HIDDEN AFTERSHOCKS. Report. Summary

Transcription

1 HIDDEN AFTERSHOCKS Summary Report An Assessment of the Mental Health and Psychosocial Status and Needs of Earthquake-Affected Communities in Rasuwa, Nuwakot, and Makwanpur Districts Conducted by With the support of In collaboration with

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3 HIDDEN AFTERSHOCKS 1 HIDDEN AFTERSHOCKS Since the earthquake, everyone is depressed. Even during minor conflicts they talk about wishing they had also been killed in the quake; they speak of suicidal thoughts, say they will jump into the river. - Youth focus group participant, Rasuwa The 2015 earthquakes in Nepal left widespread physical devastation in communities across the center north of the country: over 8,900 deaths, collapsed buildings, damaged infrastructure, and countless injuries. The less visible mental and emotional effects of the earthquakes, however, are not well understood and have been largely neglected in recovery efforts. A better comprehension of post-earthquake mental health and psychosocial problems and needs is essential for planning and implementing effective and holistic recovery programs and activities. GORKHA DHADING PARSA NUWAKOT KAVREPALANCHOK LALITPUR RAMECHHAP MAKWANPUR BARA km RASUWA KATHMANDU BHAKTAPUR RAUTAHAT SINDHUPALCHOK SINDHULI SARLAHI DOLAKHA By 2016, the Red Cross Movement s work in Nepal had transitioned from relief activities to longer-term recovery interventions across all 14 districts most severely affected by the earthquake. The American Red Cross, along with consortium partners the Spanish Red Cross and the Canadian Red Cross, was working to support the Nepal Red Cross Society in implementing Utthan, a three-year integrated earthquake recovery program in Rasuwa, Nuwakot, and Makwanpur districts. Although increases in mental health and psychosocial (MHPS) problems immediately following major disasters are expected, almost 18 months after the earthquake Utthan program staff had indications that MHPS problems might still be interfering with the ability of some highly vulnerable community members to access, fully participate in, and benefit from recovery services. It was crucial to gain more specific insight into the overall scale and nature of mental heath and psychosocial support needs as well as identify specific sub-groups of the population that were at higher risk of experiencing these problems.

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5 HIDDEN AFTERSHOCKS 3 The American Red Cross commissioned Transcultural Psychosocial Organization Nepal (TPO Nepal) to conduct a MHPS assessment between November 2016 and January 2017 to assess the prevalence of mental health and psychosocial problems in the earthquakeaffected population, examine existing MHPS services available in these communities, and make recommendations on appropriate interventions to address these needs. This assessment is the only such study to be conducted following the Nepal earthquake in the 18 months to two-year timeframe, and is an important contribution to understanding MHPS needs during recovery. METHODOLOGY The assessment used a mixed methods design, consisting of both qualitative (focus groups, key informant interviews, community consultative meetings) and quantitative (survey) approaches. It was conducted in 8 VDCs and one municipality that had been selected from the 19 VDCs and one municipality that form the Utthan program areas. 510 Survey Participants 30 Key Informant Interviews 12 Focus Group Discussions 3 District-level Community Consultative Meetings Quantitative assessment 510 households were selected randomly using a stratified multi-stage cluster sampling process in 8 program VDCs and 1 municipality; in 2 of these VDCs and 1 municipality, a database of households previously assessed by the program as most vulnerable was available 5 ; researchers selected an equal number of households that were on this most vulnerable list and those that were not. Of the 510 participating households, 171 were in Rasuwa, 169 in Nuwakot, and 170 in Makwanpur. One member aged 16 or older from each of these households responded to a quantitative survey that used multiple standardized tools for research and screening mental health and psychosocial symptoms. This included assessing their perceived needs, level of functioning in performing daily tasks, and measuring symptoms of depression, anxiety, PTSD, excessive alcohol use, and suicidal ideation and action. Qualitative assessment Researchers interviewed or held discussions with a range of district and communitylevel stakeholders. This included focus group discussions with groups including women, teachers, youths, and the elderly; key informant interviews with community-level stakeholders including health workers, traditional healers, and local leaders; and district-level community consultative meetings attended by stakeholders including representatives of government health institutions and I/NGOs.

6 4 HIDDEN AFTERSHOCKS KEY FINDINGS Prevalence of mental health problems is high There was relatively high prevalence of MHPS problems including depression, anxiety, PTSD, suicidal ideation, and alcohol use problems among earthquake-affected populations surveyed. These rates were higher than those found in a similar study conducted four months after the earthquake 1. They are also higher than both WHO estimates for depression and anxiety following a humanitarian emergency, and rates found in comparable previous studies in post-earthquake Haiti 2 and Japan 3. Mental health problems 18 months after the Nepal earthquake 39.4% 38.4% 25.5% 21.7% 16.3% Depression Anxiety Alcohol use problems Suicidal thoughts PTSD Support to cope with distress is a priority need When respondents were asked to identify serious problems resulting from the earthquake, the three most frequently cited needs across the survey areas were income/livelihood (73.2%), shelter (63.5%), and support to deal with distress or tension (61%) 4. Support for coping with distress was identified more frequently than needs related to hygiene, drinking water, food and toilets. This gives an indication of the extent of demand from communities for post-earthquake MHPS support. Most pressing needs Livelihood Shelter Distress/tension Keeping clean Drinking water Travel/movement 48.5% 47.5% 63.5% 61.0% 57.9% 73.2% Food Toilets 39.2% 39.0%

7 HIDDEN AFTERSHOCKS 5 Prevalence of MHPS problems is higher in some sub-groups Women, individuals who had been widowed or separated from their partners, and members of Janajati ethnic groups that were not the predominant Janajati group in the local context (including Chepang, Magar, Newar, and Tharu) showed significantly higher symptom rates. The prevalence of MHPS problems also varied from district to district. Prevalence of symptoms of depression (43.5%), anxiety (43.2%), PTSD (21.3%), and suicidal thoughts (27.4%) were significantly greater among women. Meanwhile, alcohol use problems were higher among men (32.4%) than their female counterparts (19.2%). MHPS problems by gender Women Men 43.5% 35.0% 43.2% 33.1% 19.2% 32.4% 27.4% 15.4% 21.3% 10.8% Depression Anxiety Alcohol use problems Suicidal thoughts PTSD Rasuwa district had the highest estimates of MHPS symptoms (depression 51.1%, anxiety 51.9%, PTSD 24.4%), followed by Makwanpur (depression 44.4%, anxiety 40.3%, PTSD 19.7%) and Nuwakot (depression 28.7%, anxiety 33.9%, and PTSD 9.0%). Alcohol problems (27.8%) and suicidal thoughts (27.8%) were higher in Makwanpur than the other two districts. MHPS problems by district Rasuwa Nuwakot Makwanpur 51.1% 28.7% 44.4% 51.9% 33.9% 40.3% 23.4% 21.1% 27.8% 11.5% 9.5% 27.8% 24.4% 9.0% 19.7% Depression Anxiety Alcohol use problems Suicidal thoughts PTSD

8 6 HIDDEN AFTERSHOCKS Highly vulnerable households were also at higher risk of MHPS problems Eighty-five of the 510 individuals included in the quantitative survey were from households that had previously been identified under the Utthan program as highly vulnerable, based on criteria including food sufficiency, land ownership, disability within the family, elderly, minor, and women-headed households and caste/ethnicity 5. The study found more perceived needs, and also significantly higher prevalence of mental health problems among these highly vulnerable households than other households. Counter to commonly held beliefs about the poor and alcohol abuse, prevalence of alcohol use problems among these most vulnerable households was less than other earthquake-affected households. MHPS problems by vulnerability Households identified as most vulnerable General earthquake-affected households 44.6% 37.7% 49.9% 34.5% 18.4% 27.9% 31.2% 18.5% 16.9% 16.1% Depression Anxiety Alcohol use problems Suicidal thoughts PTSD MHPS services are limited, and traditional healers are usually the first point of contact Most people suffering from mental health symptoms visit a traditional healer or religious leader before engaging with the formal health care system. Specialized mental health care is generally not available at the district level, with treatment options centered in Kathmandu. While there were some I/NGOs providing counseling and other mental health support after the earthquake, such efforts did not reach all communities and often were only available in the short-term period after the disaster. Here, people with heart-mind problems first visit traditional healers and when it does not work, they go to the health post and take general medication When it does not improve even with medications from the health posts, they are sent to Batar. If they do not recover even in Batar, they are referred to Kathmandu. LIMITATIONS - Female community health volunteer, Nuwakot As there were no previous MHPS studies conducted in the assessment areas that could provide baseline data, we cannot definitively conclude that high rates of mental health symptoms were due to the earthquakes. Due to the diverse ethnic and cultural composition of Nepal, results may not be representative of all earthquake-affected communities or even of the entire district where study areas were selected.

9 HIDDEN AFTERSHOCKS 7 MAJOR RECOMMENDATIONS Given the prevalence of mental health and psychosocial symptoms found by this assessment 18 months after the earthquake, it is crucial to establish mental health and psychosocial (MHPS) support systems for a full recovery. Key recommendations for recovery programming in communities that continue to deal with the impact of the earthquake include: Addressing distress as a core priority: Respondents identified income/livelihoods, shelter, and support to cope with distress/tension as the three top priority needs for immediate attention. There is, therefore, an urgent need for the government and other service providers, including the Red Cross, to incorporate MHPS in recovery programming, in addition to continuing working to address concrete needs (shelter, livelihoods, water, sanitation) in earthquake affected communities Focusing support for at-risk populations: Both specialized and non-specialized mental health services should be provided immediately for populations at high risk of mental health and psychosocial problems. These include women, older people, households previously identified by a Red Cross assessment as most vulnerable, and the Chepang community, which is a highly marginalized ethnic group with significant populations in the Red Cross earthquake recovery program areas in Makwanpur. Mobilizing existing community-level systems: Community-based service providers, including Red Cross earthquake recovery program staff and volunteers, Female Community Health Volunteers, and traditional healers, should be trained to identify symptoms of mental health problems, provide basic MHPSS services, sensitize the community to mental health problems and help reduce stigma, and refer people for more advanced care when necessary. Strengthening national policy and mental health care delivery: Mental health and psychosocial support services should be integrated into Nepal s existing government health care delivery and protection system, and must be predicated on evidence-based practices and approaches such as the Inter Agency Standing Committee guidelines and the World Health Organization s mhgap recommendations. Continued lobbying and advocacy about the need to address mental health and psychosocial issues is crucial at both the center and district level.

10 8 HIDDEN AFTERSHOCKS NOTES AND REFERENCES 1 Kane, J.C., Luitel, N.P., Jordans, M.J.D., Kohrt, B.A., Weissbecker, I., & Tol, W.A. (2017). Mental health and psychosocial problems in the aftermath of the Nepal earthquakes: findings from a representative cluster sample survey. Epidemiology and Psychiatric Sciences, Cerdá M., Paczkowski M., Galea S., Nemethy K., Pean C., Desvarieux M. (2013). Psychopathology in the aftermath of the Haiti earthquake: a population-based study of post traumatic stress disorder and major depression. Depression and Anxiety, 30(5), Sakuma A., Takahashi Y., UedaI, Sato H., Katsura M., Abe M., Nagao A., Suzuki Y., Kakizaki M., Tsuji I., Matsuoka H., Matsumoto K. (2015). Post-traumatic stress disorder and depression prevalence and associated risk factors among local disaster relief and reconstruction workers fourteen months after the Great East Japan Earthquake: a crosssectional study. BMC Psychiatry, 15, 58.DOI: /s y. 4 At the time of the assessment, ground-level service provision for some recovery activities including shelter reconstruction and livelihoods support had not yet begun, pending finalization of national-level policies. 5 The vulnerability criteria covered 10 indicators: 1. Earthquake-induced death of a productive household member; 2. Households headed by a minor under 18 years of age; 3. Households headed by women with no adult men below age 60 and excluding households receiving remittances from male members working away from home; 4. Elderly, living either by themselves or in charge of children; 5. Households with at least one differently-abled family member; 6. Households with no adults able to leave home to work due to responsibilities caring for other family members; 7. Households with no regular income; 8. Caste or ethnic group; 9. Food insecurity; 10. Lack of ownership of arable or productive land.

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12 This summary report was prepared based on an assessment conducted by Transcultural Psychosocial Organization Nepal (TPO Nepal) for the American Red Cross, in collaboration with the Nepal Red Cross Society and with input from the Spanish Red Cross. Research conducted by Transcultural Psychosocial Organization (TPO) Nepal Photographs Cover Bijay Prajapati/American Red Cross p.2 Jemima Diki Sherpa/American Red Cross p.7 Jenelle Eli/American Red Cross Copyright 2017 American Red Cross/International Federation of Red Cross and Red Crescent Societies All rights reserved, published November 2017 Citation TPO Nepal & American Red Cross (2017). of the Assessment of Mental Health and Psychosocial Status and Needs of Earthquake-Affected Communities in Rasuwa, Nuwakot, and Makwanpur Districts. Kathmandu: American Red Cross/IFRC Conducted by With the support of In collaboration with