Using Public Health Detailing to Increase Access and Confidence in COVID-19 Vaccines and Reinvest in Disproportionately Impacted NYC Communities.

CONTEXT: COVID-19 vaccination rates in New York City (NYC) began to plateau in the spring of 2021, with unacceptable inequities in vaccination rates based on race. PROGRAM: To address racial inequities in vaccination rates and COVID-19 health outcomes, the New York City Department of Health and Mental Hygiene adapted a preexisting provider outreach and education program for public health emergency use with the goals of community reinvestment and increasing patient confidence and access to the COVID-19 vaccines. The Vaccine Public Health Detailing (VPHD) program was delivered as part of a larger community outreach initiative and brought timely updates, materials, and access to technical assistance to primary care providers and staff in NYC neighborhoods experiencing COVID-19 health inequities. Outreach representatives also collected feedback from providers on resource needs to inform the agency's response. IMPLEMENTATION: Sixteen outreach representatives were rapidly trained on COVID-19-related content and strategic communication techniques and launched a 3-wave campaign across targeted neighborhoods throughout NYC. The campaign ran from May 2021 to March 2022 and was conducted in coordination with other community engagement initiatives aimed at the general public to promote greater collective impact. EVALUATION: In total, 2873 detailing sessions were conducted with 2027 unique providers at 1281 sites. Outreach representatives successfully completed visits at more than 85% of practices that were in scope and operating. Approximately 20% (285) of the sites requested a referral for technical assistance to become a COVID-19 vaccination site or enroll in the Citywide Immunization Registry. Qualitative information shared by providers offered a more in-depth understanding of vaccine-related sentiments and challenges faced by providers on the ground. DISCUSSION: VPHD is an effective method for supporting community providers, gathering feedback on resource needs and practice challenges, and increasing health systems efficacy during a public health emergency while also prioritizing racial equity and community reinvestment.

Self-Efficacy and Mental Health Help-Seeking Behavior of World Trade Center Health Registry Enrollees, 2015-2016.

The September 11th World Trade Center (WTC) disaster resulted in an elevated prevalence of Post-Traumatic Stress Disorder (PTSD) among those directly exposed, yet lower than expected rates of mental health treatment seeking and high levels of reported perceived unmet mental healthcare need were observed in this population in the years following. Self-efficacy, an individual's self-perception of their ability to succeed in specific situations or accomplish a task or goal, may in part explain this discrepancy; however, little is known about its interplay with the help-seeking behaviors of disaster-exposed populations. We used WTC Health Registry data (n = 11,851) to describe the relationship between self-efficacy and three outcomes related to help-seeking behavior: (1) seeking mental health treatment, (2) perceived unmet mental health care needs, and (3) satisfaction with mental health treatment. Multinomial logistic regression models were used to estimate adjusted odds ratios (AORs) and 95% confidence intervals (CI). We found a dose-response relationship between self-efficacy score and mental health help-seeking: for every one unit increase in self-efficacy score, we observed a 6% increase in the odds of having treatment 4 to 12 months ago (OR = 1.06, CI: 1.03-1.09), a 7% increase in the odds of having had treatment 1 to 2 years ago (OR = 1.07, CI: 1.04, 1.09), and a 10% increase in the odds of having sought treatment 2 or more years ago (OR = 1.10, CI: 1.08, 1.12) compared to those who had sought treatment more recently. An understanding of individual self-efficacy may help improve post-disaster mental health treatment in order to provide more tailored and helpful care.

Post-Traumatic Stress Disorder among Survivors of the September 11, 2001 World Trade Center Attacks: A Review of the Literature.

Prior reviews of 9/11-related post-traumatic stress disorder (PTSD) have not focused on the civilian survivors most directly exposed to the attacks. Survivors include those individuals who were occupants of buildings in or near the World Trade Center (WTC) towers, those whose primary residence or workplace was in the vicinity, and persons who were on the street passing through the area. This review reports published information on the prevalence of and risk factors for PTSD, as well as comorbidities associated with PTSD among 9/11 survivors. Articles selected for inclusion met the following criteria: (1) full-length, original peer-reviewed empirical articles; (2) published in English from 2002-2019; (3) collected data from persons directly exposed; (4) adult populations; and (5) focused on non-rescue or recovery workers (i.e., survivors). Data were extracted with focus on study design, sample size, time frame of data collection post-9/11, PTSD assessment instrument, and PTSD prevalence, risk factors, and comorbidities. Our review identified the use of cross-sectional and longitudinal designs, finding multiple direct comorbidities with PTSD, as well as the prevalence and persistence of PTSD. Future research would benefit from incorporating more mixed methods designs, and exploring the mediating mechanisms and protective factors of the known associations of PTSD among the 9/11 survivor population.

Systemic Autoimmune Disease Among Adults Exposed to the September 11, 2001 Terrorist Attack.

OBJECTIVE: Autoimmune disease is an emerging condition among persons exposed to the September 11, 2001 attack on the World Trade Center (WTC). Components of the dust cloud resulting from the collapse of the WTC have been associated with development of a systemic autoimmune disease, as has posttraumatic stress disorder (PTSD). We undertook this study to determine whether dust exposure and PTSD were associated with an increased risk of systemic autoimmune disease in a 9/11-exposed cohort. METHODS: Among 43,133 WTC Health Registry enrollees, 2,786 self-reported having a post-9/11 systemic autoimmune disease. We obtained informed consent to review medical records to validate systemic autoimmune disease diagnoses for 1,041 enrollees. Diagnoses of systemic autoimmune diseases were confirmed by classification criteria, rheumatologist diagnosis, or having been prescribed systemic autoimmune disease medication. Controls were enrollees who denied having an autoimmune disease diagnosis (n = 37,017). We used multivariable log-binomial regression to examine the association between multiple 9/11 exposures and risk of post-9/11 systemic autoimmune disease, stratifying by responders (rescue, recovery, and clean-up workers) and community members (e.g., residents, area workers). RESULTS: We identified 118 persons with systemic autoimmune disease. Rheumatoid arthritis was most frequent (n = 71), followed by SjÓ§gren's syndrome (n = 22), systemic lupus erythematosus (n = 20), myositis (n = 9), mixed connective tissue disease (n = 7), and scleroderma (n = 4). Among 9/11 responders, those with intense dust cloud exposure had almost twice the risk of systemic autoimmune disease (adjusted risk ratio 1.86 [95% confidence interval 1.02-3.40]). Community members with PTSD had a nearly 3-fold increased risk of systemic autoimmune disease. CONCLUSION: Intense dust cloud exposure among responders and PTSD among community members were associated with a statistically significant increased risk of new-onset systemic autoimmune disease. Clinicians treating 9/11 survivors should be aware of the potential increased risk of systemic autoimmune disease in this population.

Comparing life satisfaction and functioning 15 years after September 11, 2001 among survivors with and without injuries: a mixed-method study.

PURPOSE: This study compares life satisfaction and limited activity days among 9/11 survivors with and without physical injuries using quantitative and qualitative approaches. METHODS: The study population included World Trade Center Health Registry enrollees who reported being injured on 9/11 in 2003-2004 and a sample of non-injured enrollees who participated in a cross-sectional substudy. We used multivariable logistic regression to examine differences in life satisfaction and number of limited activity days in the last 30 days between those with and without injuries. The free-response section of the survey was analyzed qualitatively to compare themes of those with and without injuries. RESULTS: The final sample consisted of 2821 adult enrollees. Compared to those who were not injured, those who were injured on 9/11 were more likely to report being unsatisfied with their life (adjusted odds ratio (AOR): 1.5, 95% confidence intervals (CI) 1.1-2.0) and have 14 or more limited activity days in the last 30 days (AOR: 1.4, 95% CI 1.0-1.9). Among those who were injured, being partially or completely prevented from working increased the odds of being unsatisfied with life and having 14 or more limited activity days. In qualitative analysis, the emotional trauma experienced from 9/11 was a major and common theme, regardless of injury status. Those with injuries were more likely to express anger/lack of recognition/appreciation, describe substance use/abuse, and have financial/health care access issues. CONCLUSIONS: More than 15 years after 9/11, those who were injured continue to be impacted, reporting lower life satisfaction and more functional impairment.

Characterizing Mental Health Treatment Utilization among Individuals Exposed to the 2001 World Trade Center Terrorist Attacks 14⁻15 Years Post-Disaster.

Following the World Trade Center (WTC) attacks in New York City (NYC) on 11 September 2001 (9/11), thousands in NYC experienced significant stress reactions and disorders, presenting an immediate need for counseling and treatment. While other studies documented post-9/11 mental health treatment utilization, none have data more than two years post-disaster. We used data from 35,629 enrollees of the WTC Health Registry, a longitudinal cohort study of those exposed to the WTC attacks, to examine predictors of counseling after 9/11, the types of practitioners seen, and the perceived helpfulness of therapy up to 15 years post-disaster. Among enrollees, 37.7% reported receiving counseling at some time after 9/11. Predictors of seeking counseling included race/ethnicity, age at 9/11, education level, exposure to the WTC attacks, other traumatic experiences, mental health symptomology, and pre-9/11 counseling. Whites and Hispanics, those who were children on 9/11, and those with high levels of exposure to the WTC attacks sought counseling soonest after 9/11. Among those who sought counseling, Blacks, Asians, and those with lower education and income were less likely to see mental health specialists and more likely to see general practitioners or religious advisors. Finally, among those who sought recent counseling, women, Blacks, those aged ≥65 years, and those with very high WTC exposures were more likely to rate their recent counseling as very helpful. This study used data up to 15 years post-disaster to document mental health treatment utilization patterns, trends, and disparities that have implications for future preparedness plans and needs assessments.

Translating research into action: An evaluation of the World Trade Center Health Registry's Treatment Referral Program.

This manuscript describes the design, implementation and evaluation of the World Trade Center (WTC) Health Registry's Treatment Referral Program (TRP), created to respond to enrollees' self-reported 9/11-related physical and mental health needs and promote the use of WTC-specific health care. In 2009-2011, the TRP conducted personalized outreach, including an individualized educational mailing and telephone follow-up to 7,518 selected enrollees who resided in New York City, did not participate in rescue/recovery work, and reported symptoms of 9/11-related physical conditions or posttraumatic stress disorder (PTSD) on their most recently completed Registry survey. TRP staff spoke with enrollees to address barriers to care and schedule appointments at the WTC Environmental Health Center for those eligible. We assessed three nested outcomes: TRP participation (e.g., contact with TRP staff), scheduling appointments, and keeping scheduled appointments. A total of 1,232 (16.4%) eligible enrollees participated in the TRP; 32% of them scheduled a first-time appointment. We reached 84% of participants who scheduled appointments; 79.4% reported having kept the appointment. Scheduling an appointment, but not keeping it, was associated with self-reported unmet health care need, PTSD, and poor functioning (≥14 days of poor physical or mental health in the past 30 days) (P < 0.05). Neither scheduling nor keeping an appointment was associated with demographic characteristics. Successful outreach to disaster-exposed populations may require a sustained effort that employs a variety of methods in order to encourage and facilitate use of post-disaster services. Findings from this evaluation can inform outreach to the population exposed to 9/11 being conducted by other organizations.