Study design and assessment periods
This is a cross-cultural, quasi-experimental, non-randomised, controlled, longitudinal, face-to-face intervention study, with a pretest–posttest design. Study objectives are (1) to increase household preparedness for earthquakes and home fires in Seattle (USA) and Izmir (Turkey) by way of an intervention, (2) to evaluate changes in levels of critical awareness, self-efficacy, perceived outcome, trust, empowerment, anxiety and social cohesion, as well as levels of adjustment following the intervention, and (3) to compare results of the intervention across the different cultures. Participants in the intervention group each participate in two 3-h workshops (intervention), while controls do not receive the intervention. All participants complete assessments 1 week before and 1 week after the intervention, and they are followed up 3 and 12 months after the intervention to measure preparedness behaviour change (Table 1).
Monetary incentives are given for participation in the study. In the study conducted in Seattle,Footnote 1 participants in the intervention group were paid $250 for completing baseline and post-intervention assessments, as well as a 6-h workshop divided over 2 days (3 h each day). Participants in the control group were given $100 for completing the baseline and post-intervention assessments. To ensure completion of the pretest and posttest assessments, participants in both groups were paid only after completion of the second assessment. Participants are paid $40 per completed follow-up assessment, at 3 and 12 months after the intervention. Study incentives for Izmir are equivalent to the monetary incentives in Seattle.
In order to define sample size, an a priori power analysis using G*Power statistical software, version 3.1 (Faul et al. 2009) was conducted. Equal-sized sample groups were planned, meaning that the allocation ratio of N1 to N2 is 1 (Bredenkamp 1969; Orme et al. 1990). To perform a two-group comparison of a primary outcome with a standard alpha of 0.05, 64 individuals per group, or a total of 128 individuals, provide 80 % power to detect a significant difference of 5 % between the intervention group and the control group in a two-tailed analysis. Consequently, we planned to recruit 100 participants per group to account for dropouts, in order to have a minimum of 64 participants per group left in the final longitudinal follow-up. The post-intervention sample in Seattle consisted of 157 people (85 intervention group and 72 control group), which decreased at 3 months to 145 (73 intervention group and 72 control group).Footnote 2
The sample in Seattle consisted of adult residents (aged 18–80) of North Seattle, with a mean age of 50 (SD = 13). Sixty per cent of residents were female, 77 % identified as Caucasian, 47 % identified as Christian, while 36 % reported not having any religion; 59 % were married or living with their partner and 75 % were home owners. More than half of the sample reported being employed (52 %).
Since sense of community and community participation have been found to be variables that affect preparedness and adoption of mitigation measures (Bishop et al. 2000; Paton 2000), intervening in an existing community seemed appropriate. Consequently, for the Seattle study, one area was selected for the intervention group and the intervention was conducted there. A geographically separate, equally large area served as the field for those in the control condition. In February 2015, the team of researchers travelled to Seattle to explore potential areas to conduct the study and ultimately selected two of them.Footnote 3 Additional aims for the scoping trip included establishing contact with a recruitment agency and arranging meetings with Seattle emergency management experts, such as the Red Cross, the Seattle Fire Department and the Seattle Office for Emergency Management for information and collaboration in the intervention. This first trip to Seattle proved to be highly important in the design of the intervention and in making connections with experts and survivors of earthquakes, who agreed to serve as motivational speakers in the intervention. A similar trip was conducted for Izmir to explore and select the intervention areas as well as to establish contact with the respective emergency management authorities and trusted informants.
Participant recruitment and allocation
The sample constitutes adults (aged 18–80), one representative per household, who are residents of Seattle and Izmir. In each of these cities, the study areas constituted two geographically separated areas of equivalent demographic mix assigned to be the intervention and control groups, respectively. A recruitment agency from each city was hired to recruit participants. Area selection in the two cities was based on the same criteria.
In each of the two cities, the agency is instructed to recruit 100 participants from the intervention area and 100 from the control area. Specifically, they are asked, for both groups, to recruit evenly across each age group (18–35, 36–54, 55–80), 50 % male and 50 % female within each age group, two-thirds home owners and one-third renters and 50 % below $45,000 and 50 % above $45,000 annual household income (and the equivalent respective salary in Izmir). All recruiting in Seattle was completed over the phone by the recruitment agency.
One week before the intervention in Seattle, participants were called by the agency to arrange a specific date and time to visit their homes to complete the baseline assessment. After completion, the intervention group participants were called and reminded of the day, date, time and location for their workshops. One week after completion of the workshops, participants in both groups were called by the agency to schedule a specific date and time to complete the post-workshop assessments and to receive their respective incentives for participation.
Intervention design and delivery
The intervention is named fix-it, as it focuses on fixing and securing items in the home. Fix-it is a name that is easy to remember and has positive/neutral connotations, as opposed to threat and fear-inducing names with negative and catastrophic connotations. According to the literature on campaigns, in order to be effective in facilitating action, names and messages of preparedness campaigns should be positive in tone, promote a sense of empowerment, as well as being short, clear, consistent and motivating of action (Jones 2012; Kocher 1993). The intervention name received good feedback in the pilot study, with participants stating that the name was, “easy to remember”, “fine”, “concise and it implies action”.Footnote 4
Fix-it was also accepted as a good name for the intervention in Izmir, as a similar Turkish term exists.
Fix-it includes the key ingredients of previous preparedness interventions that have proven successful, such as hands-on training, face-to-face interactions, empowerment and community cohesion. In addition, determinants of behaviour such as self-efficacy, outcome expectancy and motivation are targeted through different behavioural techniques (Michie et al. 2008). The intervention design was influenced by the work of Michie et al. (2011) concerning effective behaviour change techniques to challenge specific determinants of behaviour. To address motivation, the use of rewards, incentives (gift cards for group challenge winners, magnets and mugs with acronyms and the name of the intervention), social encouragement and support (engaging with the fix-it Facebook group page, taking pictures of their homes) were used, as was persuasive communication. Self-efficacy was addressed using self-monitoring (homework review), rehearsal (videogame play), coping skills learning, social encouragement and support and feedback (homework review); all behaviour change techniques have proven effective in changing self-efficacy (Michie et al. 2008). In order to affect outcome expectancy and increase motivation, persuasive communications were given by experts who were trusted sources, such as the American Red Cross, the Seattle Fire Department and the Seattle Office of Emergency Management (Michie et al. 2008). AFAD, the equivalent trusted source for emergency management in Turkey, and their experts were used as communicators in the Izmir intervention.
The intervention consisted of two 3-h interactive, face-to-face workshops for each participant in the active group and focused on securing items in the household. The workshops were led by two professionals, experts in emergency management training and psychologists.Footnote 5 The workshops included hands-on training, as well as interactive tools, such as playing a video game, reviewing photographs of participants’ homes and engaging in a Facebook group page. With the purpose of intervening in an existing community, the intervention was delivered in a community centre (as in the case of Seattle) or space where communities gather to participate in activities. The intervention was carefully designed by the psychology researchers of the project who, in addition to reviewing the literature on natural disaster preparedness intervention studies and that on behaviour change, consulted three experts in the field of interventions, epidemiological studies and behaviour change techniques to review the intervention. This, together with the pilot study conducted in June, shaped the fix-it intervention.
The 6-h fix-it workshop, divided over 2 days (3 h each), was delivered on weekdays after work. Specifically, it focused on securing nine items in the household (Table 2): securing bookcases and large cabinets, securing TVs and computer screens, making sure that sockets were not overcharged (e.g. not having a multi-plug plugged into another multi-plug), having functioning smoke alarms and knowing how to test them, ensuring that no pictures or frames were hanging above sofas and/or beds, having all exits clear of obstruction and having in-date fire extinguishers. These nine items are taken from the 16 earthquake and 13 fire preparedness measures on questions 17 and 30 of the survey (Appendix I of supplementary material), and they constitute the primary outcome measure of preparedness (Table 2).
The literature on behaviour change interventions advocates that one limits interventions to few, simple behaviours to increase effectiveness (Michie et al. 2014). The fix-it intervention chose the nine items from a total of 29 preparedness items for earthquake and fire that individuals could carry out at home with little cost and bureaucracy and without necessarily owning their own homes. This intervention did not include structural mitigation actions because the researchers aimed to target those behaviours over which people had control. These mitigative behaviours were also chosen, as opposed to focusing on promoting kits or plans, because of evidence that they are needed. According to the 2013 American Housing Survey (U.S. Census Bureau 2015), which added questions on emergency and disaster preparedness for the first time, 52 % of American citizens reported having an emergency kit, 82 % reported having non-perishable food stored, 62 % stated having stored water and over 30 % claimed having an emergency meeting location and a communication plan (Bureau 2015). Since having a kit and storing food and water had already been adopted by 60–80 % of American residents, the fix-it intervention’s focus was on improving other adjustment measures that are low cost and easy to adopt, such as securing items in the household, which were not measured in the American Housing Survey. In addition, securing items in the house has been identified as one of the basic categories of preparedness by victims of earthquakes, reducing injuries and allowing them to focus on other categories of preparedness, such as assisting others and following their emergency plans (Paton and Johnston 2015). Despite being considered as a key aspect of preparedness and its adoption being critical for people’s outcomes in earthquakes, most preparedness studies focus on survival measures (e.g. storing food and water) and not on such mitigative behaviours (Russell et al. 1995; Spittal et al. 2006).
Day 1 of fix-it aimed to enhance the awareness and importance of being prepared. The workshop started with a free association task (Joffe and Elsey 2014), where participants were asked to write or draw their associations to “home” on a grid. This gauged how they represented the very homes that the intervention aimed to target and allowed them to share their thoughts and feelings about their homes and to begin to interact with others in their group. The grids were collected for content analysis by the researchers, with feedback provided at the next workshop. Participants were then presented with common cognitive and emotive responses regarding earthquakes that residents in each of these cities had held, as per findings of the previous study (Joffe et al. 2013), such as “denial of fear”, or “fascination with earthquakes”. A discussion was then held on how these might affect preparedness. Subsequently, a series of videos of previous earthquakes in their own city, survivor stories from each city and a home fire simulation were shown. Each of these videos was followed by a group discussion, where participants shared their experiences of earthquakes and fires and the impact that these had on them. Participants then engaged in playing “Beat the Quake”, a videogame concerning earthquake and fire preparedness, in teams of five. To create social encouragement, promote group cohesion and give incentives, participants were then divided into groups where they participated in a group challenge based on a set of questions on earthquake and home fire preparedness. Before the end of the first day of the workshop, participants were given an assignment, to be reviewed on the second day of the workshop. The assignment involved taking pictures of the following items in their houses and sending them via email to the workshop leader: a smoke alarm, a multi-plug, an important exit, a bookshelf, a bed/and or couch, a fire extinguisher, a television and a computer. These pertained to the nine preparedness measures that fix-it focused on. Participants were also invited to join a fix-it Facebook group page, with the purpose of creating a sense of community empowerment, feedback and an opportunity for social interaction with the researchers and the rest of the intervention participants, as well as for the sharing of learning. The Facebook group page was designed and managed by one of the researchers in the team.
Day 2 of the workshop focused on “how to” fix-it. The evening started with the feedback from participants’ associations to home, followed by a discussion on the possibility of their homes being a space of danger in the event of an earthquake or a home fire. A review of their assignments followed, where photographs of the participants’ homes were screened for discussion. This was followed by an examination of the nine preparedness measures with videos that explained to participants how to carry out the preparations. Trusted experts (in Seattle, the Red Cross for, the Seattle Fire Department and the Office of Emergency Management in the case of Seattle, AFAD in Izmir) then gave presentations and demonstrated live with tools how to secure items. Participants were invited to touch the earthquake preparedness and fire safety tools and interact with the experts by asking them questions at the “hands-on stations”. At the end of the workshop, the prize for the winners of the group challenge was given, along with a fridge magnet with an acronym for the nine fix-it measures, a mug with the name of the intervention and a certificate of completion. These giveaways, as well as being a reward for having participated in the workshops, aimed to serve as reminders after the intervention was over, ensuring that the fix-it measures were adopted.
Beat the Quake
In order to ensure that participants learned, practiced and mastered the nine fix-it preparedness measures, they played a videogame (on individual tablets) at the end of the first day of the workshop. Beat the Quake was originally designed by Earthquake Country Alliance in 2006 as part of the Great Shake Out earthquake preparedness campaign in California. The game is free and easily accessible from its website (http://www.dropcoverholdon.org/beatthequake/game/). In the original version of the game, the player is asked to click on items in a virtual living room and correctly identify how to secure 14 of these items (including fix-it measures) with appropriate methods and tools. The player has to choose an answer from a list of options. The more items the player correctly secures, the higher the score received. The player has to act quickly before the big earthquake hits. The player receives audio, visual and textual feedback throughout the game and additional visual feedback at the end of the game. For the purpose of the fix-it intervention, Beat the Quake was modified with the help of UCL’s EPICentre, by adding four fire preparedness items. A Turkish version also existed and was also modified to include the fire items. Beat the Quake was improved for the purpose of this study and is now a multi-hazard preparedness educational tool. Beat the Quake has proven to generate significant preparedness learning outcomes (Tanes and Cho 2013).
Ethical permission was obtained to conduct the study (UCL Ethics Project ID Number: 1392/001). Informed written consent was obtained from each participant before completing the baseline survey. A member of the recruitment agency collected all signed consent forms from participants in both groups. Both participants and recruitment agency members were blind to group allocation.
A 25-min computer-assisted survey and a checklist comprised the assessment that participants in both groups completed at the following time points in their homesFootnote 6: (1) at baseline, 1 week before the intervention, (2) 1 week after the intervention, (3) 3 months after and (4) 12 months after the intervention. At the first home visit, a member of the recruitment agency met with each participant and asked them to complete the baseline survey online. Once finished, the agency member proceeded with the second part of the assessment, which was to conduct a tour around the house and examine with a checklist whether the participant had or had not adopted each of the nine preparedness measures. This constituted the observational measure of the study. Home visits to observe and document participants’ preparedness behaviours, rather than sole reliance on self-reports, offer a novel approach to this field.
A self-administered computer-assisted survey (see Appendix I of supplementary material) using Qualtrics software was used to assess the following variables:
Demographics: Sociodemographic characteristics including gender, age, ethnicity, marital status, number of children, employment status, education level and annual income level.
Building characteristics including information such as type of residence, year and material of construction of the residence and earthquake retrofitting.
Barriers to preparedness for earthquake and for fire including a set of items that the person had to tick (all that apply) indicating barriers for not preparing, such as the lack of time, the financial cost, the need for cooperation with others, the skill required, information overload, none and other.
Critical awareness: assessed by four questions that asked how often one thinks and talks about earthquakes and how often one thinks and talks about home fires, with responses on a Likert-type scale from 1 (never) to 5 (once a week or more). This is a modified version of Dalton’s measure of critical awareness (Dalton et al. 2001) that has been used in other studies with good success (Paton et al. 2003)
Earthquake anxiety: measured by a set of items (e.g. “I avoid thinking about earthquakes”) on a Likert-type scale ranging from 1 (not at all) to 4 (a great deal). It was developed by Johnston (Paton et al. 2003) and used in several earthquake preparedness studies by Paton.
Self-efficacy: used a modified version of Riggs and Knight’s scale (Riggs and Knight 1994).
Intention to prepare was assessed by the question “Do you intend to do it in the next week or two?” for each of the nine preparedness measures.
Outcome expectancy: The perception of whether personal actions would effectively mitigate or reduce the threat was assessed by a set of five questions for each of the nine preparedness measures, to which respondents could answer yes or no.
Trust: measured by asking the participant how much trust they had in several institutions including education, armed forces, government, scientists and the church, rated from 1 (none at all) to 4 (a great deal) (Joffe et al. 2013).
Fatalism: evaluated by a set of questions used in a previous study (Joffe et al. 2013)
Empowerment: used a modified version of Speer and Peterson’s empowerment scale (Speer and Peterson 2000).
Social cohesion: used a reduced version of the scale used to measure social cohesion in European countries (Dickes and Valentova 2013).
Collective efficacy: used Riggs and Knight’s scale version in modified form (Riggs and Knight 1994).
Sense of responsibility: assessed by the question “how much responsibility do the following people and institutions have for reducing your risk from earthquakes?” The same question was asked for home fires (Joffe et al. 2013).
Perceived level of corruption of the government and the construction industry was assessed by asking: “On a scale from 1 (None at all) to 4 (A great deal) how would you rate the level of corruption of the following: the local government, the state government, the federal government, the construction industry?” (Joffe et al. 2013)
Religiousness: was assessed using a single question (“How religious would you say you are?”) rated on a five-point scale, ranging from “not at all” to “very much”.
Earthquake preparedness was assessed by a set of 16 earthquake preparedness items, which included the five earthquake-related fix-it measures; participants had to indicate whether they had adopted them or not. This set of items used to assess preparedness is a modified version of the set of items used in a previous study (Joffe et al. 2013).
Fire preparedness was measured by a set of 13 fire preparedness items, including the four fix-it measures that gauged fire preparedness.
The nine-item checklist constitutes the primary outcome measure (Table 2). As described above, a member of the recruitment agency examined the participant’s household and checked whether each of the nine preparedness measures had been adopted by the participant or not. This is a purely observational measure, and it was evaluated alongside the self-report measure.
Follow-up assessments included a modified version of the survey (with additional questions about the workshop) and the checklist. Follow-up assessments were conducted 3 and 12 months after the end of the workshops.
Interrater reliability on 5 % of the checklists in all countries, using two independent raters, produced a satisfactory result (kappa = 0.65).
Data analysis and management
The SPSS statistical software package, version 20 (Nie et al. 2011), was used for conducting the statistical analysis. Behaviour change was measured in both groups, and t tests were conducted to evaluate differences between means of behaviour change between groups. Logistic regression analysis of the outcome measure on the active group was conducted, with adjusted confidence intervals and p values. In addition, cross-tabulation and χ
2 statistics were carried out to evaluate correlations between self-report and observational preparedness measures to determine the extent of agreement between them. Moderated mediation analysis among relevant variables was carried out to explore mediators of preparedness. Levels of anxiety in relation to preparedness behaviours were also examined. Although preparedness is measured as an overall score, including earthquake and fire measures, separate analyses for earthquake and home fire preparedness were conducted in order to explore differences in preparedness for the more every day risk (i.e. fires) versus the more long return period risk (i.e. earthquakes). It must be noted that it is the difference in scores between assessment times that is the key outcome: that is, the study measures behaviour change.Footnote 7