PROTECT: Prospective Research On Terrorist Events and Collective Trauma-A cross-border study of health service utilization and prescriptions

The overall aim of PROTECT (Prospective Research On Terrorist Events and Collective Trauma) is to provide knowledge to improve the health services' preparedness to terrorist attacks and disasters. Unmet health care needs have been found among those exposed to terror attacks. The project further aims to develop a method that can be applied after terrorist attacks and similar events across Europe to allow for coordinated research internationally and to develop knowledge to strengthen the health care delivery to affected individuals and communities. The unpredictability and chaotic circumstances of terrorist attacks make it extremely challenging to conduct methodologically sound research in the wake of such events. Previous studies have important limitations. They have usually applied a cross-sectional design and lacked detailed data on health service utilization as well as comparable data from the general population. Furthermore, their results can often not be compared or applied across different settings or countries. There is an urgent need for better knowledge on how to enhance the provision of health services and psychosocial support to terror-exposed individuals and populations. PROTECT assesses both national plans for psychosocial care and health services provided in the wake of terror attacks. The project involves international interdisciplinary collaboration where perspectives from political science have been integrated into the health services research to generate knowledge about the strengths and weaknesses of different health care systems in the context of terrorist attacks. An investigation of the psychosocial care responses to terrorist attacks in Norway, France and Belgium revealed that the responses differed substantially between countries, in spite of available international guidelines for post-disaster psychosocial care and that all countries have universal health coverage with largely publicly financed health services. All countries had plans for the acute provision of psychosocial care, but there were variable and partly scarce information about how to ensure long-term follow-up of those in need of care beyond the acute phase. Furthermore, we identified several differences between the health care systems and characteristics of the attacks that may have impacted the psychosocial care responses. For instance, the provision of acute psychosocial care was primary-care based in Norway, while in France the emergency psychosocial units were mainly composed of professionals from the specialized mental health services. This was also reflected in the research results regarding individuals directly exposed to terrorist attacks, which indicated that the use of General Practitioners (GPs) was clearly more common in survivors of the Utøya attack in Norway than in survivors of the 13 November attacks in France. The findings underscore the need for more systematic monitoring, evaluation and research that can be compared across countries. We further collect longitudinal register-based and administrative claims data on health problems and different types of health service utilization from directly exposed individuals and the general population before and after terrorist attacks. So far, our analyses of register-based data from Norway indicate that it is important to anticipate an increased healthcare utilization several years following terrorist attacks. Both primary care physicians/GPs and practitioners within specialized mental health services played important roles in providing healthcare for psychological problems in young survivors of terrorism, although the health care utilization increased most within specialized mental health services. Norway has universal and mostly publicly financed healthcare and a regular GP-based gatekeeping system. It is important to bear in mind that the healthcare utilization after mass trauma may be different in countries with other health systems or psychosocial care responses. Hereafter, register-based data will be linked with self-reported information from terror-exposed individuals, e.g. about their perceived health, satisfaction with care and other factors that may be important in the planning and implementation of post-disaster health services. This approach may enable both a temporal and geographical comparative perspective with data from before as well as the early and late aftermath of terrorist attacks. This could further provide new and important insight into how the health care needs may change over time, and help us develop better models for follow-up after mass trauma.

Terrorist attacks and disasters affect a large number of persons worldwide, and have devastating consequences for individuals, families and societies. Unmet needs are commonly reported by those impacted. There is an urgent need for coordinated efforts to improve the public health preparedness to such events, and develop evidence-based guidelines for health care and psychosocial support to affected individuals and communities. This project will provide new and important knowledge about the health consequences of terrorist attacks and the challenges they impose to the health services. It covers data from directly exposed individuals and the general population before and after terrorist attacks in Norway on 22 July 2011 and in France (Paris) in January and November 2015. Accurate register-based and administrative claims data on primary and specialized health care utilization and medication prescriptions before and after the attacks will be linked with terror-exposed individuals’ reports of their perceived health, social support and other factors that are important to consider in the planning and implementation of post-disaster health services. The overall aim of the proposed project is to generate knowledge that will improve the public health response to terrorist attacks and other mass casualties. The project will establish and consolidate interdisciplinary collaboration between institutions and research groups both nationally and internationally. The comparison between countries may provide new insight about structural and organizational factors that may impede or promote integrated, coherent patient pathways in the wake of mass trauma. A long-term goal is to develop a sound research methodology that allows for international comparisons of health care delivery in the context of trauma.