Issues in Mental Health Nursing, 35:420–436, 2014 Copyright © 2014 Informa Healthcare USA, Inc. ISSN: 0161-2840 print / 1096-4673 online DOI: 10.3109/01612840.2013.875085

The Psychosocial Impact of Natural Disasters among Adult Survivors: An Integrative Review Sri Warsini, M. Med, Caryn West, PhD, Grad Dip Ed (TT), Grad Cert Res Meth, RN, and Jane Mills, RN. PhD, MN MEd, BN, GradCertEd, FACN Issues Ment Health Nurs Downloaded from informahealthcare.com by Memorial University of Newfoundland on 06/09/14 For personal use only.

James Cook University, School of Nursing, Midwifery and Health Nutrition, Cairns, Australia

Kim Usher, RN BA DipAppSc MNSt PhD School of Health, University of New England, Armidale, NSW, Australia

The aim of this review was to identify the psychosocial impact of natural disasters on adult (over the age of 18 years) survivors. Databases searched included PsycInfo, CINAHL, Proquest, Ovid SP, Scopus, and Science Direct. The search was limited to articles written in English and published between 2002 and 2012. A total of 1,642 abstracts and articles were obtained during the first search; 39 articles were retained. The results indicate that PTSD is the most-studied psychosocial impact after a disaster. Mental health nurses have a significant role to play in supporting survivors and can assist with the development of resilience in community members.

Disasters are traumatic events experienced almost every day, somewhere in the world (Norris et al., 2002). Any type of disaster, whether natural or not, results in a multidimensional impact on a large number of people. The aftermath of a disaster is a time when survivors experience many psychosocial symptoms such as stress, grief, depression, and anxiety (Cohen, 2002; Reyes & Elhai, 2004). The psychosocial impact is exacerbated and prolonged by personal and property losses, relocation, and disrupted social support networks and daily activities (Mitchell, Witman, & Taffaro, 2008; Nikapota, 2006). In the months following a traumatic disaster, acute reactions are replaced by more chronic psychological conditions that require ongoing management (Madrid & Grant, 2008; Rosser, 2008; Vijaykumar, Thata, John, & Chellappa, 2006). The long-term psychosocial impact of disasters can include serious problems, such as posttraumatic stress disorder (PTSD), substance abuse, and major depression (Leon, 2004). The purpose of this article is to review the literature on the psychosocial impact of natural disasters on adult survivors. Funding was received from the School of Nursing, Midwifery and Nutrition and the Graduate Research School at James Cook University, Australia. Address correspondence to Sri Warsini, James Cook University, School of Nursing, Midwifery and Nutrition, P.O. Box 6811, Cairns, 4870 Australia. E-mail: [email protected]

While previous literature reviews on this subject have been conducted, the last review, conducted in 2002 (Norris et al., 2002), explored empirical research on a variety of survivor groups including children, adults, and recovery workers, and other publications (Galea, Nandi, & Vlahov, 2005; Neria, Nandi, & Galea, 2008) were focused on specific issues, such as PTSD. Therefore, it was considered timely to undertake an update on the topic area. AIM The aim of this integrative review was to identify the evidence related to the psychosocial impact of natural disasters on adult (over the age of 18 years) survivors. The specific research questions were: What is the psychosocial impact of a natural disaster on survivors? Does the psychosocial impact of natural disasters on survivors differ among types of disasters? METHOD This literature review was conducted using an integrative approach, a method that draws on a diverse range of studies and methodologies to summarise the main points of past research and to delineate what is known about a topic (Whittemore & Knafl, 2005). A systematic search was conducted using the keyword terms/phrases “psychosocial impact and natural disaster,” “psychological impact and natural disaster.” and “mental health impact and natural disaster.” The databases searched included PsycInfo, CINAHL, Proquest, Ovid SP, Scopus, and Science Direct. The search was limited to articles written in English, reviewed and published in the period of 2002–2012. This time frame was selected as appropriate as a previous review conducted by Norris et al. (2002) included articles up until 2001. A total of 1642 abstracts and articles were obtained during the first search. Preliminary screening identified articles that

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Inclusion Criteria

Exclusion Criteria

Published in English language Published between 2002–2012 Primary research article Related to adult direct survivors

Published in language other than English Published prior to 2002 or after 2012 Dissertation, thesis, review, other documents Focused on other than adult (i.e., children or teenagers) or if focused on specific populations, such as female or male groups of survivors, pregnant mothers, health care workers, students, nurses, or rescue workers Man-made disaster, technological disaster

Natural disaster situation

Screening

Identification

focused on the psychological impact on adult victims. Another nine articles were found by hand searching. Duplicates were removed, resulting in a subset of 1615 articles. Articles were screened based on inclusion criteria (see Table 1). After the screening, 97 articles and abstracts were retained. A PRISMA flow chart diagram was used to show the flow of the literature selection process during the review. This flow chart, adapted from Moher et al. (2009), records the number of articles

gathered, screened, excluded, and selected during the steps of a systematic review (see Figure 1). All articles were assessed for eligibility using the Critical Appraisal Skills Programme (CASP) evaluation method. The CASP is a common tool used to assess the quality of various research articles (Burls, 2009). The final set of relevant articles was narrowed down to 39 articles, which were synthesized and included in the present review (see Table 2).

Records identified through database searching (n = 1633)

Hand search (n = 9)

Records after duplicates removed (n = 1615)

Eligibility

Titles and abstract screened (n = 1615)

Included

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TABLE 1 Inclusion and Exclusion Criteria

Full text articles assessed for eligibility (n = 97)

Records excluded (n = 1518)

Full text articles that did not meet criteria (n = 58)

Studies included in review of the literature (n = 39)

FIGURE 1 PRISMA Flow Chart (adapted from Moher, Liberati, Tetzlaff, Altman, & Group, 2009).

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TABLE 2 Natural Disasters and Psychological Impact Review Articles

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Authors

Event

Time Frames (pre- and/or post-disaster)

Sample Size

Study Type

Measurement Tool

Ali Earthquake; 8 et al. October (2012) 2005 (Pakistan)

30 months (2.5 years) postdisaster

Earthquake survivors from Mansehra, Hazara, and Abbotabad districts (n = 300)

Cross sectional

Aslam Earthquake; 8 & October Tariq 2005 (2010) (Pakistan)

1 year postdisaster

Comparative Impact of Event Scale (IES), Depression Anxiety and Stress Scale (DASS)

Basoglu Marmara et al. Earth(2004) quake; August & November 1999 (Turkey)

14 months postdisaster

Survivors from the most affected districts (Mansehra, Muzaffarabad, and Bagh) and unaffected areas (Attock, Hejlum, and Mirpur) (n = 600) Participants form Degirmendere and Avcilar (n = 650)

Cross sectional

Davidson Trauma Scale

Traumatic Stress Symptoms Checklist (TSSC)

Main Finding Possible PTSD case: 41.3%. Predictor factors: gender (female), age (elderly), marital status (unmarried), role in family (head of family), occupational status (jobless), housing (impermanent house). Protective factors: higher social economy status and spirituality. Predictor factors for PTSD, depression, and stress are geographic proximity to disaster site and marital status. Gender became a significant factor for stress whereas, for anxiety, geographic proximity area was.

The prevalence of PTSD and depression at the worst damage area was 16–23%, 8% higher than in the other area. Fear became the most significant factor of PTSD prevalence in earthquake setting. Gender, history of mental illness and trauma, property destruction, family loss, and have contribution during crisis period were weak risk factors. (Continued on next page)

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TABLE 2 Natural Disasters and Psychological Impact Review Articles (Continued)

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Authors

Event

Time Frames (pre- and/or post-disaster)

Sample Size

Study Type

Measurement Tool

Main Finding

Cao Yun Nan et al. Earth(2003) quake; 1988 (China)

5 months postdisaster

Participants from affected area (Shang Yun, Lang Cang, and Meng Lian) and from unaffected area (Lu Nan) (n = 2202)

Case control

Carroll Carlisle et al. Flood; (2009) 2005 (UK)

10–13 months postdisaster

Participants in Carlisle city (n = 40)

Chae Flood; et al. August (2005) 2002 (South Korea)

3 months pre-disaster and 4 months postdisaster

Survivors from Gangneung city and from Gangwon province (n = 285)

Chan Sichuan et al. Earth(2012) quake; 12 May 2008 (China)

7.5 months postdisaster

Respondents from Guankou town and Jiannan town (n = 1725)

Flood had become traumatic event for survivors. Some emotional terminologies have been claimed by the survivors such as, “horrifying,” “terrified,” “petrified, “traumatic,” “panic stricken,” and “never been so frightened in all my life.” Case Korean Psychological Survivors from disaster control Wellbeing Index affected area (PWI SF), Zung experienced PTSD, Self-Rate depression, anxiety, Depression Scale and health problems. (ZRDS), The Stait Among survivors in Trate Anxiety exposed area The PWI Inventory (STAI) SF score was increased 7 points after flood. The incident of anxiety cases was 21.3% whereas PTSD cases were 39.5%. Comparative Impact of Event Scale 50.2% of survivors who Revised (IESR), lost their family had Centre of PTSD and 55.8% of Epidemiological them suffered from Studies Depression depression symptoms. Scale (CES-D) It was 18-23% higher than the prevalence among participants who did not lose their beloved one. (Continued on next page)

General Health Questionnaire (GHQ), Life Event Inventory, Posttraumatic Stress Disorder section of Diagnostic Interview Schedule, Inventory of The Impact of Disaster Phenomeno- The key areas of logy questioning were broadly based on Tapsell et al.’s (2002) work

Possible psychological morbidity and PTSD case in the worst damage area was 51% and 13–23%. The average rate of PTSD among common population was only 8.9%

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TABLE 2 Natural Disasters and Psychological Impact Review Articles (Continued)

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Authors

Event

Time Frames (pre- and/or post-disaster)

Sample Size

Chan Wenchuan or et al. Sichuan (2011) Earthquake; 12 May 2008 (China)

1 month post- Survivors from disaster Qinchuan county (n = 430)

Chen Chi-Chi et al. Earth(2007) quake; 21 September 1999 (Taiwan)

2 years postdisaster

Survivors from Nantou county (n = 6412)

Dorahy Christchurch & EarthKannis- quake; 4 Dymand September (2012) 2010 (New Zealand)

2 months postdisaster

Survivors from Christchurch suburb of Avonside and Hornby North (n = 124)

Emin Marmara et al. Earth(2006) quake; 17 August 1999 (Turkey)

3 years postdisaster

Respondents of Kocaeli City Centre (n = 683)

Study Type Cross sectional

Measurement Tool Posttraumatic Stress Disorder Self-Rating Scale (PTSD-SS)

Main Finding

62.6% of victims diagnosed for PTSD. The risk factors were marital status (married), gender (female), family’s victim, educational level (low), and property loss. Cross Chinese Health The prevalence rates of sectional Questionnaire-12 PTSD and mental health (CHQ-12); Chinese illness probability among Startle, survivors were 20.9% Physiological and 39.8%. The predictor arousal, anger, and factors for both problems numbness (SPANwere gender (female), C) level of education (low), and living place (shelter). In addition, age (elderly) became a specific risk factor for psychiatric morbidity whereas property devastation was risk in PTSD problems. Comparative Acute Stress Disorder The prevalence rate of Scale (ASDS); anxiety and depression in Patient Health exposure community Questionnaire 9 were higher than others, depression module but not the acute stress (PHQ9); disorder rate. Generalized Anxiety Disorder-7 (GAD7) Cross General Health The rate of PTSD and sectional Questionnaire 12 Major Depressive (GHQ-12); Disorder (MDD) in Composite disaster site survivors International was 11.7% and 10.5%, Diagnostic and they became the Interview (CIDI); most common Beck Depression post-disaster problem. Inventory (BDI); Even though the rates Traumatic Stress were decreased over Symptom Checklist 3 years, there were (TSSC) 37.5% of victims who suffered from PTSD and fulfilled MDD criteria. (Continued on next page)

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TABLE 2 Natural Disasters and Psychological Impact Review Articles (Continued)

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Authors

Event

Time Frames (pre- and/or post-disaster)

Sample Size

Study Type Cross sectional

Gigantesco L’Aquila et al. Earth(2013) quake; 6 April 2009 (Italy)

14–19 months postdisaster

Survivors in L’Aquila city (n = 957)

Goto et al. (2006)

Volcano; 8 July 2000 (Japan)

10 months postdisaster

Survivors in Cross Miyake Island sectional (n = 231)

Irmansyah et al. (2010)

Southeast 2 months Asian postEarthquake disaster and Tsunami; 26 December 2004 (Indonesia)

Survivors from IDP group and non IDP group who live in Aceh and North Sumatra (n = 783)

Cross sectional

Measurement Tool Mini International Neuropsychiatric Interview (MINI), Patient Health Questionnaire (PHQ-8)

Main Finding

The rates of PTSD and Major Depression (MD) were 4.1% and 5.8%. The PTSD predictor factors were illness history (chronic illness) and loss of beloved one, whereas for MD, they were gender (female), living in affected area, and occupational status (jobless). Financial difficulties became a risk factor in both problems. Impact of Event Scale Volcano survivors who Revised (IESR); more frequently Centre of relocated had higher risk Epidemiological of PTSD symptoms Studies-Depression than the other group due Scale (CESD) to loss of belongings and living in an uncertain situation. The predictor factors of PTSD symptoms were age (elderly), marital status (widowed), educational level (low), and length of stay on the island (longer). Meanwhile the risk factors of depression symptom were marital status (widowed), length of stay on the island (shorter), and evacuation history due to disaster. Self-Reporting 81% of survivors who Questionnaire displaced from their (SRQ); Connor home were diagnosed Davidson Resilience with PTSD, whereas in Scale (CDR) control group only 63% were, using Ehrenreich & McQuaide cut off point. However, using other cut off points, the prevalence rates for both groups were 35–38% lower. (Continued on next page)

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TABLE 2 Natural Disasters and Psychological Impact Review Articles (Continued)

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Authors

Event

Time Frames (pre- and/or post-disaster)

Sample Size

Study Type

Measurement Tool

Main Finding

Kumar Southeast et al. Asian (2007) Earthquake and Tsunami; 26 December 2004 (India) Kun Wenchuan et al. Earth(2010) quake; 12 May 2008 (China)

2 months postdisaster

Survivors in Tamil Nadu (n = 314)

Cross sectional

Harvard Trauma Questionnaire (HTQ)

12.7% of participants were diagnosed with PTSD. The risk factors were gender (female), injured, and no revenue.

2,5 months postdisaster

Respondents from Beichuan and Langzhong in Sichuan Province (n = 3862)

Cross sectional

Short Form-12 (SF-12); Harvard Trauma Questionnaire (HTQ)

Kun Wenchuan et al. Earth(2009) quake; 12 May 2008 (China)

2,5 months postdisaster

Respondents from Beichuan and Langzhong in Sichuan Province (n = 450)

Cross sectional

Harvard Trauma Questionnaire (HTQ)

Livanou Parnitha et al. Earth(2005) quake; 7 September 1999 (Greece)

4 years postdisaster

Adult survivors (n = 157)

Cross sectional

Screening Instrument for Traumatic Stress in Earthquake Survivors (SITSES); Traumatic Stress Symptom Checklist (TSSC)

The average score of physical and mental quality of life in both locations showed below 50. The predictor factors of victims’ quality of life were gender (female), housing (living in shelter), household income (higher), family death, house destruction, and the past 2 week’s history of illness. The rate of PTSD probability was 45.5% among people who lived in the most severe destruction area, five times higher than those living in another area. The predictor factors were income of family, situation of accommodation, loss of beloved one, and house destruction. About 22% of survivors experienced distress symptoms, subjectively, and 15% of them reported adjustment problem.

(Continued on next page)

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TABLE 2 Natural Disasters and Psychological Impact Review Articles (Continued)

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Authors

Event

Time Frames (pre- and/or post-disaster)

Sample Size

Study Type

Measurement Tool

Mason Flood (UK) et al. (2010)

6 months postdisaster

Flood survivors (n = 444)

Cross sectional

Harvard Trauma Questionnaire Revised (HTQ-R); Hopkins Symptom Checklist (HSC); Coping Styles Strategies (CSQ)

Musa Southeast et al. Asian (2013) Earthquake and Tsunami; 26 December 2004 and West Sumatra Earthquake; September 2009 (Indonesia) Naeem Kashmir et al. Earth(2011) quake; 8 October 2005 (Pakistan)

4 years postdisaster

Respondents from Aceh and West Sumatra (n = 200)

Cross sectional

Depression, Anxiety, and Stress Scale (DASS)

18 months postdisaster

Survivors from Cross Muzaffarabad sectional city (n = 1298)

Norris Mexicans et al. Flood; (2004) 1999 (Mexico)

6, 12, 18, and Participants from Villahermosa 24 months Tezuitlan, postdisaster Puebla, and Tobasco (n = 561)

Main Finding The prevalence rates of anxiety, PTSD, and depression were 24.5%, 27.9%, and 35.1%, respectively. The predictor factor of those psychological problems was gender (female). The prevalence rate of depression, stress, and anxiety were 19%, 22%, and 51%, respectively. The predictor factors for these three psychological problems were gender (female), age (younger), occupational status (jobless), and marital status (being single).

Screening Instrument 46.6% respondents had for Traumatic Stress PTSD problems. The risk in Earthquake factor is gender (female), Survivors’ whereas living together in (SITSES); family was protective Traumatic Stress factor. Symptom Checklist (TSSC); Self-Reporting questionnaire (SRQ); Brief Disability Questionnaire (BDQ) Longitudinal Composite The PTSD rate and other International potentially traumatic Diagnostic events of people who lived Interview (CIDI) in Tezuitlan were higher modules K & E than those in the other city. The frequencies of MDD relatively declined from 6 months to 2 years after flood, from 9.1% to 5.9%. (Continued on next page)

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TABLE 2 Natural Disasters and Psychological Impact Review Articles (Continued)

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Authors

Event

Time Frames (pre- and/or post-disaster)

Sample Size

Study Type

North Great et al. Midwestern (2004) Flood; 1993 (USA)

4 and 5 months postdisaster

Participants from St Charles and St Louis Counties (n = 162)

Paranjothy Flood; Juneet al. July (2011) 2007(UK)

3 and 6 months postdisaster

People from South Yorkshire and Worcestershire (n = 2265)

Parslow Bushfire; et al. January (2006) 2003 (Australia)

4 years before disaster and 3–18 months postdisaster

First wave (n = 2404) and second wave (n = 2085)

Priebe Earthquake; 4 et al. September 1997 (Italy) (2011)

8 years postdisaster

Participants from Camerino city (n = 200)

Cross sectional

Soldatos Earthquake; 7 et al. September (2006) 1999 (Greece)

3 weeks postdisaster

Subjects of Athens Metropolitan Area (n = 102)

Cross sectional

Measurement Tool

Longitudinal DSM-III-R Diagnostic Interview Schedule/Disaster Supplement (DIS III-R) Comparative General Health Questionnaire -12 (GHQ 12); Generalized Anxiety Disorder (GAD7); Patient Health Questionnaire (PHQ9); PTSD Checklist Comparative Goldberg Depression and Anxiety Scores; Eysenck Personality QuestionnaireRevised (EPQ-R); Trauma Screening Questionnaire (TSQ)

Mini International Neuropsychiatric Interview (MINI), Brief Symptom Inventory (BSI), Impact of Event Scale Revised (IESR), Manchester Short Assessment of Quality of Live (MANSA) International Statistical Classification of Diseases (ICD 10)

Main Finding Four months post-flood, 22% participants had PTSD and a month later it declined to 16%. People who were exposed to flood disaster (South Yorkshire city) were diagnosed to have psychological distress, anxiety, depression, and PTSD two to five times higher than unexposed people. Only 5% of participants diagnosed with PTSD symptoms. The risk factors of PTSD were gender (female), educational level (low), mental health condition (poor), and higher levels of neuroticism. Based on MINI results, 7.5% respondents diagnosed with a mental disorder. However, the victims’ symptoms levels were not high and their quality of live was positive.

Approximately 85% of respondents were diagnosed to have Acute Stress Disorder, and 43% of the victims met the PTSD criteria. (Continued on next page)

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TABLE 2 Natural Disasters and Psychological Impact Review Articles (Continued)

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Authors

Event

Stratta L’Aquila et al. Earth(2012) quake; 6 April 2009 (Italy)

Time Frames (pre- and/or post-disaster) 1 year postdisaster

Tang Southeast 6 months (2006) Asian postEarthquake disaster and Tsunami; 26 December 2004 (Thailand) Tang Southeast 2 weeks & 6 (2007) Asian months Earthquake postand disaster Tsunami; 26 December 2004 (Thailand)

Chi-Chi Tsai Earthet al. (2007) quake; 21 September 1999 (Taiwan) Tuason Hurricane et al. Katrina; (2012) August 2005. (USA)

6 months & 3 years postdisaster

More than 4 years postdisaster

Sample Size

Study Type

Measurement Tool

Main Finding

People from L’Aquila district (affected) and unaffected district (n = 984)

Case control Trauma and Loss About 22 victims from Spectrum-Self affected area and 8 victims Report (TALS-SR); from unaffected areas were Brief diagnosed to have suicidal Multidimensional ideation. Female victims had Measure of higher risk for Suicidal ReligiousScreen Positive (SSP). ness/Spirituality (BMMRS); Impact of Event Scale (IES) Participants from Cross General Health A half-year post-disaster, 40% Phuket area sectional Questionnaire of survivors showed negative (n = 267) (GHQ); Post adjustment while 34% of traumatic Growth survivors adjusted positively. Inventory (PGI); The predictor factors for Brief Coping poor adjustment were lack of Strategies support-seeking behavior Inventory(BCSI) and greater PTSD symptoms. Survivors from Phuket area (n = 265)

Cross sectional

9 participants

Consensual qualitative

DSM-IV (ASD & PTSD); General Health Questionnaire (GHQ)

The prevalence rate of Acute Stress Disorder (ASD) (according DSM-IV) of tsunami victims was 22%; 6 months later, 30% of victims developed PTSD symptoms. 70% of the survivors had positive adjustment and became resilient, whereas the rest became chronic with a delayed stress response. First survey (n = Longitudinal Short Form 36 (SF 6 months after earthquake, 4223) and 36); Posttraumatic 23.8% participants had follow-up Stress Scale (PTSS) PTSD; after 3 years, only survey (n = 4.4% still experienced it. 1756) Multiple losses felt by survivors after hurricane disaster were loss of family, house, property, and livelihood, loss of protection, and loss of neighborhood. Displacement experiences may bring some problems for survivors, such as a lack of trust of the government, poor health care, and loss of support systems. (Continued on next page)

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TABLE 2 Natural Disasters and Psychological Impact Review Articles (Continued)

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Authors

Event

Time Frames (pre- and/or post-disaster)

Sample Size

Study Type

Measurement Tool

van Southeast 2 months & 9 Displaced and Grivensen Asian months non-displaced et al. Earthquake postparticipants (2006) and disaster from Phang Tsunami; Nga and 26 non-displaced December persons from 2004 Krabi and (Thailand) Phuket (n = 1038).

Comparative Short Form 36 (SF 36); Harvard Trauma Questionnaire (HTQ); Hopkins Checklist: (HSCL-25)

Wang Wenchuan or et al. Sichuan (2009) Earthquake; 12 May 2008 (China)

3 months postdisaster

Survivors from Yongan Town and Leigu Town (n = 1563)

Cross sectional

Weems Hurricane et al. Katrina; (2007) August 2005. (USA)

2 months postdisaster

Participants from New Orleans, Greater New Orleans, and the Mississippi Gulf Coast (n = 386)

Cross sectional

Xu & Wenchuan or Liao Sichuan (2011) Earthquake; 12 May 2008 (China)

1 year postdisaster

Adult survivors from 19 counties in Sichuan province (n = 2080)

Cross sectional

Main Finding

The prevalence rates of PTSD, depression, and anxiety of relocated victims were 12%, 30%, and 37%, respectively. Nine months later they were 7%, 16.7%, and 24.8%. The strongest factor of these three psychological problems was loss of livelihood. Los Angeles The rates of probable Symptom Checklist PTSD in both cities were (LASC) for PTSD; 37.8% and 13%. The risk Perceived Social factors were gender Support Scale (female), ethnic type, (PSSS) education level (low), social support (low), and exposure (higher). Survey Exposure to The prevalence of PTSD Hurricanes and their and psychological Aftermath (SEHA); symptoms among 3 Brief Symptom communities were Inventory (BSI); significantly different, PTSD checklist; however Mississippi Family Support survivors have the Scale highest among them. PTSD and BSI symptoms were significantly correlated with the survivors’ number of traumatic events. Posttraumatic Growth Rates for posttraumatic (PTG); Impact of growth and PTSD of Events Scale (IESR) survivors, one year post-earthquake were similar (around 50%). The factors that correlated with posttraumatic growth were gender (female), age (younger), level of education (high), exposure (high), and element of PTSD signs. (Continued on next page)

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TABLE 2 Natural Disasters and Psychological Impact Review Articles (Continued)

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Authors

Event

Yang Chi-Chi et al. Earth(2003) quake; 21 September 1999 (Taiwan)

Time Frames (pre- and/or post-disaster) 3 months postdisaster

Sample Size

Study Type

Survivors from Pu Li town (n = 663)

Cross sectional

Zhang Wenchuan or 1 year postet al. Sichuan disaster (2011) Earthquake; 12 May 2008 (China)

Survivors from earthquake (n = 1181)

Cross sectional

Zhang Yushu Earthet al. quake; 14 (2012) April 2010 (China)

Residents in Yushu county (n = 505)

Cross sectional

3-4 months postdisaster

RESULTS The articles reviewed address the psychosocial impact from a number of different types of natural disasters. The psychosocial impacts included in this review were posttraumatic stress disorder (PTSD), depression, anxiety, acute stress disorder, and suicide ideation. Quality of life also was measured in some studies. The articles considered the psychosocial impact of seven types of natural disasters: earthquake, flood, tsunami, hurricane, landslide, volcano, and bushfire. Earthquakes The most-studied type of natural disaster identified in this review is the earthquake. Among the 23 articles analysed in

Measurement Tool

Main Finding

Chinese Health Questionnaire 12 (CHQ-12); Posttraumatic symptom checklist according to DSM-IV; Simple Personality Inventory (SPI)

The prevalence of PTSD was 11.3% (full criteria) and 32% (partial), whereas the mental health sickness rate was 24.5%. The risk factors of both psychological problems were gender (female), age (elderly), loss due to disaster (financial), and personality type. PTSD The rate of survivors’ Checklist-Civilian possibility of PTSD was Version (PCL-C); 26.3%, whereas anxiety and Hopkins Symptoms depression rates were about Checklist-25 49%. The risk factors of (HSCL 25); psychological distress were Perceived Social age (middle-aged and Support Scale elderly), injured, and (PSSS) become jobless because of disaster and fear. Gender factor has correlation with PTSD and depression but not to anxiety. PTSD The proportion of survivors Checklist-Civilian who suffered from PTSD, Version (PCL-C); depression, and anxiety was Hopkins Symptoms 33.7%, 38.6%, and 43.8%, Checklist-25 respectively. The risk (HSCL 25); factors of survivors’ Perceived Social psychiatric morbidity were Support Scale gender (female), fear, and (PSSS) social support (low).

this review, nine papers were from China (studying three earthquake events), three were from Italy (studying two events), three each were from Taiwan (focusing on the Chi-chi earthquake in September 1999) and Pakistan (focusing on the Kashmir earthquake in October 2005), two were from Greece (focusing on the Parnitha earthquake in September 1999) and Turkey (Marmara earthquake in August 1999), and one article was from New Zealand (focusing on the Christchurch earthquake in September 2010). In total, 17 papers discussed the incidence of PTSD in earthquake survivors. PTSD, however, was measured at different intervals and using different measuring scales. Seven articles discussed PTSD experienced by survivors in the aftermath (less than six months) after the disaster. Of these

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articles, five indicated that PTSD manifested in earthquake survivors at a rate above 30% (33.7–62.6%) (Chan et al., 2011; Kun et al., 2009; Soldatos, Paparrigopoulos, Pappa, & Christodoulou, 2006; Wang, Zhang, Shi, & Wang, 2009; Z. Zhang, Wang, Shi, Wang, & Zhang, 2012). Two papers, by Yang et al. (2003) and Cao et al. (2003), contradicted these findings as they found less than 23% of survivors experienced PTSD. However, the partial prevalence of PTSD in the research of Yang et al. (2003) is quite high at 32%. Research conducted by Soldatos et al. (2006) assessed the incidence of PTSD soonest after the disaster hit—that is, three weeks after the earthquake—and the research indicated survivors were experiencing PTSD at a rate of 43%. The prevalence of PTSD declines as time passes after a disaster. This assertion is reflected in longitudinal research by Tsai et al. (2007) in Taiwan, which found that six months after the Chi Chi earthquake survivors were experiencing PTSD at a rate of 23.8% and three years after the event, the PTSD rate had fallen to 4.4%. In the longer term, the prevalence of post-earthquake PTSD varies between 56.8% and 4.1%. These rates also are influenced by the survivors’ losses. In Chan et al.’s (2012) study, survivors who lost family members suffered PTSD at a rate of 50.2% and those who had not lost family members reported suffering PTSD at the much lower rate of 27.1%. Interestingly, researchers studying the psychological effects felt by earthquake survivors reported very different results, even if they were conducting research with survivors of the same earthquakes. Some of these differences can be explained easily. Studies were undertaken within varying time frames pre- and post-disaster and used a range of measuring instruments. Not all discrepancies are easily explained, however. For example, two researchers working with survivors of the Wenchuan earthquake measured PTSD rates one year after the earthquake and came up with very different figures. The prevalence of PTSD in Y. Zhang and Ho’s (2011) research subjects was 26.3%, while in Xu and Liao’s (2011) study the figure was twice that amount at 56.8%. Similarly, great differences in the measured PTSD rates were noted in research conducted after the Chi Chi earthquake. Tsai et al. (2007) reported 4.4% prevalence of PTSD three years after the earthquake while Chen et al. (2007) reported a 20.9% rate two years after the earthquake. More consistency can be seen in research studies conducted in Pakistan, Turkey, and Greece. In Pakistan, the prevalence of PTSD between 1.5 and 2.5 years after the earthquake was 41.3% (Ali, Farooq, Bhatti, & Kuroiwa, 2012) and 46.6% (Naeem et al., 2011), while in Turkey the prevalence of PTSD was 19.2% after three years (Basoglu, Kilic, Salcioglu, & Livanou, 2004) and 12% after four years (Emin, Tural, Aker, Cengiz, & Erdogan, 2006). A difference in results also was obvious in studies on earthquake-related depression. The prevalence of depression in survivors 7.5 months after the Wenchuan earthquake was 55.8% (Chan et al., 2012), but according to Y. Zhang and Ho (2011), depression was experienced by 49.6% of survivors one year after

the same earthquake. Consistent results were obtained from two research studies in Turkey that indicated the prevalence of depression at 14 months after the earthquake was 16.8% (Basoglu et al., 2004) and at three years was 18.7% (Emin et al., 2006). Meanwhile the lowest rate was noted in Italian survivors who, at 14–19 months after the L’Aquila earthquake, were experiencing depression at a rate of 5.8% (Gigantesco et al., 2013). Anxiety problems were discussed in only two articles. The research by Z. Zhang et al. (2012) found the prevalence of anxiety three months after the Yushu earthquake was 43.8%. Y. Zhang and Ho (2011) also studied survivors of the Wenchuan earthquake one year later and found the anxiety rate to be 49.8%. Both researchers employed the same instrument to measure anxiety, namely the Hopkins Symptom Checklist-25 (HSCL-25). Acute stress disorder in an earthquake setting also is studied in several articles. The reviewed articles reported on earthquakes in Greece and New Zealand. Soldatos et al. (2006) found a high number of research participants—some 85.3%—were experiencing acute stress disorder three weeks after the earthquake, while Dorahy and Kannis-Dymand (2012) found 37.7% of survivors experienced acute stress disorder two months after the Christchurch earthquake in New Zealand. Earthquake survivors may be susceptible to psychological problems, which decrease their quality of life. Four articles discussed probable psychological morbidity on earthquake survivors. Research on survivors of the Yun Nan earthquake indicated probable psychiatric morbidity of 51% five months after the earthquake (Cao et al., 2003), while psychiatric morbidity was reported in Chi Chi earthquake survivors at 39.8% two years after the earthquake (Chen et al., 2007). The studies employed different instruments to measure psychological morbidity; Chen et al. (2007) utilized the Chinese Health Questionnaire 12 whereas Cao et al. (2003) used the General Health Questionnaire (GHQ). Suicide risk is another mental health concern. This issue is addressed in relation to the L’Aquila earthquake. The research of Stratta et al. (2012) conducted one year after the earthquake found 5% of the respondents reported suicidal ideation. Flood The psychological aftermath of flood has been studied in four countries (UK, US, Mexico, and South Korea). PTSD is the most-studied problem in flood victims; five out of six articles discussed PTSD. Three to six months after the 1993 Great Midwestern flood (North, Kawasaki, Spitznagel, & Hong, 2004), the prevalence of PTSD varied between 15.6% and 21.6%, while flood survivors in South Korea had a prevalence of 39.5% (Chae, Kim, Rhee, & Henderson, 2005), and flood survivors in the UK had between a 22–27.9% prevalence rate of PTSD (Mason, Andrews, & Upton, 2010; Paranjothy et al., 2011). The depression rate three to six months after the UK flood was 35.1–43% (Mason et al., 2010; Paranjothy et al., 2011), while Norris et al.’s (2004) research found a depression rate of 9.1% in flood victims; that rate decreased to 5.4% after two years.

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Anxiety rates also were found to be high after floods. Three to six months after the major flood, anxiety was calculated by researchers at rates between 21.3–48% (Chae et al., 2005; Mason et al., 2010; Paranjothy et al., 2011). Tsunami Six articles discussed the psychological impacts of the Southeast Asian Tsunami in three different locations, namely Indonesia, Thailand, and India. The psychological problems discussed in those articles include PTSD, anxiety, depression, and stress. Post-tsunami stress is studied by Tang (2007) and Musa et al. (2013). The prevalence of acute and chronic stress in tsunami survivors in Thailand and Indonesia is 22%. Tang (2007) studied acute stress disorder in survivors from Phuket two weeks after the tsunami, while Musa studied stress experienced by tsunami survivors in Aceh four years after the disaster. The researchers, however, employed different measuring instruments. The rate of posttraumatic stress disorder varies in tsunami survivors. Two months after the tsunami the prevalence rate of PTSD in Indonesia was 81% for displaced people and 63% for non-displaced people (Irmansyah, Dharmono, Maramis, & Minas, 2010), while in Thailand (Van Griensven et al., 2006) and India (Kumar et al., 2007) the PTSD rate was 12% for displaced people and 7% for non-displaced people. The result of follow-up research conducted by Van Grievensen et al. (2006) indicates that the prevalence of PTSD nine months after the disaster decreased by 7% for displaced people and by 2–3% for non-displaced people. Two researchers discuss depression and anxiety problems: Van Grievensen et al. (2006), conducting research in Thailand, and Musa et al. (2013), working in Indonesia. The results indicate that the rate of depression and anxiety in tsunami survivors in Aceh (Indonesia) was still high four years after the disaster. Van Grievensen et al. (2006) showed the depression rate two months after the tsunami was 30% and seven months later was 16.7%, while the anxiety rate was 37% after two months and 24.8% after seven months. Four years after the tsunami in Aceh, Musa et al. (2013) found that the depression rate was 19% and the anxiety rate was 51%. Hurricanes and Other Natural Disasters Two articles about the effects of hurricanes are discussed in this review. Both articles discuss Hurricane Katrina in the US. Weems’s (2007) study indicated hurricane survivors suffered from PTSD and other psychological symptoms as measured by the Brief Symptom Inventory (BSI) two months after the event while Tuason’s study (2012) found that Hurricane Katrina survivors experienced multiple losses. Two articles discussed the psychological impacts of other natural disasters (volcanoes and bushfires). The research of Goto et al. (2006) on volcano survivors in Miyake Island, Japan, found that material loss and uncertainty greatly influenced PTSD. Meanwhile, the research of Parslow et al. (2006) on the bush-

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fire disaster in Australia in January 2003 found that 5% of the survivors experienced PTSD. RISK FACTORS OF PSYCHOSOCIAL PROBLEMS POST-DISASTER SITUATION Certain factors may predict psychosocial problems likely to occur in survivors after a disaster. Posttraumatic stress disorder has been more widely studied in disaster settings than any other psychosocial disorders and is, thus, addressed in the greatest detail in this review. Few articles discuss the risk factors for anxiety and stress. None of the articles analysed consider the risk factors of acute stress disorder. The review of 19 PTSD research articles indicates that certain groups are more likely to develop PTSD. These at-risk groups include females, the elderly, and middle-aged people. The likelihood of developing PTSD also is influenced by economic status, extent of house and property damage, loss of beloved people, injury, anxiety levels during the disaster, and whether survivors are living in a shelter after the disaster. Factors such as low education level, loss of occupation, personality type, and history of mental health problems, also are mentioned by some researchers. Six articles discuss the factors that may predict depression. Most of the articles mention gender (female) and loss of occupation as the strongest factors influencing the likelihood of developing depression. There is little agreement among researchers about other factors influencing disaster-related depression. Y. Zhang and Ho (2011) found that middle-aged and old-age earthquake survivors were more likely to suffer from depression, while Musa et al. (2013) found that younger survivors of tsunamis had a greater propensity to experience depression. There is disagreement between researchers about whether depression is more commonly felt after a disaster by married or single survivors. Aslam and Tariq (2010) state that married survivors tend to experience depression in greater numbers, while Musa et al. (2013) indicate that depression is more commonly noted in unmarried survivors. The factor predictors of psychiatric morbidity are discussed in two articles. All articles mention that women and people who are living at a shelter are more prone to psychiatric problems. Old age, house and property damage, low level of education, and a history of mental illness are strong influencing factors that may explain why a survivor experiences psychosocial problems after a disaster. DISCUSSION The aim of this integrative review was to identify the evidence related to the psychosocial impact of natural disasters on adult (over the age of 18 years) survivors. The results of the review indicate that PTSD is the most-studied psychosocial problem after a disaster. Short-and long-term studies also have considered the prevalence of depression, anxiety, and stress. Fewer research studies have looked at the impacts of a

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disaster on other psychosocial disorders, such as sleep disorder and suicidal ideation. The results indicate that post-disaster research is more commonly conducted six months after a disaster or after an even longer time frame has elapsed. This may be attributed to the difficulties of conducting research during or immediately after a disaster. For example, feasibility issues and ethical considerations may make it difficult for researchers to work in a chaotic post-disaster environment. The researcher also may feel reluctant to speak to survivors in what are often miserable and difficult circumstances. It is, however, necessary to identify responses of survivors at an early phase to identify the necessary actions to be taken by mental health workers and emergency relief personnel. It is therefore important to develop a method of research that explores responses of survivors in the immediate aftermath of a disaster, which gives proper consideration to the ethical issues associated with working in such an environment. This review can only describe the various trends and observations reported in disaster studies. It is difficult to make meaningful comparisons of the data because researchers have employed a variety of tools, methodologies, data collection techniques, and time frames to analyse the after-effects of different disasters. Further complicating the data is the use of different cut-off points when deciding who had a mental illness and how much of the psychological turmoil could be attributed to the disaster. One means of addressing this for future disaster research would be the identification or development of a single tool that accurately captures and measures the psychological after-effects of a disaster. To achieve this, a study of specific, disaster-related, psychosocial problems, assessed using several different instruments, with a large study cohort, would need to be performed. The results could help explain the sensitivity and specificity of instruments so future researchers could determine which instruments were most reliable and accurate in assessing post-disaster psychological problems. Clear guidelines also need to be established to determine the point at which a person is considered to be “well” and no longer experiencing a psychosocial illness. The results show differing opinions about whether a person was experiencing a diagnosable mental illness or was actually experiencing a transient psychosocial reaction to the disaster. It is possible that study results were influenced by determination of the cut-off point for the various tools used to measure the components of psychosocial distress and differences in results can be explained largely by the way the researcher defines mental illness. Employing clear guidelines and a uniform approach would benefit researchers, policy-makers, and mental health workers. Further data could be compared in a more meaningful way, and time, money, and resources could be allocated more effectively. The results clearly highlight posttraumatic stress disorder as the most studied post-disaster psychosocial problem and several risk factors were identified. Post-disaster depression also was

explored in a number of studies, yet very few studies looked at the broader range of mental health problems, such as acute stress disorder, anxiety, sleep disorders, and suicide risk. An opportunity exists for these areas to be explored and for risk factors and triggers to be identified. Mental health nurses play an important role in the management and support of disaster survivors and are pivotal in longerterm recovery and rebuilding efforts. It is important that mental health nurses be aware of the psychosocial responses likely to be experienced by survivors of natural disasters to enable them to provide effective and timely care. Given that the numbers of natural disasters are on the rise, mental health nurses have an important role in assessment of psychosocial problems after an event as well as supporting those with psychosocial problems during the recovery phase. The provision of support in a timely manner is thought to foster resilience in survivors (Jacobowitz, 2013). Mental health nurses can assist individuals and communities to become more resilient after disasters by offering appropriate treatment and support. Limitations Despite extensive searching, it is possible a study focusing on psychological or psychosocial impacts of disasters may have been missed. Disaster research is a multidisciplinary field and studies are published in a variety of journals. Studies in languages other than English, gray literature, or anecdotal evidence were not accessed for this review. CONCLUSION This integrative review of the literature uncovered a number of valuable findings. With the frequency of natural disasters increasing, many individuals, families, and communities are experiencing the psychosocial impact of these events. Mental health nurses have a significant role to play supporting survivors in the aftermath of natural disasters and assisting with the development of resilience in community members. While the depth of the findings vary, this review provides evidence that further research is needed, especially relating to clear definitions and cut-off points for defining psychosocial distress and post-disaster impacts. A number of recommendations have been made highlighting the narrow scope of the current literature, which predominantly addresses posttraumatic stress disorder, and the inadequacies of some approaches, particularly around definitions of mental illness and transient post-disaster psychosocial impact. Needless to say, this is an area of growing interest and the available literature highlights important data for policymakers, health care systems, and individuals involved in disaster response. Critically, future research needs to build on the work currently available, including exploring other psychosocial and psychological impacts post-disaster. This will not only enhance understanding, but also provide evidence-based support for future policy and planning.

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Declaration of Interest: The authors report no conflicts of interest. The authors alone are responsible for the content and writing of the paper.

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