disaster heatlh for the community response …flghc.org/ppt/09-10/ts pp4e.pdf · disaster heatlh....

DISASTER HEATLHFOR THE

COMMUNITY RESPONSE TEAM

Andrea Allen PhDSusan Schmitz MA

James M. Shultz PhD

Source: Shultz JM, Espinel Z, Galea S, Reissman DB.Disaster Ecology: Implications for Disaster Psychiatry. In Ursano et al. (eds.)

Textbook of Disaster Psychiatry, Cambridge University Press, 2007.

A disaster is characterized asan encounter between

forces of harmand a human population

in harm’s way,influenced by the ecological context,

that creates demandsthat exceed the coping capacity

of the affected community.

DISASTER DEFINITION

Individual/Family Context

Community Context

Societal/Structural Context

Individual/Family Context

Community Context

Societal/Structural Context

Resilience Factors

Risk Factors

DISASTER ECOLOGY

MODEL

Forces of Harm

Affected Population

Disaster Impact

Source: Shultz JM, Espinel Z, Galea S, Reissman DB.Disaster Ecology: Implications for Disaster Psychiatry. In Ursano et al. (eds.)

Textbook of Disaster Psychiatry, Cambridge University Press, 2006.

Widespread and Pervasive

Spectrum of Severity

Range of Duration

Disaster-related4321

PSYCHOSOCIAL CONSEQUENCES OF DISASTER

psychological “footprint”

medical “footprint”

Source: Shultz JM, et al., Behavioral Health Awareness Trainingfor Terrorism and Disasters, Miami FL, DEEP Center, 2003

PSYCHOSOCIAL CONSEQUENCES:WIDESPREAD 1

In a disaster,the size of thepsychological“footprint”

greatlyexceeds thesize of the

medical“footprint.”

psychological “footprint”

medical “footprint”

Source: Shultz JM, et al., Behavioral Health Awareness Trainingfor Terrorism and Disasters, Miami FL, DEEP Center, 2003

PSYCHOSOCIAL CONSEQUENCES:WIDESPREAD 1

psychological “footprint”

medical “footprint”

Source: Shultz JM, et al., Behavioral Health Awareness Trainingfor Terrorism and Disasters, Miami FL, DEEP Center, 2003

PSYCHOSOCIAL CONSEQUENCES:WIDESPREAD 1

MIAMI

PSYCHOSOCIAL CONSEQUENCES:SPECTRUM OF SEVERITY 2

Fear and Distress Response

Disaster Impact

BehaviorChange

PsychiatricIllness

Source: Butler AS, Panzer AM, Goldfrank LR. Preparing for the psychological consequences of terrorism: A public health

approach. Washington, D.C.: National Academies Press, 2003.

PSYCHOSOCIAL CONSEQUENCES:RANGE OF DURATION 3

Source: Shultz JM, Espinel Z, Galea S, Reissman DB.Disaster Ecology: Implications for Disaster Psychiatry. In Ursano et al. (eds.)

Textbook of Disaster Psychiatry, Cambridge University Press, 2007.

ExposureForcesof Harm

AffectedPopulation

Time from Impact

Disaster Impact

Loss

Change

PSYCHOSOCIAL CONSEQUENCES:RANGE OF DURATION 3

Source: Shultz JM, Espinel Z, Galea S, Reissman DB.Disaster Ecology: Implications for Disaster Psychiatry. In Ursano et al. (eds.)

Textbook of Disaster Psychiatry, Cambridge University Press, 2007.

ExposureForcesof Harm

AffectedPopulation

Time from Impact

Disaster Impact

Loss

Change

PSYCHOSOCIAL CONSEQUENCES:RANGE OF DURATION 3

Source: Shultz JM, Espinel Z, Galea S, Reissman DB.Disaster Ecology: Implications for Disaster Psychiatry. In Ursano et al. (eds.)

Textbook of Disaster Psychiatry, Cambridge University Press, 2007.

ExposureForcesof Harm

AffectedPopulation

Time from Impact

Disaster Impact

Loss

Change

PSYCHOSOCIAL CONSEQUENCES:RANGE OF DURATION 3

Source: Shultz JM, Espinel Z, Galea S, Reissman DB.Disaster Ecology: Implications for Disaster Psychiatry. In Ursano et al. (eds.)

Textbook of Disaster Psychiatry, Cambridge University Press, 2007.

ExposureForcesof Harm

AffectedPopulation

Time from Impact

Disaster Impact

Loss

Change

ComplexEmergencies

PSYCHOSOCIAL CONSEQUENCES:TYPE OF DISASTER 4

Human-Generated DisastersNatural Disasters

Hurricanes, Storms

IntentionalMass Violence

Terrorism

Non-intentional

TechnologicalFloods, Mudslides

Wildfires, ExtremeHeat, Cold

Earthquakes,Tsunamis, Landslides

Pandemics

ComplexEmergencies

PSYCHOSOCIAL CONSEQUENCES:TYPE OF DISASTER 4

Human-Generated DisastersNatural Disasters

Hurricanes, Storms

IntentionalMass Violence

Terrorism

Non-intentional

TechnologicalFloods, Mudslides

Wildfires, ExtremeHeat, Cold

Pandemics

EarthquakesTsunamis, Landslides

ComplexEmergencies

PSYCHOSOCIAL CONSEQUENCES:TYPE OF DISASTER 4

Human-Generated DisastersNatural Disasters

Hurricanes, Storms

IntentionalMass Violence

Terrorism

Non-intentional

TechnologicalFloods, Mudslides

Wildfires, ExtremeHeat, Cold

Pandemics

EarthquakesTsunamis, Landslides

ComplexEmergencies

PSYCHOSOCIAL CONSEQUENCES:TYPE OF DISASTER 4

Human-Generated DisastersNatural Disasters

Hurricanes, Storms

IntentionalMass Violence

Terrorism

Non-intentional

TechnologicalFloods, Mudslides

Wildfires, ExtremeHeat, Cold

EarthquakesTsunamis, Landslides

Pandemics

CATASTROPHE

Extreme exposure during impact

Extreme hardship in the aftermath

Separation or loss of loved one

Loss of place or territory4321

Violation of meaning, justice, order5

PSYCHOSOCIAL CONSEQUENCES: MECHANISMS

Num

ber o

f Sur

vivo

rs w

ith P

sych

olog

ical

Rea

ctio

ns

Time from Impact

Mild Reactions

Moderate Reactions

PROFILE OF DISASTER STRESS & DISTRESS

Severe Reactions

Time from Impact

Mild Reactions

Moderate Reactions

Severe Reactions

WIDESPREAD

SPECTRUMOF SEVERITY

RANGE OFDURATION

Num

ber o

f Sur

vivo

rs w

ith P

sych

olog

ical

Rea

ctio

ns

SAFETY FUNCTION ACTIONis a framework

for achieving and maintaininga high level of

DISASTER HEALTHand well-being

SFA FRAMEWORK

Achieve and maintaina high level of

DISASTER HEALTHand well-being.

SAFETY FUNCTION ACTION GOAL

Homeland Security Presidential Directive 21 (HSPD 21)“National Strategy for Public Health and Medical Preparedness.”

HSPD 21 proposes a new fieldof “disaster health”

to bring together medical,public health, public safety, and

behavioral health aspects ofdisaster preparedness and response.

HSPD-21: DISASTER HEALTH

DISASTER HEALTHMaximal SAFETY,

optimal FUNCTION,and effective ACTION

in preparedness for, and response to, emergencies, disasters,

and extreme events.

DISASTER HEALTH: DEFINITION

Maximal

SAFETYOptimal

FUNCTIONEffective

ACTION

SAFETY FUNCTION ACTION3 KEYS TO DISASTER HEALTH

SUSTAINSAFEGUARD

CONNECTCOMFORT

ACTIVATEADVISE

6 STRATEGIES3 KEYS TO DISASTER HEALTH

SAFETY FUNCTION ACTION3 KEYS AND SIX STRATEGIES

Maximal

SAFETYOptimal

FUNCTIONEffective

ACTION

ACTIONADVISEACTIVATE

ADVISEACTIVATE

FUNCTIONCOMFORTCONNECT

COMFORTCONNECT

SAFETYSAFEGUARDSUSTAIN

SAFEGUARDSUSTAIN

RESPONDSKILLS SET

PREPARESKILLS SET

STRATEGIES FORRESPONDERS

STRATEGIES FORSURVIVORS

SAFETY FUNCTION ACTIONPARALLEL STRATEGIES

ACTION

ADVISE

ACTIVATE

FUNCTION

COMFORT

CONNECT

SAFETY

SAFEGUARD

SUSTAIN

RESPONDSKILL SET

PREPARESKILL SET

1 GOAL Achieve and maintain a high level ofDISASTER HEALTH and well-being.

3 KEYS TODISASTER HEALTH

6 STRATEGIES

2 SKILL SETS

SAFETY FUNCTION ACTION BUILDING BLOCKS

DISASTERHEALTH

DEFINITION

Maximal SAFETY , optimal FUNCTION,and effective ACTION in response to

emergencies, disasters, and extreme events.

PREPARESKILLS

SET

SFA Strategiesfor

Responders

SAFEGUARDResponders

SUSTAINResponders

COMFORTResponders

CONNECTResponders

ADVISEResponders

ACTIVATEResponders

SAFEGUARDSurvivors

SUSTAINSurvivors

COMFORTSurvivors

CONNECTSurvivors

ADVISESurvivors

ACTIVATESurvivors

PLAN for the

DISASTERROLE

SFAOverview

2Disaster

Health

RESPONDSKILLS

SET

SFA Strategiesfor

Survivors

SAFETY FUNCTION ACTION PATHWAY

1 3 4 5 6

PRACTICEfor the

DISASTERROLE

PRIORITIZESTRESS

MANAGE-MENT

APPROACHSURVIVORS

PresenceEmpathyRespect

Communi-cation

ATTEND toSURVIVORS

SpecialNeeds

CulturalIssues

APPRAISESURVIVORSIdentify Issues

CustomizeSFA Tactics

Refer toServices

SAFETY FUNCTION ACTIONTRAINING MODULE GUIDEBOOK

SAFETY FUNCTION ACTIONLAMINATED SHEET

SAFETY FUNCTION ACTIONFLIPBOOK

SAFETY FUNCTION ACTION FRAMEWORK

FIVE ESSENTIALELEMENTS

SAFETYSAFEGUARD

SafetySUSTAIN

FUNCTIONCOMFORT CalmingCONNECT Connectedness

ACTIONADVISE Self-EfficacyACTIVATE Efficacy & Hope

Source: Hobfoll, et al. Five essential elements of immediate and mid-term mass trauma intervention: Empirical evidence. Psychiatry 2007:70;283-315.

FIVE ESSENTIAL ELEMENTS

Primary focus on responders

One framework for responders and survivors

Operates 360o throughout the disaster cycle

43

2

1

5

Structured for evaluation

6

SAFETY FUNCTION ACTIONDISTINCTION

Incorporates resilience training for respondersand psychological support for survivors

First course focusing on DISASTER HEALTH

Public health, medical preparedness, andbehavioral health integration

7

PSYCHOLOGICALSUPPORT

FOR RESPONDERS

• Preparedness– Disaster plans– “Disaster ready lifestyle”

• Recognition– Educate about disasters

• Expectability of psychological reactions• Understanding of disaster health concept• Effective stress management and coping skills

PREVENTION

Physical Body reactionsEmotional Feelings

Cognitive Thinking/decision-makingBehavioral ActionsSpiritual Beliefs and valuesSocial Interactions

Dimensions of the Stress Response

PREPARESKILLS

SET

PLAN for the

DISASTERROLE

PRACTICEfor the

DISASTERROLE

PRIORITIZESTRESS

MANAGE-MENT

SAFETY FUNCTION ACTION FRAMEWORK

RESPONDERS-PREPARE SKILLS SET

PLAN for the DISASTER ROLE

PRACTICE for the DISASTER ROLE

PRIORITIZE STRESS MANAGEMENT

Plan and Prepare:Florida Demographics

• 3rd largest state in the nation– Overall population: 18.5 million

• 7th fastest growing state– 3+ million new residents in past 10 years

• Vast number of foreign-born individuals– 16.7% of the population– Accounts for 61% of state’s population increase

• 1.2 million people live in rural FL• 700,000+ illegal immigrants in FL (many are

migrant workers)

US Census Bureau (2010). Florida Quick Facts. http://quickfacts.census.gov/qfd/states/12000.html. Accessed May 2010.

US Immigration Support (2010). Immigration to Florida. http://www.usimmigrationsupport.org/florida.html. Accessed May 2010.

Plan and Prepare:Characteristics of Rural Communities

• High levels of:– Poverty (17.8% poverty rate in rural areas vs.

13% poverty rate in urban areas)– Unemployment– Health related problems

• A usually homogeneous community with pockets of minorities

• Large percentage of population is involved with organized religion

SAMHSA (1999). Disaster Mental Health: Crisis Counseling Program for the Rural Community.

Plan and Prepare: Rural Populations Post-Disaster

• Accessing population– Agricultural considerations (i.e. free time)– Migration– Living situation

• Cultural values– Individualism and independence– Stigma of mental health services– Religion

Plan and Prepare: Cross-Cultural Issues

• Recognizing ethnicity– Avoiding labels

• Language barriers• Migration history

– Reasons for migrating– Experiences in homeland, during migration,

and in current location• Level of acculturation• Social support networks

Association of Reproductive Health Professionals (2008). Cross-Cultural Communication with Immigrant and Refugee Patients. http://www.arhp.org/Publications-and-Resources/Clinical-Fact-Sheets/Cross-Cultural. Accessed May 2010.

Plan and Prepare:Co-occurring Issues Post-Disaster

• Poverty• Housing• Lack of understanding and/or language• Immigration status• Transient population = lowered social network• Transient population = lack of stable access to

social services• Compounding health issues• Mental health symptoms• Slavery and abuse

Immigration, Children, and Disasters

• Prior to the 2010 earthquake in Haiti– 6% of children in Florida are foreign-born– 28% of children in Florida have immigrant

parents• Following the 2010 earthquake in Haiti

SAFETY

FUNCTION

ACTION

SUSTAINSAFEGUARD

CONNECTCOMFORT

ACTIVATEADVISE

SUSTAINSAFEGUARD

CONNECTCOMFORT

ACTIVATEADVISE

STRATEGIES FORRESPONDERS

STRATEGIES FORSURVIVORS

SAFETY FUNCTION ACTIONPARALLEL STRATEGIES

DISASTERSTRESSORS:

HAITI’S YOUTH

STRESSORS FOR CHILDREN

INTENSE EXPOSURE

STRESSORS FOR CHILDREN

INTENSE EXPOSURE

LACK OF SURVIVAL NEEDS

STRESSORS FOR CHILDREN

LACK OF BASIC SUPPLIES

STRESSORS FOR CHILDREN

PERSONAL INJURY

STRESSORS FOR CHILDREN

STRESSORS FOR CHILDREN

INJURY TO CAREGIVERS

STRESSORS FOR CHILDREN

SEPARATION OR LOSS OF CAREGIVERS

STRESSORS FOR CHILDREN

FUNCTIONALLY-IMPAIRED CAREGIVERS

STRESSORS FOR CHILDREN

DISPLACEMENT / POST-IMPACT HARDSHIPS

INTENSE EXPOSURE

LOSS OF A LOVED ONE

DISRUPTION OF SURVIVAL NEEDS

DISRUPTION OF ESSENTIAL SERVICES4321

PRIOR TRAUMA5

SEVERE PSYCHOLOGICAL REACTIONS

MAJOR LIFE STRESSORS6

SUSTAINSAFEGUARD

CONNECTCOMFORT

ACTIVATEADVISE

6 STRATEGIES3 KEYS TO DISASTER HEALTH

SAFETY FUNCTION ACTION3 KEYS AND SIX STRATEGIES

Maximal

SAFETYOptimal

FUNCTIONEffective

ACTION

SAFETY FUNCTION ACTION

Maximal

SAFETYOptimal

FUNCTIONEffective

ACTION

SAFETY FUNCTION ACTION

SAFEGUARD

SAFETY FUNCTION ACTION

SAFEGUARD

SAFETY FUNCTION ACTION

SUSTAIN

SAFETY FUNCTION ACTION

SUSTAIN

SAFETY FUNCTION ACTION

COMFORT

SAFETY FUNCTION ACTION

CONNECT

SAFETY FUNCTION ACTION

CONNECT

SAFETY FUNCTION ACTION

ADVISE

SAFETY FUNCTION ACTION

ACTIVATE

SAFETY FUNCTION ACTION

ACTIVATE

• Classified according to– Timing

• When to intervene– Is the survivor receptive for services?– Does the intervention drain already minimal resources?

– Intention• Early post-disaster

– Re-establish sense of safety and security• Intermediate post-disaster

– Increase coping skills• Long-term post-disaster

– Address symptoms of PTSD, Major Depressive Episode, Complicated Grief, Anxiety

– Build Resiliency

POST-DISASTER INTERVENTIONS

• Expert panel consensus in 2001 suggests move towards– Flexible– Non-prescriptive– Multi-faceted approach

• Focus on– Securing basic needs– Applying principles of psychological first aid– Conducting needs assessment– Monitoring rescue and recovery– Providing outreach and information– Fostering resilience and recovery– Conducting triage and referral– Providing psychiatric treatment for subset of survivors (NIMH,

2002)

EMPIRICALLY-INFORMED EARLY INTERVENTION

SAFETY

FUNCTION

ACTION

SUSTAINSAFEGUARD

CONNECTCOMFORT

ACTIVATEADVISE

SUSTAINSAFEGUARD

CONNECTCOMFORT

ACTIVATEADVISE

STRATEGIES FORRESPONDERS

STRATEGIES FORSURVIVORS

SAFETY FUNCTION ACTIONPARALLEL STRATEGIES