Factors Related to the Probable PTSD after the 9/11 World Trade Center Attack among Asian Americans

A Home Disaster Preparedness Intervention Study with Korean American Residents in New York City

This study investigated the effectiveness of the Nurses Taking on Readiness Measures (N-TORM) intervention in improving disaster preparedness of Asian immigrant residents in New York City. N-TORM is an innovative, nurse-led, household disaster preparedness educational intervention provided to community members to help them create their disaster-related evacuation and communication plans, build disaster supply kits, and understand community resources available to assist residents before, during, and after disasters. The aims of this controlled before-after intervention study were to (a) pilot test the Korean translation of the Household Emergency Preparedness Instrument (K-HEPI), (b) evaluate the effectiveness of N-TORM to increase household disaster preparedness knowledge and behavior, and (c) describe the factors most necessary to maintain and expand N-TORM. Participants in the experimental group (N = 200) demonstrated significantly greater pre-to-post improvement in disaster preparedness compared to those in the control group (N = 199), as measured by the K-HEPI (effect on total General Preparedness scores, β = 1.66, SE = 0.105, p < .001). The Korean community organization that was involved in this study continues to offer N-TORM to its members, demonstrating the intervention's sustainability. Further testing of the K-HEPI and the intervention in longitudinal studies is recommended to explore potential associations between disaster preparedness and outcomes such as survival without rescue, prevention of injury, or acute exacerbations of chronic illnesses. Replicating the intervention across different immigrant populations is essential, and data from these studies can inform policy development to better address the needs of immigrant communities before, during, and after disasters. ClinicalTrials.gov Identifier: NCT0554478. Hunter College of City University of New York Protocol Record 2022-0542-Hunter, Korean Translation and Validation of the K-HEPI by a Phase 1 Feasibility Study in NYC, is registered and posted on the ClinicalTrials.gov website.

The Epidemiology and Geographic Patterns of Natural Disaster and Extreme Weather Mortality by Race and Ethnicity, United States, 1999-2018

OBJECTIVES

The adverse effects that racial and ethnic minority groups experience before, during, and after disaster events are of public health concern. The objective of this study was to examine disparities in the epidemiologic and geographic patterns of natural disaster and extreme weather mortality by race and ethnicity.

METHODS

We used mortality data from the Centers for Disease Control and Prevention from January 1, 1999, through December 31, 2018. We defined natural disaster and extreme weather mortality based on International Classification of Diseases, 10th Revision codes X30-X39. We calculated age-adjusted mortality rates by race, ethnicity, and hazard type, and we calculated age-adjusted mortality rate ratios by race, ethnicity, and state. We used geographic mapping to examine age-adjusted mortality rate ratios by race, ethnicity, and state.

RESULTS

Natural disasters and extreme weather caused 27 335 deaths in the United States during 1999-2018. Although non-Hispanic White people represented 68% of total natural disaster and extreme weather mortality, the mortality rate per 100 000 population among non-Hispanic Black people was 1.87 times higher (0.71) and among non-Hispanic American Indian/Alaska Native people was 7.34 times higher (2.79) than among non-Hispanic White people (0.38). For all racial and ethnic groups, exposure to extreme heat and cold were the 2 greatest causes of natural disaster and extreme weather mortality. Racial and ethnic disparities in natural disaster and extreme weather mortality were highest in the South, Southwest, Mountain West, and Upper Midwest.

CONCLUSIONS

Racial and ethnic minority populations have a greater likelihood of mortality from natural disaster or extreme weather events than non-Hispanic White people. Our study strengthens the current knowledge base on these disparities and may inform and improve disaster preparedness and response efforts.

Scientific Value of the Sub-Cohort of Children in the World Trade Center Health Registry

The World Trade Center Health Registry (WTCHR) was established in 2002 as a public health resource to monitor the health effects from the World Trade Center (WTC) disaster. We evaluated the representativeness of the WTC youth population (<18 years on 11 September 2001) by comparing the distributions of age, gender, race/ethnic groups, and income to 2000 census data for the matched geographic area, including distance from disaster. There were 2379 WTCHR enrolled children living in Lower Manhattan south of Canal Street on 11 September 2001, along with 752 enrolled students who attended school in Lower Manhattan but were not area residents. The WTCHR sub-group of children who were residents was similar to the geographically corresponding census population on age and sex. Black and Hispanic children are moderately overrepresented at 0.9% and 2.4% in the WTCHR compared to 0.8% and 1.7% in census population, respectively, while lower-income households are slightly under-represented, 28.8% in the WTCHR and 30.8% for the corresponding census information. Asian children appear underrepresented at 3.0% participation compared to 6.3% in the census. While the demographics of WTCHR youth are somewhat skewed, the gaps are within expected patterns of under-representation observed in other longitudinal cohorts and can be effectively addressed analytically or through targeted study design.

Anxiety, Depression and Posttraumatic Stress Disorder after Terrorist Attacks: A General Review of the Literature

Terrorism, though not well-defined, is a violent act that has been shown to have longstanding effects on the mental health of those who witness it. The aim of this general literature review is to explore the effect that terrorism has on posttraumatic stress disorder (PTSD), major depressive disorder (MDD) and anxiety disorders, as well as the bio-psycho-social determinants that mediate its impact. This paper describes the prevalence, risk factors, protective factors, common presentations and interventions identified for PTSD, depression and anxiety disorders occurring following terrorist attacks. We conducted a literature search in MEDLINE using a number of keywords detailed below. After applying inclusion and exclusion criteria, we kept 80 articles, which we summarized in tabular form. A majority of articles found detailed the impact of terrorism on PTSD, and took place in a Western, mainly American setting. The main factors that impacted the presentation of mental illness include gender, ethnicity, social supports, socioeconomic status, level of preparedness, level of exposure, pre-existing trauma and mental illness, and subsequent life stressors. The main intervention detailed in this article as showing evidence post-terrorism is trauma-focused cognitive-behavioural therapy. This study highlights the importance of this topic, and in particular, its implications for public health policy and practice.

The Impact of Job Loss on Posttraumatic Stress Disorder Among Asian Americans: 11-12 Years After the World Trade Center Attack

Adversities following disasters are associated with the delayed onset and persistence of post-traumatic stress disorder (PTSD). In the wake of the World Trade Center attack, a sizeable group of Asian Americans being directly exposed to the disaster had endured job loss during the decade afterwards. Yet, no studies to date have examined the relationship between job loss and long-term PTSD in this group. This study examined the 10-11-year prevalence of probable PTSD (≥ PCL score of 44) among Asian (n=1,712) and Caucasian American (n=25,011) participants of the World Trade Center Health Registry who had completed three waves of survey studies (2003-04, 2006-08, 2011-12). Logistic regression was used to model the relationship between job loss since the disaster and probable PTSD for the two racial groups separately while controlling for sociodemographics, disaster exposure, post-disaster traumatic/stressful events exposure, lower respiratory symptoms, PTSD history since 911, and mental health service use. The long-term prevalence of probable PTSD was 15.1% for Asian Americans and 14.4% for Caucasian Americans, with no significant difference. For both groups, having job loss since 911 was a significant risk factor for probable PTSD (Asian Americans: AOR=1.80; 95% CI=1.19, 2.71; Caucasian Americans: AOR=1.73; 95% CI=1.56, 1.93). While job loss was an important risk factor, employment opportunities were more restricted for Asian Americans given the cultural and language limitations. Current findings highlight the importance of improving employment as part of post-disaster assistance.

Characterizing Mental Health Treatment Utilization among Individuals Exposed to the 2001 World Trade Center Terrorist Attacks 14⁻15 Years Post-Disaster

Following the World Trade Center (WTC) attacks in New York City (NYC) on 11 September 2001 (9/11), thousands in NYC experienced significant stress reactions and disorders, presenting an immediate need for counseling and treatment. While other studies documented post-9/11 mental health treatment utilization, none have data more than two years post-disaster. We used data from 35,629 enrollees of the WTC Health Registry, a longitudinal cohort study of those exposed to the WTC attacks, to examine predictors of counseling after 9/11, the types of practitioners seen, and the perceived helpfulness of therapy up to 15 years post-disaster. Among enrollees, 37.7% reported receiving counseling at some time after 9/11. Predictors of seeking counseling included race/ethnicity, age at 9/11, education level, exposure to the WTC attacks, other traumatic experiences, mental health symptomology, and pre-9/11 counseling. Whites and Hispanics, those who were children on 9/11, and those with high levels of exposure to the WTC attacks sought counseling soonest after 9/11. Among those who sought counseling, Blacks, Asians, and those with lower education and income were less likely to see mental health specialists and more likely to see general practitioners or religious advisors. Finally, among those who sought recent counseling, women, Blacks, those aged ≥65 years, and those with very high WTC exposures were more likely to rate their recent counseling as very helpful. This study used data up to 15 years post-disaster to document mental health treatment utilization patterns, trends, and disparities that have implications for future preparedness plans and needs assessments.

Posttraumatic stress symptoms, shame, and substance use among Asian Americans

BACKGROUND

To examine the association between posttraumatic stress symptoms (PTSS) and substance use among Asian Americans and the influence of a culturally-relevant moderator, shame.

METHODS

From 2016 to 2017, 199 participants from Amazon Mechanical Turk and a university subject pool completed an online survey. Chi-square and Kruskal-Wallis tests explored demographic and clinical differences among three Asian American ethnic subgroups (East Asians, South Asians, and Southeast Asians). Generalized linear models assessed the association between PTSS and substance use (alcohol, tobacco, and other drugs) and the moderation of this relationship by shame.

RESULTS

Ethnic subgroups significantly differed on all three substance use variables. The severity in PTSS was significantly associated with hazardous drug use (IRR = 1.03, (1.01, 1.05), p = .003). The association between PTSS and days of tobacco use and binge drinking was significantly moderated by shame. Low levels of shame increased the effect of PTSS on binge drinking (IRR = 1.05, (1.00, 1.10), p = .035) and tobacco use (IRR = 1.15, (1.11, 1.19), p < .001). High levels of shame had no effect of PTSS on binge drinking (IRR = 1.01, (0.99, 1.03), p = .54) and a reduced effect on tobacco use (IRR = 1.07, (1.05, 1.09), p < .001).

CONCLUSIONS

Among Asian Americans, the association of PTSS and substance use depends on shame. Lower levels of shame are a risk factor, increasing the effect of PTSS on substance use. Culturally-modified addiction treatments should assess for shame among Asian Americans and attend to ethnic sub-group diversity in substance use.

Posttraumatic stress disorder in the short and medium term following the World Trade Center attack among Asian Americans

This study investigated patterns of probable posttraumatic stress disorder (PTSD) and their predictors among 2,431 Asian American and 31,455 non-Hispanic White World Trade Center (WTC) Registry participants 2-3 years and 5-6 years after the WTC attack. Participants were divided into four PTSD pattern groups: resilient, remitted, delayed onset, and chronic. Asians had a lower proportion in the resilient group (76.5% vs. 79.8%), a higher proportion in the chronic (8.6% vs. 7.4%) and remitted (5.9% vs. 3.4%) groups, and a similar proportion in the delayed onset group (about 9%) compared to Whites. In multinomial logistic regression analyses, disaster exposure, immigrant status, lower income, pre-attack depression/anxiety, and lower respiratory symptoms were associated with increased odds of chronic and delayed onset PTSD (vs. resilience) among both races. Education and employment were protective against chronic and delayed onset PTSD among Whites only. These results can inform targeted outreach efforts to enhance prevention and treatment for Asians affected by future events.