Lessons Learned from Community Health Providers in Posthurricane Receiving Communities

Abstract

There is an accumulating body of research on behavioral health, temporary displacement, and social connectedness after disasters; however, less is known about perceptions of providers regarding services and the effectiveness of the services that are offered. The purpose of this study is to provide an in-depth analysis of reflections from providers who worked immediately after Hurricane Katrina in the Greater Baton Rouge area, which was one of the largest receiving communities. This study provides a response legacy framework with findings that emphasize collaboration, improved understanding of cultural differences, disaster planning and readiness, improved understanding of trauma informed care, self-care, and policy changes. The study also provides ways to support disaster response professionals in their efforts toward increasing social justice and fostering of community resilience. Our study found that providers were satisfied with their postdisaster work and feel that evidence informed changes through lessons learned will prove beneficial to current and future disaster response.

Introduction

The 2005 hurricane season caused unprecedented community devastation to those living along the Gulf Coast. Hurricane Katrina made landfall on Monday, August 29, 2005, on the southeast Louisiana coastline and caused severe destruction, much of it due to the storm surge, flooding, and resulting tornadoes. There were >1800 known fatalities and it is likely to be one of the costliest hurricanes in U.S. history at an estimated $108 billion of total damages.¹ Less than 1 month later, Hurricane Rita made landfall off the southwestern Gulf Coast. Rita caused additional destruction throughout Louisiana, compounding the damage incurred from Hurricane Katrina and hindering existing hurricane recovery efforts.¹

Receiving communities

Although there were many communities that rose to the assistance of displaced survivors, due to its proximity, Baton Rouge and surrounding areas housed, sheltered, and cared for a larger portion of survivors. In the few days after Hurricane Katrina, the East Baton Rouge Parish population increased by 39%.² The mass influx of population, in a relatively short amount of time, was a significant stress on infrastructure, including increase in traffic, stress on public services and utilities such as water, sewerage and power, and school resources.³ In addition to housing individuals, receiving communities were also tasked with physical and behavioral health needs for many individuals. Essential health and emergency response systems were overwhelmed with the numbers in need of mental health services, including those for serious mental illness, post-traumatic stress disorder, and suicidality.^4,5,6 Importantly, the community health providers were left dealing with a multitude of unmet needs and disparities of care after disasters.⁷

Although the past decade has presented many challenges to residents of the Gulf Coast, there have also been a number of lessons learned that prove beneficial to current and future disaster response. The expertise of providers residing within these receiving communities is exceptionally valuable. The literature is limited regarding the impact on providers after such massive disastrous events; what participants called their “legacy of disaster response” informs more effective and cost-effective techniques for future disaster response. Given the lack of existing research, qualitative methods were used to encourage participatory action and increase the richness of information derived.^8,9 The purpose of this study was to provide an in-depth analysis of reflections from providers in the area that worked immediately after Hurricane Katrina in the Greater Baton Rouge area, one of the largest receiving communities. This study is designed to improve understanding of what providers feel should be addressed in future disasters and serves as an example of how the experiences of receiving communities can inform policy changes and identify vulnerable populations.

Methodology

A case study was conducted of providers' recollection of their work after Hurricane Katrina, coinciding with the 10-year anniversary of the disaster. Two focus groups were held with 22 providers and lasted ∼1 hour. The majority of participants were nurses and social workers who worked in shelters and mental health service agencies. Participants were selected based on their participation in state recovery efforts in the months after Hurricane Katrina and their continued work in behavioral health. Participation was voluntary and written consent was obtained. Focus groups were held in Baton Rouge, Louisiana, using digital tape recorders and hand-written notes; no names were recorded during the discussions. All procedures were submitted and approved by the Louisiana State University Health Sciences Center IRB. Before asking the questions, each participant was asked to briefly state his or her work or community obligations after the 2005 hurricane season. Responses to these questions were not recorded, as the roles would have identified the participants. Three guiding questions were used to structure the group and each participant was asked to comment on how his or her work related duties/career/professions and how communities have changed or grown despite disasters. Participants were also asked to comment on advice or helpful information they could provide other agencies and communities that incur repeated disasters. Consistent with qualitative data reduction techniques, words were grouped in subject matter themes and presented under each guiding question. Two researchers reviewed group themes separately to make sure they concur.

Results

Participants were asked to provide a brief statement of work or community obligations after past disasters or crises. Most of the discussion centered on the work after Hurricane Katrina, which was noted as a “surreal experience,” and centered on sheltering evacuees. All participants worked or volunteered in shelters or schools within the Baton Rouge area after Hurricane Katrina. They provided case management, supportive services, healthcare, and/or therapeutic treatment to survivors sheltered or in temporary living sites. Many of the participants noted working, “24 hours, 7 days a week,” for up to 4 months after the storm. Although this work was noted as challenging, participants were proud of their disaster recovery work and worried that the “legacy of response from Hurricane Katrina would be lost.” An important concern was that providers with field experience in sheltering and disaster response would be retiring. They felt the need to preserve their lessons learned, which can be helpful for future local and national responses. As a beginning step to this legacy, themes on lessons learned were developed, including collaboration, training, readiness and disaster planning, policy changes, and self-care; Table 1 presents a summary of these findings.

Table 1.

Summary of Themes and Lessons Learned

Theme	Lessons learned and future response
Collaboration	Monthly meetings with agencies and providers during recovery and before disaster
	Focus on localized response and existing collaborations
	Coalition development for increasing networks and communication toward future preparedness
Readiness	Systematization of technological advances in disaster recovery
	Develop strong leadership and flexibility in disaster plans
	Appropriate use of media, including social media
Training	Training for all professionals on trauma and cultural considerations in disaster response
	Trauma informed practices identity the differences and similarities between traumatic response and cultural considerations
	Supervision and experiential learning, especially for nonlocal volunteers
Policy changes	Evidence informed response
	Mental health advocacy and definition of special needs in shelters
	Focus on the mental health of displaced children and school resources
	Changing healthcare system with move to privatization—potential loss of response workers
	Addressing large population influxes and needs of children in schools
Self-care	Helping “helpers” cope
	Importance of daily debriefings and scheduling provider rest time
	Special considerations for survivors who are also mental health providers—give options of nondirect care

Collaboration

Collaboration had the most consistency in responses whereby individuals noted the importance of a system developed where providers can come together and focus on needs at hand. One participant stated, “we are much better at teamwork both within our own organization and working with other organizations.” As a direct product, monthly meetings with local agencies and providers are held to continue networks to call upon in future disasters and develop, “a more collaborative and better response.” The private sector volunteers in Baton Rouge “were helpful—they volunteered and understood.” When feasible, focusing on localized response was also suggested, as they “lived and survived for local people.” Increasing representation of localized professionals in collaborative response was noted as a positive movement toward future preparedness.

Readiness and disaster planning

Readiness centered on specific improvements for future disaster planning. The most noted improvement, advances in technology such as cell phones and texting, will help toward collaboration and connectedness. Other technological advances noted were electronically available evacuation plans, medication databases, information stored on cloud systems, survivor networking capacity (i.e., Facebook and electronic mail), smart phones, etc. Participants agreed that these represented “big advances, but [they] need to be systematized before the next disaster.” Importantly it was also noted that technological advances and media influence can be a negative aspect, and example provided was the media creating paranoia in Baton Rouge residents. These include media-driven rumors of machine guns on streets and in shelters; drug dealing, New Orleans, “dumping criminals.”

Participants further stated that communities need to recognize and respect the level of “threat and vulnerability” toward disasters and develop appropriate and flexible disaster plans. Hurricane Katrina demonstrated a real need for client preparedness and one participant noted that their work “with mentally ill clients now includes helping persons with mental illness develop actionable emergency response plans.” With regard to planning, one participant stated, “don't assume it will be all right or that you are fully prepared,” and another instructed to “have a strong Plan A and a stronger Plan B!” Strong leadership was also noted as helpful, as they are “good at piecing things together,” when things do not go according to plan. In addition, professional advances within their agencies include increased services, such as substance abuse, presence of social workers in schools, and readiness plans for receiving and evacuating communities.

Training

The theme training centered on how their experiences led to improved understanding on trauma, survivor and system-level needs, and cultural considerations after disaster. As an example one participant stated, “my attitude towards service recipients and my role in providing services is less myopic.” In addition, one participant stated, “we now have a better concept of what recovery is all about for ourselves and others (those we treat).” Other participants noted that they have a better understanding of post-traumatic stress disorder, and trauma informed care. Another participant stated, “it is one thing to get training but another to actually live through it.” Participants shared stories of some outside volunteers being “scared and shocked; some even had to be sent home because they would sit and cry.” As a response participants suggested, “better training for all professionals and increased supervision.”

Improved cultural understanding was also noted, where “there was real culture shock for New Orleans residents living in rural areas around Baton Rouge with no public transportation, or corner stores to go to.” Participants also noted that displaced families “were traumatized, uncertain about future, with no transportation and limited resources.” Displaced parents were also scared to let their kids out of sight; this was perceived as a cultural problem, but was more likely due to a trauma response. Survivors “clinched to all belongings, they had nothing; so they were scared to let go of even the smallest personal belonging and had a difficult time letting go of something so important … their kids.” One provider who relocated from New Orleans to the Baton Rouge area noted the kindness of the Baton Rouge people and that bringing one's “food, music, and faith from New Orleans” is what kept him practicing and content with his new culture.

Policy changes

Policy changes were also an important theme, which included advocating for mental health and inclusion of psychiatric medication allowances in the Stafford Act, which sets the standard for assistance during and after a major disaster. A drive for evidence informed response was noted where screenings needed to be implemented more, as this “helps to understand where people are and what needs are unmet.” It was also noted that the Baton Rouge shelters were serving some of the neediest evacuees because they were “those that could not travel or walk; the more able bodies went North because they could travel.” Also attention at the policy level needs to be given toward the definition of special needs, which currently suggests all mental illness and pregnant women at certain gestation. These definitions results in eviction from general shelters and further separation of families. There needs to be more focus on the mental health of displaced children and increased resources at schools in receiving communities. Specifically there were “unknown needs of students—had to be reevaluated with no idea of past history. Also academic concerns were evident with not knowing where “kids were academically or what their special needs were.”

In addition, current policy changes in healthcare were noted as a concern, which they were “scared for future response due to privatization of the health care system … very helpful for response were the state hospitals and providers that were housed in these venues and were willing and able to help.” Another participant echoed that many providers, essential in recovery after Hurricane Katrina, have since left the public sector. Yet another participant expressed concern that the provider “safety net is disintegrating—due to privatization.” Currently there are out-of-state contracts for providers, but it was noted that local response was imperative and it is largely unknown whether the contracted providers will fill this void. Finally, participants noted that Hurricane Katrina “tripled the amount of people in Baton Rouge,” and schools trying to accommodate the influx of displaced students “doubled some classroom sizes.” This was noted as being good for diversification among Baton Rouge residents, but that local infrastructure was not equipped to handle such a large influx, policy specific to receiving communities is needed to address sudden relocation and population expansion.

Self-care

Teaching self-care and building coping skills for providers and other helping professionals was an important theme, and the importance of daily debriefings; scheduling provider rest time; addressing difficult situations (i.e., death in shelters and effect on morale); and community treats such as securing donations for providers to have ice cream, massage, and other services. One participant stated, “we worked all day with providers and went back to crowded homes; we had 12 people in our home, we were glad to do it, but people were sleeping on the floor and there was no place to escape.” One participant noted that it was not until 4 months after the storm that they felt they were able to “stop and had time for self-care.” Another participant concluded with the importance of balance in post-disaster provider work and that “stress is pervasive and dangerous to your long-term health and your ability to perform well during the crisis.” Participants also noted that it “is complicated to have providers that were also traumatized,” and that some “co-workers were depressed professionals that needed to work, but also some were not ready to work professionally.” It was important to give options, as there is “plenty to do in non-direct care until they are ready.”

Discussion

The 2005 hurricane season caused a great deal of loss for communities and recovery efforts continue even a decade after the storm. Results uncovered in our findings centered on an increase in awareness and understanding that their expertise would increase collaboration, inform training and policy changes, and overall strengthen future disaster readiness. Most participants felt that after Hurricanes Katrina and Rita, “preparation and response were so much better.”

As many of our participants were social workers, they presented a more global approach to service provision that focuses on core social work values and concepts, including looking at a person in their environment and how this information should be used for future training in disaster-prone regions. Training regarding trauma and cultural considerations after disasters allows for a broader sharing of cultural and professional experiences that can result in improved recovery services. Previous research also supports these findings, as training before disasters increases the effectiveness of responders in meeting diverse needs.¹⁰ This participation exemplifies social justice, and allows for a broader sharing of cultural and professional difference that can result in improved recovery services; input from local providers helps identify and lessen gaps in recovery services.

Policy changes were centered on how and where recovery efforts are falling short and what steps can be taken to improve system level challenges. For example, survivors with existing mental and/or physical needs, such as individuals with sensory impairments and those who require mobility assistance, may not have all their needs considered with evacuation planning, resulting in a lack of services after disasters.^11,12 Results support the findings of another study that uncovered that <50% of sample shelters had basic guidelines or an expert in place for handling disability accommodations.¹³

Existing literature has noted the importance of implementing research findings and developing policy and practice protocols informed by frontline practitioners.¹⁴ “Partnerships between university and community program personnel can generate useful knowledge for multiple stakeholders: program participants, program developers and staff, researchers, policymakers, families, schools, and youth.¹⁵” Results of this study were directly applied to disaster response and used to develop Hope and Cope groups after the Great Flood of 2016 that subsequently displaced >35,000 state employees in the Baton Rouge area. Hope and Cope groups were evidence informed, and provided support to a diverse group of state employees who were directly impacted by the historic flooding, many of whom lost their homes and were currently displaced. Sustainability of these applied research findings has also been considered and funding for a Terrorism and Disaster Coalition for Child and Family Resilience secured. The coalition is tasked with developing regional networks for disaster response where additional expertise and experience can be recorded. A number of the professionals in this study have been asked to participate. Coalition development as a house for educational and networking activities has been noted as an important protocol for disaster response initiative and ensuring relevant and evidence and experiential informed knowledge transfers.¹⁶

Conclusions

Although these are limited to regional experiences, lessons learned are worthy of discussion to improve preparedness or recovery models for other parts of the country that are prone to disasters. Even 10 years after Katrina, it is important to reflect and continue to use those lessons to better our policies, our awareness, and how we approach our interdisciplinary work—translating lessons learned to policy approaches with critical planning, capacity building, and community resilience.^17,18,19 Furthermore, these lessons learned can be applied to communities that have not had as large a scale of a disaster for preparedness disaster planning and readiness.

This study provides a response legacy framework with emphasis on: collaboration, training, readiness and disaster planning, policy changes, and self-care. The study also provides a method for disaster response professionals to take action, as these components are agents of community resilience that tends to evolve from a set of networked-adaptive capacities.¹⁹ In general, our study and other studies of providers after Hurricane Katrina found that providers were satisfied with their postdisaster work²⁰ and feel that evidence informed changes through lessons learned will prove beneficial to current and future disaster response.

Footnotes

Author Disclosure Statement

The authors have no conflicts of interest or financial ties to disclose.