David Eisenman

Building Community Disaster Resilience: Perspectives From a Large Urban County Department of Public Health

An emerging approach to public health emergency preparedness and response, community resilience encompasses individual preparedness as well as establishing a supportive social context in communities to withstand and recover from disasters. We examine why building community resilience has become a key component of national policy across multiple federal agencies and discuss the core principles embodied in community resilience theory-specifically, the focus on incorporating equity and social justice considerations in preparedness planning and response. We also examine the challenges of integrating community resilience with traditional public health practices and the importance of developing metrics for evaluation and strategic planning purposes. Using the example of the Los Angeles County Community Disaster Resilience Project, we discuss our experience and perspective from a large urban county to better understand how to implement a community resilience framework in public health practice.

Variations in disaster preparedness by mental health, perceived general health, and disability status.

OBJECTIVES Chronic medical and mental illness and disability increase vulnerability to disasters. National efforts have focused on preparing people with disabilities, and studies find them to be increasingly prepared, but less is known about people with chronic mental and medical illnesses. We examined the relation between health status (mental health, perceived general health, and disability) and disaster preparedness (home disaster supplies and family communication plan). METHODS A random-digit-dial telephone survey of the Los Angeles County population was conducted October 2004 to January 2005 in 6 languages. Separate multivariate regressions modeled determinants of disaster preparedness, adjusting for sociodemographic covariates then sociodemographic variables and health status variables. RESULTS Only 40.7% of people who rated their health as fair/poor have disaster supplies compared with 53.1% of those who rate their health as excellent (P < 0.001). Only 34.8% of people who rated their health as fair/poor have an emergency plan compared with 44.8% of those who rate their health as excellent (P < 0.01). Only 29.5% of people who have a serious mental illness have disaster supplies compared with 49.2% of those who do not have a serious mental illness (P < 0.001). People with fair/poor health remained less likely to have disaster supplies (adjusted odds ratio [AOR] 0.69, 95% confidence interval [CI] 0.50-0.96) and less likely to have an emergency plan (AOR 0.68, 95% CI 0.51-0.92) compared with those who rate their health as excellent, after adjusting for the sociodemographic covariates. People with serious mental illness remained less likely to have disaster supplies after adjusting for the sociodemographic covariates (AOR 0.67, 95% CI 0.48-0.93). Disability status was not associated with lower rates of disaster supplies or emergency communication plans in bivariate or multivariate analyses. Finally, adjusting for the sociodemographic and other health variables, people with fair/poor health remained less likely to have an emergency plan (AOR 0.66, 95% CI 0.48-0.92) and people with serious mental illness remained less likely to have disaster supplies (AOR 0.67, 95% CI 0.47-0.95). CONCLUSIONS People who report fair/poor general health and probable serious mental illness are less likely to report household disaster preparedness and an emergency communication plan. Our results could add to our understanding of why people with preexisting health problems suffer disproportionately from disasters. Public health may consider collaborating with community partners and health services providers to improve preparedness among people with chronic illness and people who are mentally ill.

Belief systems as coping factors for traumatized refugees: a pilot study

The severity of traumatization seems to correlate with a more severe course of post-traumatic stress disorder (PTSD) (and other post-traumatic disorders), while firm belief systems have been found to be a protective factor against post-traumatic disorders. This study sought to determine the role of belief systems in the outcome of psychotherapy for traumatized refugees. The charts of 141 consecutively treated refugees were evaluated retrospectively. A firm belief system was found to be an important predictor for a better therapy outcome. The importance of a firm belief system as a coping factor, which should be used as an instrument in therapy, is discussed.

Intimate Partner Violence and Maternal Depression During the Perinatal Period: A Longitudinal Investigation of Latinas:

This study assessed the course of perinatal depression among 210 Latinas who were and were not affected by intimate partner violence (IPV) and identified associated psychosocial factors. Peak depression prevalence occurred prenatally among 45.7% of IPV-exposed and 24.6% of non-IPV-exposed Latinas. At each assessment, depression was significantly higher for IPV-exposed compared to non-IPV-exposed mothers. Mastery and social support were associated with lower depression, whereas history of IPV, perceived stress, and avoidant coping behaviors were associated with higher depression. Findings support recommendations for routine depression and IPV screening of Latinas in perinatal clinical settings.

They Blew the Levee: Distrust of Authorities Among Hurricane Katrina Evacuees

O August 29th, 2005, Hurricane Katrina made landfall just east of New Orleans, Louisiana. That night and the next day, levees in New Orleans collapsed, resulting in flooding of 80% of the city, with water levels reaching to the rooftops in many areas.1 Despite strong evacuation warnings, followed by a mandatory evacuation order,2 over 100,000 greater New Orleans residents failed to evacuate prior to the hurricane’s landfall.3 Distrust of authorities, among numerous other factors,4–5 seems likely to have played a role in New Orleans residents’ reactions to evacuation warnings and public health authorities’ advice. Prior to the hurricane, 72% of New Orleans residents were of minority race or ethnicity6 and there is a long history of minority groups in the United States distrusting the medical and public health leadership.7–9 Furthermore, distrust of authorities among New Orleans’ impoverished residents is rooted in local history. In 1927, The Great Mississippi Flood was threatening to destroy New Orleans, including its crucial downtown regional financial institutions. To avert the threat, and in part to stabilize the financial markets, it was decided to perform a controlled break of the New Orleans levees, thereby selectively flooding poor areas and saving financial institutions.10 This event lives on in the memories and oral history of the residents of the deliberately flooded areas.11 Faced with the knowledge that distrust hampers the success of recommended evacuations and other disaster responses, disaster and public health officials must

The Association of Partner Abuse with Risky Sexual Behaviors Among Women and Men with HIV/AIDS

Prior studies have found that partner abuse is related to risky sexual behavior. However, few studies have explored gender, sexual orientation, or substance use differences in this association, especially among people with HIV. We examined data from the Risk and Prevention survey from the HIV Cost and Services Utilization Study (HCSUS) sample on 726 sexually-active individuals in three gender/orientation groups (286 women, 148 heterosexual men, and 292 gay/bisexual men). The study assessed whether individuals with HIV who experienced or perpetrated abuse within a close relationship were likely to engage in unprotected intercourse with that same partner. Both abuse perpetration and victimization were significantly associated with having any unprotected intercourse. In multivariate tests, gender/orientation and substance use during sex moderated the perpetration effects. Secondary HIV prevention interventions need to take into account potentially abusive contexts in which sexual activity may occur for both men and women.

Meaningful Use of Electronic Prescribing in 5 Exemplar Primary Care Practices

PURPOSE Successful use of electronic prescribing (e-prescribing) is a key requirement for demonstrating meaningful use of electronic health records to qualify for federal incentives. Currently, many physicians who implement e-prescribing fail to make substantial use of these systems, and little is known about factors contributing to successful e-prescribing use. The objective of this study was to identify successful implementation and use techniques. METHODS We conducted a multimethod qualitative case study of 5 ambulatory primary care practices identified as exemplars of effective e-prescribing. The practices were identified by a group of e-prescribing experts. Field researchers conducted in-depth interviews and observed prescription-related workflow in these practices. RESULTS In these exemplar practices, successful use of e-prescribing required practice transformation. Practice members reported extensive efforts to redesign work processes to take advantage of e-prescribing capabilities and to create specific e-prescribing protocols to distribute prescription-related work among practice team members. These practices had substantial resources to support e-prescribing use, including local physician champions, ongoing training for practice members, and continuous on-site technical support. Practices faced considerable challenges during use of e-prescribing, however, deriving from problems coordinating new work processes with pharmacies and ineffective health information exchange that required workarounds to ensure the completeness of patient medical records. CONCLUSIONS More widespread implementation and effective use of e-prescribing in ambulatory care settings will require practice transformation efforts that focus on work process redesign while being attentive to effects on patient and pharmacy involvement in prescribing. Improved health information exchange is required to fully realize expected quality, safety, and efficiency gains of e-prescribing.

Terrorism-Related Fear and Avoidance Behavior in a Multiethnic Urban Population

OBJECTIVES We sought to determine whether groups traditionally most vulnerable to disasters would be more likely than would be others to perceive population-level risk as high (as measured by the estimated color-coded alert level) would worry more about terrorism, and would avoid activities because of terrorism concerns. METHODS We conducted a random digit dial survey of the Los Angeles County population October 2004 through January 2005 in 6 languages. We asked respondents what color alert level the country was under, how often they worry about terrorist attacks, and how often they avoid activities because of terrorism. Multivariate regression modeled correlates of worry and avoidance, including mental illness, disability, demographic factors, and estimated color-coded alert level. RESULTS Persons who are mentally ill, those who are disabled, African Americans, Latinos, Chinese Americans, Korean Americans, and non-US citizens were more likely to perceive population-level risk as high, as measured by the estimated color-coded alert level. These groups also reported more worry and avoidance behaviors because of concerns about terrorism. CONCLUSIONS Vulnerable populations experience a disproportionate burden of the psychosocial impact of terrorism threats and our national response. Further studies should investigate the specific behaviors affected and further elucidate disparities in the disaster burden associated with terrorism and terrorism policies.

Applying Community Engagement to Disaster Planning: Developing the Vision and Design for the Los Angeles County Community Disaster Resilience Initiative

Community resilience (CR) is a priority for preparedness, but few models exist. A steering council used community-partnered participatory research to support workgroups in developing CR action plans and hosted forums for input to design a pilot demonstration of implementing CR versus enhanced individual preparedness toolkits. Qualitative data describe how stakeholders viewed CR, how toolkits were developed, and demonstration design evolution. Stakeholders viewed community engagement as facilitating partnerships to implement CR programs when appropriately supported by policy and CR resources. Community engagement exercises clarified motivations and informed action plans (e.g., including vulnerable populations). Community input identified barriers (e.g., trust in government) and CR-building strategies. A CR toolkit and demonstration comparing its implementation with individual preparedness were codeveloped. Community-partnered participatory research was a useful framework to plan a CR initiative through knowledge exchange.

Developing a Disaster Preparedness Campaign Targeting Low-Income Latino Immigrants: Focus Group Results for Project PREP

Low-income immigrant Latinos are particularly vulnerable to disasters because they are both ill-prepared and disproportionately affected. Disaster preparedness programs that are culturally appropriate must be developed and tested. To develop such a program, we conducted 12 focus groups with low-income immigrant Latinos to understand their perceptions and understanding of disaster preparedness, and facilitators and obstacles to it. Participants were concerned about remaining calm during an earthquake. Obstacles to storage of disaster supplies in a kit and developing a family communication plan were mentioned frequently. Misunderstandings were voiced about the proper quantity of water to store and about communication plans. Several focus groups spontaneously suggested small group discussions (platicas) as a way to learn about disaster preparedness. They wanted specific help with building their family communication plans. They rated promotoras de salud highly as potential teachers. Results will guide the development of a disaster preparedness program tailored to the needs of low-income Latino immigrants.