Framework for strengthening primary health care and community networks to mitigate the long-term psychosocial impact of floods in Kerala
Introduction
Individuals who encounter disasters experience a range of negative consequences across physical, mental, and psychosocial domains. Post-disaster emotional and psychosocial problems are most reported, with rates being almost double that of physical health problems [[1], [2], [3]].
Floods are the commonest of natural disasters globally, accounting for nearly 53,000 deaths in the previous decade [3]. Studies on post-flood psychosocial and mental health impacts have reported that these communities experience higher rates of psychological distress, anxiety, depression, somatisation, and post-traumatic stress disorder [[4], [5], [6]]. These psychological issues are persistent, with higher enduring rates being reported 2–5 years after disaster [[7], [8], [9]]. In a small minority, exposure to disaster may precipitate severe mental illness. Those with pre-existing mental disorders are also likely to experience vulnerability due to their greater needs and disruption of supply chains and support networks [10]. Mental health problems have a significant impact on post-flood disability, owing to their tendency to persist and influence other chronic medical conditions. It has been quantified that 80% of the estimated Disability Adjusted Life Years (DALYs) attributable to floods is contributed by mental health problems [11].
In August 2018, the state of Kerala received heavy rainfall, in excess of 164%, with at least two districts (administrative sub-units of the state) receiving more than 400% rainfall. The resultant massive in-flow to dams necessitated their opening to release water. The continued torrential rains along with water released from dams led to unprecedented floods [12]. There was widespread devastation; one-sixth of the total state population was directly affected and the Government of India declared it a “Calamity of severe nature”. Timely rescue operations by the central and state forces, officials, fishermen, volunteers, and laymen, ensured that loss of life was minimized. An estimated 483 people died, 33,000 were rescued, and 1.2 million were displaced. Nearly 7000 houses were completely damaged, a further 15,000 suffered significant damage, and 6200 miles of roadway was damaged or destroyed [13]. The cost of rebuilding was calculated to be approximately 31,000 crore rupees (USD 4.4 billion) [13].
In the immediate aftermath, the local mental health services joined hands with mental health professionals from other states and the National Institute of Mental Health and Neurosciences (NIMHANS), Bengaluru (the tertiary unit of mental health care in India) to train lay volunteers to provide psychological first aid (PFA) as an immediate respite to the flood affected. PFA aimed to reduce initial distress and foster short and long-term adaptive functioning. It involved three primary steps: look (protect people from further harm and identify people with urgent basic needs or serious distress reactions), listen (ask about needs and concerns, listen and assist in calming), and link (provide information, connect people with loved ones, access services, and support). This technique has been endorsed by many international agencies and reflects the current international consensus on supporting disaster affected people while maintaining respect for their culture and abilities [14]. Persons identified to have a mental health crisis, or other serious concerns such as family violence or physical injury, were referred by the lay volunteers to their training supervisor, who facilitated necessary intervention. Over 80,000 survivors received PFA either individually or in groups [15]. Lay volunteers were involved only in immediate psychosocial response.
The initial outpouring of resources including mental health inputs that characterise disasters has been recognised to be limited in time, reach, and effectiveness [16]. Research in post-flood affected communities has consistently demonstrated that, when there are high levels of material and human loss, high water levels in the home, significant danger posed to life, inability to collect possessions, experience of evacuation, or loss of livelihood, the associated mental health problems are likely to persist for many years [6,7,16,17].
Tackling mental health issues is crucial to the overall well-being, functioning, and resilience of individuals, societies, and countries recovering from natural disasters. However, both systemic and individual factors impede service delivery. The crippling financial strain on governments in the immediate aftermath of a disaster is a major impediment in allocating requisite financial resources to tackle mental health problems [17,18]. The lack of additional resources compounds the pre-existing and well documented treatment gap for mental illness in many low- and middle-income countries (LAMIC) [19,20]. In addition, many individuals who require psychological help, face difficulties in accessing care owing to disruption in networks and perceived stigma [4].
Considering the scale of the disaster and the likelihood of persistence of mental health issues in the disaster affected population, the Government of Kerala implemented a comprehensive mental health and psychosocial project named “PARIRAKSHA” (meaning “preservation/protection” in English). Its broad objectives were:
- A.
Early Identification of persons with mental health problems in the affected communities.
- B.
Provision of appropriate care within local communities
- C.
Implementation of a structured, stepped care approach
This manuscript documents the design, steps, and detailed methodology of this project. In addition, the supplementary material contains all the prepared technical manuals, to ensure free access to mental health professionals in disaster affected zones especially in low income communities.
Section snippets
Settings
The state of Kerala in South India is the thirteenth largest state in the country. It has 14 districts (administrative sub-units of the state) of which 10 experienced flooding. Two hundred and sixty-two panchayats were affected across these 10 districts. Panchayats are the village-level self-government units in India. Each panchayat in Kerala has between twenty and thirty thousand people. Among the 262 affected panchayats, 93 experienced severe flooding with loss of life, significant damage to
Our experience of the project
The initial base-line of post-disaster psychosocial issues in the flood affected communities could not be assessed owing to breakdown of community networks. The focus during that period was on minimizing loss of life, livelihood, and property. It was envisaged that the subsequent psychosocial impact could be continuously monitored through community surveys using mixed models every 6 months, beginning a year after the disaster. However, following the COVID-19 pandemic outbreak in Kerala, the
Discussion
The paper aims to add to existing disaster literature by describing the framework of implementation of a large psychosocial project to facilitate long-term psychosocial recovery of communities affected by the floods in the state of Kerala, India. The unique nature of the project is its comprehensiveness and reach (approximately 2 million people in 93 of the worst affected panchayats). It aimed to bridge the treatment gap and improve accessibility in a population which has suffered significant
Funding
90% of the funded by the Government of Kerala.
Only the training component which composed 10% of the total funding was funded Americares India Foundation.
The funding sources has no role in study design or writing of the paper and in the decision to submit the article for publication.
Declaration of competing interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Acknowledgements
Dr Maggie Zraly of Americares has provided input for the technical materials prepared for the project.
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2022, International Journal of Disaster Risk ReductionCitation Excerpt :A third paper reported that nurses’ duties expanded to include the management of both the palliative care and the deaths of increasing numbers of patients during the COVID-19 pandemic [66]. There is a large body of evidence showing that community health workers (CHWs) can play a critical role in disaster preparedness [22,23,25,41,48,49,53,63,67,82,90,91,97,100,102,119,121,124,149]. Due to their strong relationships with the population, CHWs can act as intermediaries between the community and the primary care services.