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As the global climate is undergoing significant changes, the incidence of natural disasters of various characters and intensity is on the rise. Many direct and indirect mental health impacts have been observed as an aftermath of these disasters. The study attempts to assess the psychiatric symptoms prevalent among disaster-affected individuals, 4–6 months after the impact.
A community based cross-sectional survey was conducted 4–6 months after a flood in Kodagu (Coorg) district of Karnataka state. 171 randomly selected samples were assessed. Demographic details and disaster experiences were collected and symptoms psychiatric disorders were evaluated. The data were entered into Microsoft Excel and analyzed using SPSS version 23 software. The descriptive data were presented in percentages and bar charts appropriately. Categorical data were presented in tables tests for significance were done appropriately.
The prevalence of psychiatric symptoms among residents of flood-affected areas was 66.7%. The major symptoms detected were that of Depression, Anxiety, Somatic disorders, Sleep problems and Substance abuse. Leaving the house during the disaster and damage to the house were found as the most important factors influencing the development of these symptoms.
The Prevalence of psychiatric symptoms in the district, was high and hence more community-based activities should be designed by the health department to address this problem. The symptoms were significantly higher among people who stayed in flood relief camps and faced partial or complete damage to their house. These people should be identified to prevent further development of illness.
Extreme weather events and disasters, have increased three times since the 1960s and in expert's view, such events will become more frequent and severe in the future due to climate change all over the world.
India has witnessed both natural and manmade disasters. Nearly 60% of the Indian landmass is susceptible to earthquakes while 40 million hectares of land is flood-prone. About 8% of the subcontinent is prone to cyclones while more than two-thirds of the areas are susceptible to drought.
Psychiatric disorders are common among disaster-affected individuals. Multiple studies show a higher prevalence of psychiatric morbidity among disaster victims.
India faced one of its largest and most aggressive super cyclones in its history along the coastal lines of Odisha state in 1999. Following the disaster, more than 50% percentage of the disaster victims showed depression and anxiety with a prevalence of 52.7% and 57.5% respectively.
The 2004 Indian Ocean Tsunami was one of the most dreadful natural disasters India has faced in the 21st century. Many studies were conducted after the Tsunami, to assess the psycho-social morbidities among its victims. Most of these studies showed multiple psychiatric problems among the disaster affected individuals. In a study conducted among tsunami-affected males in Kanyakumari, 43% were diagnosed with clinically significant distress.
Another study found that 4.5 years after the 2004 Asian tsunami, the majority of the exposed people had psychiatric morbidity. Post-traumatic stress disorder was diagnosed in 70.9% of people participated and 33.7% had depression. Anxiety symptoms were prevalent in 23.1% of the sample studied.
A notable prevalence of psychiatric disorders (27.2%) was observed by the researchers in coastal areas of Tamil Nadu, 6–9 months after the disaster. A higher proportion of the residents showed indefinite psychiatric symptoms (79.7%). The major psychiatric problem among the victims was depression. A considerable portion of males showed alcohol use disorders and females showed anxiety disorders. However, post-traumatic stress disorder was less prevalent among the subjects in the study conducted by Nambi S et al.
Other types of natural disasters also regularly occur in India. The infamous Latur earthquake was followed by a surge of psychiatric disorders among its survivors. Post-traumatic stress disorder, depression, generalized anxiety disorder, and panic disorder were the major findings in these disaster victims according to different studies.
The major mental health problems found in victims of man-made disasters in India were anxiety neurosis, depression, emotional disturbances, fear, suicidal tendency, loss of libido, situational anxiety, and amnesia.
Several socio-demographic factors like age, gender, occupation, education, income, marital status, type of family, socio-economic status, etc. can influence the development of psycho-social problems. The experience during the disaster and the degree of impact also can affect the development of psychiatric problems among people residing in disaster-affected areas.
Kodagu (Coorg), a geographically unique district in the south-western part of Karnataka state. The main source of income and livelihood in the district is agriculture. The paddy fields in the valleys and coffee and pepper agro-forestry in the hilly regions makes Kodagu a home for diversity in agriculture.
Kodagu district recently witnessed its worst monsoon rainfall in the last 87 years. Over 200 villages were affected due to heavy rainfall and consequent landslides that have wiped out homes and plantations, besides roads and bridges. 16 people lost their lives and 39 were listed as missing. More than 1200 houses have collapsed.
Presently in India, priority is given only to physical rehabilitation following disasters and psychiatric problems of the victims is often neglected. Even though many epidemiological studies have been conducted on psychological impacts of natural disasters previously in India, only little is known about the same after the 2018 floods in this area. Presence of different psychosocial problems among disaster-affected individual has long term implications and can, in turn, worsen the physical health and quality of life. So, a feasible solution is required to improve the quality of life and overall health among disaster victims. In this context, this present study was an attempt to assess psychosocial problems and quality of life among the people residing in flood-affected areas Kodagu district for further planning and policymaking.
The primary objective of the study was to assess the prevalence of psychosocial problems among the residents of the flood-affected areas in Kodagu district after 6 months of the event and the secondary objective was to assess the factors influencing the psychosocial problems of people residing in flood-affected areas of Kodagu district.
This community-based cross-sectional study was conducted between 4th and 6th month after the impact of the disaster from December 2018 to February 2019. The sample size for the study was calculated based on the prevalence of psychological problems in disaster-affected areas in South India which was around 27.2%.
Based on this, with 7% absolute precision and confidence level of 95% and the required sample size was worked out to be 155, taking into consideration a non-response rate of 10% i.e.16 total sample size was estimated to be 171.
Stratified random sampling method was used to select the study participants. The Madikeri taluk of Kodagu district was selected randomly by a lottery method to conduct the study. From the list of primary health centres which were affected by landslide and flood in Madikeri talukas, one rural primary health centre viz. Bhagamandala and one urban primary health centre viz. Madikeri were selected randomly again using lottery method. As the study setting contained two different locations, the total systematically collected sample size was divided equally to recruit an equal number of samples from both the study areas for better comparison. Out of the total 171 sample size 86 were selected from Bhagamandala and 85 were selected from Madikeri. Centre of the flood or landslide affected locality was identified with the help of Accredited Social Health Activists and Auxillary Nursing Midwives serving within the community and all the directions from the centre point were numbered. One direction was selected randomly and all the unlocked houses in the lane were selected for the study. All eligible members in the house were studied until the sample size was obtained. The interviews were conducted by a qualified medical professional, who was the principal investigator. The respondents were selected by the above-mentioned procedure and only responsible adult members who were present in the households were interviewed. The research team including community health workers moved to the next unlocked house in the lane upon finishing the assessments in each house and the process was continued until the required sample size was obtained. No attempts of revisits were made as the sample size was easily saturated by single visit (December2018-January 2019) as the study setting was large and populated.
Residents who were residing in affected areas in Kodagu district during the floods and continue to reside at the same settlement and aged between 18 and 65 years were included in the study. Persons already diagnosed with or currently taking medications for any psychiatric morbidities and persons not willing to participate were excluded from the study.
An Ethical committee clearance was obtained from the parent institution of the researchers before the study. The permission to conduct the study was obtained from the Kodagu district Health and Family welfare department also. Informed consent was taken from the study participants. Socio-demographic information was collected. Mode of Impact of the disaster was assessed using the preformed questionnaire and Diagnostic Statistical Manual of Mental Disorders-5 (DSM-5) self-rated level 1 cross-cutting symptom measure was used to assess the presence of psychiatric symptoms.
The tool was administered by a survey method in the local language of respondents. (Kannada and Malayalam). The questionnaire was translated to both these languages by language experts and retranslated to English to ensure the internal consistency and quality of translation. All the respondents were interviewed by the principal investigator alone leaving no scope for inter-personal bias in data collection. The questionnaire contained different validated questions indicating symptoms of 13 psychiatric disorders or domains. A grading of 1–4 was attached with each question to be filled based on the respondent's level of severity and frequency. A rating of 2 or greater on any item within a domain (except for substance use, suicidal ideation, and psychosis) was considered as the presence of symptom of that psychiatric condition. For substance use, suicidal ideation, and psychosis, a rating of 1 or greater was considered as the presence of symptom.
The data were entered into Microsoft excel followed by the analysis using SPSS version 23 licensed to JSS Academy of Higher Education and Research. The prevalences are represented in percentages. The associations between disaster experience, demographic profile and severity of the psychosocial problems were found out using chi-square test/Fisher's exact test, and p-value less than 0.05 is considered as statistically significant.
Among the 171 participants, 118 (69%) were females and 53 (31%) were males. Majority of the participants (46.2%) were belonging to the age group of 46–65 years. 39.7% of them were in the age group 26–45 years and the rest of them (14%) were under 25 years. (Table 1.0).
Table 1.0Distribution of study participants based on various demographic characteristics.
Out of the 171 individuals participated in the study, 83% were married and 10.5% were not married. 5.8% were widowed and one person was separated from the spouse. Most of the study participants lived in nuclear families (77.2%) while 18.7% were living in three-generation families and 4.1% in joint families. The educational status of the participants was varying. 38.6% of samples were educated till high school while 16.4% had diplomas or finished their pre-university college education. 11.1% had upper primary and 10.5% had lower primary education. 9.4% of persons who participated in the study were graduates or postgraduates and 14% had no formal education. 26.9% of participants were belonging to the occupational category of clerical/shop owners and farmers. While 1.8% were semi-professionals, and 1.8% were skilled workers, 5.3% were semi-skilled workers and 5.8% were unskilled workers. 58.5% of the participants in the study were unemployed (Table 1.0).
Among the 171 study participants, 40.4% had to move to temporary shelters during the disaster. 45% faced partial or complete damage to their house. Only one person was identified with a direct physical injury. 12.9% had damage to their source of income that is agriculture fields or plantations. 32.2% of participants, all of whom were farmers and/or plantation owners were expecting a long-term reduction in their income due to the damages happened in the plantations (Table 2.0).
Table 2.0Distribution of study participants based on their disaster experience.
Among the 171 study participants, 66.7% showed the presence of symptoms suggestive of at least one psychiatric problem. The prevalence was slightly higher among females compared to males (64.2% and 67.8% respectively). However, this was not statistically significant. Many symptoms were prevalent among the study participants. 33% of persons evaluated showed symptoms suggestive of depression. Another highly prevalent symptom among the residents was that of anxiety where the prevalence was 31%. 28.7% of study participants were having symptoms of somatic disorders and 35.7% had sleep disturbances. The prevalence of substance abuse among the disaster victims was 15.80% and 4.10% complained of anger control issues. A very small minority complained of suicidal ideation, mania and symptoms of dissociation (2 each) while one case of psychosis and memory loss was identified from the study area. (Diagram 1.0).
By analyzing the symptoms by area, it was observed that symptoms suggestive of psychiatric problems were more in residents of Madikeri compared to Bhagamandala. However, this observation was not statistically significant. The presence of symptoms suggestive of psychiatric problems was significantly high among people aged between 46 and 65 years. The maximum prevalence (84.8%) was obtained in the age group 46–65 years. 54.4% of people in the age group 26–45 years showed psychiatric symptoms and 41.7% participants under 25 years had psychiatric symptoms. A statistically significant relation was observed in the distribution of psychiatric symptoms among people with different educational levels. The prevalence was maximum among illiterates (87.5%) followed by lower primary educated persons (77.8%). Prevalence in upper primary educated individuals was 73.7% and among high school educated persons it was 68.2%. People with an intermediate diploma or pre-university college education showed a 46.4% prevalence of psychiatric symptoms while graduates and postgraduates showed a prevalence of 43.8%. A statistically significant association was noted between the presence of symptoms suggestive of psychiatric problems and a direct affection of the disaster. Persons suffered any of the above-listed disaster experience was considered directly affected. Among people directly affected by the disaster, the prevalence of psychiatric symptoms was significantly high (71.5%) compared to those who were not affected (47.1%). The prevalence was also significantly high among people who had to move to temporary shelters (78.3%) compared to those who were able to stay in their houses (58.8%). Prevalence of symptoms of psychiatric problems was high in those who lost their houses completely (85.7%) and faced partial damage to the house (77.8%) compared to those whose houses were spared during the disaster (56.4%). This observation was statistically significant (Table 3.0).
Table 3.0Distribution of persons with symptoms of Psycho Social Problems based on statistically significant socio demographic factors and disaster experience.
Among the total 171 study participants, 114 individuals (66.7%) showed symptoms of at least one psychiatric problem. The high prevalence obtained in this study is comparable to a similar study conducted in the neighbouring state of Tamil Nadu following the 2004 Indian Ocean tsunami by Nilamadhab Kar et al., where a high prevalence of psychiatric morbidity was observed (77.6%).
A statistically significant association was seen between the age group of the study population and the presence of at least one psychiatric symptom. The study participants were categorized into three groups based on their age. Participants between the ages 18–25 years, showed a prevalence of 41.7% while subjects between 26 and 45 years of age showed a prevalence of 54.4%. The maximum prevalence of the presence of at least one psychiatric symptom was observed in the age group 46–65 years (84.8%). This trend can be presumed to be because of two reasons. The increasing age usually increases the vulnerability to develop psychiatric disorders. Additionally, the older population must have been more vulnerable during the disasters which might have led to a severe impact among them. However, a qualitative enquiry should be made into this and clear picture should be drawn. A similar association between age groups and the presence of mental disorders (using SRQ scale) was observed by Nilamadhab Kar et al. following the Orissa super cyclone.
The prevalence of possible mental disorders shows a rise from the age group of 18–39 years to 60 and above similar to this study. However, no such observation was made in the study following the tsunami disaster in Tamil Nadu and all the age groups showed almost constant prevalence ranging from 72.5% to 82.6%.
Another demographic character that showed a significant association with the presence of psychiatric symptoms was the level of education. The prevalence was maximum among illiterates (87.5%) followed by lower primary educated persons (77.8%). Prevalence in upper primary educated individuals was 73.7% and among high school educated persons it was 68.2%. People with an intermediate diploma or pre-university college education showed a 46.4% prevalence of psychiatric symptoms while graduates and postgraduates showed a prevalence of 43.8%. A similar significant association was observed by Nilamadhab Kar et al. after the Indian Ocean tsunami and the prevalence was maximum in people with no formal education.
As a higher educational level denotes a better socioeconomic status, it can be assumed that the mental health and coping capacity were better among the residents belonging to higher socioeconomic classes.
A direct impact from the disaster like being forced to move to temporary shelters, damage to the house, damage to the source of income etc, was proven to be another significant association with the presence of psychiatric symptoms in this study. This finding is coinciding with the results of both studies from Tamil Nadu and Orissa where a direct impact was contributing to the development of mental illness.
Need for evacuation within 24 h was associated with the presence of psychiatric morbidity in the post-cyclone scenario in Orissa and damage to house or income source was found significant in Tamil Nadu.
In this study, 28.7% of study participants were having symptoms of somatic disorders and 35.7% had sleep disturbances. In a review study of 160 studies related to disaster victims, Norris et al. identified that health-related problems such as somatization, sleep disturbances, and substance abuse were reported in 23% of studies.
Two common psychiatric conditions observed in disaster-affected individuals are depression and anxiety. In this study, the proportion of study participants with symptoms of depression was 33%. A similar prevalence of 33.6% was observed in tsunami-affected individuals and a higher prevalence of 52.7% was observed in cyclone-affected individuals. 31% of study subjects showed symptoms of anxiety in this study. A lesser prevalence, 23.1% was seen following the tsunami and higher prevalence, 57.5% were seen following the cyclone disaster.
During the data collection, it was observed that none of our study participants was screened before for mental health problems. All the disorders were newly identified by the investigators and it shows that the mental issues of the residents of the disaster-affected area were not given adequate attention. The existing disaster management system neglects the need to follow up of the victims for psychiatric diagnosis and treatment. Hence, this study highlights the existence of a high prevalence of the psychosocial issues and have generated enough evidence for local policymaking in the management of the psychosocial problems in the area. All the respondents diagnosed with psychosocial problems were referred to psychiatrists and community health workers including Accredited Social Health Activists and Auxiliary Nursing Midwives were notified about such persons for further follow-up.
The questionnaire used for assessing the psychiatric symptoms was DSM-5 self-rated level 1 cross-cutting symptom measure. The questionnaire is useful only for screening and the results obtained from the questionnaire cannot be a reliable diagnosis. As the study was conducted 4–6 months after the disaster, most of the victims who faced complete damage to their house or had a severe impact from the disaster had moved from the localities and hence many such individuals could not be identified in this study. As the landslide affected area was an urban locality and flood-affected area was a rural locality, possible confounding may have occurred while associating the nature of disaster to the psychiatric symptoms.
The prevalence of psycho psychiatric problems among residents of flood-affected areas was 66.7%. The major problems noted among flood-affected individuals were Depression (33%), Anxiety (31%), Somatic disorders (28.7%), sleep problems (35.7%) and substance abuse (15.8%). Many psychiatric problems were significantly high in Madikeri urban area compared to Bhagamandala rural area. The age group with the maximum prevalence of psychiatric problems was 45–65 years. Leaving the house during the disaster and damage to the house were found as the most important factors influencing the development of psychiatric problems among the residents of flood-affected areas of Kodagu. The Prevalence of psychiatric symptoms in the district, especially among disaster-affected individuals was alarmingly high and hence more community-based activities should be designed by the health department to address this problem. The psychiatric symptoms were significantly higher among people who stayed in flood relief camps and temporary shelters. These people should be identified and treated or counselled for the prevention of further development of illness. People who faced partial or complete damage to their houses are particularly at risk and they should be identified for further interventions.
Frontline health workers in the area like accredited social health activists and Anganwadi Workers can be trained for identification and referral of people with psychiatric symptoms since they belong to the community and also are victims of the rain havoc. A policy should be added to the disaster management guidelines to assess the psychiatric symptoms among disaster-affected individuals and appropriate measures should be taken to improve the quality of life and overall health of the victims.
Obtained from the Institutional Ethical Committee.
Declaration of competing interest
We acknowledge the Health and Family Welfare department and District Health and Family Welfare officer of Kodagu district, for their support to the study. We also express the gratitude to the Medical Officers of Bhagamandala and Madikeri Primary Health Centres, the supporting staff and the field workers (ASHAs and ANMs), helped us in conducting the survey. Last but not the least we thank the 171 study participants for their cooperation to us amidst the many sufferings of the disaster.
Source of funding
Annual Disaster Statistical Review 2011: The Numbers and Trends.
Centre for Research on the Epidemiology of Disasters (CRED),