stigma and barriers to care - Uniformed Services University of the ...

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Stigma and Barriers to Care — Caring for Those Exposed to War, Disaster and Terrorism
In the context of
stigma, there are
things we can learn
from disasters that
can assist us in
thinking about the
military context and
culture.
in the past 100 years: the frequency of disasters is increasing. Everybody asks, “Why
is the frequency of disasters increasing” Meteorological and hydrological disasters
are probably linked to changing global and environmental conditions. Another
reason is probably due to urbanization, concentrating more people in smaller areas.
The same natural events that were happening 200 years ago perhaps resulted in trees
falling into forests with no human injury toll. Now, when trees fall in the forest there
are a thousand people underneath it so disasters are increasing. We are packing more
people into areas where these large scale traumatic events are happening. The good
news is that more people are surviving disasters. One more piece of bad news is that
many more people are being affected.
An interesting phenomenon from an epidemiologic point of view is that every
time a disaster passes we have an unerring ability to forget all about the disaster and
think another one will not happen. We see this time and time again including recently
with Haiti. Of course, these events attract a great deal of attention and breathless
reporting in the news like, “Wow, this is shocking and surprising and we don’t know
anything about it.” Then two months later you forget all about it. In fact, Haiti was
not predictable but it is entirely predictable that some other big event was going to
happen and something else will happen again.
Having said that, it is well worth the effort to make epidemiologic inquiry into
disasters. In the context of stigma, there are things we can learn from disasters that
can assist us in thinking about the military context and culture. When thinking about
barriers and stigma to mental health care after disaster, three central domains are
pertinent: predisposing characteristics, enabling factors, and need. I am going to
focus my comments around the health behavior model. I am going to show you some
data related to predisposing characteristics, enabling factors, and need as associated
with barriers to care and stigma after one particular event.
I want to talk about Hurricane Ike in the Galveston Bay recovery study. Hurricane
Ike is one of those neglected events. On September 13, 2008, it essentially
wiped out Galveston on the Texas gulf coast. The interesting thing about Hurricane
Ike is that much of the impact on the population was a combination of the winds
as well as the flood. This was an event that we studied as part of a consortium. It is
a National Center grant funded by NIMH that is co-directed by Dean Kilpatrick,
myself, and Fran Norris at Dartmouth who works as part of the National Center
for PTSD. We were able to launch a study soon after Hurricane Ike to look at the
consequences. The study is called the Galveston Bay Recovery Study.
It was a fairly large event with substantial impact. Then it faded from public
awareness soon afterwards because it occurred just before the national election and
our attention span is short.
We made a big effort to recruit a population representative sample of people
who were living in the area before the disaster. This is no easy task when you think
about the population displacement. We reconstructed sampling frames and found
people all over the country. We ended up talking to 658 people, 80% by phone,
20% in person. Of particular interest is that we asked about mental health service
need, utilization, and reasons for not using services. We used a fairly structured
instrument, the primary care needs questionnaire, which allowed us to study some
of the barriers that were discussed in the previous discussions. We looked at concerns
around stigma, preferences for care, expectations, and resource barriers. About 40%
reported mental health service need, which is fairly consistent with the previous
presentations. It is astonishingly consistent in these samples that we have a little