The impact of a terrorist attack: Survivors' health, functioning and need for support following the 2019 Utrecht tram shooting 6 and 18 months post-attack.

Background: Extremely violent events such as terrorist attacks and mass shootings form a severe risk for the health and wellbeing of affected individuals. In this study based on a public health monitor, we focus on the health impact (including PTSD symptoms, physical problems and day-to-day functioning) of the Utrecht tram shooting, which took place in the morning of March 18th 2019. A lone gunman opened fire on passengers within a moving tram. Four people died, and six people were injured in this attack. The attack resulted in nationwide commotion and drew much media attention. Aim of this study was to increase insight into the health effects for the survivors (those directly impacted by a terrorist attack and the bereaved), and whether they received the needed care and support. Methods: Semi-structured interviews with accompanying questionnaires were conducted at six and 18 months post-attack. Overall, 21 survivors (victims/witnesses and loved ones of deceased victims) participated in the first series of interviews, 15 in the second series. Qualitative data were analyzed using reflexive thematic analysis, quantitative data was only described because of the low sample size. Results: At both six and 18 months after the attack many survivors had been able to resume daily life, and most rated their overall health as (very) good or excellent. At the same time, a substantial portion suffered from health problems such as posttraumatic stress symptoms and other complaints, and needed professional care. Furthermore, those in need did not always find their own way to appropriate care through the existing health system: half of the survivors still needed support in finding the right care 18 months later. Conclusion: Although the design and implementation of this public health monitor were accompanied by multiple challenges, it was possible to track a portion of the survivors and gain insight in the considerable health burden of the attack. Also, it is clear in this study that the health impact of terrorism affects survivors in the long run and requires attention from health authorities and professionals, as survivors were not able to find the right care by themselves.

The primary care workforce in Europe: a cross-sectional international comparison of rural and urban areas and changes between 1993 and 2011.

Rural areas have problems in attracting and retaining primary care workforce. This might have consequences for the existing workforce. We studied whether general practitioners (GPs) in rural practices differ by age, sex, practice population and workload from those in less rural locations and whether their practices differ in resources and service profiles. We used data from 2 studies: QUALICOPC study collected data from 34 countries, including 7183 GPs in 2011, and Profiles of General Practice in Europe study collected data from 32 countries among 7895 GPs in 1993. Data were analyzed using multilevel analysis. Results show that the share of female GPs has increased in rural areas but is still lower than in urban areas. In rural areas, GPs work more hours and provide more medical procedures to their patients. Apart from these differences between locations, overall ageing of the GP population is evident. Higher workload in rural areas may be related to increased demand for care. Rural practices seem to cope by offering a broad range of services, such as medical procedures. Dedicated human resource policies for rural areas are required with a view to an ageing GP population, to the individual preferences and needs of the GPs, and to decreasing attractiveness of rural areas.

Anxiety and depression symptoms, and lack of emotional support among the general population before and during the COVID-19 pandemic. A prospective national study on prevalence and risk factors.

BACKGROUND: The effects of the COVID-19 pandemic on the mental health and emotional support among the general population are unclear. We therefore assessed if the prevalence of high Anxiety and Depression Symptoms (ADS) levels and lack of Emotional Support (ES) increased, and if risk factors of ADS and ES changed. METHODS: Data was extracted from surveys conducted with the Dutch longitudinal population-based LISS panel (N = 3,983). ADS and ES were assessed in March 2019 and 2020. Risk factors for ADS and ES were extracted from surveys in November 2018 and 2019. These were: ADS, gender, education, domestic situation, employment, age, ethnicity, lung and heart problems, and diabetes. RESULTS: The prevalence of high ADS levels and lack of ES did not increase compared to the pre-outbreak prevalence. ADS, non-native ethnic background, (partial) work disabilities and lung problems were predictive of both ADS and lack of ES in March 2019 and 2020. Job seekers, students and those who take care of housekeeping were more at risk for ADS in March 2020, but not in 2019. While 35-49 years old respondents were less at risk for ADS in March 2019, they were more at risk in 2020. Parents with child(ren) at home and those who take care of housekeeping more often lacked ES in March 2020, but not in 2019. LIMITATIONS: No other mental health problems were assessed. CONCLUSIONS: No increase in the prevalence of ADS and lack of ES was found. Some risk factors remained significant after the outbreak, while others changed notably.

The longitudinal effect of social recognition on PTSD symptomatology and vice versa: Evidence from a population-based study.

A specific type of social support after potentially traumatic events is called "social recognition". It is the acknowledgement or validation of event-related thoughts, behavior, and feelings by the individual or others. It consists of positive individual or societal reactions that recognize and acknowledge victims' traumatic experiences and difficulties. Current studies suggest that social recognition protects against the development of PTSD symptomatology, but there is a lack of population-based studies assessing the longitudinal interplay between PTSD symptomatology and social recognition. For this purpose, we conducted a longitudinal study using the Dutch LISS panel, based on a random sample of the Dutch population. Structural equation modeling showed that among recently affected adults (0-2 months ago), those with relatively higher levels of social recognition had lower levels of PTSD symptomatology 6 months later. Victims with high levels of PTSD symptomatology at baseline received less social recognition 6 months later. On the intermediate term (affected 5-12 months ago), baseline social recognition was no longer predictive of PTSD symptoms 6 months later, in contrast to PTSD symptomatology predicting lack of social recognition. In sum, PTSD symptom levels eroded social recognition on the short and intermediate term, while the protective role of social recognition was limited to the short term.

Wages and employment security following a major disaster: A 17-year population-based longitudinal comparative study.

OBJECTIVES: The effects of disasters on mental health are well documented, but very little is known about the short to long-term effects of human-made disasters on wage and employment security careers of the affected residents. METHODS: Residents affected by a major fireworks disaster (May 13, 2000) in a Dutch residential area were all anonymously identified, based on postal codes of the affected area. To gain insight in these effects, data were derived from Statistics Netherlands that records all individual demographic, gross annual wages and employment security data of the entire Dutch population since 1999. A quasi-experimental matched control group design was used by constructing two pair-wise matched groups of non-affected residents of the city of Tilburg and the general Dutch population. Matching was based on nine demographic variables such as gender, age, education level and gross annual wage in 1999 (Ntotal = 12,648). The effects of the disaster on wage and employment security from 1999 to 2016 among the total group and among those with low wages in 1999, were assessed using fixed-effects panel regression analyses. RESULTS: Affected residents had significant lower gross annual wages in the medium and long term than the non-affected groups from the Netherlands, but differences were (very) small. Compared to the Tilburg group the significant differences were trivial in the medium term. Among the low-wage groups, no relevant differences were found between affected and non-affected residents. With respect to employment security, no or trivial differences were found between the total group of affected and matched comparison groups. Among those with low wages in 1999, in 2001 and especially 2002 affected residents worked fewer weeks per year than non-affected from Tilburg. In 2002 the difference with the Tilburg group was above moderate. CONCLUSIONS: These results speak to the resilience of affected residents, given the mental health problems and PTSD-symptomatology they suffered from, as shown in previous research.

The Effect of Employment Status in Postdisaster Recovery: A Longitudinal Comparative Study Among Employed and Unemployed Affected Residents.

Population studies have shown that employed adults are healthier than unemployed adults. In this study, we examined whether this "healthy worker effect" is relevant in postdisaster mental health by examining whether trauma-exposed employed individuals have lower postdisaster initial mental health problems and/or whether they recover faster than trauma-exposed unemployed individuals. We compared the course of postevent intrusion and avoidance reactions, anxiety, depression, and sleeping difficulties of employed residents (n = 291) and unemployed residents (n = 269) affected by a fireworks disaster in a residential area of Enschede, The Netherlands. Measurements took place at 2-3 weeks (T1), 18 months (T2), and 4 years (T3) postdisaster. We used linear mixed-effect models to examine the course of mental health problems. Employment status was relevant, to a degree, in posttrauma recovery; although affected employed residents had significantly lower levels of mental health problems (initially and over time) than the unemployed, ds = 0.41-0.72, the recovery rate was the same for both groups. At T1 (neglecting the DSM 1-month criterion), T2, and T3, the prevalence of probable posttraumatic stress disorder was 45.4%, 18.9%, and 11%, respectively, among employed individuals, and 70.1%, 32.5%, and 30% among unemployed individuals. We concluded that research into the mental health of disaster victims should take employment status into account. Regarding postdisaster care, unemployed individuals may need special attention; although they may recover at the same rate as employed individuals, they suffer from more severe mental health problems, even years after the disaster.

Potentially Traumatic Events and Job Satisfaction: A Prospective Population-Based Comparative Study.

OBJECTIVE: The aim of this study was to examine the effects of potentially traumatic events (PTEs), posttraumatic stress symptoms (PTSS), and coping self-efficacy (CSE) on post-event job satisfaction. METHODS: Repeated analysis of variance (ANOVA) was used to assess differences in the course of job satisfaction during 1 year between population-based samples of affected and nonaffected workers. Multivariate regression analyses were conducted with pre-event health, job satisfaction and insecurity, and postevent PTSS and CSE as predictors. RESULTS: About 16% of the affected workers had probable PTSD. The course of job satisfaction between affected (n = 123) and nonaffected workers (n = 644) did not differ significantly. PTSS and CSE did not independently predict post-event satisfaction, in contrast to pre-event job satisfaction. CONCLUSION: Findings suggest that when needed social support is provided, concerns about the negative effects of potentially traumatic events on job satisfaction could be somewhat relaxed.

Cross-lagged associations between posttraumatic stress symptoms and coping self-efficacy in long-term recovery: A four-wave comparative study.

RATIONALE: Trauma-related coping self-efficacy (CSE) - in brief, the perceived ability to cope with the aftermath of a traumatic event - has been shown to affect psychological outcomes. A previous study showed that CSE affects subsequent PTSS levels, but not vice versa among a sample exposed 0-6 months ago. OBJECTIVE: In this four-wave follow-up study we examined the cross-lagged relationships between CSE and posttraumatic stress symptoms (PTSS) among those exposed to PTEs (potentially traumatic events) 1-2 years before T1 in order to examine direction of influence. Research questions were: 1) what are the cross-lagged associations between CSE and PTSS levels among those exposed to PTE in the relatively long-term (1-2 years ago, called PTE long-term group), and 2) to what extent do these associations differ from the cross lagged associations among those exposed to PTE in the relatively short-term (0-6 months ago)? METHOD: Study samples consist of adult respondents of a representative internet panel who experienced a PTE between 1 and 2 years before T1, and did not experience any new PTE between T1 and T3 (long-term group, N = 438) and those exposed in the six months before T1, and not exposed to any additional PTE (short-term group, N = 400). Levels of CSE and PTSS were measured with 4-month intervals. In addition, prospectively assessed personality traits and peritraumatic distress were entered in the analyses. RESULTS: Structural equation modeling showed that CSE perceptions will continue to influence subsequent PTSS levels in the long-term, just as they did in the short-term. Contrary to the more short-term post-exposure period however, CSE levels do not just influence recovery from PTSS. Over time, degree of PTSS experienced also influences subsequent CSE perceptions. CONCLUSION: Results suggest that while trauma-related CSE perceptions are relatively robust in the short-term recovery period, they can be affected by posttraumatic stress in the long-term.

Predictors of workplace violence among ambulance personnel: a longitudinal study.

AIM: To examine predictors of repeated confrontations with workplace violence among ambulance personnel, the proportion of exposure to potentially traumatic events that are aggression-related and to what extent personnel was able to prevent escalations. Although previous research assessed the prevalences among this group, little is known about predictors, to what extent PTE's are WPV-related and their abilities to prevent escalations. DESIGN: A longitudinal study with a 6 months' time interval (N = 103). METHODS: At T1 demographics, workplace violence and potentially traumatic events in the past year, mental health, personality, handling of rules, coping and social organizational stressors were assessed. Confrontations with aggression were also examined at T2. RESULTS: Multivariate logistic regression analyses showed that only problems with superiors independently predicted repeated verbal aggression and that only the (absence of the) ability to compromise very easily predicted repeatedly being on guard and repeatedly confronted with any form of aggression. Due to very low prevalences, we could not examine predictors of repeated confrontations with physical aggression (N = 5) and serious threat (N = 7). A large majority reported that in most workplace violence cases they could prevent further escalations. About 2% reported a potentially traumatic event in the year before T1 that was WPV related and perceived as very stressful.

Pre-event trajectories of mental health and health-related disabilities, and post-event traumatic stress symptoms and health: A 7-wave population-based study.

It is unknown to what extent classes of trajectories of pre-event mental health problems (MHP) and health-related disabilities (HRD), predict post-event traumatic stress symptoms (PTSS), MHP and HRD. Aim of the present 7-wave study was to assess the predictive values using a representative sample of adult Dutch (N=4052) participating in three health-surveys in November-December 2009 (T1), 2010 (T2), 2011 (T3). In total, 2988 out of 4052 also participated in trauma-surveys in April(T4), August(T5) and December(T6) 2012 and a fourth health-survey in November-December 2012 (T7). About 10% (N=314) was confronted with potentially traumatic events (PTE) in the 4 months before T4 or T5. Latent class analyses among 4052 respondents identified four classes of pre-event MHP and HRD. Series of multivariate logistic regression analyses with class membership, peri-traumatic stress, type of event, gender, age and education as predictors, showed that classes with high levels of MHP or HRD, were more at risk for high levels of PTSS at baseline and follow-ups at 4 and 8 months, than classes with low levels of MHP or HRD. These classes were very strong predictors for high levels of post-event MHP and HRD: no differences were found between non-affected and affected respondents with different levels of peri-traumatic stress.

The predictive value of trauma-related coping self-efficacy for posttraumatic stress symptoms: Differences between treatment-seeking and non-treatment-seeking victims.

OBJECTIVE: To assess and compare the (independent) predictive value of trauma-related coping self-efficacy (CSE) for posttraumatic stress symptoms (PTSS) among a treatment sample and a comparison group of nontreatment seeking victims. METHOD: Both the treatment (N = 54) and comparison group (N = 144) were exposed to potentially traumatic events (PTEs), experienced a heightened level of PTSS (IES > = 19), and were matched on work status and time between PTE and first measurement (T1). Respondents completed both baseline (T1) and follow-up measures (T2) approximately 8 months after T1. RESULTS: Multiple regression analyses among the treatment sample showed that neither PTSS at T1 (start of treatment) nor CSE levels at T1 predicted PTSS at T2 among the treatment group. Among the comparison group, higher CSE levels at T1 and younger age were significantly associated with lower PTSS at T2. In both the treatment group and the comparison group PTSS levels were significantly lower at T2 than at T1. As expected, treatment seeking victims have higher PTSS and lower CSE levels than nontreatment seeking victims. CONCLUSIONS: Pretreatment CSE did not affect recovery during treatment: higher pretreatment CSE perceptions do not give treated individuals an advantage while CSE is predictive of PTSS among untreated victims.

Coping with burns: the role of coping self-efficacy in the recovery from traumatic stress following burn injuries.

We conducted a three-wave prospective study among patients with burns (N = 178) to examine the prospective influence of coping self-efficacy (CSE) perceptions on trajectories of posttraumatic stress symptoms in the first 12 months after burn injuries. Using linear growth curve modeling, we corrected for demographics, the number of surgeries during initial admittance, trait coping styles, and changing levels of health-related quality of life. CSE during initial admission was by far the strongest predictor of both initial PTSD symptoms and degree of symptom change with higher CSE levels associated with lower initial symptoms and a steeper decline of symptoms over time. Of the other variables only avoidant coping was associated with higher initial symptom levels, and only emotional expression associated with greater rate of recovery. Current findings suggest that CSE plays a pivotal role in recovery from posttraumatic stress after a burn injury, even when the role of burn-related impairments is taken into consideration. Implications of findings are discussed.

Longitudinal interplay between posttraumatic stress symptoms and coping self-efficacy: A four-wave prospective study.

Trauma-related coping self-efficacy (CSE), the perceived capability to manage one's personal functioning and the myriad environmental demands of the aftermath of potentially traumatic events (PTE), has been shown to affect psychological outcomes after these events. Aim of the present four-wave study was to examine the cross-lagged relationships between CSE and posttraumatic stress disorder (PTSD) symptoms following PTEs in order to examine direction of influence. Levels of CSE and PTSD symptoms were measured with 4-month intervals. In addition, prospectively assessed personality traits and general self-efficacy perceptions as well as peritraumatic distress were entered in the analyses. The study sample consists of adult respondents of a representative internet panel who experienced PTE in the six months before T1, and did not experience any new PTE or life event between T1 and T3 (N = 400). Respondents were administered the coping self-efficacy scale (CSE-7), impact of event scale (IES) and arousal items of IES-R at each wave (T1 through T3), as well as questions on peritraumatic stress and prospectively measured personality traits (T0). Results of structural equation modeling showed that the effect of CSE on subsequent PTSD symptom levels was dominant. CSE significantly predicted subsequent symptoms, over and above earlier symptom levels, with higher CSE associated with lower PTSD. Symptoms in turn, did not predict subsequent levels of CSE. Higher peritraumatic distress was associated with both higher initial PTSD symptoms and lower initial CSE levels. Higher levels of the personality traits of emotional stability and agreeableness were associated with higher initial CSE levels. This supports a model in which CSE perceptions play an important role in recovery from trauma.

Social organizational stressors and post-disaster mental health disturbances: a longitudinal study.

Social organizational stressors are well-known predictors of mental health disturbances (MHD). However, to what extent these stressors predict post-disaster MHD among employed victims hardly received scientific attention and is clearly understudied. For this purpose we examined to what extent these stressors independently predict MHD 1.5 years post-disaster over and above well-known risk factors such as disaster exposure, initial MHD and lack of general social support, life-events in the past 12 months and demographics (N=423). Exposure, social organizational stressors and support were significantly associated with almost all examined mental health disturbances on a bi-variate level. Multivariate logistic regression analyses showed that these stressors, i.e. problems with colleagues, independently predicted anxiety (Adj. OR=5.93), depression (Adj. OR=4.21), hostility (Adj. OR=2.85) and having two or more mental health disturbances (Adj. OR=3.39) in contrast to disaster exposure. Disaster exposure independently predicted symptoms of PTSD symptoms (Adj. OR=2.47) and agoraphobia (Adj. OR=2.15) in contrast to social organizational stressors. Importantly, levels of disaster exposure were not associated nor correlated with (levels of) social organizational stressors. Findings suggest that post-disaster mental health care programs aimed at employed affected residents, should target social organizational stressors besides disaster-related stressors and lack of general social support.

The burden of research on trauma for respondents: a prospective and comparative study on respondents evaluations and predictors.

The possible burden of participating in trauma research is an important topic for Ethical Committees (EC's), Review Boards (RB's) and researchers. However, to what extent research on trauma is more burdensome than non-trauma research is unknown. Little is known about which factors explain respondents evaluations on the burden: to what extent are they trauma-related or dependent on other factors such as personality and how respondents evaluate research in general? Data of a large probability based multi-wave internet panel, with surveys on politics and values, personality and health in 2009 and 2011, and a survey on trauma in 2012 provided the unique opportunity to address these questions. Results among respondents confronted with these events in the past 2 years (N = 950) showed that questions on trauma were significantly and systematically evaluated as less pleasant (enjoyed less), more difficult, but also stimulated respondents to think about things more than almost all previous non-trauma surveys. Yet, the computed effect sizes indicated that the differences were (very) small and often meaningless. No differences were found between users and non-users of mental services, in contrast to posttraumatic stress symptoms. Evaluations of the burden of previous surveys in 2011 on politics and values, personality and health most strongly, systematically and independently predicted the burden of questions on trauma, and not posttraumatic stress symptoms, event-related coping self-efficacy and personality factors. For instance, multiple linear regression analyses showed that 30% of the variance of how (un)pleasant questions on trauma and life-events were evaluated, was explained by how (un)pleasant the 3 surveys in 2011 were evaluated, in contrast to posttraumatic stress symptoms (not significant) and coping self-efficacy (5%). Findings question why EC's, RB's and researchers should be more critical of the possible burden of trauma research than of the possible burden of other non-trauma research.

The associations between coping self-efficacy and posttraumatic stress symptoms 10 years postdisaster: differences between men and women.

The mediating role of coping self-efficacy (CSE) perceptions between disaster-related posttraumatic stress symptoms (PSS) in the intermediate term (4 years postevent) and PSS in the long term (10 years postevent) were examined. Participants were 514 adult Dutch native residents affected by the Enschede fireworks disaster. The disaster (May, 2000) was caused by a massive explosion in a fireworks storage facility that destroyed a residential area. Multiple regression analysis and path analysis were used to examine the mediating role of CSE and whether the mediating role was the same for men and women. Age, education, disaster exposure, home destruction, optimism, and stressful life events were also taken into account. Regression analysis showed that the former variables were not associated with PSS at 10 years postevent, in contrast to PSS at 4 years, and were therefore omitted from the path analyses. CSE assessed at 10 years postdisaster partially mediated the relationship between PSS at 4 and PSS at 10 years postdisaster. Post hoc multigroup analysis showed that this effect was significantly stronger for men, whereas the association between PSS at 4 and 10 years postevent was stronger for women. PSS at 10 years postevent were better predicted among men (explained variance 59.5% vs 50.8%).