severity of the event,
2) the probability of occurrence, and 3) the efficacy of a recommended coping response.
In this model, cognitive processes stimulate protection motivation, which arouses, sustains, and directs behavior to minimize exposure to risk and protect the self from harm. The third component of the cognitive process, the efficacy of a recommended coping response, has two components: 1) the individual’s belief that the response will mitigate potential damage and 2) the individual’s belief that they are capable of adopting the recommended response (Maddux & Rogers, 1983). Mishra and Suar (2012) suggest that individuals will only engage in preventive responses if both beliefs are held. Self-
21 efficacy, or an individual’s expectations of personal mastery, is this second component of the efficacy of a recommended coping response.
Specific predictions about how efficacy beliefs interact with perceived threat when predicting behaviors have been presented in the Risk Perception Attitude framework (RPA; Rimal & Real, 2003). Although this framework has usually been used in the behavioral health literature, it can also be applied to disaster outcomes. The RPA framework predicts both a direct effect of self-efficacy on behaviors as well as an interaction between self-efficacy and perceived threat on behaviors. It is argued that those who feel efficacious are likely to view potential risks or threat as challenges to overcome, whereas those lacking in efficacy are likely to interpret potential risks or threat more fatalistically, and, as a result, are less likely to engage in risk-reducing behaviors (Rimal
& Real, 2003).
This model proposes four outcomes of perceived threat and self-efficacy interactions. When both self-efficacy and perceived threat are low (i.e., “indifferent attitude”), individuals are not motivated to take action. When self-efficacy is high, but perceived threat is low (i.e., “proactive attitude”), individuals have the belief that they can prepare but may lack the motivation to do so because of their low perceived threat status. In contrast, when threat perception is high, self-efficacy beliefs may have a greater effect on behaviors. Specifically, when both self-efficacy and perceived threat are high
(i.e., “responsive attitude”), individuals may be motivated to prepare because they believe they can reduce their threat. On the other hand, when self-efficacy beliefs are low but threat perception is high (i.e., “avoidant attitude”), individuals’ perceived inability to prepare for threatening events may decrease their motivation and they may prepare less
22 than those with responsive attitudes (Rimal & Real, 2003; Turner, Rimal, Morrison &
Kim, 2006).
While the Protection Motivation Theory (Maddux & Rogers, 1983) provides a model of the cognitive appraisal process that is initiated by threats of personal harm and demonstrates the importance of self-efficacy, the Risk Perception Attitude framework
(Rimal & Real, 2003) illustrates specific predictions for behavioral outcomes as they relate to an individual’s varying levels of perceived threat and self-efficacy. Thus, RPA adds to the PMT model by predicting specific outcomes.
As predicted by RPA, emergency preparedness self-efficacy has been shown to moderate the relationship between perceived threat and symptoms of anxiety and distress
(Burns et al., 2014a) and the relationship between perceived threat and emergency preparedness (Marceron & Rohrbeck, 2014). Previous research by Benight and colleagues found that perceived coping self-efficacy mediated post-traumatic recovery post-disasters (Benight & Bandura, 2004). However, those studies were conducted soon after significant exposure to a disaster, and thus address one’s perceived ability to cope with the aftermath of disasters. In fact, coping constructs such as self-efficacy do not only arise from a particular stressor, but may also interact with a stressor when predicting outcomes (Holmbeck, 1997). Thus, both RPA and the coping literature suggest that self- efficacy should also buffer, or moderate, the relationship between ongoing disaster threat and disaster outcomes.
Some studies looking at the relationship between perceived threat and behavioral activation show positive relationships while others show negative relationships. There are several explanations for mixed results. First, perceived threat may induce excessive fear
23 which subsequently inhibit action, therefore making clouding a potential direct effect.
Second, due to the correlational nature of most studies, researchers are unable to disentangle the positive and negative effects perceived threat has on engaging in behavioral modification (Rimal & Real, 2003).
Potential Confounds
There are several variables that could be confounds in this study, and are important to include as covariates in analyses. First, exposure to disasters may be related to an individual’s emergency preparedness self-efficacy and emergency preparedness behaviors. For example, a person who has experienced a blizzard may be more likely to understand the threat involved in disasters, believe they are capable of preparing and engage in preparedness behaviors. Exposure to disasters has been measured in different ways, including direct exposure to an event (e.g., losing a loved one, bodily injury, seeing others harmed) and indirect exposure to an event (e.g., knowing others who have suffered, watching media coverage after the disaster, etc.) (Neria et al., 2008; Silver et al.,
2013). Such measures probably reflect a continuum in degree of exposure to disasters. In the disaster literature, exposure to disaster is consistently related to risk for developing psychological symptoms (Sattler et al., 2000). Direct victims are at greatest risk for developing psychological symptoms, followed by emergency response workers, and finally the general population (Neria et al., 2008; Sederer, 2012).
In addition to including exposure to disasters, data highlights the importance of including demographics when considering the role of disabilities in emergency preparedness. All racial and ethnic groups are represented in the population of individuals with physical disabilities in the United States (25.6% Native Hawaiian or Pacific
24 Islander, 18.5% African-American, 16.3% American Indian, 14.8% Caucasian, 15.3%
Hispanic, and 9.1% Asian; CDC, 2012b). In 2013, Black, Non-Hispanic adults reported the highest prevalence rates of any type of disability in the United States (Courtney-Long et al., 2015). Racial and ethnic minorities are both disproportionately affected by disasters and less prepared for disasters (Eisenman, Glik, Maranon, Gonzales, & Asch,
2009a). Further, risk of mobility impairment and disability is positively associated with low income, low education, and living in an economically disadvantaged neighborhood
(Courtney-Long et al., 2015; Nordstrom, 2007). Not only are individuals with physical disabilities at increased risk of injury or death during disasters because of their potential inability to evacuate, but they are also disproportionately affected by low income status, lack of social support, and violence—factors detrimental to emergency preparedness
(Smith & Notaro, 2009). Research on emergency preparedness among individuals with disabilities shows that the following demographics are associated with being less prepared for an emergency: female, non-white, younger (e.g., younger than age 44), uncoupled, less educated, unemployed, low income, and urban residential area (FEMA,
2009; Smith & Notaro, 2009). A lack of resources is a considerable barrier to both emergency preparedness self-efficacy and emergency preparedness behaviors.
Research on how gender, race, and ethnicity (White, Black, Mexican American men and women) affect age-trajectories of disability severity supported an interactional effect where all subgroups showed greater functional limitations than White men (Warner
& Brown, 2011). Although baseline disability levels remained stable with age for most groups, Black women in their 50s and early 60s demonstrated a trajectory of accelerated physical disablement, suggesting worse outcomes than any other subgroup. The social
25 mechanisms behind more rapid accumulation of physical disability for this group are unclear; however, prior studies demonstrate perceived discrimination, earlier and greater caregiving responsibilities, elevated stress hormones and segregation in disadvantaged neighborhoods as possible contributing factors. Several risk factors may cluster together and exacerbate disaster risk (Levac et al., 2012; Warner & Brown, 2011).
Disability severity may also be another characteristic that could impact emergency preparedness beliefs and behaviors. Disability is a construct on a continuum from fully enabled to completely disabled (NIDRR, 2014) and, due to the heterogeneity of this population, it is important to control for differences that may exist. For example, individuals using wheelchairs or other assistive devices may have more significant problems engaging in emergency response plans (Rahimi, 1993) or rely on the assistance of others (Kelman & Stough, 2015) as compared to individuals lower on the continuum of disability. As a result, disability severity may impact important variables in the study model including perceived threat of disasters, emergency preparedness self-efficacy, emergency preparedness and symptoms of anxiety and distress.
As these study data were self-reported, it is important to consider the role of social desirability, or the tendency for an individual to misrepresent herself in order to maintain a favorable self-presentation, in participants’ responses (Ray, 1984). Although the tendency to “fake good” is more likely to occur with socially sensitive questions, previous research has noted the tendency for participants to respond with social desirability bias regardless of the sensitivity of the survey content (Miller, 2012). For example, although reporting actions taken to prepare for a disaster may not be
“sensitive,” participants may respond in a manner that is socially favorable and over
26 report preparedness behaviors. Controlling for social desirability will correct for socially desirable responding and increase the validity of research findings.
Current Study
Emergency preparedness is important for individuals with all types of disabilities; however, the current study focused on individuals with physical disabilities that might have an impact on one’s capacity to respond to an emergency situation (FEMA, 2009).
Although emergency preparedness planning literature (FEMA, 2004) reveals policies, strategies and funding focused on involving individuals with disabilities in emergency preparedness planning, these initiatives are general and do not speak to the unique needs of specific subpopulations of those with disabilities (Smith & Notaro, 2009). In addition to providing general guidelines about how to prepare, such as checklists of actions to take to prepare for emergencies, it is important to investigate perceptions about self-efficacy as well as obstacles to preparedness or emergency response behaviors for this population as these factors may be important for increasing engagement in emergency preparedness and response. Further, emergency preparedness planning teams often do not include individuals with physical disabilities, potentially causing these teams to overlook the specific needs of this population (Smith & Notaro, 2009). Clearly, this is a sizable group of the population that has been neglected in research on emergency preparedness planning.
In our prior work, the Emergency Preparedness Self-Efficacy (EPSE) scale was positively correlated with general self-efficacy and positive outcomes (e.g., emergency preparedness behaviors) and was inversely correlated with perceived threat of disasters and symptoms of anxiety and distress (Marceron, Rohrbeck, & Burns, 2013; Rohrbeck &
27 Burns, 2012). Our research has also shown that the EPSE has strong psychometrics in both natural and human-made disaster contexts (Marceron et al., 2013). Our research
(and that of others) has not, however, included perspectives and health outcomes from individuals with physical disabilities. As a result of this gap in the literature, there is a need to better understand domain-specific self-efficacy from the perspective of members of this population (Becker & Schaller, 1995), in addition to how self-efficacy interacts with threat in predicting preparedness behaviors and psychological symptoms.
As previously mentioned, past research on the effects of disasters on individuals with physical disabilities has been limited primarily to direct exposure, consequences, and recovery from disasters with considerably less focus on preparedness for disasters or adjustment to the ongoing threat of disasters. As emergency preparedness is crucial for disaster mitigation, it is important that research addresses this gap in the literature.
Conducting research on perceived threat and emergency preparedness prior to the occurrence of disasters rather than post-disaster can inform preventive interventions. Few studies have investigated levels of preparedness for individuals with physical disabilities and researchers are now starting to investigate how to improve emergency preparedness for this population.
The current study addresses gaps in knowledge about individual characteristics associated with emergency preparedness behaviors for individuals with physical disabilities and subsequently aims to reduce barriers to preparedness for individuals with physical disabilities, specifically with mobility impairments and other physical disabilities that may affect one’s capacity to respond in an emergency situation. This study tested hypotheses about relationships between perceived threat, emergency
28 preparedness self-efficacy and emergency preparedness and psychological symptoms.
The current study defines “physical disability” in accordance with the Americans with
Disabilities Act (Americans with Disabilities Act of 1990). Further, a “physical impairment” is defined by the ADA “any physiological disorder or condition, cosmetic disfigurement, or anatomical loss affecting one or more of the following body systems: neurological, musculoskeletal, special sense organs, respiratory (including speech organs), cardiovascular, reproductive, digestive, genitourinary, hemic and lymphatic, skin, and endocrine” (Americans with Disabilities Act, 1990). As the disabled population is heterogeneous, identifying sub-groups of this population (i.e. persons with physical disabilities vs. intellectual disabilities) may be most informative for understanding the unique needs for specific subpopulations.
To address these gaps in research, this study used a cross-sectional design to assess exposure to disasters, perceived threat of disasters, emergency preparedness self- efficacy, emergency preparedness behaviors, and symptoms of anxiety and distress for individuals with physical disabilities. The overall model (see Figure 1) is based on the
Protection Motivation Theory (Maddux & Rogers, 1983) and Risk Perception Attitude framework (Rimal & Real, 2003) and suggests that self-efficacy may moderate the relationships between perceived disaster threat and outcomes and that the “outcomes”
(emergency preparedness and anxiety/distress) may be interrelated.
29
Figure 1. Summary Model. Lines in bold represent this study’s hypotheses.
Clearly some of these relationships over time will also be reciprocal, but those will not be included in this study. This study focused on the latter part of the model. As illustrated in this model emergency preparedness self-efficacy may serve as a protective factor that might interact with, or moderate, the relationship between perceived threat of disasters and emergency preparedness and psychological outcomes (anxiety and distress). A moderation model is used in the current study because self-efficacy does not account for the relationships between perceived threat of disasters and outcomes (preparedness and psychological symptoms) as a mediation model would assume, but rather affects the strength and/or direction of those relationships. Perceived threat and emergency preparedness self-efficacy are highlighted in this study because these constructs appear to be more malleable than other constructs in the model, such as exposure, and are likely to influence emergency preparedness behaviors as well as psychological symptoms
(anxiety, distress; Gist & Mitchell, 1992). Although not represented in the model, other individual differences, (e.g., disaster exposure, demographic variables (e.g., SES,
30 education, gender, ethnicity, and age), disability severity, social desirability) could be significantly related to emergency preparedness self-efficacy, emergency preparedness behaviors, and physical and psychological outcomes, and are therefore included as control variables. The following hypotheses were tested:
Hypothesis 1: Emergency preparedness self-efficacy will interact with the perceived threat of disasters when predicting emergency preparedness behaviors such that higher levels of perceived threat of disasters will be positively associated with emergency preparedness for individuals with high emergency preparedness self-efficacy and less strongly associated with emergency preparedness for individuals with low emergency preparedness self-efficacy (See arrow 1 on above model).
Hypothesis 2: Emergency preparedness self-efficacy will interact with perceived threat of disasters when predicting anxiety such that higher levels of perceived threat of disasters will be positively associated with anxiety for individuals with low emergency preparedness self-efficacy, but will be less strongly associated with anxiety for individuals with high emergency preparedness self-efficacy (See arrow 2 on above model).
Hypothesis 3: Emergency preparedness self-efficacy will interact with perceived threat of disasters when predicting distress such that higher levels of perceived threat of disasters will be positively associated with distress for individuals with low emergency preparedness self-efficacy, but will be less strongly associated with distress for individuals with high emergency preparedness self-efficacy (See arrow 3 on above model).
31 Method
Participants
Data were collected from 294 community members living in the United States.
The sample was composed of 199 females and 95 males, ranging in age from 18 to 84 years (M = 44.67 years, SD = 14.38). Approximately 84 percent of participants self- identified as White/Caucasian, 17% identified as ethnic minorities including 7% identified as African American, 5% identified as Biracial or Multiracial, and less than 2% each as
Hispanic or Latino, “Other,” Asian or Asian American, Alaska Native, Native American, or American Indian (none of the participants identified as Native Hawaiian or Pacific
Islander). All 294 participants identified as having a physical disability. Participant disability severity measured by a self-report of participants’ difficulties due to health conditions including physical disabilities (WHODAS 2.0) varied (M = 82.65, SD = 25.75, range 36-161). Additionally, participants reported the number of days per month difficulties were present (M = 15.09, SD = 12.56), that they were totally unable to carry out usual activities (M = 5.92, SD = 9.62), and cut back usual activities (M = 9.29, SD =
10.33) due to their physical disability. Approximately 60% of participants described their disability as acquired (developed during childhood or adulthood) and the rest as lifelong
(since birth). The estimated income reported by participants varied, with approximately
42% earning less than $25,000, 36% between $25,000 and 75,000, 6% earning between
$75,000 and 100,000, and 4% earning more than $100,000 annually (approximately 11% were not sure of their income). Participants included all levels of education, with approximately 13% having some high school, trade school or graduating high school,
50% with some college or graduating college, and approximately 37% with some post-
32 graduate education or degree. Social desirability varied (M = 18.74, SD = 4.12, range 8-
24). See Table 1 for sample characteristics.
Approximately 60% of participants reported their relationship status as single with approximately 40% identifying as married/living with partner. Residential community type varied, with approximately 37% living in an urban community, 46% living in a suburban community and 18% of participants living in a rural community.
Participants were representative of most of the states in the United States of America.
The states with the highest representation include Colorado (9%), Illinois (9%),
California (8%), North Carolina (8%), Kansas (5%), Pennsylvania (5%), Virginia (5%),
Oregon (5%), and Washington, DC (4%).
Procedure
Prior to initiating this project, researchers applied for and obtained approval from
The George Washington University’s Institutional Review Board. Power analyses were run with the following parameters/assumptions: power = .80, alpha = .10 (given the study’s directional hypotheses), and a small effect size based on prior research (.08). That analysis suggested a sample size of approximately 300. Participants were recruited through organizations serving individuals with physical disabilities (See Appendix A).
Individuals were eligible for participation if they met the following criteria at the time of the study: 1) 18 years or older, 2) self-identification as someone with a physical disability, and 3) residing in the US. Potential participants were asked to email the study coordinator for more information about participating in the study; in response, the coordinator emphasized eligibility criteria, asked for the potential participant to confirm these criteria and asked if he or she was interested in the online or telephone survey
33 format. If responders acknowledged meeting these criteria, the study coordinator emailed the individual a unique link to the survey on Qualtrics (or arranged for a telephone interview at a later time with the primary researcher or a research assistant). Blank emails and emails with no content about disability status were ignored.
Various organizations and individuals involved in serving adults with physical disabilities were contacted to assist with participant recruitment (See Appendix A for organizations who agreed to assist with recruitment). United Cerebral Palsy (UCP) was the first organization to advertise the current study and assist with participant recruitment.
UCP recruited participants through web page posts, social media announcements
(Twitter, Facebook) and emails. Affiliates at UCP also collaborated with the primary researcher to create a brief video recording describing the study. The video was posted on a UCP web page along with a description of the study, eligibility requirements and contact information for those wanting to participate in the study. The web page describing the study noted the primary researcher’s disability status as a person with cerebral palsy to provide the community of individuals with physical disabilities some context and background on why this study was personally important to the researcher.
The aim of establishing the primary researcher’s membership in this community was to reduce suspicion and build trust with the population. This web page was posted on UCP
Facebook and Twitter accounts and was also disseminated to other organizations serving people with physical disabilities. Approximately 100 participants completed the survey during the first seven months of recruitment using this approach.
At that time, it became clear that additional resources would be necessary to recruit the planned sample size (N = 300). Various other organizations serving
34 individuals with physical disabilities were contacted and asked to disseminate the research opportunity to their respective clients (See Appendix A for a list of organizations who were contacted). Those interested in assisting with recruitment received a short description of the study including eligibility and participation information as well as a link to the UCP web page and a copy of the electronic flyer and were encouraged to use any or all of the recruitment materials. Several responders volunteered to disseminate the research opportunity to other individuals and organizations in their network. Additonally, researchers periodically posted an electronic copy of the recruitment flyer on various social media and networking sites (e.g.,
Instagram, LinkedIn, MeetUp.com), that focused on individuals with disabilities. These strategies resulted in approximately 224 additional participants during the last two months of data collection and a final total of 324 participants.
The first 104 participants were given the option to be compensated by electronic or paper gift cards; 92 of those participants elected to receive electronic gift cards. Due to this participant compensation procedure, it was possible for individuals to complete the survey despite residing outside of the United States, thus not meeting eligibility requirements for participation. Some responses were suspect, due to a number of responses with poor English. In addition, study materials were found on non-contacted organizational websites. For all these reasons, the recruitment and participant compensation procedures were modified (and those modifictions were approved by the
GWU IRB). In the modified procedure, individuals interested in participating were instructed to email the study coordinator their names and addresses (for participant compensation purposes; this information was later discarded) and preferred survey format
35 (online or telephone interview) in addition to providing acknowledgement of meeting the study’s eligibility criteria. From that point on, a respondents responding with poor
English were cross checked with whitepages.com to ensure that the participant was an individual person who has not already completed the survey and was also living in the
United States. As before, the study coordinator then emailed each eligible participant an individual a link to a Qualtrics survey (or arranged for a telephone interview).
The survey began with a consent form. If participants consented to the study, they chose “Yes, I would like to continue” and proceeded to the survey. Approximately 70 participants read the consent and chose not to proceed with the survey. The online format was set to be accessible for individuals with disabilities according to the accesibility features on Qualtrics to allow the use of screen readers, if needed. On average, the survey took approximately 20-30 minutes (or 40-60 minutes by telephone) to complete. As participants were given the opportunity to pause the survey and resume at a later time (to prevent fatigue or drop out for individuals with severe limitations), duration of the survey varied (ranging from approximately 9 minutes to 10 days). 43 participants completed the survey by telephone interview and 281 participants completed the survey online and independently.
Participants were compensated with a $10 gift card of their choice (Amazon,
Target, or iTunes) for their time completing the survey. The first 103 participants were given the option to receive the gift card electronically or by mail. After changes to the payment procedure, the remaining participants received the gift card by mail at the address they provided during participant recruitment.
36 Measures
After agreeing to the consent form, the survey measures were presented in a randomized order. The final question on the survey asked the participant “Is there anything else you want to share about your beliefs and reactions to emergencies and disasters?” and allowed an open-ended response. After completing the survey questions, participants selected their preferred gift card, were given the option to receive the results of the research upon completion of the study. (They were also asked if they would be willing to be contacted (by email) for a possible follow-up study; 277 of participants who completed the survey consented to be contacted in the future for a follow-up study).
Perceived threat of disaster. Questions addressed three components of perceived threat of natural and human-made disasters that have been used in previous research
(Slovic et al., 2004). First, participants reported their estimated likelihood of occurrence of a natural or human-made disaster in the next 6 months (e.g., “In your view, what is the likelihood of another human-made disaster (for example, bombing, hurricane, tornado, or bioterrorism) in [your city or town] the next six months?”) on a 7-point Likert scale. Second, they were asked about the severity of consequences of a future human- made disaster (e.g., “In your view, how negative would the consequences be for you if another natural or human-made disaster occurred [in your city or town] in the next six months?”) on the same 7-point Likert scale. Finally, participants were asked about how much they dread future disasters (e.g., “How concerned or worried are you about the possibility of another natural or human-made disaster occurring in [your city or town] the next six months?”) on a 7-point likert scale. The three questions were asked with regard to their local area of residence (“in your city or town”), and again, with regard to the
37 entire United States (“in the United States”). When combined, prior research has found an alpha of .70 for those 6 items.
Emergency preparedness self-efficacy. The EPSE (Burns, Rohrbeck, Moore, &
Peterson, 2014b) is designed to assess individuals’ self-efficacy beliefs regarding preparedness for emergencies that occur in all types of natural and human-made disasters.
It includes 7 items; for example “I can protect my property and myself in an emergency” and “I can deal with the emotions that arise in an emergency.” Instructions ask participants to rate how confident they are in their ability to successfully carry out each item on a Likert scale from 1 (not at all capable) to 5 (totally capable). Internal consistency (Cronbach’s alpha = .89) and test-retest reliability (r = .83, p < .001) has been strong (Burns et al., 2014b). Similar psychometric support has been found in both natural and human-made disasters (Marceron et al., 2013). In our prior work, the EPSE was positively correlated with general self-efficacy and positive outcomes (e.g., emergency preparedness behaviors) and was negatively correlated with perceived threat of disasters and symptoms of anxiety and distress (Rohrbeck & Burns, 2012).
Emergency Preparedness Checklist. The Emergency Preparedness Checklist
(EPC) assesses participants’ level of emergency preparedness. Items were drawn from the emergency preparedness literature and relevant websites, including the American Red
Cross and FEMA, which include emergency management behaviors recommended for individual households preparing for a natural or human-made disaster. The 21-item checklist was piloted with a sample of undergraduate students, and their feedback prompted revisions. This measure has shown evidence of reliability and validity in both college student (Burns et al., 2014b, Cronbach’s alpha= .84) and community samples
38 (Marceron et al., 2013; Cronbach’s alpha=.85). Instructions ask participants to indicate if they have “taken the action in the last year” by marking yes or no for each item. Sample items from the EPC include “Have stored a three-day supply of water,” “Have a map of local area with shelters in the car or close by,” and, “Have fire, police, and hospital phone numbers readily available” (Marceron et al., 2013).
Anxiety. Symptoms of anxiety were measured with the GAD-7. The GAD-7 is a widely used and empirically based measure (Spitzer, Kroenke, Williams, & Lowe, 2007) that includes 7-items on a 4-point Likert scale ranging from “not at all” (0) to “nearly every day” (3). Participants report how frequently they have experienced symptoms of anxiety over the past two weeks. Items include “feeling nervous, anxious or on edge” and
“not being able to stop or control worrying”. The GAD-7 has a high internal consistency
(Cronbach’s alpha = .92) and high test-retest reliability (.83) (Spitzer et al., 2007).
Psychological distress. Symptoms of distress were measured with the Kessler
Distress Scale (K6; Kessler et al., 2002). The 6-item K6 scale was developed to estimate the prevalence of individuals with a high likelihood of non-specific diagnostic psychological distress (Kessler et al., 2010). Participants report how frequently they have experienced symptoms of psychological distress in the past 30 days on a 5-category scale.
Items include “During the past 30 days, how often did you feel…nervous?” and
“hopeless?” The K6 scale is preferred for assessing the presence of anxiety or mood disorders because it is brief and has minimal bias with regard to education level and gender (Baillie, 2005; Furukawa, Kessler, Slade, & Andrews, 2003). The K6 has demonstrated high internal consistency (Cronbach’s alpha = .89; Kessler et al., 2003) and evidence of discriminant validity and convergent validity (Kessler et al., 2010).
39 Potential Confounds
Exposure to disaster. Currently there is no standard method for measuring exposure or severity of exposure (Chan & Rhodes, 2014). Unlike most disaster research, measures from this study did not assess participants directly following a specific disaster event, but instead assessed past disaster history. As with our prior research on disasters, exposure to disaster was measured by self-report items assessing lifetime direct personal and indirect exposure to disasters (Marceron et al., 2013). Participants were asked to think about (up to) three emergency situations they had personally been experienced due to natural and human-made disasters. For each event, participants indicated the extent to which they experienced consequences of the disaster by checking boxes next to descriptions such as “were injured yourself” or “lost electricity for three days or more.”
Participants could endorse any or all of the exposure descriptions.
Previous studies suggest there may be limits to the extent to which past experience makes perceived threat more salient or may activate cognitive and behavioral schemas (Anderson, 1969; Mileti & O’Brien, 1992). People tend to forget events that took place a long time ago and memory biases form (Sattler et al., 2000). Thus, exposure to disasters was dichotomized into two categories: high and zero to low exposure, based on theory that salience of personal exposure would be less likely to deteriorate over time and would be most likely to impact other study variables. Participants who endorsed any of the following items for any of the three disaster experiences described were categorized into the “high” level of exposure: “were injured yourself,” “saw others injured or killed,” and/or “had family members that were injured or killed.” Participants who endorsed any of the other descriptions of exposure to disasters were categorized into
40 the “zero to low” level of exposure. More than half of participants endorsed items consistent with a “low” level of disaster exposure (71.09%) and 29.81% of participants endorsed items consistent with a “high” level of disaster exposure (See Table 1).
Demographic Data. The following demographic variables were collected: age, gender, race/ethnicity, relationship status, disability status (yes/no; if yes: lifelong/acquired), city/state of residence, residential community type (urban, suburban, rural), income, and level of education.
Disability Severity. The World Health Organization Disability Assessment
Schedule 36-item version, self-administered (WHODAS 2.0) assesses participants’ difficulties due to health conditions including physical disabilities. The WHODAS 2.0 was developed based on the same conceptual basis as the International Classification of
Functioning, Disability, and Health (IFC) (WHO, 2014). Items include “In the past 30 days, how much difficulty did you have in: Standing for long periods such as 30 minutes?
Moving around inside your home?” Previous research has shown this measure to be valid across samples of older people in seven developing countries including urban sites in
Cuba, Dominican Republic and Venezuela, and rural and urban sites in Mexico, Peru,
China and India (Sousa et al., 2010). Internal consistency is reported as good to excellent
(Schlote et al., 2009).
Social Desirability. The social desirability scale assesses participants’ tendency to respond to questions in ways that are usually perceived as more favorable by others, and was measured by a shortened 8-item version of the Marlowe-Crowne scale (Ray,
1984). Items are answered as “True,” “False,” or “I don’t know.”
41 Statistical Analysis
Prior to hypothesis testing, the data were examined for outliers, skewed distributions, missing data, and errors, and corrected when possible. Participants were removed from data analysis if they completed the survey twice, denied having a physical disability, did not provide an address within the United States, and completed the survey in less than 9 minutes.1 Participants endorsing all 21 items of the Emergency Behavior
Checklist, the total number of possible preparedness behaviors, were excluded from further analyses as well. 30 participants were removed for the final sample. Descriptive data and hypothesis testing was completed using this final sample (N = 294) 2.
All analyses were carried out using Statistical Analysis System (SAS). Three separate ANCOVAs were used to test each hypothesis and included relevant covariates
(SES, education, gender, race/ethnicity, age, social desirability, disability severity, and disaster exposure).
Results
Demographic characteristics of the final sample are included in Table 1. Pearson’s product-moment correlations were calculated to examine the bivariate relationships between study variables of interest (See Table 2). As expected, perceived threat of disasters was inversely related to emergency preparedness self-efficacy (r = -.29, p<.0001) and positively related to symptoms of anxiety (r = .26, p<.0001) and symptoms of distress (r = .24, p<.0001). Contrary to what was expected, perceived threat was not related to emergency preparedness (r = -.05, ns). Also as expected, emergency
1 The minimum survey duration time (9 minutes) was determined by several pilot assessments taken as quickly as possible by the researchers while completing the survey. 2 The hypotheses were later tested using all participants, including the questionable respondents (N = 324). Results were similar—significant results were the same across both samples.
42 preparedness self-efficacy was positively related to emergency preparedness (r = .41, p<.0001) and inversely related to symptoms of anxiety (r = -.26, p<.0001) and symptoms of distress (r = -.32, p<.0001). Emergency preparedness was not related to symptoms of anxiety (r = -.06, ns) or distress (r = -.05, ns) (See Table 2).
Emergency preparedness self-efficacy means were similar for this sample of adults with physical disabilities (M = 22.78, SD = 5.93, N = 294) as compared to a college sample (M = 23.65, SD = 5.56, N = 319; Burns et al., 2014b), and a community sample (M = 24.42, SD = 5.79, N = 310; Burns et al., 2014a). Further, this sample of adults with physical disabilities reported similar levels of distress (M = 11.42, SD = 4.34,
N = 294) as compared to a college sample (M = 12.93, SD = 4.18, N = 385; Marceron &
Rohrbeck, 2013) and a community sample (M = 12.51, SD = 4.10, N = 310); Burns et al.,
2014a).
Bivariate correlations between study variables and potential confounding variables including disaster exposure, demographic variables, disability and social desirability were also examined (See Table 3). Perceived threat was positively correlated with disability severity (r = .35, p<.0001). Emergency preparedness self-efficacy was positively correlated with income (r = .18, p<.01), inversely correlated with disability severity (r = -.53, p<.0001) and positively correlated with social desirability (r = .16, p<.01). Emergency preparedness was positively correlated with disaster exposure (r =
.20, p<.001), income (r = .20, p<.001) and social desirability (r =.16, p<.01) and inversely correlated with disability severity (r = -.12, p<.05). Symptoms of anxiety was positively correlated with exposure to disasters (r = .13, p<.05) and disability severity (r
= .46, p<.0001) and inversely correlated with income (r = -.19, p<.01), age (r = -.12,
43 p<.05) and social desirability (r = -.17, p<.01). Symptoms of distress was positively correlated with exposure to disasters (r = .15, p<.01) and disability severity (r = .55, p<.0001) and inversely correlated with income (r = -.17, p<.01) and social desirability (r
= -.16, p<.01) (See Table 3).
Differences in study variables by race/ethnicity and gender were examined (See
Tables 4 and 5, respectively). Individuals who identified as non-White reported higher levels of perceived threat than those reporting as White (t = 2.08, p<.05; See Table 4).
Individuals who identified as male reported higher levels of emergency preparedness self-efficacy than individuals who identified as females (t = 3.22, p<.01; See Table 5).
Open-ended self-reports of beliefs and reactions to emergencies and disasters at the end of the survey were examined for themes. Participants’ responses were consistent with themes in the literature suggesting that adults with physical disabilities perceive and/or experience limited or no access to emergency services meeting their specific needs. In addition, they described these limitations as barriers to emergency preparedness
(Stough, Sharp, Decker, & Wilker, 2010; Van Willigen et al., 2002).
The Moderating Role of Self-Efficacy on the Relationship Between Threat and
Outcomes
Hypotheses 1 through 3 were tested using analyses of covariance (ANCOVAs): the interaction between the moderator (emergency preparedness self-efficacy) and the presumed causal factor (perceived threat) when predicting the outcomes (emergency preparedness, symptoms of anxiety and symptoms of distress) were examined for significance. Analyses were computed with the previously mentioned covariates including disaster exposure, demographic variables (SES, education, gender,
44 race/ethnicity, age), disability severity (Schlote et al., 2009), and social desirability (Ray,
1984).
Because our past research indicated that self-efficacy was a moderator only at high levels (e.g., Burns et al., 2014a; Marceron & Rohrbeck, 2014), emergency preparedness self-efficacy was dichotomized into two groups, low and high self-efficacy, based on a median split (median = 22.78). Participants with an emergency preparedness self-efficacy score below 23 were categorized into the “low” group and participants with an emergency preparedness self-efficacy score above 23 were categorized into the “high” group.
As hypothesized (Hypothesis 1), results indicated that emergency preparedness self-efficacy moderated the relationship between perceived threat of disasters and emergency preparedness behaviors such that perceived threat of disasters was more positively associated with emergency preparedness for individuals with high emergency preparedness self-efficacy but less strongly associated with emergency preparedness for individuals with low emergency preparedness self-efficacy (B = -.38, p < .001) (See
Table 6 and Figure 1). In order to more fully examine this effect, participants were divided into four equal groups of self-efficacy (by quartiles) and the relationships between perceived threat and emergency preparedness self-efficacy when predicting emergency preparedness were plotted (See Figure 2). As illustrated in Figure 2, only participants in the top fourth of emergency preparedness self-efficacy show a positive relationship between perceived threat and emergency preparedness.
Contrary to the above results for the outcome of emergency preparedness, the hypothesized interactions between perceived threat and emergency preparedness self-
45 efficacy when predicting symptoms of anxiety and distress were not significant
(Hypothesis 2 and 3) for either anxiety (B = -.05, ns) or distress (B = .02, ns) (See Tables
7 and 8, respectively). Given the lack of interactions, main effects between perceived threat and emergency preparedness on anxiety and distress were then examined.
Perceived threat of disasters was positively related to symptoms of anxiety (B = .18, p<.05) but not to symptoms of distress (B = .03, ns). Emergency preparedness self- efficacy was not related to symptoms of either anxiety (B = 1.08, ns) or distress (B = -.08, ns).
Discussion
This study was designed to test relationships among perceived threat of disasters, emergency preparedness self-efficacy, and two types of outcomes—emergency preparedness, and symptoms of anxiety and distress—for adults with physical disabilities.
The findings of this study add to the small body of literature on psychological and behavioral components of disaster research for individuals with physical disabilities.
Before testing hypotheses, it was important to report descriptive statistics and relationships among variables to examine whether they were as expected, or if they might differ for individuals with physical disabilities compared to individuals without disabilities. Because there is some evidence that individuals with physical disabilities report lower self-efficacy in some areas (Becker & Shaller, 1995), it may be expected that emergency preparedness self-efficacy would be lower for a sample of adults with physical disabilities as compared to adults without physical disabilities; however, this was not the case for this sample. This study found similar levels of emergency
46 preparedness self-efficacy as has been found in past studies with college student and adult community samples.
Relationships among threat, self-efficacy, preparedness and psychological symptoms were as expected and also similar to studies with samples not selected for disabilities. For example, individuals who reported higher threat had fewer self-efficacy beliefs and were more likely to experience psychological symptoms of anxiety and/or distress (Burns et al., 2014a; Burns et al., 2014b; Marceron et al., 2013; Marceron &
Rohrbeck, 2014; See Table 2). Also as expected, the extent to which people believed they could prepare for emergencies was positively related to preparing for emergencies (Burns et al., 2014a; Burns et al., 2014b; Marceron et al., 2013; Marceron & Rohrbeck, 2014;
See Table 2) but not related to symptoms of anxiety or distress (See Table 2). In the current study, perceived threat of disasters was not related to emergency preparedness.
Previous research on the relationship between perceived threat of disasters and preparedness are mixed; some studies support a positive relationship between perceived threat and preparedness while others do not (Wachinger, Renn, Begg & Kuhlicke, 2013).
It is possible that the relationship between perceived threat and emergency preparedness is curvilinear such that perceiving either little to no threat or overwhelming threat may inhibit preparedness.
Relationships between study variables and potential covariates also showed similar results as has been found in other studies. For example, individuals who identified as non-White and those endorsing high disability severity reported higher levels of perceived threat. This is consistent with previous research (Bourque et al., 2013). Perhaps individuals who identify as ethnic minorities experience more immediate threats in daily
47 life than their white counterparts. Such relationships suggest the importance of including race/ethnicity, if only as a covariate, in models of disaster preparedness. These relationships also suggest that people with more severe physical disabilities are likely to perceive higher disaster threat. Emergency preparedness self-efficacy was significantly related to gender, income, disability severity and social desirability such that high self- efficacy was associated with identifying as male, having a higher income, having lower disability severity and responding in a socially desirable manner. These relationships are also consistent with previous findings. The positive relationships between social desirability and emergency preparedness self-efficacy and emergency preparedness suggest participants responded in a favorable manner and reinforces the importance of using social desirability as a covariate in this research. The relationship between disability severity and emergency preparedness is consistent with prior research (Smith &
Notaro, 2009), suggesting that people are less likely to prepare for emergencies as physical disability severity increases. Symptoms of anxiety and distress were positively related to disaster exposure, disability severity, age and social desirability and inversely related to income. Findings on the relationship between disability severity and symptoms of anxiety and distress were also consistent with prior research (Zeinomar, Caracciolo,
Andersen, Brumback, & Defries, 2007; Jones et al., 2014). These results highlight the importance of including demographic variables in disaster research as they are related to important variables in models of disaster outcomes.
Hypotheses. Emergency preparedness self-efficacy had a bolstering effect on the relationship between perceived threat of disasters and emergency preparedness behaviors for individuals with physical disabilities (hypothesis 1). In general, participants with
48 higher emergency preparedness self-efficacy reported more preparation for disasters than those with lower emergency preparedness self-efficacy; however this relationship was strongest for those with both higher threat and higher self-efficacy. For this sample, higher levels of emergency preparedness self-efficacy are necessary for a strong positive relationship between threat and preparedness. At low levels of emergency preparedness self-efficacy, high perceived threat may even inhibit preparedness (See Figures 1 and 2).
Furthermore, this interaction was significant when controlling for potential confounding variables including demographic characteristics (SES, education, gender, race/ethnicity, age), in addition to social desirability, disability severity, and past disaster exposure. This result is consistent with previous research showing that self-efficacy can moderate the relationship between stressors and health outcomes (Amtmann et al., 2012; Rigby,
Domenech, Thornton, Tedman, & Young, 2003). These findings are consistent with research on the relationship between self-efficacy and preparedness (Lee & Lemyre,
2009) and research on the relationship between emergency preparedness self-efficacy and preparedness (Marceron & Rohrbeck, 2014) in college student and general community samples not sampled for physical disabilities.
This moderating effect of emergency preparedness self-efficacy suggests that within the context of ongoing threat of natural and human-made disasters, higher levels of perceived threat can motivate individuals to prepare for disasters but only for those who also have high emergency preparedness self-efficacy. For this sample, self-efficacy had a more significant impact when perception of threat was high; differences in preparedness were greatest between individuals with highest self-efficacy and who perceive high threat than those with low self-efficacy and who perceive high threat (See
49 Figure 2). For individuals with physical disabilities, there may be a greater tendency to avoid preparedness behaviors when perception of threat is high and when self-efficacy is low. For individuals with lower self-efficacy there is an inverse relationship between perceived threat and preparedness (See Figure 2; EPSE 1 and 2). Thus, at low levels of self-efficacy, high threat may even inhibit preparedness. For individuals with higher self- efficacy, there is a positive relationship between perceived threat and preparedness and this relationship is stronger for those with the highest level of self-efficacy (See Figure 2;
EPSE 3 and 4). At high levels of self-efficacy, high threat appears to motivate preparedness.
These results are consistent with both the Protection Motivation Theory (PMT;
Maddux & Rogers, 1983) and the Risk Perception Attitude framework (RPA; Rimal &
Real, 2003). Generally, those who feel efficacious (high emergency preparedness self- efficacy) are likely to view potential risks or threat as challenges to overcome, whereas those lacking in efficacy (low emergency preparedness self-efficacy) are likely to interpret potential risks or threat more fatalistically, and, as a result, are less likely to engage in risk-reducing behaviors, such as preparing for disasters (Rimal & Real, 2003).
Results of this study are also consistent with the RPA proposed four outcomes of perceived threat and self-efficacy interactions. For example, with regard to emergency preparedness, when both perceived threat and emergency preparedness self-efficacy are low (i.e., “indifferent attitude”), individuals are not motivated to prepare for emergencies.
When perceived threat is low, but self-efficacy is high (i.e., “proactive attitude”), individuals have the belief that they can prepare but may lack the motivation to do so because of their low perceived threat status, therefore engaging in less emergency
50 preparedness. People with high self-efficacy may be only slightly more likely to prepare for emergencies than people with low self-efficacy in low perceived threat situations. In contrast, when both self-efficacy and perceived threat are high (i.e., “responsive attitude”), individuals may be motivated to prepare because they believe they can reduce their threat. On the other hand, when self-efficacy beliefs are low but perceived threat is high (i.e., “avoidant attitude”), individuals’ perceived inability to prepare for threatening events may decrease their motivation and they may prepare less than those with responsive attitudes (Rimal & Real, 2003; Turner, Rimal, Morrison & Kim, 2006).
Figures 1 and 2 show this pattern for individuals in this study.
Although emergency preparedness self-efficacy moderated the relationship between perceived threat and emergency preparedness for this sample, emergency preparedness self-efficacy did not have a buffering effect on the relationship between perceived threat and symptoms of anxiety (hypothesis 2) or distress (hypothesis 3). These findings differ from previous research demonstrating a buffering effect of emergency preparedness self-efficacy on relationships between perceived threat and symptoms of anxiety and distress (Burns et al., 2014b). In that study, the relationship between perceived threat and psychological symptoms was stronger for individuals with low emergency-preparedness self-efficacy in comparison to individuals with high emergency preparedness self-efficacy. In other words, emergency preparedness self-efficacy appeared to be a protective factor when coping with perceived threat.
Burns et al. (2014b), however, focused on only perceived terrorism threat, not a broader definition of disaster threat including natural disasters. In addition, it was based on a college sample, which would differ in many ways from the national adult sample
51 with physical disabilities used in this study. Lack of support for the hypothesized interaction between threat and self-efficacy on anxiety and distress was consistent with another study using an adult community sample (Marceron & Rohrbeck, 2014). Future research may want to include disability severity as more than a covariate in the model; perhaps disability severity is a moderator of the proposed interaction between threat and emergency preparedness self-efficacy when predicting psychological symptoms. Because people with physical disabilities in previous research reported lack of access or perceived lack of access to services and assistance as the reasons for not evacuating or as barriers to recovery after the event, these perceived barriers and realistic barriers may also interact with perception of threat and emergency preparedness self-efficacy (Stough, Sharp,
Decker, & Wilker, 2010; Van Willigen et al., 2002).
Another possible explanation for the lack of significant interactions may be due to the context in which the study variables were measured. Outcomes may have been different, for example, with increased immediacy or saliency of perceived threat of disasters. This study measured perceived threat of disasters with six questions measuring general concerns regarding disaster events (likelihood, severity, worry/dread) rather than specific concerns about specific disasters (i.e. perceived impact of sheltering in place during a hurricane). Symptoms of anxiety and distress were also measured based on general clinical symptoms rather than specifically associated with disaster exposure.
While broader measures of these variables increases generalizability to all potential disasters, the lack of specificity of measurement may have decreased their sensitivity and therefore account for the lack of findings. In contrast to other disaster studies, this study
52 measured threat and symptoms pre-disaster; perhaps relationships between those constructs is highlighted after disasters.
Another explanation for the lack of significant interactions between perceived threat of disasters and emergency preparedness self-efficacy when predicting symptoms of anxiety and distress may be due to the nature of the relationship between threat and psychological symptoms. The statistical tests used in this study assume linear relationships among variables, disregarding the possibility of a nonlinear/curvilinear relationship; however, if that relationship is curvilinear, models of quadratic regression may be more appropriate. It is possible that the lack of interaction between threat and self-efficacy when predicting psychological symptoms is due to a “goldilocks principle,” such that low perceived threat may not motivate people to prepare, while high perceived threat may overload coping resources, induce helplessness and prevent engaging in preparedness; this relationship occurred for individuals with the lowest level of self- efficacy (See Figure 2). However, when the perception of threat is “just right,” individuals may feel both motivated and capable of preparing for disasters and therefore engage in emergency preparedness behaviors. This would be consistent with Protection
Motivation Theory (Maddux & Rogers, 1983) which suggests that threats of personal harm initiate a cognitive appraisal process by which the individual evaluates 1) the severity of the event, 2) the probability of occurrence, and 3) the efficacy of a recommended coping response. Perhaps, in this case, probability of occurrence must be sufficiently high, but not overwhelming, in conjunction with high efficacy of the coping response for an individual to feel motivated and capable of preparing for disasters. This would also be consistent with several stress and coping models which imply that
53 exposure to stressful or threatening circumstances may strain an individual’s coping resources to a certain point at which he or she becomes motivated enough to actively reduce stress (Epstein, 1993; Lazarus & Folkman, 1991) but if coping resources are strained beyond means and the individual does not behave in a way that reduces stress, he or she may be at a greater risk for psychological symptoms or avoidance behaviors
(Lazarus & Folkman, 1991).
Due to the lack of support for hypotheses 2 and 3, main effects (or direct relationships) between threat and emergency preparedness self-efficacy and psychological symptoms were also tested. There was a significant positive link between threat and anxiety; as perceived threat increased, symptoms of anxiety increased. This is consistent with previous research indicating that the anticipation of a stressful event may generate as much anxiety as the actual occurrence of an event (Mantler, Matejicek,
Matheson, & Anisman, 2005). In contrast, perceived threat was not related to symptoms of distress (Burns et al., 2014b). Thus these results provide mixed support for previous research demonstrating that as perceived threat of disasters increases, symptoms of anxiety and distress increase (Benight et al., 1999; Lee et al., 2010; Schuster et al., 2001;
Silver et al., 2013, Swenson & Henkel-Johnson, 2003).
Emergency preparedness self-efficacy was not directly related to symptoms of anxiety or symptoms of distress. These findings are contrary to previous research demonstrating relationships between self-efficacy and symptoms of anxiety and distress for general populations without explicit physical disabilities (Benight & Bandura, 2004).
The current study, however, measured relationships between self-efficacy and psychological symptoms pre-disaster rather than post-disaster, as Benight & Bandura
54 (2004) have done. This difference in the timing of measurement may account for the lack of findings in the current study.
Although this study reported bivariate correlations between perceived threat and symptoms of anxiety and distress, and between self-efficacy and symptoms of anxiety and distress, only the main effect between threat and anxiety remained significant in more complete analyses controlling for potential confounding variables (See Table 5). Prior studies reporting support for such relationships among threat, self-efficacy and psychological symptoms have reported only bivariate relationships and not included possible confounds or interactions (Mantler, Matejicek, Matheson, & Anisman, 2005;
Marceron, Rohrbeck, & Burns, 2013). Thus, it can be argued that the lack of expected findings with regard to psychological symptoms suggests the need to include more multivariate models in disaster research.
Limitations of this study include its cross-sectional design, which prevents the possibility of establishing directional relationships among variables. Future research over time, and use of experimental designs, should provide increased understanding of the direction of relationships among variables and cause and effect relationships. Use of an internet-based survey enabled nationwide data recruitment and participants were free to express themselves without fear of stigma. On the other hand, for those participants responding online, there is no guarantee that participants met the participation eligibility criteria or provided accurate or valid responses. This may have increased error variance and prevented additional significant results. In addition, use of internet- and social media- based methods to advertise this study no doubt prevented a completely representative sample of adults with physical disabilities in the United States.
55 Because this survey was distributed to subscribers on the FEMA Office of
Disability Integration and Coordination email listserv, resulting participants may be more self-efficacious and more prepared than the overall population of adults with physical disabilities in the United States. It is also possible that individuals who completed this study are more invested in emergency preparedness than the general population of adults with physical disabilities. Additionally, this sample appears wealthier and more educated than typical samples of individuals with physical disabilities. The median annual income of individuals with physical disabilities in the US in one study was $23,976 (Brault,
2010) whereas, in the current sample, the median response was in the income range of
$25,000 to $34,999. In 2013, approximately 11.5% of adults with a physical disability
(defined as difficulty walking up stairs) had attained a bachelor’s degree or higher
(Houtenville, Brucker & Lauer, 2015). The current sample, however, was characterized by 50% with some college or graduating college and approximately 37% with some post- graduate education or degree. Thus, results may generalize most to individuals with physical disabilities who have higher education levels and incomes (Courtney-Long et al., 2015; Nordstrom, 2007; Van Willigen et al., 2002). Future studies should address these limitations by recruiting participants with lower incomes and/or by collecting data through surveys completed in-person or by telephone.
Despite these limitations, the current study makes several important contributions.
First, this study recruited a sample of adults with physical disabilities, thereby addressing a major gap in disaster research on individuals with physical disabilities (Becker &
Schaller, 1995; Fox et al., 2007; Smith & Notaro, 2009). Participants’ open-ended self- reports of beliefs and reactions to emergencies and disasters at the end of the survey,
56 suggests that adults with physical disabilities perceive and/or experience limited access to emergency services that meet their specific needs. They describe these limitations as barriers to emergency preparedness, consistent with previous research (Stough, Sharp,
Decker, & Wilker, 2010; Van Willigen et al., 2002). Thus, this study and others call for collaboration with community partners and health care providers to increase emergency preparedness with and for this population (Eisenman et al., 2009b; Smith & Notaro,
2009; UNISDR, 2013). Without the direct involvement of persons with disabilities on emergency preparedness planning teams, important preparedness mechanisms may be overlooked, subsequently increasing the risk of emergency related injury or death for persons in this population (Smith & Notaro, 2009). Interventions aimed at increasing emergency preparedness self-efficacy may be an important key in empowering this population.
Second, the results provide some support for the emergency preparedness self- efficacy scale (EPSE) as a measure of emergency preparedness self-efficacy for adults with physical disabilities, in addition to college students and adults not selected for disabilities. The EPSE showed similar means and relationships with threat and psychological symptoms as found in prior studies (Burns et al., 2014a; Marceron &
Rohrbeck, 2013; Marceron & Rohrbeck, 2014). The bivariate correlation (r=-.26) between the EPSE and anxiety (GAD-7 in this sample) was similar to the relationship between the EPSE with another measure of anxiety (the State Trait Anxiety Inventory) in a community sample from the greater Washington DC area (Burns et al., 2014a); a Fisher
Z test showed no significant difference. There was also no significant difference between the relationship between the EPSE and the K-6 (distress) in this sample and distress in
57 that community sample. In contrast, the relationship between the EPSE and preparedness behaviors was stronger (r=.41) in this study than that in the other sample (r=.18), a significant difference (Fisher’s Z=3.1, p<. 01). In summary, the pattern of correlations provides some evidence for the EPSE’s validity for adults with physical disabilities.
Future research can also examine specific EPSE items to see if individuals with physical disabilities respond similarly to items compared to those without physical disabilities.
Factor analyses may also indicate similar patterns of responses.
Interventions can focus on increasing emergency preparedness self-efficacy in order to directly increase emergency preparedness behaviors. Emergency preparedness self-efficacy is a malleable belief, which can be increased as new information is incorporated and as new experiences are acquired (Gist & Mitchell, 1992). Interventions aimed at increasing emergency preparedness self-efficacy could therefore teach individuals with physical disabilities how to prepare for disasters and provide vicarious and/or in vivo experiences of preparing. Interventions aimed at helping people prepare may also lead to increased emergency preparedness self-efficacy.
In addition, results from this study, indicating that emergency preparedness self- efficacy moderates the relationship between perceived threat of disasters and emergency preparedness behaviors, suggests the importance of increasing self-efficacy for those who perceive higher threat. In high threat conditions, those with lower self-efficacy appear to shut down and prepare less than others. In contrast, individuals who perceive high threat and also have higher self-efficacy, prepare the most. Thus it is particularly important to increase emergency preparedness self-efficacy for individuals who perceive high threat.
58 Because emergency preparedness is not always enough when implemented on a macro-level (e.g., government assistance; Fox et al., 2007), it is crucial to continue to increase individual or household preparedness, at a more micro-level. This study supports the work of emergency preparedness organizations, such as FEMA and the Red Cross who have noted the need for increased preparedness in individuals with disabilities. This study’s findings are also consistent with the mission of organizations working towards supporting individuals with physical disabilities. For example, the National Institute on
Disability and Rehabilitation Research (NIDRR) notes the need to “generate, disseminate and promote knowledge that will improve the lives of persons with disabilities in their communities” and conduct “comprehensive and coordinated programs of research and related activities to assist in the achievement of the full inclusion, social integration, employment, and independent living of people with disabilities” (NIDRR,
2013, p. i-1).
It should be noted that the rates of physical disabilities reported in the current study reflect prevalence at a given point in time, but not lifetime prevalence. Although fifty-three million adults living in the United States currently have a physical disability, many more will acquire a physical disability at some point in their lifetime. Chronic health conditions and circumstances of living contribute to the development of physical limitations and disabilities. Dunn (2015) describes disability as “part of the human condition and something that will likely affect all of us” and “as we age, the likelihood that we will experience functional challenges increases substantially” (p. 2). Although concerns relating to physical disabilities may seem distant to many people’s experience,
59 disability status can change for any person and, as a result, there is motivation for the general population to consider the needs of this group.
Communities cannot become adequately prepare for disasters without understanding the challenges faced by this large group of individuals. Potential differences in emergency preparedness beliefs for individuals with physical disabilities and how those beliefs impact their emergency preparedness have been crucial gaps in our understanding of emergency preparedness. The current study contributes to a more inclusive understanding of emergency preparedness beliefs and behaviors and subsequently informs interventions aimed at improving health and function for this population through targeting emergency preparedness self-efficacy. According to
FEMA’s Office of Disability Integration and Coordination, “when communities integrate the needs of children and adults with disabilities and others with access and functional needs into their community-wide planning initiatives, they maximize resources, meet their obligations and strengthen their ability to prepare for, protect against, respond to, recover from and mitigate all hazards” (FEMA, 2014). In addition, when emergency preparedness is increased for this group, the resilience of the entire community is strengthened as well (Levac et al., 2012).
60 Tables
Table 1
Sample characteristics
Variable N % Variable N %______
Gender Associate’s degree 25 8.50 Female 199 67.69 Bachelor’s degree 70 23.81 Male 95 32.31 Some graduate school 27 9.18 Master’s degree 67 22.79 Race/Ethnicity Doctoral degree 21 7.14 Alaska Native, Other 5 1.70 Native American, or American Indian 2 0.68 Income African American 20 6.80 $7,499 or less 35 11.90 Asian or Asian American 3 1.02 $7,500 to $14,999 47 15.99 Biracial or Multiracial 16 5.44 $15,000 to $24,999 44 14.97 Hispanic or Latino 4 1.36 $25,000 to $34,999 41 13.95 Native Hawaiian $35,000 to $49,999 40 13.61 or Pacific Islander 0 0 $50,000 to $74,999 25 8.50 Other 4 1.36 $75,000 to $99,999 19 6.46 White/Caucasian 245 83.33 $100,00 or over 11 3.74 Not sure 32 10.88 Education Pre-high school 1 .34 Disaster exposure Some high school 2 .68 High 85 28.91 High school diploma 23 7.82 Low 209 71.09 Some college 41 13.95 Trade school 12 4.08 ______
61 Table 2
Means, Standard Deviations, Ranges and Inter-Correlations for All Study Variables ______
Variable M SD Range 1 2 3 4 5 ______
1. Perceived Threat 17.18 4.06 6-28
2. Self-Efficacy (EPSE) 22.78 5.93 8-35 -.29****
3. Emergency Preparedness 10.02 4.25 0-20 -.05 .41****
4. Anxiety (GAD-7) 11.85 4.82 7-28 .26**** -.26**** -.06
5. Distress (K6) 11.42 4.34 6-30 .24**** -.32**** -.05 .76****
______Note: *p<.05, **p<.01, ***p<.001, ****p<.0001; N = 294.
62 Table 3
Correlations for Study Variables and Demographic Variables ______
Variable Perceived threat Self-efficacy Emergency Anxiety (GAD-7) Distress (K6) preparedness
Exposure .08 .01 .20*** .13* .15**
Education -.01 -.03 -.07 -.01 .00
Income -.11 .18** .20*** -.19** -.17**
Age .08 -.05 .02 -.12* -.04
Disability severity .35**** -.53**** -.12* .46**** .55**** (WHODAS)
Social desirability .02 .16** .16** -.17** -.16**
______
Note: *p<.05, **p<.01, ***p<.001, ****p<.0001; N = 294.
63 Table 4
Differences in means of study variables and Race/Ethnicity
White Non-White t-value
Perceived threat 16.88 18.40 2.08*
Self-efficacy 22.96 22.40 -0.49
Emergency preparedness 9.97 10.48 0.76
Anxiety (GAD-7) 11.72 12.52 1.06
Distress (K6) 11.20 12.50 1.56
Note: *p<.05, **p<.01, ***p<.001, ****p<.0001; N = 294.
64 Table 5
Differences in means of study variables and Gender
Female Male t-value
Perceived threat 17.39 16.59 -1.59
Self-efficacy 22.11 24.44 3.22**
Emergency preparedness 9.72 10.75 1.95
Anxiety (GAD-7) 11.91 11.72 -0.32
Distress (K6) 11.67 10.86 -1.49
Note: *p<.05, **p<.01, ***p<.001, ****p<.0001; N = 294.
65 Table 6
Parameter Estimates of ANCOVA for Emergency Preparedness Including Covariates
B t
Race/ethnicity 0.44 0.70
Gender 0.62 1.28
Age -0.00 -0.31
Income 0.31*** 3.34
Disability severity -0.00 -0.08
Social Desirability 0.14* 2.57
Exposure -1.64** -3.26
Perceived threat 0.23* 2.55
Emergency preparedness self-efficacy (EPSE) 4.10* 2.04
Perceived threat*EPSE -0.38*** -3.34
Note: *p<.05, **p<.01, ***p<.001, ****p<.0001; N = 294.
66 Table 7
Parameter Estimates of ANCOVA for Anxiety Including Covariates
B t
Race/ethnicity 0.23 0.33
Gender -0.002 -0.00
Age -0.05** -2.79
Income -0.14 -1.33
Disability severity 0.07**** 6.31
Social Desirability -0.13* -2.16
Exposure -0.86 -1.54
Perceived threat 0.18* 1.77
Emergency preparedness self-efficacy (EPSE) 1.08 0.49
Perceived threat*EPSE -0.05 -0.37
Note: *p<.05, **p<.01, ***p<.001, ****p<.0001; N = 294.
67 Table 8
Parameter Estimates of ANCOVA for Distress Including Covariates
B t
Race/ethnicity 0.72 1.21
Gender -0.56 -1.21
Age -0.03 -1.66
Income -0.07 -0.77
Disability severity 0.08**** 8.81
Social Desirability -0.10* -1.99
Exposure -0.80 -1.67
Perceived threat 0.03 0.41
Emergency preparedness self-efficacy (EPSE) -0.08 -0.04
Perceived threat*EPSE 0.02 0.18
Note: *p<.05, **p<.01, ***p<.001, ****p<.0001; N = 294.
68
Figure 1. The moderating effect of emergency preparedness self-efficacy on the relationship between perceived disaster threat and emergency preparedness behaviors.
Figure 2. The moderating effect of emergency preparedness self-efficacy (in four discrete groups (quartiles), from low to high self-efficacy) on the relationship between perceived disaster threat and emergency preparedness behaviors.
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83 Appendix A
1. Ability Connection of Colorado 2. Adaptive Sports and Recreation Association, CA 3. Agency for Persons with Disabilities 4. Alabama Disabilities Advocacy Program 5. American Association on Health and Disability (AAHD) 6. Arlington County Aging and Disability Services 7. California Foundation for Independent Living Centers 8. Centers for Independent Living in Florida 9. Centers for Independent Living in Illinois 10. Challenged Athletes Foundation, CA 11. Coalition of Citizens with Disabilities in Illinois 12. Colorado Chapter of National Multiple Sclerosis Society 13. Colorado Cross-Disability Coalition 14. Colorado Department of Human Services’ Division of Vocational Rehabilitation 15. Colorado Developmental Disabilities Council 16. Coverly Physical Therapy 17. DC Office of Disability Rights 18. DC Quality Trust 19. Denver Office of Disability Rights 20. Denver Physical Therapy – Centennial/DTC 21. Disability Action Center – NW, Inc. (DACNW) 22. DisAbility Resource Center in Fredericksburg 23. Disability Support Services, at The Catholic University of America 24. Disability Support Services, George Washington University 25. Disability Support Services, Georgetown University 26. Disability Support Services, James Madison University 27. Disability Support Services, University of Maryland 28. Disabled World 29. Easter Seals of Colorado 30. Easter Seals of DC, Maryland 31. Equal Employment Specialist, U.S. Department of State 32. Federal Emergency Management Agency, Office of Disability Integration and Coordination 33. Healthy Independent Leisure and Lifestyles 34. Kennedy Krieger Institute; Maryland Center for Developmental Disabilities 35. Lex Frieden, M.A., disability policy expert and disability rights activist 36. Maryland Developmental Disabilities Administration (DDA) 37. Mountain States Chapter of Paralyzed Veterans of America 38. Muscular Dystrophy Association, CA 39. National Council on Disability 40. National Disability Institute 41. National Disability Rights Network 42. National Multiple Sclerosis Society, National Capital Chapter 43. National Organization on Disability
84 44. National Rehabilitation Info Center 45. Northern Nevada Center for Independent Living 46. REACH, Inc. – Fort Worth, Dallas, Denton & Plano, TX 47. SourceAmerica 48. Spina Bifida Association of Colorado 49. Tara Sonenshine, GWU School of Media and Public Affairs 50. Texas Centers for Independent Living 51. The Arc of Denver 52. The Arc Serving Boulder & Broomfield Counties, CO 53. The Arc: National Office 54. The CP Network 55. The Endependence Center 56. United Cerebral Palsy 57. United Spinal Association 58. Virginia Board for People with Disabilities 59. Virginia Department for Aging and Rehabilitative Services 60. World Learning, Amy Reid
85