Myanmar Health Sciences Research Journal
Original Articles :
Myanamr Health Research Registration 2020; 32(2): 112-119.
DOI: DOI: https://doi.org/10.34299/mhsrj.00990

Psychological Impact of Disaster among Flood and Landslide Victims in Mon State, Myanmar

Win Kyaw Thu Kaung San Kyaw, Soe Lin Naing & Win Le Mon

Myanmar Health Sciences Research Journal, 2020; 32(2):112-119

ABSTRACT

Torrential monsoon rain hit Mon State in southern Myanmar with severe flooding and a catastrophic landslide in the 2nd week of August 2019. The landslide smashed into a cluster of houses in Ye Pyar Gone village, Paung Township which destroyed 27 houses and killed 72 people. Mental health and psychosocial support (MHPSS) was delivered to disaster-affected victims and a mental health survey was conducted to assess the psychological consequences of disasters. The survey was a cross-sectional observational study and used Screening Questionnaire for Disaster Mental Health (SQD) to assess depression (SQD-D) and post-traumatic stress disorder - PTSD (SQD-P). The survey involved 109 participants and it lasted three weeks. Data extraction and analysis were done by using the Excel Spread Sheet and IBM SPSS 25 software. Socio-demographic variables and SQD scores were categorized and their proportions and means were compared by Chi-squared test. Regression analysis was used to test the association between continuous variables like age and scores. Severe depressive symptoms were found in 41.7% (95% CI=27.7-55.6%) of the landslide and 4.9% (95% CI=0-10.3%) of flood victims. Possible PTSD was found in 45.8% (95% CI=31.7-59.9%) of the landslide and 1.6% (95% CI=0-4.7%) of flood victims. The presence of severe depressive and PTSD symptoms was strongly associated with: being landslide victims (p<0.001), loss of close relatives (p<0.001) and having prior physical illnesses (p<0.001). Joblessness was also associated with more depressive symptoms (p=0.014). Increasing age was associated with higher SQD-D scores (p=0.018) and having more life-lost was associated with significantly higher SQD-D and SQD-P scores (p<0.001). After exposure to a disaster, people tend to develop PTSD and/or depression when they are associated with loss of lives, having prior physical diseases, joblessness and older age. Disaster relief workers should pay more attention and provide extra support to people with the aforementioned risk factors which should also be considered for future disaster relief planning.



RESULT
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The survey conducted involved 109 participants of which 61 were flood- and 48 were landslide victims (Table 1). The mean age was 37.53 (SD=17.13; minimum 7 and maximum 80) and 83% of participants belonged to 10 to 60 aged groups (Table 1 and 2). Some 68% of the study group (N=74) were female and 32% (N=35) were male, with a male to female ratio of 1:2.1. Regarding the educational level, 83% of the study group (N=91) had a primary or lower level and only 2 respondents were graduated. Thirty-one participants (28%) had lost one or more of their close relatives during disasters of which almost all (except one flood victim who had lost one son during flooding and one grandson before it) were landslide victims. No pre-disaster mental health condition was reported in the survey group but 12 persons (11%) informed that they had one or more physical illnesses before the disaster.The survey results informed that the mean score of SQD-P was 3.06 (SD=2.712; range =0-9); mean SQD-D score was 2.39 (SD=1.981; range=0- 6) and SQD-total score was 4.40 (SD=3.616, range=0-11)

(Table 2).

Table 1. Demography of  the study  population  and  associations  between demographic and SQD categories

   (chi-squared test)

Variables

Total

SQD-D (Depression)

SQD-P (PTSD)

p-

value

N=109
(%)

Less likely
to be depressed

N=86

More likely
to be depressed

N=23

p-

value

Slightly affected

N=63

Moderately affected

N=23

Severely 

affected 

N=23

Age group distribution (year)

 

 

 

 

 

 

<10

6(5.5)

5

1

   0.186

4

1

1

0.766

10-19

11(10.1)

8

3

5

2

4

20-29

21(19.3)

18

3

13

6

2

30-39

25(22.9)

21

4

14

3

8

40-49

18(16.5)

17

1

13

3

2

50-59

16(14.7)

10

6

7

5

4

60-69

6(5.5)

3

3

4

1

1

70

6(5.5)

4

2

3

2

1

Sex

 

 

 

 

 

 

 

 

Male

35(32.1)

28

7

0.846

24

5

6

0.279

Female

74(67.9)

58

16

39

18

17

Educational level

 

 

 

 

 

 

Read & write

45(41.3)

33

12

   0.434

29

8

8

0.625

Primary school

46(42.2)

36

10

21

13

12

Middle school

9(8.3)

8

1

6

1

2

High school

7(6.4)

7

0

5

1

1

Graduate

2(1.8)

2

0

2

0

0

Types of victims

 

 

 

 

 

 

 

 

Landslide

48(44.0)

28

20

0.000

14

12

22

0.000

Flood

61(56.0)

58

3

49

11

1

Presence of life lost

 

 

 

 

 

 

 

Absent

78(71.6)

72

6

0.000

57

14

7

0.000

Present

31(28.4)

14

17

6

9

16

Occupational status

 

 

 

 

 

 

 

Absent

34(31.2)

22

12

0.014

16

7

11

0.138

Present

75(68.8)

64

11

47

16

12

History of mental illness

 

 

 

 

 

 

 

Absent

109(100.0)

-

-

-

-

-

-

-

Present

0(0)

Presence of physical illness

 

 

 

 

 

 

 

Absent

97(89.0)

84

13

   0.000

63

20

14

0.000

Present

12(11.0)

2

10

0

3

9

Marital status

 

 

 

 

 

 

 

 

Single

28(25.7)

23

5

 0.535

17

4

7

0.615

Married

76(69.7)

60

16

42

18

16

Widow/widower

5(4.6)

3

2

4

1

0
























SQD-D=Screening Questionnaire for Disaster Mental Health (Depression), SQD-P=Screening Questionnaire for Disaster Mental Health (Post-traumatic Stress Disorder)

 


Table  2.   Mean age, number of life lost and SQD scores

 

Mean(SD)

Minimum

Maximum

Age distribution

37.53(17.128)

7

80

No. of life lost

1.15(2.921)

0

14

SQD-P

3.06(2.712)

0

9

SQD-D

2.39(1.981)

0

6

SQD-Total

4.40(3.616)

0

11

SQD-P=Screening Questionnaire for Disaster Mental Health (Post-traumatic Stress Disorder), SQD-D=Screening Questionnaire for Disaster Mental Health (Depression)

 

Some 41.7% (95% CI=27.7-55.6%) of landslide and 4.9% (95% CI=0-10.3%) of flood victims were found more depressed compared to other participants in the respective groups (Table 3). Possible PTSD was found in 45.8% (95% CI=31.7-59.9%) of landslide victims whereas it was found in just 1.6% (95% CI=0-4.7%) of flood victims. While performing the chi-squared test, it was found that landslide victims, people who experienced life lost and people with pre-existing physical illness were found more depressed (p<0.001 for all three groups), and they also had higher possibility for PTSD than other people in the study group (p<0.001 for all three groups) (Table 1).  Fig. 1. Regression analysis of age and number of life lost vs SQD-D and SQD-P scores

 


Table 3. The pevalence of depressive and PTSD symptoms  among  landslide  and flood victims

SQD

Landslide

Flood

N

%

(95% CI)

N

%

(95% CI)

SQD-D (Depression)

 

 

 

Less likely to be depressed

28

58.3

(44.3-72.2)

58

95.1

(89.6-100)

More likely to be

depressed

20

41.7

(27.7-55.6)

3

4.9

(0-10.3)

Total

48

100.0

61

100.0

SQD-P (PTSD)

 

 

 

 

Slightly affected

14

29.2

(16.3-42.0)

49

80.3

(70.3-90.2)

Moderately affected

12

25.0

(12.7-37.2)

11

18.0

(8.3-27.6)

Severely affected

22

45.8

(31.7-59.9)

1

1.6

(0-4.7)

Total

48

100.0

61

100.0

SQD-D=Screening Questionnaire for Disaster Mental Health (Depression), SQD-P=Screening Questionnaire for Disaster Mental Health (Post-traumatic Stress Disorder)

Also, jobless people were found to have more depressive symptoms than their counterparts (p=0.014). In the linear regression analysis, increasing age was associated higher de-pression (SQD-D) scores (p=0.018), and increasing number of life lost was associated with higher depression (p<0.001), PTSD (p<0.001) and total SQD scores (p=0.001) (Figure 1).

 



INTRODUCTION
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On a daily basis, at least one disaster happens at some corner of the world causing displacement of people, loss of lives, destroying properties and posing a social and economic burden on society.1 Although the incidence of disasters remains stable, there is an obvious rise in human impacts caused by them, which scientists have described as a result of global climate change. Those damages caused by disasters are com-pounded by the growing population density where more people are living in disaster-prone areas.2 Myanmar is not exempt from this  global  phenomenon  and it  appears that disasters and subsequent damages have occurred with an increasing tendency in recent years. Department of Disaster Management (2019)3 reported that disasters of all kinds resulted in death tolls of 218 people from 658 incidents in 2015, which projected to 518 people from 1,632 events in 2016, and climbed again to 554 people in 2017 from 2,511 incidents. During the 1980-2011 period, the majority of disasters in Myanmar were caused by floods (50%), followed by storms (23%), earthquakes (15%), and mass movement of people (12%).4 According to the Global Climate Risk Index (2019), Myanmar sits on the third place behind Puerto Rico and Honduras in the list of the most disaster-affected countries in the 20 years (1998-2017).5 The reason behind this is the result of devastating Cyclone Nargis in 2008, which claimed 140000 lives and destroyed properties of approximately 2.4 million people.The majority of floods in Myanmar are caused by storms and heavy rainfalls during the rainy season that starts in June and ends in October. As the geographical structure of Myanmar is arranged in that the central plain region is bounded by western mountainous and eastern highland areas, rainfall in those mountains and highlands means the central plain and coastal regions are liable for flooding. While cyclones, storms and heavy rainfalls threaten coastal and riverside areas, landslides often occur in mountainous and hilly regions attributable to heavy rain, earth-quakes, man-made excavations, and mining. Some notable landslides associated with life lost in the past two decades were Mogok landslide in 2008 (11 people died), Maung-taw landslide in 2010 (46 people died), landslide in Hpakant jade mine in 2015 that killed 116 people and missing 100, and recent landslide in Hpakant jade mine (2019) where at least 19 people were killed.6-8Immediately following a disaster, most of the affected population suffer psychological distress of varying degree and duration. For the majority of that population, the distress is transient (i.e., only days to weeks) as many can cope well with their distress, show resiliency and rapidly regain normal levels of functioning. For some others, they develop trauma-related psychopathology including post-traumatic stress disorder, depression, anxiety disorders, substance abuse, somati-zation and complicated bereavement disorder in people who have lost loved ones.9, 10 There are some agreed risk factors for the development of psychopathology in victims of disaster during the post-disaster period. These factors can be grouped as 1) pre-disaster factors such as female gender, adversity during childhood, past traumatic experiences, presence of physical or mental illness, low socio-economic status, and people in minority ethnic or religious group; 2) peri-disaster factors that involve frequency and severity of the disaster, perceived life threat, personal injury, interpersonal violence, and peri-traumatic dissociation; and 3) post-disaster factors including the successive exposure to reminders of the traumatic event, the presence of ongoing life stressors, and low social support.10-13

Disasters in Mon State, 2019 Torrential monsoon rain resulted in floods and landslides in many areas of Myanmar, starting from the last week of July 2019. Among those affected areas, Mon State in southern Myanmar was hit worst by severe flooding and a catastrophic landslide. Flooding, although it is a habitual occurrence in the Mon State, became more severe and widespread this time than those of earlier years. Flooding affected severely in Mawlamyaing, Kyaik Mayaw, Ye and Bee Linn Townships, damaging properties and displacing thousands of people, during the second week of August. On August 9, the tragic landslide hit Ye Pyar Gone village, a Muslim community in Paung Township, where thick mud from the nearby Malatt Mountain smashed into a cluster of houses and destroyed 27 houses, buried people alive that savaged 72 lives.

The mental health survey

To deliver mental health and psychosocial support (MHPSS) to disaster-affected popu-lation, an emergency mental health team was sent along with other emergency response teams. The MHPSS team conducted a mental health survey to assess the psychological consequences of disasters.



SUPPLEMENTARY MATERIAL
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The survey was a cross-sectional, descriptive and analytical study and used the English version of the Screening Questionnaire for Disaster Mental Health (SQD).14 It was conducted to flood victims at three emergency camps in Kyaik Mayaw Township and survivors of the landslide in their relatives’ places at Ye Pyar Gone village and it lasted three weeks (from August 20 to September 10, i.e., within one month after disasters). SQD was developed by Fujii, et al. for the screening of the two most common mental health conditions in the disaster-affected population namely depression and post-traumatic stress disorder (PTSD).14 It is a highly reliable and valid instrument, can be easily administered by a non-mental health professional and takes less than five minutes to complete it so that it has been adopted and used by researchers and field workers elsewhere. The SQD is composed of two sets of questions, one for depression (SQD-D) and the other for PTSD (SQD-P). The SQD involves a total of 12 questions, and answers are dichotomous (either yes or no). In the questionnaires, 9 items screen for PTSD (SQD-P; scores range 0-9) and 6 items for depression (SQD-D; scores range 0-6) where 3 items share features of both PTSD and depression namely diminished interest, insomnia, and psychomotor agitation. SQD-P scores are categorized into three levels: slightly affected (0-3), moderately affected (4-5) and severely affected (possible PTSD) (6-9) while SQD-D scores have only two categories: less likely to be depressed (0-4) and more likely to be depressed (5-6).


Data collection and analysis

Clinical interviews and the survey were done by psychiatrists from the MHPSS team to those who were willing to participate and those who needed help. Before administering SQD, the nature and purpose of the survey were explained and informed consent was obtained. First, background demographic variables were recorded, that followed clinical interviews and finally, SQD was administered. People with significant psycho-logical distress and clinically diagnosable mental health conditions were managed accordingly. Data extraction and analysis were done by using Excel Spread Sheet (Microsoft Excel 2013) and IBM SPSS version 25 for Windows software, respectively. Socio-demographic variables and SQD scores were first categorized and their means were compared by using the chi-squared test. Regression analysis was used to test the association between continuous variables like age and scores.

 



DISCUSSION
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The present study assessed depressive and PTSD symptoms in 109 people who were victims of floods (N=61) and landslide (N=48). It was found that 41.7% of landslide and 4.9% of flood victims were more depressed while possible PTSD was found in 45.8% of landslide and 1.6% of flood victims. The prevalence of PTSD following disaster varies broadly across studies and depends on several factors such as types of disaster, degree of exposure (e.g., frequency and severity, duration of and proximity to disaster), extents of life lost and damages, timing of the study and measurement used in the study, etc.15, 16 It is also described elsewhere that victims exposed to man-made intentional disasters (eg., rape, communal violence, terrorist attacks) have a higher prevalence of PTSD than those exposed to
a natural disaster.9-12, 15-17

For example, in the systemic review that investigates the PTSD prevalence and trajectories, Santiago, et al.15 mention that the mean prevalence of PTSD is 28.8% at one month and 17% at 12 months after exposure to disasters. The same systematic review reports that 37.1% of victims exposed to man-made intentional trauma developed PTSD. In the review of the psychological impact of disasters in children, Kar16 cited that in the adolescent refugee population who had experienced communal violence and atrocity of war, 30 to 70% of them were found suffering from PTSD.

The present study found out some risk factors for depression and PTSD in disaster-affected people namely the presence of life lost, having a prior physical illness, joblessness and old age, and our findings agreed with and replicated the above-mentioned risk factors. Landslide victims showed more depressive and PTSD symptoms than flood victims. It seems that the unexpected occurrence of the landslide, associated high death toll (72 out of 150 people lived in that place died), extensive damage of properties, minor ethnic status and uncertainty about the future (e.g., displacement) might contribute to higher depressive and PTSD symptoms in those affected victims. For flood victims, it is apparent that the greater number of people in this group could predict the possibility of floods and got some time to prepare and flee away from flooding. Virtually they have little or no life lost (only one person died of drowning) and fewer properties were destroyed compared to landslide victims which might be contributing factors for lesser psychopathology in this group.

Limitations

There are some limitations noted in the present study. First, the sample size is too small to be generalized for the whole affected population. Even though there were several hundreds of people temporarily lived in emergency camps, data could be collected only from 109 victims as people were going elsewhere; many were busy with disaster relief efforts; some others were brought away by their relatives and short-lived nature of flood-camps. Second, the use of the English version of the SQD may be another limitation. Although SQD has been adapted and used in studies of post-disaster psychopathology in different populations with diverse cultural backgrounds, the reliability, validity, and adaptability to Myanmar population have not been properly tested. The third limitation could be the timing of the study. Since the present study was performed within one month of the disaster, we could not confidently say that the prevalence of possible PTSD will be the same if the survey was conducted after one month or later of the disaster. For the diagnosis of PTSD, according to DSM 5, the duration of symptoms needs to be present for more than one month.12 If the duration of symptoms is less than one month, it is diagnosable as acute stress disorder (ASD) although a substantial portion of people suffering from the latter condition will progress into PTSD e.g. a systematic review states 77.8% of people with ASD developed into PTSD in later assessment.17

Recommendation

Pre-disaster preparations should be strengthened or instituted to reduce the frequency and impact of disasters. For instance, national and regional level disaster response committee should be organized and intersectoral collaboration should be facilitated. The central and local governments should amend rules and regulations to curb real estate development in disaster-prone areas; should control building quality to withstand disasters; and need to restrict unlawful and irresponsible mining and excavation, etc. Cyclone or emergency shelters should be built in those areas where cyclones and flooding occur frequently.10

Plan for mandatory evacuation during disasters should be made and it is also needed to raise public awareness and readiness for disasters that should be tested with scheduled and unscheduled drills. Disaster relief workers, health care personnel and volunteers should be provided with training for procedures of emergency relief efforts and they should be made accustomed to mental health and psychosocial  support (MHPSS) including psychological first aid.9, 10, 13, 18

During peridisaster and post-disaster periods, to prevent and lessen the psychological consequences of disasters, victims should be first met with their basic needs (food, shelters, health care and security) and then psychosocial support should be delivered as early as possible for those who need it and for people with risk factors for developing psycho-pathology.

Conclusion

After exposure to a disaster, people tend to develop PTSD and/or depression when they are associated with loss of lives, having prior physical diseases, joblessness and older age. As for the pre-disaster preparedness to lessen the psychological consequences of disasters, disaster relief workers should be informed about the mental health and psychosocial issues related to disaster and they should be provided with training regarding basic psychosocial support techniques. Future disaster relief planning should account for vulnerable groups of victims who have a high risk for developing post-disaster psychopathology and also, disaster relief workers should pay more attention and provide extra support to people with the aforementioned risk factors.




ACKNOWLEDGMENT
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We would like to express our heartfelt thanks to Professor Tin Oo, Head of the Myanmar Mental Health Society for his guidance and advice during the survey. We would like to


CONFLICT OF INTEREST
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The author and co-authors of this survey declare that they have no competing interests.



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