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Why is it important to include community-level risk factors into traumatic stress research?

Most traumatic stress research emphasizes person-level risk factors associated with trauma exposure and the development of PTSD. Common person-level factors include coping efforts, maladaptive cognitions, trauma history, and pre-existing psychopathology. Consequently, person-level interventions such as prolonged exposure or cognitive processing therapy have dominated the field. While these interventions are effective at reducing trauma-related symptoms, they often do not target the broader context within which trauma and PTSD are experienced. The field of public health focuses on addressing this broader ecosystem by considering the up-stream community-level risk factors that shape people’s health. One way to address trauma and PTSD more effectively is to expand trauma research by routinely including community-level risk factors.
 

What current approaches exist for assessing community-level risk factors?

There are three common approaches for measuring community-level risk factors. The first method is to use a traditional self-report instrument that asks respondents to rate features of their community such as perceived physical disorder or social cohesion. Some traumatic stress studies have used this method and found that perceived neighborhood disorder is associated with elevated PTSD risk (Gapen et al., 2011; Johns et al., 2012). The downside to this approach is that it requires including a dedicated measure in one’s research protocol. This may increase participant response burden and detract from a project’s primary purpose if community-level risk factors are not the primary focus.
 
The second method is to perform a community audit in which researchers evaluate features of a community’s environment (e.g., presence of trash, vacant housing). This process has become much easier in recent years with the rise of digital maps that allow for a “virtual street walk” through neighborhoods. The primary limitation of this method is that it necessitates a large investment of time, training, and personnel to perform it successfully.
 
The third method is to utilize publicly available census records. In the U.S. and across most of the globe, population-level data on income, education, and housing are regularly collected. For example, this information is collected annually in the American Community Survey in the U.S. This approach overcomes the limitations of self-report instruments and community audits because these data are free, available online, and only require that researchers collect their participants’ residential addresses, which is information routinely collected in most research protocols. However, to use these data, researchers must have knowledge about how to access them and how to use them to create measures of community risk.
 

How can trauma researchers access census data and create community-level risk factors?

We recently published a study that presents researchers with instructions and R scripts for using U.S. census data to compute two community-level risk factors. We also demonstrate how these risk factors relate to PTSD symptom severity in a sample of injury survivors (Hruska et al., 2022). The risk factors examined were the Neighborhood Deprivation Index (NDI) and the Index of Concentration at the Extremes (ICE). The NDI combines information on community-level education, occupation, housing, poverty, and employment to yield a measure of community socioeconomic conditions. In contrast, the ICE uses information on race and income to produce a single metric providing insight into the degree to which people with different incomes or racial identities are geographically concentrated. Findings from the study indicated that injury survivors living in communities with lower socioeconomic conditions or higher concentrations of lower income, historically disenfranchised groups reported elevated PTSD symptom severity levels in the weeks and months following their injury. Collectively, these results highlight the importance of considering the community context surrounding trauma and PTSD. Furthermore, the detailed instructions and R scripts provided make these data more accessible to trauma researchers. Regularly including these risk factors into trauma research can inform policy and prevention strategies targeting the broader context within which trauma and PTSD occurs. Only with this more comprehensive approach can we effectively reduce the significant cost and impairment associated with trauma and PTSD.
 

About the Author

Bryce Hruska (bjhruska@syr.edu) is an assistant professor in the Department of Public Health in the David B. Falk College of Sport and Human Dynamics and a Lerner Center for Public Health Promotion Faculty Research Affiliate at Syracuse University. His research examines risk and protective factors associated with trauma and PTSD among patients interacting with the healthcare system and among the healthcare workers responsible for delivering care. This work is often performed using ecological momentary assessment to better understand the daily exposures, behaviors, and processes associated with mental health outcomes following trauma.
 

References

Gapen, M., Cross, D., Ortigo, K., Graham, A., Johnson, E., Evces, M., Ressler, K. J., & Bradley, B. (2011). Perceived neighborhood disorder, community cohesion, and PTSD symptoms among low-income African Americans in an urban health setting. American Journal of Orthopsychiatry, 81(1), 31–37. 

Hruska, B., Pacella-LaBarbara, M. L., Castro, I. E., George, R. L., & Delahanty, D. L. (2022). Incorporating community-level risk factors into traumatic stress research: Adopting a public health lens. Journal of Anxiety Disorders, 86, 102529. 

Johns, L. E., Aiello, A. E., Cheng, C., Galea, S., Koenen, K. C., & Uddin, M. (2012). Neighborhood social cohesion and posttraumatic stress disorder in a community-based sample: Findings from the Detroit Neighborhood Health Study. Social Psychiatry and Psychiatric Epidemiology, 47(12), 1899–1906.