1. An Application of the Extended Parallel Process Model to Understand First Responders’ Attitudes toward Assisting Individuals with Serious Mental Illness Jeffrey Duong, MHSAnne Sawyer, BFA Doctoral StudentPhD Candidate Johns Hopkins Bloomberg School of Public Health Department of Mental Health Matthew J. Hayat, PhDLinda Rose, RN, PhD Assistant Professor Principal Investigator Associate Professor Johns Hopkins School of Nursing Handout for The American Public Health Association 139 th Annual Meeting Injury Control and Emergency Health Services 3196.0 Emergency Medical Services Poster Board 5 October 31, 2011 Washington, DC

2. Background Recent disasters highlight the vulnerability of individuals with serious mental illness (SMI). 1,2,3 The availability of care provided by mental health professionals is limited during disasters. 4,5 The responsibility of assisting persons with SMI may fall onto first responders who may not have the necessary skills to effectively provide care. 6 More training for first responders to provide psychological aid is needed but little is known about their perceptions towards individuals with SMI. Witte’s 7 Extended Parallel Process Model may inform our understanding of first responders’ willingness to assist persons with SMI during a disaster.

3. Objectives Aim 1. Identify individual characteristics associated with first responders’: –Perceived threat to self posed by individuals with SMI during a disaster. –Perceived efficacy for assisting individuals with SMI during a disaster. Aim 2. Assess the relationships between perceived threat and perceived efficacy of first responders’ willingness to assist persons with SMI during a disaster. Individual Characteristics Low Efficacy/High Threat Low Efficacy/Low Threat High Efficacy/High Threat High Efficacy/Low Threat Willingness to Assist Persons with SMI Individual Characteristics Low Efficacy/High Threat Low Efficacy/Low Threat High Efficacy/High Threat High Efficacy/Low Threat Willingness to Assist Persons with SMI

4. Methods: Procedure and Instrument Procedure. –Spring 2010: Local EMTs, firefighters, and police officers were invited to complete a survey and participate in focus groups. Instrument. –Participants completed the MI-FIRST Tool. –MI-FIRST Tool is an anonymous online survey asking respondents about the following: Demographic characteristics. Attitudes toward aiding persons with SMI during a disaster. Causal Attributions and familiarity with mental illness.

5. Methods: Data Analysis Data were analyzed using STATA 11 (StataCorp, College Station, TX). Aim 1. –Multinomial logistic regressions were used to identify associations between individual characteristics and perceived threat and perceived efficacy. Aim 2. –Logistic regressions were used to assess relationships between perceived threat and perceived efficacy with first responders’ attitudes. Analysis controlled for individual characteristics

6. Results: Figure 1. Characteristics of Respondents (n = 274)

7. Results: Figure 2. Perceptions of Persons with SMI

8. Results: Aim 1 Table 1. Associations between First Responders’ Individual Characteristics and Perceived Threat and Perceived Efficacy Reference: Low Efficacy/High Threat Low Efficacy/ Low Threat RRR (95% CI) High Efficacy/ High Threat RRR (95% CI) High Efficacy/ Low Threat RRR (95% CI) Age, years (Ref = < 20)20-290.52 (0.04, 6.34)0.21 (0.02, 1.95)0.29 (0.03, 3.18) 30-390.52 (0.04, 6.66)0.14 (0.01, 1.40)0.34 (0.03, 3.82) 40+0.68 (0.05, 8.83)0.31 (0.03, 3.05)0.62 (0.05, 7.07) Gender (Ref = Female)Male1.59 (0.69, 3.69)0.76 (0.34, 1.71)1.57 (0.65, 3.79) Role (Ref = Police)Firefighter1.42 (0.24, 3.69)1.55 (0.25, 9.45)0.93 (0.18, 4.66) EMT2.70 (0.44, 16.63)1.95 (0.31, 12.22)1.14 (0.22, 6.01) Experience, years (Ref = <10)10+ years0.58 (0.22, 1.49)0.42 (0.16, 1.11)0.27 (0.10, 0.73) Previous experience with persons with SMI (Ref = Yes) No0.84 (0.40, 1.77)0.52 (0.24, 1.23)0.54 (0.24, 1.19) Has family member with SMI (Ref = Yes) No0.80 (0.35, 1.83)0.89 (0.39, 2.04)0.80 (0.33, 1.91) Note: RRR = Relative Risk Ratio; 95% CI = 95% Confidence Interval; Bold indicates significance at p < 0.05.

9. Results: Aim 1 Most individual characteristics were not significantly associated with perceptions of threat and efficacy. Exception: The relative risk of perceiving high efficacy/low threat decreases for first responders with 10 or more of experience compared to those with less than 10 years of experience. Individual Characteristics Low Efficacy/High Threat Low Efficacy/Low Threat High Efficacy/High Threat High Efficacy/Low Threat

10. Results: Aim 2 Table 2. Associations between Perceived Threat and Perceived Efficacy and Attitudes towards Assisting Persons with Serious Mental Illness Reference: Low Efficacy/High Threat Low Efficacy/ Low Threat AOR (95% CI) High Efficacy/ High Threat AOR (95% CI) High Efficacy/ Low Threat AOR (95% CI) Willingness to help persons with SMI regardless of disaster severity 1.43 (0.71, 2.90)3.30 (1.58, 6.89)4.06 (1.86, 8.88) Willingness to help persons with SMI if asked, but not required 1.97 (0.97, 4.02)3.46 (1.66, 7.20)3.48 (1.63, 7.44) Willingness to help persons with SMI if required 2.23 (1.01, 4.88)2.83 (1.27, 6.31)2.18 (0.97, 4.90) Note: AOR = Adjusted Odds Ratio. Bold indicates significance at p < 0.05.

11. Results: Aim 2 First responders perceiving high efficacy/low threat were most willing to help persons with SMI both regardless of disaster severity as well as when asked but not required. First responders perceiving high efficacy/high threat were most willing to help persons with SMI if required. Low Efficacy/High Threat Low Efficacy/Low Threat High Efficacy/High Threat High Efficacy/Low Threat Willingness to Assist Persons with SMI

12. Conclusion This study provides insight into the attitudes of first responders towards persons with SMI. Findings suggest that perceived threat to self posed by persons with SMI and perceived efficacy for assisting persons with SMI during a disaster do not differ by first responders’ individual characteristics. First responders’ perceived threat and perceived efficacy are associated with their willingness to assist persons with SMI. Future training programs for training first responders to assist persons with SMI should consider their perceptions when designing and implementing interventions.

13. References 1. Yun K, Lurie N, Hyde PS. Moving mental health into the disaster- preparedness spotlight. N Engl J Med 2010; 363:1193-1195 2. Bendsen C, Blair R, Holandez R, et al. Coping with Katrina: Mental Health Services in New Orleans. Princeton, NJ: Woodrow Wilson School of Public & International Affairs; 2007. 3. Sontag D. In Haiti, mental health system is in collapse. New York Times March 19, 2010. 4. Thomas KC, Ellis AR, Konrad TR, et al. County-level estimates of mental health professional shortage in the United States. Psychiatr Serv 2009;60:1323-1328. 5. Hawley SR, Hawley GC, St Romain T, et al. Quantitative impact of mental health preparedness training for public health professionals. Biosecur Bioterror 2007;5:347-352 6. Rabins PV, Kass NE, Rutkow L, Vernick JS, Hodge Jr. JG. Challenges for Mental Health Services Raised by Disaster Preparedness: Mapping the Ethical and Therapeutic Terrain. Biosecur Bioterror 2011;9:175-179. 7. Witte K. Putting the fear back into fear appeals: the extended parallel process model. Communication Monographs 1992;59:329-349.

14. Acknowledgements The Johns Hopkins Preparedness and Emergency Response Research Center provided funding for this pilot study. We also thank the Maryland Institute for Emergency Medical Service Systems and local first responders for their participation.

15. Supplemental Information

16. Contact Information Jeffrey Duong, MHS –jduong@jhsph.edujduong@jhsph.edu Anne Sawyer, BFA –asawyer2@jhsph.eduasawyer2@jhsph.edu Matthew J. Hayat, PhD –mhayat2@son.jhmi.edumhayat2@son.jhmi.edu Linda Rose, RN, PhD –lrose2@son.jhmi.edu

17. Supplemental Background Witte’s Extended Parallel Process Model (EPPM) Describes how individuals respond to potential hazard messages. Two components: –Perceived threat of hazard Severity of threat Susceptibility to threat –Perceived efficacy Self-efficacy Response efficacy Suggests that high perceived threat and high perceived efficacy lead to acceptance of message and positive behaviors.

18. Our study hypothesizes that high perceived efficacy and low perceived threat lead to message acceptance and engagement in positive behavior. Individual Characteristics Low Efficacy/High Threat Low Efficacy/Low Threat High Efficacy/High Threat High Efficacy/Low Threat Willingness to Assist Persons with SMI Supplemental Background Witte’s Extended Parallel Process Model (EPPM)

19. Supplemental Methods Instrument Development: MI-FIRST Tool MI-FIRST Disaster Survey –MI-FIRST Disaster Survey is adapted from JH-PHIRST Tool (Barnett et al. 2009). –Items altered to address willingness to intervene with individuals with SMI –MI-FIRST Disaster Survey will require additional refinements as study progresses Attribution Questionnaire –Attribution Questionnaire was provided by Corrigan et al. (2003) –Original tool to be used in general population. –Will require confirmatory factor analyses to ensure that scales hold for First Responders used in this study.

20. Supplemental Results Mean: 6.547445; Standard Deviation: 1.589668 Median: 7

21. Supplemental Results Mean: 6.959854; Standard Deviation: 1.599632 Median: 8

22. Supplemental Results Mean: 7.445255; Standard Deviation: 1.206938 Median: 8

23. Supplemental Results: Aim 2 Supplemental Table. Associations between Perceived Threat and Perceived Efficacy and Attitudes towards Assisting Persons with Serious Mental Illness Reference: Low Efficacy/High Threat Low Efficacy/ Low Threat OR (95% CI) High Efficacy/ High Threat OR (95% CI) High Efficacy/ Low Threat OR (95% CI) Efficacy towards addressing questions of a concerned member of the public about another person with SMI 0.68 (0.31, 1.47)3.20 (1.52, 6.70)3.67 (1.69, 7.98) Efficacy towards addressing questions of a person with SMI 0.81 (0.38, 1.70)4.38 (2.09, 9.19)2.93 (1.38, 6.18) Belief that persons with SMI will have access to a mental health resource during a disaster 0.87 (0.42, 1.82)4.37 (2.09, 9.16)2.71 (1.29, 5.69) Belief that persons with SMI will have access to a mental health resource following a disaster 1.31 (0.64, 2.68)4.52 (2.14, 9.57)2.91 (1.36, 6.19) Belief that helping persons with SMI contributes to emergency management agency's overall success 0.66 (0.32, 1.35)2.36 (1.15, 4.84)2.46 (1.16, 5.18) Psychological preparedness to assist persons with SMI 0.85 (0.42, 1.73)2.31 (1.13, 4.72)2.32 (1.11, 4.86) Belief that persons with SMI pose threat to community 0.12 (0.05, 0.27)1.54 (0.69, 3.42)0.45 (0.06, 0.33) Note: AOR = Adjusted Odds Ratio. Bold indicates significance at p < 0.05.