Resilience to post-traumatic stress among World Trade Center survivors: A mixed-methods study.

The purpose of this study was to identify individual characteristics, behaviors, and psychosocial factors associated with symptoms of post-traumatic stress disorder (PTSD) among World Trade Center (WTC) disaster evacuation survivors. The study utilized a mixed-method design. In-depth interviews were conducted using a prepared script. PTSD was assessed using the PTSD checklist-civilian (PCL-C; a score ≥ 50 indicates probable PTSD). Thematic analysis was conducted to identify factors associated with PTSD. A purposive sample of 29 WTC evacuees was recruited using a multimodal recruitment strategy. Eligibility included: history of evacuation from the WTC (Tower 1 and/or Tower 2) on September 11, 2001, and decisional capacity for informed consent. Five participants had PCL-C scores ≥ 50. Thematic analysis identified resiliency factors (protective for PTSD), including leadership, taking action based on "gut" feelings (to evacuate), social support (staying in a group), going on "automatic survival" mode, and previous training on emergency response. Risk factors for PTSD included lack of emergency response training, lack of sense of urgency, poor physical condition, lack of communication skills, lack of direction, peri-event physical injury, peri-event traumatic exposure (horror), and moral injury (guilt and remorse). Several modifiable factors that may confer resilience were identified. In particular, the role of emergency response training in preventing disaster-related mental illness should be explored as a possible strategy for enhancing resilience to disaster events.

Psychosocial Influences on Disaster Preparedness in San Francisco Recipients of Home Care.

Disasters disproportionately impact certain segments of the population, including children, pregnant women, people living with disabilities and chronic conditions and those who are underserved and under-resourced. One of the most vulnerable groups includes the community-dwelling elderly. Post-disaster analyses indicate that these individuals have higher risk of disaster-related morbidity and mortality. They also have suboptimal levels of disaster preparedness in terms of their ability to shelter-in-place or evacuate to a shelter. The reasons for this have not been well characterized, although impaired health, financial limitations, and social isolation are believed to act as barriers to preparedness as well as to adaptability to changes in the environment both during and in the immediate aftermath of disasters. In order to identify strategies that address barriers to preparedness, we recently conducted a qualitative study of 50 elderly home care recipients living in San Francisco. Data were collected during in-home, in-person interviews using a semi-structured interview guide that included psychosocial constructs based on the social cognitive preparedness model and a new 13-item preparedness checklist. The mean preparedness score was 4.74 (max 13, range 1-11, SD. 2.11). Over 60 % of the participants reported that they had not made back-up plans for caregiver assistance during times of crisis, 74 % had not made plans for transportation to a shelter, 56 % lacked a back-up plan for electrical equipment in case of power outages, and 44 % had not prepared an emergency contacts list-the most basic element of preparedness. Impairments, disabilities, and resource limitations served as barriers to preparedness. Cognitive processes that underlie motivation and intentions for preparedness behaviors were lacking. There were limitations with respect to critical awareness of hazards (saliency), self-efficacy, outcome expectancy, and perceived responsibility. There was also a lack of trust in response agencies and authorities and a limited sense of community. Participants wanted to be prepared and welcomed training, but physical limitations kept many of them home bound. Training of home care aides, the provision of needed resources, and improved community outreach may be helpful in improving disaster outcomes in this vulnerable segment of the population.

Factors associated with the ability and willingness of essential workers to report to duty during a pandemic.

OBJECTIVE: To determine essential workers' ability and willingness to report to duty during a serious pandemic outbreak and to identify modifiable risk factors. METHODS: Workers (N = 1103) from six essential workgroups completed an anonymous, cross-sectional survey. RESULTS: Although a substantial proportion of participants reported that they would be able (80%), fewer would be willing (65%) to report to duty. Only 49% of participants would be both able and willing. Factors significantly associated with ability/willingness included individual-level (eg, intentions to adhere to respiratory protection and pandemic vaccination recommendations) and organizational-level factors (eg, preparedness planning for respiratory protection and worker vaccination programs). CONCLUSIONS: During a serious pandemic event, non-illness-related shortfalls among essential workers could be substantial. Organizational preparedness efforts should focus on worker protection programs and the development of policies that would facilitate the attendance of healthy workers.

Participatory action research methodology in disaster research: results from the World Trade Center evacuation study.

OBJECTIVE: Participatory action research (PAR) methodology is an effective tool in identifying and implementing risk-reduction interventions. It has been used extensively in occupational health research, but not, to our knowledge, in disaster research. A PAR framework was incorporated into the World Trade Center evacuation study, which was designed to identify the individual, organizational, and structural (environmental) factors that affected evacuation from the World Trade Center Towers 1 and 2 on September 11, 2001. PAR teams-comprising World Trade Center evacuees, study investigators, and expert consultants-worked collaboratively to develop a set of recommendations designed to facilitate evacuation from high-rise office buildings and reduce risk of injury among evacuees. METHODS: Two PAR teams worked first separately and then collectively to identify data-driven strategies for improvement of high-rise building evacuation. RESULTS: The teams identified interventions targeting individual, organizational, and structural (environmental) barriers to safe and rapid evacuation. CONCLUSIONS: PAR teams were effective in identifying numerous feasible and cost-effective strategies for improvement of high-rise emergency preparedness and evacuation. This approach may have utility in other workplace disaster prevention planning and response programs.

Home health care registered nurses and the risk of percutaneous injuries: a pilot study.

BACKGROUND: Home health care is the fastest-growing sector in the health care industry, expected to grow 66% over the next 10 years. Yet data on occupational health hazards, including the potential risk of exposure to blood and body fluids, associated with the home care setting remain very limited. As part of a larger study of bloodborne pathogen risk in non-hospital-based registered nurses (RNs), data from 72 home health care nurses were separately analyzed to identify risk of blood/body fluid exposure. METHODS: A 152-item self-administered mailed risk assessment questionnaire was completed by RNs employed in home health care agencies in New York State. RESULTS: Nine (13%) of the home health care nurses experienced 10 needlesticks in the 12-month period before the study. Only 4 of the needlesticks were formally reported to the nurse's employer. The devices most frequently associated with needlesticks were hollow-bore and phlebotomy needles, and included 3 needles with safety features. Exposure was most commonly attributed to patient actions, followed by disposal-related activities. CONCLUSIONS: These data suggest that home health care nurses may be at potential occupational risk for bloodborne pathogen exposure. Risk management strategies tailored to the home health care setting may be most effective in reducing this risk.

Non-hospital based registered nurses and the risk of bloodborne pathogen exposure.

The aim of this study was to assess the risk of blood and body fluid exposure among non-hospital based registered nurses (RNs) employed in New York State. The study population was mainly unionized public sector workers, employed in state institutions. A self-administered questionnaire was completed by a random stratified sample of members of the New York State Nurses Association and registered nurse members of the New York State Public Employees Federation. Results were reviewed by participatory action research (PAR) teams to identify opportunities for improvement. Nine percent of respondents reported at least one needlestick injury in the 12-month period prior to the study. The percutaneous injury (PI) rate was 13.8 per 100 person years. Under-reporting was common; 49% of all PIs were never formally reported and 70% never received any post-exposure care. Primary reasons for not reporting included: time constraints, fear, and lack of information on reporting. Significant correlates of needlestick injuries included tenure, patient load, hours worked, lack of compliance with standard precautions, handling needles and other sharps, poor safety climate, and inadequate training and availability of safety devices (p<0.05). PAR teams identified several risk reduction strategies, with an emphasis on safety devices. Non-hospital based RNs are at risk for bloodborne exposure at rates comparable to hospital based RNs; underreporting is an important obstacle to infection prevention, and primary and secondary risk management strategies appeared to be poorly implemented. Intervention research is warranted to evaluate improved risk reduction practices tailored to this population of RNs.

Factors associated with high-rise evacuation: qualitative results from the World Trade Center Evacuation Study.

INTRODUCTION: Due to the fact that most high-rise structures (i.e., >75 feet high, or eight to ten stories) are constructed with extensive and redundant fire safety features, current fire safety procedures typically only involve limited evacuation during minor to moderate fire emergencies. Therefore, full-scale evacuation of high-rise buildings is highly unusual and consequently, little is known about how readily and rapidly high-rise structures can be evacuated fully. Factors that either facilitate or inhibit the evacuation process remain under-studied. OBJECTIVE: This paper presents results from the qualitative phase of the World Trade Center Evacuation Study, a three-year, five-phase study designed to improve our understanding of the individual, organizational, and environmental factors that helped or hindered evacuation from the World Trade Center (WTC) Towers 1 and 2, on 11 September 2001. METHODS: Qualitative data from semi-structured, in-depth interviews and focus groups involving WTC evacuees were collected and analyzed. RESULTS: On the individual level, factors that affected evacuation included perception of risk (formed largely by sensory cues), preparedness training, degree of familiarity with the building, physical condition, health status, and footwear. Individual behavior also was affected by group behavior and leadership. At the organizational level, evacuation was affected by worksite preparedness planning, including the training and education of building occupants, and risk communication. The environmental conditions affecting evacuation included smoke, flames, debris, general condition and degree of crowdedness on staircases, and communication infrastructure systems (e.g., public address, landline, cellular and fire warden's telephones). CONCLUSIONS: Various factors at the individual, organizational, and environmental levels were identified that affected evacuation. Interventions that address the barriers to evacuation may improve the full-scale evacuation of other high-rise buildings under extreme conditions. Further studies should focus on the development and evaluation of targeted interventions, including model emergency preparedness planning for high-rise occupancies.

Roadmap for the protection of disaster research participants: findings from the World Trade Center Evacuation Study.

INTRODUCTION: This report addresses the development, implementation, and evaluation of a protocol designed to protect participants from inadvertent emotional harm or further emotional trauma due to their participation in the World Trade Center Evacuation (WTCE) Study research project. This project was designed to identify the individual, organizational, and structural (environmental) factors associated with evacuation from the World Trade Center Towers 1 and 2 on 11 September 2001. METHODS: Following published recommended practices for protecting potentially vulnerable disaster research participants, protective strategies and quality assurance processes were implemented and evaluated, including an assessment of the impact of participation on study subjects enrolled in the qualitative phase of the WTCE Study. RESULTS: The implementation of a protocol designed to protect disaster study participants from further emotional trauma was feasible and effective in minimizing risk and monitoring for psychological injury associated with study participation. CONCLUSIONS: Details about this successful strategy provide a roadmap that can be applied in other post-disaster research investigations.

Effectiveness of an emergency preparedness training program for public health nurses in New York City.

A public health workforce that is competent to respond to emergencies is extremely important. We report on the impact of a training program designed to prepare public health nurses to respond appropriately to emergencies. The program focused on the basic public health emergency preparedness competencies and the emergency response role of public health workers employed by the New York City School Department of Health and Mental Hygiene School Health Program. The evaluation methods included pre/post-testing followed by a repeat post-test one month after the program. The program resulted in positive shifts in both knowledge and emergency response attitudes.

Clinicians' knowledge, attitudes, and concerns regarding bioterrorism after a brief educational program.

We conducted this study to determine the knowledge, attitudes, and intended behaviors of New York City clinicians regarding bioterrorism-related diseases after a brief educational program. Data on clinicians' knowledge and attitudes toward bioterrorism and related diseases were collected using a self-administered questionnaire following a 3.5-hour educational program. Participants (n = 310, 82% response rate) reported increased confidence in recognizing symptoms of bioterrorism-related diseases (89%), in addressing patients' bioterrorism concerns (83%), and ability to treat bioterrorism victims (75%). Despite a high level of confidence in the efficacy of infection control precautions, participants' knowledge scores regarding safe work practices suggest that additional education is warranted. Educational programs are useful in enhancing the public health response to bioterrorism and its consequences.

Emergency preparedness training for public health nurses: a pilot study.

The Columbia Center for Public Health Preparedness, in partnership with the New York City Department of Health, recently developed an emergency preparedness training program for public health workers. A pilot training program was conducted for a group of school health nurses and evaluated using a pre/posttest design. A surprising finding was that 90% of the nurses reported at least one barrier to their ability to report to duty in the event of a public health emergency. The most frequently cited barriers included child/elder care responsibilities, lack of transportation, and personal health issues. These findings suggest that it may be prudent to identify and address potential barriers to public health workforce responsiveness to ensure the availability of the workforce during emergencies.