Our research explored how mental health care providers continued to work during and after Hurricane Katrina.

We interviewed 32 practitioners working in the New Orleans mental health care community during and after Hurricane Katrina. Through qualitative data analysis, we developed three temporal periods of disruption: the evacuation period, the surreal period, and the new normal period. We analyzed the actions informants took during these time periods.

The mental health care providers adapted to disruption by displaying two forms of flexibility: doing different tasks and doing tasks differently. How much and how they engaged in these forms of flexibility varied during the three periods.

Informants’ actions helped to create system resilience by adjusting the extent to which they were doing different tasks and the ways in which they were doing tasks differently during the three time periods. Their flexibility allowed them to provide basic care and adapt to changed circumstances. Their flexibility also contributed to maintaining a skilled workforce in the affected region. (Disaster Med Public Health Preparedness. 2013;7:222-231)

Promoted as a means of fueling markets and encouraging economic growth or recovery, cash transfers have become a popular approach to international assistance. The literature recognizes potential problems such as insecurity, corruption, misuse, gender inequality, market inflation, and ineffective targeting. We carried out population and beneficiary surveys in 1997 to evaluate the targeting of cash transfers in Bosnia soon after the end of the conflict.

The population survey visited a random sample of clusters from population registers in Bosnia and Herzegovina (BiH) and Republika Srpska (RS). A directly administered questionnaire asked households whether they received any cash handouts from the Municipal Welfare Office in the last year, and, if so, for what purpose, the amount, and how they used the money. We calculated coverage and inclusion and exclusion errors of the program. The field team also identified cash transfers beneficiaries from official lists of the program and attempted to contact a random sample of them to ask about their experience.

It was not possible to confirm receipts of cash in one third of the sample of 840 named beneficiaries; 19% could not be traced and 17% of those found denied receiving any cash. In the general population survey of 7182 households, coverage rates with cash assistance (11% in BiH, 3% in RS) were at least 44% lower than those declared by the distribution agencies, with considerable variation between cantons. Exclusion errors were high: 83% of those eligible according to the program's income criterion did not receive any cash. Although sufficient cash was dispensed to reach every United Nations High Commission for Refugees priority 1 (most needy) household, only 13% of these households (278/2125) admitted receiving any cash. Inclusion errors were also high: 60% of all of those who received cash were not in the priority 1 category and 46% were not eligible according to the program's income criterion. Extrapolating from the population survey findings, we could only account for a maximum of US$4 million received by households in BiH and RS up to May 1997, of the US$16 million dispersed by the program up to that time.

Targeting of the cash transfers program was poor, with large inclusion and exclusion errors. Much of the disbursed cash apparently did not reach the intended beneficiaries and could not be accounted for. Agencies on the ground did not have the necessary skills to handle the disbursements or to train national organizations to do so. (Disaster Med Public Health Prepardness. 2013;7:232-240)

To identify the most and least commonly cited security management messages that nongovernmental organizations (NGOs) are communicating to their field staff, to determine the types of documentation that NGOs most often use to communicate key security messages, and to distinguish the points of commonality and divergence across organizations in the content of key security messages.

The authors undertook a systematic review of available security policies, manuals, and training materials from 20 international humanitarian NGOs using the InterAction Minimum Operating Security Standards as the basis for a review framework.

The most commonly cited standards include analytical security issues such as threat and risk assessment processes and guidance on acceptance, protection, and deterrence approaches. Among the least commonly cited standards were considering security threats to national staff during staffing decision processes, incorporating security awareness into job descriptions, and ensuring that national staff security issues are addressed in trainings. NGO staff receive security-related messages through multiple document types, but only 12 of the 20 organizations have a distinct security policy document. Points of convergence across organizations in the content of commonly cited standards were found in many areas, but differences in security risk and threat assessment guidance may undermine communication between aid workers about changes in local security environments.

Although the humanitarian community has experienced significant progress in the development of practical staff security guidance during the past 10 years, gaps remain that can hinder efforts to garner needed resources, clarify security responsibilities, and ensure that the distinct needs of national staff are recognized and addressed. (Disaster Med Public Health Preparedness. 2013;7:241-250)

Following a sudden-onset disaster (SOD), rapid information is needed. We assessed the relevance of information available for relief planning on a main Internet portal following a major SOD.

We reviewed all information posted on the Reliefweb Web site in the first 7 days following the 2005 South Asian earthquake using a predeveloped registration form focusing on essential indicators. These data were compared with Pakistani government figures posted by the Centre for Research on the Epidemiology of Disasters.

A total of 820 reports were reviewed. More reports came from nongovernmental organizations (NGOs; 35%) than any other source. A total of 42% of reports addressed only national level information, while 32% specified information at the provincial level. Fewer than 12% of all reports discussed the earthquake at the more local division and district levels. Only 13 reports provided pre-earthquake estimates of the number of people living in the affected areas. A third of all reports cited a common figure of 2.5 million made homeless. These were lower than official figures of 5 million homeless. A total of 43% reported on the estimated number of deaths. The estimated number peaked on day 4 at 40 000. All of these reports were lower than official data, which reported 73 000 deaths in total.

Early reports heavily underestimated the number of affected, homeless, injured, and dead. Many reports repeated information provided from previous unnamed sources rather than providing unique contributions from eyewitness reports or from contextual information based on previous work in the area. Better information on predisaster essential indicators should be available and used in combination with post-SOD information to better adapt humanitarian relief and funding according to needs. (Disaster Med Public Health Preparedness. 2013;7:251-256)

Recent US disasters highlight the current imbalance between the high proportion of chronically ill Americans who depend on prescription medications and their lack of medication reserves for disaster preparedness. We examined barriers that Los Angeles County residents with chronic illness experience within the prescription drug procurement system to achieve recommended medication reserves.

A mixed methods design included evaluation of insurance pharmacy benefits, focus group interviews with patients, and key informant interviews with physicians, pharmacists, and insurers.

Most prescriptions are dispensed as 30-day units through retail pharmacies with refills available after 75% of use, leaving a monthly medication reserve of 7 days. For patients to acquire 14- to 30-day disaster medication reserves, health professionals interviewed supported 60- to 100-day dispensing units. Barriers included restrictive insurance benefits, patients’ resistance to mail order, and higher copay-ments. Physicians, pharmacists, and insurers also varied widely in their preparedness planning and collective mutual-aid plans, and most believed pharmacists had the primary responsibility for patients’ medication continuity during a disaster.

To strengthen prescription drug continuity in disasters, recommendations include the following: (1) creating flexible drug-dispensing policies to help patients build reserves, (2) training professionals to inform patients about disaster planning, and (3) building collaborative partnerships among system stakeholders. (Disaster Med Public Health Preparedness. 2013;7:257-265)

A robust medical volunteer program is critical to ensuring a successful response to public health and medical emergencies. The New York City (NYC) Department of Health and Mental Hygiene created the NYC Medical Reserve Corps in 2003 to build a multidisciplinary team of health professionals who wish to assist NYC with response during large-scale health emergencies. This article reports on the search to determine which recruitment activities have been most successful to date, with the goal of modeling future activities upon those that worked best.

A retrospective review of effectiveness of recruitment strategies to identify and register new NYC Medical Reserve Corps volunteers was undertaken.

A broad range of recruitment activities have been implemented since the program's inception, with varying degrees of success. Various recruitment modalities were tried, including direct invitations to licensed professionals by the NYC Health Commissioner and announcements through professional organization partners. The direct invitation by the NYC Health Commissioner to health professionals licensed in 1 of the 5 boroughs of NYC has proved to be the most successful recruitment tool to date.

The local health commissioner or other trusted community figure is an excellent messenger for recruiting emergency volunteers. It is also critical that recruitment messages reach as many potential volunteers as possible to ensure that the requisite number of volunteers and mix of professional disciplines are identified. (Disaster Med Public Health Preparedness. 2013;7:266-271)

There are 341 000 patients in the United States who are dependent on routine dialysis for survival. Recent large-scale disasters have emphasized the importance of disaster preparedness, including supporting dialysis units, for people with chronic disease. Contingency plans for staffing are important for providing continuity of care for a technically challenging procedure such as dialysis. PReparing Emergency Personnel in Dialysis (PREP-D) is a just-in-time training program designed to train individuals having minimum familiarity with the basic steps of dialysis to support routine dialysis staff during a disaster.

A 5-module educational program was developed through a collaborative, multidisciplinary effort. A pilot study testing the program was performed using 20 nontechnician dialysis facility employees and 20 clinical-year medical students as subjects.

When comparing pretest and posttest scores, the entire study population showed a mean improvement of 28.9%, with dialysis facility employees and medical students showing improvements of 21.8% and 36.4%, respectively (P < .05 for all comparisons).

PREP-D participants were able to demonstrate improved tests scores when taught in a just-in-time training format. The knowledge gained by using the PREP-D program during a staffing shortage may allow for continuity of care for critical services such as dialysis during a disaster. (Disaster Med Public Health Preparedness. 2013;7:272-277).

To determine prevalence and factors associated with psychological distress among nurses caring for war victims in Sri Lanka.

Descriptive, cross-sectional study design was used to collect data from 241 nurses from 2 hospitals with stratified random sampling according to workstation. Self-administered 30-item General Health Questionnaire was used to detect psychological distress.

The prevalence of psychological distress was 21%. Female sex was found to be the most significant predictor of psychological distress among nurses. Factors, such as being married, having children, or both, were found to be protective. High exposure to war victims, measured by the frequency with which a nurse tended to those patients, also resulted in less psychological distress.

The prevalence of psychological distress is higheramong nurses in this study compared with that among the general population. Brief screening instruments, such as the General Health Questionnaire, can be used to identify individuals at risk for psychological distress. Results suggest that the presence of a social support network helped to psychologically buffer these nurses. Findings also imply the importance of promoting positive attitudes and beneficial stress (eustress) to complement a well-developed focus on distress prevention. (Disaster Med Public Health Preparedness. 2013;7:278-286)

To assess local, state, federal, and global pandemic influenza preparedness by identifying pandemic plans at the local, state, federal, and global levels, and to identify any information technology (IT) systems in these plans to support critical care triage during an influenza pandemic in the Canadian province of Ontario.

The authors used advanced MEDLINE and Google search strategies and conducted a comprehensive review of key pandemic influenza Web sites. Descriptive data extraction and analysis for IT systems were conducted on all of the included pandemic plans.

A total of 155 pandemic influenza plans were reviewed: 29 local, 62 state, 63 federal, and 1 global. We found 70 plans that examined IT systems (10 local, 33 state, 26 federal, 1 global), and 85 that did not (19 local, 29 state, 37 federal). Of the 70 plans, 64 described surveillance systems (10 local, 32 state, 21 federal, 1 global), 2 described patient data collection systems (1 state, 1 federal); 4 described other types of IT systems (4 federal), and none were intended for triage.

Although several pandemic plans have been drafted, the majority are high-level general documents that do not describe IT systems. The plans that discuss IT systems focus strongly on surveillance, which fails to recognize the needs of a health care system responding to an influenza pandemic. The best examples of the types of IT systems to guide decision making during a pandemic were found in the Kansas and the Czech Republic pandemic plans, because these systems were designed to collect both patient and surveillance data. Although Ontario has yet to develop such an IT system, several IT systems are in place that could be leveraged to support critical care triage and medical response during an influenza pandemic. (Disaster Med Public Health Preparedness. 2013;7:287-291)

Community resilience (CR) is emerging as a major public policy priority within disaster management and is one of two key pillars of the December 2009 US National Health Security Strategy. However, there is no clear agreement on what key elements constitute CR. We examined exemplary practices from international disaster management to validate the elements of CR, as suggested by Homeland Security Presidential Directive 21 (HSPD-21), to potentially identify new elements and to identify practices that could be emulated or adapted to help build CR.

We extracted detailed information relevant to CR from unpublished case studies we had developed previously, describing exemplary practices from international natural disasters occurring between 1985 and 2005. We then mapped specific practices against the five elements of CR suggested by HSPD-21.

We identified 49 relevant exemplary practices from 11 natural disasters in 10 countries (earthquakes in Mexico, India, and Iran; volcanic eruption in Philippines; hurricanes in Honduras and Cuba; floods in Bangladesh, Vietnam, and Mozambique; tsunami in Indian Ocean countries; and typhoon in Vietnam). Of these, 35 mapped well against the five elements of CR: community education, community empowerment, practice, social networks, and familiarity with local services; 15 additional practices were related to physical security and economic security. The five HSPD-21 CR elements and two additional ones we identified were closely related to one another; social networks were especially important to CR.

While each disaster is unique, the elements of CR appear to be broadly applicable across countries and disaster settings. Our descriptive study provides retrospective empirical evidence that helps validate, and adds to, the elements of CR suggested by HSPD-21. It also generates hypotheses about factors contributing to CR that can be tested in future analytic or experimental research. (Disaster Med Public Health Preparedness. 2013;7:292-301)

To test the feasibility of developing evidence-based mental health training to build capacity to respond to natural disasters in black communities and the adaptation of a train-the-trainer (TTT) model for black community leaders and clinical providers in distressed areas at risk of natural disasters.

A core curriculum was developed based on a training needs assessment and resource review. Participants were recruited using network sampling in eastern North Carolina. The core curriculum was tested for usability, revised, and then pilot tested among five mental health providers. Three of the five were trained to lead one-day workshops tailored for black community leaders and clinical providers. Process data were collected, and workshop participants completed posttraining knowledge tests, evaluation forms, and debriefing focus groups.

Ten providers and 13 community leaders pilot tested the training. Posttest knowledge scores were generally higher among clinical providers. Perceived effectiveness of training was higher among community-based organization leaders than clinical providers. Evaluations indicated that the workshop components were culturally relevant and well received by all participants. We identified ways to facilitate recruitment, provide optional e-learning, evaluate effectiveness, and extend trainer support in future field trials.

The curriculum and TTT model provide culturally competent disaster mental health preparedness training for black communities. (Disaster Med Public Health Preparedness. 2013;7:302-312)

Research shows that having previous experience of major incidents has a positive impact on awareness and preparedness of organizations. We investigated the effects of major incident experience on preparedness of health organizations on future disasters in Iran.

A qualitative study using a semistructured interview technique was conducted with 65 public health and therapeutic affairs managers. Analysis of the data was performed used the framework analysis technique, which was supported by qualitative research software.

The study found that prior experience of major incidents results in better performance, coordination, and cooperation in response to future events. There was a positive effect on policy making and resource distribution and an increase in (1) preparedness activities, (2) raising population awareness, and (3) improving knowledge. However, the preparedness actions were predominantly individual-dependent.

Our findings showed that to increase system efficiency and effectiveness within health organizations, an appropriate major incident management system is needed. The new system can use lessons learned from previous major incidents to better equip health organizations to cope with similar events in the future. (Disaster Med Public Health Preparedness. 2013;7:313-318)

Rapid mental health surveillance during the acute phase of a disaster response can inform the allocation of limited clinical resources and provide essential household-level risk estimates for recovery planning.

To describe the use of the PsySTART Rapid Mental Health Triage and Incident Management System for individual-level clinical triage and traumatic exposure assessment in the aftermath of a large-scale disaster.

We conducted a cross-sectional, comparative review of mental health triage data collected with the PsySTART system from survivors of the September 2009 earthquake-tsunami in American Samoa. Data were obtained from two sources—secondary triage of patients and a standardized community assessment survey—and analyzed descriptively. The main outcome measures were survivor-reported traumatic experiences and exposures—called triage factors—associated with risk for developing severe distress and new mental health disorders following disasters.

The most common triage factors reported by survivors referred for mental health services were “felt extreme panic/fear” (93%) and “felt direct threat to life” (93%). The most common factor reported by persons in tsunami-affected communities was “felt extreme panic or fear” (75%). Proportions of severe triage factors reported by persons living in the community were consistently lower than those reported by patients referred for mental health services.

The combination of evidence-based mental health triage and community assessment gave hospital-based providers, local public health officials, and federal response teams a strategy to match limited clinical resources with survivors at greatest risk. Also, it produced a common operating picture of acute and chronic mental health needs among disaster systems of care operating in American Samoa.(Disaster Med Public Health Preparedness. 2013;7:327-331)