Building a national model of public mental health preparedness and community resilience: validation of a dual-intervention, systems-based approach.

OBJECTIVE: Working within a series of partnerships among an academic health center, local health departments (LHDs), and faith-based organizations (FBOs), we validated companion interventions to address community mental health planning and response challenges in public health emergency preparedness. METHODS: We implemented the project within the framework of an enhanced logic model and employed a multi-cohort, pre-test/post-test design to assess the outcomes of 1-day workshops in psychological first aid (PFA) and guided preparedness planning (GPP). The workshops were delivered to urban and rural communities in eastern and midwestern regions of the United States. Intervention effectiveness was based on changes in relevant knowledge, skills, and attitudes (KSAs) and on several behavioral indexes. RESULTS: Significant improvements were observed in self-reported and objectively measured KSAs across all cohorts. Additionally, GPP teams proved capable of producing quality drafts of basic community disaster plans in 1 day, and PFA trainees confirmed upon follow-up that their training proved useful in real-world trauma contexts. We documented examples of policy and practice changes at the levels of local and state health departments. CONCLUSIONS: Given appropriate guidance, LHDs and FBOs can implement an effective and potentially scalable model for promoting disaster mental health preparedness and community resilience, with implications for positive translational impact.

An academic-government-faith partnership to build disaster mental health preparedness and community resilience.

OBJECTIVES: Faculty and affiliates of the Johns Hopkins Preparedness and Emergency Response Research Center partnered with local health departments and faith-based organizations to develop a dual-intervention model of capacity-building for public mental health preparedness and community resilience. Project objectives included (1) determining the feasibility of the tri-partite collaborative concept; (2) designing, delivering, and evaluating psychological first aid (PFA) training and guided preparedness planning (GPP); and (3) documenting preliminary evidence of the sustainability and impact of the model. METHODS: We evaluated intervention effectiveness by analyzing pre- and post-training changes in participant responses on knowledge-acquisition tests administered to three urban and four rural community cohorts. Changes in percent of correct items and mean total correct items were evaluated. Criteria for model sustainability and impact were, respectively, observations of nonacademic partners engaging in efforts to advance post-project preparedness alliances, and project-attributable changes in preparedness-related practices of local or state governments. RESULTS: The majority (11 of 14) test items addressing technical or practical PFA content showed significant improvement; we observed comparable testing results for GPP training. Government and faith partners developed ideas and tools for sustaining preparedness activities, and numerous project-driven changes in local and state government policies were documented. CONCLUSIONS: Results suggest that the model could be an effective approach to promoting public health preparedness and community resilience.

Translating legal research on mental and behavioral health during emergencies for the public health workforce.

Translation strategies are critical for sharing research with public health practitioners. To disseminate our analyses of legal issues that arise relative to mental and behavioral health during emergencies, we created 10 brief translational tools for members of the public health workforce. In consultation with an interdisciplinary project advisory group (PAG), we identified each tool's topic and format. PAG members reviewed draft and final versions of the tools. We then worked with local health departments throughout the country to distribute the tools along with a brief survey to determine practitioners' perceived utility of the tools. Through survey responses, we learned that practitioners believed the tools provided information that would be useful during the planning, response, and recovery phases of an emergency. This article describes the creation of the PAG, the development of the tools, and lessons learned for those seeking to translate legal and ethical research findings for practitioner audiences.

The development of a model of psychological first aid for non-mental health trained public health personnel: the Johns Hopkins RAPID-PFA.

INTRODUCTION: The Johns Hopkins Center for Public Health Preparedness, which houses the Centers for Disease Control and Prevention-funded Preparedness and Emergency Response Learning Center, has been addressing the challenge of disaster-caused behavioral health surge by conducting training programs in psychological first aid (PFA) for public health professionals. This report describes our approach, named RAPID-PFA, and summarizes training evaluation data to determine if relevant knowledge, skills, and attitudes are imparted to trainees to support effective PFA delivery. BACKGROUND/RATIONALE: In the wake of disasters, there is an increase in psychological distress and dysfunction among survivors and first responders. To meet the challenges posed by this surge, a professional workforce trained in PFA is imperative. METHODS/ACTIVITY: More than 1500 participants received a 1-day RAPID-PFA training. Pre-/postassessments were conducted to measure (a) required knowledge to apply PFA; (b) perceived self-efficacy, that is, belief in one's own ability, to apply PFA techniques; and (c) confidence in one's own resilience in a crisis context. Statistical techniques were used to validate the extent to which the survey successfully measured individual PFA constructs, that is, unidimensionality, and to quantify the reliability of the assessment tool. RESULTS/OUTCOME: Statistically significant pre-/postimprovements were observed in (a) knowledge items supportive of PFA delivery, (b) perceived self-efficacy to apply PFA interventions, and (c) confidence about being a resilient PFA provider. Cronbach alpha coefficients ranging from 0.87 to 0.90 suggested that the self-reported measures possessed sufficient internal consistency. DISCUSSION: Findings were consistent with our pilot work, and with our complementary research initiatives validating a variant of RAPID-PFA with faith communities. LESSONS LEARNED/NEXT STEPS: The RAPID-PFA model promises to be a broadly applicable approach to extending community behavioral health surge capacity. Relevant next steps include evaluating the effectiveness of trained providers in real crisis situations, and determining if PFA training may have potential beyond the disaster context.

EPPM and willingness to respond: the role of risk and efficacy communication in strengthening public health emergency response systems.

This study examines the attitudinal impact of an Extended Parallel Process Model (EPPM)-based training curriculum on local public health department (LHD) workers' willingness to respond to representative public health emergency scenarios. Data are from 71 U.S. LHDs in urban and rural settings across nine states. The study explores changes in response willingness and EPPM threat and efficacy appraisals between randomly assigned control versus intervention health departments, at baseline and 1 week post curriculum, through an EPPM-based survey/resurvey design. Levels of response willingness and emergency response-related attitudes/beliefs are measured. Analyses focus on two scenario categories that have appeared on a U.S. government list of scenarios of significant concern: a weather-related emergency and a radiological "dirty" bomb event (U.S. Department of Homeland Security, 2007). The greatest impact from the training intervention on response willingness was observed among LHD workers who had low levels of EPPM-related threat and efficacy perceptions at baseline. Self-efficacy and response efficacy and response willingness increased in intervention LHDs for both scenarios, with greater response willingness increases observed for the radiological "dirty" bomb terrorism scenario. Findings indicate the importance of building efficacy versus enhancing threat perceptions as a path toward greater response willingness, and suggest the potential applicability of such curricular interventions for boosting emergency response willingness among other cadres of health providers.

Assessment of medical reserve corps volunteers' emergency response willingness using a threat- and efficacy-based model.

The goal of this study was to investigate the willingness of Medical Reserve Corps (MRC) volunteers to participate in public health emergency-related activities by assessing their attitudes and beliefs. MRC volunteers responded to an online survey organized around the Extended Parallel Process Model (EPPM). Respondents reported agreement with attitude/belief statements representing perceived threat, perceived efficacy, and personal/organizational preparedness in 4 scenarios: a weather-related disaster, a pandemic influenza emergency, a radiological ("dirty bomb") emergency, and an inhalational anthrax bioterrorism emergency. Logistic regression analyses were used to evaluate predictors of volunteer response willingness. In 2 response contexts (if asked and regardless of severity), self-reported willingness to respond was higher among those with a high perceived self-efficacy than among those with low perceived self-efficacy. Analyses of the association between attitude/belief statements and the EPPM profiles indicated that, under all 4 scenarios and with few exceptions, those with a perceived high threat/high efficacy EPPM profile had statistically higher odds of agreement with the attitude/belief statements than those with a perceived low threat/low efficacy EPPM profile. The radiological emergency consistently received the lowest agreement rates for the attitude/belief statements and response willingness across scenarios. The findings suggest that enrollment with an MRC unit is not automatically predictive of willingness to respond in these types of scenarios. While MRC volunteers' self-reported willingness to respond was found to differ across scenarios and among different attitude and belief statements, the identification of self-efficacy as the primary predictor of willingness to respond regardless of severity and if asked highlights the critical role of efficacy in an organized volunteer response context.

Determinants of emergency response willingness in the local public health workforce by jurisdictional and scenario patterns: a cross-sectional survey.

BACKGROUND: The all-hazards willingness to respond (WTR) of local public health personnel is critical to emergency preparedness. This study applied a threat-and efficacy-centered framework to characterize these workers' scenario and jurisdictional response willingness patterns toward a range of naturally-occurring and terrorism-related emergency scenarios. METHODS: Eight geographically diverse local health department (LHD) clusters (four urban and four rural) across the U.S. were recruited and administered an online survey about response willingness and related attitudes/beliefs toward four different public health emergency scenarios between April 2009 and June 2010 (66% response rate). Responses were dichotomized and analyzed using generalized linear multilevel mixed model analyses that also account for within-cluster and within-LHD correlations. RESULTS: Comparisons of rural to urban LHD workers showed statistically significant odds ratios (ORs) for WTR context across scenarios ranging from 1.5 to 2.4. When employees over 40 years old were compared to their younger counterparts, the ORs of WTR ranged from 1.27 to 1.58, and when females were compared to males, the ORs of WTR ranged from 0.57 to 0.61. Across the eight clusters, the percentage of workers indicating they would be unwilling to respond regardless of severity ranged from 14-28% for a weather event; 9-27% for pandemic influenza; 30-56% for a radiological 'dirty' bomb event; and 22-48% for an inhalational anthrax bioterrorism event. Efficacy was consistently identified as an important independent predictor of WTR. CONCLUSIONS: Response willingness deficits in the local public health workforce pose a threat to all-hazards response capacity and health security. Local public health agencies and their stakeholders may incorporate key findings, including identified scenario-based willingness gaps and the importance of efficacy, as targets of preparedness curriculum development efforts and policies for enhancing response willingness. Reasons for an increased willingness in rural cohorts compared to urban cohorts should be further investigated in order to understand and develop methods for improving their overall response.

Assessment of psychological preparedness and emergency response willingness of local public health department and hospital workers.

This study sought to investigate the relationship between psychologically-related attitudes/beliefs toward public health emergency response among local health department (LHD) and hospital workers and their willingness to respond to a pandemic influenza emergency scenario and a radiological 'dirty' bomb scenario, to inform workforce resilience-building interventions. LHD and hospital workers participated in a survey based on an established threat- and efficacy-oriented behavioral model (the extended parallel process model) that focused on collection of the aforementioned attitudes, beliefs, and self-reported response willingness. Odds ratios associating psychologically-related attitudes and beliefs with self-reported response willingness were computed Perceived levels of psychological preparedness and support were shown to impact response willingness, with more pronounced effects in the radiological 'dirty' bomb scenario. Compared to those who did not perceive themselves to be psychologically prepared, those who did perceive themselves as prepared had higher odds of self-reported response willingness. The relationship of these perceptions and self-reported willingness to respond in all contexts, both scenarios, and both cohorts was influenced by perceived self-efficacy andperceived family preparedness.

Characterizing hospital workers' willingness to respond to a radiological event.

INTRODUCTION: Terrorist use of a radiological dispersal device (RDD, or "dirty bomb"), which combines a conventional explosive device with radiological materials, is among the National Planning Scenarios of the United States government. Understanding employee willingness to respond is critical for planning experts. Previous research has demonstrated that perception of threat and efficacy is key in the assessing willingness to respond to a RDD event. METHODS: An anonymous online survey was used to evaluate the willingness of hospital employees to respond to a RDD event. Agreement with a series of belief statements was assessed, following a methodology validated in previous work. The survey was available online to all 18,612 employees of the Johns Hopkins Hospital from January to March 2009. RESULTS: Surveys were completed by 3426 employees (18.4%), whose demographic distribution was similar to overall hospital staff. 39% of hospital workers were not willing to respond to a RDD scenario if asked but not required to do so. Only 11% more were willing if required. Workers who were hesitant to agree to work additional hours when required were 20 times less likely to report during a RDD emergency. Respondents who perceived their peers as likely to report to work in a RDD emergency were 17 times more likely to respond during a RDD event if asked. Only 27.9% of the hospital employees with a perception of low efficacy declared willingness to respond to a severe RDD event. Perception of threat had little impact on willingness to respond among hospital workers. CONCLUSIONS: Radiological scenarios such as RDDs are among the most dreaded emergency events yet studied. Several attitudinal indicators can help to identify hospital employees unlikely to respond. These risk-perception modifiers must then be addressed through training to enable effective hospital response to a RDD event.

Characterizing public health emergency perceptions and influential modifiers of willingness to respond among pediatric healthcare staff.

OBJECTIVES: The aim of this study was to characterize the public health emergency perceptions and willingness to respond (WTR) of hospital-based pediatric staff and to use these findings to propose a methodology for developing an institution-specific training package to improve response willingness. METHODS: A prospective anonymous web-based survey was conducted at the Johns Hopkins Hospital, including the 180-bed Johns Hopkins Children's Center, between January and March 2009. In this survey, participants' attitudes/beliefs regarding emergency response to a pandemic influenza and a radiological dispersal device (RDD or "dirty bomb") event were assessed. RESULTS: Of the 1,620 eligible pediatric staff 246 replies (15.2 percent response rate) were received, compared with an overall staff response rate of 18.4 percent. Characteristics of respondent demographics and professions were similar to those of overall hospital staff. Self-reported WTR was greater for a pandemic influenza than for an RDD event if required (84.6 percent vs 75.1 percent), and if asked, but not required (74.4 percent vs 64.5 percent). The majority of pediatric staff were not confident in their safety at work (pandemic influenza: 51.8 percent and RDD: 76.6 percent), were far less likely to respond if personal protective equipment was unavailable (pandemic influenza: 33.5 percent and RDD: 21.6percent), and wanted furtherpre-event preparation and training (pandemic influenza: 89.6 percent and RDD: 82.6 percent). The following six distinct perceived attitudes / beliefs were identified as having institution-specific high impact on response willingness: colleague response, skill mastery, safety getting to work, safety at work, ability to perform duties, and individual response efficacy. CONCLUSIONS: Children represent a uniquely vulnerable population in public health emergencies, and pediatric hospital staff accordingly represent a vital subset of responders distinguished by specialized education, training, clinical skills, and disaster competencies. Even though the majority of pediatric hospital staff report WTR, nearly 15 percent for a pandemic influenza emergency and 25 percent for an RDD event would not respond if required. Other institutions can apply the methodology used here to identify particularly influential response willingness modifiers for pediatric care providers. These insights can inform customized preparedness training for pediatric healthcare workers, through identification of high-impact attitudes/beliefs, and training initiatives focused on addressing these modifiers.

Public health-specific National Incident Management System trainings: building a system for preparedness.

Local health departments (LHDs) are at the hub of the public health emergency preparedness system. Since the 2003 issuance of Homeland Security Presidential Directive-5, LHDs have faced challenges to comply with a new set of all-hazards, 24/7 organizational response expectations, as well as the National Incident Management System (NIMS). To help local public health practitioners address these challenges, the Centers for Disease Control and Prevention-funded Johns Hopkins Center for Public Health Preparedness (JH-CPHP) created and implemented a face-to-face, public health-specific NIMS training series for LHDs. This article presents the development, evolution, and delivery of the JH-CPHP NIMS training program. In this context, the article also describes a case example of practice-academic collaboration between the National Association of County and City Health Officials and JH-CPHP to develop public health-oriented NIMS course content.

Characterizing hospital workers' willingness to report to duty in an influenza pandemic through threat- and efficacy-based assessment.

BACKGROUND: Hospital-based providers' willingness to report to work during an influenza pandemic is a critical yet under-studied phenomenon. Witte's Extended Parallel Process Model (EPPM) has been shown to be useful for understanding adaptive behavior of public health workers to an unknown risk, and thus offers a framework for examining scenario-specific willingness to respond among hospital staff. METHODS: We administered an anonymous online EPPM-based survey about attitudes/beliefs toward emergency response, to all 18,612 employees of the Johns Hopkins Hospital from January to March 2009. Surveys were completed by 3426 employees (18.4%), approximately one third of whom were health professionals. RESULTS: Demographic and professional distribution of respondents was similar to all hospital staff. Overall, more than one-in-four (28%) hospital workers indicated they were not willing to respond to an influenza pandemic scenario if asked but not required to do so. Only an additional 10% were willing if required. One-third (32%) of participants reported they would be unwilling to respond in the event of a more severe pandemic influenza scenario. These response rates were consistent across different departments, and were one-third lower among nurses as compared with physicians. Respondents who were hesitant to agree to work additional hours when required were 17 times less likely to respond during a pandemic if asked. Sixty percent of the workers perceived their peers as likely to report to work in such an emergency, and were ten times more likely than others to do so themselves. Hospital employees with a perception of high efficacy had 5.8 times higher declared rates of willingness to respond to an influenza pandemic. CONCLUSIONS: Significant gaps exist in hospital workers' willingness to respond, and the EPPM is a useful framework to assess these gaps. Several attitudinal indicators can help to identify hospital employees unlikely to respond. The findings point to certain hospital-based communication and training strategies to boost employees' response willingness, including promoting pre-event plans for home-based dependents; ensuring adequate supplies of personal protective equipment, vaccines and antiviral drugs for all hospital employees; and establishing a subjective norm of awareness and preparedness.

Assessment of local public health workers' willingness to respond to pandemic influenza through application of the extended parallel process model.

BACKGROUND: Local public health agencies play a central role in response to an influenza pandemic, and understanding the willingness of their employees to report to work is therefore a critically relevant concern for pandemic influenza planning efforts. Witte's Extended Parallel Process Model (EPPM) has been found useful for understanding adaptive behavior in the face of unknown risk, and thus offers a framework for examining scenario-specific willingness to respond among local public health workers. We thus aim to use the EPPM as a lens for examining the influences of perceived threat and efficacy on local public health workers' response willingness to pandemic influenza. METHODOLOGY/PRINCIPAL FINDINGS: We administered an online, EPPM-based survey about attitudes/beliefs toward emergency response (Johns Hopkins approximately Public Health Infrastructure Response Survey Tool), to local public health employees in three states between November 2006-December 2007. A total of 1835 responses were collected for an overall response rate of 83%. With some regional variation, overall 16% of the workers in 2006-7 were not willing to "respond to a pandemic flu emergency regardless of its severity". Local health department employees with a perception of high threat and high efficacy--i.e., those fitting a 'concerned and confident' profile in the EPPM analysis--had the highest declared rates of willingness to respond to an influenza pandemic if required by their agency, which was 31.7 times higher than those fitting a 'low threat/low efficacy' EPPM profile. CONCLUSIONS/SIGNIFICANCE: In the context of pandemic influenza planning, the EPPM provides a useful framework to inform nuanced understanding of baseline levels of--and gaps in--local public health workers' response willingness. Within local health departments, 'concerned and confident' employees are most likely to be willing to respond. This finding may allow public health agencies to design, implement, and evaluate training programs focused on emergency response attitudes in health departments.