Individual and Community-Level Determinants of Mental and Physical Health After the Deepwater Horizon Oil Spill: Findings from the Gulf States Population Survey Amy Z. Fan Marta R. Prescott Guixiang Zhao Carol A. Gotway Sandro Galea Abstract The 2010 Deepwater Horizon oil spill had enormous consequences on the environment. Prevalence of mental and physical health conditions among Gulf residents after the disaster, however, are still being assessed. The Gulf State Population Survey (GSPS) was a representative survey of 38,361 residents in four Gulf States and was conducted from December 2010 to December 2011. Analysis of the GSPS data showed that differences in individual characteristics and direct or indirect exposure to the disaster drove the individual-level variation in health outcomes (mental distress, physical distress, and depression). Direct exposure to the disaster itself was the most important determinant of health after this event. Selected county-level characteristics were not found to be significantly associated with any of our health indicators of interest. This

Address correspondence to Amy Z. Fan, Division of Behavioral Surveillance, Public Health Surveillance and Informatics Program Office, Office of Surveillance, Epidemiology and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, GA, USA. Email: [email protected]. Guixiang Zhao, Division of Behavioral Surveillance, Public Health Surveillance and Informatics Program Office, Office of Surveillance, Epidemiology and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, GA, USA. Carol A. Gotway, Division of Behavioral Surveillance, Public Health Surveillance and Informatics Program Office, Office of Surveillance, Epidemiology and Laboratory Services, Centers for Disease Control and Prevention, Atlanta, GA, USA. Marta R. Prescott, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA. Sandro Galea, Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA.

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Journal of Behavioral Health Services & Research, 2014. 23–41. c 2014 National Council for Behavioral Health (outside the USA). DOI 10.1007/s11414-014-9418-7

Findings from the Gulf States Population Survey

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study suggests that in the context of an overwhelming event, persons who are most directly affected through direct exposure should be the primary focus of any public health intervention effort.

Introduction The Deepwater Horizon oil rig exploded 48 miles southeast of the Louisiana coast on April 20, 2010, spilling nearly 5 million barrels of oil into the Gulf of Mexico over a 3-month period. Eleven workers died in the explosion.1 The lives and livelihoods of persons residing in Gulf Coast communities in Louisiana, Alabama, Florida, and Mississippi were affected for months after the oil spill. Residents lost work, changed their patterns of leisure activities, and were faced with a rapid, unanticipated change in their physical environment and disruptions in the fishing and tourism industries. Moreover, many residents participated in cleanup activities that brought them into direct contact with the oil and the devastation it caused to wildlife and coastal environments. In addition to the environmental consequences of the oil spill, there were, and will likely continue to be, public health consequences as well. Abundant evidence clearly shows that there exists a population burden of psychopathology after disasters2–7 and that this burden is often accompanied by poor physical health.7 The physical and mental health consequences among those who experience a disaster, however, vary depending on the scope of the disaster exposure,3,8 individual characteristics of the residents, and the built, social, and natural environments of their affected communities.8,9 Characteristics of individuals and individual experiences before, during, and after the disaster all play a role in shaping each resident’s risk of poor health after these events.9 For example, history of psychopathology before the disaster,3,10 the dose of trauma experienced during the disaster,11 or job loss experienced after the disaster10 increase a person’s risk of psychopathology. Additionally, a person’s ability to cope and function after the disaster is enhanced by his or her social support received before, during, and after the disaster.8,12–14 There is good evidence that community-level factors shape population health, independent of individual-level characteristics.15,16 Community-level factors may also contribute to, or mitigate the risk of individual-level psychopathology after a disaster.9,17–19 For example, community capacity, or positive resources that characterize communities, may help mitigate the consequences of disasters over and above individual characteristics. Community-level social cohesion has been shown to be protective against depression, particularly in the context of substantial post-disaster displacement.20 The sheer extent of the Deepwater Horizon oil spill raises concern about the long-term health consequences for the population of the Gulf region experiencing the disaster.21 Oil spills are known for long-term disruption of the cultural, social, and economic aspects of a region largely dependent upon the natural resources of the environment, thus possibly contributing to poor psychological and social well-being for the population.18,21–24 In the aftermath of the 1989 Exxon Valdez oil spill in Alaska, where nearly half of the commercial fishing areas reported damage,25–28 those exposed to the disaster were more likely than those who were not exposed to develop poor health outcomes including depression, posttraumatic stress disorder, substance abuse issues,21 and poor selfreported mental and physical health after the disaster.18,21,25–28 Early reports after the Deepwater Horizon oil spill found an association between mental health and exposed regions.18,28–32 In a rapid assessment, Buttke et al. reported that the prevalence of mental health symptoms shortly following the disaster was higher than that reported in 2008 and 2009 for the same region.29 The Community Assessment for Public Health Emergency Response (CASPER) also reported that the prevalence of symptoms for depression and anxiety 1-year after the oil spill was lower than that immediately following the oil spill.30 In their comparison of the psychopathology 5-months after the Exxon Valdez in Alaska and the Deepwater Horizon Oil spillaffected region in Alabama, Gill et al. reported similar levels of distress between the two regions

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and that individual-level factors such as direct exposure to the disaster and financial impact of it were predictors of individual distress.18 To our knowledge, only one study has examined how community-level factors affect individual psychopathology in the aftermath of the Deepwater Horizon oil spill; the authors reported that, contrary to expectations, an individual’s community attachment was negatively associated with his/her mental health.24 Rapid assessments such as these examples are very important for early determination of public health problems and allocation of resources. There is a paucity of work, however, that thoroughly examines the Gulf Coast region as a whole (i.e., across the four affected states), and examines not only individual level but also county-level predictors of health. More in-depth studies that address these issues are necessary to fully understand the factors affecting physical and mental health and possibly mitigate the long-term consequences of the Deepwater Horizon oil spill. This paper examined the correlates of poor mental and physical health in the Gulf States region after the Deepwater Horizon oil spill. The roles of both individual and community-level factors were considered.

Methods Description of GSPS Data for this study came from the Gulf States Population Survey (GSPS). GSPS was a 12-month (December 2010 to December 2011), random-digit dial telephone survey of adults aged 18 years or older who resided in four Gulf states affected by the 2010 oil spill: Alabama, Florida, Louisiana, and Mississippi. The GSPS was conducted to collect information on the physical and mental health status of the population and to assess the need for mental and behavioral health services in the region that has been affected by the oil spill. There were 27,947 participants who resided in one of 25 coastal counties/parishes located within a 32-mile region where fishing was closed due to the oil spill; the rest of participants (n=10,414) lived in the remainder of counties/parishes of the Gulf States. The GSPS survey methodology (including survey design, sampling methods and weights) was based on previously tested methods that have been used for the Behavioral Risk Factor Surveillance System.33 The GSPS included both landline (n=32,813) and cellular (n=5,548) telephone surveys and was conducted in both English and Spanish. Detailed information on the GSPS is available at http://www.cdc.gov/osels/phsipo/dbs/gsps.html. The cooperation rate (the percentage of eligible persons contacted who completed the interview) of the GSPS was 44.2%. Data were weighted to adjust for US Census population estimates by county, using age, race, sex, geographic location, and phone type (landline or cellular telephone). Health outcomes of interest Data on frequent physical distress (FPD) and frequent mental distress (FMD) were collected in the GSPS. FPD was measured with the question “For how many days in the past 30 days was your physical health not good?” Respondents who reported 14 days or more in which their physical health was poor were characterized as having FPD.34 Similarly, FMD was measured with the question, “For how many days in the past 30 days was your mental health (due to stress, depression, or problems with emotions) not good?” Respondents who reported 14 or more days in which their mental health was poor were classified as having FMD.34 To measure current depression, the GSPS included eight questions adapted from the 8-item Patient Health Questionnaire (PHQ-8).35–37 PHQ-8 was adapted from PHQ-9 by omitting the suicidal ideation question based on the concern that telephone-based assessment of suicidal ideation was inappropriate. Research indicated that the PHQ-8 has similar operating characteristics compared with PHQ-9 and is an acceptable alternative to PHQ-9.35,38 In the PHQ-8, each of the

Findings from the Gulf States Population Survey

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eight items, scored 0 to 3, provides a 0 to 24 severity score of depression.39 For the purposes of the GSPS and BRFSS, the PHQ-8 items asked the number of days in the past 2 weeks that the person experienced a particular depressive symptom. The days version of the PHQ-8 is a valid dimensional alternative to the traditional PHQ-8.40–42 For analytic purposes, the modified response set was converted to the original response set: 0 to 1 days = “not at all”; 2 to 6 days = “several days”; 7 to 11 days = “more than half the days”; and 12 to 14 days = “nearly every day,” with points (0 to 3) assigned to each category, respectively. Item scores were summed for a total score of 0 to 24. A score of greater than or equal to 10 was used to define current depression in this study. A PHQ-8 score of 10 or greater has been widely used as the cut point to define current depression. Use of this cut point is recommended because a score of 10 or greater has a reasonable sensitivity and a specificity for diagnosing any depressive disorder among primary care patients.35,38,43

Exposures of interest Individual-level characteristics The individual-level characteristics included participants’ demographics, health characteristics, factors of resilience, and social and emotional support, and exposure to the oil spill. The demographics of interest included sex (male, female), age (18–24, 25–34, 35–44, 45–54, 55–64, ≥65 years), race/ ethnicity (non-Hispanic white, non-Hispanic black, Hispanic, other), and marital status [married or living with a partner, previously married (divorced, separated or widowed), never married]. Socioeconomic status variables included employment status (employed, unemployed, retired) and annual household income (G25 K, 25 K to G50 k, ≥50 K, don’t know/not sure/missing). To characterize participants’ health characteristics, information on the presence of chronic health conditions, alcohol use, and smoking status were gathered from the GSPS. For the presence of chronic health conditions, a composite score was calculated by adding all positive responses to the questions ascertaining current asthma, arthritis, coronary heart disease, stroke, diabetes, and any health problem that requires using special equipment. Three categories were created (no chronic health conditions, one condition, two or more conditions). The occurrence of physical activity in the last month (yes/no) was categorized using this question: “During the past 30 days, other than your regular job, did you participate in any physical activities or exercises such as running, calisthenics, golf, gardening, or walking for exercise?” Excessive drinkers were defined as current drinkers who met either of the following criteria: (a) male respondents who reported having more than two drinks per day, or female respondents who reported having more than 1 drink per day in the past month; (b) respondents who reported having five or more drinks (for men) or four or more drinks (for women) on one or more occasions in the past month.44 To ascertain smoking status, the GSPS collected information on the following questions: “Have you smoked at least 100 cigarettes in your entire lifetime?” and “Do you now smoke cigarettes every day, some days, or not at all?” Respondents who had never smoked or smoked less than 100 cigarettes in their lifetime were categorized as never smokers. Respondents who reported having smoked at least 100 cigarettes in their lifetime and who were currently smoking were categorized as current smokers. Respondents who reported having smoked at least 100 cigarettes in their lifetime and who were not currently smoking were categorized as former smokers. Indicators on the presence of health care coverage, ability to cope, and self-reported social support were examined to capture participants’ level of social support and resilience. Health plan coverage (yes/ no) was categorized using the question “Do you have any kind of health care coverage, including health insurance, prepaid plans such as HMOs (health maintenance organizations), or government plans such as Medicare?” Participants’ self-reported ability to cope was assessed using five questions about resiliency/ coping, which consisted of 5 items from Pearlin and Schooler’s Mastery Scale.45 A Likert scale was used: 1 = strongly disagree, 2 = disagree, 3 = neither agree nor disagree, 4 = agree, 5 = strongly agree. A coping

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score (ranging from 5 to 25) was calculated by adding up the scores obtained from these five items with a higher score indicating better coping or mastery skill. Finally, self-reported social and emotional support was captured with the question “How often do you get the social and emotional support that you need?” The response was categorized to 1 = Always, 2 = Usually, 3 = Sometimes, 4 = Rarely or never or don’t know/not sure or refused. To characterize an individual’s exposure to the Deepwater Horizon oil spill disaster, several questions were gathered from the GSPS. Specifically, four relevant questions were examined: (1) Location of home with respect to the oil spill (proximal or non-proximal); (2) Did participants have direct contact with the oil? (yes/no); (3) Were participants involved in cleanup activities? (yes/no); and (4) How did the oil spill impact upon their job and/or income? (1 = no job loss or no income decrease; 2 = job loss; 3 = income decrease; 4 = both job loss and income decrease).

Community-level (contextual) characteristics To characterize community-level characteristics, and therefore, capture a community’s ability to cope and organize after a disaster, data on the Social Vulnerability Index (SoVI) for all counties involved in the GSPS were collected. The SoVI was designed by the Hazards and Vulnerability Research Institute and is a measure of a county’s overall vulnerability to environmental disasters. The SoVI was created using principal component analysis from indicators from the 2010 US Census and American Community Survey.46,47 Quartiles of the index were created for all counties involved in the GSPS. This resulted in an indicator to represent if a county had a low, mid-low, mid-high, or high level of vulnerability to a natural disaster. To enhance our description of counties’ level of economic resilience beyond the SoVI,21,47 indicators on the communities’ overall level of resources were gathered, for example, effective law indicator as collected from data reported by the Law Enforcement Management and Administrative Statistics and National Archive of Criminal Justice Data, resource inequity (i.e., Gini coefficient as reported by the 2010 US Census), and resource diversity (i.e., urban influence and natural amenities as reported by the US Department of Agriculture).21 All community-level data were collected closest to and before the date of the Deepwater Horizon oil spill to best represent the status of the counties shortly before the disaster and discussed in greater detail below. To further characterize a community’s overall level of resources, a variable was created to indicate the ability of the region in which individuals reside to maintain effective law and order for its constituents. More than just an indicator of crime,21 the variable was calculated as the ratio of total arrests over the total number of employed law enforcement agents in the area. Data on the total number of employed law enforcement agents were collected from the Law Enforcement Management and Administrative Statistics for 200748 and accessed through the Inter-university Consortium for Political and Social Research (ICPSR) at the University of Michigan.49 Additionally, data on the count of violent and property crimes that resulted in arrests by county for 2009 were collected from the National Archive of Criminal Justice Data (NACJD) accessed through ICPSR.49 All crime and law enforcement data were aggregated to the county level, a ratio of the count of crimes to the count of employed law officers was created. A ratio of the count of crimes to the population size reported by the US 2010 census at the county level was created (crimes committed per capita). Quartiles of the above two indicators were created for all counties involved in the GSPS. To characterize counties’ level of internal resource inequity, the Gini coefficient was collected from the United States Census 2010.50 The Gini coefficient ranges from 0 to 1 and measures the level of household income inequality within a county. The higher the coefficient, the more inequity exists in income throughout the county. Income inequality is likely to have negative effect on population health.51

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To characterize the counties’ level of resource diversity, two additional factors were included: the natural amenities score and the level of urban influence. As detailed in the work by Sherrieb et al. (2010), both the natural amenities score and the amount of urban influence for a county are useful indicators of a county’s level of resilience in the face of a disaster.21 Both the Natural Amenities Score52 and the Urban Influence Codes (reflecting the level of urban influence)53 were publically available and obtained from the US Department of Agriculture, Economic Research Service. The Natural Amenities Score was created in 1999 from several factors including the county’s climate, topography, and water area; the higher the scale the more natural amenities for a region.52 The Urban Influence Codes were gathered from 2003 US Census data and were used to identify both metro and non-metro regions by their size as well as identify non-metro regions on their proximity to metro areas, thus characterizing the level of urban influence rather than categorizing a location as merely urban or rural.53 Statistical analysis First, the prevalence of each health outcome of interest by selected individual- and county-level characteristics was examined. SAS-callable SUDAAN (release 9.0; Research Triangle Institute, Research Triangle Park, NC, USA) was used to account for the complex sampling design. Chisquare tests were conducted to examine the bivariate association between these characteristics and outcome variables. A P value less than 0.05 is considered statistically significant. Second, log linear regression was used to examine the adjusted prevalence ratios (APRs) and 95% confidence intervals for the presence of our health outcome variables (yes/no) in association with individual characteristics, oil spill effects, and county-level contextual variables. Three models were tested for each outcome, specified hierarchically to emphasize the nature of the examined factors. Model 1 included only individual-level factors. Model 2 included the factors for model 1 as well as factors related to the oil spill (proximity of county to affected Gulf region, direct contact with oil spill, and oil spill impact upon their job and income). Finally, model 3 included the factors in model 2 as well as each of the contextual variables, added individually in a stepwise manner.

Results Bivariate analysis Table 1 lists the results from weighted bivariate analysis. The following individual characteristics were associated with higher prevalence of the three adverse health outcomes: divorced, widowed, or separated; unemployed; having G$25,000 annual household income; having one or more chronic health conditions; current smokers; not participating in any form of exercise; having no health coverage; having a lower coping score; having suboptimal social and emotional support when needed, and loss of job or income decrease caused by the oil spill. In addition, older age was associated with higher prevalence of FPD and lower prevalence of depression. Direct contact with oil was associated with higher prevalence of both FMD and depression. The prevalence of depression was higher among females. No community-level variable was associated with any of the three health outcomes. Multivariate analysis Table 2 lists the results of the multivariable log linear regression with individual-level characteristics. The prevalence of FMD and current depression was higher among women [FMD: prevalence ratio (PR), 1.27; 95% confidence interval (CI), 1.03, 1.57; depression, (PR, 1.42; 95% CI, 1.14, 1.76)]. The prevalence of FMD and current depression were also associated

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Table 1 Weighted prevalence estimates for frequent physical distress, frequent mental distress, and depression by selected individual and contextual characteristics. Gulf States Population Survey (GSPS), December 2010–December 2011 % Frequent physical distress (95% CI)

% Frequent mental distress (95% CI)

% Current depression (95% CI)

37,664

37,805

36,669

14.2 (11.7, 16.6)

11.9 ( 9.7, 14.2)

16.8 (14.6, 19.1)

14.9 (12.9, 16.9)

0.12

0.058

12.7 (10.3, 15.2) 17.7 (15.3, 20.1) 0.004

18–24

8.8 (5.0, 12.6)

8.6 (5.8, 11.4)

25–34

7.7 (4.7, 10.7)

14.1 (10.4, 17.7)

35–44

15.0 (10.8, 19.2)

13.9 (9.9, 17.8)

45–54

19.3 (15.2, 23.5)

16.7 (13.1, 20.2)

55–64

20.6 (16.9, 24.4)

14.1 (11.2, 16.9)

65+

19.4 (15.1, 23.8)

12.0 (7.9, 16.2)

Sample size Gender Male Female P valuea Age

15.3 (10.0, 20.5) 13.3 (9.9, 16.9) 16.2 (11.8, 20.6) 20.4 (15.9, 24.9) 17.1 (13.3, 20.8) 10.2 (6.3, 14.0) 0.016

P value Race Non-Hispanic white

G0.001

0.02

13.9 (12.2, 15.5)

12.1 (10.6, 13.6)

Non-Hispanic black

16.7 (13.2, 20.2)

14.3 (11.1, 17.4)

Hispanic

20.2 (12.1, 28.3)

18.1 (10.3, 26.0)

Non-Hispanic other

20.2 (11.1, 29.3)

15.2 (7.9, 22.6)

0.14

0.29

13.3 (11.2, 15.4)

11.6 (9.5, 13.7)

23.3 (19.6, 27.1)

18.8 (15.6, 22.1)

14.1 (10.5, 17.7)

13.2 (10.2, 16.3)

G0.001

0.001

13.0 (10.7, 15.4) 19.5 (16.3, 22.7) 17.2 (13.3, 21.0) 0.0045

8.4 (6.5, 10.2)

8.5 (6.7, 10.2)

8.5 (5.7, 11.3)

P value Marital status Married or living with someone Divorced, widowed, or separated Never married P value Employment status Employed

Findings from the Gulf States Population Survey

13.0 (11.3, 14.8) 18.6 (14.8, 22.5) 18.3 (10.4, 26.1) 22.6 (12.6, 32.7) 0.01

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Table 1 (continued)

% Frequent physical distress (95% CI)

% Frequent mental distress (95% CI)

27.9 (24.1, 31.7)

24.9 (21.4, 28.4)

Retired 17.9 (14.1, 21.7) P value G0.001 Chronic health conditions (no.) None 6.9 (5.2, 8.5) 1 16.5 (13.4, 19.6)

11.0 (7.5, 14.6) G0.001

Unemployed

2 or more

27.8 (23.0, 32.6)

G0.001

G0.001

26.2 (22.5, 30.1)

24.0 (20.5, 27.6)

25,000–74,999

10.6 (8.5, 12.7)

9.3 (7.4, 11.3)

≥ 75,000 Unknown

8.4 (5.3, 11.5) 18.7 (14.0, 23.3)

8.5 (5.3, 11.7) 11.7 (8.0, 15.4)

G0.001

G0.001

16.7 (14.9, 18.6)

13.7 (12.0, 15.4)

9.6 (6.7, 12.5)

12.2 (9.2, 15.1)

P value Excessive drinking No Yes P value Smoking status Never smoker

G0.001

0.38

12.7 (10.5, 15.0)

11.1 (9.0, 13.2)

Former smoker

16.2 (13.2, 19.1)

11.0 (8.4, 13.6)

Current smoker

20.2 (16.5, 24.0)

21.2 (17.6, 24.7)

P value 0.003 Participate in any form of exercise Yes 10.7 (9.1, 12.4) No P value Current health plan Yes

30

32.9 (28.7, 37.1) 8.5 (5.7, 11.3) G0.001

8.4 (6.9, 9.9) 14.5 (11.3, 17.6)

41.8 (36.6, 46.9)

P value Household income G 25,000

% Current depression (95% CI)

9.2 (7.4, 11.0) 16.2 (13.0, 19.4) 33.6 (28.2, 38.9) G0.001 30.1 (26.0, 24.2) 10.6 (8.3, 13.0) 6.3 (3.2, 9.4) 13.6 (9.9, 17.3) G0.001 15.3 (13.4, 17.2) 15.5 (11.6, 19.4) 0.93 11.4 (9.2, 13.6) 14.2 (10.9, 17.6) 25.7 (21.5, 30.0) G0.001

G0.001 10.5 (8.9, 12.1)

28.1 (24.1, 32.1)

21.2 (17.7, 24.7)

G0.001

G0.001

14.4 (12.6, 16.2)

11.8 (10.1, 13.4)

The Journal of Behavioral Health Services & Research

11.5 (9.7, 13.3) 25.7 (21.7, 29.7) G0.001 13.6 (11.7, 15.5)

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Table 1 (continued)

No P value Coping score G 20

% Frequent physical distress (95% CI)

% Frequent mental distress (95% CI)

19.1 (15.2, 23.1)

19.5 (15.8, 23.2)

0.03

G0.001

24.7 (21.1, 28.1)

24.4 (21.0, 27.7)

≥ 20 9.5 (8.0, 11.0) P value G0.001 How often they get the emotional support they need Always 11.1 (9.0, 13.4) Usually 12.5 (9.6, 15.4) Sometimes Rarely, never, missing, don’t know P value Location of home Non-proximal Proximal

6.6 ( 5.4, 7.8) G0.001 6.9 ( 5.1, 8.8) 10.1 (7.5, 12.6)

23.8 (19.2, 28.5)

27.4 (22.5, 32.3)

34.1 (27.2, 41.0)

36.0 (29.2, 42.8)

G0.001

G0.001

15.6 (13.8, 17.5)

133 (11.6, 15.0)

15.0 (14.2, 15.9)

14.9 (14.0, 15.7)

P value Direct contact No

0.56

0.10

14.4 (12.8, 16.0)

11.9 (10.5, 13.4)

Yes

20.2 (11.7, 28.8)

23.7 (15.1, 32.3)

P value 0.21 Participate in cleanup activities No 15.0 (13.3, 16.7) Yes

0.016 12.8 (11.2, 14.3)

13.6 (6.7, 20.6)

11.3 (5.8, 16.8)

0.71

0.61

13.6 (12.0, 15.1)

10.5 (9.2, 11.9)

22.9 (16.5, 29.4)

23.4 (17.3, 29.9)

Income decrease

21.1 (0, 43.8)

24.2 (2.1, 46.2)

Both

16.5 (10.7, 22.2)

24.4 (16.8, 32.0)

P value Oil spill impact No job loss or income decrease Lost job

Findings from the Gulf States Population Survey

% Current depression (95% CI) 21.6 (17.4, 25.8) G0.001 27.9 (24.4, 31.5) 8.0 (6.3, 9.7) G0.001 7.0 (5.1, 9.0) 12.2 (8.9, 15.4) 31.7 (26.5, 37.0) 43.9 (36.7, 51.1) G0.001 15.3 (13.3, 17.2) 15.5 (14.6, 16.4) 0.80 13.8 (12.1, 15.4) 24.9 (16.1, 33.8) 0.026 14.5 (12.8, 16.3) 14.8 (7.8, 21.8) 0.94 11.9 (10.3,13.5) 23.5 (17.1, 30.0) 38.9 (17.3, 60.4) 34.3 (24.0,

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Table 1 (continued)

P value SOVI quartile Lowest vulnerability Mid-low vulnerability Mid-high vulnerability High vulnerability

% Frequent physical distress (95% CI)

% Frequent mental distress (95% CI)

% Current depression (95% CI)

0.04

G0.001

44.6) G0.001

14.2 (11.9, 16.6)

12.6 (10.5, 14.8)

14.8 (11.9, 17.7)

13.2 (10.3, 16.1)

17.8 (13.3, 22.3)

14.6 (10.6, 18.6)

20.0 (14.5, 25.5)

16.3 (11.6, 20.9)

P value 0.18 Crimes committed/employed law officers (quartile) Low 14.8 (12.5, 17.1)

13.4 (11.1, 15.6)

15.3 (12.8, 17.8)

11.5 (9.4, 13.7)

Mid-high

18.1 (13.3, 22.9)

18.7 (13.7, 23.7)

High

14.5 (12.0, 16.9)

15.9 (13.1, 18.7)

0.60

0.019

17.0 (11.8, 22.1)

14.9 (9.8, 20.0)

Mid-low

15.0 (11.8, 18.2)

14.8 (11.6, 18.0)

Mid-high

15.2 (11.8, 18.7)

13.5 (10.4, 16.5)

High

15.6 (13.4, 17.9)

13.1 (11.0, 16.5)

0.93

0.79

16.6 (12.8, 19.5)

14.8 (11.7, 17.9)

Mid-low inequity

18.7 (14.5, 23.0)

16.4 (12.3, 20.5)

Mid-high inequity

14.1 (11.5, 16.8)

10.6 (8.4, 12.8)

High inequity

14.1 (10.9, 17.2)

13.5 (10.5, 16.5)

P value GINI quartile Low inequity

P value 0.25 Urban influence code (higher is more rural)

32

0.50

Mid-low

P value Crimes per capita (quartile) Low

14.2 (11.8, 16.7) 15.6 (12.2, 19.0) 16.2 (12.0, 20.4) 18.1 (12.6, 23.6) 0.58 13.7 (11.3, 16.1) 14.8 (12.2, 17.4) 18.5 (13.6, 23.5) 16.7 (13.7, 19.7) 0.24 13.7 (8.7, 18.7) 15.5 (11.9, 19.2) 16.4 (12.4, 20.5) 15.1 (12.9, 17.4) 0.86 14.6 (11.4, 17.8) 20.9 (16.0, 25.9) 13.5 (10.8, 16.2) 13.3 (10.6, 15.9) 0.06

0.039

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Table 1 (continued)

% Frequent physical distress (95% CI)

% Frequent mental distress (95% CI)

G2

17.2 (13.8, 20.7)

13.4 (10.3, 16.5)

≥2

14.5 (12.9, 16.1)

13.5 (11.9, 15.1)

P value 0.16 Natural amenities rank (higher is more amenities) G4 15.0 (12.9, 17.1) ≥4 P value a

0.96 14.9 (12.7, 17.1)

15.7 (13.7, 17.6)

13.1 (11.3, 14.9)

0.66

0.24

% Current depression (95% CI) 15.0 (11.6, 18.3) 15.5 (13.7, 17.4) 0.77 15.5 (13.3, 17.8) 15.2 (13.2, 17.3) 0.85

P values are for Chi-square tests. A P value less than 0.05 is considered statistically significant

with younger age (global P valueG0.01), being unemployed at the time of the interview (PR, 1.53; 95% CI, 1.18, 1.98 and PR, 1.66; 95% CI, 1.27, 2.18 respectively); having multiple chronic conditions as compared with having none (PR, 2.34; 95% CI, 1.77, 3.09, and PR, 2.23; 95% CI, 1.70, 2.93); lower income (global P value=0.01, and pG0.01); being a current smoker as compared with never smoking (PR, 1.22; 95% CI, 0.95, 1.57, and PR, 1.35; 95% CI, 1.07, 1.70); not participating in any form of exercise (PR, 1.28; 95% CI, 0.96, 1.52, and PR, 1.26; 95% CI, 1.01, 1.58), and having suboptimal social and emotional support when needed (PR, 2.09; 95% CI, 1.50, 2.91, and PR, 2.10; 95% CI, 1.48, 2.98). The prevalence of FPD was associated with being unemployed as compared with employed (PR, 1.59; 95% CI, 1.21, 2.08); having multiple chronic health conditions as compared with having none (PR, 3.93; 95% CI, 2.81, 5.50); not participating in any form of exercise (PR, 1.54; 95% CI, 1.24, 1.92); and not having a current health plan (PR, 1.33; 95% CI, 1.05, 1.69). Table 3 lists the results of the log linear regression examining the association between the experience during and after the disaster and current health outcomes after accounting for individual-level characteristics. Direct contact with the oil spill was associated with negative health outcomes (FPD: PR, 1.44; 95% CI, 1.09, 1.91; FMD: PR, 1.63; 95% CI, 1.24, 2.16; and depression, PR, 1.58; 95% CI, 1.15, 2.16). Loss of job as a result of the oil spill as compared with no income change after the oil spill was associated with higher prevalence of depression (PR, 1.83; 95% CI, 1.02, 3.28). Loss of income and loss of a job as compared with no indirect financial impact after the disaster was associated with higher prevalence of depression (PR, 1.52; 95% CI, 1.08, 2.12). Table 4 lists the results of the multivariable log linear regression examining the additional association between county-level factors and current health outcomes after accounting for individual characteristics and experience during and after the oil spill. While most of the countylevel variables were not associated with current health outcomes, there was some variation in the association between the level of income inequality and the report of mental health in the past 30 days (pG0.01), but there was no apparent trend.

Findings from the Gulf States Population Survey

33

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Table 2

Non-Hispanic white Non-Hispanic black Hispanic Non-Hispanic other

18–24 25–34 35–44 35–54 55–64 65+

Male Female

Marital status Married or living with someone Divorced, widowed, or separated Never married Employment status Employed Retired Unemployed Chronic health conditions (no.) None 1 2 or more

Race

Age

Gender

– (0.94, 1.45) (0.89, 1.63) – (0.81, 1.92) (1.21, 2.08) – (1.49, 2.85) (2.81, 5.50)

Ref 1.25 1.59 Ref 2.06 3.93

– (0.71, 1.16) (0.88, 1.91) (0.64, 1.35)

– (0.45, 1.46) (0.67, 2.12) (0.62, 1.85) (0.59, 1.81) (0.46, 1.66)

– (0.89, 1.32)

95% CI

Ref 1.16 1.20

Ref 0.91 1.29 0.93

Ref 0.82 1.19 1.07 1.03 0.87

Ref 1.08

PR

G0.01

G0.01

0.30

0.41

0.57

0.42

P value

Frequent physical distress

Ref 1.55 2.34

Ref 1.24 1.53

Ref 1.15 0.87

Ref 0.85 1.31 0.84

Ref 1.25 1.02 0.77 0.65 0.61

Ref 1.27

PR

– (1.19, 2.01) (1.77, 3.09)

– (0.72, 2.14) (1.18, 1.98)

– (0.90, 1.46) (0.65, 1.17)

– (0.67, 1.08) (0.88, 1.94) (0.49, 1.42)

– (0.83, 1.89) (0.62, 1.68) (0.49, 1.21) (0.40, 1.06) (0.31, 1.18)

– (1.03, 1.57)

95% CI

G0.01

G0.01

0.19

0.22

G0.01

0.03

P value

Frequent mental distress

Ref 1.58 2.23

Ref 0.89 1.66

Ref 0.97 0.91

Ref 1.00 1.23 1.24

Ref 0.70 0.74 0.58 0.45 0.38

Ref 1.42

PR

– (1.23, 2.03) (1.70, 2.93)

– (0.45, 1.74) (1.27, 2.18)

– (0.79, 1.20) (0.70, 1.19)

– (0.79, 1.26) (0.82, 1.86) (0.87, 1.76)

– (0.47, 1.04) (0.48, 1.14) (0.38, 0.88) (0.28, 0.70) (0.19, 0.78)

– (1.14, 1.76)

95% CI

G0.01

G0.01

0.78

0.48

G0.01

G0.01

P value

Current depression

Frequent Physical distress, frequent mental distress and depression in association with individual characteristics as predictors: results from log linear regression models. Gulf States Population Survey (GSPS), December 2010–December 2011

Findings from the Gulf States Population Survey

35

No Yes

G25,000 25,000–74,999 ≥75,000 Unknown

– (0.82, 1.31) (0.85, 1.38) – (1.24, 1.92) – (1.05, 1.69) (0.64, 0.70) – (0.73, 1.30) (0.92, 1.62) (0.97, 1.76)

Ref 1.54 Ref 1.33 0.67 Ref 0.97 1.22 1.31

– (0.65, 1.22)

– (0.58, 0.97) (0.56, 1.16) (0.72, 1.26)

95% CI

Ref 1.04 1.08

Ref 0.75 0.81 0.95 ` Ref 0.89

PR

G0.01 0.20

0.02

G0.01

0.81

0.47

0.15

P value

Frequent physical distress

All individual characteristic variables were entered simultaneously for each health outcome A 95% confidence interval not including 1 is considered statistically significant PR prevalence ratio

Never smoker Former smoker Current smoker Participate in any form of exercise Yes No Current Health plan Yes No Coping score (in the increment of 5) How often they get the emotional support they need Always Usually Sometimes Rarely, never, missing, don’t know

Smoking status

Excessive drinking

Household Income

Table 2 (continued)

Ref 1.25 2.09 2.08

Ref 1.28 0.47

Ref 1.28

Ref 0.97 1.22

Ref 1.09

Ref 0.73 0.91 0.63

PR

– (0.91, 1.72) (1.50, 2.91) (1.48, 2.93)

– (1.01, 1.61) (0.45, 0.49)

– (0.96, 1.52)

– (0.74, 1.28) (0.95, 1.57)

– (0.86, 1.40)

– (0.56, 0.96) (0.65, 1.28) (0.45, 0.87)

95% CI

G0.01 G0.01

0.04

0.11

0.23

0.47

0.01

P value

Frequent mental distress

Ref 1.32 2.10 2.39

Ref 0.97 0.50

Ref 1.26

Ref 1.39 1.35

Ref 1.26

Ref 0.64 0.48 0.62

PR

– (0.94, 1.84) (1.48, 2.98) (1.67, 3.41)

– (0.77,1.22) (0.48, 0.52)

– (1.01, 1.58)

– (1.07, 1.81) (1.07, 1.70)

– (0.96, 1.65)

– (0.50, 0.83) (0.30, 0.78) (0.46, 0.84)

95% CI

G0.01 G0.01

0.80

0.04

0.01

0.09

G0.01

P value

Current depression

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Table 3

– (0.88, 1.11) – (1.09, 1.91) – (0.97, 2.36) – (0.45, 1.85) (0.95, 1.61) (0.57,1.38)

Ref 0.99

Ref 1.44

Ref 1.51

Ref 0.92 1.24 0.89

(95% CI)

0.37

0.07

0.01

0.86

P value

Ref 1.37 1.40 1.43

Ref 1.26

Ref 1.63

Ref 1.07

PR

– (0.71, 2.66) (1.03, 1.90) (0.98, 2.07)

– (0.73, 2.16)

– (1.24, 2.16)

– (0.95, 1.22)

(95% CI)

0.06

0.4

G0.01

0.27

P value

Frequent mental distress

Ref 1.83 1.10 1.52

Ref 1.39

Ref 1.58

Ref 0.95

PR

– (1.02, 3.28) (0.81, 1.48) (1.08, 2.12)

– (0.86, 2.25)

– (1.15, 2.16)

– (0.84, 1.07)

(95% CI)

0.02

0.18

G0.01

0.39

P value

Current depression

PR prevalence ratio a All models were run separately for each oil spill exposure for a total of 16 models. All models include individual characteristics listed in Table 2. A 95% confidence interval not including 1 is considered statistically significant

Location of home Non-proximal Proximal Direct contact No Yes Participate in cleanup activities No Yes Oil impact No effect Lost job Income decrease Both

PR

Frequent physical distress

Frequent physical distress, frequent mental distress, and current depression in association with oil spill exposure as predictors: results from loglinear regression models.a Gulf States Population Survey (GSPS), December 2010–December 2011

Findings from the Gulf States Population Survey

37

Table 4

– (0.75, 1.18) (0.96, 1.65) (0.78, 1.45) – (0.61, 1.37) (0.61, 1.39) (0.73, 1.57) – (0.97, 1.52) (1.08, 1.79) (0.85, 1.34) – (0.78, 1.38) (0.66, 1.13) (0.74, 1.33) (0.94, 1.02) (0.94, 1.15)

Ref 0.94 1.26 1.06 Ref 0.92 0.92 1.07 Ref 1.22 1.39 1.07 Ref 1.04 0.86 0.99 0.98 1.04

(95% CI)

0.28 0.42

0.47

0.05

0.46

0.26

P value

Ref 1.07 0.68 1.00 1.00 0.90

Ref 0.95 1.49 1.13

Ref 0.98 0.95 0.95

Ref 0.89 1.10 0.95

PR

– (0.81, 1.43) (0.52, 0.90) (0.75, 1.32) (0.96, 1.04) (0.81, 1.00)

– (0.75, 1.21) (1.14, 1.95) (0.88 1.45)

– (0.66, 1.48) (0.6,3 1.43) (0.65, 1.40)

– (0.70, 1.14) (0.82, 1.47) (0.67, 1.35)

(95% CI)

0.95 0.05

G0.01

0.01

0.98

0.59

P value

Frequent mental distress

Ref 1.21 0.84 0.95 0.98 1.00

Ref 1.18 1.35 1.09

Ref 1.01 1.06 1.10

Ref 0.99 1.16 0.96

PR

– (0.90, 1.65) (0.64, 1.11) (0.72, 1.25) (0.94, 1.02) (0.90, 1.13)

– (0.93, 1.50) (1.0,4 1.76) (0.87, 1.37)

– (0.69, 1.49) (0.72, 1.57) (0.77, 1.57)

– (0.79, 1.25) (0.87, 1.54) (0.68, 1.36)

(95% CI)

0.36 0.65

0.06

0.13

0.89

0.73

P value

Current depression

PR prevalence ratio a All models are run separately for each oil spill exposure for a total of 20 models. Models adjusted for individual characteristics, proximity of county to Gulf region, direct contact with oil spill, and oil spill effect

Lowest vulnerability Mid-low vulnerability Mid-high vulnerability High vulnerability Crimes committed per capita (quartile) Low Mid-low High-low High Crimes committed/employed law officers (quartile) Low Mid-low High-low High GINI quartile Low inequity Mid-low inequity Mid-high inequity High inequity Urban influence code (higher is more rural) Natural amenities rank (higher is more amenities)

SOVI quartile

PR

Frequent physical distress

Frequent physical distress, frequent mental distress, and current depression in association with county-level contextual factors as predictors: results from log linear regression models. Gulf States Population Survey (GSPS), December 2010—December 2011

Discussion Using data from a community-representative sample of residents of Gulf Coast states affected by the Deepwater Horizon oil spill, it was found that differences in individual characteristics and exposure to the disaster (whether direct or indirect exposure) were the drivers of the individual-level variation in health outcomes. Consistent with what has been determined through study of previous oil spills25,54 and exposure to disasters in general,7,10,11 there was no greater determinant of health indicators following the Deepwater Horizon oil spill than the direct exposure to the disaster itself. Direct exposure, what Palinkas coined as a tier-one exposure in his conceptual framework for mental health outcomes after oil spills, is a well-known driver of long-term health consequences in the aftermath of such a disaster.2,3,7,54 Palinkas showed that those who were directly exposed to the Exxon Valdez oil spill had a higher risk of long-term psychopathology and poorer physical health outcomes than those who were not.25,54 Our findings are consistent with work in other disasters; for example, Galea et al. (2007) found that in the aftermath of Hurricane Katrina, exposure to the disaster was the main driver of population health.10 Additionally, evidence suggested that certain sub-groups such as women and the young may be particularly vulnerable to mental health outcomes after the oil spill. It has been well-documented in the literature that55–57 certain characteristics such as gender, age, and income can help identify those most vulnerable to psychopathology after disasters, and therefore, help policy makers target interventions to better mitigate the mental health consequences of disasters. In contrast to evidence after the Exxon Valdez oil spill, those who were directly exposed through cleanup efforts were not found to be at greater risk of negative mental health.25,54 After the Exxon Valdez oil spill, local businesses and economies were disrupted both through environmental contamination and because employees left local jobs to receive higher-than-average salaries for their temporary cleanup efforts, thus affecting lives and livelihoods of many local economies.25,54 Additionally, when these temporary positions ended, many unskilled laborers became unemployed, as the local businesses had long since closed. With respect to the Deepwater Horizon oil spill, research suggests that the economic processes as a result of the oil spill will be more complex and nuanced than that of the Exxon Valdez disaster because of the variations of the state legislation and local economies along the Gulf Coast region.18,58 It is possible, therefore, that the general association between the cleanup efforts and mental health did not occur to the same extent as it did within Alaska after the Exxon Valdez oil spill. Indirect exposure, as measured by either income reduction or job loss, was also associated with increased negative health outcomes. This is consistent with observations about the relation between income loss and poor mental health after the Exxon Valdez oil spill,25 and in the earlier work that has been conducted after the Deepwater Horizon oil spill.29–32 The CASPAR (Community Assessment for Public Health Emergency Response) study reported that those who had reduced income were more likely to report mental health symptoms as compared with those who did not lose income after the oil spill.30 In heavily affected communities in southeastern Louisiana, disruption of participants’ livelihoods (e.g., work and family life) was similarly associated with increased risk of mental health symptoms.32 To fully understand the implications of the relation between indirect exposure and health, it is important to note that while direct exposure to a disaster may have the most consistent relation with negative health outcomes, indirect exposure usually affects a greater number of people.11,59 County-level contextual factors were not associated with health indicators following the Deepwater Horizon oil spill after accounting for individual-level differences and experiences. This is consistent with work by Grattan et al., who examined communities in Alabama and Florida directly and indirectly affected by the Deepwater Horizon oil spill.31 The authors found that the location of the community was not associated with mental health in the population and that communities both directly and indirectly exposed had elevated mental health symptoms.31 There

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are two likely explanations for this observation. First, in the context of an overwhelming event, the direct exposure to the event was in many ways the primary predictor and the amount of direct and indirect exposure to the oil spill masked potential community-level effects. Second, the sample sizes for non-proximal counties were rather small. The statistical power in this study is insufficient to detect inter-county variability with respect to our population.5 Longitudinal studies may help shed light on the complicated relationship between county-level factors and long-term mental health consequences resulting from indirect and direct exposure to the oil spills. This study has several limitations. First, the survey was initially conducted only in English and just in the 25 counties that lie within a region of 32 miles of areas closed to fishing following the oil spill. The addition of a Spanish version, the extension of the sample area to the entirety of the four states to allow comparison of results between proximal counties/parishes and other regions, and the addition of cell phones to the sampling frame were all added at a later date. All these changes might influence the comparability between health outcomes obtained from proximal and non-proximal counties/parishes. The mental distress associated with the disaster may diminish over time. The addition of non-proximal counties in a later time point may exaggerate the difference between proximal and non-proximal counties in prevalence of mental distress if any exists. However, the authors did not detect any difference in mental distress between these two regions. More sophisticated analysis on the effects of time lag is not feasible due to the limitation of the study design. Second, the study is based on selfreported data and not on clinical diagnoses of physical or mental health. Third, the time frames for different modules/questions were different in GSPS/BRFSS questionnaire. This may complicate interpretation of the study findings. Finally, the nature of physical or mental health problems was not ascertained. The extent of the relevance to the oil spill could not be directly established. In conclusion, the authors found that differences in individual characteristics and exposure to the disaster (whether direct exposure or indirect financial impact) were the drivers of the individual-level variation in health outcomes after the Deepwater Horizon Oil spill. Implications for behavioral health There are three central implications for practice that emerge from this work. First, in the context of an overwhelming event, persons who are most directly affected through direct exposure should be the primary focus for any public health intervention effort. Second, it bears noting that factors that characterize indirect exposure, such as earning a low income or job loss, are widely prevalent and may contribute to a greater burden of overall adverse population health than do factors that characterize direct exposure. Third, epidemiologic studies with more sophisticated designs and larger sample sizes would bear more power to assess the impact of a natural disaster.

Conflict of Interest The authors claimed no conflict of interest.

References 1. Institute of Medicine. Research Priorities for Assessing Health Effects from the Gulf of Mexico Oil Spill: A Letter Report. Washington, DC: The National Academies Press, 2010. 2. Norris FH, Friedman MJ, Watson PJ. 60,000 disaster victims speak: Part II. Summary and implications of the disaster mental health research. Psychiatry (Edgmont) 2002;65:240–260. 3. Norris FH, Friedman MJ, Watson PJ, et al. 60,000 disaster victims speak: Part I. An empirical review of the empirical literature, 1981– 2001. Psychiatry (Edgmont) 2002;65:207–239. 4. Maguen S, Neria Y, Conoscenti L, et al. Depression and Prolonged Grief in the Wake of Disasters. In: Y Neria, S Galea, F Norris (Eds). Mental Health and Disasters. New York: Cambridge Univeristy Press, 2009, pp. 116–130. 5. McFarlane A, Van Hooff M, Goodhew F. Anxiety Disorders and PTSD. In: Y Neria, S Galea, F Norris (Eds). Mental Health and Disasters. New York: Cambridge University Press, 2009, pp. 47–66.

Findings from the Gulf States Population Survey

39

6. van der Velden P, Kleber RJ. Substance Use and Misuse after Disaster: Prevalences and Correlates. In: Y Neria, S Galea, F Norris (Eds). Mental Health and Disasters. New York: Cambridge University Press, 2009, pp. 94–115. 7. Yzermans C, van den Berg B, Dirkzwager AJE. Physical Health Problems after Disasters. In: Y Neria, S Galea, F Norris (Eds). Mental Health and Disasters. New York: Cambridge University Press, 2009, pp. 67–93. 8. Norris F, Tracy M, Galea S. Looking for resilience: understanding the longitudinal trajectories of responses to stress. Social Science & Medicine. 2009;68:2190. 9. Norris FH, Stevens SP, Pfefferbaum B, et al. Community resilience as a metaphor, theory, set of capacities, and strategy for disaster readiness. American Journal of Community Psycholology. 2008;41:127–150. 10. Galea S, Brewin CR, Gruber M, et al. Exposure to hurricane-related stressors and mental illness after Hurricane Katrina. Archives of General Psychiatry. 2007;64:1427–1434. 11. Norris F, Wind L. The Experience of Disaster: Trauma, Loss, Adversities, and Community Effects. In: Y Neria, S Galea, F Norris (Eds). Mental Health and Disasters. New York: Cambridge University Press, 2009, pp. 29–46. 12. Pietrzak RH, Tracy M, Galea S, et al. Resilience in the face of disaster: prevalence and longitudinal course of mental disorders following hurricane Ike. PLoS One. 2012;7:e38964-e38964. 13. Bonanno G, Gupta S. Resilience after Disaster. In: Y Neria, S Galea, F Norris (Eds). Mental Health and Disasters. New York: Cambridge University Press, 2009, pp. 145–160. 14. Benight C, Cieslak R, Waldrep E. Distinctions that Matter: Received Social Support, Perceived Social Suppor, and Social Embeddedness after Disasters. In: Y Neria, S Galea, F Norris (Eds). Mental Health and Disasters. New York: Cambridge University Press, 2009, pp. 175–202. 15. Meijer M. Do neighborhoods affect individual mortality? A systematic review and meta-analysis of multilevel studies. Social Science & Medicine (1982). 2012;74:1204–12. 16. Diez Roux AV. Investigating neighborhood and area effects on health. American Journal of Public Health. 2001;91:1783–9. 17. Cope MR, Slack T, Blanchard TC, et al. Does time heal all wounds? Community attachment, natural resource employment, and health impacts in the wake of the BP Deepwater Horizon disaster. Social Science Research. 2013;42:872–881. 18. Gill DA, Picou JS, Ritchie LA. The Exxon Valdez and BP Oil Spills: A Comparison of Intitial Social and Psychological Impacts. American Behavioral Scientist. 2012;56:3–23. 19. Lee MR, Blanchard TC. Community Attachment and Negative Affective States in the Context of the BP Deepwater Horizon Disaster. American Behavioral Scientist. 2012;56:24–47. 20. Le F, Tracy M, Norris F, et al. Displacement, county social cohesion and depression after a large-scale traumatic event. Social Psychiatry and Psychiatric Epidemiology. 2013; 48(11): 1729–41. 21. Sherrieb K, Norris F, Galea S. Measuring Capacities for Community Resilience. Social Indicators Research. 2010;99:227–247. 22. Picou JS, Marshall BK, Gill DA. Disaster, litigation and the corrosive community. Social Forces. 2004;82:1493–1522. 23. Picou JS, Martin CG. Long-term impacts of the Exxon Valdez oil spill: Patterns of social disruption and psychological stress seventeen years after the disaster. Report prepared for the National Science Foundataion. Mobile: University of South Carolina; 2007. 24. Ritchie LA, Gill DA. Fostering resiliency in renewable resource communities: Subsistence lifescapes and social capital. In: JD Rivera, DS Miller (Eds). How ethinically marginalized Amreicans cope with catastrophic disasters: Studies in suffering and resiliency. Lewiston, NY: Edwin Mellon Press, 2010. pp. 51–81. 25. Palinkas LA. The Exxon Valdez Oil Spill. In: Y Neria, S Galea, F Norris (Eds). Mental Health and Disasters. New York: Cambridge University Press, 2009, pp. 454–472. 26. Palinkas LA, Petterson JS, Russell J, et al. Community patterns of psychiatric disorders after the Exxon Valdez oil spill. American Journal of Psychiatry. 1993;150:1517–1523. 27. Palinkas L, Downs M, Petterson J, et al. Social, cultural and psychological impacts of the Exxon Valdez oil spill. Human Organization. 1993;52:1–13. 28. Impact Assessment, Inc. Economic, social and psychological impact assessment of the Exxon Valdex oil spill. Final report prepared for Oiled Mayors Subcommittee, Alaska Conference of Mayors; 1990. 29. Buttke D, Vagi S, Bayleyegn T, et al. Mental health needs assessment after the Gulf Coast oil spill—Alabama and Mississippi, 2010. Prehospital and Disaster Medicine. 2012;27:401–408. 30. Buttke D, Vagi S, Schnall A, et al. Community Assessment for Public Health Emergency Response (CASPER) one year following the Gulf Coast oil spill: Alabama and Mississippi, 2011. Prehospital and Disaster Medicine. 2012;27:496–502. 31. Grattan LM, Roberts S, Mahan WT, et al. The early psychological impacts of the Deepwater Horizon oil spill on Florida and Alabama communities. Environmental Health Perspective. 2011;119:838–843. 32. Osofsky HJ, Osofsky JD, Hansel TC. Deepwater horizon oil spill: mental health effects on residents in heavily affected areas. Disaster Medicine and Public Health Preparedness. 2011;5:280–286. 33. Centers for Disease Control and Prevention. Behavioral Risk Factor Surveillance System. Available online at http://www.cdc.gov/brfss/. Accessed May 22nd, 2013. 34. Zahran HS, Kobau R, Moriarty DG, et al. Health-related quality of life surveillance—United States, 1993–2002. MMWR Surveillance Summary. 2005;54:1–35. 35. Kroenke K, Strine TW, Spitzer RL, et al. The PHQ-8 as a measure of current depression in the general population. Journal of Affective Disordors. 2009;114:11–11. 36. Spitzer RL, Kroenke K, Williams JB. Validation and utility of a self-report version of PRIME-MD: the PHQ primary care study. Primary Care Evaluation of Mental Disorders. Patient Health Questionnaire. The Journal of the American Medical Association. 1999;282:1737– 1744. 37. Spitzer RL, Williams JB, Kroenke K, et al. Validity and utility of the PRIME-MD patient health questionnaire in assessment of 3000 obstetric-gynecologic patients: the PRIME-MD Patient Health Questionnaire Obstetrics-Gynecology Study. American Journal of Obstetrics & Gynecology. 2000;183:759–769. 38. Kroenke K, Spitzer RL. The PHQ-9: A new depression diagnostic and severity measure. Psychiatric Annals. 2002;32:509–515.

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39. Patient Health Questionnaire (PHQ)-8 and Generalized Anxiety Disorder (GAD)-7 Screeners. Available online at http:// www.phqscreeners.com/. Accessed April 10th, 2013. 40. Dhingra SS, Kroenke K, Zack MM, et al. PHQ-8 Days: a measurement option for DSM-5 Major Depressive Disorder (MDD) severity. Popul Health Metrics. 2011;9:11. 41. Dhingra SS, Zack MM, Strine TW, et al. Psychological distress severity of adults reporting receipt of treatment for mental health problems in the BRFSS. Psychiatric Services. 2011;62:396–403. 42. Strine TW, Mokdad AH, Dube SR, et al. The association of depression and anxiety with obesity and unhealthy behaviors among community-dwelling US adults. General Hospital Psychiatry. 2008;30:127–137. 43. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. Journal of General Internal Medicine. 2001;16:606–613. 44. U.S. Department of Agriculture, U.S. Department of Health and Human Services. Dietary Guidelines for Americans, 2010. Available online at http://www.health.gov/dietaryguidelines/2010.asp. Accessed May 22nd, 2013. In. 7th ed. Washington, DC: U.S. Government Publishing Office; 2010. 45. Pearlin L, Schooler C. The Structure of Coping. Journal of Health and Social Behavior. 1978;19:2–21. 46. Cutter S, Boruff B, Shirley W. Social Vulnerability to Environmental Hazards. Social Science Quarterly. 2003;84:242–261. 47. Hazards and Vulnerability Research Institute. Social Vulnerability Index for the United States 2006–10. Available online at http:// webra.cas.sc.edu/hvri/products/sovi2010_data.aspx. Accessed May 22nd, 2013. 2012. 48. Bureau of Justice Statistics. Law Enforcement Management and Administrative Statistics (LEMAS). Available online at http:// www.bjs.gov/index.cfm?ty=dcdetail&iid=248. Accessed February 26, 2013. 49. Inter-university Consortium of Political and Social Research. ICRSR: find and analyze data. Available online at https:// www.icpsr.umich.edu/icpsrweb/ICPSR/. Accessed February 26, 2013. 50. U.S. Census Bureau. U. S. Census 2010. Available online at http://www.census.gov/2010census/data/. Accessed Feb. 26th, 2013. In. 51. Wagstaff A, van Doorslaer E. Income inequality and health: what does the literature tell us? Annual Review of Public Health. 2000;21:543–67. 52. U.S. Departement of Agriculture, Economic Research Service. Natural Ammenities Scale. Available online at http://www.ers.usda.gov/ data-products/natural-amenities-scale.aspx#.UYKNoCtoRSQ. Accessed May 22nd, 2013. 53. U.S. Department of Agriculture, Economic Research Service. Urban Influence Codes. Available online at http://www.ers.usda.gov/ briefing/rurality/. Accessed May 22nd, 2013. 54. Palinkas LA. A conceptual framework for understanding the mental health impacts of oil spills: lessons from the Exxon Valdez oil spill. Psychiatry (Washington DC). 2012;75:203–222. 55. Neria Y, Nandi A, Galea S. Post-traumatic stress disorder following disasters: a systematic review. Psychological Medicine. 2008;38:467. 56. Galea S, Nandi A, Vlahov D. The epidemiology of post-traumatic stress disorder after disasters. Epidemiologic Review. 2005;27:78–91. 57. Boscarino JA. A prospective study of PTSD and early-age heart disease mortality among Vietnam veterans: implications for surveillance and prevention. Psychosomatic Medicine. 2008;70:668. 58. Ritchie LA, Gill DA, Picou JS. The BP Disaster as an Exxon Valdez Rerun. Contexts. 2011;10. 59. Galea S, Ahern J, Resnick H, et al. Psychological Sequelae of the September 11 Terrorist Attacks in New York City. New England Journal of Medicine. 2002;346:982–987.

Findings from the Gulf States Population Survey

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