Pilot Projects

The current study builds on an evidence-base and preparedness collaborations between FBOs and Johns Hopkins that have been established in prior studies.Reference McCabe, Lating and Everly^18–Reference McCabe, Mosley, Gwon, Kaminsky, Everly and Mitchell²⁰ These projects sought to develop, characterize, and assess the potential effectiveness of a systems-based partnership model to enhance the capacity to prepare for, respond to, and recover from the psychological sequelae of public health emergencies in urban and suburban communities. Most recently, the model has incorporated the leadership of LHDs in four rural counties of Maryland as collaborators. The full approach involves the sequential provision of two preparedness interventions to members of participating faith communities, as follows:

1. 1 Motivational Preparedness Training (in Psychological First Aid)—The first intervention, designated Motivational Preparedness Training (MPT), was a specialized form of training in psychological first aid (PFA) that was co-hosted by the LHDs and AHC (Johns Hopkins) partners, with faculty from the latter conducting the training. Ongoing efforts to develop and refine the Johns Hopkins MPT/PFA model are consistent with, and complementary to, the development of disaster mental health core competencies for the public health preparedness and response workforce being conducted under the aegis of a Cooperative Agreement between the Association of Schools of Public Health and the [US] Centers for Disease Control and Prevention (CDC).²¹

   The MPT/PFA intervention is hypothesized to serve multiple purposes. First, it is intended to impart relevant knowledge, skills, and attitudes to lay persons so that, collectively, they constitute a prospective new class of paraprofessional responders for inclusion in the Maryland Medical Professional Volunteer Corps administered by the Office of Preparedness and Response of the Maryland Department of Health and Mental Hygiene. Second, while labeled somewhat differently, the content of the John Hopkins paraprofessional PFA training model is concordant with the five principles of immediate and mid-term mass-trauma intervention that have been empirically-derived by expert consensus: (1) self- and community efficacy; (2) a sense of safety; (3) calming; (4) connectedness; (5) and hope.Reference Hobfall, Watson and Bell²² Third, the MPT/PFA training event offers a forum for participating leaders of LHDs and FBOs to become acquainted with each other and to begin developing a partnership mind set. Fourth, by educating faith members in core disaster concepts and training them in PFA principles and procedures, MPT/PFA appears to motivate trainees to participate in subsequent, joint disaster preparedness planning activities with their LHD representatives. To avoid confusion, the MPT/PFA intervention shall be referenced as PFA in the remainder of the report.

2. 2 Guided Preparedness Planning—Capitalizing on participants’ raised awareness of the need for emergency preparedness by the PFA training experience, the second intervention, designated Guided Preparedness Planning, provides members of the community with the training and technical assistance developing community mental health disaster plans, further advancing the capacity and capabilities of participating faith communities’ to respond during disasters. Only the results of the PFA intervention are reported here.

Aims of the Project

The project addressed questions in three domains of inquiry, feasibility, effectiveness, and impact of the model:

1. 1 Feasibility of the Tri-Partite Collaborative Model—The first aim was to determine if the basic, three-entity collaboration idea was workable, i.e., would already-burdened and often under-resourced people from three disparate cultures in the public health system prove ready, willing, and able to come together and work on a common-cause project?

2. 2 Effectiveness of the PFA Intervention—Assuming an affirmative response to the above question, the second aim was to assess the effectiveness of PFA in enhancing: (a) psychological first aid knowledge and skills in lay members of the community; and (b) willingness of participants to become formal disaster responders (assuming the state of Maryland would accept trainees into the Medical Professional Volunteer Corps); and

3. 3 Translational Impact of Model/Intervention—The third aim was to determine if the PFA intervention, delivered within the framework of the academic/government/faith partnership model, would result in a change in prevailing (pre-study) government policy/practice of accepting into the Volunteer Corps.

Recruitment of Participants

Organizational Participants (Project Partners):

1. 1 Academic Health Center—The academic partners were faculty members and administrators of multiple offices, departments, and centers within the Johns Hopkins Bloomberg School of Public Health, the Johns Hopkins School of Medicine, and the Johns Hopkins Hospital and Health System, who had been collaborating in the previously-described pilot projects.

2. 2 Local Health Department—Government partners were Emergency Planners or Preparedness Coordinators of four local health departments in the mid- and eastern shore region of Maryland, one of whom (CP) served as the liaison between AHC and LHD representatives. The latter were introduced to the project opportunity by CP via a conference call.

3. 3 Faith-Based Organizations—Clergy and lay leaders of Christian parishes in the same local health jurisdictions (“counties”) were recruited by each LHD-partner using various outreach methods such as telephone calls, e-mail, presentations at FBO meetings, and networking that built upon pre-existing LHD/FBO relationships. A Partnership Steering Committee was the primary vehicle through which AHC/LHD representatives participated in project planning, implementation, and evaluation activities; and

4. 4 Individual Participants (PFA Trainees)—Prospective trainees were recruited by FBOs and LHDs using a range of approaches including newspaper ads, announcements at Sunday worship services, brochure mailings, and person-to-person networking. Eligible participants were adult residents of the four identified counties.

PFA Intervention Sessions

Six PFA sessions were provided to different individual participants between 24 June 2008 and 14 July 2008. Training sessions were conducted using a professional continuing education one-day format. The PFA trainers were two licensed, doctoral-level psychologists who possessed extensive experience as disaster responders and as disaster mental health trainers. Training sessions involved a combination of didactic and experiential teaching methods. The former depended heavily on a Microsoft PowerPoint-based 2003, [Microsoft, Inc., Redmond, Washington] lecture, and the latter entailed group exercises, role playing, and discussions to encourage active involvement and to promote the development of new skills and abilities. The PFA training curriculum was derived from an integration of the PFA model originally developed for health professionals at the Johns Hopkins Center for Public Health PreparednessReference Everly²³ and the PFA model for paraprofessional trainees created by the Johns Hopkins Department of Psychiatry through previously-mentioned projects.Reference McCabe, Lating and Everly^18–Reference McCabe, Mosley, Gwon, Kaminsky, Everly and Mitchell²⁰ These base curricula were customized to focus on rural populations, including the provision of special-needs information on children, the elderly, and persons with physical or psychiatric disabilities. Session content was organized into four modules, listed here in the order presented): (1) Introduction to Disasters and Behavioral Health Surge; (2) The Johns Hopkins Reflective Listening, Assessment, Prioritization, Intervention, and Disposition (RAPID) Model of Psychological First Aid; (3) Special Needs of Vulnerable Populations; and (4) Self Care and Practical Resources for the Caregiver.

Data Collection and Measures

Feasibility of Model—Model feasibility was operationalized using a recently-developed conceptual framework of “Ready, Willing, and Able” (RWA).Reference McCabe, Barnett, Taylor and Links²⁴ The specific questions and operational criteria for the three constructs in the order they evolved and were assessed were:

1. 1 Willingness of LHDs to Respond to the AHC-Initiated Project Concept:

   Question—Will LHD leaders agree in concept and be motivated to participate in the project?

   Hypothesis/Criteria—The majority (>50%) of the LHDs approached will provide verbal agreement to participate in the study and subsequently sign a “Letter of Collaborative Intent”.

2. 2 Readiness of LHDs and FBOs to Respond to the AHC-Initiated Project Concept and Obligations:

   Questions—If prospective partners indicate that they are inclined and favorably disposed to collaborate in the proposed project as hypothesized above, will they, individually and collectively, deploy the necessary human effort and material resources to support and sustain regular, timely participation in project planning and implementation activities? Hypothesis/Criteria—Participants will attend, in person or by teleconferencing, a minimum of 80% of all monthly Partnership Steering Committee meetings hosted by the AHC and LHD partners on an alternating monthly schedule; and

3. 3 Ability to Respond to Project Concept:

   Question—If LHD and FBO leadership agree in concept and deploy the resources required to support the pursuit of project objectives as described above, will they be able to perform the necessary behaviors to ensure the success of the project? Hypothesis/Criteria—Local health departments will promote the program to FBOs effectively, and FBOs will promote the program to community members effectively, as measured by a minimum of 20 persons attending each PFA workshop in all participating counties.

Effectiveness of the PFA Intervention: Psychological First Aid Knowledge, Skills, and Attitudes

At the end of each training session, participants completed an evaluation process where they were asked to report the extent to which they agreed with statements related to module-specific learning objectives. The evaluation included items under three domains: (1) acquisition of disaster mental health concepts (knowledge); (2) reported confidence (perceived self-efficacy) in executing PFA strategies and techniques (abilities, skills), and (3) willingness to be a disaster volunteer first-responder (attitudes, motivation). The items were worded in a manner that sought to measure (retrospectively) perceptions of pre/post training changes. For example: “Compared to what I knew before today’s training, I am much more confident in my ability to differentiate severe from normal reactions to stress”. Participants responded using a 5-point Likert-scale (‘Strongly Disagree’ to ‘Strongly Agree’). Core study questions, hypotheses, and criteria for hypothesis confirmation were as follows:

1. 1 Knowledge and Skills:

   Question—Can knowledge and skills supportive of being an effective disaster responder/PFA provider be imparted effectively to lay members of the community?

   Hypothesis/Criterion—The majority of participants will endorse component-items measuring PFA-related knowledge and skills with “Agree” or “Strongly Agree” responses.

2. 2 Attitudes and Beliefs:

   Question—Will participants’ have, and functionally demonstrate, a favorable attitude toward serving in the capacity of responder/PFA provider is real life emergency scenarios?

   Hypothesis/Criteria—If given an opportunity by MD-DHMH, a minimum of one-quarter of the trainees will complete and submit applications to serve as members of the MPVC

Translational Impact of Model/Intervention—A key aim of the project was to assess the project’s translational impact

• Question—Is the model/intervention capable of effecting change in government policy or practice? No hypothesis was offered for this outcome construct. Rather, the investigators hoped the goodwill created by the collaboration, along with observing the quality of the training, would result in a reconsideration of the policy to exclude paraprofessional responders.

• Criterion—State government acceptance of project-prepared, PFA-trained participants [for the first time] as bona fide members of the Medical Professional Volunteer Corps.

Data Processing

Simple frequency counts (e.g., number of meetings attended by organizational partners, number of participants completing volunteer corps applications) and descriptive statistics were used as metrics to characterize outcomes on key dependent/criterion variables. The number of Likert-item endorsements of “Agree or Strongly Agree” were aggregated from each participant’s PFA evaluation forms and summarized as percentages of total possible endorsements of all participants. Only fully-completed and legible forms were used in the data analysis (explaining the discrepancy between the 238 registered participants and the 178 respondents used in the statistical processing).

Model Feasibility

Willingness of LHD Leaders to Respond to Project Concept—Five LHDs were formally approached to participate in the partnership. Four (80%) LHD leaders provided the AHC investigators with affirmative verbal responses about project participation during a conference call, and all four submitted signed Letters of Collaborative Intent.

Readiness of LHD to Respond to Project Responsibilities—Once the project began, LHD representatives or designees attended 100% of the meetings of the Partnership Steering Committee.

Ability of LHD and FBOs to Respond to their Recruitment Responsibilities—The LHD and FBO partners successfully carried out project planning and implementation activities, including the key task of ensuring an adequate volume of community residents to participate in PFA training workshops.

The LHD partners were able to recruit 120 FBOs to collaborate in the project (Table 1). In turn, FBO clergy and lay leaders were responsible for enlisting 238 community residents as formal participant-trainees in the six PFA workshops. The average number who attended a training was 40 participants.

Table 1 Training workshops for psychological first aid (PFA): Summary of participating individuals and faith organizations, by county

Participant demographics are listed in Table 2, indicating that the typical enrollee was a Caucasian female in her mid-50s. However, one of every four trainees was of African-American race/ethnicity. Fourteen trainees were mono-lingual Hispanic participants. Real-time translation of the training into Spanish using electronic transmission/reception equipment was provided to those participants.

Table 2 Demographic characteristics of participants (n = 239)

Intervention Effectiveness

Knowledge: Participant Understanding of Disaster Mental Health Concepts—Essentially all participants indicated that they “Agreed” or “Strongly Agreed” that the training objectives relating to knowledge-acquisition of the principles and practices of disaster mental health, PFA, at-risk populations, and self care were met (Table 3).

Table 3 Understanding concepts in disaster mental health (PTSD = post-traumatic stress disorder)

Data reflect the percentage of participants who indicated that they “Agreed” or “Strongly Agreed” that the training objectives were met in the content areas identified.

Skills (Beliefs about): Participant Self-Efficacy as a PFA Provider—A compelling question is whether training sessions of such relative brevity can enhance a participant’s perceived self-efficacy in providing the component-activities of PFA effectively in “real world” disaster settings. The data summarized in Table 4 indicate consistently high (96–98%) levels of participant agreement across all workshops that their perceived self-efficacy for applying the techniques of PFA was improved. The lowest relative level of expressed technical self-efficacy was associated with recognizing and referring to appropriate resources, disaster survivors whose pre-morbid condition and/or magnitude of traumatic reaction occasioned the risk for suicide.

Table 4 Understanding techniques of psychological first aid

Data reflect the percentage of participants who indicated that they “Agreed” or “Strongly Agreed” that the training objectives were met in the content areas identified.

Attitudes: Willingness to Respond as a PFA Provider—Immediately following the workshops, 56 (31.5%) of the 178 trainees submitted same-day applications to be members of a paraprofessional category of volunteers in the Medical Professional Volunteer Corps, to be called up by the state of Maryland to provide PFA interventions and general pastoral care relevant to disaster responses or recovery (Table 5).

Table 5 Trainee willingness to respond

*Number of applications submitted immediately following training sessions; data on number of deferredw presentations not available.

Impact

State Government Policy Change—As a result of the project, the Maryland Department of Health and Mental Hygiene, which historically had accepted into the Medical Professional Volunteer Corps only board-licensed healthcare professionals, approved the 56 project-trained applicants as members of a new paraprofessional class of disaster mental health responders.

Model Feasibility

The fact that four of the five LHDs approached about study participation agreed to, and were judged to have met, the responsibilities of the partnership, would seem to signal the positive potential of similar systems-based collaborations. Even the one LHD leader who declined study participation because of competing obligations, as a gesture of support for the project, made her facilities available for meetings of the Partnership Steering Committee. Although the collective effort of the local government partners was sufficient to accomplish the aims of the project, it is noted that there was considerable variability in LHD success in recruiting FBO participation. The differentiating factor seemed to be the extent to which prior informal relationships with the faith community already had been established. A systematic study of the barriers to and facilitators of LHD/FBO collaboration would seem a key focus for future research if this partnership model were expanded successfully.

Intervention Effectiveness

Rather than a true experimental design, a pre-experimental design was used in the study. The use of a concurrent control group to which PFA trainees randomly were assigned would have optimized internal validity and permitted greater confidence in inferences about intervention effectiveness. The investigators are encouraged by the findings, however, not only because of their direction, breadth, and magnitude, but also because they were generated within the framework of a (post-test only) design that acknowledged experts in these matters have described as appropriate and valuable when certain criteria are met, as they were in the project, namely, when “…multiple outcome variables are measured at posttest; contextual knowledge is rich, even if impressionistic; and, intelligent presumptions can be made about what this group would have been like ....Reference Cook and Campbell²⁸ According to the same source, additional scientific value is conferred to such studies when the design is made “…more complex by adding respondents’ posttest recollections of how they were at the pretest….”.Reference Cook and Campbell²⁸

Notwithstanding the above points, history and maturation often are rival causal explanations attending some post-test only designs.Reference Campbell and Stanley²⁹History, or the possibility that external change-producing events other than the intervention could have occurred during the conduct of the training, is problematic when a long period of time has elapsed between the pre- and post-assessments. Given the same-day assessment points in the present study, history does not seem a highly plausible explanation of observed results. Maturation, or the possibility that systematic internal (biological, psychological, etc) changes in trainees, (e.g., growing older, wiser, etc.) with the passage of time, independent of external events, can confound uncontrolled studies, but given the seven-hour length of the intervention, it seems unlikely that maturational variables influenced outcome data.

Ideally, an evaluation of a PFA training intervention would involve an in vivo assessment of competencies with disaster survivors or with other individuals experiencing acute crises, but the obstacles to realizing that aspiration are substanial. As a proxy for real-world competency assessment, the perceived self-efficacy construct used in the study has a long and laudable record as a strong mediating predictive variable for actual performance, particularly when affirmation-of-capability is combined with an assessment of strength-of-belief, as opposed to the less predictive potency of the more idiomatic term, confidence, when allowed to remain semantically non-specific relative to the extent or level of anticipated attainment.Reference Bandura³⁰

Translational Impact

Maryland state’s policy change to accept lay members into its professional volunteer corps means that Workers’ Compensation and general liability coverage will be provided to the new Corps members when they are called upon to respond to a gubernatorially declared disaster. This policy change acknowledges the significant resource the faith/lay community can be in time of disaster, with its capabilities presumably enhanced by the training received through this project. Registering the volunteers provides the state with the ability to deploy the participants in an expeditious manner and better ensures an organized callout reflective of support needs, rather than the alternative of sometimes-problematic spontaneous responses.

Overall Multi-Level Significance

By bringing together key actors in the public health emergency preparedness system and jointly executing a program that empowers citizens to meet community emergency behavioral health needs without the widespread availability of professional disaster expertise, the investigators believe they have begun to establish a base of evidence for an approach that could have considerable public health significance. Considering that the results reported here are for PFA only versus results for PFA and the other one-day training and subsequent technical assistance workshops in community disaster preparedness planning (see “Guided Preparedness Planning”), the significance is likely to be enhanced with the full, two-intervention program.

Presumably, if taken to scale, the approach embodies an innovative model of capacity building at multiple levels of societal impact, including neighborhoods, communities, townships, counties, and the state. Specifically, as a function of a project administered ex novo over a summer season: (1) neighborhoods and communities in each of the participating counties now have access to individuals trained in disaster mental health competencies who can directly provide and perpetuate training in emergency mental health services to the community; (2) clergy and lay leaders of faith organizations report benefiting from the opportunity to acquire specialized knowledge and skills for application not only in disasters, but also for use in their regular pastoral crisis intervention work with victims of everyday “mini-disasters”, (and their relationships with county health departments are strengthened, presumably resulting in increased trust); (3) rural hospitals and other clinical facilities potentially have, in the form of the increased congregational crisis-intervention capacity and more knowledgeable referral capabilities, a diversion mechanism for those persons—psychologically affected but physically uninjured—who otherwise, likely would consume resources needed for genuine medical emergencies; and (4) county and state governments now have their have their continuum of disaster workforce assets enhanced with an important new category of grassroots responders.