As of 2015, there are over 70 million children in the United States. 1 Many of them spend a significant part of their day away from their parents and guardians. Their safety is entrusted to individuals or organizations whose intent is to provide some sort of care for them. In total, 8 million American children under the age of 5 attend daycare and more than another 50 million American children are in school or daycare settings. 2
Outside of the school setting, daycare is provided in private homes or specialized facilities. Many of the expectations from school settings are expected from daycares as well. To be a licensed daycare provider, minimum health, safety, and program standards must be met. However, not all states require licenses or regulate all child care settings, and standards vary state to state. Implementing drills and providing adequate training for emergencies is important as they may lead to fewer pediatric injuries, traumas, and deaths during disasters.Reference Grabowski, Simmons and Eichelberger 3
Worldwide, care providers are generally underprepared for mass-casualty disasters. Providers in the United States are also included. Additionally, children present unique challenges for a variety of reasons ranging from biological to psychological. One of the challenges is that children are dependent on adults for care, and this is especially true of the children with access and functional needs.Reference Sakashita, Matthews and Yamamoto 4
More can be done to prepare for pediatric victims, including creating emergency plans at places where large numbers of children spend their time. To help address this shortcoming, a free video tutorial was created using the Delphi technique. Developed by the RAND Corporation, the Delphi technique’s ultimate goal is to achieve an unbiased consensus among experts. First, a panel of experts is identified. Their judgment and opinions on a topic are collected and made available for open discussion, after which the experts’ opinions are collected again. This process is repeated until consensus is achieved.Reference Helmer-Hirschberg 5
The video was created in collaboration with the Save the Children Fund (Save the Children), a free standing level 1 trauma center, and the Los Angeles Children in Disasters Working Group (LA CID Working Group) with the intent of providing daycare providers a rubric for creating their own disaster plans. We report the creation of the short, easily accessible child-care disaster training video designed for providers of child care through the use of the Delphi technique and the video’s implementation.
METHODS
Delphi Technique
In total, 17 participants representing various groups in child safety and protection were brought together in the LA CID Working Group. Their intent was to complete a series of projects designed to increase child safety knowledge in the larger audience. Included in these projects was an instructional video for daycare providers to create a disaster plan.
Stakeholders were those involved with child safety and protection from academia, government, hospital, non-profit organizations, and non-governmental organizations. Given the diversity of stakeholders, material for the video was compiled via the Delphi technique. Members initially described topics and categories to be addressed in future surveys for possible incorporation into the video. Members were initially asked what to include based on their expertise. Anonymous surveys were produced asking the members to rate these items on a Likert scale. Results were then shared with the group and discussed.
Video Creation and Survey
A 20-minute online video was produced in collaboration with Save the Children and the hospital to sufficiently cover all topics. The video was created with the intention of fulfilling the safety requirements for daycare providers in Los Angeles County.
The video itself contained an easy-to-follow narrative of key points in disaster planning for the child care provider. Included in the video were short overviews that related child anatomy and psychology to provide context.
Once completed, the video was made publicly available (https://vimeo.com/95673229) at no cost and as a method for daycare providers to complete the necessary educational component of first aid training for licensing in Los Angeles County.
An elective 10-question survey was available after completion of the video. Questions evaluated the participants’ comprehension of the video’s content. There was 1 correct answer per multiple choice question. Responses were anonymously tracked and collected.
An IRB was approved for the responses from both the Delphi technique and post-video surveys.
Data Interpretation
A Fleiss κ score was obtained for the responses from the Delphi technique to analyze for inter-rater agreement, using Microsoft Excel 2007. Post-video survey responses were collected with percentages of correct responses shown.
RESULTS
Basic demographic data was collected from the 17 Working Group members. There was near equal representation of men and women, 47% versus 53%, respectively. The ages of the participants ranged from <30 years old to >60, with the majority falling in the 50-59 year range (11/17). The largest group consisted of those from government agencies (11/17). Academic (3/17) and hospital (1/17) interest groups were also represented as well as individuals representing a non-profit (1/17) and a non-governmental organization (1/17).
Topics were rated from “strongly disagree” to “strongly agree.” As seen in Table 1, the Working Group’s data showed that most members agreed (either agreeing or strongly agreeing) with nearly all the proposed topics for the video. Based on the modes of each rating, members did not agree in providing a broad overview in the informational video and they preferred to create a specific and informative presentation. Also, there were 4 individuals who disagreed with certification for video participants and for coordinating training with local groups and governments. For the topic, a total of 6 stakeholders disagreed with including training enhanced liability while 3 disagreed with including transitory custody as a topic. Three disagreed with further videos to be developed in conjunction with local institutions and non-governmental groups. There were multiple additional topics where 1 or 2 stakeholders were at some level of disagreement.
Working Group Delphi Survey Prior to Video Creation
Three responders partially completed the Delphi survey for unknown reasons. Using the survey responses from Table 1, a Fleiss’ κ of 0.07 was obtained, which indicates poor agreement between raters.
For video participants, their questions came directly from what was addressed in the video. Fifty-seven responses were available for each multiple-choice question (Table 2). Two different questions were each skipped once. Participants correctly answered the individual question between 72% and 100% of the time. Six of the 10 questions had responses where more than 90% of the participants were correct. Results for individual participant comments were not available for analysis.
Post-Video Survey Responses
DISCUSSION
As evidenced by our Fleiss κ value, consensus by the Working Group on what should be included in the video was difficult to achieve, but it does reflect the diversity of their backgrounds and opinions. Each stakeholder brought knowledge and insight that highlighted the importance of reviewing each possible topic. Rather than conflicting with each other, Working Group members either agreed or strongly agreed to most items. The low κ value is likely a result of differentiating those that agreed from those that strongly agreed. While trying to find agreement on a large number of topics was difficult, our Delphi modeling did allow for the inclusion of a diversity of items to be addressed in all disaster plans for daycare providers. Therefore, we were successful in documenting a path to create an effective teaching tool to provide disaster preparedness training to the public.
Historically, prevention through disaster planning has been shown to be lacking in several disaster situations. Our video represents a possible rubric for a general daycare disaster plan that can easily be adapted to various disasters in any location. Strategies such as drill training, assigning roles to older children and plans for family reunification are relevant in any disaster scenario. The Federal Emergency Management Agency recommends an “all-hazards” approach to plan creation. 6 Many of these elements have been addressed in various publications, but not all these materials have been compressed in a format widely available to the public. While available resources and infrastructure may differ amongst counties and states, the generality of our video allows providers in different locations to utilize the strategies while also adapting to disasters, infrastructure, and resources unique to their locations.
It is recommended that disaster plans should include at least a 3-day minimum of emergency supplies. 6 Yet, many erroneously believe that help will arrive within hours of a disaster, which leaves many inadequately prepared for the delays involving the arrival of aid.Reference Sakashita, Matthews and Yamamoto 4 Inadequate resource planning may result in unnecessary morbidity and mortality. Educational interventions such as our video can provide more realistic expectations for families and other care providers.
Daycare center disaster planning is improving overall, but gaps still remain in running drills and having infrastructure in place to provide certain services. A study surveying Pennsylvanian daycares showed that most had plans in place, but respondents lacked plans for certain emergency situations.Reference Olympia, Brady and Kapoor 7 In a Michigan study of daycare directors, there were certain scenarios where they felt unprepared and they were generally interested in additional pediatric disaster training.Reference Chang, Bradin and Hashikawa 8 Across the country, there remains ample opportunity for the implementation of disaster preparedness tools for providers.
Our video provided additional information in regard to reuniting children with their families. Family reunification has also proven itself to be logistically difficult in mass-casualty disasters.Reference Brandenburg, Watkins and Brandenburg 9 During Hurricane Katrina, many children were separated from their parents and legal guardians as a direct cause of the disaster itself, during medical triage, or during transportation. From basic safety concerns to child victims of crime, evacuation camps proved to be similarly dangerous due to the large influx of people and the strain on resources.Reference Grabowski, Simmons and Eichelberger 3 , Reference Brandenburg, Watkins and Brandenburg 9
Ideally, children should be in the care of a trusted adult and families should remain united or be reunited as soon as possible after an emergency. This remains true for health workers with families who may be affected by the disaster. Their motivation to assist may be correlated to their assurance that their children are safe.Reference Stuart and Huggins 10 Providing a preset structure establishes some level of control and normalcy for caregivers and children, which aids in lowering the level of stress.
Based on how the participants correctly answered most of the questions, our video appears to be able to provide an adequate framework for creating disaster plans. Our video provided an outline that could apply to various emergency scenarios throughout the nation, while also allowing providers the flexibility to adapt plans.
Weaknesses of our study include the limited number of survey participants for this retrospective study and the lack of pre- and post-video surveys for comprehension assessment. Additionally, demographic information regarding the participants was not captured. Although most did exceptionally well on the post-video survey, level of education may play a role in regards to comprehension. Additionally, participants may have had some preparedness knowledge prior to our video and test. Capturing details of the participants’ disaster plans prior to viewing the video would have also provided insight to the participants’ level of preparedness for a mass-casualty disaster.
Although we had a small sample size, our video provides insight to the possibility of similar online training for others in similar fields to provide comprehensible, basic emergency training on a large scale.
Currently, the free educational video remains available for viewing.
CONCLUSION
We document a successful pathway to creating similar educational tools for disaster preparedness education that can be generalized to the greater public or tailored to the needs of a particular location. Although we achieved little agreement between our experts in what should be included in the tool, we understand that each expert was able provide diverse insight. Together, a comprehensive pre-disaster training video was created and made available to the public that increased their comprehension of planning for disasters.
