Abstract
Hospitals are perceived as stable sources of support and assistance for the community during disasters. Expectations may outstrip hospital plans or ability to provide for the public. The purpose of this project was to explore racial disparities found in prior research and general perceptions related to the public's expectations of hospitals during disasters. Qualitative interviews were conducted with members of the general public. Content analysis was used to analyze the data and identify themes that describe racial differences related to public expectations of hospitals. A total of 28 interviews were conducted. Half of the participants (n = 14) were black, 57% (n = 16) female, with a mean age of 49 years. No racial differences in terms of the general public's expectations of hospitals were identified. Participants believed that hospitals have a service role and responsibility during disaster response to provide both tangible and intangible supplies and resources to the uninjured public. Hospitals were perceived as able to provide these resources, in terms of having sufficient funds and supplies to share with the uninjured public. In addition, hospitals are perceived as being caring organizations that have compassion toward the public and thus as welcoming places to seek assistance following a disaster. Hospitals need to be prepared to manage the general public's expectations both before and during disasters.
Hospitals are perceived as stable sources of support and assistance for the community during disasters, but expectations may outstrip hospital plans or ability to provide for the public. The purpose of this project was to explore racial disparities found in prior research and general perceptions related to the public's expectations of hospitals during disasters. Qualitative interviews were conducted with members of the general public. Participants believed that hospitals have a service role and responsibility during disaster response to provide both tangible and intangible supplies and resources to the uninjured public.
I
The emergency functions of hospitals are defined not only by formal guidelines and regulations, but by the expectations of the general public, who perceive hospitals as sanctuaries and as a part of the social network during disasters. 4 Hospitals are expected not only to administer healthcare services during a disaster but also to deliver tangible and nontangible nonmedical resources to the community.4,5 The magnified role of the hospital as a community resource to meet a surge in both medical and nonmedical needs during disasters has the potential to stretch the hospital beyond reasonable capacity. Even absent a public emergency, hospitals struggle to meet the competing demands of reducing costs without negatively affecting the quality of care to their patients. 6 This economic challenge exacerbates the tension between the hospital's business to provide health care and its ethical obligation to serve its community. 4
Little research has been conducted on this topic. One prior study, consisting of a convenience sample of individuals surveyed at 3 St. Louis–area hospital emergency departments, found that the public has high expectations of hospitals to provide nonmedical resources, even to the uninjured, during disasters. 7 Examples of such nonmedical resources expected by the public include food, water, links to federal resources (eg, through the Federal Emergency Management Agency, FEMA), short- and/or long-term shelter, family reunification, and nonemergency transportation to and from the hospital. 7 An interesting finding from this study was that African American race was associated with having higher expectations of hospitals to provide nonmedical resources during a disaster; 7 however, the study's limited scope was unable to discern the reasons for this potential difference across races. The purposes of the present study were to expand the prior research by exploring potential racial differences in public expectations of hospitals to provide nonmedical resources to the uninjured during a disaster and to simply explore the public's expectations of hospitals in more depth.
Methods
Qualitative interviews were conducted with white and African American members of the general public in St. Louis, Missouri. We developed the questions for this study. Inclusion criteria included being either white or African American, being a St. Louis City or County resident, speaking English, and expressing the belief that hospitals should provide nonmedical resources to the uninjured during a disaster. Participants were recruited using posters hung at grocery stores, restaurants, and other venues across the St. Louis City and County region. Interviews were conducted by a single member of the research team and were audio recorded and then transcribed verbatim. Given the research team's assumption, based on findings from previous research, that there are racial disparities affecting individuals' expectations of hospitals, all interview transcripts were de-identified in terms of race prior to analysis.
Qualitative content analysis was used to analyze the data. Interview data were coded and categorized to identify concepts and themes that describe the public's expectations of hospitals to provide nonmedical support to the uninjured during a disaster. After coding and categorizing the interview data by theme, the research team analyzed the data for differences between white versus African American participants. No thematic differences were found across races, so the team combined the data for final analysis and summary. Thematic concepts identified are outlined, including participant quotes that characterize these themes. In addition to qualitative data, participants were asked questions about their demographics, number of primary care provider visits, hospital emergency room visits, hospital admissions that had occurred in the past 12 months, and whether they had suffered a loss of health or property during a past disaster. The study was approved by the university institutional review board (IRB).
Results
In all, 28 individuals participated, of whom half (n = 14) were white and 57.1% (n = 16) were female. Participants ranged in age from 20 to 79 years, with an average of 49 years. About a third (35.7%, n = 10) had a bachelor's degree; just under a quarter (21.4%, n = 6) had a high school diploma or less education. Over half (60.7%, n = 17) reported having an annual income below the median in Missouri (≤$40,000). A full description of participants' demographics is outlined in Table 1.
Participant Demographics
More than half (60.7%, n = 17) of the participants reported that they lacked medical insurance. Over one-third (39.3%, n = 11) reported having been to a hospital emergency department, either as a patient or a patient's caregiver, at least once during the past year. Of those visits, just over one-third (35.3%, n = 6) resulted in at least 1 hospital admission. Nearly three-fourths (71.4%, n = 20) of participants reported that they, their children, or their partner had been to a primary care provider at least once within the past year. Over half of the participants reported that they or their immediate family had experienced family separation (53.6%, n = 15), property loss (57.1%, n = 16), or physical injury (57.1%, n = 16) as a result of a natural or man-made disaster or as a result of war or conflict. With respect to medical vulnerabilities, half of the participants (50.0%, n = 14) indicated that they or a family member had a medical condition that necessitates ongoing use of electricity, and over a third of participants or their family members (39.3%, n = 11) regularly used medications that might require a refill during a disaster. The participants identified multiple themes or concepts related to their expectations of hospitals to provide nonmedical resources to the uninjured during a disaster.
Belief that Hospitals Have a Responsibility to Provide Resources to the Uninjured During a Disaster
Belief that this responsibility is part of hospitals' mission
Multiple participants expressed the belief that hospitals have the responsibility to provide nonmedical services to the uninjured during disasters, and that this is part of their mission:
The hospital's main goal … their purpose of being, is providing care to people, which may be medical, a lot of times it is preventative. … Medicine is inherently a human discipline, so if you're looking at it that way, one of the quickest jumps in people's mind is “I need help, I need somewhere to go”; it's probably going to be a hospital. Hospitals are a public service. [A hospital's] goal is to be responsive to the public and provide services and things that people need in times of disaster.
Additionally, participants expressed the belief that hospitals' mission is to show compassion and caring, which they believe translates into a responsibility to provide nonmedical resources for the public during disasters:
It's in [the hospital's mission] to [give] care and compassion for the poor and the less fortunate, and if my whole place is flooded, I'm less fortunate, so yeah, I think [hospitals have that responsibility to the community]. [Hospitals] talk about prayer and, you know, helping those who are poor and in need and that was the whole reason [hospitals were] based on that, so it was kind of like, you know, [hospitals] kind of got to practice what [they] preach here.
Beyond having a stated mission of caring, hospitals were perceived by participants to be caring members of the community and thus would naturally want to provide nonmedical resources and aid to the community out of their compassionate nature. As one participant stated:
[Hospitals want to provide these nonmedical resources] because they're … they're caring. They're a part of society that cares. So, I think it would be nice if they did that too [provided nonmedical resources to the uninjured]—during times of natural disasters.
Another participant stated, “I think hospitals are there because they care about people and they want to heal people, and I don't think you can go into that business if you don't care about humanity.” Some also expressed the belief that hospitals have a responsibility to help the community during a disaster, because hospitals are an essential part of the community as a whole. As one participant stated, “[Hospitals] are in the community, and as a member of the community, they should be responsible for the community to the extent that they can.”
Referrals to other agencies or sources for services and supplies for the uninjured
Multiple participants expressed the belief that they expect hospitals to, at the least, provide information or referrals regarding where the uninjured may obtain food, shelter, and other supplies during a disaster. As one participant noted, “It's the job of [hospitals] to direct people to areas where they can get [tangible supplies]. If nothing else, saying you can go to this agency and you can get food here, or something.” Another participant stated, “If [hospitals] can't help you right away, they could give you suggestions or advice of some services that they wouldn't have or some phone numbers [for referrals to obtain those services].”
Some participants expressed the belief that hospitals already have this information and should, therefore, be able to simply provide it to the public during disasters. As one participant stated, “[Hospitals] have a whole list of places you can go, services you can call. I wouldn't personally know anything about that, but a hospital should have a whole list of things.” Another stated:
If somebody needs some help or something, guide them to when they need to go someplace else to get additional assistance or whatever; I'm sure [hospitals] have people on staff that are capable of doing that.
Some participants described past experiences with disasters and the roles they perceived hospitals to have played during previous events. One participant said, “I've heard, when there's been disasters down in Louisiana or whatever, they'll say that the hospital can give resources on where to get clothing or shelter or something.” One participant believed that hospitals should have an assigned staff member(s) for this purpose. As the participant described it:
There needed to be a social worker or just someone who came in and spoke with that person without a home on where to place them next. … The hospital [should] have those resources as far as a referral.
Belief that Hospitals Have a Responsibility to Provide Nontangible Services to the Uninjured During a Disaster
Reunification
Multiple participants expressed the belief that hospitals need to provide reunification services during disasters. Reunification was perceived as an invaluable resource for disaster victims. As one participant stated, “It would be very beneficial and help people feel like they have a sense of place if their name is on a list so I can look on a list and see if my relatives are there.” Participants noted that hospitals are a logical place to meet up with or to seek out one's family members if they became separated due to a disaster. As one participant stated, “It just kind of makes sense to me that the hospital is kind of a rallying point for [finding your family].”
Another stated, “I think a hospital … should definitely be in your top three places to meet [up with family] in disasters.” One possible reason why so many participants expressed the belief that hospitals should provide reunification services is that there seemed to be a lack of awareness about other agencies that could provide this service. As one participant noted, “I don't know if many other agencies would be able to provide that [reunification].”
Safety and security
Many participants stated that they expect hospitals to provide safety and security to community members during disasters, even to the uninjured who are not seeking medical care. A common theme emerged that hospitals have a reputation of being a place of safety and security for the community. As one participant stated, “The hospital would be my automatic thought in terms of [seeking] safety [after a disaster].” Another stated:
I think there are probably other organizations that can help out, but I would think that the majority of people would probably feel more comfortable [and safe] in a hospital setting. I would.
It was noted by participants that hospitals already have security staff in place:
[Hospitals provide] security, too, because they have private security forces, and I would be worried about people's behavior, rioting and stuff like that, like a breakdown of law and order. So, I would expect the hospital to have a security staff that is functional, so I would feel safer there in general. It just makes sense [to go to hospitals during disasters], and if anyone's going to loot or try to steal something from me, [hospitals] typically have security guards. If I lived near a hospital—very near a hospital—my first thought would be, “I know it's operating or at least I know it's operating at some capacity,” and I'm sure it's full of first responders and security.
In addition to perceiving hospitals as a source of human security during disasters, participants also discussed the structural security provided by hospitals. Participants stated that they believe hospitals are constructed to remain intact during natural disasters, and they expect them to remain operational on a 24-hour basis. As one participant noted, “I would like to think that a hospital and its facilities are built to withstand a major disaster.”
Belief that Hospitals Have a Responsibility to Provide Tangible Supplies to the Uninjured During a Disaster
In addition to the expectation that hospitals would provide nontangible services, participants indicated that they believe hospitals should provide nonmedical supplies and resources to the uninjured during disasters. For example, participants expect hospitals to provide food, water, clothing, blankets, shelter, and other tangible nonmedical supplies to the uninjured during disasters. As one participant stated, “I feel that hospitals can give you more than just medical attention. I feel like they can give you water, food, blankets, gloves, hats … anything in a disaster.” Many participants discussed their belief that hospitals already have the infrastructure and capacity to provide these resources to the general public during disasters:
There really aren't that many other large-scale facilities that could house or provide supplies and shelter to a lot of people. [Hospitals] have better facilities [than other response groups/agencies] to handle [providing shelter], along with the personnel. Hospitals have the facilities to house people or give them shelter and a place to meet up. Hospitals are generally big buildings [and have room to provide shelter].
Food and water were also commonly listed as supplies the participants expect to be provided by hospitals:
[Hospitals] are feeding people every day … so they have some sort of large-scale food setup … that's better than most other places. … It just seems like a logical option. I feel like a hospital would be able to provide or potentially provide food and water more easily since it already has restaurant facilities. To have a nutritional bar or MRE on hand and providing water, I would say that's not being unreasonable.
Belief that Hospitals Have Excess Supplies and Resources or the Funding that Can and Should Be Shared
Many expressed the belief that hospitals have an abundance of supplies and resources that could be shared with the community during a disaster. For example, one participant stated, “I know hospitals have sit-down computer learning [stations] where there's space, where you could put human beings.” Another stated, “Usually hospitals have a load of ugly shirts [gowns]; … hand them out to people who need them.” Another suggested, “Maybe [hospitals] could donate old wheelchairs or walkers, anything they are upgrading or improving.”
Many participants expressed the belief that hospitals have the funding to provide these supplies to the general public. Perceived sources of this funding included operational profits, hospital budgeting, taxes, or receiving federal dollars:
If someone is going to provide [supplies], [hospitals] probably have the most funding to do it. I feel like hospitals have more money [than other agencies] to make this happen. We live in a capitalist society and medicine is a capitalist system, and I know [hospitals] are making profits … so I expect hospitals to take on a larger share of the burden. [Hospitals'] funding probably has some sort of contingency for natural disaster. That's the first place people go—to a hospital or a police station, you know. We're paying for that … it comes out of our taxes this year. They're collecting money from us in some kind of way … tax breaks or something, you know. So I expect [hospitals] to be able to provide service for people that really need it. In a community where there is a medical school hospital, they are [given funds] … all the public tax-funded facilities have … more responsibility [to fund disaster response]. I mean [hospitals] are a nonprofit [agency], and aren't nonprofits supposed to help out your community?
Belief that Hospitals Should Be Prepared for Disasters and Collaborate with Other Agencies in Community-wide Preparedness Efforts
Many participants expressed their belief that hospitals are already, or should be becoming, prepared for disasters:
Hospitals [are] probably better prepared than most other agencies. Hospitals think of [disaster planning] ahead of time … before a crisis comes. There's a lot of people at hospitals that are trained, training for natural disasters. It makes sense, for hospitals in particular, to be actively involved with emergency preparedness. I would like for them to have some sort of emergency preparedness agenda so that in the event of an emergency, they could have resources to provide. You know, just the very basics. You know, food, shelter, and some sort of communication network.
An aspect of disaster planning that many participants indicated should be part of hospitals' preparedness efforts included the expectation that hospitals collaborate with other response agencies in the community, both government and nongovernment. Participants expressed the expectation that hospitals would and should be interwoven with the community at large in terms of emergency preparedness efforts. As one participant stated:
It should be imperative … the hospitals and police department, fire department, paramedics … they all should work hand in hand and resolve nonemergency issues, work hand in hand. That's how ideas and answers are created: by sharing.
Other participants believed that this coordination is already in place. As one participant stated:
I imagine there is a lot of coordination at a local or regional level, like if there's a disaster who's going to provide what services, what role is the government going to do, what is the role of the hospitals, what is the role of other institutions.
Another expressed a similar belief: “[Hospitals] work with other organizations or like the Red Cross [in preparing for events].”
Discussion
One of the primary goals of this study was to explore racial disparities regarding the public's expectations of hospitals to provide nonmedical resources and services during disasters, something that had been identified during previous research.7,8 This study found no such racial disparities; common themes were identified across races. It is clear from this study and previous research that the public expects hospitals to provide resources to the uninjured during disasters.7,8 Findings from this study indicate that the public expects hospitals to provide reunification services and tangible goods (eg, food, shelter, water) or referrals and information on how to obtain such resources during a disaster. Recent experiences indicate that some hospitals have been able to accommodate some of the community's needs for these resources. For example, during Superstorm Sandy, some hospitals served as shelter for uninjured community members, primarily because they were among the few buildings that had electricity. 9 Some hospitals distributed food and supplies to the uninjured, though administrators noted that it was not a sustainable practice given the cost burden. 9 In addition, some hospitals were able to meet individuals' nonemergent medical needs during the disaster, such as providing electrical outlets for the oxygen-dependent. However, long-term or large-scale provision of food, shelter, water, and other nonmedical resources is beyond the abilities of most hospitals to provide.
Findings from this study indicate that the public perceives hospitals as safe havens and they expect hospitals to provide safety and security to both those seeking medical care and the uninjured during disasters. This perception of hospitals as safe havens reflects previous research and past experiences with disasters.4,7,8,10-12 Hurricane Katrina in 2005 demonstrated the vital role of law enforcement at hospitals during disasters to provide protection for individuals' health and property. 10 However, during Superstorm Sandy, hospital administrators reported that local law enforcement professionals were unavailable to assist at the facility, leaving some concerned about patient and staff safety. 9 Staff surge capacity is essential to hospital functioning during disasters, and this must include provision of adequate security personnel. Hospitals need to have back-up plans for obtaining additional security personnel during disasters and should not rely solely on local law enforcement. Research and experiences during Hurricane Katrina indicate that local law enforcement will be understaffed due to unwillingness or inability to report to work during disasters, which will prevent them from being available to provide security at hospitals.13,14
Participants in this study reported expecting hospitals to collaborate with other agencies in disaster planning efforts. Collaborative planning among hospitals, public health agencies, and local response agencies is imperative to the resilience of a community after a disaster, and the Office of the Assistant Secretary for Preparedness and Response's (ASPR) Hospital Preparedness Program (HPP) requires inter-facility collaboration.2,15,16 Furthermore, community-wide collaborative disaster planning is an expectation of the Joint Commission, the accreditation body for hospitals. 4 Despite this, research indicates that, although hospitals and emergency medical services consistently work together, other healthcare groups, such as long-term care facilities, dialysis centers, and primary care physicians, are not as engaged in community-wide planning efforts.17,18
Collaborative, community-wide planning could aid hospitals in preparing for the influx of uninjured during a disaster. One option would be for local disaster planning agencies to bring community resources to the hospital for distribution to the public, given that so many individuals plan to seek nonmedical resources from hospitals. This type of plan would require extensive pre-planning and community-wide coordination to ensure rapid distribution of resources during an event without interfering with the hospital's primary mission of addressing the community's health needs.
Another option would be for community disaster planners to partner with hospitals to develop alternative care sites. Alternative care sites are facilities that temporarily provide medical care to the public during disasters, when medical clinics and hospitals are overwhelmed by patient influxes. The exact purpose of an alternative care site may vary, depending on the community's need. For example, an alternative care site may be used for medical triage, as an ambulatory clinic, or as a medical distribution site for community members. 19 If alternative care sites are to be deployed during a disaster, it is critical that hospitals and local response agencies partner together to create pre-event standardized messages that would direct the public to the appropriate alternative care site instead of coming to the hospital. During Superstorm Sandy, the lack of communication and coordination between hospitals and other response agencies led to community members seeking shelter at local hospitals rather than being directed to public shelters. 9 This overburdened hospitals and made provision of health care more challenging.
Findings from this study suggest that the public expects hospitals to provide nonmedical resources to the uninjured during disasters because of their belief that these actions are in line with the mission of hospitals. Hospitals are viewed as being compassionate and caring, as well as being a vital part of the community. They are also perceived to be already prepared for disasters and to have excess resources obtained from federal funding that can and should be shared with the community during disasters.
There is a disconnect between the public's perception of hospitals as being fully prepared and having an abundance of resources for both those requiring medical care and the uninjured, and the reality of hospital disaster preparedness. Routine healthcare financing does not have the flexibility to cover the costs of planning for surge capacity, including maintaining empty hospital beds, hiring and cross-training healthcare and security personnel, and purchasing and stockpiling excess equipment.10,17 Hospital preparedness programs have focused primarily on the ability to continue daily operations and handle healthcare surge.2,20 Research indicates that many hospitals lack the ability to provide medical care to large numbers of patients during disasters, and access to tangible supplies will be strained by the acute needs of patients and staff.10,17,21,22 It is unlikely that hospitals will have access to supplies and resources that can be distributed to the uninjured unless they are given these items by community response agencies. Research is needed to identify best practices for dissemination of information to the public about appropriate hospital use in a disaster.
Limitations
Overall, the qualitative individual interview methodology served as a valuable tool for eliciting rich, detailed information about the general public's expectations of hospitals to provide nonmedical resources to the uninjured during disasters, as well as to explore their beliefs about why hospitals have this duty. Structured quantitative surveys with closed-ended responses used in previous studies not only indicated that there was an association between race and expectations of hospitals that was not found when using a qualitative approach, but it also may have yielded different findings.7,8 Due to the small study sample size typical of qualitative research, and specific regional, cultural, and socio-demographic factors, findings from this study may not be generalizable to other areas in the United States or even throughout Missouri. There is likely a self-selection bias in those who agreed to participate. For these reasons, the generalizability of these findings may be limited.
Conclusion
While no racial differences were found, participants in this study reported expecting hospitals to provide multiple tangible supplies and services to the uninjured during a disaster. It is impossible to plan for every possible scenario, but it is imperative that hospitals partner with local response agencies to address the public's expectations of resource needs in advance of a disaster. Similarly, cooperation between hospitals and non-hospital-based medical entities, such as pharmacies, clinics, home health agencies, and rehabilitation centers, may be additional outlets for provision in a trusted environment. Public education and enhanced community collaborations and coalitions are essential to ensure that hospitals will be able to continue providing medical care to community members during disasters. Enhanced partnerships among hospitals, public health agencies, non-hospital-based healthcare entities, and other response agencies will maximize community resilience.