**What Happened to People with Non-Communicable Diseases during COVID-19: Implications of H-EDRM Policies**

**Emily Ying Yang Chan 1,2,3,\* , Jean Hee Kim <sup>3</sup> , Eugene Siu Kai Lo 1,3, Zhe Huang 1,3 , Heidi Hung <sup>3</sup> , Kevin Kei Ching Hung 1,4 , Eliza Lai Yi Wong <sup>3</sup> , Eric Kam Pui Lee <sup>3</sup> , Martin Chi Sang Wong <sup>3</sup> and Samuel Yeung Shan Wong <sup>3</sup>**


Received: 18 June 2020; Accepted: 27 July 2020; Published: 3 August 2020

**Abstract:** People with existing non-communicable diseases (NCDs) are particularly vulnerable to health risks brought upon by emergencies and disasters, yet limited research has been conducted on disease management and the implications of Health-EDRM policies that address health vulnerabilities of people with NCDs during the COVID-19 pandemic. This paper reports the baseline findings of an anonymous, random, population-based, 6-month cohort study that aimed to examine the experiences of people with NCDs and their relevant self-care patterns during the COVID-19 pandemic. A total of 765 telephone interviews were completed from 22nd March to 1st April 2020 in Hong Kong, China. The dataset was representative of the population, with 18.4% of subjects reporting at least one NCD. Results showed that low household income and residence in government-subsidized housing were significant predictors for the subjects who experienced difficulty in managing during first 2 months of the pandemic (11% of the NCD patients). Of those on long-term NCD medication, 10% reported having less than one week's supply of medication. Targeted services for vulnerable groups during a pandemic should be explored to support NCD self-care.

**Keywords:** Health-EDRM; non-communicable disease; COVID-19; self-care; NCD management; home care; early phase of pandemic

#### **1. Introduction**

People with existing non-communicable diseases (NCDs) are particularly vulnerable to health risks brought upon by emergencies and disasters [1]. People who suffer from chronic diseases, such as cardiovascular disease, chronic lung disease, and diabetes, are more vulnerable to disruption and stress induced by disasters. A significant proportion of mortality in post-disaster phases results from the failure of health care services to cater to the needs of patients with chronic diseases [2].

The Health emergency and disaster risk management (Health-EDRM) framework emphasizes prevention and risk mitigation through hazard and vulnerability reduction, disaster preparedness, and response and recovery measures [3]. As the presence of NCDs are reported to be associated with worse outcomes of the COVID-19 disease, [4–6] strengthening NCD self-care and disease management during the pandemic could mitigate the health harm caused by COVID-19. In addition to the maintenance of healthy behaviours (e.g., regular exercise, personal hygiene), NCD patients should continue their regular medication and are recommended to stockpile at least one-month's supply of medication during the pandemic [7]. Ironically, some of the infection control measures, such as lockdowns, and the reallocation of healthcare resources to handle COVID-19 cases, have posed challenges for maintaining care among NCD patients.

The impact of COVID-19 on NCD management has caused global concerns, and the European WHO Regional Office has begun devising recommended actions for people with NCDs during this pandemic [8]. However, research on the status and disease management of NCD patients in the context of COVID-19 remains very limited. This study examines the situation of people with NCDs, their disease management difficulties, and household supply of medication during the early phase of the pandemic. The most vulnerable NCD patient subgroups were identified and discussed.

#### **2. Materials and Methods**

This is an anonymous, random, population-based, 6-month cohort study. This report highlights findings of the baseline data collection (22nd March to 1st April 2020). Participants were recruited through computerized random digit dialing (RDD). Stratified sampling was used to ensure that the dataset was representative of the Hong Kong general population in terms of age group, gender, and district of residence. Details of the methodology were reported in our previous study [9], which investigated the perception, attitude and preparation for the COVID-19 epidemic among the Hong Kong population. Data were collected in Hong Kong, a southern metropolis in China, and the health services delivery was in an urban setting.

The study population included those aged 18 years or above and residing in Hong Kong. Socio-demographic data (age, gender, household income, employment status, housing type) and details of NCD patients' disease management situation (presence and types of chronic condition(s), healthcare services utilization, routine care requirements) were collected by a standardized questionnaire. Participants were also asked about their past medical history and whether their family members had chronic condition(s). An NCD was defined as a self-reported, existing, chronic condition through the questions "Do you suffer from any form of chronic disease?" and "Which type of the chronic disease(s) are you diagnosed". Households reporting at least one member with an NCD were asked if they had at least one week's supply of NCD medications at home during the COVID-19 pandemic. In addition, they were further asked whether the COVID-19 pandemic had caused difficulty to their usual NCD care and the nature of these difficulties [9].

Differences between participants with and without perceived difficulty in their usual NCD care during the COVID-19 pandemic were examined by Chi-square tests and Fisher's exact tests (α = 0.05). Respondents gave verbal informed consent and the study was approved by the Survey and Behavioral Research Ethics Committee at The Chinese University of Hong Kong (SBRE-19-498).

#### **3. Results**

Our telephone survey reached 765 households, and the final response rate was 44.0% (765/1738). Our sample was comparable to the Hong Kong general population [9]. Of all the households interviewed, 31.5% reported the presence of at least one person in the household diagnosed with an NCD, and among them, 9.1% reported not having at least one week's supply of NCD medications at the time of phone interview.

– –

Of all the participants, 18.4% (*n* = 141) reported having at least one type of NCD, and approximately 5% (or 27% of these patients) reported more than one type of NCD. Approximately 44.7% of these NCD patients were aged 65 or above. The most commonly reported NCDs were hypertension (48.6%), diabetes (22.1%), cardiovascular diseases (16.4%), and hyperlipidemia (10.0%). Of NCD patients, nearly four-fifths (*n* = 110) had required medication(s) for their condition.

Around 11% of participants with NCDs reported difficulty in their routine NCD care, with the most common reasons being difficulty in getting to medical consultations/follow-up visits during the pandemic (62.5%) and difficulty in purchasing supplies, such as face masks and hand sanitizers, during this period (56.3%) (Figure 1). Among participants who reported difficulties in NCD management, those with lower income and those living in government-subsidized housing were more likely to perceive difficulties in NCD management (Table 1), while no statistically significant differences were noted for other demographic variables. The results also revealed no statistically significant difference between participants with different types of NCD or between patients with one NCD versus multiple NCDs.

**Figure 1.** Difficulties reported by study samples for non-communicable diseases (NCD) management during COVID-19 pandemic (*n* = 16).




**Table 1.** *Cont.*

<sup>a</sup> Fisher's exact test. <sup>b</sup> USD = 7.8 HKD. \* *p* < 0.05.

#### **4. Discussion**

In our study, we found that around one-fifth of the Hong Kong population reported to have NCDs. Among those NCD patients, lower household income and residing in government-subsidized housing were found to be significantly associated with difficulty in NCD management during the first two months of the pandemic. In addition, households with NCD patients were reasonably well-prepared in terms of medication stockpiling during the COVID pandemic in Hong Kong, with over 90% possessing at least a week's supply of drugs. Moreover, all public outpatient clinics were open during COVID-19 with enhanced infection control measures, and allowed relatives/friends to obtain drugs for NCDs on the patients' behalf. Nonetheless, nearly one in ten NCD patients were insufficiently prepared with their medication supply.

Previous studies indicated that social distancing and quarantine could result in poor management of NCD behavioral risk factors, including various unhealthy lifestyle habits [10]. In particular, reduced social interaction, uncertainty in economic situations, and changes in the activities of daily living could further worsen disease management among NCD patients [8]. While only about 11% of the NCD patients in this study reported perceived difficulties in managing their NCD during the pandemic, the results indicate the pandemic disrupted access to NCD clinical care, possibly due to services/traffic interruption and difficulties arising from rescheduling of routine check-ups. NCD patients of lower income and those living in government-subsidized housing were significantly more likely to perceive difficulty in NCD management during the pandemic, indicating that material resources may be major barriers to care. A possible reason may be that since the willingness to wear face masks to prevent infection transmission in Hong Kong is high (e.g., around 90% of Hong Kong residents wore mask during the A/H5N1 avian influenza period in 2007 and A/H1N1 influenza period in 2009 [11]), it is

not surprising that the most commonly reported difficulties for NCD care are getting to medical consultations/follow-up visits and purchasing medical supplies, given the soaring price of face masks in the first few months of the pandemic [12]. Thus, NCD patients should thereby receive more targeted services to facilitate their NCD self-care during a pandemic. Further studies, in particular on telemedicine, can investigate interventions to minimize such NCD management interruptions [13].

Health-EDRM concerns the analysis and management of health risks through reduction in hazard, exposure and vulnerability in every phase of the disaster management cycle [14]. Resilience-building is a key concept for minimizing the health risks of older people and chronic disease patients, and could be built through empowerment initiatives to improve their health outcomes. Self-care by the population concerned should also be promoted. For chronic disease patients, they should have adequate knowledge on how to use their medication (e.g., type of insulin used, insulin self-injection kit with instructions). For people with multiple drug prescriptions, it would be important for them to identify the critical, life-maintaining ones, and the key contraindications of their regular medications. In the event that health facilities and medical supplies are interrupted, it is important for chronic disease patients to stockpile, preferably, a 10–14 days' supply of medications [15]. Moreover, extensive effort is required to promote emergency preparedness among chronic disease patients, as a systematic review published in 2014 found that a considerable number of chronic disease patients lost their medication and medical aids during evacuation. Many did not bring prescriptions with them when evacuated, which made it difficult to fill in prescriptions, and that medication and prescription loss posed a significant burden on the medical relief teams [16]. Community partnership is crucial, and health care workers who are involved in disaster response and relief should be sensitive in choosing the most appropriate NCD health interventions (e.g., adverse drug interactions, unsuitable diets for people with diabetes [17]) to support patients during extreme events.

There were some limitations of this study. For the question of NCD medication stockpiling, since the interview could be answered by the patient's family members, the accuracy could be undermined by recall bias. In addition, the sample size of the chronic disease patients was very small and did not permit multivariable analysis. Although the results provided some initial insight into NCD healthcare needs and service gaps in a region that was affected by the early phase of the COVID-19 pandemic, the representativeness of the NCD subsample to the general population of NCD patients is unknown. The results should therefore be taken with caution, and future studies need to capture a larger, representative sample of NCDs patients for examination. In order to capture a representative sample of NCD patients with high quality data, a future study should be conducted by randomly sampling NCD patients from patient lists (which provides investigators with documentation of the clinical diagnoses and prescribed medications). These patients can be followed periodically during the epidemic in order to track changes in their healthcare needs and service gaps in the early and later phases. The time effect of self-reported disease management patterns will be examined in the second phase of data collection. Future studies should also examine the impacts of large-scale pandemics and public health emergencies on long-term NCD management.

#### **5. Conclusions**

This study examines the disease management difficulties faced by NCD patients during the early phase (first 2 months) of the COVID-19 pandemic and identified the most vulnerable NCD patient subgroups in an urban context. Study findings indicated low household income and residence in government-subsidized housing were found to be significant predictors among the 11% who reported difficultly in managing during first 2 months of the pandemic. Of those on long-term NCD medication, 10% reported having less than one week's supply of medication. Targeted services for vulnerable groups during a pandemic should be explored to facilitate resilience-building in Health-EDRM and to enable better self-care for people with NCDs.

**Author Contributions:** Conceptualization, E.Y.Y.C., E.L.Y.W., S.Y.S.W., and K.K.C.H.; methodology, J.H.K., E.K.P.L., E.S.K.L. and Z.H.; validation, J.H.K., M.C.S.W., H.H.; formal analysis, E.S.K.L. and Z.H.; investigation, E.Y.Y.C.; resources, E.Y.Y.C.; data curation, E.S.K.L. and Z.H.; writing—original draft preparation, J.H.K. and H.H.; writing—review and editing, E.Y.Y.C., J.H.K., E.L.Y.W., E.K.P.L., M.C.S.W. and S.Y.S.W.; supervision, K.K.C.H. and J.H.K.; project administration, E.S.K.L. and Z.H.; funding acquisition, E.Y.Y.C. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was fully funded by CCOUC development fund.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

International Journal of *Environmental Research and Public Health*

### *Review* **Narrative Review on Health-EDRM Primary Prevention Measures for Vector-Borne Diseases**

**Emily Ying Yang Chan 1,2,3,4,5,\* , Ti**ff**any Sze Tung Sham 3,4, Tayyab Salim Shahzada 3,4 , Caroline Dubois <sup>4</sup> , Zhe Huang 1,3, Sida Liu 1,4 , Kevin K.C. Hung 1,3,5 , Shelly L.A. Tse <sup>3</sup> , Kin On Kwok <sup>3</sup> , Pui-Hong Chung <sup>3</sup> , Ryoma Kayano <sup>6</sup> and Rajib Shaw <sup>7</sup>**


Received: 15 July 2020; Accepted: 13 August 2020; Published: 18 August 2020

**Abstract:** Climate change is expanding the global at-risk population for vector-borne diseases (VBDs). The World Health Organization (WHO) health emergency and disaster risk management (health-EDRM) framework emphasises the importance of primary prevention of biological hazards and its value in protecting against VBDs. The framework encourages stakeholder coordination and information sharing, though there is still a need to reinforce prevention and recovery within disaster management. This keyword-search based narrative literature review searched databases PubMed, Google Scholar, Embase and Medline between January 2000 and May 2020, and identified 134 publications. In total, 10 health-EDRM primary prevention measures are summarised at three levels (personal, environmental and household). Enabling factor, limiting factors, co-benefits and strength of evidence were identified. Current studies on primary prevention measures for VBDs focus on health risk-reduction, with minimal evaluation of actual disease reduction. Although prevention against mosquito-borne diseases, notably malaria, has been well-studied, research on other vectors and VBDs remains limited. Other gaps included the limited evidence pertaining to prevention in resource-poor settings and the efficacy of alternatives, discrepancies amongst agencies' recommendations, and limited studies on the impact of technological advancements and habitat change on VBD prevalence. Health-EDRM primary prevention measures for VBDs require high-priority research to facilitate multifaceted, multi-sectoral, coordinated responses that will enable effective risk mitigation.

**Keywords:** health-EDRM; primary prevention; vector-borne disease; biological hazards; climate change; narrative review

#### **1. Introduction**

Vector-borne diseases (VBDs) are viral, parasitic and bacterial illnesses transmitted to humans through vectors such as mosquitoes, sand flies and ticks. Common VBDs affecting human health include malaria, yellow fever, dengue, Zika, chikungunya, Lyme disease, tick-borne encephalitis, leishmaniasis and African trypanosomiasis [1]. The complacency towards and reduced emphasis on vector control [2] and the redirection of health resources, together with population growth, urbanisation and globalization, have contributed to the increased frequency of VBD outbreaks in tropical areas of the world in the past decade [2]. With the impact of climate change on ecological and human living environment, the burden of VBDs has expanded from tropical and subtropical areas to temperate regions, placing 80% of the world's population at risk [3]. This shift in the human vulnerability profile has been attributed to rising temperatures, which favour the migration and geographical expansion of disease vectors [4]. Furthermore, altered precipitation patterns favour larval breeding and have accelerated VBD spread [5]. Contact patterns between humans and pathogens, vectors or hosts may also be altered by climate change in an unpredictable manner [4]. Increased occurrences of natural hazards, such as floods and cyclones, pose a further risk of VBD outbreaks [4]. Geographical areas that were previously unaffected are now facing growing risks [6,7], but are often underequipped in disaster prevention, preparedness and response capacities.

The World Health Organization (WHO) estimates that VBDs currently account for over 17% of the global burden of infectious diseases [1]. As indicated in the Global Burden of Disease Study [8], VBDs have substantial disability weights [9] and can be detrimental to the socioeconomic development of communities. Malaria is a disease which accounts for more than 50% of total deaths caused by VBD [10], and high-risk countries have on average a gross domestic product per capita growth that is over five times lower than countries not affected by the disease [11]. The economic burden of VBDs stems from increased household expenditure on disease prevention and management, lost income from minimised productivity due to sickness or care for the ill [3], damages to crops and livestock by disease vectors [2], and other impacting factors. The United Nations Sustainable Development Goals (SDG) emphasise good health and well-being (SDG 3) [12]. Collaborative initiatives and investments prioritising prevention and treatment research by international bodies in recent decades, such as efforts by the Global Fund [13], have contributed to the alleviation of the global disease burden induced by VBDs [10].

The WHO health-emergency and disaster risk management (health-EDRM) framework was developed in 2018 as an integrated approach for the utilisation and management of resources in addressing current and emerging risks to public health, with the aim of promoting joint action and coherence in implementing other global strategies such as the International Health Regulations (2005), the Sendai Framework for Disaster Risk Reduction 2015–2030, the Paris Agreement on Climate Change, and the Sustainable Development Goals 2015–2030 [14]. Overall, the framework guides the structured analysis and management of health risks brought on by emergencies and disasters, focusing on risk mitigation through hazard and vulnerability reduction, preparedness, response, and recovery measures [14,15]. Health-EDRM emphasises the significance of community involvement to mitigating and counteracting the potential negative impacts of hazardous events such as VBD outbreaks, which are considered biological hazards [14].

The concept of prioritising health in disaster risk management policies was already recognised in the Sendai Framework for Disaster Risk Reduction 2015–2030 [16]. Health actors at all levels have engaged with each other and the WHO in the implementation and monitoring of disaster risk reduction. WHO offices at the regional level, and country governments, have incorporated disaster risk management policies in the health sector, which is an important step in contextualising actions for implementation [17]. The Sendai Framework has been crucial in highlighting health as a core dimension of disaster risk management, and has paved the way for the establishment of the WHO Health-EDRM Research Network, strengthening research and knowledge-sharing globally, allowing for the enhancement of evidence-based policies and practices [17]. There is a crucial need for multi-sectoral, coordinated approaches between the countries' governments, health systems and other stakeholders, especially in the area of recording and reporting against the framework [17]. Additionally, systems need to reinforce the recognition of prevention and recovery within disaster management [17].

The health-EDRM framework outlines a hierarchisation of health risk prevention into primary, secondary and tertiary prevention [14,18]. Primary prevention mitigates against the onset of disease through health promotion targeted at behavioural modification and health risk reduction. Secondary prevention involves inhibiting disease progression through strategies such as screening and early detection. Tertiary prevention focuses on treatment and rehabilitation in order to minimise disabilities and complications [18,19]. Taking into consideration financial, clinical and infrastructural costs, primary prevention can effectively alleviate the burden of VBDs in a community, if necessary through measures that address a wide spectrum of VBDs, such as targeting diseases transmittable through multiple vectors [20] or focusing on vectors that are capable of transmitting multiple diseases [1]. Primary prevention measures often offer the most cost-effective outcomes and enhance health protection through increased community resilience against diseases where treatment is unavailable or access to healthcare is complicated. Secondary and tertiary prevention measures require significant human resources and health infrastructural support, and may therefore be costly, with higher programmatic risks, causing further economic stress on impacted communities.

There is a large amount of available evidence and research concerning clinical treatment approaches to some VBDs, such as Malaria. However, other VBDs, such as dengue, chikungunya, tick-borne encephalitis, Japanese encephalitis, yellow fever and leishmaniasis, lack standardised or straightforward treatments, and rely primarily on therapeutic interventions built on symptom management [21]. There are ongoing clinical trials in these areas, such as vaccine development for Zika and chikungunya, research into rapid malaria tests, as well as drug trials for chikungunya [22].

This narrative literature review examines published evidence on health-EDRM primary prevention measures for VBD risk mitigation, maps the contextual effectiveness or limitations of each preventive measure, and aims to identify areas of research that need be strengthened in order to develop effective strategies for VBD prevention. The strength of the available scientific evidence is evaluated for each of the prevention measures. Based on the health-EDRM framework, which emphasises the context-based determination of intervention efficacy, analysis of enabling and limiting factors is also included for each measure [14].

#### **2. Materials and Methods**

A keyword search-based narrative literature review was conducted using the databases PubMed, Google Scholar, Embase, Medline and ScienceDirect. The search was conducted in May 2020 and included English language-based international peer-reviewed articles, online reports, electronic books and press releases, as well as grey literature by institutions such as the WHO, the United Nations, the Global Fund, the United Nations Children's Fund, the International Energy Agency, the World Bank, the United States Centres for Disease Control and Prevention, the U.S. Food and Drug Administration, and the Hong Kong Centre for Health Protection, published between January 2000 and May 2020. The snowballing search methodology was also applied. Specific keywords and phrases used can be found in Appendix A. The emergence, primary prevention, associated risk factors and management of VBDs were reviewed in order to generate 10 core primary prevention measures for discussion.

With reference to the Oxford Centre for Evidence-Based Medicine (OCEBM) 2009 Levels of Evidence (Figure 1) criteria, the identified papers were categorised into their respective levels according to strength of evidence based on the study design and methodology [23]. Reviewed literature that could not be categorised using the OCEBM Levels of Evidence was classified as 'Others', which includes, but is not limited to, news articles or releases, books, textbooks, position papers, guidelines, case reports and organisational reports.

#### *Int. J. Environ. Res. Public Health* **2020**, *17*, 5981


**Figure 1.** The Oxford Centre for Evidence-Based Medicine (OCEBM) 2009 Levels of Evidence (adapted from www.cebm.net) [23].

#### **3. Results**

The search identified 134 relevant publications, all of which were included in the results analysis. Using the identified research, 10 core bottom-up primary prevention measures were proposed and discussed based on the health-EDRM framework. Five personal protection practices (wear protective clothing when outdoors, avoid heading outdoors to vector-prone areas and during peak biting conditions, apply insect repellent, sleep under bed nets, receive prophylactic vaccinations and chemoprophylaxis), three environmental management practices (use insect-killing traps, manage stagnant water appropriately, manage waste appropriately), and two customary household practices (minimise household entry points, cover exposed foodstuffs) were included. Tables 1 and 2 (personal), Table 3 (environmental) and Table 4 (customary household) highlight relevant health risk, desired behavioural change, potential co-benefits, enabling and limiting factors, alternatives, and strength of evidence available in published literature with regard to these primary prevention measures. Table 5 categorises all 134 reviewed publications according to the OCEBM Levels of Evidence [23]. Of note, a number of the reviewed articles report an assessment of more than one primary prevention measure. The review results indicate that approximately 60% of the studied literature relate to personal protection, 24% to environmental management, and merely 16% focus on customary household practices. Measures such as outdoor avoidance, sleeping under bed nets and receiving prophylactic vaccinations and chemoprophylaxis are amongst the most commonly reported studies. Details on the precise breakdown of each reviewed reference can be found in Table S1.

**Table 1.** Personal Protection Practices as Health Emergency and Disaster Risk Management (Health-EDRM) Primary Prevention Approaches against Vector-borne Diseases (VBDs) (Part 1).



**Table 1.** *Cont.*




#### **Table 2.** *Cont.*


#### **Table 2.** *Cont.*

**Table 3.**Environmental Management Practices as Health-EDRM Primary Prevention Approaches against VBDs.




#### **Table 3.** *Cont.*


#### **Table 4.**Customary Household Practices as Health-EDRM Primary Prevention Approaches against VBDs.



#### **Table 4.** *Cont.*



**Table 5.** Overview of Health-EDRM Primary Prevention Approaches against VBDs in the Reviewed Articles, Categorised by the Oxford Centre for Evidence-Based Medicine (OCEBM) Levels of Evidence. (Please see Table S1 for details.).


\* 'Others' includes but is not limited to news articles or releases, books, textbooks, position papers, guidelines, case reports and organisational reports.\*\* Of the 134 publications reviewed, some included findings on more than one primary prevention measure, and are counted more than once in Table5.

#### **4. Discussion**

VBDs are classified as biological hazards under the WHO health-EDRM framework [14] and their associated health risks should be managed according to the disaster management cycle (prevention, mitigation, preparedness, response and recovery), which encompasses both top-down and bottom-up interventions [157,158]. Top-down interventions require well-driven bottom-up initiatives to achieve effective primary prevention and to modify community health risk reduction-related measures [159]. Both the WHO health-EDRM framework [14] and the WHO global vector control response 2017–2030 framework [3] emphasise community engagement and mobilisation in enhancing protection against VBDs. The scientific effectiveness and feasibility of the community-level implementation of the 10 proposed primary prevention measures in this review can each be influenced by distinctive external factors, particularly with regards to access to financial or material resources.

Health promotion enables people to have more control over the improvement of their health outcomes, and is done through enhancing health literacy, encouraging behavioural change, and developing supportive policies [160]. There are numerous models which explore behavioural change as a result of education-based health promotion, one of which is the 'knowledge, attitudes, practices model', which prompts behavioural changes through knowledge enhancement [160]. In the case of vaccinations and chemoprophylaxis, it is critical for health interventions to enhance individual knowledge and awareness on why and how to receive prophylaxis as a primary prevention mechanism against VBDs, particularly in addressing misconceptions which underestimate the danger of VBDs [81]. Behaviour can be changed through addressing attitudes, such as misunderstandings [81], perception of social norms, cultural traditions and religious beliefs, for example in the case of ultra-orthodox Jewish communities who do not practice vaccination [81,82]. Finally, the behavioural change theory should consider how to promote practice. The viability and efficacy of the practice itself is favoured or limited by a variety of factors; policies will have to address barriers to accessing, and augmenting motivation in, the community [159].

The enabling and limiting factors that impact the effective uptake of primary prevention measures are closely interlinked. This review identified a number of determinants of success, including adequate resources, risk awareness, and well-coordinated supportive systems. A number of primary prevention measures rely on the availability and affordability of material resources, such as insect repellents, protective clothing, UV lamps, household building materials and bed nets (which additionally require space and equipment to set up [73]). Resource-deprived communities, which are at a higher risk of facing vulnerability, may lack the necessary material or financial resources. Materials must be accompanied by knowledge of their appropriate use. Inadequate information can lead to the improper maintenance of vector-prevention commodities, subsequently compromising their efficacy. For example, damaged bed nets with holes and improper bed net usage have been shown to lead to outcomes worse than no usage at all [64–66]. Some measures may also be affected by other health conditions, such as allergic reactions to insect repellent active ingredients [76], while others may be limited by cultural concerns, as demonstrated in the case of vaccination hesitancy in certain religious communities [81,82]. The feasibility of certain measures, such as the avoidance of outdoors, is dependent on an individual's personal, professional and socioeconomic situation. Avoidance of going outdoors into vector-prone areas and during peak biting conditions can be impractical, such as in farming populations that need to spend long periods outdoors, and in tropical areas where the climate is 'peak-biting'—hot and humid—all year long [50]. Similarly, there may be cases where access to a fully enclosed shelter or household improvements are not feasible, such as for those who are homeless or living in temporary shelters. Beyond resource access, proper education and personal circumstances, some primary prevention measures rely heavily on infrastructural and systemic support. Ensuring community access to vaccinations and chemoprophylaxis requires functioning health systems able to provide the necessary services, including an adequate supply of vaccines or medicine, trained health workers for administration and education, and an established clinic (fixed or mobile) from where the vaccine or drug can be distributed. Health system infrastructure is a critical enabling factor

lacking in many rural or resource-poor contexts [84]. The environmental management of vectors also requires a robust and coordinated top-down waste management system [109,117], with multi-sectoral collaboration [161] between the health, environmental and civil engineering sectors, as well as other local and national-level authorities. Authorities should ensure the sufficiency of waste collection points such as waste bins [123], which can affect proper waste disposal, and the supply of electricity [118], which can affect the use of insect-killing traps, particularly in developing contexts [116]. Therefore, the success or failure of a community's uptake of primary prevention measures is shaped by the availability of material resources and information, supportive health and civil infrastructure, policy formulation, geographical climate, individual or professional flexibilities, and social contexts. Nonetheless, it should always be noted that each measure offers its contribution towards VBD prevention, and the measures serve as an alternative to one another. When one measure cannot be carried out, the practice of other measures is not necessarily impeded.

In comparing the strength of evidence of the reviewed literature (Table 5, please see Table S1 for details), the largest proportion (45%) fell into Level 5 classification, which covers a wide range of study designs and methodologies, such as entomological studies, observational exploratory studies, experimental studies, modelling studies, qualitative studies, and expert opinions. 20% of the reviewed literature was categorised into 'Others', which includes but is not limited to news releases, reports by international organisations like the WHO, and textbooks. Level 4 publications, such as cross-sectional mixed method studies, behavioural surveys, household surveys, questionnaires, interventional studies and case series studies contributed a relatively large portion (17%), with many addressing the knowledge, perceptions, acceptance and opinions of populations with regards to VBD-prevention measures. Regarding individual primary prevention measures, evidence is most lacking at all levels with regard to the practices of covering exposed foodstuffs (4%) and proper waste management (6%). The literature relevant to sleeping under bed nets and minimising household entry points was significantly stronger in study design. There is published evidence on the risk reduction relating to wearing protective clothing and the management of stagnant water; however, while a multitude of studies emphasised the impact of primary prevention measures on VBD health risk reduction, a limited number of studies focused on the impact of the measure itself on disease prevention efficacy or outcome. For instance, many studies demonstrate the potential VBD-related health risks of exposed foodstuffs [136–139] and household entry points [140,141]; however, there are limited studies that demonstrate the effectiveness of covering food or household crack-repairing on disease incidence reduction within a community [156]. Similarly, for solid waste management, while evidence on the health risks [134,135] associated with improper solid waste accumulation is available, there is a lack of in-depth comparative studies between different waste management system models and their strengths and weaknesses.

The methodology used for this review is limited in that it does not include non-English-based literature, non-electronically-accessible literature, grey literature outside of those areas deliberately searched, any publications before 2000, or any publication not identified due to incompatibility with the keywords used for the literature search. Notably, publications documenting experiences from low-resource VBD-endemic settings that are not readily accessible via mainstream databases or online platforms may not have been included in this review.

Certain areas were found to be lacking in the updated evidence. On the efficacy of light-coloured clothing, while the WHO provides recommendations for protective wear against VBDs [21], the search generated no clear evidence, that had been updated within the past two decades, to support the rationale behind vector landing preferences on darker surfaces, and vice versa. Recommendations concerning the appropriate concentration of DEET in insect repellent are often inconsistent across international organisations and governments. More extensive research is needed to better establish the correlation between DEET concentration, repellent strength and duration of efficacy. In addition, while there are various observational studies on the correlation between modern technological advancements, such as air conditioning, and decreased disease vector bites [162–165], there is limited updated

scientific evidence available on the precise impacts of such advancements on changes to vector habitat. Addressing these research gaps will facilitate better-grounded and more evidence-based institutional guidelines.

The best available evidence is always evolving, requiring the continuous updating of guidelines and recommendations. The ongoing research on VBD prophylactic strategies is very active, as well as that on the development of insecticide resistance regarding insecticide-treated bed nets [166,167] and insect repellents [168]. In light of the many different designs, parameters, sample sizes and investigation methods used, it is often difficult to evaluate and compare related studies, thus resulting in a lack of standardisation in guidelines. For instance, a variety of attraction and killing mechanisms, as well as door and window screen designs [141], are used in different studies to evaluate insect-killing trap and household modification efficacies. Efforts to achieve increased consistency in the methodology of published research are crucial to making comparative analyses between studies on different VBD-prevention commodities possible [169–172].

Three areas are particularly lacking in the published evidence. Firstly, there has been minimal research done on available alternatives to the proposed practices. Taking the case of insect repellents, numerous studies are available to prove the efficacy [59–61,85] and explore the potential safety concerns [86–88] of DEET. However, the strength of research supporting the repellence of natural alternatives like plant oils is variable [74]. For instance, limited and conflicting findings on citronella efficacy were identified [74,85], and potential health hazards, like dermatitis under high-concentration neem-oil use, are indicated, with less stringent safety testing conducted compared to DEET [74]. Secondly, limited research is available on other disease vectors such as sand flies and ticks. A bulk of the literature identified in this analysis focuses on mosquitoes—the discussions on common vector breeding grounds [52,106–108] and the efficacy of insect-killing traps seldom involve other disease vectors [128]. There is a need for research into effective methods to better understand the breeding habitat ecology of sand flies in immature stages, which will facilitate the development of targeted control strategies such as source reduction, which are not yet possible as sand fly larvae can be difficult to detect, in contrast to other vectors such as mosquitoes [173–175]. Similarly, in the case of insect-killing traps, only limited studies demonstrate their potential in targeting sand flies in addition to mosquitoes [129], and evidence on tick elimination by the traps is lacking entirely. Thirdly, research on the spectrum of VBDs is disproportionately distributed; studies are oftentimes skewed towards more prevalent VBDs, such as malaria. While consideration is given to other VBDs such as Zika or tick-borne encephalitis, this literature review occasionally extrapolates the primary prevention measures proposed for the more extensively-researched diseases so as to apply them to other VBDs as well—for example, the determination of the time of day with peak biting conditions was based on *Plasmodium*-infected (malaria) mosquitoes being active from dusk to dawn [29–31]. Further research on these three areas is necessary in order to develop comprehensive and informed guidelines or policies that can be implemented in varying contexts to mitigate against the risk and alleviate the disease burden of VBDs.

This review has identified major research gaps in the current published literature relating to health-EDRM primary prevention measures for VBDs (Table 6). Strengthening the available evidence in these areas will create a scientific basis on which governments, policy-makers and community stakeholders can develop effective, targeted and achievable strategies for protecting at-risk populations against VBDs. Aspects of the WHO health-EDRM framework can be applied to address these research gaps. Increasing capacities for information and knowledge management can support collection, analysis and dissemination across multiple sectors, allowing for the comparative evaluation of available evidence, as well as the development of consistent guidelines and recommendations [14]. This is particularly important for any research undertaken in resource-poor contexts, which will provide necessary evidence towards developing effective and targeted VBD prevention measures in such contexts. The framework highlights the need for more multifaceted and multisectoral approaches, the lessons of which will lead to the further development of evidence-based strategies [14].

**Table 6.** Major Research Gaps in Current Published Literature Relating to Health-EDRM Primary Prevention Measures for VBDs.


All 10 primary prevention measures require sustainable, continuous implementation and maintenance in order to be truly effective in preventing VBDs. Primary prevention measures focusing on stagnant water, waste management and the covering of exposed foodstuffs offer the long-term co-benefit of mitigating risks arising from other biological hazards under the health-EDRM framework [14], such as water-borne and food-borne diseases [139]. Practising continuous primary prevention is particularly necessary as long as certain VBDs do not have standardised effective treatment options, and if vector-elimination is not feasible. Some preventive measures face more complex challenges in practise without adequate health or governance infrastructure. Others are more easily implemented, but are nonetheless reliant on materials such as insect repellents or bed nets, which can be an obstacle in resource-poor settings where the population is already facing vulnerability to impoverishment or disease. It is crucial for policymakers to ensure that systems are able to identify and assess needs, and provide the necessary support for the sustainable and fair distribution of resources. Empowering bottom-up initiatives requires well-coordinated top-down policies [83] that effectively disseminate resources and information, especially in resource-deprived, rural, or health-illiterate populations. A strong, accessible health system is key to providing materials and education to the at-risk population. Centralised, coordinated and well-regulated infrastructure, such as a uniform waste management system [176], can significantly enhance the efficacy of primary prevention practices.

Climate change and its associated consequences, such as changing weather patterns and increased disaster occurrences [18], have shifted the epidemiological patterns of VBDs, as well as the volume and spread of the at-risk population, thus affecting the development policies and strategies for mitigating the VBD burden on health systems. Rising temperatures and unpredictable precipitation patterns, for example, lengthen peak-biting periods and further complicate the capacity for outdoor avoidance, especially in tropical areas which are sultry throughout the year. The increased incidence of hydro-meteorological hazards such as floods and cyclones brings about more extreme rainfall, as well as increased humidity and water accumulation [18], and impact stagnant water management, thus possibly facilitating further larval habitat development for disease vectors [18]. Insect vectors cannot regulate their internal temperatures and are very sensitive to changes, which has caused them to invade new areas in order to adapt [177]. This puts previously unexposed populations at risk, who may lack protective immunity or the experience, resources or services necessary to mitigate the prevalence of disease [6]. The WHO health-EDRM framework stresses the importance of strengthening health systems, with an increased emphasis on climate change adaptation [14], to reducing health risks associated with hazardous events, including VBD outbreaks. It is important for governing bodies to consider the associated challenges of climate change during policy formulation, with the inclusion of climate change scenarios in disaster risk assessments [18]. Considering the limitation of the predicted impact of climate change on VBD transmission, governing bodies should enhance individual capacities and community resilience in cases of sudden VBD surges [178]. For instance, early warning systems should be in place to communicate the health risks associated with seasonal VBD outbreaks to vulnerable populations in advance [18]. As such, primary prevention measures that emphasise the broader aspects of environmental management, resource distribution and public education must not be overlooked. Public education, to encourage early symptom identification and subsequent health-seeking behaviours, can serve as a steppingstone in propagating secondary and tertiary VBD intervention amongst vulnerable populations.

In light of the growing burden of VBDs and emerging public health threats, a progressive primary prevention model is key to disaster risk reduction, as encompassed in the four priorities set out in the Sendai Framework for Disaster Risk Reduction (risk understanding, governance, preparedness and resilience) [16]. In terms of disaster risk understanding, a thorough examination of the enabling and limiting circumstances is required in at-risk populations, including local disease prevention capacity, specific VBD characteristics, and risk drivers such as climate change [16,18]. Disaster governance should be strengthened through stakeholder involvement and multi-sectorial collaboration, as well as through adopting a well-coordinated top-down approach to empowering bottom-up community initiatives in a sustainable manner. Resilience enhancement should be driven by global investments in innovation and research, for instance the development of better prophylactic strategies and better vector-prevention commodity designs for utilisation against VBDs. Finally, disaster preparedness can be reinforced through raised awareness, secured healthcare accessibility and health-seeking behaviour encouragement, so as to better equip vulnerable populations facing future VBD outbreaks.

#### **5. Conclusions**

This narrative study identified 10 health-EDRM primary prevention measures against VBDs. Resource availability, risk awareness and systemic support were identified as the core enabling factors for the success of these measures. Resources, health and civil infrastructure, policy formulation, geographical climate and socioeconomic factors were the core sources of limitations, which necessitate the need to consider alternatives. Evidence supporting the effectiveness of alternative preventive measures is lacking, in particular with regards to prevention in resource-poor settings. Similarly, evidence related to preventive measures focusses heavily on mosquitoes, whereas research on effective prevention against diseases transmitted by other vectors such as sand flies and ticks is lacking. At a global level, the necessity of VBD prevention increases with the growing impact of climate change and globalisation.

Health risks associated with VBDs will remain an ongoing biological hazard to communities, and thus sustainability of practice is crucial. As recommended by the WHO health-EDRM framework, in addition to the health sector, the successful adoption of primary prevention measures against VBDs requires a multi-faceted, multi-sectoral and coordinated response, encompassing sectors such as meteorology for hazard prediction, education for health awareness and promotion, and the environmental and civil engineering sectors for waste collection and water management.

In conclusion, this review has shown that evidence of the effectiveness and management of primary prevention practices is focused on a narrow spectrum of VBDs and vector types. In order to fill research gaps, the scope of VBD research should be broadened, and standardised protocols should be adopted so as to better prepare communities for disaster risk mitigation and to build the capacities of populations that are vulnerable with regards to health-EDRM practices.

**Supplementary Materials:** The following is available online at http://www.mdpi.com/1660-4601/17/16/5981/s1, Table S1: Relevant Intervention(s), Study Design, Relevant Key Finding(s) and/or Conclusion of Each Reviewed Article Referenced (*n* = 134).

**Author Contributions:** Conceptualization, E.Y.Y.C. and C.D.; methodology, T.S.T.S. and T.S.S.; formal analysis, T.S.T.S; T.S.S.; writing—original draft preparation, E.Y.Y.C.; T.S.T.S.; T.S.S.; C.D.; writing—review and editing, Z.H.; S.L.; K.K.C.H.; S.L.A.T.; K.O.K.; P.-H.C.; R.K.; R.S.; supervision, E.Y.Y.C.; funding acquisition, E.Y.Y.C. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by the CCOUC-University of Oxford research fund (2019–2023).

**Conflicts of Interest:** The authors declare no conflict of interest. Professor Emily Ying Yang Chan serves as the Co-Chair of the Health-EDRM Global Research Network and Ryoma Kayano serves as the Secretary of the Health-EDRM Global Research Network.

#### **Appendix A. Keywords Used for Literature Search**

'bed nets', 'blue-light irradiation', 'bottom-up approach', 'breeding sites', 'carbon dioxide', 'cement', 'chemoprophylaxis', 'chikungunya', 'climate change', 'clothes moth larvae', 'clothes wear and tear', 'cockroaches', 'crack repair', 'dengue', 'diethyltoluamide (DEET) ', 'disease burden', 'door screening', 'doors and windows burglary', 'electricity access', 'fall injury water', 'floods', 'food decay', 'food fermentation', 'food mould and fungi', 'food-borne pathogens', 'forests', 'health hazards', 'health-EDRM', 'heat stroke', 'heat-seeking ability', 'heavy rain', 'household waste management', 'housing improvements', 'humidity', 'immunisation', 'infectious disease', 'insect repellents', 'insect traps', 'insecticide-treated nets', 'Japanese encephalitis', 'larval habitats', 'larvicides', 'lime', 'living environment', 'long clothing', 'long-lasting insecticide-treated nets', 'malaria', 'mosquito larvae', 'mosquito traps', 'mosquitoes', 'mould development water', 'mud', 'natural repellents', 'octenol', 'pesticide', 'primary prevention', 'protective behaviour', 'protective clothing', 'rodents', 'rubber plantations', 'sand flies', 'solid waste management', 'sticky traps', 'sunburns', 'temperature', 'tick-borne diseases', 'tick-borne encephalitis', 'ticks', 'top-down approach', 'tropical climates', 'ultraviolet irradiation', 'vaccination', 'vaccine complacency', 'vaccine hesitancy', 'VBDs', 'vector attraction', 'vector biting', 'vector contamination', 'vector exposure risk', 'vector human movement', 'vector landing preference', 'vector light clothing', 'vector net', 'vector traps', 'vectors', 'wall cracks', 'waste management', 'waste mismanagement', 'water storage', 'water supply', 'West Nile virus', 'window screening', 'yellow fever', 'Zika'.

#### **References**


disability for 354 Diseases and Injuries for 195 countries and territories, 1990-2017: A systematic analysis for the Global Burden of Disease Study 2017. *Lancet* **2018**, *392*, 1859–1922. [CrossRef]


© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

International Journal of *Environmental Research and Public Health*

### *Commentary* **The Asia Pacific Disaster Mental Health Network: Setting a Mental Health Agenda for the Region**

**Elizabeth A. Newnham 1,2,\*, Peta L. Dzidic <sup>1</sup> , Enrique L.P. Mergelsberg <sup>1</sup> , Bhushan Guragain <sup>3</sup> , Emily Ying Yang Chan 2,4,5 , Yoshiharu Kim <sup>6</sup> , Jennifer Leaning <sup>2</sup> , Ryoma Kayano <sup>7</sup> , Michael Wright <sup>8</sup> , Lalindra Kaththiriarachchi <sup>9</sup> , Hiroshi Kato <sup>10</sup>, Tomoko Osawa <sup>10</sup> and Lisa Gibbs <sup>11</sup>**


Received: 30 July 2020; Accepted: 21 August 2020; Published: 24 August 2020

**Abstract:** Addressing the psychological mechanisms and structural inequalities that underpin mental health issues is critical to recovery following disasters and pandemics. The Asia Pacific Disaster Mental Health Network was established in June 2020 in response to the current disaster climate and to foster advancements in disaster-oriented mental health research, practice and policy across the region. Supported by the World Health Organization (WHO) Thematic Platform for Health Emergency and Disaster Risk Management (Health EDRM), the network brings together leading disaster psychiatry, psychology and public health experts. Our aim is to advance policy, research and targeted translation of the evidence so that communities are better informed in preparation and response to disasters, pandemics and mass trauma. The first meetings of the network resulted in the development of a regional disaster mental health agenda focused on the current context, with five priority areas: (1) Strengthening community engagement and the integration of diverse perspectives in planning, implementing and evaluating mental health and psychosocial response in disasters; (2) Supporting and assessing the capacity of mental health systems to respond to disasters; (3) Optimising emerging technologies in mental healthcare; (4) Understanding and responding appropriately to addressing the mental health impacts of climate change; (5) Prioritising mental health and psychosocial support for high-risk groups. Consideration of these priority areas in future research, practice and policy will support nuanced and effective psychosocial initiatives for disaster-affected populations within the Asia Pacific region.

**Keywords:** disaster; mental health; psychosocial; Asia Pacific; COVID-19; Health EDRM

#### **1. Introduction**

Disasters create an environment of disruption, trauma and grief, with potential for sustained mental health impacts. Heightened stress during pandemics and disasters can impair individual wellbeing (with effects on psychological health and sleep), cognitive function (memory, concentration and executive function), high-risk behaviours (alcohol and substance use, increased rates of domestic violence) and behavioural outcomes (such as compliance or disregard for public health orders) [1,2]. The mental health effects of disasters result not only from trauma exposure but may also arise from the implementation of public health response strategies such as quarantine, physical and social distancing or evacuation [3,4]. Economic insecurity, unemployment or underemployment, school closures and the shutdown of regional infrastructure can have devastating effects for population mental health. In addition, concerns regarding safety measures and sufficient supply of personal protective equipment can contribute to psychological distress [4,5]. Moreover, while many people demonstrate tremendous resilience during emergencies and in the immediate aftermath [6], the long-term psychological effects of disasters and pandemics are often debilitating [7,8].

The Asia Pacific region records the highest frequency of hazards and greatest number of people affected by disasters annually [9,10]. The immense psychological consequences are particularly concerning in nations with developing mental health systems and services [11]. A significant proportion of mental health need is unmet, and this has substantial effects on the social ecology and economic stability of affected communities. As climate change, growing urbanization, population density and animal–human viral transmission generate increasingly severe impacts of hazards and health emergencies, attention to mental health will be critical.

In response, the Asia Pacific Disaster Mental Health Network was established in June 2020 to create a collaborative platform for rigorous research, evidence-based practice and tailored policy designed to support improvements in mental health among disaster-affected communities. The network is supported by the World Health Organization (WHO) Thematic Platform for Health Emergency and Disaster Risk Management (Health EDRM) and its research network [12]. At its formation, the network represented seven Asian-Pacific nations, and it is growing. The network's membership represents practitioners and scholars with broad interdisciplinary expertise in the fields of humanitarian response, psychiatry, psychology, public health, disaster risk reduction, human rights and security, indigenous mental health, emergency and mental health services and climate change action. In its first meetings, the network sought to determine an agenda for the advancement of disaster mental health evidence and practice within the region that would inform the design of future collaborative research, policy development and delivery of services.

#### **2. Materials and Methods**

The Asia Pacific Disaster Mental Health Network comprises fifteen representatives (57% female), selected for their expertise in responding to health emergencies and natural disasters, and work with trauma-affected communities within the region. The network is open to all Asia Pacific nations and currently includes representatives from Australia, Japan, China, Nepal, Sri Lanka, India and the USA. The purpose of the network's early meetings was to establish a collaborative platform for future research and policy development and set overarching priorities in line with the goals of the WHO Thematic Platform for Health EDRM and its research network. Monthly meetings are conducted via videoconference. The selection of research priorities was conducted through open consultation within the network. An iterative-generative reflective method was adopted, whereby experiential knowledge of network members gleaned through their immersion with affected communities allowed for iterative debate [13]. As reflective-generative practitioners, each network member provided community-relevant insights as to potential priority areas. An iterative and deliberative discussion occurred across two meetings, held in June and July 2020. A list of key priorities identified by the group as central to mental health practice, research and policy within the region was generated. Thirteen representatives attended the first meeting and ten representatives attended the second. Impromptu

responses on the priority list were systematically collated; the list was adapted following a second round of discussion and then circulated among the representatives for feedback. An additional round of input from representatives on the priorities and supporting evidence was incorporated into the write-up. All network members contributed to and provided feedback on the final priority list.

#### **3. Results**

#### *3.1. Key Priorities for Disaster Mental Health*

Large-scale climate disasters, severe wildfires and the COVID-19 pandemic have drawn renewed global attention to disaster response this year. The COVID-19 pandemic has amplified the structural injustices of race, faith, gender, age, migration and economic inequality within and across societies, with significant implications for mental health (e.g., [14–18]). Addressing structural disadvantage and inequality is vital, and without attention to these issues, many mental health difficulties during and after disasters may not be amenable to psychological treatment. Mental health practitioners and researchers play a vital role in highlighting injustice, community needs and the role of economic empowerment in supporting mental health. It is critical that psychological first aid and evidence-based interventions suitable for response to mass trauma events are implemented to support individual, family and community level improvements in mental health, recognizing that psychological distress occurs on a continuum and multi-level strategies are required [19,20]. First, broad public health strategies such as psychological first aid, mental health education, family reunification and child-friendly spaces, should be implemented at the community level to address general distress following an event; second, delivery of low-intensity programs to assist those dealing with sustained distress and psychological difficulties; third, clinical treatment provided for those with diagnosable conditions [19,21,22]. However, the effectiveness of treatments will vary due to the sociocultural context in which they are delivered [23]. A nuanced, solution-based approach will support significant advancements in this field. In line with this point, we identified the following priorities for a regional disaster mental health agenda.

#### *3.2. Strengthening Community Engagement and the Integration of Diverse Perspectives in Planning, Implementing and Evaluating Mental Health Response*

Reinforcing local social networks, social solidarity and engagement with community groups in responding to disasters and other mass trauma events will enhance psychosocial outcomes [24–26]. Community-driven responses are led by the community and may invite external agency partnership, whereas community-supported responses are facilitated by an external agency with the endorsement of the community [27]. Central to both approaches is that the community be recognised as valued authorities on their own lived experience. Listening to and incorporating diverse knowledges and multiple perspectives are essential to ensure that mental health services and psychosocial initiatives designed for any community are accessible, acceptable, culturally secure and developmentally appropriate [28] and that intervention models, disaster risk reduction strategies and mental health policy are designed and delivered in ways that are meaningful and relevant [29]. Furthermore, emerging evidence suggests that mutual reinforcement of public health messages and actions among community members has positive implications for health-related behaviors and compliance with public health directives during pandemics [30]. Restoring connections to the natural environment will have additional mental health benefits [31]. Working within existing community social structures and across a broad cross section of the community—with Elders, youth, local faith leaders and community groups—helps to establish respectful and collaborative relationships. Measures to access broad input and community guidance will result in treatment models, services and strategies that meet the diversity of mental health needs [32–34].

#### *3.3. Supporting the Capacity of Mental Health Systems to Respond to Disasters*

Disasters create multiple waves of healthcare need. Early response requires a focus on physical injuries, bereavement and re-establishing critical infrastructure for survival [35]. Establishing conditions for safe recovery will lessen distress for a vast majority of the population [19,36]. Mental illness tends to emerge in a second surge of health need, often months and years following the initial emergency [37]. However, the COVID-19 pandemic highlighted mental health needs that required immediate support during this crisis [2,5]. Health systems need to be prepared to address the short- and long-term mental health needs that arise within disaster-affected settings. Disaster response must begin with a diverse and well-supported workforce and include ensuring that workers are trained and supported with ongoing supervision and further training in psychological care for traumatized people—including how to cope with the added overlay of mass trauma impacts. Where disasters are more likely to affect remote areas, infrastructure to support regional health workers and digital health platforms will be important [38]. Lessons learned from the COVID-19 pandemic have already sparked significant expansion of mental health systems in many nations, including in China, where an increased workforce was engaged in order to address the psychological distress and grief arising from the pandemic in Wuhan [39,40]. Similar initiatives have been developed in other parts of the Asia Pacific region, including increased mental health budget funding in Australia [41], improved and expanded mental health helpline services in Nepal [42] and increased in-person and remote counselling services in Japan [43]. The challenge will be an ongoing commitment to the long-term sustainability of services to address the growing incidence of disaster-related trauma and grief within our region and ensuring that first responders, medical, nursing and allied health staff are well supported [44,45]. Mental health services research is both urgent and critical to evaluate the efficacy of models for rapid upskilling and ongoing support of the healthcare workforce, and to design and implement the appropriate expansion of access; acceptability and cultural security of services; effectiveness of trauma-informed treatments in low resource settings and community-based strategies to prevent the escalation of psychological distress.

#### *3.4. Optimising the Integration of Digital Platforms in Mental Healthcare to Support Access and Acceptability of Care*

The COVID-19 pandemic has fast-tracked the development and widespread adoption of technology in mental healthcare in many settings. Digital mental health services include treatment sessions conducted via video call, telephone helplines, clinical text messaging services, digital health applications and platforms, online streaming and therapy services and mass dissemination of mental health resources on social media [39,46]. Enabling the safe continuation of mental health services during lockdown or physical distancing, tele-mental health services have been widely implemented in many nations including China, Japan, Australia and New Zealand and have received additional funding for development and dissemination globally [39,47,48]. New and adapted technologies have the potential to transform the delivery of mental healthcare, as care can be tailored on a personal level, provided anywhere, be perceived as less stigmatizing and can empower people to take a more active role in their own healthcare decisions [49–51]. Although many settings within the Asia Pacific region still lack reliable access to electricity, internet and phone coverage, all limiting the use of digital mental healthcare [52]; the growing ubiquity of smartphone use has enabled rapid communication of disaster and mental health messaging, reaching populations less likely to be engaged with mainstream health services, such as international migrant workers [53]. Technology may also enable people to maintain the social connections that are critical to mental health and wellbeing outcomes. However, the digitalization of mental healthcare has possible negative implications. Reliance on technology can lead to social disengagement, and there are increasing concerns about the potential for misinformation with unregulated online information, as well as technical issues, unreliable internet access, low digital competences of health providers and clients, safety of data handling and perceived loss of therapeutic relationships [49,54]. It is thus essential to now identify which services and strategies have proven to

be protective and efficient in improving mental health outcomes in the context of COVID-19 so as to design approaches that will have relevance beyond this pandemic.

#### *3.5. Addressing the Mental Health Impacts of Climate Change*

Climate change has increased the frequency and severity of natural disasters in the Asia Pacific region, with resulting risks for mental health problems [55–57]. The relationship between climate change and mental health impacts can be direct, by experiencing trauma caused by climate hazards, or indirect, through resulting physical health consequences, increased economic vulnerability and detrimental effects on community cohesion [55,56]. Further indirect effects from climate change may arise through a reduced sense of hope and self- and community-efficacy, identified as essential elements in recovery from mass trauma events such as natural disasters [58]. Within the Asia Pacific region, Indigenous communities and those dependent on agricultural production or coastal fishing experience disproportionate adverse impacts of climate change [55,56,59]. However, the effects are broadening—the Australian 2020 wildfires demonstrated widespread ecological and economic damage—with substantial psychological effects [38,60]. Similarly, climate change has had significant effects on mental health in the Pacific Island of Tuvalu [59], where the changing climate threatens irreversible changes to the way of life [61]. Climate-related hazards (i.e., tropical cyclones and increasing ocean temperatures) combined with urbanization, land shortages, overcrowding, limitations in infrastructure, services and poor governance have resulted in high levels of stress, anxiety and depressive symptoms among the Tuvaluan population [59]. Similar issues accompanied the impact of 2013 super typhoon Haiyan in the Philippines [62]. Direct and indirect mental health consequences from climate change are current and understudied [57]. This gap in our knowledge requires our immediate and collective attention in order to bring about an efficient, effective and holistic approach to mitigating the inequity of climate change impacts on mental health, led by local experts. This effort must become a central focus of disaster risk reduction in the coming decades.

#### *3.6. Prioritising Mental Health and Psychosocial Support for High-Risk Groups*

High-risk groups, including those disadvantaged or discriminated against due to the characteristics and intersection of age, gender, sexuality, ethnicity, faith, ability, migration and economic status, may be at greater risk of mental health difficulties during and after disasters [63,64]. In addition, those affected by domestic violence, chronic mental illness, forced displacement, job loss or homelessness will require tailored solutions [65]. The damage to the natural environment from climatic hazards may also generate an additional level of pain and loss for First Nations people with historical and cultural connections to the land [66], as well as for many others who find solace and peace in the persistence of nature. Failure to recognize historical circumstances and cultural values can result in interventions reinforcing existing patterns of disadvantage and prejudice [67]. Risk factors are dynamic, and an individual's level of vulnerability during disasters is dependent on a range of contextual factors, resulting in resilience at times and vulnerability at others [63]. For example, there is a complex relationship between disaster exposure and suicide risk, with increased risk associated with large-scale disaster impacts and length of time following exposure [68]. Specific groups, such as working-age men and older women, and factors including limited social connections, economic insecurity, living in temporary housing and pre-existing or new mental health conditions may increase suicide risk following disasters [68,69]. COVID-19 has demonstrated the potential for mental health risks to emerge as a result of both disaster-related trauma and the public health safety measures implemented to reduce transmission. This has been highlighted in Nepal, where widespread job loss and economic insecurity arising from government lockdown measures during the pandemic has resulted in a tragic spike in suicides, with 1200 deaths reported due to suicide during the 74 day lockdown [70,71]. Established mental health services in Nepal are working to provide helpline services through telephone and social media and further improve the capacity of community psychosocial workers to respond to individuals experiencing psychological distress [42]. Thus, effective services working within high-risk communities must be supported to continue and,

where needed, expand their services during and after disasters. As we see an increasingly sophisticated global response to disaster risk reduction, inclusion and support for high-risk groups will be vital for effective mental healthcare.

#### **4. Conclusions**

The Asia Pacific Disaster Mental Health Network was established to foster advancements and coordination of psychosocial supports and mental health service delivery, policy development and collaborative research in the region. In line with the priorities of the WHO Thematic Platform for Health EDRM and its research network [12,72], the Asia Pacific Network aims to contribute to improvements in mental healthcare and psychosocial support through rigorous research and policy. Within the context of the COVID-19 pandemic and recent climatic hazards, the network set an agenda that prioritises strengthened community engagement, improved capacity for mental health and community services to respond to the needs of disaster-affected populations, integrating emerging technologies, addressing the impacts of climate change and supporting high-risk groups. Through multidisciplinary regional partnerships, the network will contribute to effective and culturally secure intervention design and delivery, translation of evidence to support community preparedness and response, and the collection of high-quality data to inform knowledge, policy and practice specific to the Asia Pacific region and relevant across the globe.

**Author Contributions:** Conceptualization, E.A.N., E.Y.Y.C., P.L.D., L.G.; B.G., Y.K., J.L., L.K., H.K., writing—original draft preparation, E.A.N., E.L.P.M., P.L.D.; writing—review and editing, E.A.N., P.L.D., E.L.P.M., B.G., E.Y.Y.C., Y.K., J.L., R.K., M.W., L.K., H.K., T.O., L.G., funding acquisition, E.A.N., Y.K., H.K., L.G., P.L.D., J.L. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was supported by the World Health Organization Centre for Health Development (WHO Kobe Centre—WKC: K19007).

**Conflicts of Interest:** The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; or in the decision to publish the results.

#### **References**


© 2020 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (http://creativecommons.org/licenses/by/4.0/).

International Journal of *Environmental Research and Public Health*

### *Article* **Long-Term Impact of Disasters on the Public Health System: A Multi-Case Analysis**

#### **Nina Lorenzoni 1,\*, Verena Stühlinger <sup>1</sup> , Harald Stummer 1,2 and Margit Raich <sup>1</sup>**


Received: 31 July 2020; Accepted: 25 August 2020; Published: 27 August 2020

**Abstract:** As past events have shown, disasters can have a tremendous impact on the affected population's health. However, research regarding the long-term impact on a systems level perspective is still scarce. In this multi-case study, we analyzed and compared the long-term impacts on the public health system of five disasters which took place in Europe: avalanche (Austria), terror attack (Spain), airplane crash (Luxembourg), cable-car tunnel fire (Austria), and a flood in Central Europe. We used a mixed-methods approach consisting of a document analysis and interviews with key stakeholders, to examine the various long-term impacts each of the disasters had on health-system performance, as well as on security and health protection. The results show manifold changes undertaken in the fields of psychosocial support, infrastructure, and contingency and preparedness planning. The holistic approach of this study shows the importance of analyzing long-term impacts from the perspective of the type (e.g., disasters associated with natural hazards) and characteristic (e.g., duration and extent) of a disaster, as well as the regional context where a disaster took place. However, the identified recurring themes demonstrate the opportunity of learning from case studies in order to customize the lessons and apply them to the own-disaster-management setting.

**Keywords:** long-term impact; disaster; public health; case study; disaster management; multi-case analysis; Europe

#### **1. Introduction**

The impact of disasters on the health of the people affected and on the public health system can be far-reaching and long lasting. However, studies examining these long-term influences months or even years (mid- to long-term periods) after the event are rare, although their importance is repeatedly underlined [1–3]. Nomura et al. (2016) emphasize the need for a better understanding of long-term health impacts of disasters, in order to be able to set measures and guide actions (before, during, and after the event) to reduce health risks [4]. Moreover, the Sendai Framework for Disaster Risk Reduction points out, in Priority 4 ("Enhancing disaster preparedness for effective response and to 'Build Back Better' in recovery, rehabilitation and reconstruction"), that the importance of post-disaster reviews as they offer a valuable source for learning lessons for the public health system and consequently raise disaster preparedness [5]. Such a systematic review of challenges, dysfunctions, and, consequently, changes, as well as impacts, would be essential to improve preparedness for future events [6]. A better understanding of the impacts of disasters on the public health system and which determinants influence these impacts would be an important contribution to reduce disaster risk. The Sendai Framework advocates for the collection and analysis of the impacts of disasters

and consequently the dissemination of the resulting lessons learned across all relevant stakeholders. Researchers are asked for their contributions, sharing their evaluations with practitioners, government officials, and policy makers, to support decision-making and the implementation of good practices on local, regional, and national level [5]. Especially studies on mid- to long-term periods, i.e., months to years after the event, would be needed. A long-term study is difficult, since data are hardly available in a consistent form, and the quality of these data also varies greatly depending on jurisdiction and time frame [7]. Furthermore, the literature review provided no recommendations for the definition of "long-term". The studies differed in the use of time spans, but no discussion was found as to why the authors used specific time spans.

Investigations on the long-term impact of disasters on the health of people affected cover a wide field of research topics (e.g., disaster impacts such as economic losses of the affected population or effects on mental and/or physical health; or focus on specific target groups such as children or the elderly [8–13]). Research on economic and human loss or damage tends to focus on short-term effects, while longer-term effects are difficult to track, and public attention often shifts on the next disaster event [4,14]. Murthy et al. [15] analyzed the progress made in public health preparedness within the US after 9/11, until 2016, by using self-reports from "Centers for Disease Control and Prevention" and reports of congress funding. Fitter et al. [16] examined the recovery of the public health system of Haiti following the 2010 earthquake and cholera outbreak. By using a framework consisting of 10 essential public health services, their research demonstrated progress and improvement made regarding the public health system seven years after the disaster. Our literature review revealed that the research on long-term impact mainly focuses on individual or population health, but less on the systems perspective.

The purpose of this study was to investigate the various long-term impacts on the public health system of five different disasters occurring in Europe, from 1999 to 2013. The chosen holistic research approach allowed the representation of the complexity, specific circumstances, and undertaken measures for each disaster in detail. This process allowed us to identify undertaken adaptions and changes that result in longer-term impacts.

#### **2. Materials and Methods**

#### *2.1. Design*

We decided to use a case study approach, as it allowed for us to capture both the diversity in disaster management and the complexity of specific circumstances. An extensive collection of rich data makes an embedded multiple-case analysis and presentation possible. The selection of multiple cases resulted from replication logic [17]. We built upon contrasting cases [18], since a variety of contexts, circumstantial factors, and their impact on each case could offer a more complete picture of the longer-term impact of disasters on public health. Since the study was conducted within the EU project PsyCris (PSYchosocial support in CRISis Management), the selected case studies all took place in the European Union. The project consortium decided to use disasters, which are relevant for many EU countries. In addition to the high probability, further criteria for the decision of which cases to use were the scale of the disaster, complexity and number of institutions involved, long-term consequences, and data availability. Moreover, the analysis should include disasters caused by natural hazards, as well as human-caused disasters (e.g., technological or mass-violence).

We decided to use a mixed-method approach consisting of document analysis and expert interviews. As we could not identify a standardized assessment tool to investigate the long-term impact of disasters to the public health system in the literature, we decided to focus on impact models [19–22] that serve as a foundation for the development of the interview guide and the category grid used for the document analysis.

The main categories in the grid were as follows:


For our analysis, we reviewed key documents relevant to the disaster-management process and the long-term impact of chosen disasters. The reviewed documents included governmental and organizational reports, legislative documents, journal articles, books, letters, TV documentaries, brochures, and newspaper articles.

As a reconstruction of the complex disaster management process is not possible with existing public documents only, we also conducted expert interviews.

The interview partners all played key roles in the management of the respective disaster. When selecting the interview partners, care was taken to obtain a picture as broad and holistic as possible of the most diverse organizations and units. The professional fields of the interview partners included fire department, emergency psychologists, politicians, armed forces, police, physicians, red cross, forensic, and priests. The average interview duration was 60 min. Table 1 shows the number of interviewees per case study.

**Table 1.** Overview of number of interviewees per case study.


The main themes of the interviews were as follows:


For the interview analysis, we used GABEK® (Holistic Processing of Complexity) (Josef Zelger, Innsbruck, Austria), a qualitative method of knowledge organization developed by Josef Zelger, supporting analysis of unstructured texts on the basis of the theory of "linguistic gestalten". The method helps to handle individual thoughts and attitudes and present them in a structured and systematic way. GABEK allows for the transparent organization of knowledge and captures the holistic representation of complex social situations, like disasters, from the perspective of those affected [23]. The analysis was conducted with the corresponding software application GABEK–WinRelan, which combines qualitative content analysis (e.g., coding of keywords, evaluations, or causal relationships) and quantitative measures (e.g., frequencies of keywords and relations) and therefore offers a profound understanding of data, their interlinkages, and their weight [24].

#### *2.2. The Case Studies*

#### 2.2.1. Avalanche, Austria, 1999

On 23 February 1999, shortly after 4:00 p.m., an avalanche buried around 100 people in the village of Galtuer (Austria). Ongoing snowfall in the previous days triggered high avalanche risk in the entire federal state of Tyrol. The Paznaun valley, in which Galtuer is located, was already cut off from the outside world before the avalanche, due to the snow conditions. The avalanche hit areas in the village center, which had previously been considered safe from avalanches. Due to the bad weather conditions, no rescue teams were able to reach Galtuer for assistance. The people affected were left to their own devices to rescue the buried victims. Only on the 24 February did the first helicopters could take off and bring the injured from the village to the surrounding hospitals. The Austrian government asked NATO (North Atlantic Treaty Organisation) and neighboring countries for support with additional helicopters. On 25 February, aerial evacuation of the whole valley began with 37 helicopters from Austria, Germany, Switzerland, France, and the US. Thirty-one people died in the avalanche, and 35 were injured (11 of them severely).

#### 2.2.2. Cable-Car Accident, Austria, 2000

In Kaprun (Salzburg), on 11 November 2000, in the tunnel of the cable-car, a fire occurred in the ascending train. The glacier around the Kitzsteinhorn is a popular all-the-year skiing region. On 11 November, the train started at 8:57 in the morning, with 161 passengers aboard. At 9:02 a.m., the first smoke formed. At 9:05 a.m., the train stopped after 600 m in the tunnel; the total distance from the entrance to the exit was 3.8 km. Passengers broke the windows. Smoke rose from the train at the back. The operator saw the fire and gave alarm. Twelve passengers walked with their ski boots downstairs and survived. The other 149 passengers and the operator were in the tunnel. At 9:35 a.m., because of the danger of explosion, the outfall of electricity, and the formation of toxic smoke, the fire brigade had to stop the rescue mission. The mountain station had to be evacuated. At 10:16 a.m., a rescue team started to enter the tunnel. Three people died at the mountain station because of exhaust-gas poisoning. One person survived. At 12:00 p.m., a second team of the fire brigade entered the tunnel. In total, 155 passengers died on 11th of November.

#### 2.2.3. Airplane Crash, Luxembourg, 2002

On Wednesday, 6 November 2002, an airplane of the national air company crashed during the approach to Luxembourg airport. At 10:05 a.m., the airplane reported difficulties during the landing procedure, and 42 s later, the plane disappeared from the radar. The reasons for the airplane crash are based on a mix of technical problems, human errors, and bad weather conditions. At 10:06 a.m., the plane ploughed into a field, and one side of the plane was ripped open. Six passengers were catapulted out. After the crash, the aviation fuel caught fire, and the plane began to burn. Both pilots were trapped in the wreckage. After fire brigades had extinguished the fire, the rescue of the trapped passengers began. The only survivors had been sitting in the front of the aircraft, which had been torn off during the crash, leaving the nose cone embedded in the ground. Twenty people died and two survived severely injured.

#### 2.2.4. Terror Attack, Spain, 2004

On 11 March 2004, ten explosions occurred aboard four commuter trains in the city of Madrid. It was later reported that thirteen improvised explosive devices had been hidden on the trains. The explosions happened during rush hour, on a normal workday, between 7:37 a.m. and 7:39 a.m. At 7:37 a.m., three bombs exploded on train number 21,431, on track two, inside Atocha station, the main capital railway station. At 7:38 a.m., two bombs exploded in train number 21,435, at El Pozo del Tío Raimundo Station. One bomb exploded on train number 21,713, at Santa Eugenia Station, at 7:38 a.m. Then, at 7:39 a.m., four bombs exploded on train number 17,305, on Calle Téllez, approximately 500 m

from Atocha station. The bombing was the deadliest terror attack in the history of Spain: 191 people died, and more than 2000 were injured.

#### 2.2.5. Flood, Austria/Germany, 2013

Due to exceptionally heavy rainfalls in early June 2013, extreme flooding of the major river systems occurred throughout Central Europe (particularly Switzerland, Germany, Austria, Czech Republic, Slovakia Hungary, and Serbia). Thousands of people needed to be evacuated from their houses. Twice as much rainfall as average during the month in Austria resulted in the soil becoming saturated. Although forecasts predicted a high rise of water levels, the prognoses have been too low. The water level exceeded the levels seen during the disastrous "once in a century" Central European floods of 2002 in many areas. In Austria, six people died in the flood, and thousands of people had to be evacuated. The infrastructural damages were extensive; railway lines, roads, bridges, and houses were damaged severely.

#### **3. Results**

The following section describes the long-term effects of the disasters on the public health system. Figure 1 gives an overview of the framework of analysis. We decided to categorize the identified impact factors into the categories health system performance, and security and health protection. The increased demand during and after a disaster has a direct effect on the health system performance, i.e., the delivering of services, the creation of resources, the stewardship, and, finally, the related financing [25]. Security and health protection refers to post-disaster efforts aiming at optimizing leadership and governance, contingency and preparedness planning, infrastructure, and training, or may lead to an increase in security research funding activities, as well as information and communication activities. The information stated in this section was extracted from the stated sources, as well as from the expert interviews.

**Figure 1.** Overview of the aggregated long-term impacts of the analyzed disasters on the public health system (source: the authors).

#### *3.1. Long-Term Impact on Health System Performance*

#### 3.1.1. Mental Health and Demand for Healthcare Services

For an adequate public health policy, different dimensions have to be taken into account to optimize the offer for healthcare services, including mental health. The identification and evaluation of how many people are affected by a disaster and develop adjustment disorders because of distress seems to be a challenge for health service providers. For the chosen disasters, statistics about the health status of people affected and derived demand for healthcare services are rare.

#### Distinction of Target Groups

For an analysis of the demand for healthcare services, a distinction of target groups has to be undertaken. Standardized programs for psychosocial and psychological support are not sufficient, as one crisis manager from Luxembourg stated. The demand for psychosocial and psychological support, but also for medical and physical treatments, mainly differs depending on who is affected. The target groups have to be defined carefully, to guarantee adequate support. A study conducted by the Complutense University of Madrid, with 526 victims of the bombings in Madrid, shows that, ten years later, almost 30% of them presented symptoms of anxiety, depression, and PTSD (posttraumatic stress disorder). Ten years later, nearly 200 victims still received psychological treatment [26]. Moreover, a care program has been launched for people with hearing disabilities after the terror attack in Madrid. The explosions and the effects of the blast caused hearing impairments resulting in total deafness in many victims of these attacks. The General Directorate of Support for Victims of Terrorism taught sign language to victims of these attacks and to their families to help them recover communication within their families [27].

#### Psychosocial Support for Specific Target Groups

An important lesson that has been identified in all cases is the demand for performance-linked psychosocial support. Target-oriented healthcare delivery has to consider the different needs of people affected (e.g., survivors, families, witnesses, and volunteers). Standardization in the provision of services is seen critically by most of the interview partners. One interview partner from Luxembourg explained: "The pilot survived, there was certainly a different need, with the family, than with those where people died; I also think that people had different approaches to dealing with the accident . . . To accommodate these different "points of view", that's extremely difficult. It is often the case that you think you have a solution to a problem, but actually you have to realize in retrospect that you need many solutions for many types of people . . . and you also have to give people the freedom to deal with the problem in their own way which is enormously difficult". Because of the fact that nearly all people in the airplane died, the psychosocial support for families played the most important role. The challenge for the disaster management team was the information management to the relatives of the victims, the organization of their arrivals and accommodation, and how to offer psychosocial support.

Compared to our analyzed disasters associated with natural hazards (avalanche and flood), only a small number of passengers survived in the case of the airplane crash or cable-car accident. The main target group for psychosocial support was the relatives who had to arrive from longer distance or respectively from abroad. Locals and tourists have been identified as important relevant target groups for psychosocial and psychological support after the avalanche. Results have shown that the cohesiveness of the community in Galtuer (=locals) had an essential impact on the demand for psychosocial and psychological support.

The terror attack in Spain, with its destructive power for humans and infrastructure, caused a large number of deaths and people injured. Because of the characteristic of the disaster that occurred in this urban area, more walk-in volunteers entered the scene during the acute phase of the disaster, for help. This has an effect on the demand of psychosocial and psychological support in order to consider a large number of walk-in volunteers.

#### People Affected Who Originate from Abroad

Additionally, in some of the analyzed disasters, no information about psychosocial and psychological support, as well as medical or physical treatment of people who originate from other countries, was given. Especially in the case of the airplane crash, the avalanche and the cable-car accident many victims came from abroad. They were tourists or traveling persons. Survivors and relatives stayed for a certain period time in the country of the event. This leads to the inability to diagnose disorders and reactions, especially of those who were not directly affected by the disaster since

some diagnoses cannot be identified immediately after the event, but occur later on (e.g., flashbacks and posttraumatic stress reaction). About 100 of the evacuated tourists in Galtuer were traumatized seriously, and some eventually were confronted with posttraumatic stress disorders later on [28,29].

#### Refusal of Psychosocial or Psychological Support

Individuals or a community may refuse psychosocial or psychological support. An interview partner involved in psychosocial support after the terror attack in Spain explained the following: "I've learned not to take it personally but as a normal reaction to emotional trauma. Sometimes we had to work with volunteers who were affected by the comments of relatives, like "if you're not going to return my son to me I don't know what you're doing here . . . Emotional trauma can cause aggressive reactions and that's normal". Some families who lost relatives during the airplane crash in Luxembourg refused psychosocial support. One survivor of the avalanche was buried for several hours. He preferred to talk with his family to cope with the disaster. It was reported that only one woman with adjustment disorders consulted a psychologist after the avalanche disaster in Galtuer [30].

A community may also refuse psycho0social and psychological support. In Galtuer, locals dealt intensively with the event and experienced common grief. In the first year, they talked among themselves about the disaster and about their experiences, until they felt some relief from their burden. From the cultural point of view, the locals preferred to talk with family, relatives, or friends, but not with outsiders. Locals also had negative associations with psychologists because of two reasons. First, they experienced an insufficient management of psychosocial support directly after the event. Second, a big distance from and distrust of mental healthcare services were observed. The trust into the community was more helpful for the locals to recreate a meaningful life, as compared to professional organized support.

#### Risk Perceptions

Results gave interesting insights in the awareness of possible causes of risks. People living in endangered zones may perceive possible causes of risks induced by predictable disasters (e.g., risk of a flood or avalanche) as neutral compared to events that arise abruptly without any advanced warning (e.g., airplane crash or terror attack). The resistance of people living in an endangered zone can be influenced of their motivation and individual risk perception living in such an area. This conscious decision has an impact on the mental and physical health in the context of a disaster. The persons may dispose of a higher acceptance of the forces of nature, given the fact that the inhabitants of Galtuer do not evaluate the avalanches negatively [30]. Moreover, in the investigated flood case, in an area that is prone to flood, people are used to dealing with the flood. One interview partner explained the following: "The people down there, they can handle the water... they have their own strategies, they can handle it. And the humility and the acceptance with which they take the flood there, that's fascinating for me. I couldn't imagine that every 10 years I clean out my house, clear out the silt, pump out the water. For them, it's just the water, it's as simple as that". Moreover, most people had family or friends close by with whom they could stay during evacuation, when needed. These two factors are assumed to be a huge reduction of stress for the effected people.

#### Legal Proceedings

A relevant aspect in dealing with disasters is the way of legal response, especially in the case of organizational failures. One important impact on health was identified in the context of legal proceedings after the cable-car accident. Many family members of the victims complained about the lack of empathy during the legal proceedings. The trial was experienced as unfair by many families, leading to a lot of anger and disappointment. The need for clarity and mental processing was not fulfilled [31,32]. During the trial, a self-help initiative was founded which fought for years for resumption of the legal process [33]. Moreover, after the airplane crash, the legal proceedings lasted over years. One interview partner said the following: "[These] court proceedings have simply taken

far too long, and that is disastrous for the people who are affected, who simply want decisions and that they can finish their mourning at some point. It has simply taken far too long".

#### 3.1.2. Structure and Organization of Psychosocial Support

Different longer-term impacts in the structure and organization of psychosocial support have been identified. In one case, the formation of a new organization was induced; in other cases, major or smaller organizational improvements were undertaken. After the avalanche, the disorganization of psychosocial support caused enormous costs for the life assurances, public authorities, and governments. Good management of psychosocial and psychological support, distinct functional attributions, structures, and responsibilities lead to the reduction of conflicts between organizations and institutions involved in the management of a disaster. After the disaster, a discussion was started with regard to financial responsibilities of long-term mental treatments. In the context of psychosocial support, the responsibilities and financing structures for further events were revised.

#### Formation of New Organizations and Units

A completely new organization for psychosocial support was formed after the Galtuer avalanche. The management of psychosocial support was not organized by one central responsible body. Competition between psychologists and psychotherapists was the source of many conflicts. Additionally, journalists disguised themselves as psychologists and psychotherapists to access the disaster scene. In the years following the disaster, the Austrian Red Cross established the crisis intervention team (KIT—Kriseninterventionsteam). Moreover, it was decided to provide uniforms for the emergency psychologists as they were not associated as professionals by the surviving dependents. An interview partner who was in Galtuer after the avalanche explained the following: "Today it is taken for granted that already the emergency doctor asks if you want a crisis intervention team. But it was different in the past. We didn't wear a uniform, that was a big problem. And nobody knew the service. The care of uninjured survivors simply didn't exist". Although Kaprun, where the cable-car accident happened, is located in Salzburg, in the neighboring province of Tyrol, no structure for psychosocial support existed there at the time of the disaster. However, the tunnel fire was seen as trigger event to also establish a crisis intervention team in Salzburg. In the context of psychosocial support, the extent of the event has led to the formation of a special psychological care unit which takes over the organization and management of psychosocial support. Because of the huge dimension of the terror attack, a systemized supply of psychosocial support for rescue workers in their organizations was established. The awareness for the necessity of psychosocial support for people affected (victims, relatives, and also rescue teams) has grown after all of the analyzed disasters.

#### *3.2. Long-Term Impact on Security and Health Protection*

#### 3.2.1. Contingency and Preparedness Planning

#### Plans and Checklists

An important long-term impact that was identified in all analyzed disasters is the update of existing emergency, civil protection, and national rescue plans and the development or adaption of checklists. Protocols for different contexts have been developed (e.g., intervention protocols for psychological intervention), as well protocols for recruiting people to participate in emergency volunteer management and psychological interventions. The emergency plans and the interfaces between the participating organizations were modified to improve the cooperation and coordination between security teams, armed forces, medical teams (doctors and nurses) in hospitals, social workers, and psychologists. After the airplane crash, psychosocial support was officially integrated as a necessary component into the national rescue plan of Luxembourg.

#### Establishment of Working Groups and New Units

As a central long-term impact, many different units and working groups were created after the disasters. The established working groups with experts and persons concerned analyzed past events, with the objective of developing recommendations for further improvements. The National Counter-Terrorism Coordination Centre has also been created, aiming to improve coordination between the National Police and the Guardia Civil, and terrorism experts have been sent from the Ministry of Interior to key embassies, to improve exchanges of information. After the airplane crash, an airline emergency committee was rebuilt, and a crisis-support center for Luxair accidents abroad was established. After the avalanche, the local government established a center to link research institutions, non-profit organizations, and businesses in the field of environmental hazards, to improve security measures, create databases, and develop efficient and up-to-date scenario plans.

#### Legal Changes

Several changes in laws (fire safety regulations and railway act, which also includes funiculars) have occurred after the Kaprun tunnel fire [34]. As a response to the disaster in Galtuer, the federal minister decided to update the guidelines of the danger areas. Basics of the administration procedures are the danger-zone plans, state-specific land-use planning laws, and the forest law of 1975. As a consequence of the flood, the land registry plans have been re-evaluated, and danger zones have been updated. However, various interview partners pointed out the difficulty of keeping danger zones up in the long-term: "The danger is simply that the pressure on the administrative employees comes when nothing has happened for a long time, that one says the yellow zone is no longer necessary. Or people demand the red zone to become a yellow zone in which building, under certain conditions, is possible. The pressure is certainly there, because we are in need of soil that can be built on". Moreover, concepts for resettlement from the endangered areas have been developed. However, it is unclear if and how many people have agreed to resettlement. A decision of the airline management after the crash in Luxembourg led to the implementation of all recommendations from aircraft designers concerning technical details in a compulsory way.

#### 3.2.2. Infrastructure

For all investigated disasters, measures concerning infrastructure were initiated. These measures are referred to as items that improve security, in general, or specific measures to optimize processes, to be better prepared for future disasters. The costs of these infrastructure measures differ substantially.

#### Large-Scale Investments

After the avalanche, the avalanche barriers around Galtuer were improved and extended. In order to protect the houses of Galtuer in the future, an avalanche barrier was built in the middle of the village center. This special construction, called "Alpinarium", combines avalanche protection and an integrated museum, which deals with the history of Galtuer and the avalanche risk in the area. Further infrastructural measures were the improvement of the meteorological station, a reforestation project, and the extension of the security tunnels at the access road to Galtuer.

High investments were also undertaken in the case of the Austrian flood. Improvements and extended flood protection measures with 34 new building projects were realized. The building process had to be sped up after the flood because 17 projects had not been realized until then. Compared to the building projects, public authorities weighed the importance of the security of the public and decided not to invest in a dam, because of the complex construction project, the enormous monetary investment, and low benefit [35]. For affected public buildings like kindergartens and community buildings, the high possibility of future floods was considered, and a flood-proof way of construction and the addition of flood-resistant materials were implemented. For better forecasts and accurate prognosis, automated water-level measurement stations have been installed. However, improved

technical equipment does not automatically lead to better flood protection, as one interview partner explains: "The most difficult thing is the final interpretation of the measured values. A river is a living organism, constantly changing". The damage of the transport medium—as what took place in Kaprun—catalyzed the building of a new ropeway instead of a new funicular due to security reasons. Due to the legal adaptions, many existing funiculars in Austria had to be adapted to guarantee a high level of security for the passengers. Finally, new helicopters with a higher load capacity were purchased for the Austrian Armed Forces, to ensure access to the valleys in the event of natural hazards restricting access to the population.

#### Small- and Medium-Scale Investments

Small- and medium-sized investments were undertaken in the case of Luxembourg, to improve transport by using more containers for meeting places or restrooms for rescue teams for future operations. These decisions were based on low costs and high flexibility. Additionally, a new operation control car was acquired. In Spain, public infrastructures were controlled more intensively after the terror attack, and constructional adaptions were undertaken. Security measures, like video surveillance, emergency exits, controls of specific infrastructure, and future usage of flak vests, were implemented.

#### 3.2.3. Research

After the Galtuer avalanche, the local government invested in research projects which should reduce future disaster risks. One project was the "Alpine Safety and Information Centre (ASI)". The mission of this non-profit organization was to promote safety mountain environment and to act as a communication bridge between all participating institutions and local organizations. One product of these research investments that is now being used in practice is the "ESIS Tirol" mission information system, an internet platform that facilitates communication and coordination in the event of a disaster. Moreover, new calculations for avalanche simulation models have been developed.

#### *3.3. Others*

Because there were some problems in the flow of information between the response organizations, the communication processes have been updated in all investigated disasters. Moreover, technological improvements like the implementation of a uniform radio system in Tyrol and special software have been undertaken. The high media interest after the avalanche and the tunnel fire had a negative impact on the well-being and health of people affected. Therefore, improvements in media management were undertaken. Changes regarding the trainings and exercises (e.g., special topics such as media or psychosocial support, more joint trainings, and cross-border cooperation) could also be observed in all cases. Measures for improvements in the coordination of processes between the organizations and of the handling of professionals and volunteers have been initialized in all cases. Formal and informal networking was identified as a valuable basis for future cooperation. An interview partner pointed out the following: "I would add that in order to improve our response in emergencies, all the teams intervening in an emergency should have more meetings and we should learn to coordinate ourselves better, defining new plans on coordination, structure and control to make sure we all know who's in charge, where we have to go and what we have to do".

Tables 2 and 3 summarize the various impacts each disaster had on the public health system.


#### **Table 2.**Overview of long-term impacts on health-system performance.

#### **Table 3.** Overview of long-term impacts on security and health protection.


Many of the identified impacts overlap with the recommendations in the Sendai Framework [5]: update of preparedness and contingency plans (Paragraph 33a), forecasting and early warning system (Paragraph 33b), trainings and exercises (Paragraphs 33f, 33h, 34f, and 34h), land-use planning (Paragraph 33j), provision of psychosocial support (Paragraph 33o), and revision of laws (Paragraph 33p). It can be concluded from this that the opportunity to "Build Back Better" and consequently enhance disaster preparedness has been taken.

#### **4. Discussion**

Based on the results of the literature review, we identified highly fragmented studies without any standardized approach to investigating the long-term impacts of disasters on public healthcare. We did not find any standard definition of long-term impact on the healthcare system. In the context of long-term impacts, the literature mainly focuses on long-term psychological impact effects on affected populations. A broader approach is missing. The studies have also chosen different time frames that do not allow any comparative conclusions.

The investigation of the case studies has shown that each disaster causes aftermaths in various fields. Learning circles [36] play a substantial role in the context of disaster management, as many of the identified long-term impacts on the public health system are the result of a learning process because of inadequate outputs in the past.

The changes observed all seem to have been sustained over the years. One exception is the ASI center, which, according to one interviewee, was closed for political reasons. The necessity of the acquired helicopters is regularly discussed in politics and media. However, landslides and roadblocks due to avalanche risk repeatedly demonstrate their importance for the protection of the affected population.

The study showed us that federalism and organizational boundaries can be a hindrance to improvements: After the 1999 avalanche in Galtuer, the Red Cross created a crisis intervention team in the province of Tyrol. In the neighboring province of Salzburg, however, there was no such infrastructure for psychosocial support yet established when the tunnel fire happened in November 2000. Christensen, Lægreid, and Rykkja (2013) describe something similar in their study: A major obstacle after the terrorist attack in Oslo was the fragmentation of responsibility within government departments. This might have hindered information-sharing and, consequently, taking measures which could have reduced the impact of the Oslo terror attack in 2011, as plans for improving the security of the building had already been established prior the attacks, but not implemented yet [37].

There is the need to analyze the individual and social circumstances of people affected. Results show the importance of analyzing long-term impacts from the perspective of the type (e.g., disaster associated with natural hazards or human-made disaster) and characteristic (e.g., duration and extent) of a disaster, as well as the regional context where a disaster took place. The effectiveness of disaster management procedures is dependent on a number of contingencies (e.g., not only how accurately one system is implemented, but also how well aligned a system is with cultural subsystems) [5,38,39]. As became apparent in Galtuer, the inhabitants applied coping strategies that are rooted in local traditions (e.g., importance of spiritual support). Nevertheless, the consequences of the avalanche led the local population to increasingly open up and cope with this specifically challenging situation by augmented communication. The ex post facto identification of local practices could be highly valuable as basis for discussion within a broader audience of special interest groups (e.g., experts for avalanche risk areas in Austria, Italy, and France).

The chosen cases include disasters caused by natural hazards, as well as human-made disasters. Both types of disasters have been demonstrated to have a potentially high impact on the public health system. However, they might have different consequences concerning preparedness planning. As avalanches and floods are often foreseeable, proactive actions like early warning and evacuation are possible in many cases. On the other hand, avalanches and floods result in relatively large impact areas, which makes response more difficult and requires thorough preparedness regarding mobilization and

equipment. Differences between disasters caused by natural hazards and human-caused disasters are also observed with regards to mental health.

Dynes and Quarantelli [40] describe disasters caused by natural hazards as "consensus crises", leading to an increase of community cohesiveness and moral, whereas human-made disasters are characterized by human blame [41]. This has consequences for the coping process and the need for psychological support. Although the disasters analyzed in the case studies may have different characteristics, they share many similarities in their impact. Recurring themes in all the case studies were infrastructural measures, update of emergency plans, changes in communication procedures, and a raised awareness for the importance of mental health and providing psychosocial support. It might prove difficult to compare different individual disaster-management cases in order to elect one best practice example. However, the use of historical lessons can be a valuable source for improvements regarding disaster preparedness [38]. Gaining insights from out-of-sector lessons is often overlooked or considered as not relevant [42]. The recurring themes we identified across the various disasters analyzed in this study, however, demonstrate the learning opportunities from other fields or kinds of disasters. Crichton et al. [42] recommend broadening the perspective and trying to apply lessons beneficially to the own environment. Therefore, the learnings from these European cases can also be of use for countries with other structures and regulations regarding their public health system and disaster management structure. Even though political, socioeconomic, cultural, environmental, and hazard circumstances vary in every state, good practices might be transferable. This learning can be achieved when using a customized approach by "making use of others' experience, for instance by reviewing the contexts of particular measures and the nature of good practices and lessons learned, and then tailoring these to implement policies and activities that are appropriate for the local contexts" [43] (p. 5). Moreover, the Sendai Framework [5] points out the need for adaptions to the respective jurisdictions, capacities, and capabilities of each country.

Although each disaster is unique in its progress and coping, we ask for the design of a standardized assessment system for long-term disaster impacts. This would help to increase comparability of disasters. We share the recommendation expressed in the WHO Health-EDRM framework [1] regarding future research needs: a holistic all-hazard perspective across all disaster-management phases which includes physical, mental, and psychosocial needs. In order to achieve this, multidisciplinary and multi-sectoral collaboration between science, policy makers and practitioners is needed [39,44,45]. Such an exchange and dialogue between stakeholders is important in order to identify knowledge gaps, jointly develop knowledge, and, finally, to put scientific findings into practice [5].

#### **5. Limitations**

The chosen case-study methodology can be criticized because of its limited generalizability. The results of our case studies are a preliminary investigation with the intention of generating a first understanding of long-term impact and its underlying determinants. Although it is hardly possible to derive a holistic model covering all cumulative effects of disasters, such case studies can serve as a guide for researchers, policy makers, and disaster managers [3].

The case studies refer to disasters that have occurred in the European Union. Analyzing cases from other countries, which have different disaster management structures and health system regulations, might be an interesting task for future research offering further insights.

#### **6. Conclusions**

In this study, we investigated the long-term impacts of disasters on the public health system. We used a mixed-method approach consisting of document analysis and expert interviews. For our analysis, we chose the following cases: an avalanche, a cable-car accident, an airplane crash, a terror attack, and a flood. The analysis of the case studies revealed the variety of direct and indirect impacts on population health and health systems major incidents can have. We grouped the identified impacts into the categories of health-system performance, and security and health protection. Subcategories in

health-system performance were mental health and demand for healthcare services, as well as structure and organization of psychosocial support. The subcategories for security and health protection were contingency and preparedness planning, infrastructure, and research. Although we chose contrasting cases, we identified recurring themes in all the cases investigated. A change in communication processes, updates of emergency plans, infrastructural measures, and a higher awareness for psychosocial support was observed in each case study. Our chosen holistic strategy gave us deep insights into each case study and helped us to better understand the undertaken or missing reactions concerning public health. By analyzing past events and their consequences on the public health system, one can develop strategies for better dealing with similar events in the future.

**Author Contributions:** Conceptualization, M.R., V.S., N.L., and H.S.; methodology, M.R. and V.S.; formal analysis, M.R. and N.L.; investigation, M.R., N.L., and V.S.; writing—original draft preparation, N.L.; writing—review and editing, N.L., M.R., V.S., and H.S.; supervision, M.R. and H.S.; project administration, M.R., N.L., and H.S.; funding acquisition, M.R. All authors have read and agreed to the published version of the manuscript.

**Funding:** This research was funded by the European Union's Seventh Framework Programme for research, technological development, and demonstration, under grant agreement No. 312395.

**Acknowledgments:** We thank all disaster managers and other stakeholders who shared their experiences with us, gave us feedback during these initial steps, and helped us develop the current concept. We would also like to thank all our project partners for their tireless support during the past months, to finally reach this point, where we can start to discuss our current research.

**Conflicts of Interest:** The authors declare no conflict of interest. The funders had no role in the design of the study; in the collection, analyses, or interpretation of data; in the writing of the manuscript; or in the decision to publish the results.

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International Journal of *Environmental Research and Public Health*
