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Evidence brief: Psychosocial interventions for post-disaster or post-emergency settings

What you need to know

The coronavirus disease (COVID-19) pandemic has severely impacted the mental health of Canadians. Adults reported having worse mental health six months into the pandemic than before the pandemic and continued to decrease more than a year later (Statistics Canada, 2022). This effect has been seen both among men and women and all age groups. Ontario was one of the worst off provinces in terms of residents who reported poor mental health during the pandemic (Statistics Canada, 2022).

Evidence Exchange Network (EENet) conducted a literature review in response to a public health stakeholder request to identify community-based, psychosocial interventions, programs or initiatives that have been shown to be effective to build coping skills and resilience and increase a sense of belonging in the recovery stages of a disaster, emergency or epidemic.

A variety of interventions were identified, which show promise to build coping skills and enhance well-being and resilience.In most cases, the evidence is preliminary as the studies had limitations in terms of sample sizing and selection. However, they do show that certain common elements may improve resilience, including a focus on community strengths and activities that are of interest or of value to the community, such as art, sports, music and dance, as well as cultural and interpersonal activities that allow people to connect with others who have had similar experiences.

What’s the knowledge gap?

Since March 2020, the coronavirus disease (COVID-19) pandemic has had a negative impact on the mental health of Canadians. According to data from Statistics Canada, the proportion of adults who rated their mental health as high (self-reported mental health) was lower in the fall of 2020 than before the pandemic (Statistics Canada, 2022). One year later, this number had decreased further from 64% to 58% (Statistics Canada, 2022). This decrease was seen both among men and women and among all age groups. In addition, Ontario had one of the lowest proportions of residents with high self-reported mental health compared with the national average (58%) and with other provinces (Statistics Canada, 2022).

Evidence Exchange Network (EENet) conducted a literature review for a public health stakeholder, which sought to answer to the following question: What are community-based, psychosocial interventions, programs or initiatives that have been shown to be effective to support parents, families, children or youth in building coping skills and resilience and increase feelings of belonging in the recovery stages of a disaster, emergency or epidemic.

What did we do?

In February 2022, an EENet knowledge broker with the help of the CAMH librarian conducted a literature review of academic and grey literature using Medline and PsycINFO databases. The search strategy combined terms related to community-based psychosocial programs, initiatives or interventions used in the recovery stages of a disaster, emergency or epidemic. The search used the following terms: community-based intervention, psychosocial support, resilience, disaster, emergency, coping skills, community building and sense of coherence. The target populations were children, young adults and adults. Due to time constraints, the literature review restricted the research to articles published from 2012 to 2022.

Inclusion criteria captured biological epidemics as well as natural disasters and large-scale emergencies. We excluded articles focusing on programs, initiatives or interventions:

What did we find?

The initial search of the Medline and PsycINFO databases resulted in a total of 10,031 records. After removing duplicates, the abstracts of the remaining 543 records were reviewed by the knowledge broker based on the inclusion and exclusion criteria. Among these, 59 peer-reviewed articles qualified for a full-text review. Of these, six met the inclusion criteria. A search using Google Scholar yielded an additional 34 records. Of these, 14 qualified for a full-text review, for a total of 19 articles for full-text review.

In reviewing the findings of the literature review, we defined the term psychosocial support as services that aim to help individuals cope with illness or distress (such as mental health counselling, psychological education, group or spiritual support) (American Psychological Association, n.d.).

We also used the following definition of resilience: “the process and outcome of successfully adapting to difficult or challenging life experiences, especially through mental, emotional, and behavioral flexibility and adjustment to external and internal demands” (American Psychological Association, 2022). Finally, we defined a sense of coherence as an individual’s ability to "be more resilient to stressors in daily life, stay well and improve their health” (Galletta et al., 2019).

This evidence brief summarizes the literature supporting the use of programs, initiatives or interventions that met the defined criteria and answer the following research question: What are community-based, psychosocial interventions, programs or initiatives that have been shown to be effective to support parents, families, children or youth in building coping skills and resilience and increasing a sense of coherence in the recovery stages of a disaster, emergency or epidemic?

Adult-focused interventions, programs or initiatives

Skills for Psychological Recovery training program for disasters workers

The Skills for Psychological Recovery intervention is a skill-based, psychosocial intervention designed to promote the recovery of trauma survivors and increase their self-efficacy to deal with life stressors. While no studies that evaluated the effectiveness of this intervention were identified in our literature search, two studies found that service providers who received facilitator training felt it was useful and that they acquired the skills they needed to deliver this intervention (Heinz et al., 2022; Wade et al., 2014).

This intervention uses five modules with the following aims:

Two studies were identified that evaluated the effectiveness of Skills for Psychological Recovery facilitator training (Heinz et al., 2022; Wade et al., 2014). One of these evaluated the effectiveness of a training and support program for trainers and practitioners working with survivors of floods and cyclones in Queensland, Australia (Wade et al., 2014). This study followed a “train-the-trainer” model and study participants were classified into two groups, trainers and practitioners. The program aimed to recruit, train and support competent trainers, provide systematic high-quality training in the skills required to facilitate the intervention, improve facilitators’ confidence to deliver the intervention and promote its use in disaster-affected areas.

Study participants in the trainer group were required to have experience with evidence-based psychological interventions (e.g., cognitive-behavioural therapy) and to have excellent teaching, communication and interpersonal skills (Wade et al., 2014). Of the 40 trainers who met the minimum requirements for competency, 20 had a background in psychology and the rest identified social work, nursing, medicine, occupational therapy and a variety of other therapeutic professions. Participants in the practitioner group were enrolled in the study if they were providing direct support to people in disaster-affected communities in their current work role and had proficient in counselling and personal support. These practitioners worked in the field of psychology as well as social work and other mental health professions, as well as nursing, medicine, community work and occupational therapy.

Participants in the study’s trainer group completed a two-day in-person training as well as brief online refresher modules at three and six months (Wade et al., 2014). They also had a one-hour session where they received virtual advice, support and feedback from the developers of SPR. A subgroup of the trainers also received coaching support and feedback. Forty of these trainers met minimum competency standards (i.e., clear speech, professional delivery, audience engagement and ability to clearly explain the content).

The 788 participants in the study’s practitioner group completed a one-day, in-person training as well as brief online modules at three and six months (Wade et al., 2014). Of the 730 who agreed to participate in the program evaluation, 684 provided completed data at the pre- and post-training time-points and qualified as Skills for Psychological Recovery practitioners.

The practitioners rated the trainers as being highly competent to deliver the training (Wade et al., 2014). There was no significant association between a trainer’s competency and their professional background. There was a positive association between the total number of sessions with a trainer and their ratings for confidence, effectiveness, time management, facilitation of skills rehearsal, ability to explain the content and ability to answer participants’ questions.

Among practitioners, confidence to use the intervention increased significantly from the pre-training to the six month follow-up evaluation (Wade et al., 2014). However, there was a significant loss of confidence by the six-month follow-up. At the three month and six month assessments, almost two-thirds of practitioners said they had used at least one component of SPR with one or more person. The majority said they had used the intervention with up to 10 people. The most frequently reported barrier to using the intervention was not having seen any clients with problems requiring its use (37 percent at three months and 42 percent at six months). The next most common reasons were being satisfied with their existing approach and lack of time, but these were reported only by six to eight percent of practitioners.

In a second study of Skills for Psychological Recovery training for facilitators, researchers evaluated the effectiveness of training local counsellors and paraprofessionals (not licensed to practice as a fully qualified professional) working with survivors of wildfires in Sonoma County, California (Heinz et al., 2022). The training in this study consisted of five two-day workshops delivered to 389 local counsellors and paraprofessionals. These participants were local marriage and family therapists, clinical psychologists, counsellors, social workers, paraprofessionals and students. The workshops were led by the intervention developers, who also provided group phone consultation and a moderated Facebook group.

The post-workshop evaluation showed that participants found the workshops to be practical and well organized and the materials useful (Heinz et al., 2022). They reported that speakers were knowledgeable, experienced, flexible and responsive. When looking at intention to use the intervention in 10 hypothetical cases, the researchers found that participants were more likely to use an adapted version of Skills for Psychological Recovery than to use another intervention or an approach that did not require psychosocial skills. There were not enough survey responses to report on whether they followed through on their intention to use it. In written feedback at the 12-month follow-up, some counsellors said the training was too long and felt they needed training on how to support clients with the long-term effects of the wildfires and other life stressors. Many asked for ongoing support, such as monthly meetings.

These two studies suggest that Skills for Psychological Recovery training is effective in building the capacity of various health care and non-healthcare professionals to provide support to wildfire survivors, but training is needed to give them the skills to support clients with their ongoing recovery (Heinz et al., 2022; Wade et al., 2014). However, these two studies did not evaluate the outcomes of the intervention, so it remains to be determined if the intervention reduces mental distress and enhance resilience in the recovery stages of a disaster.

Skills for Life Adjustment and Resilience (SOLAR) for bushfire survivors

The Skills for Life Adjustment and Resilience (SOLAR) program is a brief, skills-based, five session, psychosocial intervention. This program was found to be an acceptable intervention to implement in two non-randomized, uncontrolled pilot studies of survivors of mass disasters (O’Donnell et al., 2020). The intervention includes the following modules:

An open-label pilot study of SOLAR enrolled survivors of two 2015 bushfires in South Australia (O'Donnell, 2020). The intervention was delivered by seven facilitators (called “coaches”), consisting of a community nurse, an intern social worker, two case workers and three Australian Red Cross volunteers. To be enrolled as coaches, the trainees completed a two-day training and received weekly supervision, which included skill building and learning to identify bushfire survivors who might need more intensive or specialized treatment. To be successful, they needed to have an 80 percent knowledge score and 70 percent understanding score in their post-training assessment.

Evaluations after the training showed there were significant improvements in coaches' knowledge of the intervention and in their confidence to deliver it to participants after training (O’Donnell et al., 2020).

The study participants were 15 adult bushfire survivors. Participants were either referred by local partner organizations or self-referred through information provided by flyers in the community (O’Donnell et al., 2020). To participate in the study, they were required to have mental health symptoms that caused them to have difficulty functioning in their daily lives but did not meet criteria for a diagnosis of anxiety, posttraumatic stress or depression. They also must not have a previous or current mental health diagnosis or disorder. Anyone with distress or psychiatric symptoms was referred to an appropriate mental health service and was excluded from the study. The researchers assessed the effectiveness of SOLAR based on participants’ reports, based on the main problem they were experiencing, their level of functioning and well-being, and how much the problem was affecting them.

All 15 participants completed the intervention modules. Of the six participants who filled out the satisfaction questionnaire, all felt the program was useful and would recommend it to others. There were large improvements in all outcomes measured (general health and relationship concerns; daily stressors). There were no adverse events and mental health symptoms did get worse in the three months after the intervention ended.

A second pilot study conducted in 2018 showed that a culturally-adapted version of SOLAR was effective, acceptable and safe for survivors of 2015 Tropical Cyclone Pam in the Pacific island nation of Tuvalu (Gibson et al., 2021). This study enrolled 99 adult residents of two islands: one island was used as the active treatment group and the other as the control group. Coaches had experience in disaster response or community support or had a leadership role in Tuvalu. They were trained in the use of SOLAR over a six-day period and received group supervision throughout the intervention period. They received a manual for coaches that was culturally adapted to use in Tuvalu.

The 49 participants in the active treatment group received the SOLAR intervention over five consecutive days in groups of up to 10 people (Gibson et al., 2021). The 50 participants in the control group received usual care (i.e., informal family, community and church-based supports) for two weeks and then received the SOLAR intervention over five days. Both groups were assessed at the beginning and end of the intervention period and six months after completing the SOLAR program. These assessments looked at anxiety, depression and/or posttraumatic stress symptoms and functional impairment (ability to perform daily activities). Participants also completed a demographic questionnaire, a program experience survey and a questionnaire about their experience during Cyclone Pam.

There was a significant decrease in distress and functional impairment, and a small decrease in PTSD-symptoms after  participants received the intervention. In all outcomes measured, there were large significant differences between active and control groups, which were sustained during the six-month follow-up period. While there were increases in symptom scores on each outcome at six months, they were still significantly lower than baseline.

Attendance at the SOLAR sessions was high, with 80 percent attending at least one session and the majority attending an average of four sessions. The mean score on usefulness of the intervention was 9 out of 10 and ranged from 7 to 10. In addition, the intervention was safe, even for participants who had very high levels of distress or post-traumatic stress symptoms at the start of the study.

Results from both pilot studies found large, statistically significant improvements in coaches’ knowledge of SOLAR content, their ability to apply that knowledge and their confidence to deliver the content 2020).They also suggest that SOLAR is a useful psychosocial intervention for adults who continue to have mental distress in the recovery stages of a disaster. One study was limited by its small sample size, lack of randomization and control group, and short follow-up period (O’Donnell et al., 2020). The second pilot was limited because it lack of randomization and by its use of a usual care control group rather than comparing against another type of intervention (Gibson et al., 2021).

Katatagan: A culturally-appropriate resilience intervention after a typhoon

A resilience intervention called Katatagan appeared to build adaptive coping skills among adults living in temporary resettlement areas in Tacloban City, The Philippines, during the recovery phase of 2013 Super Typhoon Haiyan (Hechanova et al., 2015). The intervention was adapted from Skills for Psychological Recovery and integrates the community and spirituality of Filipino culture, in addition to components of the cognitive behaviour therapy model. Katatagan is different from SPR in that it begins by identifying strengths, including cultural strengths, rather than providing prioritizing assistance and psychoeducation (Hechanova et al., 2015).

Katatagan is intended for small groups of adults with mild to moderate difficulties and was delivered by trained paraprofessionals. The intervention includes the following modules:

  1. “Finding and Cultivating Strengths” – Identifies sources of strength to increase self-efficacy
  2. “Managing Physical Reactions” – Teaches coping and mindfulness skills
  3. “Managing Thoughts and Emotions” – Uses reframing and thought substitution activities to manage negative thoughts
  4. “Engaging in Positive Actions” – Explores actions that can help with coping
  5. “Seeking Solutions and Support” – Teaches problem-solving skills
  6. “Moving Forward” – Reflects on the person’s recovery journey to find meaning in their experience (Hechanova et al., 2015).

The program was evaluated in a study with 163 adult survivors of Super Typhoon Haiyan (Hechanova et al., 2016). In this study, the facilitators were mostly psychology faculty from various colleges and universities in The Philippines. The rest of the facilitators were senior graduate students in counselling psychology, a professional counsellor and a member of the clergy with a psychology graduate degree. They received training on the Katatagan intervention, facilitation guidelines and evaluation of the program components. Facilitators also received a detailed manual, which included optional scripts. Those who were less experienced were paired with those who were more experienced.

The intervention was delivered over two days with three modules on each day (Hechanova et al., 2016). Participants were divided into 27 small groups and were mostly women living in communities severely impacted by the typhoon. Outcomes were measured before the intervention, immediately after the intervention and at six months. Thirty-seven participants completed the six-month survey. Two focus groups were conducted with 15 participants at the six month follow-up. Focus group facilitators asked participants about the material they retained from each module, the impacts the intervention had on their ability to cope and whether they had continued to use any of the skills they had learned.

The results of this study showed significant improvements in all the outcomes measured (Hechanova et al., 2016). The greatest changes were seen in the modules focused on harnessing strengths, seeking solutions and support, managing physical reactions, and moving forward. The researchers noted that follow-up peer support may be useful to reinforce the learnings on some modules where they observed a smaller intervention effect (i.e., managing thoughts and emotions, positive actions). Focus group responses showed that participants remembered something from each module, with mindfulness being the most commonly remembered component of the intervention.

In another study of Katatagan, researchers evaluated its effect when delivered by trained paraprofessionals to adults who were still living in a temporary resettlement in The Philippines 18 months after Super Typhoon Haiyan (Hechanova et al., 2018). This study used a mixed methods design that did not randomize participants but compared two Katatagan groups (one month apart) against a group that did not receive the intervention. There were 96 participants who received the Katatagan intervention and 104 in the non-intervention group. The three facilitators, who were undergraduates in psychology, were trained by three of the researchers and were coached by three psychology faculty members experience in Katatagan facilitation. Outcomes were assessed at four points over nine months with a focus on anxiety, adaptive coping and resilience. Two focus groups were conducted after six months, with eight participants in each.

Results showed significant improvements in anxiety and individual resilience in the intervention groups over the follow-up period, while these scores did not change considerably in the no-intervention group (Hechanova et al., 2018). There was a small but significant improvement in adaptive coping scores over time in the intervention group, but this improvement was not maintained at the nine-month follow-up.

Focus group participants reported using adaptive coping skills they learned during the Katatagan sessions, such as managing thoughts and emotions (Hechanova et al., 2018). They described experiencing challenges related to practical aspects of living in a resettlement, such as lack of water and other basic needs. They coped with these challenges by giving and receiving social support and by relying on their faith.

The findings from these two studies show that the Katatagan intervention has the potential to decrease anxiety and improve resilience among adults temporarily resettled following a typhoon in The Philippines (Hechanova et al., 2016; Hechanova et al., 2018). The researchers theorized that the inability to maintain adaptive coping skills over time may have been due to the poor living conditions and lack of clear plans regarding permanent resettlement for participants in this study.

A limitation of the 2016 study was the lack of a control group and the small number of participants in the follow-up assessments. Also, the researchers looked only at participants’ perception that they were able to cope and not at actual behaviours or symptoms (Hechanova et al., 2016). Limitations of the 2018 study were the lack of randomization as well as participants moving out of the resettlement area (Hechanova et al., 2018).

Mind–body yoga for community impacted by wildfires

A mind–body yoga program appeared to enhance well-being in a study of survivors of wildfires in 2017 and 2019 in Sonoma Country, California (Heinz et al., 2022). The mind-body yoga program, called iRest, is a trauma-informed intervention intended to reduce the physical impacts of psychological trauma.  The program uses breathing, relaxation and meditation techniques and restorative yoga postures. The yoga component can be adapted to the needs and limitations of participants and can be used in settings, such as schools and hospitals. The intervention is delivered by yoga instructors who complete training and certification in iRest.

The study included 60 instructors, who led classes for more than 2,000 community members (Heinz et al., 2022). A total of 160 classes were delivered during the study, which followed participants for one year. The instructors completed a survey after each class, focusing on the number of participants and the trauma-informed yoga strategies they had used in the class. Community members were also asked to complete a brief survey after each class they attended.

In their survey responses, instructors described using various trauma-informed techniques, such as breath work and asking permission before touching a participant (Heinz et al., 2022). They reported that many community members did not want to attend the mind–body classes because they believed they were intended for those who had been directly impacted by the wild fires. The instructors felt they needed help in marketing the classes to ensure that community members understood everyone was invited.

Of the 621 surveys gathered from class participants, 63 percent were from individuals who attended more than one class and 60 percent of these said they attended once weekly (Heinz et al., 2022). Eighty-five percent of respondents said they felt much better at the end of class. A third of repeat attendees said they felt better for the rest of the week following a class, and more than a quarter said they felt better for the rest of the day. One in ten attendees said they felt better for several hours. Some participants said that although they had been skeptical that yoga could help them with their distress, they now felt it had improved their ability to cope.

Participants were highly satisfied with the classes: 87 percent rated them as “excellent”, 97 percent felt the class was easy to understand, 95 percent would recommend it to a friend, and 97 percent intended to attend another class (Heinz et al., 2022). Written responses showed that participants felt iRest improved their ability to function and facilitated their recovery. Among instructors, written responses demonstrated general satisfaction with the two-day training, although some felt it was longer than necessary for those with more advanced knowledge of mental health.

Although the study did not gather information about the age, race or sex of participants, the results suggest that trauma-informed yoga could be a useful component of a recovery intervention for disaster survivors (Heinz et al., 2022).

Group-based, integrated mental health and disaster preparedness intervention for disaster survivors

In Haiti and Nepal, a community-based, group intervention that integrated mental health and disaster preparedness education decreased reported depression and PTSD symptoms and increased a sense of belonging (social cohesion) (James et al., 2019; Welton-Mitchell et al., 2018). This three-day intervention specifically was applied in contexts that are chronically exposed to disaster.

One study enrolled 480 randomly selected residents of three disaster-affected communities in the Haitian capital of Port-au-Prince between July 2014 and April 2015 (James et al., 2019). In each of the three communities, half of residents were randomly selected to receive the integrated intervention in small groups of 20 participants. Facilitators were two trained Haitian lay mental health workers.

The intervention used an experiential approach and included the following components:

Research team members facilitated the sessions and interviewed participants (James et al., 2019). Participants were nearly evenly split by gender and were about 37 years old on average. A total of 144 participants completed the intervention sessions. Most were unemployed and about a third were students. Participants in the active treatment and control groups were assessed before the intervention and then at intervals of three to four months for a total of four assessments. These four assessments were used to form the comparison. Members of the control group were invited to participate in the intervention at the fourth assessment.  

At the second assessment, which was three to four months after the intervention, the active treatment group had significantly increased disaster preparedness behaviours and significantly decreased symptoms of depression, anxiety and PTSD. The active treatment group also had increased intention to provide disaster-related and mental health-related help to others. The intervention also increased disaster-related help seeking but not mental health-related help seeking. These effects were the same at the second and the third assessment. While functional difficulties decreased significantly at the second assessment, this did increase did not continue at the third assessment. The data showed an improvement trend in social cohesionscores.

Results from this study showed that this intervention, delivered by local lay mental health workers, may help reduce symptoms of depression, anxiety and PTSD, with effects lasting for at least eight months (James et al., 2019). This study was limited by its high drop-out rate and the use of team members who served as both facilitators and interviewers.

In a second study, an intervention showed positive effects on mental health symptoms and disaster preparedness among survivors of the 2015 earthquake in Nepal (Welton-Mitchell et al., 2018). This intervention was adapted from the intervention developed in Haiti and incorporated similar coping skills and community-building activities. This second study randomly assigned 207 adults to an intervention or control group then used sequential crossover of clusters until all participants had received the three-day intervention. The control group received the intervention about two weeks after the first group.

Sessions were facilitated by six local clinicians (two per group), who were familiar with the local culture and languages and whose educational backgrounds ranged from a certificate in counselling to a Master’s in Psychology (Welton-Mitchell et al., 2018). They received two weeks of training on the intervention and onsite supervision by senior members of the research team. Two support staff with health degrees helped with facilitation. Facilitators were trained to introduce topics related to Nepalese cultural and religious beliefs and encourage participants to engage in supportive discussions. Participants were encouraged to share personal experiences and provided peer support to each other. They also learned and practised coping skills they could use when experiencing distress and received hands-on training on disaster preparedness and peer-based mental health models.

Participants were interviewed individually at three time points: before the start of the sessions, about two weeks later and after the second community received the intervention Welton-Mitchell et al., 2018). The interview questions asked about the impact of the earthquake on their lives, exposure to chronic stressors after the earthquake, self-reported disaster preparedness, symptoms of depression and PTSD, social cohesion and their comfort level with asking for help related to mental health or disaster-related needs. In addition, seven focus groups were conducted with 58 participants about two weeks after the intervention, with questions related to exposure to stressors and the impact of the intervention. One of these focus group consisted only of family members of participants.

Before receiving the intervention, greater depression symptoms and lower social cohesion were associated with lower ratings on disaster preparedness, but PTSD symptoms were not associated with preparedness (Welton-Mitchell et al., 2018). In addition, higher rates of depression and PTSD were associated with lower social cohesion.

Results showed that participation in the intervention increased the level of disaster preparedness and social cohesion and decreased depression and PTSD-related symptoms (Welton-Mitchell et al., 2018). Help seeking behaviours related to both mental health and disaster preparedness increased after participation in the program. The researchers found that the effect of the intervention on depression was partially explained by its effect on disaster preparedness and the effect on disaster preparedness was partially explained by its effect on social cohesion. The effect of the intervention on depression and on PTSD was also partially explained by social cohesion.

The primary themes from the focus groups related to participants feeling that they were better prepared for future disasters, better able to manage distress, more willing to seek mental health support and more willing to support others (Welton-Mitchell et al., 2018). Another theme was the belief that it is important to work together to solve challenges.

The findings from this study supports the use of a group-based intervention that integrates peer support and mental health and disaster-preparedness education for disaster survivors (Welton-Mitchell et al., 2018). However, this study did not use randomization due to ethical concerns related to withholding the intervention from any members of the community. The study also did not follow participants beyond the brief study period.

Volunteer peer support within a health support teamfor earthquake survivors

Participation as a volunteer peer worker within a Health Support Team (HST) disaster recovery program appeared to enhance resilience among earthquake survivors in Haiti and give increase their sense of hope and purpose (Carlile et al., 2014). This intervention was evaluated among survivors of the 2010 earthquake, who received training as part of the HST. The HST used a train-the-trainer model to build the capacity of volunteers to provide psychosocial support to other earthquake survivors.

The study enrolled earthquake survivors who had been volunteering with the HST program for at least six months and had been trained in the previous two years (Carlile et al., 2014). Due to challenges associated with recruiting study participants in a post-disaster setting, the researchers were able to interview only 10 volunteers out of an estimated 150 volunteers who met the enrollment criteria. In addition, there was complete data from only four interviews due to transcription challenges. These four volunteers were single males 28 to 37 years old and three were university students during the earthquake. The researchers used a narrative inquiry interview method that included open-ended, non-directive questions about the HST program and the volunteer’s life before and after the earthquake.

Interview responses showed that the volunteers had felt a sense of fear and hopelessness after the earthquake, and two had experienced more severe symptoms of posttraumatic stress (Carlile et al., 2014). They felt the HST program had helped them connect meaningfully with others and had given them a renewed sense of hope and purpose. Most of them said the main reason for volunteering was to help others, and one also said he felt that if he helped others, they might be more likely to help him in return. The volunteers felt that the training made them better able to help other survivors as well as more capable of coping with their own stress. They said the training also gave them access to social support and networking opportunities.

All four volunteers said that although it was difficult to witness other survivors’ extreme suffering, the work was also a source of comfort and strength (Carlile et al., 2014). One participant described the program as providing tools that the community could use to help rebuild Haiti. However, they felt frustrated at the lack of physical resources or materials they could provide to survivors in need. They also were not satisfied with the quality of translation during the trainings, which they felt might impact their ability to learn the course content.

This study provided preliminary evidence that earthquake survivors who participate as trained volunteer peer workers within a Health Support Team are connected meaningfully with others, learn to deal with their own stress and gain a sense of hope and purpose (Carlile et al., 2014). This study, however, was limited by its small sample size and by difficulties associated with the need to translate interview questions when using a narrative inquiry approach.

Strong Women Strong Families program for farming women who experienced drought

The Strong Women Strong Families program was implemented in 2007 by a group of health and drought service providers working in the Moira Shire of Australia, a largely agricultural area that experienced an extensive period of drought from 1997 to 2010 (Congues, 2014). The program name, “Strong Women Strong Families,” was seen to recognize “the key role that farming women played in maintaining the mental well-being of their families during times of crisis and of the heavy toll that this emotional burden was taking on the mental well-being of the women themselves (Congues, 2015)”.

The program was designed in consultation with five local rural women's groups and consisted of events aiming to share information about mental health and well-being and provide women with food and well-being services, such as facials or manicures (Congues, 2014). The rural women's groups selected the location where these events would be held and the foods that would be provided.

The program was evaluated based on attendance at the events and a survey that gathered data on what participants learned about available drought support services and mental health and well-being services (Congues, 2015). Two-thirds of respondents stated they knew more about available mental health and well-being services than before the events. Participant comments showed that this type of program was needed as long as the drought continued, with many suggesting that similar events should be held for farming men. A key theme from responses was that people in the region needed more opportunities to connect with each other.

The researcher concluded that engaging rural women in mental health promotion activities such as those provided in this program allowed them to connect with each other helped to improve the mental health and well-being of this population (Congues, 2015).

Social group support for earthquake survivors

The use of culturally-appropriate, recreational group activities appeared to enhance well-being among women and older adults living in a transitional community after the 2008 earthquake in Wenchuan County, China (Huang et al., 2013). This initiative was developed as a result of a needs assessment conducted approximately one year after the earthquake, which found that many residents felt distressed or depressed, ruminated about the earthquake and felt lonely and bored a year after the earthquake. To reduce feelings of distress and depression and to enhance social connection, a group of social workers organized two recreational activity groups, which met for 60 to 90 minutes at least once a week. Participants were recruited using convenience sampling.

Each group could select one activity that their group would do together at each session, facilitated by a social worker (Huang & Wong, 2013). One group consisted of about 20 older people: women at least 55 years of age and men at least 60 years of age. This group selected waist drum beating, a traditional Chinese group recreational activity. The second group consisted of 20 women between 30 and 54 years of age. This group chose dance as their recreational activity. The groups sometimes performed their activity for their communities at holiday festivities and other special events. In a later phase of the study, the social workers connected the groups to groups outside the transitional community.

The researchers conducted a focus group with 10 participants from each group to gather qualitative data about subjective feelings, thoughts and experiences related to the earthquake as well as in-depth, semi-structured individual interviews with 13 participants (Huang & Wong, 2013). The researchers tested the validity of individual reports in the focus groups by separately interviewing two participants from each focus group to find out if these reports still rang true.

Results showed that most of the older participants said that, prior to joining the group, they used to stay at home thinking about the earthquake and felt distressed or depressed (Huang & Wong, 2013). Most of them also said that, after joining the group, they felt physically and mentally better, they thought less about the earthquake and they felt that life had become meaningful. They mentioned that being in the group allowed them to build and strengthen relationships and allowed them to cooperate with others. Participants in the women-only group said they had previously felt bored, depressed and even desperate, but they now felt happier and had a sense of meaning. Many participants said their physical health had improved. Some said that being in the group had strengthened and broadened their social networks and some mentioned that their confidence had grown after participating in their group.

The researchers concluded that this type of group work, led by a social worker, can enhance well-being and reduce feelings of distress in disaster survivors (Huang & Wong, 2013). They noted that their study was limited by its small sample size (only two groups of 12 participants) and only two men in the group of older participants. In addition, this study used self-reports of measures rather than objective measures of mental health and well-being. However, it shows that social groups may have the potential for reducing distress and enhancing well-being in disaster survivors.

Group Problem Management Plus for adults following humanitarian disasters in Nepal

Group Problem Management Plus (Group PM+) appears to reduce psychological distress in people living in a disaster-prone region of Nepal when delivered in a group setting by non-specialist facilitators. PM+ is a five-session intervention designed for delivery to individuals and groups in humanitarian settings by facilitators who are not mental health specialists (Jordans et al., 2021). This intervention specifically focused on the use of Group PM+. Group PM+ was previously evaluated in conflict-affected areas and for survivors of gender-based violence, so researchers conducted a study to evaluate its effectiveness in women and men living a disaster-prone region of Nepal.

The study compared Group PM+ against enhanced usual care (Jordans et al., 2021). Participants in both groups were screened for psychological distress and functional impairment. Group PM+ sessions were 2.5 hours long, delivered weekly over five weeks. Sessions focused on problem solving, stress management through deep breathing, behavioural activation and promoting social support. Both intervention groups received a 30-minute psychoeducation session with a briefly trained local community member, focused on adversity and mental health as well as information about referral options. The family psychoeducation and the referral information were the only services given to the study’s enhanced usual care group.

Facilitators were residents of the communities that participated in this study and had no mental health training (Jordans et al., 2021). They completed a 10-day training on foundational helping skills and 10 days of Group PM+ facilitator training, which included supervised practice sessions. They also received weekly, in-person, group supervision from two trained psychologists and counsellors. Facilitators used a training manual and materials that were adapted for use in Nepal. Only those facilitators who had high scores on their competency assessments facilitated the study’s Group PM+ sessions.

The researchers enrolled 611 participants, who ranged in age from 18 to 91 years (average age 45 years). Half had recently experienced a natural disaster, 82 percent were women and one third had a chronic physical illness (Jordans et al., 2021). Groups were assigned based on gender. Participants were assessed for psychological distress, depression symptoms, PTSD symptoms, distress, social support, physical symptoms and functional impairment. The study excluded anyone with severe mental illness, cognitive impairment or harmful alcohol use. Facilitators recruited participants using the Community Informant Detection Tool, which was designed to help people outside of clinical settings identify people who may need mental health support. The research team were masked to group assignment. In the Group PM+ group, 78 percent of participants attended four or five sessions.

Results at the three-month follow-up showed greater decreases in depression symptoms in the Group PM+ group (29.9 percent) than in controls (17.3 percent) (Jordans et al., 2021). Group PM+ participants were 70 percent more likely to have a 50 percent reduction in symptoms than the enhanced usual care participants. The rate of distress was lower in those who received Group PM+ (58.8 percent) than in those who received enhanced usual care (69.4 percent). Thirty-one percent of the difference in distress reduction between the two groups was explained by participants’ use of the psychosocial skills they learned through Group PM+.

The researchers concluded that Group PM+ provides “modest” mental health benefits to people living in a disaster-prone region (Jordans et al., 2021). They noted that the benefits would be greater if activities were added to increase and maintain participants’ use of the skills they learn through the intervention.

A salutogenic approach using community engagement following a disaster

In Lac Mégantic, Quebec, a community-based intervention appeared to reduce the negative psychosocial impacts of a large-scale disaster, including decreasing rates of anxiety disorder diagnoses and increasing protective factors, such as social support and sense of cohesion (sense of belonging) (Généreux et al., 2020). This multi-pronged approach to community recovery emphasized social networks and relationships and was grounded in the principles of salutogenesis, an strengths-based theory used to identify factors that foster well-being, resources or abilities. This approach was developed and implemented after a 2013 train derailment and oil spill led to explosions and a fire, causing 47 deaths and destroying 44 buildings. It also led to the mass evacuation of 2000 residents, the equivalent to one-third of the town’s population.

The intervention was developed by the regional Public Health department with researchers and members of the community based on a series of survey for residents of the region, a one-day priority-setting activity and a recovery plan (Généreux et al., 2020). One key component of the intervention was the creation of a multidisciplinary community outreach team, permanently located in downtown for Lac Mégantic. It consisted of two social workers, an outreach worker, two community organizers, a kinesiologist and a nutritionist. They offered psychosocial support, responded to service requests, provided rapid detection and response to residents’ needs, organized activities and co-led various projects.

Another component of the intervention was a photovoice initiative, in which participants met once a month for six months to take pictures of the community’s assets and used the images to illustrate their vision for the community (Généreux et al., 2020). They also met to share their photos with each other and talk about issues important to them. This group hosted two exhibitions and engaged in discussions with local and federal decision makers.

A third component was Ephemeral Place, an outdoor venue in downtown Lac Mégantic (Généreux et al., 2020). It was created in 2018 in the downtown area, which was largely destroyed during the disaster. This space was used for various free social activities and temporary installations, such as musical shows, barbecues, outdoor film screening, laughter yoga and karaoke.

Finally, the outreach team oversaw the Lessons Learned from a Citizen’s Perspective initiative, a series of individual and group interviews intended to gather residents’ ideas of what could be changed or improved in the future (Généreux et al., 2020). The Public Health department developed a semi-structured interview guide based on the CHAMPSS Functional Capabilities Framework (Communication, Awareness, Mobility/Transportation, Psychosocial, Self-Care and Daily Tasks, and Safety and Security). Outreach team members identified the key themes of the interview responses, validated them with participants, and used these to develop a best practices document for use in the event of another disaster.

A comparison of the community survey responses from 2015 and 2018 showed a reduction in negative psychosocial impacts seen among Lac Mégantic residents in the two years after the disaster (Généreux et al., 2020). For example, the rates of anxiety disorder diagnosed among adults in 2018 had decreased among Lac-Mégantic residents, whereas they had increased significantly in the rest of the region. And while post-traumatic stress remained high (about 72 percent) in 2018, protective factors, such as social support and sense of cohesion, had increased.

While this is a case study and not an effectiveness study, this integrated approach shows promise as an asset-based intervention based on salutogenic principles (Généreux et al., 2020). The researchers concluded that their case study provides “a concrete example of how asset-based approaches can be fruitful for enhancing community resilience and improving the health and well-being of a community in a post-disaster landscape” (p. 1463).

Child-focused interventions, programs and initiatives

Calligraphy training for children with post-traumatic stress symptoms after earthquakes

A calligraphy training intervention appeared to reduce symptoms of post-traumatic stress in children who lived through the 2011 earthquakes in Sichuan, China (Zhu et al., 2014). The intervention began one year after the earthquakes and consisted of a daily one-hour calligraphy class delivered five days a week for 30 days. At each calligraphy session, the children were asked to trace 40 medium-sized characters from five pages using a calligraphy brush.

The children were selected randomly from five classrooms in two schools in areas that had been hit by the earthquakes (Zhu et al., 2014). Three of the classes were randomly selected as the intervention group (65 boys and 64 girls) and two were the control group (41 boys and 40 girls), which did not participate in the calligraphy training. Both groups were assessed for post-traumatic stress symptoms and cortisol levels before the start of training, after 15 days and at the end of training (Zhu et al., 2014). The assessment scale looked at three symptoms: intrusive thoughts and images; avoidance of people, situations or circumstances similar to or associated with the event; and arousal (e.g., hypervigilance, irritability, and sleep problems).

There was a highly significant decrease in stress at the 30-day assessment in the intervention group compared to the control group (Zhu et al., 2014). The intervention group also had much lower intrusion and arousal scores compared to baseline. Arousal scores at 30 days were significantly lower compared to mid-test scores among girls but not boys, although the boys’ scores were both significantly improved compared to pretest. Salivary cortisol levels were much lower at the 30-day assessment than at baseline and mid-test, and levels in the intervention group were significantly lower than in the control group.

These findings show that an arts-based intervention such as calligraphy training can have beneficial effects on post-traumatic stress symptoms in children (Zhu et al., 2014). The researchers noted that this was the first study to show the positive effects of calligraphy training in reducing the post-traumatic stress symptoms in child survivors of a natural disaster. They noted that the act of brush writing are similar to those seen in studies on meditation, which may help explain the beneficial effects of this intervention.

Playing to Live program for children who live through an Ebola epidemic

The arts-based Playing to Live program addressed the psychosocial and mental health needs of children affected by the Ebola epidemic in Liberia (Decosimo et al., 2019). The evidence-based, child-specific and culturally-appropriate program also appeared to build the capacity of local paraprofessionals to provide mental health and psychosocial support to children in the affected communities.

Playing to Live was developed by an art therapist, a child life specialist, a play therapist and a yoga therapist for delivery by paraprofessionals (Decosimo et al., 2019). The aim was to help children heal by engaging them in activities that foster creativity, mentorship and peer support. The intervention included child—friendly activities aimed at increasing their ability to describe emotions and their understanding of the trauma response, and normalized their symptoms and allowed them to share their thoughts, memories and emotions.. Components included art therapy, play therapy, yoga and life skills.

The study started at the end of the epidemic, which hit Liberia from 2013 to 2015 (Decosimo et al., 2019). The study enrolled 40 facilitators, all Ebola survivors and female, who received training on how to build healthy relationships, use trauma coping skills and create an environment that encourages self expression among children. Forty psychosocial workers were also hired and each was partnered with a facilitator to collect data, support the programming and have discussions with family members.

Children were not screened for symptoms (Decosimo et al., 2019). Instead, the facilitators and psychosocial workers were trained in culturally-appropriate approaches to assessing psychosocial stress in children. Children were assessed through observation and interviews with the children and their caregivers. Symptoms were recorded only when the perspectives of the child, their caregiver and the facilitators/workers were aligned. Each facilitator delivered the program to a group of 15 to 25 children in their own community two to three times per week. They were able to choose the activities they felt would be most beneficial.

The program was delivered to two groups using a delayed treatment model, with communities randomized to one of the two groups (Decosimo et al., 2019). The 870 participants were three to 18 years old and were Ebola survivors, from Ebola-infected homes or living in a community affected by Ebola. Group 1 had 533 children, who participated in Playing to Live for five months. Group 2 had 337 children, who participated for three months starting two months after Group 1 started. Group 2 started the intervention two months after Group 1.

The researchers compared seven psychological stress symptoms for each group immediately before the participants started the intervention and at the end of the intervention (Decosimo et al., 2019). Post-intervention data were available for 233 of the original 533 children in Group 1 and for 123 children of the original 337 children in Group 2. Participants without post-intervention assessments were not included in the analysis.

Results showed that symptoms decreased significantly in both treatment groups (Decosimo et al., 2019). The difference between the two groups was not statistically significant. Group 2, which started the intervention two months after Group 1, suggests that symptoms increased while Group 2 waited to start Playing to Live, and that the intervention prevented stress symptoms from getting worse in Group 1.

The researchers concluded that these findings lend support to the use of expressive arts to improve physical and mental health and social well-being in the short term (Decosimo et al., 2019). The study is limited by its short follow-up period and the lack of a control group and a midpoint assessment. In addition, there were numerous data collection challenges, including lack of post-intervention data for 510 participants.

The researchers noted that a Playing to Live representative visited a few of the participating communities a year after the program ended (Decosimo et al., 2019). While they were not able to collect follow-up data during these visits, they found that those who had been program facilitators were still using the activities with children in their communities and with their own children. The researchers noted that this supports the program’s theory that by focusing on building skills within the community, the program is a sustainable approach to post-disaster psychosocial support.

Building Resilience in Kids through Sport for children who experience floods

Building Resilience in Kids through Sport was an interactive sport initiative that used local student-athletes as coaches and appeared to build resilience in children impacted by the 2013 flood in Alberta, Canada (McDonald-Harker et al., 2021). The aim of this initiative was to teach the children about resilience, improve their physical and mental health and well-being and facilitate interactions with others. Soccer was chosen as the sport because it was popular among children and youth in the community, it encouraged collaboration and respect, and it was seen as a low-risk activity. Children were actively consulted throughout the planning and implementation of the program.

This initiative involved 72 children, between the ages of seven and 12 years, who participated in a free, all-day event held in one of the worst-hit regions four years after the flood (McDonald-Harker et al., 2021). The day’s activities consisted of an interactive workshops, with the children grouped by age into four separate groups to learn evidence-based, age-appropriate information about five ways to increase resilience: 1) “communicate with others,” 2) “make connections,” 3) “help others,” 4) “have a positive outlook,” and 5) “think critically.” The workshop was led by three research team members, while six research assistants were student mentors/facilitators. Breakout sessions followed the workshops, where the children practised what they learned using case scenarios. The rest of the day consisted of soccer warm-up activities, drills and ice breakers, followed by non-competitive soccer games, where coaches encouraged the children to put into practice what they learned in the workshop. Eight student-athletes coached the children during the soccer games.

The research team evaluated the impact of the initiative using observation, taking detailed notes during and right after the event, focusing on behaviours, interactions, frequency counts and impacts, as well as group dynamics and the types of assistance provided to the children (McDonald-Harker et al., 2021). The notes were examined, compared, analyzed and coded by all researcher team members.

The researchers concluded that the Building Resilience in Kids Through Sport initiative was effective in teaching children resilience-building strategies (McDonald-Harker et al., 2021). The researchers felt that the children improved their technical and social skills, received guidance and mentorship and had opportunities to talk about challenges and apply resilience strategies.

Whole-community interventions, programs and initiatives

Community-based integrated psychosocial intervention to improve well-being after an earthquake

A community-based, integrated, mental health and psychosocial support intervention showed the potential to improve well-being and decrease levels of distress in a study of survivors of the 2010 earthquake in Haiti (Budosan et al., 2014). The intervention was designed to build the capacity of community psychosocial workers and healthcare providers to provide psychosocial support, with the aim of reducing distress and strengthening resilience among survivors and helping those with severe mental health needs access appropriate mental health services.

The study was conducted 10 months after the earthquake and continued for 15 months. It included:

The capacity-building program followed a train-the-trainer model and was provided by local managers of the emergency relief and organization that developed the training along with a team of psychiatrists, psychologists and social workers (Budosan et al., 2014). The implementation team consisted of a psychiatrist and a team of general practitioners, psychologists and social workers. This team selected 190 local community psychosocial workers and 115 local non-specialized healthcare providers to staff the programs, which included general practitioners, nurses, psychologists, social workers and non-mental health specialists.

There were three cycles of training totaling 90 hours provided to separate groups of seven to 33 community psychosocial workers and the non-specialized healthcare providers (Budosan et al., 2014). The interactive training sessions focused on building the psychosocial workers’ understanding of common mental health problems, psychosocial interventions, practical psychosocial skills, diagnostic tools, the public mental health system and community mental health services. Training was provided separately to psychosocial workers and to non-specialized healthcare providers, and supportive supervision was provided by local implementation team members, the expatriate psychiatrist, and local consultants. Training results were evaluated at the beginning and end of each training cycle.

A total of 115,191 residents received the intervention (Budosan et al., 2014). Of these, 55 percent were women, 45 percent were men, 18 percent were children under five, 24 percent were children between six and 17 years and less than one percent were adults over 65 years. One percent of participants were identified as needing psychiatric consultation (the majority for epilepsy, depression or psychosis). Of these, three quarters received the psychosocial intervention as well as medications, while the remainder received only the psychosocial intervention.

The intervention was evaluated using quantitative community surveys distributed to randomly-selected participants who represented the targeted communities (Budosan et al., 2014). The surveys were given at the beginning of the intervention and one year after its completion. The survey asked about satisfaction with aspects of their well-being, such as economic, family, social, emotional, mental and spiritual.

Satisfaction with all aspects of the training program was 75 percent for the psychosocial community workers and 91 percent for non-specialized healthcare providers (Budosan et al., 2014). Survey results showed that one year after the intervention, there was an increase in participants’ level of well-being and a decrease in their level of distress.

The findings of this study suggest that a community-based, integrated, mental health and psychosocial intervention has the potential to improve well-being and reduce distress for earthquake survivors (Budosan et al., 2014). The researchers acknowledged that the study did not have a control group, so they could not account for other factors that might have had an impact on well-being and distress. They also did not use any formal instruments to validate the scales and tests they used.

Conclusion

Several interventions, programs and initiatives have been shown to provide potential benefit in enhancing well-being and resilience and building coping in the recovery stages of a disaster. Although the evidence identified in the literature had limitations, the interventions show some promise for building coping skills and enhancing well-being and resilience. Common elements in these interventions include a focus on community strengths and the use of activities that were already of interest or of value to the community, such as art, sports, music and dance, as well as cultural and interpersonal activities that allow people to connect others who have had similar experiences.

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This knowledge exchange activity is supported by Evidence Exchange Network (EENet), which is part of the Provincial System Support Program (PSSP) at the Centre for Addiction and Mental Health (CAMH). EENet has been made possible through a financial contribution from Ontario Health. The views expressed herein do not necessarily represent the views of either OH or of CAMH.

This evidence brief was developed by Rossana Coriandoli, Knowledge Broker at PSSP. The author would like to acknowledge Jessica Taylor, Editor at PSSP, and Reena Besa, Librarian at CAMH, for their invaluable support in developing this evidence brief.

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