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.

Psychological first aid: a consensus-derived, empirically supported, competency-based training model.

Surges in demand for professional mental health services occasioned by disasters represent a major public health challenge. To build response capacity, numerous psychological first aid (PFA) training models for professional and lay audiences have been developed that, although often concurring on broad intervention aims, have not systematically addressed pedagogical elements necessary for optimal learning or teaching. We describe a competency-based model of PFA training developed under the auspices of the Centers for Disease Control and Prevention and the Association of Schools of Public Health. We explain the approach used for developing and refining the competency set and summarize the observable knowledge, skills, and attitudes underlying the 6 core competency domains. We discuss the strategies for model dissemination, validation, and adoption in professional and lay communities.

Guided preparedness planning with lay communities: enhancing capacity of rural emergency response through a systems-based partnership.

INTRODUCTION: Community disaster preparedness plans, particularly those with content that would mitigate the effects of psychological trauma on vulnerable rural populations, are often nonexistent or underdeveloped. The purpose of the study was to develop and evaluate a model of disaster mental health preparedness planning involving a partnership among three, key stakeholders in the public health system. METHODS: A one-group, post-test, quasi-experimental design was used to assess outcomes as a function of an intervention designated Guided Preparedness Planning (GPP). The setting was the eastern-, northern-, and mid-shore region of the state of Maryland. Partner participants were four local health departments (LHDs), 100 faith-based organizations (FBOs), and one academic health center (AHC)-the latter, collaborating entities of the Johns Hopkins University and the Johns Hopkins Health System. Individual participants were 178 community residents recruited from counties of the above-referenced geographic area. Effectiveness of GPP was based on post-intervention assessments of trainee knowledge, skills, and attitudes supportive of community disaster mental health planning. Inferences about the practicability (feasibility) of the model were drawn from pre-defined criteria for partner readiness, willingness, and ability to participate in the project. Additional aims of the study were to determine if LHD leaders would be willing and able to generate post-project strategies to perpetuate project-initiated government/faith planning alliances (sustainability), and to develop portable methods and materials to enhance model application and impact in other health jurisdictions (scalability). RESULTS: The majority (95%) of the 178 lay citizens receiving the GPP intervention and submitting complete evaluations reported that planning-supportive objectives had been achieved. Moreover, all criteria for inferring model feasibility, sustainability, and scalability were met. CONCLUSIONS: Within the span of a six-month period, LHDs, FBOs, and AHCs can work effectively to plan, implement, and evaluate what appears to be an effective, practical, and durable model of capacity building for public mental health emergency planning.

Participatory public health systems research: value of community involvement in a study series in mental health emergency preparedness.

BACKGROUND: Concerns have arisen over recent years about the absence of empirically derived evidence on which to base policy and practice in the public health system, in general, and to meet the challenge of public health emergency preparedness, in particular. Related issues include the challenge of disaster-caused, behavioral health surge, and the frequent exclusion of populations from studies that the research is meant to aid. OBJECTIVE: To characterize the contributions of nonacademic collaborators to a series of projects validating a set of interventions to enhance capacity and competency of public mental health preparedness planning and response. SETTING(S): Urban, suburban, and rural communities of the state of Maryland and rural communities of the state of Iowa. PARTICIPANTS: Study partners and participants (both of this project and the studies examined) were representatives of academic health centers (AHCs), local health departments (LHDs), and faith-based organizations (FBOs) and their communities. PROCEDURES: A multiple-project, case study analysis was conducted, that is, four research projects implemented by the authors from 2005 through 2011 to determine the types and impact of contributions made by nonacademic collaborators to those projects. The analysis involved reviewing research records, conceptualizing contributions (and providing examples) for government, faith, and (nonacademic) institutional collaborators. RESULTS: Ten areas were identified where partners made valuable contributions to the study series; these "value-areas" were as follows: 1) leadership and management of the projects; 2) formulation and refinement of research topics, aims, etc; 3) recruitment and retention of participants; 4) design and enhancement of interventions; 5) delivery of interventions; 6) collection, analysis, and interpretation of data; 7) dissemination of findings; 8) ensuring sustainability of faith/government preparedness planning relationships; 9) optimizing scalability and portability of the model; and 10) facilitating translational impact of study findings. CONCLUSIONS: Systems-based partnerships among academic, faith, and government entities offer an especially promising infrastructure for conducting participatory public health systems research in domestic emergency preparedness and response.

Applying behavioral science to workforce challenges in the public health emergency preparedness system.

When disasters and other broad-scale public health emergencies occur in the United States, they often reveal flaws in the pre-event preparedness of those individuals and agencies charged with responsibility for emergency response and recovery activities. A significant contributor to this problem is the unwillingness of some public health workers to participate in the requisite planning, training, and response activities to ensure quality preparedness. The thesis of this article is that there are numerous, empirically supported models of behavior change that hold potential for motivating role-appropriate behavior in public health professionals. The models that are highlighted here for consideration and prospective adaptation to the public health emergency preparedness system (PHEPS) are the Transtheoretical Model of Intentional Behavior Change (TTM) and Motivational Interviewing (MI). Core concepts in TTM and MI are described, and specific examples are offered to illustrate the relevance of the frameworks for understanding and ameliorating PHEPS-based workforce problems. Finally, the requisite steps are described to ensure the readiness of organizations to support the implementation of the ideas proposed.

Community capacity-building in disaster mental health resilience: a pilot study of an academic/faith partnership model.

We describe an academic/faith partnership approach for enhancing the capacity of communities to resist or rebound from the impact of terrorism and other mass casualty events. Representatives of several academic health centers (AHCs) collaborated with leaders of urban Christian-, Jewish-, and Muslim faith-based organizations (FBOs) to design, deliver, and preliminarily evaluate a train-the-trainer approach to enhancing individual competencies in the provision of psychological first aid and in disaster planning for their respective communities. Evidence of partner commitment to, and full participation in, project implementation responsibilities confirmed the feasibility of the overall AHC/FBO collaborative model, and individual post-training, self-report data on perceived effectiveness of the program indicated that the majority of community trainees evaluated the interventions as having significantly increased their: (a) knowledge of disaster mental health concepts; (b) skills (self-efficacy) as providers of psychological first aid and bereavement support services, and (c) (with somewhat less confidence because of module brevity) capabilities of leading disaster preparedness planning efforts within their communities. Notwithstanding the limitations of such early-phase research in ensuring internal and external validity of the interventions, the findings, particularly when combined with those of earlier and subsequent work, support the rationale for continuing to refine this participatory approach to fostering community disaster mental health resilience, and to promoting the translational impact of the model. An especially important (recent) example of the latter is the formal recognition by local and state health departments of program-trained lay volunteers as a vital resource in the continuum of government assets for public health emergency preparedness planning and response.

Psychological first-aid training for paraprofessionals: a systems-based model for enhancing capacity of rural emergency responses.

INTRODUCTION: Ensuring the capacity of the public health, emergency preparedness system to respond to disaster-related need for mental health services is a challenge, particularly in rural areas in which the supply of responders with relevant expertise rarely matches the surge of demand for services. PROBLEM: This investigation established and evaluated a systems-based partnership model for recruiting, training, and promoting official recognition of community residents as paraprofessional members of the Maryland Medical Professional Volunteer Corps. The partners were leaders of local health departments (LHDs), faith-based organizations (FBOs), and an academic health center (AHC). METHODS: A one-group, quasi-experimental research design, using both post-test only and pre-/post-test assessments, was used to determine the feasibility, effectiveness, and impact of the overall program and of a one-day workshop in Psychological First Aid (PFA) for Paraprofessionals. The training was applied to and evaluated for 178 citizens drawn from 120 Christian parishes in four local health jurisdictions in rural Maryland. RESULTS: Feasibility-The model was demonstrated to be practicable, as measured by specific criteria to quantify partner readiness, willingness, and ability to collaborate and accomplish project aims. Effectiveness-The majority (93-99%) of individual participants "agreed" or "strongly agreed" that, as a result of the intervention, they understood the conceptual content of PFA and were confident about ("perceived self-efficacy") using PFA techniques with prospective disaster survivors. Impact-Following PFA training, 56 of the 178 (31.5%) participants submitted same-day applications to be paraprofessional responders in the Volunteer Corps. The formal acceptance of citizens who typically do not possess licensure in a health profession reflects a project-engendered policy change by the Maryland Department of Health and Mental Hygiene. CONCLUSIONS: These findings are consistent with the conclusion that it is feasible to consider LHDs, FBOs, and AHCs as partners to work effectively within the span of a six-month period to design, promote, conduct, and evaluate a model of capacity/capability building for public mental health emergency response based on a professional "extender" rationale. Moreover, consistently high levels of perceived self-efficacy as PFA responders can be achieved with lay members of the community who receive a specially-designed, one-day training program in crisis intervention and referral strategies for disaster survivors.

Ready, willing, and able: a framework for improving the public health emergency preparedness system.

Every society is exposed periodically to catastrophes and public health emergencies that are broad in scale. Too often, these experiences reveal major deficits in the quality of emergency response. A critical barrier to achieving preparedness for high-quality, system-based emergency response is the absence of a universal framework and common language to guide the pursuit of that goal. We describe a simple but comprehensive framework to encourage a focused conversation to improve preparedness for the benefit of individuals, families, organizations, communities, and society as a whole. We propose that constructs associated with the well-known expression "ready, willing, and able" represent necessary and sufficient elements for a standardized approach to ensure high-quality emergency response across the disparate entities that make up the public health emergency preparedness system. The "ready, willing, and able" constructs are described and specific applications are offered to illustrate the broad applicability and heuristic value of the model. Finally, prospective steps are outlined for initiating and advancing a dialogue that may directly lead to or inform already existing efforts to develop quality standards, measures, guidance, and (potentially) a national accreditation program.

Preparing for an influenza pandemic: mental health considerations.

There is a common belief that an influenza pandemic not only is inevitable, but that it is imminent. It is further believed by some, and dramatized by a 2006 made-for-television-movie, that such a pandemic will herald an end to life as we know it. Are such claims hyperboles, or does a pandemic represent the most significant threat to public health in the new millennium? Any potential effects of a disease on a population are mediated not only through the pathophysiological mechanisms of the disease itself, but through the psychological and behavioral reactions that such a disease might engender. It is the purpose of this paper to explore the potential psychological and behavioral reactions that may accompany an influenza pandemic.

The tower of ivory meets the house of worship: psychological first aid training for the faith community.

Clergy and laity have been a traditional source of support for people striving to cope with everyday tragedies, but not all faith leaders have the specialized knowledge required for the challenges of mental health ministry in the aftermath of widespread trauma and mass casualty events. On the other hand, some mental health professionals have acquired high levels of expertise in the field of disaster mental health but, because of their limited numbers, cannot be of direct help to large numbers of disaster survivors when such events are broad in scale. The authors have addressed the problem of scalability of post-disaster crisis mental health services by establishing an academic/faith partnershipforpsychological first aid training. The curriculum was piloted with 500 members of the faith community in Baltimore City and other areas of Maryland. The training program is seen as a prototype of specialized first-responder training that can be built upon to enhance and extend the roles of spiritual communities in public health emergencies, and thereby augment the continuum of deployable resources available to local and state health departments.

Psychological first aid training for the faith community: a model curriculum.

Traditionally faith communities have served important roles in helping survivors cope in the aftermath of public health disasters. However, the provision of optimally effective crisis intervention services for persons experiencing acute or prolonged emotional trauma following such incidents requires specialized knowledge, skills, and abilities. Supported by a federally-funded grant, several academic health centers and faith-based organizations collaborated to develop a training program in Psychological First Aid (PFA) and disaster ministry for members of the clergy serving urban minorities and Latino immigrants in Baltimore, Maryland. This article describes the one-day training curriculum composed of four content modules: Stress Reactions of Mind-Body-Spirit, Psychological First Aid and Crisis Intervention, Pastoral Care and Disaster Ministry, and Practical Resources and Self Care for the Spiritual Caregiver Detailed descriptions of each module are provided, including its purpose; rationale and background literature; learning objectives; topics and sub-topics; and educational methods, materials and resources. The strengths, weaknesses, and future applications of the training template are discussed from the vantage points of participants' subjective reactions to the training.

Clinical assessment in disaster mental health: a logic of case formulation.

Despite increased professional attention to the mental health aspects of disaster medicine in recent years, advances in clinical assessment of survivors of mass casualty incidents have been few. Contemporary assessment methods often yield little more than check lists of symptoms that, while they may lead to reliable DSM-IV diagnoses, provide no sense of the individual patient's plight and so are inadequate for case formulation, treatment planning, and prognosis estimation. The authors describe a comprehensive model for assessing patients developed at the Johns Hopkins Department of Psychiatry and Behavioral Sciences. Relating it to the field of disaster mental health for the first time here, the approach uses four distinct but overlapping appraisal perspectives, each of which drives a set of exploratory propositions and leads to an understanding of the essential natures of clinical disorders and their underlying etiologies. The perspectives address the following: (a) what the individual "has" (biologically based disease and physical illness); (b) who the individual "is" (graded dimensions of temperament, disposition, traits, intelligence, etc); (c) what the individual "does" (purposeful, goal-directed, conditioned behavior, etc); and (d) what the individual "has encountered" (his/ her life story and the meaning that has been given to those experiences). Following a description of each perspective from the standpoint of its underlying logic, inquiry domain, and indicated intervention, the authors highlight the potential hueristic value of the model by illustrating numerous testable hypotheses that can be generated through the juxtaposition of the four assessment perspectives with three longitudinal considerations for the management of trauma patients, ie, the stress-related constructs of (pre-incident) resistance, (peri-incident) resilience, and (post-incident) recovery.

Psychiatry and terrorism: the profession's role in disaster response planning.

While America wages the "war" on terrorism and endeavors to protect the physical safety of its citizens, it is imperative to plan for the population's mental health needs in future terrorist/disaster scenarios. The importance of psychiatry's potential role in preparing the community for the psychological impact of terrorism is underscored against the historical backdrop of the field being "carved out" from the organization, delivery, and financing of health services in our society. A practical framework is offered for designing an organization's mental health disaster plan, including recommendations for strategic infrastructure and tactical response capabilities. Finally, the unique features of clinical practice with disaster victims are noted, including intra-clinician conflicts between professional/community interests and personal/family obligations during acute disaster events.

Academic psychiatry and health care reform: strategic initiatives for sustaining the clinical mission.

Health care reform has posed special challenges for departments of psychiatry in academic medical centers. This report describes one department's strategic responses to a marketplace with high penetration by managed care and provides examples of the kinds of faculty concerns that can arise when major departmental reorganizations are attempted. The department's successful adaptation to a radically altered professional environment is attributed to the following five initiatives: vertical integration and diversification of clinical programs, service line management, outcomes measurement, regional network development, and institutional managed care partnerships Although the authors did not design their adaptive efforts as a research study, they offer objective data to support their conclusion that the viability of their overall clinical enterprise has been sustained despite an external environment inhospitable to academic psychiatry.