Trends and social inequalities in self-reported health and activity limitations in France between 2017 and 2021: results from four nationwide representative surveys

BACKGROUND

Like other countries in Europe and around the world, France was hit by the COVID-19 pandemic in 2020, although it had also experienced several social crises since 2017. This study assessed the evolution of self-reported health and activity limitations and explored the dynamics of their socio-territorial inequalities among the French population aged 18-75 years between 2017 and 2021.

METHODS

Self-reported health (SRH) and global activity limitation indicator (GALI) were assessed in the same way in the four last editions of the French Health Barometer surveys conducted in the general population in 2017, 2019, 2020, and 2021, with between 9,200 and 24,500 subjects interviewed depending on the year. The prevalence of good or very good SRH and GALI (any limitation) and their evolution between 2017 and 2021 were studied according to sex, age, main socioeconomic positions (SEP), and regions. Poisson regression models were used to estimate adjusted prevalence ratios and potential modification effects of sociodemographic and geographic characteristics.

RESULTS

Between 2017 and 2021, SRH and GALI deteriorated in adults in France in a continuous way. Very good or good SRH decreased from 75.2% (CI95% [74.5-75.9]) of subjects in 2017 to 68.5% (CI95% [67.7-69.3]) in 2021. In parallel, GALI increased from 21.5% (CI95% [21.0-22.2) in 2017 to 25.2% (CI95% [24.5-26.0]) in 2021.The deterioration of indicators affected both sexes, all age classes (except 65-75 years), especially younger age classes (18-24 and 25-34 years), all geographical regions, and all SEP variables, with groups with a higher SEP deteriorating more than others. Negative variations exceeding 20% (8-10 percentage points on the absolute scale of indicators) were observed in several population groups from 2019 onwards.

CONCLUSION

The previously observed deterioration of the SRH and GALI continued in France between 2017 and 2021, with narrowing socio-territorial gradients of inequalities. The impact of successive social and health crises on the poor evolution of self-reported health and activity limitations warrants further investigation over time and across locations using complementary and possibly more detailed indicators.

"Will you need this health at all? Will you be alive?": using the bioecological model of mass trauma to understand HIV care experiences during the war in Ukraine

INTRODUCTION

Russia's invasion of Ukraine in February 2022 has severely impacted the healthcare system, including the provision of HIV care. The ongoing war is a human-caused mass trauma, a severe ecological and psychosocial disruption that greatly exceeds the coping capacity of the community. The bioecological model of mass trauma builds on Bronfenbrenner's concept of interaction between nested systems to argue that social context determines the impact of life events on the individual and how an individual responds. This paper uses the bioecological model of mass trauma to explore the impact of Russia's aggression against Ukraine and the ongoing war on HIV-positive people who use drugs in Ukraine, a particularly vulnerable population that may be negatively affected by disruptions to social networks, healthcare infrastructure and economic conditions caused by mass trauma.

METHODS

Data were collected between September and November 2022. A convenience sample of 18 HIV-positive people who use drugs were recruited from community organizations that work with people living with HIV, drug treatment programmes, and HIV clinics through direct recruitment and participant referral. A total of nine men and nine women were recruited; the age ranged from 33 to 62 years old (mean = 46.44). Participants completed a single interview that explored how the war had affected their daily lives and access to HIV care and other medical services; their relationships with healthcare providers and social workers; and medication access, supply and adherence. Data were analysed using the Framework Method for thematic analysis.

RESULTS

The war had a profound impact on the social, emotional and financial support networks of participants. Changes in social networks, coupled with limited job opportunities and rising prices, intensified financial difficulties for participants. Relocating to different regions of Ukraine, staying at somebody else's home, and losing connections with social workers impacted medication adherence and created lengthy treatment gaps. Participants also experienced a decreased supply of antiretroviral therapy, concerns about accessing medication for opioid use disorder, and overwhelming fears associated with the war, which overshadowed their HIV-related health concerns and negatively impacted medication adherence.

CONCLUSIONS

Our analysis reveals the complex impact of war on social networks and healthcare access. Maintaining support networks and competent healthcare providers will be essential amid the ongoing war.

Attempted suicide rates before and during the COVID-19 pandemic: interrupted time series analysis of a nationally representative sample

BACKGROUND

To characterize the association between the protracted biopsychosocial coronavirus disease 2019 (COVID-19) pandemic exposures and incident suicide attempt rates.

METHODS

Data were from a nationally representative cohort based on electronic health records from January 2013 to February 2021 (N = 852 233), with an interrupted time series study design. For the primary analysis, the effect of COVID-19 pandemic on incident suicide attempts warranting in-patient hospital treatment was quantified by fitting a Poisson regression and modeling the relative risk (RR) and the corresponding 95% confidence intervals (CIs). Scenarios were forecast to predict attempted suicide rates at 10 months after social mitigation strategies. Fourteen sensitivity analyses were performed to test the robustness of the results.

RESULTS

Despite the increasing trend in the unexposed interval, the interval exposed to the COVID-19 pandemic was statistically significant (p < 0.001) associated with a reduced RR of incident attempted suicide (RR = 0.63, 95% CI 0.52-0.78). Consistent with the primary analysis, sensitivity analysis of sociodemographic groups and methodological factors were statistically significant (p < 0.05). No effect modification was identified for COVID-19 lockdown intervals or COVID-19 illness status. All three forecast scenarios at 10 months projected a suicide attempt rate increase from 12.49 (7.42-21.01) to 21.38 (12.71-35.99).

CONCLUSIONS

The interval exposed to the protracted mass social trauma of the COVID-19 pandemic was associated with a lower suicide attempt rate compared to the unexposed interval. However, this trend is likely to reverse 10 months after lifting social mitigation policies, underscoring the need for enhanced implementation of public health policy for suicide prevention.

Resource allocation, individual social network, community trust and recovery from depression among rural survivors in the Wenchuan Earthquake

Using the three-wave longitudinal survey data of the Wenchuan disaster area, this study employed Hierarchical Linear Modeling (HLM) to explore the recovery trajectory from depression of rural survivors after the Wenchuan earthquake. Across the three waves, 221 respondents (118 male, 103 female) provided complete data. We found that, at the individual level, the survivors' individual social networks had a significant effect on the change in depression scores in the four years following the earthquake, implying that a strong social network could help survivors recover from depression. At the community level, community trust had a significant effect both on the initial depression score at the time of the earthquake and on the survivors' change in depression scores after the earthquake. Survivors with high community trust had significantly lower depression scores, compared with those with low community trust at the time of the earthquake; however, the depression scores of the former increased in the four years following the earthquake and gradually approached the average depression level. At the social level, relief resource allocation also had a significant effect on the change in survivors' post-disaster depression; those who deemed the resource allocation to be very fair had a decrease in depression scores. The results of our study show that rich individual social networks and allocation of relief resources contribute to earthquake survivors' recovery from depression. Therefore, besides providing more adequate relief resources to survivors, we should also emphasize the rebuilding of their social networks.

Pregnancy during the pandemic: the impact of COVID-19-related stress on risk for prenatal depression

BACKGROUND

Pregnant women may be especially susceptible to negative events (i.e. adversity) related to the coronavirus disease 2019 (COVID-19) pandemic and negative affective responses to these events (i.e. stress). We examined the latent structure of stress and adversity related to the COVID-19 pandemic among pregnant women, potential antecedents of COVID-19-related stress and adversity in this population, and associations with prenatal depressive symptoms.

METHOD

We surveyed 725 pregnant women residing in the San Francisco Bay Area in March-May 2020, 343 of whom provided addresses that were geocoded and matched by census tract to measures of community-level risk. We compared their self-reported depressive symptoms to women matched on demographic factors and history of mental health difficulties who were pregnant prior to the pandemic.

RESULTS

Women who were pregnant during the pandemic were nearly twice as likely to have possible depression than were matched women who were pregnant prior to the pandemic. Individual- and community-level factors tied to socioeconomic inequality were associated with latent factors of COVID-19-related stress and adversity. Beyond objective adversity, subjective stress responses were strongly associated with depressive symptoms during the pandemic.

CONCLUSIONS

Highlighting the role of subjective responses in vulnerability to prenatal depression and factors that influence susceptibility to COVID-19-related stress, these findings inform the allocation of resources to support recovery from this pandemic and future disease outbreaks. In addition to policies that mitigate disruptions to the environment due to the pandemic, treatments that focus on cognitions about the self and the environment may help to alleviate depressive symptoms in pregnant women.

Associations between Adverse Childhood Experiences and Pandemic-Related Stress and the Impact on Adolescent Mental Health during the COVID-19 Pandemic

Vulnerabilities of adolescents during times of crisis have been previously identified, but little research has investigated the compounding effects of lifetime adversities and pandemic-related stress on adolescent mental health. This study uses adolescent self-report data to model relationships between stress exposures and indicators of poor mental health from the longitudinal COVID Experiences (CovEx) Surveys. These surveys were administered online in English to U.S. adolescents ages 13-19 using the NORC AmeriSpeak® panel, a probability-based panel designed to be representative of the U.S. household population. Two waves of data were collected (Wave 1: October-November 2020, n = 727; Wave 2: March-May 2021, n = 569). Measures included demographics, adverse childhood experiences (ACEs, 8 items), pandemic-related stress (Pandemic-Related Stress Index [PRSI], 7 items), and depression symptoms (Patient Health Questionnaire for Adolescents [PHQ-A], 9 items). Path analyses were conducted to examine pathways between Wave 1 ACEs, Wave 1 PRSI, and Wave 2 PHQ with covariates of sex and race/ethnicity. Females had higher ACEs, PRSI, and PHQ scores than males. The PRSI score at Wave 1 was positively associated with the PHQ at Wave 2 (b = 0.29, SE = 0.14, p < 0.001). ACEs at Wave 1 were positively associated with PRSI at Wave 1 (b = 0.31, SE = 0.03, p < 0.001) and with PHQ at Wave 2 (b = 0.32, SE = 0.12, p < 0.001). The direct effect of ACEs on PHQ (b = 0.23, SE = 0.12, p < 0.001) remained significant even after accounting for the indirect effect of pandemic-related stress (b = 0.09, SE = 0.05, p < 0.001). Pandemic-related stress had a direct, adverse impact on adolescent depressive symptoms and demonstrates a compounding effect of childhood adversity and pandemic-related stress on depression. Findings can aid the design of interventions that promote mental health and support adolescent coping and recovery.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40653-022-00502-0.

A trauma-informed approach to understanding firearm decision-making among Black adolescents: Implications for prevention

Firearm violence remains a public health crisis in marginalized, urban communities, with Black adolescents bearing the burden of firearm homicides and injuries. As such, the prevention of firearm violence among adolescents has moved to a high priority of the U.S. public health agenda. The current paper reviews recent literature to highlight the heterogeneity in firearm behavior among Black adolescents and underscore the need for additional research on decision-making and firearm behavior to better understand how adolescents make decisions to acquire, carry, and use firearms. Through a discussion of the disproportionate levels of trauma exposure and trauma symptoms experienced by Black adolescents, the current paper also proposes a trauma-informed approach to understanding decision-making for risky firearm behavior. We discuss the broader impacts of this approach, including the development of a more comprehensive and contextually relevant understanding of the variability in risky firearm behavior and improvements in risk screening capabilities and preventive intervention strategies.

Resilience and Risk Factors Predict Family Stress Among Married Palestinians in Israel During the COVID-19 Pandemic

The present study examined effects of sociodemographic, risk, and resilience factors on marital, parental, and financial stress early in the COVID-19 pandemic. A cross-sectional online survey was conducted among 480 married Palestinians living in Israel, using self-report questionnaires. Descriptive statistics and bivariate correlations were computed. Then, hierarchical multiple regression analyses were conducted to predict each of the three stress measures. Finally, dominance analyses were conducted to compare the contributions of sociodemographic, risk, and resilience factors. The results showed considerable differences between predictors of marital and parental stress and predictors of financial stress. For marital and parental stress, resilience factors mainly family resilience were the strongest predictors, followed by risk factors and then sociodemographic characteristics. For financial stress, risk factors (mainly financial damage and prior stressful life events) were the strongest predictors, followed by sociodemographic characteristics and resilience factors (mainly individual resilience). These results suggest that family and individual resilience reduce marital and parental stress under difficult conditions, including the COVID-19 pandemic. Though resilience has been found to ameliorate financial stress to some extent, it appears that other measures are required to manage stress related to financial difficulties.

Interconnectedness Is Associated with a Greater Sense of Civic Duty and Collective Action Participation through Transcendental Awareness and Compassion during COVID-19

The COVID-19 pandemic has a unprecedented impact on the way individuals make sense of the interconnected nature of themselves in relation to the world. This study investigated the mediating role of transcendental awareness and compassion in the association of interconnectedness with a sense of civic duty and collective action participation during COVID-19 using a longitudinal design. A total of 336 young adult participants were recruited at baseline and were asked to complete measures of interconnectedness, transcendental awareness, compassion, civic duty, and collective action participation at three time points over a 6-month period. Path analysis was used to test the hypothesized mediation model. The results showed that compassion fully mediated the positive association between interconnectedness and collective action participation and partially mediated the positive association between interconnectedness and civic duty. Transcendental awareness also partially mediated the positive association between interconnectedness and civic duty but not collective action participation. This study highlighted the potential of interconnectedness in promoting civic duty and engagement in collective action through transcendental awareness and compassion during the COVID-19 pandemic.

Characterizing Unusual Spatial Clusters of Male Mental Health Emergencies Occurring During the First National COVID-19 "Lockdown" in the East Midlands Region, UK: A Geospatial Analysis of Ambulance 999 Data

The widespread psychological effects of contagion mitigation measures associated with the novel coronavirus disease 2019 (COVID-19) are well known. Phases of "lockdown" have increased levels of anxiety and depression globally. Most research uses methods such as self-reporting that highlight the greater impact of the pandemic on the mental health of females. Emergency medical data from ambulance services may be a better reflection of male mental health. We use ambulance data to identify unusual clusters of high rates of male mental health emergencies occurring in the East Midlands of the United Kingdom during the first national "lockdown" and to explore factors that may explain clusters. Analysis of more than 5,000 cases of male mental health emergencies revealed 19 unusual spatial clusters. Binary logistic regression analysis (χ2 = 787.22, df = 20, p ≤ .001) identified 16 factors that explained clusters, including proximity to "healthy" features of the physical landscape, urban and rural dynamics, and socioeconomic condition. Our findings suggest that the factors underlying vulnerability of males to severe mental health conditions during "lockdown" vary within and between rural and urban spaces, and that the wider "hinterland" surrounding clusters influences the social and physical access of males to services that facilitate mental health support. Limitations on social engagement to mitigate effects of the pandemic are likely to continue. Our approach could inform delivery of emergency services and the development of community-level services to support vulnerable males during periods of social isolation.

Posttraumatic stress disorder and related factors among nurses working during the COVID‐19 pandemic

Aim

To analyse the prevalence of posttraumatic stress disorder (PTSD) and examine its related factors among nurses who worked during the coronavirus disease 2019 (COVID‐19) pandemic in Daegu, South Korea.

Background

Nurses are a high‐risk population for PTSD, especially during the COVID‐19 pandemic. This study was conducted to identify the nursing work environmental factors that should be addressed to reduce PTSD.

Methods

Using a cross‐sectional design, 365 nurses were enrolled. Their characteristics (intrapersonal, interpersonal, organizational, and COVID‐19‐related) and PTSD Checklist‐5 scores were analysed.

Results

The average PTSD score was 14.98 ± 15.94, and 16.5% of the participants had a high risk of PTSD. Nurses were more likely to have PTSD if they were married (odds ratio = 3.02, p = .013) and when nurse managers' abilities, leadership, and support of nurses were low (odds ratio = 3.81, p < .001).

Conclusions

The nursing work environment was found to be associated with PTSD. Therefore, interventions are necessary to increase nurse managers' abilities, leadership, and support for nurses to reduce the risk of PTSD among nurses.

Implications for Nursing Management

Effective professional and social support and interventions to improve nurse managers' abilities, leadership, and support of nurses are needed to reduce PTSD.

Attachment Style Moderates Polygenic Risk for Incident Posttraumatic Stress in U.S. Military Veterans: A 7-Year, Nationally Representative, Prospective Cohort Study

BACKGROUND

Posttraumatic stress disorder (PTSD) develops consequent to complex gene-by-environment interactions beyond the precipitating trauma. To date, however, no known study has used a prospective design to examine how polygenic risk scores (PRSs) interact with social-environmental factors such as attachment style to predict PTSD development.

METHODS

PRSs were derived from a genome-wide association study of PTSD symptoms (N = 186,689; Million Veteran Program cohort). We evaluated combined effects of PRS and attachment style in predicting incident PTSD in a 7-year, nationally representative cohort of trauma-exposed, European-American U.S. military veterans without PTSD (N = 1083). We also conducted multivariate gene-by-environment interaction and drug repositioning analyses to identify loci that interact with multiple environmental factors and potential pharmacotherapies that may be repurposed for this disorder.

RESULTS

Veterans with higher PTSD PRS were more likely to have an incident-positive screen for PTSD over 7 years. A gene-by-environment interaction was also observed, such that higher PRS only predicted incident PTSD in veterans with an insecure attachment style and not those with a secure attachment style. At an individual locus level, the strongest gene-by-environment interaction was observed for the rs4702 variant of the FURIN gene with cumulative lifetime trauma burden. Drug repositioning revealed that genes implicated in PRS are perturbated by the drug doxylamine.

CONCLUSIONS

Attachment style moderates polygenic risk for the development of PTSD in European-American veterans. These findings may inform PTSD prevention and treatment for veterans with high polygenic risk for PTSD and suggest a potential pharmacotherapeutic target for risk genes moderated by social-environmental factors.

Has the COVID-19 Pandemic Traumatized Us Collectively? The Impact of the COVID-19 Pandemic on Mental Health and Sleep Factors via Traumatization: A Multinational Survey

PURPOSE

The COVID-19 pandemic affects mental health and sleep, resulting in frequent nightmares. Therefore, identifying factors associated with nightmare frequency is important, as it can indicate mental health issues. The study aimed to investigate increases in nightmare frequency comparing the pre-pandemic and pandemic period, and identify its risk factors. Further, the mediating role of post-traumatic stress disorder symptoms between the pandemic and nightmares is explored.

PATIENTS AND METHODS

For this cross-sectional survey data were obtained via self-rating online survey (ICOSS: details in Partinen et al, 2021), which was open to anyone older than 18 years. The final volunteer sample consisted of 15,292 participants, divided according to their nightmare frequency (high: ≥1-2 nights/week; low: <1-2 nights/week). A total of 9100 participants were excluded if answers on variables of interest were missing or receiving rewards for participation. Chi-square tests identified changes of nightmare frequency. Predictors of high nightmare frequency were assessed using logistic regression and presented as Odds Ratios. Post-hoc mediation models were used to investigate the role of post-traumatic stress symptoms (PTSS).

RESULTS

The mean age was 41.63 (SD=16.55) with 64.05% females. High nightmare frequency increased significantly from 13.24% to 22.35% during the pandemic. Factors associated with it included self-reported PTSS (OR=2.11), other mental disorders and various sleep disorders or problems. Financial burden due to the pandemic, confinement, having had COVID-19, and work situation during the pandemic were associated with nightmare frequency, those relations were partly mediated through PTSS.

CONCLUSION

Our results display the pandemic influence on nightmare frequency, which in turn connects to multiple mental health and sleep factors. These relations were partly mediated through PTSS. The COVID-19 pandemic appears to have caused traumatization of a substantial proportion of society. Health care workers should consider nightmares in their screening routines, as it might indicate PTSS and/or other mental and sleep disorders.

Examining the elevated risk of COVID-19 in transgender communities with an intersectional lens

COVID-19 has presented unique and unprecedented struggles for all people, yet they tend to be magnified among marginalized communities. Indeed, in the United States, transgender (trans) people experience oppression in many facets of their lives, which places them at an increased risk for both COVID-19 exposure and complications. This oppression can be broadly categorized into two distinct, yet interrelated categories: health disparities (e.g., decreased immune health) and structural barriers (e.g., employment discrimination, policing). Recent scholarship has examined trans people’s risk for COVID-19 exposure and mortality, however few articles examine intersectional identities, and, to our knowledge, none have interrogated oppressive power structures (e.g., the prison industrial complex). We aim to fill these critical gaps and argue that it is imperative for cisgender people to partner with trans communities to dismantle these harmful systems, positively impacting the lives of trans individuals during the pandemic and beyond. We make several key recommendations for researchers, policymakers, healthcare workers, and allies to do so.

Disaster Healthcare Workers' Experience of Using the Psychological First Aid Mobile App During Disaster Simulation Training

OBJECTIVE

The study aimed to examine the experience of disaster healthcare workers with simulation training using the Psychological First Aid (PFA) mobile app.

METHODS

This study was designed using qualitative research methodology with focus group interviews. The participants were 19 disaster healthcare workers from community mental health service centers who attended disaster simulation training in flood, fire, or leakage of hazardous chemicals. Before the simulation, participants were provided the PFA mobile app and allowed to practice the PFA techniques to apply them during the simulation. Data were collected through focus group interviews and qualitatively analyzed using the content analysis method.

RESULTS

The findings were divided into 6 categories: experience in realistic disaster situations, satisfaction with education methods using a mobile app, effectiveness of the PFA app in disaster relief, confidence in disaster relief by integrating experience and knowledge of the PFA app, self-reflection as a disaster healthcare worker, and identifying limitations and making developmental suggestions.

CONCLUSIONS

Based on the participants' developmental proposals in this study, the disaster simulation training, incorporating improvements in the disaster simulation training and the PFA app features, will serve as a new framework for disaster support education and systematic mental health services to survivors by disaster healthcare workers.

Attempted suicide rates before and during the COVID-19 pandemic: interrupted time series analysis of a nationally representative sample

BACKGROUND

To characterize the association between the protracted biopsychosocial coronavirus disease 2019 (COVID-19) pandemic exposures and incident suicide attempt rates.

METHODS

Data were from a nationally representative cohort based on electronic health records from January 2013 to February 2021 (N = 852 233), with an interrupted time series study design. For the primary analysis, the effect of COVID-19 pandemic on incident suicide attempts warranting in-patient hospital treatment was quantified by fitting a Poisson regression and modeling the relative risk (RR) and the corresponding 95% confidence intervals (CIs). Scenarios were forecast to predict attempted suicide rates at 10 months after social mitigation strategies. Fourteen sensitivity analyses were performed to test the robustness of the results.

RESULTS

Despite the increasing trend in the unexposed interval, the interval exposed to the COVID-19 pandemic was statistically significant (p < 0.001) associated with a reduced RR of incident attempted suicide (RR = 0.63, 95% CI 0.52-0.78). Consistent with the primary analysis, sensitivity analysis of sociodemographic groups and methodological factors were statistically significant (p < 0.05). No effect modification was identified for COVID-19 lockdown intervals or COVID-19 illness status. All three forecast scenarios at 10 months projected a suicide attempt rate increase from 12.49 (7.42-21.01) to 21.38 (12.71-35.99).

CONCLUSIONS

The interval exposed to the protracted mass social trauma of the COVID-19 pandemic was associated with a lower suicide attempt rate compared to the unexposed interval. However, this trend is likely to reverse 10 months after lifting social mitigation policies, underscoring the need for enhanced implementation of public health policy for suicide prevention.

Individual and community psychological experiences of the COVID-19 pandemic: The state of emergency in Portugal

Individuals have different ways of coping with crisis. Individual factors, family and contextual features, and community support may influence how individuals feel, think and act during a crisis. COVID-19 was an unexpected pandemic that forced many European countries to take confinement measures and restrict social face to face interactions. This study is an effort to understand how Portuguese residents dealt with the pandemic during the first confinement period, considering different sociodemographic characteristics and trauma exposure perceptions. Five hundred and five adults, between 18 and 79 years old participated in this study via an online self-report assessment protocol. Sociodemographic characteristics such as gender, age, marital status, employment status, and caring responsibilities had an impact on individuals' perceptions regarding their exposure to the pandemic and their quality of life. Perceived exposure to the pandemic was found to predict quality of life in the physical, psychological, and environmental domains. Results have practical implications for European and local policy-making, as well as for targeting psychological interventions for those whose mental health has been negatively affected by the pandemic and for those who may become more affected if confinement measures are implemented again.

Investigation of the Effects of Violence Experience During Political Demonstrations

In this study, predictors of post-traumatic stress symptom levels (PTSSL) and post-traumatic growth levels (PTGL) resulting from the experience of violence were investigated. The sample of the study consisted of 514 Gezi Park demonstrators. Participants completed measures assessing stress symptoms, post-traumatic growth, social support and beliefs about the world as well as the open-ended event specific questions. Results showed that being politically active, psychologically prepared and experiencing mild levels of violence were related with decreased PTSSL individually but not in combination as the literature suggested. The two hierarchical regression analyses showed that: (1) PTSSL were predicted by violence exposure levels, perceived social support from significant others and "randomness" and "self-worth" beliefs about the world; (2) PTGL were predicted by violence exposure levels, total amount of time spent at the demonstrations and "benevolence" and "justice" beliefs about the world. These findings suggest that psychological preparedness might be an important variable in violence experience regarding human masses. Also, violence exposure levels and duration of participation seems to be important event- specific variables. Lastly, political activism needs to be more precisely operationalized and measured in future studies.

A Bioecosystem Theory of Negative Symptoms in Schizophrenia

Objective: Negative symptoms are a core feature of schizophrenia that has been linked to numerous poor clinical outcomes. Although person-level mechanisms have been identified for negative symptoms, psychosocial and pharmacological treatments targeting these mechanisms have been ineffective. The current theoretical paper proposes that limited treatment progress may result in part from a failure to identify and target environmental processes that cause and maintain negative symptoms. Methods: A novel theoretical model is outlined, called the bioecosystem theory of negative symptoms, that offers a conceptual framework for studying interactions among environmental systems and person-related biological and psychosocial factors. Results: Relying on Bronfenbrenner's developmental theory as an organizing framework, four interactive environmental systems are proposed to be critical for the genesis and maintenance of negative symptoms: (1) Microsystem: the immediate environment; (2) Mesosystem: the interactions among microsystems; (3) Exosystem: indirect environments that influence the individual through the microsystems; (4) Macrosystem: socio-cultural factors. The environmental factors within these systems are proposed to function as a network and have dynamic within-system interactions, as well as cross-system interactions that change over time and across phases of illness. Conclusions: Environmental contributions to negative symptoms have received minimal empirical attention, despite their potential to explain variance in negative symptom severity. The bioecosystem model of negative symptoms introduced here offers a novel conceptual framework for exploring environmental contributions to negative symptoms and their interaction with person-level biological and psychological factors. This theory may facilitate new avenues for identifying environmental treatment targets and novel systems-level interventions.

Bioecological Implications of Narrative Exposure Therapy in Low-Resource Settings: Individual, Family, Community, and Socio-Political Contexts

Traumatic stress can have detrimental effects on individuals, families, and communities. Narrative Exposure Therapy (NET) is an evidence-based intervention for decreasing individuals' posttraumatic stress disorder (PTSD) symptoms and has been tested in some of the most challenging contexts, such as in post-conflict refugee camps. Although the focus of NET is on reducing individual PTSD symptoms, the impact of NET can be seen beyond the individual level. The purpose of this manuscript was to examine some of the ecological implications of using NET with trauma-affected populations in low-resource settings. We highlight select implications of NET that extend beyond the individual to systemic effects at the family, community, and sociopolitical levels using several case examples. Finally, we outline limitations and future directions for improving the delivery of NET in settings with limited resources.

Supporting Disaster Relief Efforts Internationally: A Call to Counseling Psychologists

The increased occurrence of natural and human-made disasters has led to a greater call for culturally sensitive engagement in disaster mental health. In this article, we aim to stimulate culturally focused participation and competence among counseling psychologists who engage in disaster mental health work. Framed within an ecological and systemic interaction of individual, cultural, community, and structural factors, the article is based on two cross-cultural competency models emphasizing, cultural intelligence, language proficiency, cognitive complexity and flexibility, and highly developed interpersonal and communication skills, in the planning and delivery of disaster relief services. In particular, we address (a) specific cultural challenges, (b) skills and competencies needed, and (c) recommendations for online resources, that are relevant to counseling psychologists who seek to promote emotional resiliency in individuals and communities impacted by a disaster.

Exploring Contextual Trauma in Cambodia: A Sociointerpersonal Perspective on Posttraumatic Stress Disorder

Trauma literature has proposed multiple theories of trauma development, maintenance, and transmission, which has led to a lack of clarity surrounding trauma in individuals, families, and communities. We investigated the impact of community-level trauma experiences on individual posttraumatic stress disorder (PTSD) symptoms using a sociointerpersonal model of PTSD (Maerker & Horn, 2013). A nationally representative sample (N = 2, 690) of Cambodian households across all regions of the country was surveyed regarding individual trauma experiences during and after the Khmer Rouge regime, symptoms of PTSD, and current stressors. Individual experiences of war trauma and current stressors were aggregated based on the district in which each individual lived. District mean and individual war trauma and current stressors were included in a multilevel model as predictors of individual levels of PTSD. Findings indicated that mean trauma experiences, β = .05, p < .001, and current stressors, β = .10, p < .001, in the district in which individuals live were positively and significantly associated with their individual PTSD symptoms. Individual war trauma, β = .02, p < .001, and current stressors, β = .08, p < .001, were also positively and significantly associated with individual PTSD symptoms. District trauma experiences accounted for 7% of the variance in individual PTSD symptoms, R² _{Level 1} = .21, R² _{Level 2} = .80. Additionally, current stressors at both the individual and district levels had a greater impact on individual PTSD symptoms than war trauma at either level of the model. Implications for policy and intervention are presented.

Veterans’ Perspectives on the Psychosocial Impact of Killing in War

Based on focus group and individual interviews with 26 combat veterans, this qualitative thematic analysis examines the psychosocial and interpersonal consequences of killing in war. It describes the consequences that veterans identify as most relevant in their lives, including postwar changes in emotions, cognitions, relationships, and identity. Furthermore, it illustrates the linked psychological and social dimensions of those consequences—namely, how the impact of killing in war is rooted in the unique perspectives, actions, and experiences of individual veterans, as well as the social worlds they confront upon returning from war. We found that, for many veterans, killing provokes a moral conflict with a lasting impact on their sense of self, spirituality, and relationships with others. In working with combat veterans, mental health professionals should be sensitive to the complexities of discussing killing and attuned to the psychosocial challenges veterans may face after taking a life in war.

Adolescents' Exposure to Disasters and Substance Use

This paper reviews the impact of exposure to man-made or natural disasters on adolescent substance use. It covers empirical studies published from 2005 to 2015 concerning (a) the scope of the problem, (b) vulnerable groups and risk and protective factors, and (c) evidence-based interventions. The review suggests a strong link between adolescent substance use and exposure to either man-made or natural disaster. Vulnerable groups include adolescents with previous exposure to traumatic events, living in areas that are continually exposed to disasters, and ethnic minorities. Risk and protective factors at the individual, familial, community, and societal levels are described based on the bioecological model of mass trauma. Given that mass trauma is unfortunately a global problem, it is important to establish international interdisciplinary working teams to set gold standards for comparative studies on the etiology for adolescent substance use in the context of disasters.

Political violence, collective functioning and health: a review of the literature

Political violence is implicated in a range of mental health outcomes, including PTSD, depression, and anxiety. The social and political contexts of people's lives, however, offer considerable protection from the mental health effects of political violence. In spite of the importance of people's social and political environments for health, there is limited scholarship on how political violence compromises necessary social and political systems and inhibits individuals from participating in social and political life. Drawing on literature from multiple disciplines, including public health, anthropology, and psychology, this narrative review uses a multi-level, social ecological framework to enhance current knowledge about the ways that political violence affects health. Findings from over 50 studies were analysed and used to build a conceptual model demonstrating how political violence threatens three inter-related domains of functioning: individual functioning in relationship to their environment; community functioning and social fabric; and governmental functioning and delivery of services to populations. Results illustrate the need for multilevel frameworks that move beyond individual pathology towards more nuanced conceptualizations about how political violence affects health; findings contribute to the development of prevention programmes addressing political violence.

Individual and collective dimensions of resilience within political violence

Research has documented a link between political violence and the functioning of individuals and communities. Yet, despite the hardships that political violence creates, evidence suggests remarkable fortitude and resilience within both individuals and communities. Individual characteristics that appear to build resilience against political violence include demographic factors such as gender and age, and internal resources, such as hope, optimism, determination, and religious convictions. Research has also documented the protective influence of individuals' connection to community and their involvement in work, school, or political action. Additionally, research on political violence and resilience has increasingly focused on communities themselves as a unit of analysis. Community resilience, like individual resilience, is a process supported by various traits, capacities, and emotional orientations toward hardship. This review addresses various findings related to both individual and community resilience within political violence and offers recommendations for research, practice, and policy.

A Call to Action

The ascendance of large-scale disasters, catastrophes, and traumas as a concentrated focus of academic inquiry in counseling psychology is timely, and this special issue and subsequent investigations represent welcome areas of scholarship. The observations and comments herein salute the authors for responding to a post-Katrina discovery by counseling psychology of the heretofore localized and less than systematic responses to large-scale disasters, catastrophes, and traumas. Extensions to and invited elaborations on the collective observations of this team of authors are offered for consideration. This article also doubles as an invitation to counseling psychologists to put into action programs, procedures, policies, and political advocacy aimed at tapping and sustaining the hope and resilience of national and international communities forced to reconcile sudden and life-changing devastation.

Counseling Psychology and Large-Scale Disasters

Juntunen and Parham each reacted positively with important personal reflections and/or calls to action in response to “Counseling Psychology and Large-Scale Disasters, Catastrophes, and Traumas: Opportunities for Growth.” We comment on the primary themes and suggestions they raised. Since the time we were stimulated by Katrina and its aftermath and the Indian Ocean tsunami to conceptualize and bring to fruition this major contribution, large-scale disasters seemed to be happening everywhere (even to some of us personally or as responders). This underscores the need Juntunen highlighted to examine our motivations, self-care, privilege, and the long-term impact of disasters and disaster response work. Also, we agree with Parham that it makes palpable the need for counseling psychology to move beyond compassion and action by a relative few to act now, respond to, and engage in systematic action and research on large-scale disasters, through a bioecological and social justice approach.

Reflections on the Opportunities and Challenges of Disaster Response

This reaction article applauds the authors of the Major Contribution for their thoughtful and thorough consideration of the myriad issues that accompany disaster mental health work. The reaction highlights three themes that emerged in the articles of the contribution: opportunities for collaboration, opportunities for the application of social justice, and opportunities for bioecological research and interventions. In addition, suggestions are made for future exploration of prevention opportunities, separating the reality of disaster response from popular media images, and ethical considerations for counseling psychologists working as disaster responders.

Introduction and Overview

Counseling psychologists have responded to many disasters, including the Haiti earthquake, the 2001 terrorist attacks in the United States, and Hurricane Katrina. However, as a profession, their responses have been localized and nonsystematic. In this first of four articles in this contribution, “Counseling Psychology and Large-Scale Disasters, Catastrophes, and Traumas: Opportunities for Growth,” the authors assert that counseling psychology can make important contributions in disaster research and response. Throughout all the articles, the authors use Bronfenbrenner’s bioecological model of human development as a foundation from which to more broadly view counseling psychology’s role in training, prevention, intervention, and research in mass trauma work. Disasters affect individuals, families, communities, work places, and disaster responders. Thus, they require a multisystem analysis and response, which counseling psychologists can provide through their scientist-practitioner, strength-based approaches, supported by social justice values based in multicultural and vocational counseling. The authors also provide the history of the Society of Counseling Psychology’s response to disasters following Hurricane Katrina, from which the need for this contribution arose.

Ecologically Based, Culturally Concordant Responding Following Disasters

This article reviews the existing theory, research, policy, and practice of disaster mental health and the role of counseling psychology in post-disaster and catastrophic situations, all from a social justice perspective. Specifically, we discuss the phases and stages, social ecology, and individual reactions to disasters. A case study is presented, followed by mental health interventions and counseling psychology’s role in these interventions at both the individual and systemic levels. We conclude with an overview of professional issues that often emerge when working in disaster areas, cultural issues that arise, and ways for counseling psychologists to become involved in this work.

Training and Practice in Trauma, Catastrophes, and Disaster Counseling

Trauma-related assistance in response to disasters or catastrophes is needed locally, regionally, nationally, and internationally, and the authors argue that there is a necessity for counseling psychologists and counseling psychology programs to incorporate it into their prevention, training, and social justice repertoire. Counseling psychologists are in a unique position to engage in disaster relief efforts because of their values and training, particularly around work with diverse clients. The authors present examples from two training programs of disaster mental health work completed in the field with students and their preparation of students for this work. They discuss some struggles and challenges in involving students and interventions for resolutions and further show how real-world crisis situations and interventions can easily be used as training tools. The authors discuss a number of themes that emerged throughout the disaster site examples, including students’ flexibility, openness to cultural issues, self-care, good interpersonal skills, resilience, and compassion.