Citation
Displacement and distress among low-income African American women after hurricane Katrina : a systemic review

Material Information

Title:
Displacement and distress among low-income African American women after hurricane Katrina : a systemic review
Creator:
Martinez, Amanda M.
Place of Publication:
Denver, CO
Publisher:
University of Colorado Denver
Publication Date:
Language:
English

Thesis/Dissertation Information

Degree:
Master's ( Master of Arts)
Degree Grantor:
University of Colorado Denver
Degree Divisions:
Department of Geography and Environmental Sciences, CU Denver
Degree Disciplines:
Applied Geography and Geospatial Science
Committee Chair:
Thomas, Deborah
Committee Members:
Bosick, Stacey
Anthametten, Peter
Wee, Bryan

Notes

Abstract:
The relationship between hurricane displacement experiences and mental health outcomes is currently under-researched in disaster literature. Examining the impacts of displacement outcomes on mental health can serve to inform policies and procedures on post-disaster relocation and emergency management, as well as identify needs and gaps in access to mental health services. Often, populations displaced by hurricanes are socially vulnerable, and already experience baseline stressors. Hurricane Katrina served as a powerful and recent example of a hurricane population displacement which had significant impacts on the mental health of low-income women. This study explores the relationship between displacement and mental health in low-income African American women after Hurricane Katrina through a systematic review of 25 peer-reviewed studies published from 2006 to 2016. Themes identified across the studies provide insights into how displacement outcomes and mental health are interrelated and suggest protective factors against mental distress such as social support and income. Results indicated that African American women experienced elevated mental distress from the trauma of displacement, exposure to Hurricane Katrina, and coping with few psychosocial and economic resources. This work identifies a clear need for mental health support as a fundamental component of disaster response and recovery.

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University of Colorado Denver
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Auraria Library
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Copyright Amanda M. Martinez . Permission granted to University of Colorado Denver to digitize and display this item for non-profit research and educational purposes. Any reuse of this item in excess of fair use or other copyright exemptions requires permission of the copyright holder.

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DISPLACEMENT AND DISTRESS AMONG LOW INCOME AFRICAN AMERICAN WOMEN AFTER HURRICANE KATRINA: A SYSTEMATIC REVIEW by AMANDA M. MARTINEZ B.A., Texas State University, 2009 M . Ed . , Texas State University, 2012 A thesis submitted to the Facult y of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Master of Arts Applied Geography and Geospatial Science 201 8

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ii This thesis for the Master of Arts degree by Amanda M. Martinez has been ap proved for the Master of Arts in Applied Geography and Geospatial Science Program by Deborah Thomas, Chair Stacey Bosick Peter Anthamatten Bryan Wee Date : July 28 , 2018

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iii Martinez, Amanda, M. (MA, Applied Geography and Geospatial Science) Displacement and Distress Among Low Income African American Women After Hurricane Katrina: A Systematic Review Thesis directed by Dr. Deborah Thomas. ABSTRACT The relationship between hurricane displacement experiences and mental health outcomes is current ly under researched in disaster literature . Examining the impacts of displacement outcomes on mental health can serve to inform policies and procedures on post disaster relocation and emergency management , as well as identify needs and gaps in ac cess to mental health services. Often, populations displaced by hurricanes are socially vulnerable, and already experience baseline stressors. Hurricane Katrina served as a powerful and recent example of a hurricane population displacement which had signif icant impacts on the mental health of low income women. This study explores the relationship between displacement and mental health in low income African American women after Hurricane Katrina through a systematic review of 25 peer reviewed studies publish ed from 2006 to 2016. Themes identified across the studies provide insights into how displacement outcomes and mental health are interrelated and suggest protective factors against mental distress such as social support and income . Results indicated that A frican American women experienced elevated mental distress from the trauma of displacement , exposure to Hurricane Katrina , and coping with few psycho social and economic resources . This work identifies a clear need for mental health support as a fundamental component of disaster response and recovery.

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iv The form and content of this abstract are approved. I recommend its publication. Approved: Deborah Thomas

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v DEDICATION I dedicate this work to mi familia y mi gente en Puerto Rico que sufrieron mucho a cau sa del huracán María y aún están sufriendo. Espero que alguien les dará una voz y descubra la verdad de lo que sucedió. Con mucho amor.

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vi ACKNOWLEDGMENTS I would like to thank the faculty and staff who taught me and supported me in finding my path and my p assion in this program. Especially the members of my committee: Dr. Deborah Thomas, Dr. Peter Anthamatten, Dr. Bryan Wee, and Dr. Stacey Bosick for providing me with guidance , resources, and support in completing this work . I would also like to thank Dr. B r ia n Page and Dr. Rafael Moreno for providing amazing instruction and support during the foundations and research design courses that helped steer me towards this passion project.

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vii TABLE OF CONTENTS I. INTRODUCTION ................................ ................................ ................................ ........... 1 II. LITERATURE REVIEW ................................ ................................ ............................... 4 II I . METHODS ................................ ................................ ................................ ................. 16 IV. RESULTS ................................ ................................ ................................ ................... 21 V. DISCUSSION ................................ ................................ ................................ .............. 32 VI. CONCLUSION ................................ ................................ ................................ .......... 39 REFERENCES ................................ ................................ ................................ ................. 42 APPENDIX ................................ ................................ ................................ ....................... 49

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viii L IST OF TABLES TABLE 1. MeSH Terms ................................ ................................ ................................ .......... 17 2. Inclusion and Exclusion Criteria ................................ ................................ ............ 18 3. Findings by Theme and Author ................................ ................................ ............. 23

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ix LIST OF FIGURES FIGU RE 1. M ap of Hurricane Tracks in the Gulf of Mexico 1992 to 2009 ............................... 5

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x LIST OF ABBREVIATIONS ABBREVIATIONS 1. MDD Major Depressive Disorder 2. MeSH Medical Subject Headings 3. PD Psychological distress 4. PTS Post traumatic stress 5. PTSD /PTSS Post Traumatic Str ess Disorder or Post Traumatic Stress Syndrome 6. DSM Diagnostic and Statistical Manual of Mental Disorders 7. RISK Resilience in Survivors of Katrina projec t

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1 CHAPTER I INTRODUCTION Two and a half million people along the Gulf Coast of the United States wer e displaced by Hurricane Katrina, making it the most significant displacement event in the United States since the Dust Bowl in the 1930s (Blackmon et al., 2017) . The impacts of the displacement on Hurricane Katrina evacuees encompass a broad range of physical, social, mental , and economic changes to their lives. While there is much discussion about the social and economic issues surrounding displacement, the mental health of affected is e xamined in conjunction with their displacement experiences (Wadsworth et al., 2009) . Vulnerable or disadvantaged populations refer to individuals who are at a high risk of significant harm or exploitation, who receive or may be in need of community services, and can include but are not limited to: the elderly, racial minorities, and families whose incomes are 200 percent or less of the federal poverty level (low income) (Cepeda et al. , 2010) . Being forcefully uprooted from their homes, whether permanently or te mporarily, becomes a significant source of mental stress, especially for vulnerable groups. In research conducted prior to Hurricane Katrina on low income African American women living in New Orleans, psychological distress was more closely associated with major life events while chronic stressors had no psychological effects (Norris & Mitchell, 2018) . This carries important implications for the psychological effects of Katrina. Rese arch that examines the experiences of low income African American women displaced by Hurricane Katrina alongside measures of their mental health may inform

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2 approaches to providing mental health services and support for the problems associated with the stre ss of displacement. Although mental health is increasingly the subject of inquiry in disaster literature, no systematic review exists that focuses on the displacement and mental health of African American women during and after Hurricane Katrina. Looking a t the sum of studies conducted about African American women affected by Hurricane Katrina in a systematic way provides insigh t into how disasters affect this particular cultural group and also what we can expect in terms of mental health outcomes for popul ations affected by other disasters. The lessons learned from Hurricane Katrina could also be applied to more current disasters , such as Hurricanes Harvey, Irma, and Maria, as well as other disasters which cause large displacement events. To fill the ident ified gap, t his study explores the relationship between displacement and mental health in low income African American women after Hurricane Katrina through a systematic review of 25 peer reviewed studies published from 2006 to 2016. For the purposes of thi depressive symptoms (MDD) , anxiety symptoms, post traumatic stress symptoms (PSS and PTSD) , and symptoms of psychological distress (PD). Themes from selected peer reviewed studies were examined alon gside resiliency factors. Resiliency factors were analyzed to examine what can ameliorate negative mental health impacts during disaster displacement events. Research Questions 1) How did displacement experiences relate to measures of mental health in low income African American women after Hurricane Katrina? 2) What are the protective or preventative factors for mental health outcomes among African American women

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3 displaced by Hurricane Katrina?

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4 CHAPTER II LITERATURE REVIEW In the review of literature th at follows, the research on displacement by hurricanes and the impacts of hurricanes on mental health are summarized separately and then together. This way of arranging the literature review highlights the limitations and gaps within the existing body of l iterature. Hurricane Disaster Burden The Gulf Coast of the United States experiences highly variable hurricane risk , with the highest frequency of hurricane force winds and hurricane return s occurring in the center (Trepanier et al. , 2015) . The coastline areas at the great est risk include southeast Louisiana and the Alabama coastline (Trepanier et al., 2015). Hurricane frequency and intensity varies both geographically and temporally. Figure 1 highlights the tracks of major hurricanes that made landfall in Gulf Coast states from 1992 to 2009.

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5 Figure 0.1 Map of Hurricane Tracks in the Gulf of Mexico from 1992 to 2009. While the annual landfall probability along the coastline is fairly low across the hurricane record (~0.46% to ~0.39%), Gulf Coast states experienced ten int ense hurricanes during this seventeen year time period which resulted in disasters (Wallace & Anderson, 2010) . Notably, in just one North Atlantic season in 2005, 15 hurricanes formed, including Hurricane Katrina (Trepanier et al., 2015). This abnormally high frequency of intense hurricane s striking coastlines in recent history can be considered an increased hurricane disaster burden for the region . Th e burden extends to the peop le affected by these disasters. In the United States, the hurricane disaster burden is disproportionately carried by the poor, the elderly, and racial and ethnic minorities (Toldson et al. , 2011) . Among the effects of such disasters that can p otentially impact the lives of the residents of this region is the risk of displacement by hurricanes.

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6 Displacement by Hurricanes Population d isplacement from disasters refers to significant numbers of individuals and families being force d from their pre disaster homes (Fullerton et al., 2015) . Four dimensions of displacement affect individuals' post disaster experiences: time spent in temporary housing, number of moves, distance from origin to relocation, and type of housing (Fullerton et al., 2015). Disp lacement can also carry several personal challenges to individuals and families who experience it, including being more likely to have health problems , experienc ing worse living conditions, los ing their social networks, and los ing their jobs and income (Ho ri & Schaefer, 2010 ; Lê et al., 2013 ). The literature provides substantial evidence that population displacement from disasters disproportionately affects vulnerable populations. Vulnerability can be defined as being exposed in some way to a type of harm . It is an important factor to examine and consider within disaster displacement because it facilitates understanding of how communities respond and recover after a disaster (Cutter & Emrich, 2006). Two key facets of vulnerability are social and economic v ulnerability. Social vulnerability is a susceptibility to the effects of hazards, and it originates from social inequalities such as inequitable access to health care and support services as well as quality and lo cation of the built environmen t (Cutter & Emrich, 2006) . to recover from economic shocks (Chen et al., 2007). Specific demographic characteristics have been identified which can be associated with vulnerability, and people with these characteristics combined with a risk of being exposed to disasters can be referred to as a vulnerable p opulation (Cutter & Emich, 2006). Vulnerable populations

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7 are most affected by natural disasters in part because they are more likely to experience displacement. Home ownership and disaster assistance are two factors which protect against displacement, but the same factors that predict home ownership also predict housing loss after a disaster . L ow income and minority populations are more likely to rent, reside in substandard housing, and experience housing loss after a disaster (Esnard et a l. , 2011; Fullerton et al., 2015; Hori & Schafer, 2010 ; Sastry & Gregory, 2013 ) . Thus , unequal housing access may play a critical role in displacement. Additionally, African Americans and unemployed populations have a higher likelihood of living in houses that experience flooding (Graif, 2016) . Displacement is also likely to lead to job and income loss, which for low income families is often devastating (Hori & Schafer, 2010). In the case of Hurri cane Katrina, the flooding in New Orleans was so significant that it displaced significant numbers of low income residents who had lived in their homes for a relatively long period of time . Among a population of displaced Louisianans living in FEMA trailer parks, the reported average time in their former residence was fourteen and a half years (Singelmann & Schafer, 2010) . Many evacuees were displaced without stable housing for more than two years after the hurricane due to failures on the pa rt of government agencies and emergency management, and as many as 400 families lived in FEMA trailers until May of 2008 (Singelmann & Schafer, 2010). The diaspora following Hurricane Katrina extended to all 50 states (Sastry & Gregory, 2014) . A year after the hurricane, just over half of a sample affected population had returned to New Orleans, while roughly 40% of those who did not return resided in Texas , 12% resided in other parts of Louisiana, another 12% resided in other states in the South, and 5% resided elsewhere in the United States (Sastry & Gregory, 201 4 ). The declin e in the population of

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8 New Orleans mirrored a significant increase in population growth for the cities of Houston and Baton Rouge (Li et al. , 2010) . Hurricane Katrina was disproportionately experienced by poor and working class African Americans (Keithly & Rombough, 2007 ; Sastry & Gregory, 201 4 ) . The racial disparity in post Katrina displacement cannot be accounted for based on any other demographic or socioeconomic covariates ( Fussell et al. , 2010 ; Sastry & Gregory, 201 4 ). While Hurricane Katrina serves as an extreme example of displacement, populations living along the Gulf of Mexico and the Atlantic coasts of the United States will continue to experience displacement because of hurricanes. Evacuation is a phenomenon within human mobility, displa cement, and migration which has unique attributes due to it being involuntary and short term (Li et al., 2010; Th ie de & Brown, 2013). Distinct social determinants of evacuation behavior exist, and the ability to evacuate or not is largely based on factors outside of personal choice based on the opinion of the weather or the danger it could present. With evacuation also comes the desire or intention to return once the danger and damage from the disaster is over. The evacuation prior to Hurricane Katrina occu rred unevenly, along racial and economic lines (Thiede & Brown, 2013) . Low education, low income, and being African American were associated with being unable to evacuate prior to the hurricane (Th ie de & Brown, 2013). The disparity in outcomes and experiences for vulnerable populations affected by Katrina extended well beyond the evacuation process. Differ ing outcomes of displacement existed between people who stayed in their new location and those who return ed to their city of origin. If vulnerable individuals found stable housing in their new location, the quality of their housing and level of poverty ten d ed to improve (Asad,

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9 2015) . The quality of housing generally improved for a sample population displaced by hurricanes Andrew (1992), Katrina (2005), or Ike (2008) (Esnard et a l., 2011). Outcomes for the population displaced by Katrina that chose to remain in their current residence were that they were on average less impoverished than the population that returned to New Orleans (Asad, 2015). Returning to their original city of residence is often difficult for low income individuals and families, and they either have the slowest return rates or do not return at all (Fussell, 2015) . Impacts of Hurricanes on Mental Health Disasters are non normative life e vents which can produce symptoms of depression, anxiety , and post traumatic stress disorder (PTSD) among individuals exposed to them (Blackmon et al., 2017; Cepeda et al., 2010 ; Norris et al. , 2002 a; Norris et al., 2002 b ). The widespread disruption and destruction caused by hurricanes has been documented to cause significant adverse mental health effects in affected populations (Norris et al. , 2002a) . These effects can be mitigated by the presence of accessible psychosocial resources ( Norris & Mitchell, 2018; Wadsworth et al., 2009) . For example, many of the negative mental health effects of h urricane s Hugo (1989) and Andrew (1992) could be ex plained by declines in perceived social support (Norris et al., 2002a). Positive social experiences and psychological resiliency have the greatest impacts on individuals' mental health following a natural disaster (Blackmon et al., 2017 ; Norris et al., 20 02b ). Psychological resiliency is defined as an individual's capacity to adapt and adjust when confronted with adverse conditions which would otherwise cause significant stress. Though difficult to measure, resiliency can be evaluated on an individual leve l, resilient responses to disasters are more common than non resilient, and there is an

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10 inverse relationship between resiliency and rates of depression (Blackmon et al., 2017). Community efficacy is associated with positive effects on mental health follow ing a disaster (Fullerton et al., 2015; Lowe et al. , 2010) . Communities with high levels of cohesion are more effective at carrying out relief efforts, getting outside aid from other organiza tions, identifying members of the community most in need, mitigating crime and illness in the community, and rebuilding after disasters (Lê et al. , 2013) . Effective communities can act as a buffer from common stressors stemming from natural disasters. Continuity of social relations can also help ameliorate the negative mental health impacts of disasters. Katrina evacuees who were housed in FEMA trailers near their old friends rep orted lower levels of depressive symptoms than those who had been separated from their friends (Singlemann & Schafer, 2010). Mental Health and Vulnerable Populations. Vulnerable populations are more likely to have high er levels of disaster exposure and to experience the subsequent negative mental health impacts of that exposure (Cepeda et al., 2010). Despite the high probability of experiencing psychological symptoms, the majority who are exposed to disasters do not receive mental health services (Lowe et al. , 2016) . This is unfortunately the archetypal care experience of low income and minority adults in the United States, who typically do not receive adequate medical care or mental health s ervices (Chan & Rhodes, 2014; Rhodes et al., 2010) . As such, v ulnerable populati ons are at especially high risk of experiencing the negative mental health effects of a disaster. Numerous factors contribute to negative mental health outcomes following a disaster, and susceptibility to experiencing these factors is heightened by vulnera bility.

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11 Contributors to Mental Health Declines. Access to housing, community resources, high levels of education, and sufficient income are all factors which promote coping and adjusting after a disaster ( Edwards, 1998 ; Singelmann & Schafer, 2010 ) . Having health insurance also significantly lowers the likelihood of experiencing depression after a disaster (Blackmon et al., 2017). Pre exi sting socia l or family problems such as unemployment are exacerbated by natural disasters. Pre disaster exposures such as childhood trauma, more recent traumatic events that occurred before the disaster (such as assault), or problems with intimate partner relationshi ps put individuals at a higher risk for depression after a disaster (Lowe et al. , 2015) . Among vulnerable populations, disasters may produce either acute or long term psychiatric disorders and distress, especially among individuals with prior mental illness ( Edwards, 1998 ; Lieberman Cribbin et al. , 2017) . In a general population study of victims of Hurricane Katrina, for example, t he rates of mental illness among the participants who lost their homes as a result of the hurricane were almost six times higher than the general population (Blackmon et al., 2017). Demographic factors influence post disaster rates of mental illness . Fema le gender, being a member of a racial or ethnic minority, poor physical health, not having ever attended college, and financial hardship are among the demographic factors linked to higher rates of mental illness (Blackmon et al., 2017; Singelmann & Schafer , 2010). Women in vulnerable populations are particularly impacted by the mental health effects of natural disasters because they are often given the role of primary care takers (Lowe et al., 2010). The role of age is less clear ; a dults ages 40 to 59 impac ted by Hurricane Katrina reported higher levels of mental distress than individuals over 60 (Adams et al. ,

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12 2011) . The available studies on age and vulnerability suggest distinct developmental components to copi ng with disaster that are not yet fully understood. Though most individuals recover from the physical impacts of a hurricane, the effects on depression and other mental health conditions can endure for years (Calvo et al. , 2014) . Texas coastal residents affected by Hurricane Ike reported elevated levels of depression eighteen months after the disaster, and , depending on their individual circumstances, individuals affected by Hurricane Katrina reported increased levels of depression thirty two months after the hurricane (Blackmon et al., 2017). Housing destruction, financial difficulties, and human loss were all reported circumstances that raised levels of long term depression for indivi duals affected by Hurricane Katrina (Blackmon et al., 2017; Calvo et al., 2014). Negative religious experiences or beliefs also play a role in enduring psychological distress: i ed their religious beliefs were more likely to experience psychological distress four years after the disaster (Waters, 2016) . Relating Displacement to M ental Health Many debates exist within the study of mental health and disasters. Contended topics include defining characteristics of mental health, as well as whether the study of natural disasters should be distinguished from technological disaster resea rch (and whether or not they should be distinguished from one another) (Edwards, 1998). Definitions differ across disciplines, and a cohesive, interdisciplinary body of research on the topic does not yet exist . A n inherent issue with studying natural disas ters exists as well, as populations affected can be difficult to identify and sample and studies are typically done post disaster (Galea et al. , 2008) .

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13 Attempting to disentangle displacement as a risk factor is particularly challenging because n umerous factors affect populations that could all result in significant mental stress , including social stressors (discrimination, la ck of institutional support, personal losses, and lack of community), economic stressors (housing, property loss, lack of income, and employment issues), and physical health issues (disruption in healthcare access, personal injury, pre existing disability, and health issues complicated by displacement). While the body of literature is incredibly limited, existing evidence suggests a direct relationship between poor mental health and displacement (Lê et al., 2013). In addition to the factors of displacement itself, which can have a negative effect on mental health, displaced populations are more likely to be vulnerable or disadvantaged. Displaced populations are also more likely to be unemployed and to show symptoms of severe mental il lness (Hori & Schafer, 2 010). Housing and Financial Insecurity . Distress over housing and levels of available social support are critical factors in displacement and mental health outcomes. Mental health can be positively or negatively affected by displacement according to hous ing experiences (Fullerton et al., 2015). Negative social and institutional experiences after displacement can contribute to mental stress, while better housing and employment improve mental health outcomes (Fullerton et al, 2015). The more social support available and the higher quality the housing in the new location is, the less likely the individual is to experience significant stress and/or depression. Low income populations displaced by Hurricane Katrina described relocation and unstable housing as mo re stressful than returning to New Orleans (Fullerton et al., 2015). People housed in FEMA trailers following Hurricane Katrina who encountered

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14 problems with neighborhood security while living in the trailer parks reported higher levels of depressive sympt oms than those who felt safe where they were housed (Singlemann & Schafer, 2010). Conditions in the FEMA trailer parks were particularly difficult for Katrina evacuees, as they were often isolated and residents did not have access to public transportation, medical services, or stores (Singlemann & Schafer, 2010). Though evidence shows that levels of PTSD increase with the number of times individuals are forced to relocate after a hurricane, there has not been any detectable effect of the number of relocatio ns on depressive symptoms (Singlemann & Schafer, 2010). Disruptions in Social Networks . S ocial support networks are disrupted by displacement , further complicating mental health outcomes . There is a direct relationship between the levels of social cohesi on and support and depression among displaced populations (Lê et al., 2013). Low income families frequently depend on their social supports to make ends meet (Fussell & Harris, 2014) . The length of residence in their home before displacement and their unfulfilled intention to return to their original residence are other factors which can alter levels of depressive symptoms (Singelm ann & Schafer, 2010). Those who resided in their homes for longer periods of time or who were unable to return to their former residence in spite of their desire to do so were more likely to have higher levels of depressive symptoms. A significant gap pe rsists on disaster displacement experiences and mental health outcomes , particularly as related to vulnerable populations . As such, s tudying low income, African American women impacted by Hurricane Katrina offers a valuable

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15 avenue of inquiry because of the implications for mental health. A systematic review of existing studies to characterize the research on displacement and mental health outcomes , develop theoretical understandings of the relationship be tween them, and identify valuable avenues for further study , is vital for address ing mental health during disaster recovery, particularly for those mos t at the fringes .

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16 CHAPTER III METHODS The objective of a systematic review is to provide a clear, incl usive, and succinct narrative of mental health for African American women post Katrina, providing a comprehensive examination of published studies (Timulak, 2009) . Qualitative s ystematic reviews o r qualitative meta analys es have be en used in previous research on natural disasters to study mental health outcomes (Brown et al., 2017; Harada et al. , 2015; Ironson et al., 2014; Lai et al. , 2017; Neria et al. , 2008; Parker et al., 2015; Rataj et al. , 2016; Tang et al. , 2014; Wang et al. , 2013) . A systematic review of disaster mental health literature provides evidence to inform decision making for disaster planning, response, and recovery (Kadhiravan, 2015) . This approach address es a complex, multi disciplinary, multi faceted, and under researched topic in a comprehensive fashion and yields an enhanced understanding of how hurricane displacement and mental health outcomes are interrelated. To enhance the narrative of the results, quot es are included from interviews of African American women affected by Hurricane Katrina taken by Bosick (2015) . The quot es are not included as part of the analysis or research process. Study Search Studies were selected from search results in the foll owing databases: PubMed, ScienceDirect, SpringerLink, and J STOR . A list of Medical Subject Headings (MeSH) keyword search terms was created based on the research questions. Table 1 lists the MeSH terms used in the study search. Terms were linked together w within each Sixteen searches were conducted in each of the four databases using combinations of the

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17 terms. Search results were reviewed by title, journal title, publicat ion date, and abstract to determine their relevance before being run through the inclusion and exclusion criteria. Only peer reviewed articles in the English language published after 2005 were considered. The number of results as well as the references tha t would be considered were documented. Duplicate results were tallied as well. 101 studies from the search were considered for the inclusion and exclusion criteria. Table 0.1 MeSH Terms Category MeSH Terms Displacement sing Disaster vi Mental Health , psychological Vulnerable Populations Study Selection: Inclusion a nd E xclusion Criteria After inclusion and exclusion criteria were applied to the 101 studies, t wenty five studies were included in the systematic review . Seven inclusion criteria and four exclusion criteria were applied . Table 2 lists the study selection crite ria.

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18 Table 0.2 Inclusion and Exclusion Criteria Inclusion criteria Studies of victims of Hurricane Katrina African American women included as part of the sample population or the only population sampled Observational studies (case control, cross sectional and cohort studies) on mental health [psychological distress, PTS, PTSD, depression, and/or significant mental impairment] OR qualitative/ethnographic studies on mental health Reports on findings for mental health specific to African American women Clear and testable hypothesis Validated survey instruments and measures Exclusion criteria Not published in English Not published in a peer reviewed academic journal Studies focusing on multiple disasters or generalizing disasters Studie s focusing on participant groups known to be more susceptible to depression: pregnant and postpartum women, drug users, and prison populations The studies had to present a clear and testable hypothesis, use validated survey instruments and/or psychologic al measures , and involve mental health outcomes (Parker et al., 2015; Timulak, 2009). following: psychological distress (PD), depression, major depressive disorder (MDD), anxiety, post traumatic stress (PTS), and post traumatic stress syndrome or post traumatic stress disorder (PTSD). PD is a generalized term for psychological discomfort characterized by disruption in normal functioning and is a way to measure non specific mental distress (Rhodes et al., 2010) . PTS and PTSD can both occur from traumatic events. Their distinguishing factor is that PTS is considered an acute condition in response to an event, and not a mental disorder. PTSD is a mental health disorder characterized by chronic re experiencin g of a traumatic event and persistent symptoms of increased alertness causing significant impairment in functioning (Shalev et al. , 2017) .

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19 Mental health disorders in the United States are diagnosed by licensed mental health professionals using the most current Diagnostic and Statist ical Manual of Mental Disorders (DSM) (Shalev et al., 2017) . Studies included observational (case control, cross sectional, and cohort studies) or qualitative/ethnographic studies on mental health (Tang et al., 2014) . In addition, the studies had to includ e and report on findings specific to low income African American women who were either temporarily or permanently displaced because of Hurricane Katrina. Choosing one disaster and one demographic group prevents variability concerns between different disast ers and/or demographic groups (Ch an & Rhodes, 2014). The studies were initially read and reviewed to determine their relevance and were excluded if they were determined to be inappropriate for the systematic review. Full texts of studies that met the incl usion criteria were reviewed for quality. Criteria for study quality was based on the reliability and validity of the research procedure, sampling, data . Studies not published in English or a peer reviewed journal were excluded. Additionally, studies which had insufficient data, focused on multiple disasters , or generalized disasters were excluded to ensure the primary focus of the study was Hurricane Katrina. Studies which centered on sp ecific participant groups who are known to be highly susceptible to depression and other mental illnesses were excluded. This included studies whose primary focus was pregnant and post partum women, drug users, or prison populations (Tang et al., 2014). St udy selection and exclusion was carried out by the same investigator to avoid concerns of inter rater reliability.

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20 Analysis of Studies Studies w ere initially analyzed for overlapping themes in their primary findings as well as commonality of variables. B roadly, these variables included : displacement experiences, disaster experiences, mental health, and vulnerable population factors. The selected studies were intensively reviewed and coded based on the variables to identify how well each study addresse d bo th displacement experiences and mental health outcomes , as well as to enrich the analysis of the themes . Coding data allows the researcher to categorize and retrieve data with similar meaning, which facilitates finding relationships in the data (Stuckey, 2015) . Predetermined codes were written based on the variables ( see Appendix ) . E mergent codes from the data were included to ensure a well rounded data set. Coded data were entered and analyzed utilizing Coding Analysis Toolkit (CAT) software (Lu & Shulman, 2008) . CAT is a free, open source, and web based qualitative analytic software originally developed by the Qualitative Data Analysis Program at the University of Pittsburgh. Difficulties with the use of analytic software often arise due to costs, time to train users in the software, and coordination with collaborative coding efforts (Vaughn & Turner, 2016) . Because this work was performed by a single investigator using open source software, some common problems with qualitative software were m inimized . However, this approach can introduce personal (ideological and psychological) bias into the research, and the results and methods should be compared in a critical manner to similar studies (Greenland, 2009) . During data analysis, the researc her transcribe d notes about interpretations based on the data to facilitate th e exploration of similarities and differences in the data (Stuckey, 2015).

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21 CHAPTER IV RESULTS INTERVIEWER: Do you think race had something to do with it? R ESPONDENT: said, these peop le are black and we a re going to go in their house. We are not going to go i When Quarte d which I thought was peculiar. That struck a bad core with me. Objective to popul ar belief, we did hear a boom. or if it fell or was blown up. But they saved the French Quarte r which struck me in a bad way. If i t classed p eople for the high end people. INTERVIEWER: How so? RESPONDENT: Quarter and Canal Str The lower end of Canal Street got it but down there t in my opinion, they saved it. (Bosick, 2015) Analysis of t he selected studies broadly indicated that low income African American women were the demographic group most susceptible to suffering the adverse effects from Hurricane Katrina ( Chen et al., 2007; Coker et al., 2006; Green et al., 2013; Laditka et al., 2010; Lowe et al., 2010; Rhodes et al., 2010; Sastry & Gregory, 2013 ; Waters, 2016; Zwiebach et al., 2010 ) . Among populations of evacuees sampled after the disaster , African American women had the highest PTSD score s , were more likely to experience significant depression and anxiety , and reported poorer general mental health (Coker et al. , 2006 ; Chen et al., 2007 ; LaJoie et al., 2010 ). Generally, pre disaster levels

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22 of distress could predict post disaster levels of distress ( Chan et al., 2011; Chan et al., 2015; Coker et al., 2006; Fussell & Lowe, 2014; Green et al., 2012; King et al., 201 6; Lajoie et al., 2010; Lee et al., 2009; Merdjanoff, 2013; Rhodes et al., 2010; Waters, 2016 ). However, there were exceptions. D elayed distress reactions were found in almost 20% of a sample of low income African American women (Paxson et al., 2012). Thi s indicates a very slow recovery from hurricane exposure and a continuing high vulnerability to mental distress for this population of women ( Lowe & Rhodes, 2013; Lowe et al., 2015; Paxson et al., 2012). A nother sample had low pre disaster distress , but ex perienced the highest levels of post disaster distress (Lowe & Rhodes, 2013). The severely deleterious effects on the mental health of these women post disaster occurred for a variety of reasons, some of which are detailed within each theme. Findings from the studies were summarized and organized into two major sections : displacement , disaster exposure and mental health , and resilience and risk factors. Relevant themes are discussed with in each section, and m ajor findings by author are summarized in Table 3 .

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23 Table 0. 3 Findings by Theme and Author Theme Findings Authors Displacement , disaster exposure , and mental health Property loss associated with higher mental distress Lee, 2009 ; Merdjanoff, 2013; Zwiebach et al. , 2010 Lower depression associated with lower exposure King et al. 2016; Lai et al. , 2016 ; Lee et al., 2009 Elevated risk of delayed PTS from trauma exposure Laditka et al., 2010 ; Paxson et al., 2012 Elevated PTSD in those who experienced racial discrimination Chen et al. , 2007 ; Laditka et al., 2010 Elevated levels of distress and mental impairment after hurricane compared to both normative samples and other populations exposed to the same hurricane Chen et al. , 2007 ; Green et al. , 2013; Laditka et al., 2010; Lowe et al., 2010; Rhodes et al., 2010; Sastry & Gregory, 2013 ; Waters, 2016 Elevated levels of distress aft er hurricane within the population Chan et al. , 2012 ; Paxson et al., 2012; Rhodes et al., 2013 Traumatic stress exposure predicted psychological distress Chan et al., 2011; Chan et al. , 2015; Coker et al. , 2006 ; Green et al., 2012; King et al., 2016; Lajoie et al. , 2010 ; Lee et al., 2009; Merdjanoff, 2013; Rhodes et al., 2010; Waters, 2016 Resilience and risk factors Perceived lower social support/resources associated with higher distress Chan et al., 2011; Chan et al., 2015; Chen et al . , 2007; Green et al., 2012; Lowe et al., 2010; Paxson et al., 2012; Waters, 2016 ; Zwiebach et al., 2010 Positive role of family Coker et al., 2006; Paxson et al., 2012 Higher social support as a protecting factor Chan et al., 2011; Chan et al., 20 15; Chen et al. , 2007; Coker et al., 2006; Lai et al., 2015; Lowe et al., 2010; Paxson et al., 2012; Rhodes et al., 2010 ; Waters, 2016 Vulnerability to distress prior to hurricane: pre disaster distress predicts post disaster distress Chan et al., 2011; Green et al., 2012; Lowe et al., 2010; Lowe et al., 2011; Paxson et al., 2012; Waters, 2016 ; Zwiebach et al., 2010 Feeling hopeful about their future/optimism Chan et al., 2011 ; Coker et al., 2006 Positive role of religion Chan et al., 2011; Coker et al., 2006; Laditka et al., 2010 Higher resilience associated with lower levels of psychological distress both pre and post disaster Lee et al., 2009; Lowe & Rhodes, 2013; Waters, 2016 Displacement , Disaster Exposure, and Mental Health Displacement. R INTERVIEWER: How come? RESPONDENT: Because it made me have to start life all over again in a new place at a

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24 without you even having input on it. You had to be ready to move. You had to get up and it was you gotta go. the w orst thing that ever happened. You lost a lot of things, valuable things. It taught you a lot of lessons, but at the same time you lo st a lot of things that you came close to you and that you expected to have all of your life that you wound up not having. (Bosick, 2015) Displacement is a primary factor in the disaster experiences of low income African American women because of the well documented evidence that they were much more likely to live in the neighborhoods with the greatest damage from Hurricane Ka trina. Thus , they experienced the highest rates of displacement and the slowest and lowest rates of return ( Fussell et al., 2010; Sastry & Gregory, 2013). S elected studies that covered both displacement and mental health iden tified some key factors within the dimensions of displacement which affected mental health. Displaced women were particularly vulnerable to the negative mental health effects due to evacuation without their families which resulted in prolonged separat ion from children, spouses, or pare nts, and they experienced multiple moves during the evacuation process (Chen et al., 2007 ; Fussell & Lowe, 2014; Laditka et al., 2010 ). In fact, displaced women moved an average of three times and spent an average of 130 days in interim housing (Fussell & Lowe, 2014) . A n a bove average number of moves and a greater amount of time spent in temporary housing were associated with the highest levels of distress and declines in mental health over time (Fu s sell & Lowe, 2014). The relationship between h ome damage or property loss and mental health outcomes was unclear . One stud y indicated it had only a small effect on PD (Merdjanoff,

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25 2013 ), while another associated it with significant effect s on PD (Lee et al., 2009). Property loss was also associated with a higher risk of PTS and PTSD ( Paxson et al. , 2012 ; Rhodes et al., 2010 ) . Renters reported greater PD than homeowners, wh ich indicates that the type of housing can influence the risk of PD (Merdjanoff, 2013). However, when controlling for housing factors the effect of gender and race became non significant (Merdjanoff, 2013). Regardless, renters were more likely to have lost their homes and experience the subsequent negative mental health effects of property loss (Waters, 2016). Displacement experiences seemed to have varying , and sometimes contradictory , findings in terms of their effects on mental health. Some results indic ated that a higher percentage of African American women who returned to the Gulf Coast reported additional trauma and subsequent poorer mental health compared to those who did not ( Graif, 2016; LaJoie et al., 2010). The rates of PTSD in a sample of women w ho returned were twice that of women who permanently moved away from the Gulf Coast (LaJoie et al., 2010). This could be related to the positive effect of moving to less disadvanta ged neighborhoods and having greater employment opportunities when they chos e not to return (Graif, 2016 ; Waters, 2016 ). Another study contradicted these results, as women who returned were found to have significantly lower general PD and perceived stress than women who relocated (Fussell & Lowe, 2014). Geographic network dispersi on , or the proportion of kin and close friends living 100 km or more from the respondent , was found to be positively associated with PTS, which could explain why some women who permanently relocated experienced elevated PD (Morris & Deterding, 2016). Geogr aphically dispersed social networks are associated with psychological strain, which

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26 creates feelings of longing and burden that are amplified by significant individuals in their lives being distant from them after they have been displaced (Morris & Deterdi ng, 2016). Disaster e xposure . ever happened to you? RESPONDENT: Some people died. A lot of people lost homes. But it opened a lot of people. For me, that did it. Because a lot of people took life for granted. In New Orleans, Betsy or Camille was the worst storm that they had, the worst thing that happened. That was like 20 or 30 years. So peo ple were living in sin, drinking and partying and taking ly person that would say that. I hear people say that Katrina hurt some people but it he lped more people than it hurt. It helped people to wake up. (Bosick, 2015) E xposure to Hurricane Katrina put low income African American women at a higher risk for MDD , PD, and anxiety, and the re were certain types of traumatic disaster exposure that were also closely associated with higher PTS and PTSD ( Chan et al., 2012; Chen et al., 2007; Fussell & Lowe, 2014; King et al., 2016; Laditka et al., 2010; Lai et al., 2015; LaJoie et al., 2010; Low e, 2015; Paxson et al., 2012 ; Rhodes et al., 2010 ). Only one study had counter findings , which did not establish exposure as a risk factor (Calvo et al., 2015). Participants reported multiple hurricane related stressors, and there was a direct association between hurricane stressors and all mental health outcomes (Rhodes et al., 2010). Specific exposure variables highly associated with MDD included sheltering in

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27 the Superdome, losing their job , and being in a flooded area (King et al., 2016). These variable s were not associated with PTS D symptoms , but disaster incident MDD can create further vulnerability to developing PTSD (King et al., 2016) . Death of a friend or relative was associated with lower cognitive well being and a higher risk of PTS ( Calvo et al. , 2015; Paxson et al., 2012). E levated PTSD was found in those who experienced racial discrimination ( Chen et al., 2007; Laditka et al., 2010 ; Waters, 2016 ). The only measured variable within traumatic disaster exposure that could not predict mental health outcomes was flood depth (Rhodes et al., 2010). Resilience and Risk Factors Pre existing v ulnerability . INTERVIEWER: Was there anyone during all that stressful time, your grandma had passed away, who did you turn to for support? R ESPONDENT: mot her died when I was young. So that w as the only grandmother I had. My mom was there with me. no different w hether my dad had another wife. My mom was still in. mily gathering and everything. But it was more foc us on momma, I got a bill. Mom had a heart attack after the hurricane so now I have to put all my problems aside and be strong because I have to be there for my mom. I have an older brother and a younger brother. My oldest o ne is a selfish kind. stayed here and had to walk through that water du ring the hurricane. Then when we did talk to him where he was, he was with a family and he said the f amily was fighting each other. ou k now what they may do to me. If they fighting each other, you know what they may to do me. (Bosick, 2015) Measures of psychological distress in low income African American women

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28 living in New Orleans were higher than the general population prior to Hurrican e Katrina (Paxson et al., 2012). Behavioral Risk Factor Surveillance System (BRFSS) data measuring frequent mental distress and mean mentally unhealthy days for the Gulf Coast states from 1993 to 2010 indicated that African American responses were statisti cally significantly higher than the overall average for their state throughout that time period. They were distressed to begin with, and the hurricane amplified that distress and caused a lasting, perhaps even permanent, increase in their mental distress ( Paxson et al., 2012) . Women with low socioeconomic status were found to be more likely than others to have PD ( Chen et al., 2007; Paxson et al., 2012) . Additionally, a comorbidity exists between PD and P T S (Paxson et al., 2012). Prior exposure to childhood trauma was a risk factor associated with higher pre disaster distress (Lowe et al., 2015). Social and e conomic r esources . INTERVIEWER: RESPONDENT: ttered. And back, and my sister, she has a lot of stuff going on. In the church I was at at home, they are really all over the world. So I just came here and really starting from scratch. INTERVIEWER: How has that been for you? RESPONDENT: It was hard at first, because I went through some other situations, and I was kind of desti tute going through that by myself. Like I said, everybody was going time, it allowed me the opportunity to get the dependence on myself in God that I should have had a long time ago. So I think it still worked out for good. (Bosick, 2015 )

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29 T he presence and amount of psycho social and economic resources generally contributed to positive mental health outcomes and lowered risk of depression, PD, P T S, and PTSD . However, r es ults for social and economic resources were mixed. While findings in many studies pointed to specific resources that ameliorated stressors or supported positive mental health, others reported a distinct lack of a buffer for all types of resources (Morris & Deterding, 2016 ; Rhodes et al., 2010). One study found a complete lack of association between PD and psychosocial and e conomic resource gains (Zwiebach et al., 2010). Psychosocial resources and social support . Social resources for l ow income African American women were critical be cause they frequently mitigated hurricane related stressors (Chan et al., 2015 ; Chen et al., 2007 ). African American w omen were more likely to experience lower levels of happiness four years after the storm if they lived alone or reported lower perceived l evels of community support (Calvo et al., 201 5 ; Chan et al., 2015; Merdjanoff, 2013 ). Higher perceived levels of social support had a positive effect on low income mothers one and four years after the storm (Calvo et al., 2014 ; Chan et al., 2015 ; Lai et al ., 2015 ). Pre disaster social support also played an important role, as it was associated with lower pre disaster psychological distress (Lowe et al., 2010). This resulted in fewer hurricane related stressors and higher perceived social support post disast er. The survey responses of a sample of African American women demonstrated how a greater number of psychosocial resources was more highly associated with positive mental health outcomes (Lowe & Rhode s, 2013; Lowe et al., 2015) . Unfortunately, many women experienced significant decreases in their levels of perceived social support from pre to post disaster, and that decrease was maintained for

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30 four years following the event (Chan et al., 2015 ; Lowe et al., 2010 ). Family level factors significantly contributed to these lowered levels of perceived social support and social resources, as the disaster was associated with a high rate of household break ups and child related stressors such as severely lowe red school outcomes (Lowe et al., 2011; Lowe et al., 2015; Sastry & Gregory, 2013). Many reported that their post disaster social support came primarily from other Katrina victims, not social systems or receiving communities (Chen et al., 2007). Economic r esources. Lacking economic resources affected the mental health of vulnerable women in substantial ways. F inancial strain was associated with a greater number of reported PTSD symptoms (Chen et al., 2007). Possession of certain economic resources was tied to lowered levels of distress, but others had no effect. Higher personal income and ownership of a car predicted fewer hurricane related stressors, but receipt of public benefits did not ( Fussell & Lowe, 2014; Lee et al., 2009; Rhodes et al., 2010). Income demonstrated the strongest effect on the likelihood that women would recover from elevated PD (Lee et al., 2009). One study presented counter findings which indicated that income was not a resilience factor (Calvo et al., 2015). Other r esilience and r isk f actors . P ositive experiences and optimistic attitudes post disaster were associated with improve d resiliency ( Lowe, 2015; Lowe & Rhodes, 2013). Resilient women (those with the lowest levels of PD) reported experiencing personal growth and tended to de emp hasize the negative and traumatic experiences associated with the hurricane (Lowe, 2015). The finding s for religion and its role in mental health and resilience are mixed. While some found that religion and religious involvement had a positive effect on th eir mental health ( Coker et al., 2006; Laditka et

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31 al., 2010 ), others found that there was no clear effect ( Calvo et al., 2015; Chan et al., 2012; Chen et al., 2007). This potentially ties to optimism, access to psychosocial resources from religious involve ment, and the amount of perceived social support One of the major risk factors, especially for African American women , was access to mental healthcare and the ability to continue pre existing mental health service s post disaster. Unfortunately, many of those who need ed mental health services in the months after the hurricane d id not receive it (Waters, 2016). Notable among the findings for mental healthcare in these studies was the widespread and enduring disruptio n of mental health services post disaster (Laditka et al., 2010). This suggests lasting mental healt h challenges for this population . Physical health seems inextricably tied to mental health, as positive or negative outcomes for one are associated with a m arked increase or decrease in the other. Good physical health was found to be associated with lower distress , while higher PD was found to produce negative physical health consequences ( Lowe et al., 2014; Merdjanoff, 2013) . The risk of experiencing health problems post disaster for young and middle aged African American women builds on the empirical relationship that has been found within health research where higher levels of mental stress are associated with worse physical health ( Lowe et al., 2014; Sastr y & Gregory, 2013).

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32 CHAPTER V DISCUSSION The distress experienced by low income African American women affected by Hurricane Katrina was significant, especially because they had levels of distress higher than the general population even before the storm . T he population of women who exhibited lower pre disaster distress compared to their peers , and then experienced the highest levels of post disaster distress is disconcerting and poses a particular challenge for mental health care . This finding is perhaps atypical and indicates that these individuals had experiences which were unlike anything previously experienced and that they could not cope with it over the long term. Thus , their levels of distress remained elevated and did not return to pre disaster le vels. Pre disaster vulnerability extend ed beyond the elevated levels of distress found in African American women prior to the hurricane. Many of the systemic problems that contribute to their heightened social vulnerability fall under the broader issue of institutionalized racism . Disparate treatment of African Americans based on their race occurs repeatedly throughout the history of the Gulf coast region, primarily because of slavery, Jim Crow segregation, and prevalent white supremacy groups and movement s. Environmental racism also plays a significant role in social vulnerability in the Gulf Coast region. From being forcibly detained to work on levees at gunpoint following the Great Mississippi Flood of 1927 to the portentous devastation of the Lower Nint h Ward by Hurricane Betsy in 1965 , African Americans have experienced the disproportionate impacts of flooding and hurricanes throughout history (Bullard, 2008) . New Orleans is an unequal city, structured very similarly to other coastal and floodplain citi es: the more

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33 affluent neighborhoods live on the higher ground. The geographic location of the poorest neighborhoods is not by chance, but by design. The poorest, primarily African American communities in New Orleans are situated in the most vulnerable area s of the city , placing them at a heightened vulnerability to Hurricane Katrina as a result of the heightened environmental risk of flooding. Furthermore, it is well established within the disaster literature which populations are the most vulnerable and w ho is most likely to be left behind or neglected in a disaster situation. Emergency planners have had this knowledge for decades, and FEMA simulations conducted prior to Hurricane Katrina foretold how unprepared the organization was for a disaster on that scale to affect New Orleans (Bourne, 2004) . Yet preparedness measures were not implemented. address social vulnerability did not end with Hurricane Katrina, and persists with current disasters, particularly Hurricane Maria. Contemporary disaster management and emergency preparedness conti nues to neglect vulnerable groups , which implicates a systemic apathy towards addressing social vulnerability. The perspective taking and understanding of communit ies required to compr ehend and address the challenges vulnerable populations will face in a disaster is not conducted . For this reason, emergency management fail s to account for the situations which cause heightened vulnerability in the first place. Lack of transportation, for example, became one of the primary disaster management problems following Hurricane Katrina. African Americans have a higher likelihood of not owning a car, which is a key aspect of disaster vulnerability because it facilitates safe and timely evacuation (Bullard, 2008). Transportation also facilitates disaster recovery, because it provides a means to

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34 access education, employment opportunities, health care, and public services. Nearly a quarter of African American adults in the United States do not own a c ar, and more than half of African American adults who lived in New Orleans prior to Katrina did not own a car (Bullard, 2008; Coker et al., 2006; Rhodes et al., 2010; Lowe, 2015; Fussell & Lowe, 2014 ). In either context, more African American adults lack p ersonal vehicles than any other demographic group. The disparity was highly visible in the wake of Hurricane Katrina, as emergency plans failed to account for thousands of people who did not own cars and relied on public transportation . Lacking personal tr ansportation contributed not only to vulnerability, but to higher mental distress as well. While the conditions which resulted in pre existing vulnerability contributed to poorer mental health for African American women, the effects of Hurricane Katrina o n mental health are highly evident. Exposure variables such as being in a flooded area, sheltering in the Superdome, and mental health outcomes across demographic groups compared to populations that did n ot experience the same exposure variable s . Moreover, it was evident that even among populations with similar levels of exposure to Hurricane Katrina, African American women experienced the highest levels of distress. These two key findings indicate that Hu rricane Katrina did negatively affect the mental health of affected populations, and that effect was greatest for African American women. The amplified effect of Katrina for African American women existed in part due to losses in psychosocial and economic resources and disruption of social networks which were critical for them. This finding supports similar research on the differential mental health effects of disasters for vulnerable groups , as the extent of personal impact, property damage, and impeded

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35 ac cess to services associated with experiencing disasters significantly contributed to PTSD and depression ( Davidson et al., 2013 ; Fothergill & Peek, 2004; Norris et al., 2002a; Norris et al., 2002b ) . African American women also experienced poorer mental hea lth as a result of displacement . T he cumulative results provided strong evidence that displacement is not a e . It is a multi dimensional occurrence that can have significant negative consequences for mental healt h . The relationship between home damage and associated with displacement: the sometimes prolonged search for a new home, loss of the ir community and its support, and the delays and uncertainties associated with government housing support. T he findings on displacement and its interaction with PTSD indicate that the when they a re displaced from their community. Among the dimensions of displ acement, type of housing seemed to have a substantial impact on distress, particularly for renters. This can be attributed to renters lacking the authority, rights, and control over rebuilding their apartments and houses, making them more likely to permane ntly lose their homes. The elevated PTSD in some returners indicates that the disaster affected them well beyond the evacuation period and that the adjustment of returning home during the recovery period can carry its own trauma. The results concerning the dimensions of displacement support the idea that Hurricane Katrina had a negative impact on African American women and their mental health because they lived in neighborhoods where home damage and destruction was exceedingly common . High levels of psychol ogical resilience are critical to mental health in disaster

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36 situations and disaster recovery. The long term decreased perceived levels of social support and its ties to mental health implies that their recovery has been impeded by a lack of social support. I ncreased distress experienced several years after Hurricane Katrina could be attributed in part to the permanent fractures in their communities caused by this disaster of support back to pre disaster levels . Additionally, the lack of impact that psychosocial and economic resource gains has on existing PD supports the well established psychological theory of negativity bias: humans are much more likely to be affected by negative ev ents than positive ones. This theory could be applied to much of what African American women experienced post disaster, as many positive changes and events in their lives paled in comparison to the trauma and negative effects of Hurricane Katrina. Limitati ons The design itself is a distinct limitation because the systematic review had to be carried out in a manner that ensured a sufficient number of studies. This limitation, though derived from the availability of the studies themselves, is notable. It plac ed significant restraints on an ability to pinpoint specific mental health outcomes and how they related to the displacement experienced by African American women because of Hurricane Katrina. For this reason, the study search was , which encompass ed many psychological conditions, all of which have distinct behavioral, symptomatic, and clinical components that had to be generalized for the sake of this study . Additionally, the availability of studies that specifically addressed d isplacement and mental health and how they are interrelated was far too small to be its own systematic review. Hence, several other themes within mental health and disaster

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37 experiences were identified and analyzed to determine how they may or may not relat e to displacement. S ystematic reviews offer an opportunity to analyze the research itself and the approaches taken on a topic. Th is study highlighted disparities within the research on Hurricane Katrina in terms of what demographic groups were chosen for study after the disaster. The original research design sought to compare studies between different demographic groups: either comparing male and female or comparing African American women with women of a different race or ethnic group. These studies were e ither too few in number , had inadequate sample sizes, or, in the case of African American men, were almost entirely absent from the body of research . The only study found during the initial search that reported findings specific for African American men wa s a study of a prison population in New Orleans. This is representative of contemporary mental health research on disasters in general, as it tends to focus primarily on wome n. M en, especially men from minority ethnic groups , are often completely overlooke d , in part because their effect sizes and results from common psychological measures tend to be smaller than women . The bias that existed within the literature on Hurricane Katrina carries important implications for disaster research. The groups chosen for study post disaster originate from inherent biases in the portrayal of disaster effects on particular demographic groups coupled with factors which favor convenience for researchers . While disasters can have widespread effects, the population sampling is largely done based on factors of convenience and cost for the researchers. Broadly, studies are conducted post disaster in shelters and evacuation centers, and willing adults who are physically and mentally capable of being interviewed at the time of the r

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38 sample population. Often, participants for follow up studies are selected based on factors such as owning homes, being able to speak, read, and write in English, having access to a landline or cellular phone, and having home internet access. These factors all contribute to greater information access, meaning participants selected in this manner are not as likely to represent those who live below the federal poverty level. The goal of disaster research has seldom been to h one in on differences between demographic groups by providing a level of detail in the analysis and data collection capable of speaking to the experiences of different groups. Prior to Hurricane Katri na, very little literature on the experiences of Africa n American women affected by disasters existed. Furthermore, among the studies of African American women, the overwhelming majority were undertaken using the same sample of women in New Orleans from the Resilience in Survivors of Katrina ( RISK ) project . Al though the major benefit of this project was its timely pre disaster data, it is geographically and demographically narrow in terms on the Gulf Coast . Davis ( 2015) discuss es how the stories of African American women in Mississippi take place on the periphery and how the focal point of academic research and popular media coverage of Hurricane Katrina has remained on New Orl eans . D espite the destruction and trauma that took place in coastal counties in Mississippi, Alabama, and parts of Louisiana outside of New Orleans, they have been, essentially, left out of the Hurricane Katrina narrative along with African American men an d other demographic groups.

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39 CHAPTER VI CONCLUSION The Gulf Coast of the United States was forever changed by Hurricane Katrina. Though much of its unique culture, traditions, and events remain unchanged, too much of its population was permanently displ aced by the disaster in a manner which denied them vital community, financial, and mental health support. Hurricane Katrina highlights the inequities that often occur with disaster displacement , where highly vulnerable populations are forcibly detached fro m their home communities and left with very little support to rebuild their lives . Disaster recovery also happens in a very uneven manner, along economic and often racial lines. The mental health effects of disaster displacement cannot be ignored, as they can be the source of family and social problems within the host or destination community. Without proper mental health support and treatment of psychological symptoms, individuals cope with a very stressful series of events in their lives on their own. L ow income African American women displaced by Hurricane Katrina struggled to meet basic needs in new and unfamiliar places, and often had to contend with multiple moves alongside their disaster experiences and losses. They were more likely than any other dem ographic group to suffer the harmful physical and mental health consequences of the disaster. Most were left to cope with the stress without support and with few social and economic resources . This study highlights how complex, how important, and also how neglected and overlooked mental health is in the wake of a disaster. It identifies a clear need for post disaster mental health support to facilitate the recovery process, as well as highlighting the systemic issues which factor into poorer mental health for African American women.

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40 Institutional racism and pervasive social inequities persist in the Gulf Coast region, and hurricane disasters bring these systemic issues to the surface and force us to examine l the systemic issues are addressed, vulnerable populations will continue to be disproportionately affected by hazards and face the largest recovery obstacles post disaster. Most significant of all, this work gives a voice to the women whose lives were int errupted and altered in profound ways by Hurricane Katrina. Though African American women arguably experienced the most severe mental health effects of Hurricane Katrina, future research of large disaster displacement events should cover all demographic g roups and affected areas in an equitable way to comprehensively examine how displacement and mental health interact for people from different genders, places, races, and cultures. The selection bias within disaster research also needs to be explored furthe r in terms of who is typically identified for study post disaster, why, and the implications of that selection bias. In the case of Hurricane Katrina, the bias was based on availability of pre disaster data for low income African American women. The implic ations of biases based on convenience for the researchers should be a priority for future meta research in disasters. Additionally, t he gaps identified in the research carry important implications for disaster and mental health literature. Significant gap s include not only how displacement relates to mental health, but also how disasters affect mental health during the recovery period. Much disaster literature focuses on the immediate post disaster effects, and not eff ects on mental health over time. For t his reason, delayed distress reactions are not well understood, but longitudinal research could provide great insight into the mechanisms

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41 behind worsening mental health during the recovery period. This study supports understanding of how mental health effe cts can persist for years post disaster, but the The complexities of this interaction merit additional multi disciplinary research efforts. Future research should examine the differential, longitudinal effects of disasters across and between demographic groups , as well as potential causes and factors for worsening mental health post disaster. These next steps would create a strong theoretical basis and justification for mental health to become an integral part of post disaster health response. Post disaster mental health support for displaced people is a fundamental service that is missing from disaster response and recovery. Treatment of displacement and disaster related mental health problems can prevent soc ial withdrawal, suicide, physical and emotional abuse, and substance abuse, among other social and familial problems. The results of these studies not only suggest a need for more research on the mental health effects of the displacement caused by Hurrican e Katrina, but also highlight the necessity of mental health services for low income African American women who experience these non normative life events.

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45 Laditka, S. B., Murray, L. M., & Laditka, J. N. (2010). In the e ye of the s torm: Resilience and v ulnerability a mong African American w omen in the w ake of Hurricane Katrina. Health Care for Women International , 9332 . https://doi.org/10.1080/07399332.2010.508294 Lai, B. S., Lewis, R., Livings, M. S., Greca, A. M. La, & Esnard, A. (2017). Posttraumatic s tress s ymptom t rajectories a mong c hildren a fter d isaster e xposure: A r eview, Journal of Traumatic Stress , 30 , 571 582. https://doi.org/10.1002/jts.22242 Lai, B. S., Tiw ari, A., Beaulieu, B. A., Self brown, S., & Lou, M. (2016). Hurricane Katrina: Maternal depression trajectories and child outcomes. Current Psychology , 34 (3), 515 523. https://doi.org/10.1007/s12144 015 9338 6.Hurricane Lajoie, A. S., Sprang, G., & Mckinn ey, W. P. (2010). Long term effects of Hurricane Katrina on the psychological well being of evacuees, Disasters , 34 ( 4 ), 1031 1044. Lê, F., Tracy, M., Norris, F. H., & Galea, S. (2013). Displacement, county social cohesion, and depression after a large sca le traumatic event. Social Psychiatry and Psychiatric Epidemiology , 48 (11), 1729 1741. https://doi.org/10.1007/s00127 013 0698 7 Lee, E. O. (2009). Coping w ith Hurricane Katrina: Psychological d istress and r esilience a mong African American e vacuees, Journ al of Black Psychology, 35 (1), 5 23. https://doi.org/10.1177/0095798408323354 Li, W., Airriess, C. A., Chen, A. C., & Leong, K. J. (2010). Katrina and migration: Evacuation and return by African Americans and Vietnamese Americans in an Eastern New Orleans Suburb. The Professional Geographer , 62 (1), 103 118. https://doi.org/10.1080/00330120903404934 Lieberman Cribbin, W., Liu, B., Schneider, S., Schwartz, R., & Taioli, E. (2017). Self r eported and FEMA f lood e xposure a ssessment after Hurricane Sandy: Assoc iation with m ental h ealth o utcomes. Plos One , 12 (1), e0170965. https://doi.org/10.1371/journal.pone.0170965 Lowe, S. R., Chan, C., & Rhodes, J. E. (2010). Pre h urricane perceived social support protects against psychological distress: A longitudinal analy sis of low income mothers. Journal of Consulting and Clinical Psychology , 78 (4), 551 560. https://doi.org/10.1037/a0018317 Lowe, S. R., Norris, F. H., & Galea, S. (2016). Mental h ealth s ervice u tilization a mong n atural d isaster s urvivors w ith p erceived n e ed for s ervices. Psychiatric Services , 67 (3), 354 357. https://doi.org/10.1176/appi.ps.201500027

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46 Lowe, S. R., & Rhodes, J. E. (2013). Trajectories of psychological distress among low income, female survivors of Hurricane Katrina. American Journal of Ort hopsychiatry , 83 (2 PART 3), 398 412. https://doi.org/10.1111/ajop.12019 Lowe, S. R., Rhodes, J. E., & Waters, M. C. (2015). Understanding r esilience and o ther t rajectories of p sychological d istress: A m ixed m ethods s tudy of l ow i ncome m others w ho s urvived Hurricane Katrina. Current Psychology , 34 (3), 537 550. https://doi.org/10.1007/s12144 015 9362 6 Lu, C. J., & Shulman, S. W. (2008). Rigor and flexibility in computer based qualitative research: Introducing the Coding Analysis Toolkit. International Jour nal of Multiple Research Approaches , 2 , 105 117. consequences of Hurricane Katrina on the displaced residents of New Orleans. Social Science Research , 42 (5), 1222 1235. https:// doi.org/10.1016/j.ssresearch.2013.04.004 Morris, K. A., & Deterding, N. M. (2016). The emotional cost of distance: Geographic social network dispersion and post traumatic stress among survivors of Hurricane Katrina. Social Science & Medicine , 165 , 56 65. https://doi.org/10.1016/j.socscimed.2016.07.034 Neria, Y., Nandi, A., & Galea, S. (2008). Post traumatic stress disorder following disasters: A systematic review, Psychological Medicine , 38 , 467 480. https://doi.org/10.1017/S0033291707001353 Norris, C. M ., & Mitchell, F. D. (2018). Exploring the s tress s upport d istress p rocess a mong b lack w omen, Journal of Black Studies, 45 (1), 3 18. https://doi.org/10.1177/0021934713517898 Norris, F. F. H., Friedman, M. J. M., & Watson, P. P. J. P. (2002). 60,000 disast er victims speak: Part II. Summary and implications of the disaster mental health research. Psychiatry , 65 (3), 240 260. https://doi.org/10.1521/psyc.65.3.240.20169 Parker, G., Lie, D., Siskind, D. J., Martin Khan, M., Raphael, B., Crompton, D., & Kisely, S. (2015). Mental health implications for older adults after natural disasters : A systematic review and meta analysis. Int Psychogeriatr , 28 (1), 11 20. https://doi.org/10.1017/s1041610215001465 Paxson, C., Fussell, E., Rhodes, J., & Waters, M. (2012). Fiv e years later: Recovery from post traumatic stress and psychological distress among low income mothers affected by Hurricane Katrina. Social Science & Medicine , 74 (2), 150 157. https://doi.org/10.1016/j.socscimed.2011.10.004

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47 Rataj, E., Kunzweiler, K., & Garthus niegel, S. (2016). Extreme weather events in developing countries and related injuries and mental health disorders : A systematic review. BMC Public Health , 1 13. https://doi.org/10.1186/s12889 016 3692 7 Rhodes, J., Chan, C., Paxson, C., Rouse, C. E., Waters, M., & Fussell, E. (2010). The i mpact of Hurricane Katrina on the m ental and p hysical h ealth of l ow i ncome p arents in New Orleans. American Journal of Orthopsychiatry , 80 (2), 237 247. https://doi.org/10.1111/j.1939 0025.2010.01027.x Sastry, N. , & Gregory, J. (2013). The effect of Hurricane Katrina on the prevalence of health impairments and disability among adults in New Orleans: Differences by age, race, and sex. Social Science & Medicine , 80 , 121 129. https://doi.org/10.1016/j.socscimed.2012. 12.009 Sastry, N., & Gregory, J. (2014). The location of displaced New Orleans residents in the year after Hurricane Katrina. Demography , 51 (3), 753 775. https://doi.org/10.1007/s13524 014 0284 y Shalev, A., Liberzon, I., & Marmar, C. (2017). Post Trauma tic Stress Disorder. The New England Journal of Medicine , (376), 2459 2470. https://doi.org/10.1056/NEJMra1612499 Singelmann, J., & Schafer, M. (2010). Dislocation and d epression: Social c onsequences of Hurricanes Katrina and Rita. Society and Natural Res ources , 23 (10), 919 934. https://doi.org/10.1080/08941920903214108 Stuckey, H. (2015). The second step in data analysis: Coding qualitative research data. Journal of Social Health and Diabetes , 3 (1), 7. https://doi.org/10.4103/2321 0656.140875 Tang, B., Liu, X., Liu, Y., Xue, C., & Zhang, L. (2014). A meta analysis of risk factors for depression in adults and children after natural disasters. BMC Public Health , 14 (623). Thiede, B. C., & Brown, D. L. (2013). Hurricane Katrina: Who s tayed and w hy? Populati on Research and Policy Review , 32 (6), 803 824. https://doi.org/10.1007/s11113 013 9302 9 Timulak, L. (2009). Meta analysis of qualitative studies: A tool for reviewing qualitative research findings in psychotherapy. Journal of the Society for Psychotherap y Research , 19 (4 5), 591 600. https://doi.org/10.1080/10503300802477989 Toldson, I. A., Ray, K., Hatcher, S. S., & Louis, L. S. (2011). Examining the long term racial disparities in health and economic conditions among Hurricane Katrina survivors: Policy implications for Gulf Coast recovery. Journal of Black Studies , 42 (3), 360 378. https://doi.org/10.1177/0021934710372893

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48 Trepanier, J. C., Ellis, K. N., & Tucker, C. S. (2015). Hurricane risk variability along the Gulf of Mexico Coastline. PLoS ONE , 10 (3) . https://doi.org/10.1371/journal.pone.0118196 Vaughn, P., & Turner, C. (2016). Decoding via c oding: Analyzing q ualitative t ext d ata t hrough t hematic c oding and s urvey m ethodologies. Journal of Library Administration , 56 (1), 42 51. https://doi.org/10.1080 /01930826.2015.1105035 Wadsworth, M. E., Santiago, C. D., Einhorn, L., Wadsworth, M. E., Santiago, C. D., & Einhorn, L. (2009). Coping with displacement from Hurricane Katrina: P redictors of one year post traumatic stress and depression symptom trajectori es, 5806 . https://doi.org/10.1080/10615800902855781 Wallace, D. J., & Anderson, J. B. (2010). Evidence of similar probablility of intense hurricane strikes for the Gulf of Mexico over the late Holocene. Geology , 38 (6), 511 514. https://doi.org/10.1130/G30 729.1 Wang, C. W., Chan, C. L. W., & Ho, R. T. H. (2013). Prevalence and trajectory of psychopathology among child and adolescent survivors of disasters: A systematic review of epidemiological studies across 1987 2011. Social Psychiatry and Psychiatric Epidemiology , 48 , 1697 1720. https://doi.org/10.1007/s00127 013 0731 x Waters, M. C. (2016). Life after Hurricane Katrina: The Resilience in Survivors of Katrina (RISK) Project. Sociological Forum , 31 (September), 750 769. https://doi.org/10.1111/socf.1227 1 Zwiebach, L., Rhodes, J., & Roemer, L. (2010). Resource l oss, r esource g ain, and m ental h ealth a mong s urvivors of Hurricane Katrina. Journal of Traumatic Stress , 23 (6), 751 758. https://doi.org/10.1002/jts.

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49 APPENDIX Codes by Variable Variable Set Code Type of code Tally of occurrence Authors Displacement experiences Quality of housing Moving from public housing to renting Original 0 Displacement experiences Number of moves More than 3 moves Original 1 Fussell & Lowe, 2014 Displacement experi ences time spent in temporary housing More than 4 months spent in temporary housing Original 1 Fussell & Lowe, 2014 Displacement experiences desire to return to previous location Unable to return but having the desire to do so Original Displacement experiences return to previous location Experienced additional trauma on return Emergent 1 LaJoie et al., 2010 Displacement experiences Separation from family Emergent 2 Laditka et al., 2010; Morris & Deterding, 2016 Disaster experiences level of d isaster exposure Experienced racial discrimination Emergent 4 Laditka et al., 2010; Chia Chen Chen, 2007; Waters, 2016; Graif, 2016 Disaster experiences level of disaster exposure Did not evacuate prior to hurricane Original 4 Coker et al., 2006; King e t al., 2016; Lee et al., 2009; Fussell & Lowe, 2014 Disaster experiences level of disaster exposure Injury as a result of hurricane Original 0 Disaster experiences level of disaster exposure Deprivation (inadequate food/ water) Emergent 2 Rhodes et al., 2010; Lowe, 2015 Disaster experiences level of disaster exposure Saw others injured or dying Emergent 3 Coker et al., 2006; King et al., 2016; Lowe, 2015 Disaster experiences Personal losses Human loss Original 9 Paxson et al., 2012; LaJoie et a l., 2010; Laditka et al., 2010; Rhodes et al., 2010; King et al., 2016; Lee et al., 2009; Lowe, 2015; Lowe et al., 2014; Calvo

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50 et al., 2015 Disaster experiences Personal losses Property loss/home damage Original 14 Green et al., 2012; Paxson et al., 201 2; Lai et al., 2015; Zwiebach et al., 2010; Lowe et al., 2011; Laditka et al., 2010; Rhodes et al., 2010; King et al., 2016; Merdjanoff, 2013; Lee et al., 2009; Lowe, 2015; Fussell & Lowe, 2014; Calvo et al., 2015; Graif, 2016 Disaster experiences level of disaster exposure Declines in physical health as a result of hurricane Emergent 2 Zwiebach et al., 2010; Lowe et al., 2014 Disaster experiences Personal losses Financial strain Emergent 1 Chia Chen Chen, 2007 Mental health depressive symptoms Dep ressed mood/anhedonia Original 1 Lowe, 2015 Mental health depressive AND PTS symptoms Impairment of normal functioning Original 1 Sastry & Gregory, 2013 Mental health depressive AND PTS symptoms Social withdrawal Original 0 Mental health depressi ve AND PTS symptoms Sleep disturbance Original 0 Mental health depressive AND PTS symptoms Vulnerability to distress prior to hurricane Emergent 8 Green et al., 2012; Paxson et al., 2012; Zwiebach et al., 2010; Lowe et al., 2011; King et al., 2016; C hia Chen Chen, 2007; Lowe, 2015; Fussell & Lowe, 2014 Mental health depressive AND PTS symptoms Feeling hopeful/optimism Emergent 3 Coker et al., 2006; Chan et al., 2011; Lowe, 2015

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51 Mental health depressive AND PTS symptoms Family as way to cope Eme rgent 3 Coker et al., 2006; Paxson et al., 2012; Lowe, 2015 Mental health depressive AND PTS symptoms Religion as way to cope Emergent 4 Coker et al., 2006; Chan et al., 2011; Laditka et al., 2010; Lowe, 2015 Mental health PTS symptoms Elevated di stress after hurricane Emergent 10 Green et al., 2012; Coker et al., 2006; Paxson et al., 2012; Chan et al., 2011; Rhodes et al., 2010; Lowe & Rhodes, 2013; Lowe et al., 2010; Waters, 2016; Lowe, 2015; Fussell & Lowe, 2014 Mental health PTS symptoms Al terations of arousal and reactivity Original 0 Mental health Access to mental health services No knowledge of availability of mental health services Original 0 Mental health Access to mental health services Impeded access to mental health services/ disruption of ongoing services Original 2 Laditka et al., 2010; Lowe, 2015 Mental health Perceived levels of social and/or community support Perceived high level of social/community support as a protecting factor Original 9 Coker et al., 2006; Paxson et al., 2012; Lai et al., 2015; Rhodes et al., 2010; Chan et al., 2015; Chia Chen Chen, 2007; Lowe et al., 2010; Lowe, 2015; Calvo et al., 2015 Mental health Perceived levels of social and/or community support Perceived low level of social/community suppor t as a risk factor Original 5 Green et al., 2012; Chan et al., 2011; Chia Chen Chen, 2007; Lowe, 2015; Calvo et al.,

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52 2015 Vulnerable population factors Income Low income (as identified by study authors) Original 22 Green et al., 2012; Paxson et al., 201 2; LaJoie et al., 2010; Lai et al., 2015; Zwiebach et al., 2010; Lowe et al., 2011; Chan et al., 2011; Laditka et al., 2010; Rhodes et al., 2010; Lowe & Rhodes, 2013; Morris & Deterding, 2016; Chan et al., 2015; Merdjanoff, 2013; Chia Chen Chen, 2007; Lee et al., 2009; Lowe et al., 2010; Waters, 2016; Lowe, 2015; Fusell & Lowe, 2014; Lowe et al., 2014; Calvo et al., 2015; Graif, 2016 Vulnerable population factors Transportation Lacking personal transportation Emergent 4 Coker et al., 2006; Rhodes et al., 2010; Lowe, 2015; Fussell & Lowe, 2014 Vulnerable population factors Age Less than 35 years of age Original 9 Green et al., 2012; Lowe et al., 2011; Chan et al., 2011; Rhodes et al., 2010; Lowe & Rhodes, 2013; Lowe et al., 2010; Waters, 2016; Lowe, 201 5; Fussell & Lowe, 2014

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53 Vulnerable population factors Employment status Unemployed or underemployed Original 0 Vulnerable population factors Educational attainment High school diploma or less Original 14 Green et al., 2012; Paxson et al., 2012; Lai et al., 2016; Zwiebach et al., 2010; Lowe et al., 2011; Chan et al., 2011; Rhodes et al., 2010; Lowe & Rhodes, 2013; Chan et al., 2015; Chia Chen Chen, 2007; Lowe et al., 2010; Waters, 2016; Lowe, 2015; Fussell & Lowe, 2014 Vulnerable population factors family stressors Single Parent Original 18 Green et al., 2012; Paxson et al., 2012; Zwiebach et al., 2010, Lowe et al., 2011; Chan et al., 2011; Rhodes et al., 2010; King et al., 2016; Lowe & Rhodes, 2013; Morris & Deterding, 2016; Chan et al., 2015; Merd janoff, 2013; Chia Chen Chen, 2007; Lowe et al., 2010; Waters, 2016; Lowe, 2015; Fussell & Lowe, 2014; Calvo et al., 2015 Vulnerable population factors family stressors Positive effect of having children Emergent 1 Paxson et al., 2012 Vulnerable popula tion Child related Original 2 Lowe et al.,

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54 factors family stressors stressors 2011; Lowe, 2015 Vulnerable population factors Family stressors Separation, break up, or divorce with partner/spouse Original 3 Sastry & Gregory, 2013; Lowe, 2015; Calvo et al., 2015