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After Hurricane Floyd Passed: Investigating the Social Determinants of Disaster Preparedness and Recovery

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In September 1999, Hurricane Floyd struck eastern North Carolina. Investigators from the health promotion study "Health Works for Women/Health Works in the Community" responded by initiating a focused research study, "Health Works After the Flood." Participatory research involving a multilevel design and qualitative methods was applied to investigate how community preparedness, response, and recovery are affected by social factors such as social capital, social cohesion, and collective efficacy. This article presents evidence from qualitative research conducted for "Health Works After the Flood" and links these findings to observations regarding current conceptualizations of social capital and related concepts.
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LWW/FCH AS294-03 May 25, 2004 15:31 Char Count= 0
Fam Community Health
Vol. 27, No. 3, pp. 204–217
c
2004 Lippincott Williams & Wilkins, Inc.
After Hurricane Floyd
Passed
Investigating the Social
Determinants of Disaster
Preparedness and Recovery
Spencer Moore, PhD, MPH; Mark Daniel, MSc, PhD;
Laura Linnan, ScD, CHES; Marci Campbell, PhD;
Salli Benedict, MPH; Andrea Meier, PhD
In September 1999, Hurricane Floyd struck eastern North Carolina. Investigators from the health
promotion study “Health Works for Women/Health Works in the Community”responded by initiat-
ing a focused research study, “Health Works After the Flood.”Participatory research involving a mul-
tilevel design and qualitative methods was applied to investigate how community preparedness,
response, and recovery are affected by social factors such as social capital, social cohesion, and
collective efficacy. This article presents evidence from qualitative research conducted for “Health
Works After the Flood” and links these findings to observations regarding current conceptualiza-
tions of social capital and related concepts. Key words: disaster preparedness,disaster recovery,
natural disasters,social capital
IN THE EARLY MORNING of September
16, 1999, Hurricane Floyd, a category-two
From the Departments of Health Behavior (Drs
Moore, Daniel, and Linnan) and Health Education,
Epidemiology (Dr Daniel), and Nutrition (Dr
Campbell), School of Public Health; the Center for
Health Promotion and Disease Prevention (Ms
Benedict); and the School of Social Work (Dr Meier),
The University of North Carolina at Chapel Hill.
This research was supported by the Centers for Dis-
ease Control and Prevention, Atlanta, Georgia (Grant
#S1217–19/19). The authors thank and appreciate all
community participants in the HWATF project. Our
words can not capture the grief and loss that many
eastern North Carolinians felt and still feel as a result
of Hurricane Floyd. We hope, nevertheless, that our re-
search can help bring attention to the importance of
planning for preparedness and the need for monitoring
and multisector support to enable the recovery of com-
munities over the course of disaster cycles. The authors
also thank our anonymous reviewers for insightful and
helpful suggestions and comments.
Corresponding author and reprint requests: Spencer
Moore, PhD, MPH, Centre for Health & Policy Stud-
ies, Department of Community Health Sciences, 3330
Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada
(e-mail: spencer.moore@ucalgary.ca).
storm with wind speeds of 110 mph, made
landfall at Cape Fear, North Carolina. Floyd’s
rains, combined with already high inland wa-
ter levels, caused unprecedented flooding
along three river basins: the North East Cape
Fear, Neuse, and Tar. Consequently, President
Clinton declared 66 North Carolina counties
to be federal disaster areas (Figure 1). Hur-
ricane Floyd became, in the words of for-
mer North Carolina governor Jim Hunt, “the
worst disaster to hit North Carolina in mod-
ern times” with 52 reported deaths.1
High winds, tornados, and a tidal surge re-
lated to Floyd caused vast damage across east-
ern North Carolina. Heavy rains brought a
further 15 inches of water to land already sat-
urated by rainfall from a lesser storm (Hurri-
cane Dennis) that had deluged the area two
weeks earlier. Cities, towns, and communities
throughout eastern North Carolina became
isolated as a result of flooding and impassable
ground networks.
At the time of the flooding, Health Works
for Women/Health Works in the Community
204
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After Hurricane Floyd Passed 205
Figure 1. North Carolina: declared federal disaster counties and HWATF counties.
(HWW/HWC), a worksite-based health pro-
motion study for women working in the
textile, manufacturing, and food processing
industries, was active in five eastern North
Carolina counties: Duplin, Lenoir, Pender,
Sampson, and Wayne. In response to the
needs of communities in these five counties
experiencing flooding, a new project, Health
Works After the Flood (HWATF), was initi-
ated by HWW/HWC to examine the social
determinants of community preparedness, re-
sponse, and recovery. Funded by the Cen-
ters for Disease Control (CDC) and managed
by the Center for Health Promotion and Dis-
ease Prevention at the University of North
Carolina at Chapel Hill, the HWATF initia-
tive was uniquely positioned to conduct pol-
icy relevant, multilevel research on macro-
social aspects of how communities respond
to and recover from a flooding disaster. Rele-
vant aims of HWATF were to develop, in rela-
tion to the impact and aftermath of Hurricane
Floyd, “home-grown” measures of social cap-
ital, social cohesion, and collective efficacy;
and to understand how such indicators relate
to community preparedness, responsiveness,
and capacity to recover from a natural disas-
ter. The term “home-grown” signifies locally
specific, contextualized measures developed
through a participatory research approach.
This article presents the conceptual frame-
work and methods used by investigators from
HWATF. In addition, preliminary findings from
a thematic analysis of HWATF focus group
and interview data are presented. Data re-
ported here are limited to qualitative find-
ings from local media, focus groups, and in-
terviews that relate to flood-related commu-
nity preparedness, responsiveness, and recov-
ery. These findings are discussed in terms
of theoretical challenges relevant to ongoing
analyses of HWATF data and their relation-
ship to contemporary meanings of social co-
hesion, social capital, and collective efficacy
for use in “real world”community-based inter-
ventions. In particular, dynamic community
processes relating to disaster relief and recov-
ery suggest a need, in terms of natural disas-
ters and possibly other contexts as well, for
critical appraisal of various prevailing under-
standings of social indicators, including so-
cial capital and similar concepts. While the
meanings of these concepts and the contro-
versy concerning their use are discussed later
in this article, the three concepts (as they are
frequently used in the health sciences litera-
ture) may be considered to refer collectively
to the degree of social integration in a com-
munity as indicated by extent of trust, reci-
procity, and civic engagement, as well as the
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206 FAMILY &COMMUNITY HEALTH/JULY–SEPTEMBER 2004
capacity of community members to act to-
gether to pursue common goals based on
these attributes.
METHODOLOGY
Setting and context: Eastern North
Carolina
The two projects—HWW/HWC—have
been active in eastern North Carolina for
several years.2–5 Primarily rural and agricul-
tural, Duplin, Lenoir, Pender, Sampson, and
Wayne counties lie in the southeastern part of
North Carolina (Figure 1). Relative to North
Carolina averages, these five counties have
lower household and per capita income, a
greater proportion of children and families
living below the federal poverty level, and
a higher percentage of minorities, including
Latinos (Table 1). Minority status and income
are considered to be important indicators
for examining the influence of race, ethnic-
ity, and class on disaster preparedness and
recovery.6
The towns and residents of all five counties
experienced flooding associated with Hurri-
cane Floyd. In Sampson County, flooding oc-
curred primarily along the Black River and
hit hardest in the southern tip of the county
and in towns including Harrells, Tomahawk,
and Ivanhoe. Residents of Ivanhoe, ostensibly
accustomed to periodic flooding of the low
plain on which the town stands, were sur-
prised by the intensity of the flooding that cut
them off from the rest of the county, with-
out useable well water, phones, and power
for more than four days.7Flooding affected
Duplin County more severely. The Northeast
Cape Fear runs through the southern portion
of the county, and its rising waters created
a lake over the town of Chinquapin. At its
peak, the floodwater covered more than 50
homes, a church, and the main part of town.
Some 500 residents were isolated and forced
to evacuate in boats and helicopters.8Other
areas of Duplin County were also isolated as a
result of the flooding. Pender County, which
lies south of Duplin, was also heavily affected
Table 1. Select sociodemographic and socioeconomic data for HWATF counties
Under
Race (%) 1999 1999 18 years
Sociodemographic Persons Graduated Household Per old, in Families
and socioeconomic Population aged 65+African Hispanic from High Median Capita poverty in poverty
characteristics Population density(%) White American or Latino School (%) Income Income (%) (%)
North Carolina 8,049,313 165.2 12.00 72.1 21.6 4.7 78.1 39,184 20,307 15.7 9.0
Duplin County 49,063 60.0 12.90 58.7 28.9 15.1 65.8 29,890 14,499 22.5 15.3
Lenoir County 59,648 149.2 14.60 56.5 40.4 3.2 71.9 31,191 16,744 22.0 12.6
Pender County 42,007 47.2 14.1 72.7 23.6 3.6 76.8 35,902 17,882 18.6 9.5
Sampson County 60,161 63.6 12.80 59.8 29.9 10.8 69.1 31,793 14,976 21.5 13.5
Wayne County 113,329 205.1 11.60 61.3 33.0 4.9 77.2 33,942 17,010 18.6 10.2
Persons per square mile.
Source: Data from US Government, 2000 US Census Data. Available at: www.census.gov. Accessed March 2002.
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After Hurricane Floyd Passed 207
by the flooding, particularly in the vicinity of
Burgaw (see Figure 1).
Lenoir and Wayne counties were the sites
of some of the most dramatic events of the
Floyd floods. The Neuse River, which runs
through the county seats of Kinston and
Goldsboro, respectively, crested at 27.7 feet,
almost 13 feet above its regular flood stage.9
More than 300 residents of southeastern
Kinston had to leave their homes, and
Kinston’s overloaded wastewater system sub-
sequently caused sewage backups in down-
town buildings and homes.10 Other communi-
ties in Lenoir County, such as Pink Hill,
Grifton, and Tick Bite, were also damaged
by floods. In Wayne County, flooding engul-
fed 90 of Seven Spring’s 94 homes and
businesses.9Interstate 40, which runs
through parts of Pender, Duplin, and Samp-
son, was completely flooded near Burgaw
with cars submerged beneath the waters.
All but one of the 12 participating work-
sites were forced to shut down for several
days due to power outages, flooded roads,
or flooding in and immediately surrounding
the plants. HWC worksites lost from 1 to 10
days of operation, with an average loss of 2.5
days. Of 1,250 women participating in the
HWW/HWC study, 36% were personally af-
fected by the floods, with consequent prop-
erty damage, loss of income, and other unto-
ward outcomes.
Conceptual distinctions
Research on disasters and disaster manage-
ment has typically divided the disaster event
into four phases: preparation, response, re-
lief, and recovery.11–13 To these four phases,
some researchers also include a “warning”
phase between the preparation and response
phases.14 While we acknowledge the impor-
tance of this phase as a component of the dis-
aster cycle, HWATF grouped warning-related
events within the preparation phase. Rather
than existing in a simple linear relationship,
these four phases are traditionally seen as be-
ing cyclic in nature.12 This vision of cyclical
patterns in disaster events suggests that com-
munities might use their recovery phase to
prepare for, or to mitigate, effects of a possible
future disaster. It also suggests that commu-
nities vulnerable to disasters will remain so,
without enactment of mitigation measures to
prevent or buffer a potential disaster.6,15
The traditional representation of the dis-
aster event cycle is easily extended from
the community to the county. Individual and
household-level factors have been shown to
influence the capacity of individuals, house-
holds, and communities to respond to or re-
cover from a disaster.15 The HWATF team
hypothesized that the economic, human, and
social resources and structures of a county
could also influence the capacity of indi-
viduals, households, and communities to be
prepared for, respond to, or recover from a
disaster.6Thus, to the extent that the five
HWATF counties fall below state averages in
important economic and social indicators,
these counties might experience greater diffi-
culty than more affluent counties in preparing
for or recovering from a disaster.
The HWATF initiative did not assume a
direct relationship between individual, com-
munity, and county-level vulnerability and
capacity to prepare for, respond to, or
recover from the Floyd-related floods. In-
stead, as shown in Figure 2, we hypothe-
sized that social factors such as social co-
hesion, collective efficacy, and social capital
might operate as moderating variables. The
role of these social factors will be exam-
ined in future reports. Yet, as documented
here, the disaster context itself raises impor-
tant questions about the appropriateness of
Figure 2. HWATF conceptual model.
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208 FAMILY &COMMUNITY HEALTH/JULY–SEPTEMBER 2004
prevailing definitions and measures of these
concepts.
In the field of public health, research on
concepts such as social cohesion, social capi-
tal, and collective efficacy has brought atten-
tion to the contextual influences of place and
the social environment on health.16–17 Social
cohesion can refer to processes by which in-
dividuals have the desire or capacity to live to-
gether in some harmony.18 The concept of so-
cial cohesion has focused on issues of social
solidarity, participation, and integration, in
particular.19 Social cohesion has been viewed
as an independent variable20 as well as a medi-
ating variable,19 influencing important health
outcomes.20
Various understandings of social capital ex-
ist, but the concept as defined by Robert
Putnam and utilized in the work of Ichiro
Kawachi has been that most frequently
employed in public health:21,22 “networks,
norms, and trust—that enable participants
to act together to pursue shared objecti-
ves.”23(p34) Social capital has been promul-
gated as an ecological characteristic of com-
munities and an important mediator of health
effects attributed to income inequality.24 Al-
though controversial, one of the fundamen-
tal properties ascribed to social capital is
non-exclusive benefits (ie, an individual com-
munity member is presumed to benefit from
living in a community or society with high
levels of interpersonal trust, etc., regardless
of that person’s position or influence in the
community).
The concept of collective efficacy is meant
to capture the link between the degree of mu-
tual trust in a neighborhood and residents’
willingness to act for the public good of
that particular neighborhood.25,26 Sampson
and colleagues26 have measured collective ef-
ficacy by blending scales on informal social
control and social cohesion. “Informal social
control”is considered to represent the capac-
ity of a group to regulate by nonformal mech-
anisms the actions and behaviors of members
to achieve a common goal.26
Events such as natural disasters make it
possible to study concepts such as social co-
hesion, collective efficacy, and social capital
in an unusual, yet important context. The
circumstances surrounding Hurricane Floyd
and its aftermath enabled investigators to
learn firsthand from those experiencing the
disaster how these important concepts res-
onated (or did not) across the four stages of
a disaster event cycle: preparation, response,
relief, and recovery.
Methods
Multiple data collection methods were
used, including focus groups, photo
voice methods, key-informant interviews,
participant-observation fieldwork, collection
of archival data (newspaper reports), and
surveys of individuals. These methods were
used at three levels of the social ecological
framework: individual, organization, and
community. A core set of questions were
asked across all methods—integrated into
the focus group scripts, interview questions,
and photo voice assignments. Data were
collected over two years following the flood.
This article presents materials from the focus
group, interview, and archival data sources.
Focus groups
Focus groups were conducted at both the
organizational (“blue collar” worksite) (n=
8) and community (n=3) levels. The sam-
pling frame and design of the parent project,
HWW/HWC, determined the selection of
worksites and counties in which focus groups
could be conducted. Worksite focus groups
took place in the companies participating in
the HWW/HWC health promotion program
and were open to all employees regardless of
gender or whether they were active partic-
ipants in the HWW/HWC health promotion
program in that worksite. Community-level fo-
cus groups targeted communities or neigh-
borhoods within the five-county HWW/HWC
program area that had been specifically af-
fected by the flooding. Community-level fo-
cus groups were held in southern Sampson
County (n=2) and the city of Kinston in
Lenoir County (n=1). The median size of
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After Hurricane Floyd Passed 209
the worksite groups was 9 members (range
5–13), whereas the community focus groups
were smaller with a median size of 4 members
(range 4–10). Ninety-two percent of the par-
ticipants in both the worksite and community
focus groups were women.
The focus group script was first piloted
at one of the worksites and modified based
on the pilot testing. The same focus group
script was employed at worksite and commu-
nity levels. A structured script solicited par-
ticipants’ responses to questions about their
communities before, during, and after the
floods. The 10 focus group interview ques-
tions prompted group members to recall their
experiences immediately prior to and after
the hurricane and flood of September 1999
and during the recovery process over the fol-
lowing year (see Apppendix 1). Participants
were asked to discuss four aspects of the dis-
aster experience: 1) their personal and their
county’s preparedness for such a disaster; 2)
their thoughts and feelings and active efforts
to cope during the flood; 3) their experiences
with and perceptions of community and
state agency responses to the emergency and
later recovery; and 4) their experiences with
families, neighbors, and community agencies
coming to the aid of flood victims during
the emergency and in the recovery period
afterwards.
Key informant interviews
Sixteen key-informant interviews were con-
ducted with volunteers for local nonprofit
organizations, community and religious lead-
ers, and local government officials in all five
HWC-project counties. These representatives
were chosen on the basis of their county or
city administrative position (eg, emergency
management or assistant county managers),
as well as on the basis of leadership in flood-
related relief activities, as identified by local
officials or as reported in local newspapers.
Interviews included the core set of questions,
along with questions to elicit a more general
discussion on county-wide events during the
flooding.
Secondary data sources
Newspaper reports and census data were
drawn on to complement HWATF data. News-
paper reports provided information on flood-
related North Carolina governmental policies
as well as the experiences of residents in other
eastern North Carolina counties. US census
data from 1990 and 2000 were obtained and
used to contextualize participant responses
in terms of area variation in aggregated data
on income, race, gender, and household
type.
ANALYSIS AND PRELIMINARY RESULTS
Results presented here describe prelimi-
nary findings concerning flood-related com-
munity preparedness, responses, and recov-
ery issues. Results are based on the content
and thematic analyses of focus group and key-
informant interview transcripts and comple-
mented by the comments of eastern North
Carolinian residents as found in local news-
papers. Content and thematic analyses were
performed using Atlas.ti,27 a computerized
qualitative data analysis program. The anal-
ysis concentrated on the general themes of
the focus group protocol addressing individ-
ual and community preparedness, responsive-
ness, relief, and recovery. Preparedness in-
cluded descriptions of individual perceptions
of vulnerability to the flood and of actions
taken by individuals, households, or commu-
nities to limit the impact of the winds or
flooding associated with the hurricane. The
responsiveness and relief theme included de-
scriptions of the participants’ efforts to seek
safety, their descriptions of neighbors’ efforts
to help each other, and the emergency and
relief services provided to their communities
during and immediately after the flooding.
The recovery theme included descriptions of
participants’ experiences trying to get their
lives back to normal, the type of assistance
that they received from local, state, and fed-
eral authorities and nonprofit agencies, and
their perceptions about community efforts
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210 FAMILY &COMMUNITY HEALTH/JULY–SEPTEMBER 2004
to improve long-term preparedness for future
floods.
Preparedness
Me, personally, I thought it was gonna be pouring
rain, and then wind and rain and stop. It came all
at once. No one expected the flood. The water just
kept on coming. Thought it would just rain and the
next day it would be a pretty day. But the next day
we had a (knocks on table) firemen knocking on
the door, “Ya’llneed to leave, the waters rising; that
creek behind your house is gonna get high, high,
high.” (Focus Group #4)
Many participants indicated that they felt
prepared for the hurricane, but not for the
inland flooding that developed in the hours
and days following the storm. In the areas
where the flooding hit during the night, par-
ticipants reported being awoken to the sound
of water in their homes or neighbors knock-
ing on their doors. In those cases, residents
were forced to evacuate quickly leaving be-
hind valued possessions and family heirlooms.
Those who could fled to the homes of rela-
tives. Others were forced to go to community
shelters.
The unprecedented levels of flooding left
many participants feeling that there is no truly
effective way to prepare for potential future
exposures to extensive flooding. Other par-
ticipants, however, suggested that local au-
thorities and media outlets could have done a
better job of informing county residents of
potentially severe flooding. In one group,
members reported that they never received
any warnings. In another, members reported
that the information they received was
wrong.
Focus group members commented on the
ways that socio-economic factors affected
their individual and community vulnerabili-
ties. In one group, members noted that poor
people in their community were more vul-
nerable because they lived on lower ground.
In another group, members angrily described
how waters were released from reservoirs in
Raleigh to protect the urbanized areas from
flooding, without any apparent regard for the
risks to people living in smaller towns down-
stream.
In places such as Harrells, a small town
in Sampson County, a prevalent conception
was that news coverage did not sufficiently
report on local issues, instead concentrating
on events in more populated areas such as
Kinston and Goldsboro. Leaders of the lo-
cal Latino/Hispanic communities perceived a
lack of concern among county and state of-
ficials about warning Latino/Hispanic people
who were already largely marginalized from
the mainstream rural population. “I heard
something was coming, but the officials didn’t
know when or where. None of my bosses at
work told me anything. They don’t give any
interest to the Hispanic people,” said one lo-
cal resident.28 Compounding this was the rel-
ative unavailability of Spanish-language infor-
mation about the hurricane and flooding from
the media.
Response and relief
During the hurricane [my neighbors] were really
nice to me ...they came and got me and wouldn’t
let me stay in the house by myself and I told them
“the same Lord that’s in her house is in my house”
...I wasn’t too keen on leaving my house, but I left
to satisfy them. (Focus Group #8)
My sister-in-law was living on this back street and
we tried to get to her and they wouldn’t let us go no
where near her ...all she could do was stand back
and see how high the water was come up before
they could rescue her to bring her out, because
she was trying not to leave her house, but eventu-
ally they had to bring her out on a boat too. (Focus
Group #5)
Reports of heroic acts by rescuers, in-
numerable accounts of “neighbors helping
neighbors,”and the comments of HWATF par-
ticipants suggest that residents, stranded mo-
torists, relief workers, and rescuers worked
and came together in remarkable ways during
the relief and response phases of the disaster.
Like people get along better ...they can talk to
each other.. People who hadn’t talked before, they
talk now, a lot closer. That goes, not only for the
neighborhood, job-wise, organization-wise, and all
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After Hurricane Floyd Passed 211
that. ...[our] union sent some stuff for some of the
families that were flooded out. (Focus Group #4)
When asked if they thought that their
community came together during the flood-
ing, most HWATF participants replied “yes.”
While the meaning of “community” might
vary among participants according to the
place they live, the county in which they live,
or the church/worksite to which they belong,
most participants expressed the sense that
they found aid and solace in fellow commu-
nity members: “Nobody turned you down un-
less they were completely out of everything.
If they had it you could get it.”
Many local businesses, community orga-
nizations, and churches also rallied in sup-
port of flood victims. They donated food and
other emergency goods and provided sites to
receive donations. In two worksite groups,
members described how their companies had
collected emergency supplies and mobilized
workers from a nearby division to help with
relief effort. One company also provided shut-
tles to help workers get to work and, in one
case, furnished an employee who had lost her
car with one of the company cars.
However, not all accounts of the flood-
ing and postflooding events spoke of unity
and togetherness; other reports and state-
ments about the response and relief phases
described cases of looting and of certain peo-
ple taking advantage of the exceptional cir-
cumstances. In one focus group, members re-
ported that some smaller stores had engaged
in price-gouging for “badly needed stuff”such
as ice and batteries. HWATF participants of-
ten expressed that, at the time of the flood-
ing, they were strongly concerned about loot-
ing and felt the need to return quickly to their
homes to secure personal property: “You go
back, and this is gone and that is gone. Some-
body broke in and took people’s things. They
[looters] didn’t have a heart.”
In one of the worksite focus groups, mem-
bers reported that the company had been
unsupportive. Participants were angry that
they had not been allowed to leave work
early to prepare for the storm. Afterwards, the
company did hand out short-term emergency
loans, but workers were resentful about be-
ing forced to pay the money back, when they
were in such difficult straits:
They didn’t give us the money; they offered it to us
and we had to pay it back! A loan. Which I didn’t
think was right, you know. We had to pay it back
out of our own checks [within 30 days.] (Focus
Group #6)
Some focus group members recognized
that the enormity of the disaster made it im-
possible to meet all victims’ needs. In one
group, however, members faulted agencies in
charge of emergency assistance for being un-
fair in their distribution of aid or for having
the wrong priorities:
When I went to Red Cross, they told me that they
would give me $150 for me, my husband, and my
little boy. There was some people that didn’t get
any water and they got $500 and more. (Focus
Group #7)
People that wasn’t flooded got help before the peo-
ple that was flooded. The people that was flooded
was trying to get their homes situated ...while we
were preparing our homes, the ones that weren’t
flooded were getting the help.(Focus Group #7)
Recovery
[The Red Cross] served us hot meals, parcels, wa-
ter, a lot of basic things. They also helped us in
starting to rebuild. They gave us vouchers to get
furniture and they gave us vouchers to get clothes.
(Focus Group #2)
When asked if the “feeling of togetherness”
that they recalled during the response and
relief phase continued to exist in their com-
munities after the flood, most participants
responded “no.” Indeed, some HWATF par-
ticipants no longer reside in the communi-
ties in which they lived prior to September
1999. Many of those in the harder hit areas
have relocated to live with family or friends
in other counties or were forced to live in-
definitely in temporary housing accommoda-
tions away from their homes. Commenting
on the lack of attention given to finding and
helping local residents, one participant stated,
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212 FAMILY &COMMUNITY HEALTH/JULY–SEPTEMBER 2004
For example, in January 2002, over
two years after the flooding, over
3,000 families were still waiting
for assistance guaranteed by the
North Carolina Crisis Housing
Assistance Funds.
“About eight months ago, we tried to put a
survey together and we estimated approxi-
mately 400 people that we don’t know where
they’re at. But do you think anybody around
here cares? But there again, I can show you
all these empty houses, but I can’t tell you
where all the people are who were living in
them.”
With support from the federal government,
the state of North Carolina committed some
$836 million for emergency aid to flood vic-
tims. The majority of these funds were allo-
cated to housing repair and reconstruction
programs.29 With over 56,000 houses dam-
aged, 17,000 made uninhabitable, and 7,000
houses destroyed by the flood,30 housing re-
construction remains a challenge for eastern
North Carolina. For example, in January 2002,
over two years after the flooding, over 3,000
families were still waiting for assistance guar-
anteed by the North Carolina Crisis Hous-
ing Assistance Funds.31 Of the HWATF study
counties, the proportion of authorized repair
and replacement units completed by January
2002 stood at 29% for Wayne County, 25% for
Duplin County, 12% for Lenoir County, and
10% for Sampson County.32 Such delays can
affect the trust that residents have in their lo-
cal government.
I know this woman, the storm came and messed
up her house right. Anyway the government or
whatever or however they was gonna give her
help ...get a trailer. So they, the state, burnt down
her other house, you know; they went in and seen
what need to be fixed, and they said that it would
cost them too much money to fix everything so
they was gonna get her a house. Well, this has been
over a year ago ...they don’t know when she was
going to be able to get a house. (Focus Group #6)
Despite state pressure on local county gov-
ernments to speed up housing program de-
livery, counties have faced serious challenges
in effective implementation of programs. As
expressed by HWATF participants, one such
challenge involves securing licensed contrac-
tors willing to undertake renovation or recon-
struction projects with small profit margins.
Although nonprofit and faith-based organiza-
tions have undertaken to fill this gap, such
organizations have also found it increasingly
difficult to find local volunteers to help re-
build as memories of the Floyd floods fade:
“I can’t get any local volunteers here to volun-
teer help. I can get people from all over the
United States of America, I’ve even had volun-
teers from Alaska and Canada, but I can’t get
the churches, I can’t get anybody here to go
help anybody else.”
Some focus group members were skepti-
cal about whether their counties had “learned
anything”from the experience of 1999 floods.
They believed that government efforts to pre-
vent future floods were inadequate and that
flood prevention resources would not be dis-
tributed equitably. They mentioned that, since
the flood, counties had not done a good job
of keeping the drainage ditches clear of de-
bris and that bridges over the rivers were
not high enough to surmount future high
water levels. Some reported that they had
been unable to obtain flood insurance be-
cause they lived below the 100-year flood
plain. In one group, members again raised
the issue of socio-economic discrimination.
Members believed that state officials did not
value their counties as much as they did other
more prosperous areas in the state. As a re-
sult, hurricane-prone tourist destinations in
the coastal counties would continue to re-
ceive more funding for flood control.
You know once you go to the water what’s going
to happen, but yet and still, it’s quicker to get more
help down there in the tourist area to pump up the
tourist to get the money in down there. Who is the
money going for ...it’s not going for us ...it’s not.
They will give us just enough to shut your mouth
up so they can keep pumping it over there. (Focus
Group #7)
LWW/FCH AS294-03 May 25, 2004 15:31 Char Count= 0
After Hurricane Floyd Passed 213
DISCUSSION
The anthropologist Victor Turner33 used
the concept “communitas” to describe the
momentary upsurge in collective unity and
spirit associated with certain ritual events
and social crises. Communitas refers to
brief moments in which social structural
differences are no longer important and a
“full unmediated communication”among per-
sons might occur.33 Referring to such col-
lective moments as “altruistic or therapeutic
communities,”34–36 mental health researchers
have also identified and recorded the upsurge
of mutual assistance and solidarity that can
overtake whole communities in the immedi-
ate wake of a disaster. Yet, even if this im-
age of collective unity is accepted uncritically,
it must be kept in mind that experiencing
communitas or an “altruistic community” is
of a temporary nature. While eastern North
Carolinians spoke of a strong collective spirit
associated with the immediate response and
relief period as neighbors helped neighbors
or as flood victims found support from local
churches or nonprofit organizations, such de-
scriptions and narratives shifted in the later
phases of the disaster cycle.
In place of comments about solidarity and
mutual assistance, HWATF participants de-
scribed the later phases as being character-
ized by a general lack of concern on the
part of fellow residents and governmental
authorities for flood victims. This sense of be-
ing neglected stands in sharp contrast to feel-
ings of mutual assistance and common iden-
tity expressed about the period immediately
following the disaster. Mental health profes-
sionals have reported similar sequential reac-
tions to disasters—a period of heroic unity
and mutual support followed by a period
of disillusionment and anger—that they at-
tribute to psychological after-effects37 or the
deterioration of perceived social suppport.35
Other researchers have suggested, however,
that larger social forces may be influencing
individual responses and capacity to develop
and sustain social support resources.35–37 For
example, the degree of social stratification in
The significance of these earlier
findings and of those of HWATF
requires that the issue of community
change over the disaster cycle
be addressed.
a community has been used to explain both
the victims’ differential exposure to stressors
and their access to resources.36 The signifi-
cance of these earlier findings and of those of
HWATF requires that the issue of community
change over the disaster cycle be addressed.
Yet, much previous work on social indica-
tors has suffered from an over reliance on
cross-sectional data obtained from or about a
specific community at one time point. As a re-
sult, these indicators may not be true indica-
tors of the dynamics of community change in
the course of a disaster cycle or indeed any cri-
sis in a community. Three points may be made
in this regard. First, the suddenness of a dis-
aster and the usual inability of researchers to
respond immediately (eg, due to lack of fund-
ing in close proximity to the event) creates
delays and temporal problems in assessing the
dynamics of change. A survey, interview, or fo-
cus group occurs at a particular point in time
that may be weeks or months after the initial
crisis. In addition, practical constraints reduce
the possibility that all interviews or groups
can take place at the same time or even close
to the precipitating event. In practice, there-
fore, participants’ responses or comments re-
garding community trust or recovery could
change as the disaster cycle passes through
various phases. Careful research is needed to
document these changes in a timely fashion
to understand better the true impact on com-
munity health and measures of community
cohesion and efficacy. In addition, research
on disasters constitutes something of a “mov-
ing target” in terms of community attention.
Whereas individuals may report experiences
and perceptions indicative of high levels of
trust, social cohesion, or collective efficacy
in the early phases of a disaster, a decrease
LWW/FCH AS294-03 May 25, 2004 15:31 Char Count= 0
214 FAMILY &COMMUNITY HEALTH/JULY–SEPTEMBER 2004
in government or community support during
the disaster may lead to changes in the way
people view their community and their place
in it.
Second, there is a socio-economic dispar-
ity that predisposes certain groups to disas-
ter vulnerability. Factors such as race, eth-
nicity, class, gender, age, health, income, and
household living arrangements can each af-
fect the capacity of groups, households, and
individuals to prepare for, respond to, or re-
cover from a natural disaster.11,39,40 Land set-
tlement patterns in eastern North Carolina (as
in much of the world) reflect this political
economy of vulnerability. Historically, the po-
litical, social, and economic marginalization
of African Americans, Latinos, other minority
groups and the poor in the Southern United
States has meant that many such households
have had little choice but to settle in low-
lying flood plains where land is more afford-
able. The result of such settlement patterns
is that minority groups remain disproportion-
ately vulnerable to inland flooding, which fre-
quently occurs with hurricanes. The histori-
cal disempowerment and marginalization of
both minority groups and the poor did not,
in the example of Hurricane Floyd, disappear
with brief moments of unity and togetherness.
Although reports of community cohesiveness
and togetherness at the time of the floods
were frequent, research measures should be
able to reflect the re-entrenchment (at per-
haps greater levels) of social inequalities that
occur over the course of the disaster cycle.
Yet, current measures of social capital, social
cohesion, and collective efficacy serve bet-
ter to capture people’s sentiments and per-
ceptions of community relations, rather than
the resources belonging to those communi-
ties. Without concurrent attention to commu-
nity resources, however, such concepts will
not adequately describe pre-existing inequal-
ities among communities or those disparities
that arise from or are attenuated by a disaster
event.
Third, we hypothesize that to more ade-
quately describe and understand the dynam-
ics of social change and disaster recovery war-
rants a reconsideration of current conceptu-
alizations of social indicators such as social
capital. For example, Kawachi’s24 conceptu-
alization of social capital emphasizes the idea
that social capital is a collective asset or pub-
lic good available to all community members.
Others have provided alternative definitions
of the concept. For example, Bourdieu41 ar-
gues that social capital consists of the re-
sources to which individuals or groups might
have access through their own particular so-
cial networks.In contrast to Kawachi’s24 ear-
lier formulation, Bourdieu41 suggests that so-
cial capital is less a public good than the
property of specific individuals or groups and,
thus, may be unequally distributed in soci-
ety. More influential (ie, well-connected and
powerful) individuals or groups in a commu-
nity may be able to accumulate and call upon
such resources at the potential expense of
other individuals and groups.42 In the con-
text of a natural disaster, it may be that
certain groups or neighborhoods have more
resources to draw or call upon during a cri-
sis. Such groups may therefore recover more
quickly and effectively than others in a com-
munity. This point emerged strongly in the
focus groups, in the context of which more
affluent groups in the community (eg, the
tourist areas) would be more likely to re-
ceive help and resources. Hence, hypotheses
for future investigation should assess whether
the distribution of social capital in a commu-
nity is related to postdisaster differentials in
recovery and, if so, whether inequities in as-
sistance and recovery aid mediate variation in
recovery.
CONCLUDING REMARKS
Current conceptualizations of social cohe-
sion, social capital, and collective efficacy
may perform arguably well in capturing cer-
tain aspects of social relationships as reflected
through individual feelings of trust, norms of
reciprocity, and degree of civic involvement.
Yet, when called upon to capture the pro-
cesses of marginalization and exclusion that
LWW/FCH AS294-03 May 25, 2004 15:31 Char Count= 0
After Hurricane Floyd Passed 215
can occur over the course of the disaster cy-
cle, current conceptualizations and measure-
ments are in need of improvement. How do
intra- and inter-community dynamics influ-
ence the capacity of individuals, households,
or communities to prepare for, respond to, or
recover from disastrous events?
To begin answering such a question, re-
searchers should be prepared to delve deeply
and thickly into local contexts. While the con-
cepts of reciprocity and trust are frequently
used to measure social capital, an examination
of the contexts in which disaster prepared-
ness, relief, and recovery takes place show
the advantages of a qualitative approach that
grounds these concepts in the local experi-
ences of communities over the disaster cycle.
One advantage of such an approach is that
it highlights the dynamic processes of com-
munity change. For example, if we hypothe-
size that a feeling of shared experience in a
disaster is the source of community-wide or
generalized trust in the early months after a
disaster, then we may ask how the processes
and events that take place over the disaster
cycle affect this sense of shared experience.
How do postdisaster differentials in recovery
among individuals, households, and commu-
nities lead to the breakdown of generalized
trust into its particularized forms? How might
policy initiatives seek to lessen these postdis-
aster differentials to help sustain community-
wide and community-led recovery and de-
velopment? In its next phases, HWATF will
attempt to provide answers to these and re-
lated questions through analyses of the differ-
ing disaster experiences among HWW/HWC
counties.
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After Hurricane Floyd Passed 217
Appendix 1
Focus Group Script
HEALTH WORKS AFTER THE FLOOD
FOCUS GROUP SCRIPT
1. When the hurricane arrived, were you
prepared for it? Why or why not? Was the
county where you live prepared for it?
Why or why not? What else could you
(the county) have done to better prepare
for the hurricane?
2. Were some groups hit harder than oth-
ers? Which areas do you think were hit
the hardest? Why? Who lives in these
areas/towns/streets?
3. When the waters started rising, what
were some of your immediate thou-
ghts ...what did you do in response?
How about your neighbors?
4. When the waters were at their peak,
where were you and what kind of things
were you doing? How about some of
your neighbors?
5. When the waters start going back down,
what do you remember about going back
home or driving around your neighbor-
hood? What do you remember about the
county?
6. Based on your own experiences, which
organizations or state agencies were
most successful in aiding you or oth-
ers in recovering? In what ways did
they help? What organizations or agen-
cies were least helpful? Why or why
not?
7. Do you think that your neighborhood
came together during the flooding? Did
you feel a part of or left out of neigh-
borhood efforts? Who was working well
together? Do you think anyone was left
out? Who? What happened to make you
feel that way?
8. When did the willingness to help begin
to ebb? What happened to make you feel
that way?
9. Did you need aid or help from your
friends during the flooding? Were they
able to help you? Do you feel indebted
to others now in ways that you didn’t be-
fore? What kinds of things or activities
have you been thinking about doing in
your neighborhood or community since
the flooding?
10. As you approached the anniversary date
of the flood (September 2000), what
thoughts or feelings did you have? Is the
county or your local area still recovering
from the flooding? How?
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Border regions between different countries are of special interest in studying international relationships, which is a current topic in today’s globalized and interconnected world. To strengthen their disaster resilience, it is important for local decision-makers to understand the spontaneous willingness of the population to help affected people in their region. This article presents a novel framework based on Social Capital and Weiners’ Motivational Theory of Mutual Help to quantify peoples’ willingness to help (WTH) surveyed for the hypothetical case of a natural disaster. We compared the potential helping behavior between neighbored regions and neighbored countries in France and Germany, and also in the border area between the two countries. We found a significant correlation between trust and WTH in a neighboring region and identified determinants of WTH in a neighboring country. Implications for today’s world in terms of globalization and disaster response as the Covid-19 pandemic are discussed.
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Health and well‐being are promoted when primary care teams partner with patients and provide care coordination to mitigate risks and promote optimal health. Identification of patients for care coordination is typically based on claim‐driven risk assessments. Evidence shows that social determinants of health (SDOH) drive risk for adverse health outcomes but are omitted from existing risk tools. Missed opportunities for care coordination contribute to increased healthcare costs, poorer health outcomes and reduced patient well‐being. To address the gap of risk‐informed care coordination that includes SDOH, the aim of this project was to implement process improvement of a system's care coordination program through refined patient selection and customised engagement in intensive care coordination. A non‐randomised care coordination quality improvement project was conducted at a community health centre in 2020. Inclusion criteria (i.e. presence of risk attribution score, SDOH questionnaire completed) resulted in 540 patients being offered care coordination services; Patients having at least one month of care coordination were included in the analysis (N = 216). Analysis included the 216 patients that chose participation and the 324 patients that maintained usual care. Descriptive statistics were generated to distinguish patient demographics, frequency of care coordination contact, and specific SDOH insecurities for both the study and comparison groups. Paired t‐tests were incorporated to evaluate statistical significance of the intervention group. Impact on well‐being, SDOH barriers, appointment adherence and health outcomes were assessed in both conditions. Intervention condition patients reported improvement in well‐being [feeling anxious (t = 4.051; p < 0.000)] and reduced SDOH barriers [food access (t = 4.662; p < 0.000); housing (t = 2.203; p = 0.008)] that were significantly different from the usual care condition in the expected directions. Care coordination based on factors including SDOH risks shows promise in improving patient well‐being. Future research should refine this approach for comprehensive risk assessment to intervene and support patient health and well‐being.
Article
While research relating to hurricane evacuation behavior and perceptions of risk has grown throughout the years, there is very little understanding of how these risks compound during a pandemic. Utilizing the U.S. territories of Puerto Rico and the U.S. Virgin Islands (PRVI) as a study region, this work examines risk perceptions and evacuation planning during the first hurricane season following the COVID-19 pandemic before vaccines were widely available. Analyses of how people view public shelters and whether evacuation choices will change in light of COVID-19 concerns were conducted, and results reflect major changes in anticipated evacuation behavior during the 2020 hurricane season. Key findings include that over half of the sample considered themselves vulnerable to COVID-19. When asked about their intended actions for the 2020 hurricane season, a significant number of individuals who would have previously evacuated to a shelter said that they would choose not to during the pandemic, reflecting that public shelter usage has the potential to decrease when the decision is coupled with COVID-19 threats. Additionally, individuals were shown to have a negative perception of public shelter options. Approximately half of the respondents had little faith in shelters’ ability to protect them, and three-quarters of respondents found the risks of enduring a hurricane to be less than those posed by public shelters. These results will inform future hazard mitigation planning during a disease outbreak or pandemic.
Article
For more than 30 years, the network of Centers for Disease Control and Prevention (CDC)–funded Prevention Research Centers (PRCs) has worked with local communities and partners to implement and evaluate public health interventions and policies for the prevention of disease and promotion of health. The COVID-19 pandemic tested the PRC network’s ability to rapidly respond to multiple, simultaneous public health crises. On April 28, 2020, to assess the network’s engagement with activities undertaken in response to the early phase of the pandemic, PRC network leadership distributed an online survey to the directors of 34 currently or formerly funded PRCs, asking them to report their PRCs’ engagement with predetermined activities across 9 topical areas and provide case studies exemplifying that engagement. We received responses from 24 PRCs, all of which reported engagement with at least 1 of the 9 topical areas (mean, 5). The topical areas with which the greatest number of PRCs reported engagement were support of frontline agencies (21 of 24, 88%) and support of activities related to health care (21 of 24, 88%). The mean number of activities with which PRCs reported engagement was 11. The PRCs provided more than 90 case studies exemplifying their work. The results of the survey indicated that the PRCs mobilized their personnel and resources to support the COVID-19 response in less than 6 weeks. We posit that the speed of this response was due, in part, to the broad and diverse expertise of PRC personnel and long-standing partnerships between PRCs and the communities in which they work.
Book
Full-text available
Many disasters are a complex mix of natural hazards and human action. At Risk argues that the social, political and economic environment is as much a cause of disasters as the natural environment. Published within the International Decade of Natural Hazard Reduction, this book suggests ways in which both the social and natural sciences can be analytically combined through a 'disaster pressure and release' model. Arguing that the concept of vulnerability is central to an understanding of disasters and their prevention or mitigation, the authors explore the extent and ways in which people gain access to resources. Individual chapters apply analytical concepts to famines and drought, biological hazards, floods, coastal storms, and earthquakes, volcanos and landslides - the hazards that become disasters'. Finally, the book draws practical and policy conclusions to promote a safer environment and reduce vulnerability.
Article
This is a book review of the 2nd edition of Wisner et al. At Risk: natural hazards, people's vulnerability and disasters (Routledge 2004)
Article
Objective: To understand health concerns, barriers, and facilitators for change in women in blue-collar worksites. Methods: Focus groups were conducted with 121 women in four small-to medium-sized workplaces in rural North Carolina. Results: Concerns centered on wellness (exercise, healthy eating, weight loss, smoking cessation). Women saw the importance of changing unhealthy behaviors but lacked the skills and information to make changes. Major barriers to change were no time and no willpower. Social support in the workplace was considered a potential facilitator for change. Conclusion: Findings helped design a worksite health-promotion intervention using tailored health messages and natural (lay) helpers.
Article
Objective: To determine whether there is a relationship between baseline levels of social support and women's health behaviors. Methods: Baseline surveys for 859 women assessed smoking, diet (fat, fruit, and vegetable consumption), physical activity, breast and cervical cancer screening, and levels of social support. Results: Women had substantial social networks and a high level of interaction with their co-workers. Social support was associated with physical activity, fruit and vegetable intake, and cervical cancer screening. Conclusion: Findings suggest that work-site health-promotion programs for women could benefit from intervening at the social-network level, especially for some health behaviors.