Framework for strengthening primary health care and community networks to mitigate the long-term psychosocial impact of floods in Kerala

https://doi.org/10.1016/j.ijdrr.2020.101947Get rights and content

Highlights

  • Kerala, India witnessed unprecedented floods in 2018.

  • The disaster led to large scale of loss of life and property.

  • To facilitate psychosocial recovery a large psychosocial project was launched.

  • This paper describes the detailed methodology of the project.

Abstract

Individuals who encounter disasters experience negative consequences across physical, mental and psychosocial domains. Impacts on mental health and psychosocial domains are more common, and last longer than physical health problems. In August 2018, the state of Kerala, India witnessed unprecedented floods that resulted in 483 deaths and significant loss of property and livelihood. Project “PARIRAKSHA” was implemented by the Government of Kerala, to mitigate the long-term psychosocial impact of the disaster. It has been one of the largest comprehensive post-disaster psychosocial project in India till date, aimed to benefit approximately 2 million people across 93 panchayats which experienced severe flooding and loss of life.

This paper describes the detailed methodology of this project. In addition, the supplementary material includes the technical manuals that were prepared, and is freely accessible to personnel in disaster affected zones.

Counsellors were newly appointed in all the primary health centres in affected panchayats to provide mental health and psychosocial support. Accredited Social Health Activists (community level health workers) undertook home-visits to ensure early case-detection. Medical officers’ in affected areas received booster training regarding pharmacological management of mental health issues. Multi-disciplinary mobile mental health teams were constituted to ensure availability of specialised mental health inputs locally.

The project integrated additional mental health resource personnel, into the existing health care system. Existing health care personnel received training to improve competency in dealing with post-disaster psychosocial issues. This framework is expected to ensure early detection and intervention, thus facilitating timely psychosocial recovery of communities impacted by the floods.

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.

References (40)

  • E. Goldmann et al.

    Mental health consequences of disasters

    Annu. Rev. Publ. Health

    (2014)
  • Mental Health Assistance to the Populations Affected by the Tsunami in Asia

    (2005)
  • Kerala Floods of August 2018

    (2018)
  • Government of Kerala. Kerala Post Disaster Needs Assessment. Floods and Landslides, August 2018. Published October...
  • World Health Organization

    War Trauma Foundation and World Vision International

    (2011)
  • Post-floods, 83,028 given psychosocial support

  • J.M. Shultz et al.

    Mitigating the mental and physical health consequences of Hurricane Harvey

    Jama

    (2017)
  • S. Galea et al.

    Financial and social circumstances and the incidence and course of PTSD in Mississippi during the first two years after Hurricane Katrina

    J. Trauma Stress

    (2008)
  • The pitt review learning lessons from the 2007 floods - full report

  • K. Demyttenaere et al.

    Prevalence, severity, and unmet need for treatment of mental disorders in the World health organization World mental health surveys

    J. Am. Med. Assoc.

    (2004)
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