Public health CBRN course Psychosocial Support Bonnie Henry,

Public health CBRN course Psychosocial Support Bonnie Henry,

Public health CBRN course Psychosocial Support Bonnie Henry, MD, FRCPC Goals of session To understand normal reactions to stress To learn dos and donts of emergency psychological first aid To understand the impact of infectious disease outbreaks on HCWs and ways to mitigate the impact

To understand the role of public health in reception centres The Impact Pyramid Disaster Response Guiding Principles No one who experiences a disaster is untouched by it Panic is rare Most people pull together and function during and after a disaster Mental health concerns exist in most aspects of preparedness, response and recovery

Disaster stress and grief reactions are normal responses to an abnormal situation Disaster Response Guiding Principles Survivors respond to active, genuine interest and concern. Disaster mental health assistance is often more practical than psychological in nature (offering a phone, distributing coffee, listening, encouraging, reassuring, comforting). Disaster relief assistance may be confusing to disaster survivors. They may experience

frustration, anger, and feelings of helplessness related to disaster assistance programs and may reject disaster assistance of all types. Psychosocial 1 Psychosocial Phases of Disaster 1. Warning of Threat: Ranges from no advance notice (suicide bomber) to weeks (hurricane) 2.

Impact: Actual onset of disaster Varies. BT has fuzzy beginning/end; bombing is precise 3. Rescue or Heroic: People watch out for, protect, even risk own safety to save strangers 4. Remedy or Honeymoon: People initially pitch in and collaborate for the collective good Psychosocial Phases of Disaster 5.

6. 7. Inventory: External resources begin to come onlinepeople watch what goes where Disillusionment: Resource allocation often seen as too little too late, poorly distributed Reconstruction and Recovery: People move beyond self interests and start to rebuild Severity of Psychological Reactions

Emotional Support In a major disaster, some victims arriving at reception centres, hospitals, or morgues will be experiencing such strong emotional reactions as Fear Anxiety Helplessness Confusion Others may be grieving the loss of a loved one, of their home, of their community Or experiencing distress because a loved one is seriously injured or missing Psychological First Aid: Do

Do help people meet basic needs for food & shelter, and obtain emergency medical attention. Provide repeated, simple and accurate information on how to obtain these Do listen to people who wish to share their stories and emotions and remember there is no wrong or right way to feel Do be friendly and compassionate even if people are being difficult

Do provide accurate information about the disaster or trauma and the relief efforts. This will help people to understand the situation Do help people contact friends or loved ones Psychological First Aid: Do Do keep families together. Keep children with parents or other close relatives whenever possible Do give practical suggestions that steer people

towards helping themselves Do engage people in meeting their own needs Do find out the types and locations of government and non-government services and direct people to services that are available If you know that more help and services are on the way do remind people of this when they express fear or worry Psychological First Aid: Dont Dont force people to share their stories with you, especially very personal details Dont give simple reassurances like everything will be ok or at least you

survived Dont tell people what you think they should be feeling, thinking or doing now or how they should have acted earlier Psychological First Aid: Dont Dont tell people why you think they have suffered by giving reasons about their personal behaviors or beliefs Dont make promises that may not be kept Dont criticise existing services or relief activities in front of people in need of these services

Support for Emergency Responders Characteristics of the SARS outbreak that increased psychological risk Conditions Rapid spread Rapidly changing state of knowledge Initially unclear infectivity and mortality Hospital-based infection Adverse Consequences Uncertainty Inconsistency & change Information, rules

Protective equipment High perceived risk for HCWs Acute effects of SARS on Healthcare Workers By July 2003 more than 20,000 HCWs worldwide had participated in quantitative studies of the psychological impact of caring for SARS patients Moderate to high levels of distress in the shortterm Significant distress in 18-57 % Acute effects of SARS on Healthcare Workers

Acute distress is associated with Fear of contagion Concern for family health Treating colleagues with SARS Job stress Interpersonal isolation Perceived stigma Quarantine

The Impact of SARS Study Designed to assess the long term psychological and occupational impact of working during the SARS outbreak Broad range of indicators of the impact of SARS Maunder, R., et al 2006 Emerging Infectious Diseases. Vol12, no12:1924-32. Methods HCWs surveyed at 8 Toronto hospitals that treated SARS

patients in 2003 Comparison group of recruited from 4 hospitals in Hamilton similar public health precautions and surveillance but had no SARS cases. August 2004 to September 2005, 13 to 25 months after the last SARS patients were

treated in Toronto. Maunder, R., et al 2006 Emerging Infectious Diseases. Vol12, no12:1924-32. Participants Primarily nurses 71% in Toronto, 83 % in Hamilton ICU, ER, medical and surgical inpatient units (including dedicated SARS isolation units)

Maunder, R., et al 2006 Emerging Infectious Diseases. Vol12, no12:1924-32. Proportion of healthcare workers who report problems Burnout MBI-EE27 Psychological distress Toronto Hamilton n = 587

n = 182 30.4 % 19.2 % 44.9 % 30.2 % 13.8 % 8.4 % P-value

0.003 < 0.001 K1016 Posttraumatic stress 0.06 IES26 Maunder, R., et al 2006 Emerging Infectious Diseases. Vol12, no12:1924-32. Proportion of healthcare workers who report problems & changes since SARS

Toronto Hamilton P-value n = 587 n = 182 patient contact 16.5 % 8.3 %

0.007 work hours 8.6 % 2.2 % 0.003 smoke, drink, other prob. 21.0 % 8.1 %

0.001 4 shifts missed in 4 mo. 21.6 % 12.6 % 0.007 Maunder, R., et al 2006 Emerging Infectious Diseases. Vol12, no12:1924-32. Psychiatric diagnosis There

was no difference between cities in Lifetime history of psychiatric disorder before SARS Onset of new psychiatric disorder since SARS Rates of psychiatric disorder were rates in Canadian community samples Maunder, R., et al 2006 Emerging Infectious Diseases. Vol12, no12:1924-32. Maladaptive coping Escape & avoidance I hoped for a miracle

I wished that the situation would go away or be over with Confrontive coping I tried to get the person responsible to change his or her mind I expressed anger to the person(s) who caused the problem Self-blame & taking responsibility I promised myself things would be different next time I criticized or lectured myself Maunder, R., et al 2006 Emerging Infectious Diseases. Vol12, no12:1924-32. Training, Protection and Support

I had adequate training to deal confidently with the situations that I faced. Infection control procedures were adequately explained. The hospital where I worked took my well-being into account when decisions were made that affected me. Emotional support (e.g. counseling) was available to those who needed help. I felt appreciated by the hospital/clinic/my employer etc.

Maunder, R., et al 2006 Emerging Infectious Diseases. Vol12, no12:1924-32. Things that were not related to adverse outcome Intensity of contact with SARS patients Treating SARS patient-colleagues Working in a SARS isolation unit Maunder, R., et al 2006 Emerging Infectious Diseases. Vol12, no12:1924-32. Conclusions and Discussion Resilience SARS does not appear to have caused

psychiatric disorder in health care workers Depression Post-traumatic stress Other anxiety disorders Substance abuse Somatoform disorders Maunder, R., et al 2006 Emerging Infectious Diseases. Vol12, no12:1924-32. Distress In Toronto HCWs, 1-2 years after SARS 55% were experiencing at least one of: Traumatic stress symptoms Nonspecific psychological distress Burnout

Maunder, R., et al 2006 Emerging Infectious Diseases. Vol12, no12:1924-32. Functional Impact In Toronto HCWs, 1-2 years after SARS: 21% had increased smoking, drinking or problematic behaviour since SARS 22% had missed 4 shifts due to stress, fatigue or illness over 4 months Maunder, R., et al 2006 Emerging Infectious Diseases. Vol12, no12:1924-32. Staff Retention In Toronto HCWs, 1-2 years after SARS, 22% had decreased direct patient work since SARS

Decreased direct patient contact Decreased work hours Maunder, R., et al 2006 Emerging Infectious Diseases. Vol12, no12:1924-32. Recommendations Pre-event Training Unfamiliar tasks Unfamiliar roles Development of effective, responsive communications Identification of natural opinion leaders

Training, partnering with organizational leaders Recommendations Pre- event Attend to pre-existing distress Building the relational infrastructure in which support will be delivered during the event Staff participation in transparent planning process Especially regarding policy for contentious and difficult to resolve issues support of family/dependants prioritizing scarce resources

distributing medications, vaccine Recommendations During Event Implementation of strategies determined in pre-event period Communications Psychological support Multiple options, personal choice Family & care of dependents, pets etc. Workplace safety and security Long-term Psychological Support

In some areas public health has trained psychological support counselors Most often we will need to connect people who need longer term support to other community resources Knowing who in your community can provide these services is key

Community and Personal Support Services Emergency Clothing Emergency Lodging Emergency Food Registration and Inquiry Personal Services Reception Centre Service Community and Personal Support Services (1)

Community and personal support services are most effective when they: are provided in a coordinated, timely and culturallyappropriate manner are available for all people affected by the disaster, including:

individuals families communities groups/organisations, and emergency service, recovery workers and volunteers; include the affected community in their development and management Community and Personal Support Services (2)

facilitate sharing of information between agencies provide people with accurate and current information about the situation and the services available are integrated with all other recovery services enhance and support existing community resources recognize that cultural and spiritual symbols and rituals are an important dimension to the recovery process involve personnel with appropriate capacities,

personal skills and who know the full range of services available Community and Personal Support Services (3) In major disasters or emergencies, evacuees may arrive at Reception Centres: with minor wounds or injuries

without their medication, mobility aids having been recently discharged from hospital with various ailments or illnesses experiencing medical symptoms as a result of the disaster (e.g., rising flood waters, approaching forest fires) with health concerns generated by the disaster (e.g., fear that their own health or their childrens health are at risk because of exposure to toxic smoke, radiation, biochemical agents) from nursing homes, special care facilities, hospitals because of damage or interruption of utilities in their facility Objectives of Personal Services

Arrange for the initial reception of disaster victims/evacuees arriving at reception centres Provide people with information on the emergency help available Provide temporary care (i.e. children) Provide information on financial or other aid available Offer immediate support to people with emotional or medical issues Assist in arranging long-term support for those in need

Public Health Roles in Reception Centres (1) Providing regular inspection of all Reception Centres to ensure compliance with public health regulations Monitoring food, water, sanitation and crowding, vector control Carrying out water purification measures if required Providing consultation to the Reception Centre Supervisor of all public health related activities. Public Health Roles in Reception Centres (2)

Establishing surveillance for communicable disease, respiratory infections and other illnesses Establishing procedures to detect and refer persons with medical or health problems Assisting evacuees requiring health services (for example infants, the elderly, pregnant women) Public Health Roles in Reception Centres (3) Provide

KI or other prophylactic medications or vaccinations if needed Assisting evacuees with special needs get what they need (e.g. canes, wheelchairs) Assisting evacuees to get prescription drugs if needed Assisting in arranging transportation for those evacuees requiring hospitalization. Summary We all need to know the principles of psychological first aid Disasters have an impact on entire

communities Psychological impact on our staff can be great and long term but there are things we can do pre-event to mitigate We need to define the role public health will play in providing personal support services and in reception centres in each health unit

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