Evacuation BY ISABELLEZABAT HOW EVACUEES RESPOND WHILE EXPERIENCING TRAUMA (Source: http://www. ncbi. nlm. nih. gov/pmc/articles/PMC1854990/) Trauma and Stress Response Among Hurricane Katrina Evacuees Mary Alice Mills, BA, Donald Edmondson, MA, and Crystal L. Park, PhD Additional article information Abstract Objectives. Hurricane Katrina’s impact on public health has been significant and multifaceted, with trauma-related psychological sequelae likely to result in a sizable burden of disease.
Data were collected that assessed acute stress disorder (ASD) prevalence and factors related to ASD symptomatology among sheltered evacuees. Methods. On days 12 to 19 after Katrina, evacuees at a major emergency shelter completed surveys that assessed demographics, Katrina-specific experiences, and ASD symptomatology. Results. Sixty-two percent of the sample met ASD threshold criterion. Projections based on the predictive power of ASD to posttraumatic stress disorder (PTSD) suggest that 38% to 49% of the sample will meet PTSD criteria 2 years post-disaster.
Female gender (odds ratio [OR] = 4. 08), positive psychiatric history (OR=5. 84), injury (OR=2. 75), increased life-threat perception (OR??”I . 37), and decreased ense of personal control (OR??”I . 56) were significantly related to ASD. Black race was associated with greater symptom severity (8=7. 85, Conclusions. Katrina- related trauma and its psychological sequelae will remain a significant public health issue for years to come. The identification of several vulnerability factors related to ASD and PTSD provides a brief sketch of those at greatest risk.
Between late August and September 4, 2005, the Red Cross operated 470 shelters and evacuation centers across the nation to accommodate survivors of Hurricane Katrina. l More than 386000 vacuees received medical or mental health services from such shelters,2 and survivors remained widely dispersed for significant periods, temporarily residing in all 50 US states and the District of Columbia. 3 Common evacuee health care concerns include poor sleep quality,4depressed immune functioning,5,6 increases in negative health behaviors (e. g. , alcohol and cigarette use),7 and elevated relapse rates for pre- existing health conditions. Although primary care physicians and other health care providers are often well prepared to manage physical needs in the immediate wake f disaster, their role as sole treatment contact9,10 for the more than 50% of evacuees who will experience persistent and severe psychological consequences is likely less familiar. Given the mental health repercussions of Hurricane Katrina projected to emerge in the coming years, including depression, anxiety, and post- traumatic stress disorder (PTSD),11 , 12 physician and health care provider familiarity with trauma-related symptoms and differential risk profiles is crucial.
Multiple vulnerability factors have combined in the case of Hurricane Katrina to heighten urvivors’ risks of long-term difficulties. The high rate of poverty in New Orleans (close to 28%) amplified disaster impact on individuals through increased exposure, decreased disaster preparedness, and a lack of resources to offset losses. 13 Also, the predisaster chronic disease complicated by inadequate health care access. 14 Minority status itself has been shown to increase the risk of PTSD after trauma, 1 5although this effect may be largely because of differential exposure to poverty and violence. 6,17Also, previous disaster research has shown that separation from amily18 and relocation19 elevate risk for postdisaster mental health problems. A recent meta-analysis investigating the effects of displacement on mental health outcomes indicated that displaced persons evince worse mental health than nondisplaced comparison groups and that internally displaced persons (displaced within their own country) experience worse outcomes than refugees relocated to other countries.
Living in institutional accommodations, as opposed to private housing, and experiencing restricted economic opportunity are also consistently associated with worse mental health. 0 After Cyclone Tracy devastated the community of Darwin, Australia, a study of survivors found that evacuees who did not return to the community within 1 year fared worse in terms of somatic complaints, depression, and worry than did both individuals who evacuated but returned and those who had never evacuated during the disaster. 1,22 In a recent review of the displacement literature, the authors suggested that the negative effects of forced relocation spring largely from the loss of social ties and support systems. 23 With hundreds of thousands of evacuees dislocated all over the country, Hurricane Katrina as set the stage for a public mental health crisis that may unfold for years to come. In post-Katrina New Orleans, the outlook may be no better for evacuees with the means and desire to return to their communities.
A recent New York Timesreport illustrated the multitude of mental health consequences that have accompanied the disaster and rebuilding. 24 The suicide rate in the area tripled in the first 4 months and remains significantly higher than the pre-Katrina rate; substance abuse and mental health needs have reached unprecedented levels; and many feel that the rest of the country has lost interest. Complicating this crisis, more than half of New Orleans’ mental health professionals have relocated elsewhere, and only 60 of the citys hospital beds are available for psychiatric patients. 4 We sampled residents of New Orleans and surrounding parishes who were evacuated to the major Red Cross shelter in Austin, Tex, within the first 2 weeks of the Katrina disaster. Our study is the first, to our knowledge, to examine how demographic and disaster-related experiences predict acute stress symptomatology among Katrina’s evacuees. Acute stress disorder (ASD), a major stress response in the first month posttrauma, or “early PTSD,” was chosen as the mental health outcome of interest because of its use in predicting PTSD up to 2 years postevent. 5,26 METHODS Sampling and Data Collection Data were collected over 7 days at the Austin Convention Center, which housed approximately 1600 Hurricane Katrina evacuees. Collection was initiated 12 days after Hurricane Katrina made landfall outside New Orleans. Access to the shelter was granted by the City of Austin and Travis County Emergency Medical Services. Survey booths were set up in 4 different locations to increase researcher visibility and to provide a representative sample of the shelter population. Because of the anonymous nature of the data obtained, written informed consent was waived. he purpose, risks, and benefits of study participation. Instruments The research instrument was a structured survey consisting of demographic and background questions, a lifetime trauma history questionnaire, Katrina-specific items, and the Acute Stress Disorder Scale (ASDS). Survey completion required approximately 1 5 minutes, and interviews were offered to visually impaired or low- literacy participants. A total of 175 surveys were distributed, of which 132 were completed sufficiently for analysis (75%).
Twelve percent of the surveys were administered in interview format; responses did not differ significantly by format. Demographic variables were assessed using items adapted from the US Census Report. Participants were asked to write in their age and parish of residence. For all other demographic items, participants were asked to check the appropriate box. Categories assessed were race/ethnicity, gender, marital status, household income, pre-Katrina employment status, receipt of public assistance, level of education, number of children, and self- or physician-diagnosed mental health problems.
Previous exposure to trauma was assessed with the Traumatic Events Questionnaire. 27 The Traumatic Events Questionnaire assesses experiences with 9 stressors defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, 25 as criterion A1 for PTSD as being of sufficient intensity to elicit posttraumatic stress symptoms. For each event endorsed, respondents indicate how many times the event occurred (1, 2, 3 or more). Katrina-specific items were constructed based on previous disaster research and media reports of the evolving situation in New Orleans and evacuation shelters. Katrina-specific items assessed exposure to stressors (number of days waited for evacuation; experience of injury, illness, or the exacerbation of a pre-existing health problem; seeing dead bodies; death of relative or loved one; separation from family members; and loss of home or vehicle) by asking participants to what extent they had experienced each stressor, and assessed perceived impact of stressors by asking participants to rate on a scale of O (not at all) to 6 (extremely) the statements regarding their disaster-related perceptions (preparation for Katrina, perceived stressfulness of evacuation, perceived life threat uring Katrina, and perceived control over present circumstances). ASD symptoms were assessed with the ASDS,29 a self-report inventory consisting of 19 items based on criteria for ASD as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. 5 Based on previous research, between 72% and 83% of those who develop ASD go on to meet criteria for PTSD at 6 months posttrauma30,31 and between 63% and 80% at 2 years posttrauma. 26,32Validation studies revealed that an ASDS cutoff score of 56 correctly identified 91% of people who developed subsequent PTSD and 93% who did not. 3Therefore, this cutoff was adopted as the threshold score for this study. Participants exceeding this threshold were classified as having levels of acute stress symptoms indicative of high risk for subsequent PTSD. 29,34 Analyzed as a continuous outcome (number and severity of symptoms endorsed), the ASDS serves as a measure of current trauma-related distress, distinct from its prognostic significance. 35ASDS total score was, therefore, analyzed as a measure of symptom severity.
The ASDS has been shown to possess good reliability and validity in previous studies and has good sensitivity (95%) and resent study, the ASDS showed high internal reliability (Cronbach a = . 92). Social and occupational functional impairment was assessed using a 5-item self-report scale. Participants were asked to rate on a scale of O (not at all) to 4 (extremely) the degree to which Katrina had interfered with the ability to experience companionship, social support and community, intimacy, overall personal achievement, and achievement in career or work. The scale showed good internal reliability in the present sample (Cronbach a = . 80). Statistical Analysis Logistic regression was used to predict an above-threshold score on the ASDS.
First, bivariate odds ratios for ASD were calculated for demographic and background variables (age, race/ethnicity, gender, marital status, income level, receipt of public assistance, employment status, education, parish of residence, psychiatric history, and previous trauma exposure), as well as for Katrina-specific variables (experiences of injury, illness, exacerbation of a pre-existing health problem, exposure to corpses, death of a relative or loved one, separation from family, and property loss). A multivariate logistic regression model was created using significant bivariate redictors (P < . 05) chosen for both theoretical soundness and noncollinearity. Next, to identify variables associated with severity of acute stress symptoms, bivariate correlations were calculated between ASDS total score and the above demographic, background, and Katrina-specific variables. ASDS total score was regressed on those bivariate predictors found to be both significant (P < . 05) and independent from other predictors (variance inflation factor 1. ) in a multivariate linear regression model. The first and second authors carried out all of the analyses. RESULTS Description of Sample Participants were 132 adult evacuees (56% men and 44% women; mean age, 43 y; range, 20-80 y) from New Orleans and surrounding parishes. The sample was 74. 2% Black, 16. 7% non-Hispanic White, 3% multiracial, 1 . 7% Hispanic, and 2. 4% "other. " Eighty-one percent reported a high school diploma or higher, with 22% having completed college or an advanced degree. Thirty-seven percent of participants reported an annual income of less than US $10 000, with 45% reporting between US $10 000 and US $30 000, and 18% reporting an income greater than US $30000.
Sixty- seven percent of all participants reported a previous psychiatric condition depression, 33%; anxiety, 20%; bipolar disorder, 8%; schizophrenia, 4%; PTSD, 3%), with the distribution of diagnoses evincing a similar pattern across income levels. Of those participants in the lowest income group (less than US $10000), 78% were Black, 17. 1% were non-Hispanic White, 2. 4% were Asian, and 2. 4% were multiracial. The rate of employment in at least part-time work was 57% for this group, as was the rate of enrollment in a public assistance or disability program. Fifty-four percent of these participants had a positive psychiatric history. Of those participants in the highest ncome group (more than US $30000), 50% were Black, 45% were non-Hispanic White, and 5% were multiracial.
Ninety-five percent of these participants were employed either part-or full-time, with 10% receiving a form of public assistance or disability. Similar to the lowest income group, 55% of these participants reported a positive psychiatric history. Katrina-specific Experiences and Perceptions Nearly all participants (95%) waited multiple days to be evacuated from the New and loss. Systematic differences existed in wait times, with Black participants waiting a mean of 4. 73 days (SD= 2. 42) for evacuation compared with 2. 86 days (SD= 2. 5) for White participants (t  = 2. 83; P< . 01). Figure 1 presents rates of particular types of Katrina-specific trauma and loss experienced by participants.
The majority reported sustaining minor-to-severe injuries (62. 6%) and mild-to-severe illness (71 in the hurricane or evacuation process, whereas a sizeable minority (40%) reported the exacerbation of a pre-existing health condition (e. g. , hypertension or back problems). Slightly more than 63% reported being directly exposed to corpses during the disaster. Fourteen percent of participants suffered the death of a relative or loved one, and the vast majority (81. %) was separated from at least 1 family member for 1 day or more because of Katrina. Property loss was also prevalent and severe, with 69. 5% of participants having lost their home, and 48% reporting vehicle loss.
Sixty-six percent of participants who lost property lacked any form of property insurance. FIGURE 1??” Percentage of participants who experienced Hurrican Katrina-specific trauma and loss and bivariate odds ratios (ORs; with 95% confidence intervals [Cls]) for associated acute stress disorder. Figure 2 presents data on participants’ Katrina- related perceptions. On a scale of O (not at all about to prepare) to 6 (totally repared), participants perceived themselves as having been unable to prepare for Hurricane Katrina (mean = 2. 21; SD = 2. 18). On a scale of O (not stressful) to 6 (extremely stressful), participants saw the evacuation as very stressful (mean = 4. 66; SD = 1. 87).
Slightly more than half of participants (51. 6%) felt a moderate-to-severe degree of life threat during the disaster, and 62% felt no-to-moderate control over the present, (mean = 2. 9; SD = 2. 30, with O being no control and 6 being total control). FIGURE 2??” Hurricane Katrina-specific perceptions and bivariate odds ratios (ORs; with 95% onfidence intervals [Cls]) for associated acute stress disorder. Note. Scale: O (not at all) to 6 (extremely). Prevalence and Clinical Significance of ASD ASDS scores ranged from 19 (lowest possible) to 95 (highest possible; mean = 61. 10; SD = 19. 23), with 62% of the total sample meeting ASD threshold criterion.
Table 1 presents, by demographic group, the percentage of participants meeting the criterion. Scores on the functional impairment measure ranged from 5 (lowest possible) to 20 (highest possible; mean = 13. 36; SD = 4. 69). Higher ASDS scores were related to a higher degree of functional impairment (r = 0. 25; P< . 05). Based on the redictive power of ASD leading to PTSD, our data suggest that between 38% and 49% of the total sample of evacuees will meet criteria for chronic PTSD at 2 years post-Katrina . 30,31 TABLE 1??” Demographic Associations With ASD Threshold Scores and Symptom Severity Demographic and Katrina-specific Predictors of ASD demographic and Katrina-specific variables and ASD (Table 1).
Demographic characteristics were treated as categorical variables; disaster-specific variables were treated as either categorical (e. g. , seeing dead bodies and death of family members) or continuous (e. g. , degree of perceived life threat and perceived control over resent). To compare the unique importance of each risk factor for ASD, a multivariate logistic model was generated (Table 2) that included potential predictors that evinced significant (P < . 05) associations at the bivariate level. The model was significant (X2 = 41. 39; P < . 001) and included 5 independent predictors of ASD: perception of peridisaster life threat (OR = 1. 37; 95% confidence interval = 1. 08, 1. 75), female gender (OR = 4. 08; 95% Cl = 1. 45, 1 1. 8), experience of Katrina-related injury (OR = 2. 75; 95% Cl = 1. 05, 7. 11), decreased perceived control over the present (OR = 1. 6; 95% Cl = 1. 16, 2. 09), and positive psychiatnc history (OR = 5. 84; 95% = 1. 92, 17. 80). TABLE 2??” Multivariate Logistic Regression Model Predicting Acute Stress Disorder Demographic and Katrina-specific Predictors of ASD Symptom Severity Bivariate correlations were used to assess relationships between demographic and Katrina-specific variables with degree of acute stress symptomatology as measured by the ASDS total score (Table 1). Age, income level (4 levels), and education (4 levels), were analyzed as continuous.
Race/ethnicity and parish residence were each coded as dichotomous using 1/0 (i. e. 1= Black, O = other; Orleans, O = other). All of the other variables were analyzed consistent with the above univariate analysis. To compare the unique importance of each independent variable found to be significant (P < . 05) at the bivariate level, a multivariate regression model was generated (Table 3). The model explained a significant proportion of the variance in acute stress symptom severity (R2 [adjusted] = . 31; F5,109 = 1 1. 02; P< . 001) and yielded 4 significant predictors. Black race/ethnicity (B = 7. 85, SE[B] = 3. 50, P< . 05), perception of peridisaster life threat (B = 2. 29, SE[B] = 0. 73, P