Considerations for designing Inclusive Emergency Alerts for People with Mental Health and Mobility Challenges

Patient and public involvement

Members of the public were not involved in the formal development of this specific study, including the study design, research questions, choice of outcome measures, recruitment strategy prior to study commencement, data collection, analysis, or drafting of the manuscript.

Design

Qualitative interviews, conducted from February to April 2024.

Participants

Participants were recruited through charities that support local communities and people with mental health problems, and adverts circulated via email. Potential participants were screened to give a diverse sample based on age, gender, ethnicity, and highest level of education. Participants were included in the study if they were UK residents with self-reported mental health problems (including mood disorders, anxiety disorders, and personality disorders) or mobility issues. People under the age of 18 years and those living outside of the UK were excluded.

Ethics

This study was approved on the 14 December 2023 by the King’s College London Research Ethics Committee (reference number: HR/DP-23/24–39133). All participants were adults aged 18 years or over. Written informed consent was obtained from all participants prior to participation. Participants were informed of the purpose of the study, their right to withdraw, data handling procedures, and confidentiality arrangements before consent was provided. Participants also confirmed consent verbally at the start of their interview.

Materials

Barriers and facilitators to protective behaviours were investigated using a semi-structured discussion guide. The interview guide was based on the PMT² and included questions about perceived susceptibility to the threat, perceived severity of the threat, perceived self-efficacy for a behaviour, and perceived effectiveness of the protective behaviours.²

Procedure

Participants completed a one-hour interview over Teams or by phone. They were randomly allocated to be shown simulated EAMs crafted for one of three plausible UK scenarios: extreme heat, a large-scale chemical attack, and an active shooter. The interviews followed the discussion guide² before using the think-aloud technique to explore participants’ perceptions, emotional reactions, and likely behavioural responses to the scenario and EAMs.

Where participants reported experiencing mental health problems and mobility issues, they were asked to reflect on both when responding to the interviewer’s questions.

Analysis

Interviews were analysed thematically to identify patterns and themes⁸ in intention to adopt protective behaviours.

Mental health

Participants’ responses varied more by diagnosis than by scenario. Anticipated emotional reactions to receiving an EAM were common, and included fear, dissociation and freeze responses:

The siren sound that accompanies EAMs was reported as distressing for those sensitive to sudden noises and urgent language such as “EXTREME” or “IMMEDIATE DANGER” heightened anxiety. Active shooter alerts were seen as particularly likely to trigger intense fear or emotional reactions. For some, however, distress would not prevent protective behaviour:

Some participants perceived that receiving an EAM would elicit a need for emotional reassurance or support mechanisms.

Participants highlighted that their mental state would influence their responses. During manic episodes, individuals might disregard heat warnings due to altered perceptions of temperature. Conversely, others reported hypervigilance, leading to quick protective action and close monitoring of updates. Those with psychosis noted risks of misinterpreting alerts as hallucinations, undermining trust. EAMs were also perceived as especially distressing for people with panic disorder or paranoia:

Mobility considerations

Mobility issues can affect how some people respond to EAMs. Some reported that protective actions such as blocking doors or closing windows would be physically difficult or impossible without help, potentially leading to a sense of helplessness’:

The decision to flee or hide was often influenced by the perceived proximity of the threat and whether the participant had access to a mobility aid, such as a scooter.

Individuals with pre-existing emergency plans expressed greater readiness and clarity about what actions to take during such events:

Implications for policy and practice

EAM cannot be assumed to work equally well for all members of the public. Mental health conditions and mobility challenges can shape how messages are perceived and acted upon. Policymakers and emergency planners should prioritise inclusive design in developing and testing EAMs. Involving individuals with lived experience in co-design processes for pre-determined threats that might require an EAM can reveal barriers that are otherwise overlooked and point to simple, practical changes that are more effective in promoting protective behaviour.