|Year : 2019 | Volume
| Issue : 2 | Page : 97-101
Mental health status of flood-affected adults in rural Tamil Nadu: A cross-sectional study
Venkatesh Ashok1, KC Premarajan2, Ravi Philip Rajkumar3, Bijaya Nanda Naik4
1 Department of Obstestrics and Gyenecology, JIPMER, Puducherry, India
2 Department of PSM, JIPMER, Puducherry, India
3 Department of Psychiatry, JIPMER, Puducherry, India
4 Department of Community Medicine, SVMCH and RC, Puducherry, India
|Date of Submission||24-Oct-2018|
|Date of Decision||20-Jan-2019|
|Date of Acceptance||08-Mar-2019|
|Date of Web Publication||23-May-2019|
K C Premarajan
Department of PSM, JIPMER, Puducherry - 605 006
Source of Support: None, Conflict of Interest: None
Objectives: The objective is to study the mental health status (in terms of posttraumatic stress disorder [PTSD]) of flood-affected adults aged 18 years and above residing in a rural village of Tamil Nadu affected by flood in December 2015. Methods: The study adopted a cross-sectional descriptive design. One adult member (age >18 years) preferably, head from each of the flood-affected households of Koonimedu village, Tamil Nadu, was included in the study. Participants were interviewed face to face 8 months after the occurrence of flood, and information on sociodemographic details and immediate effect of flood on health and property was obtained using semi-structured pretested questionnaire. Mental health and social support were assessed using the Impact of Event Scale-Revised (IES-R) and Crisis Support Scale, respectively. Mental health was expressed in terms of PTSD based on IES-R screening. Data analysis was done using statistical software. Results: The prevalence of PTSD as screened by IES-R among adults was found to be 51.3%. PTSD was found to be higher among females (56.7%) than males (43.3%). The elderly reported highest PTSD (63%). PTSD was found to be higher among participants who had received adequate social support. Conclusions: Even after 8 months of flood, the prevalence of screened PTSD was found to be very high and crisis social support low among individuals aged 18 years or above. Hence, mental health-care services including counseling support during and after the flood should be given priority by policy-maker.
Keywords: Community-based study, disaster, mental health, posttraumatic stress disorder
|How to cite this article:|
Ashok V, Premarajan K C, Rajkumar RP, Naik BN. Mental health status of flood-affected adults in rural Tamil Nadu: A cross-sectional study. CHRISMED J Health Res 2019;6:97-101
|How to cite this URL:|
Ashok V, Premarajan K C, Rajkumar RP, Naik BN. Mental health status of flood-affected adults in rural Tamil Nadu: A cross-sectional study. CHRISMED J Health Res [serial online] 2019 [cited 2019 Jun 16];6:97-101. Available from: http://www.cjhr.org/text.asp?2019/6/2/97/258972
| Introduction|| |
The World Health Organization defines the term disaster as “a serious disruption of the functioning of a community or a society causing widespread human, material, economic, or environmental losses which exceed the ability of the affected community or society to cope using its own resources.”
Flood accounts for about 40% of all natural disasters worldwide and half of all deaths from disasters. Asia, which is more prone to floods, accounted for roughly 93% of all flood-related deaths worldwide between 1987 and 1997. On an average, in India, 75 lakh hectares of land are affected and 1600 lives are lost due to flood every year. Properties worth 1800 crores which included crops, houses and public utilities etc., are lost every year. The frequency of major floods is more than once in 5 years.
Extreme events such as flood can affect people's lives irrespective of their social status. Disasters affect the mental health of affected population 2–3 times more than general population and can be acute or long term in nature. Various mental health problems are abnormal grief, depression, anxiety disorder, substance abuse, nonspecific somatic symptoms, and posttraumatic stress disorder (PTSD).,, Mental health problems appear because of loss of life and property, threat to life, survivor's guilt, inability to cope with the loss and damage, and poor support mechanism. The affected population has the fear of recurrence which leads to stress and affects the usual livelihood. Unlike physical illness, importance of mental health symptoms are often neglected.
PTSD is one of the most commonly encountered mental health problems after disaster., PTSD is a complex and chronic disorder caused by unusual threats or catastrophic events. It has been estimated that the lifetime prevalence of PTSD in the general population varies from 1% to 9%. However, the prevalence of PTSD can be as high as 69% among disaster-affected people. The persons affected by PTSD after a worst disaster events take a long time to recover.
Literature on PTSD following cyclones or floods is limited. The state of Tamil Nadu is exposed to cyclone frequently during the winter period of the year leading onto flood-like situation, especially in coastal areas. In December 2015, many districts of Tamil Nadu experienced torrential rain leading to flood situation in coastal parts of many districts. Koonimedu is one such village affected by flood in December 2015. Hence, the present study was conducted to assess the PTSD of flood-affected adults aged 18 years or above residing in Koonimedu village of Villupuram district, Tamil Nadu.
| Methods|| |
A cross-sectional study was conducted in Koonimedu village during the months of August and September 2016. Koonimedu is a block panchayat village bordering Pondicherry in the coastal area of Villupuram district, Tamil Nadu. Fishing and daily wage labor work are the main occupations of the villagers. Majority of the population lived in kutcha houses. The village had been severely affected by flood in December 2015 leading to huge property loss. Many people left homeless.
Of the 350 households in the flood-affected area of Koonimedu village, 302 gave written informed consent by head of the households to participate. The response rate for the study was 87%. One adult respondent (aged 18 years or above) from each household was selected and enrolled by house-to-house visits. Respondents included preferably the head of the household and in his/her absence any adult member with the highest date of birth present at the time of visit. Respondents having any psychiatric disorder prior to the occurrence of flood were excluded, and replacement was selected from the same household as mentioned earlier. The information on sociodemographic details and impact of flood on health and property of the flood-affected individuals was collected using a pretested semi-structured questionnaire. Information on mental health status of flood-affected individuals was collected using Impact of Event Scale-Revised (IES-R) which is validated for the use in Indian setting. IES-R was translated in Tamil and back translated to English for face and language validation. Mental health status was expressed in terms of the presence of PTSD. IES-R contains 22 items in five-point Likert scale where “0” denotes “never” and “4” denotes “extremely.” Information on social support received was obtained using Crisis Support Scale (CSS) which has seven items in a Likert scale of “1” to “7.” A person with score of 28 or more in CSS was operationally considered to have received adequate social support. Negatively worded items were reverse scored.
Biostatistical descriptive analysis was done using SPSS version 22 and OpenEpi version 3.2 (Open Source Epidemiology Statistics for Public Health, Emory University, Atlanta, GA, US). An individual was said to have PTSD if his/her IES-R score was ≥33. Results were expressed as proportions. The association of PTSD with various sociodemographic characteristics and social support was tested using Chi-square test. P < 0.05 was considered statistically significant. Ethical clearance has been obtained for this study from the Institute Ethics Committee, JIPMER.
| Results|| |
Of the total 302 participants, majority (60.3%) were females. Most of the participants (36.1%) were in the age group of 30–44 years, followed by 45–59-year age group (26.5%). Majority (53%) of the participants had completed education up to 10th standard and only 5.3% had been educated up to graduation or above. About 61% of the study participants were unskilled workers. Nearly 40% of the participants belonged to lower middle socioeconomic class. Majority (57%) of the participants lived in kutcha house. About one-third of the study participants self-reported to have chronic diseases. Almost 90% (273/302) of the study participants were currently married [Table 1].
|Table 1: Sociodemographic profile of study population affected by flood in December 2015 at Koonimedu village (n=302)|
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About 21% of the participants reported illness among family members during the flood in December 2015 and almost all were fever cases. About 93% of the participants reported damage to their house due to flood and only 40% of them had repaired their house.
[Table 2] describes the prevalence of PTSD and its distribution and association with various sociodemographic factors. The prevalence of PTSD among adults was found to be 51.3%. PTSD was found to be significantly more among females than males (56.6% vs. 43.3%, P = 0.024). Although PTSD was not found to be significantly associated with age, the proportion of elderly with PTSD was highest among all age groups. Among different education groups, highest proportion (61%) of PTSD was reported among participants with no formal education. PTSD was found to be more among currently married individuals (52%) than single/unmarried individuals (45%). Unemployed participants (72%) followed by skilled participants (58%) had proportionately higher PTSD. PTSD was found to be more common among individuals belonging to middle socioeconomic class. Individuals who had adequate social support had proportionately higher PTSD than those without adequate social support. PTSD was found to be significantly associated with gender, occupation, socioeconomic status, and adequacy of social support at the time of flood [Table 2].
|Table 2: Association of posttraumatic stress disorder with the sociodemographic characteristics of the study population in Koonimedu village (n=302)|
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| Discussion|| |
Our study assessed the prevalence of PTSD after a period of nearly 8 months following flood.
Majority (51%) of the flood-affected adults were found to have PTSD in the present study. The prevalence of PTSD was higher in our study compared to the similar study by Rajkumar et al. (15%) from India and Hollifield et al. (21%) from Sri Lanka. Other studies from India as well as outside India which reported lower prevalence of PTSD than our study have used either different study instrument,,,,,, or assessed PTSD about 14 years after the occurrence of flood.,, The high prevalence of PTSD in our study could be due to higher proportion of female individuals in the study population and repeated exposure of study population to cyclone/flood. Previous studies have also reported increased likelihood of PTSD following repeated disaster experience. Flood also has been reported to influence the severity of PTSD symptoms. Compared to other studies,,, higher proportion of houses in our study, most of which were kutcha or thatched house, reported to be damaged as result of flood. Majority of the participants were unskilled (daily wage laborer) worker. As reported by participants, they could not get a job due to rain and flood for many days.
Females (56%) compared to males (43%) were found to significantly higher PTSD. Similar findings have been reported by Rajkumar et al. (67% of females) and Matsubara et al. (63% of females). However, Stepien and Kantorska-Janiec have reported higher PTSD among males than females. Similar to our study, elderly individuals were reported to have higher PTSD than other age groups by Stepien and Kantorska-Janiec, King et al., Liu et al., and Pyari et al. Contrast to this, Huang et al. and Dai et al. have reported comparatively lower PTSD among the elderly than others. About 63% of the elderly were found to have PTSD in our study. Contrary to this, about 12% and 17% of the elderly were reported to have PTSD as reported by Huang et al. and Dai et al.
In the present study, participants with no formal education had proportionally highest PTSD (61.2%). Unemployed participants (72%) followed by skilled participants (58%) had proportionately higher PTSD. Rajkumar et al. also reported higher PTSD among illiterates and people belonging to lower socioeconomic class. Stepien and Kantorska-Janiec also have reported higher PTSD among individuals with lower education and no employment. Loss of source of earning and damage to house as a result of flood could have affected these individuals more.
We found PTSD to be more common among individuals with no formal education, currently married, chronic illness, living in kutcha/thatched house, family having vulnerable population, and house got damaged during flood although statistically not significant. Similarly, Pyari et al. and Kumar et al. have reported higher PTSD among individuals had sustained injury themselves or by any of their family members during Tsunami in 2004. Frankenberg et al. also have reported higher PTSD among individuals who had lost property during disaster.
PTSD was found to be associated with occupation of the affected individuals. Individuals with no employment followed by individuals with unskilled job were found to have maximum PTSD.
The social support acts as buffer to symptoms of PTSD and helps in recovery from traumatic experience of disaster. Similar to other studies,,,,, we also have found statistically significant association between PTSD and social support. Contrary to other studies, people with adequate social support had higher PTSD than those without adequate social support (72% vs. 46%) in our study. Probably, damage suffered by individuals with adequate social support was huge and more than the damage suffered by individuals without adequate social support. Another reason could be due to meager practical or monetary support received, compared to adequate social support received by the affected individuals just after the flood. Practical help received to come back to normalcy was probably less than what was expected by the flood-affected individuals leading to further distress.
Strength and limitation
This is one of the few studies which have assessed the long-term impact of flood on PTSD in community setting. IES-R is validated in India and in Tamil language to assess the impact of disaster on PTSD. A single investigator collected information by face-to-face interview using the semi-structured questionnaire and IES-R scale. The nonresponse rate was low at 14%.
Although IES-R has been validated and used in earlier studies, still it is only a screening tool. Hence, clinical corroboration is required for more definitive treatment of PTSD. However, the screening provided an important insight on the prevalence of probable PTSD to initiate counseling and other supportive services. Subjective variation on response to different items of IES-R scale cannot be completely ruled out despite taking adequate precautionary measures.
| Conclusions|| |
The prevalence of PTSD as screened by IES-R among flood-affected adult was found to be very high. PTSD was found to be more common among females, the elderly, and individuals with no employment or unskilled job. PTSD was found to be more among individuals who had adequate social support than the individuals without adequate social support.
Health facilities in flood-prone areas need to have counselor to provide appropriate mental health service. Provision of specialized psychiatric health services should be an important priority of policy-makers as high prevalence of PTSD exists even after 8 months following the occurrence of flood.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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