Flood-Related Mental Illness in Bangladesh

ASSESSMENT OF FLOOD RELATED
MENTAL ILLNESS IN
BANGLADESH
Shafkat Jahan
M.B.B.S
Submitted in fulfilment of the requirements for the degree of

Master of Applied Science (Research)
School of Public Health
Faculty of Health
Queensland University of Technology
2015
Keywords
Floods
Post-traumatic stress disorder
Depression
Anxiety
Drug Abuse
Socio-economic and exposure factors
Multivariable logistic regression
ASSESSMENT OF FLOOD RELATED MENTAL ILLNESS IN BANGLADESH Page i

Abstract
Mental disorders are an emerging global health concern. Natural disasters such as
flooding, tornadoes, cyclones, drought and earthquakes impose substantial psychological
and social stress on affected communities. The adverse human health consequences of
flooding are complex and extensive, including drowning, injuries and an increased
incidence of common mental disorders. It is accepted that floods take a heavy toll on the
mental health of the people affected, who mostly live in developing countries, where the
capacity to deal with the event is extremely limited. Examining the psychological impacts
of flooding is essential for improving the mental health strategies of emergency
preparedness programs, especially for developing countries like Bangladesh which have
limited resources and infrastructure.
The purpose of this study was to assess the mental health impacts of flooding and to
explore the key determinants of flood-related mental illness in the coastal regions of
Bangladesh. Pre and post-flood mental health data in the year 2010-2011 were obtained
from the Directorate General of Health Services of Bangladesh (DGHS). In this research,
data were obtained from Upazila Tala, a county in the Shatkhira district of Bangladesh. A
total of 2,500 people were surveyed before and after the floods in Upazila Tala between
2010 and 2011. More than 67% of the households in this area were flooded with >6 feet of
water in their homes. This study examines the relationship between flooding and mental
illness, including depression, anxiety, post-traumatic stress disorder (PTSD) and drug
abuse.
Chi-square tests with cross tabulation were used to examine the associations between
socio-economic and exposure variables and psychological disorders to find out significant
factors which should be entered into the regression model.
Variables that were significantly associated with each psychological outcome at p≤0.2
were then included in multivariable logistic regression analyses. Psychological disorders
are significantly associated with flood exposure variables. Victims who were flooded with
>6 feet of water in their home suffered 3.98 to 7.13 times more depression than those with
<2 feet water in their home. Victims who were injured during flooding had 1.32 to 3.90
times more depression than those who did not suffer an injury. Similarly, most of the
ASSESSMENT OF FLOOD RELATED MENTAL ILLNESS IN BANGLADESH Page ii

exposure variables were associated with the prevalence of anxiety, PTSD and drug abuse
among the flood victims.
Females are 2.49 to 8.17 times more prone to develop depression than males after a
flooding episode. Married people were 1.52 to 6.82 times more likely to develop
depression than unmarried people. Unemployed people had 2.91 to 4.89 times more risk of
developing depression than employed people after a flood. Respondents with a low
income (<2000 taka) had a higher risk of developing depression than those with a higher
income (>4000 taka) when they were exposed to a flood. After the flood they suffered 3.91
to 6.17 times more depression than the higher income group (>4000 taka).
The total number of mental illness cases increased from 950 (38.0%) to 1,647 (65.9%).
Before the flood, the prevalence of mental illness was 16.7% (depression), 10.6%
(anxiety), 4.9% (PTSD), and 5.7% (drug abuse). After the flood the prevalence increased
to 27.6% (depression), 16% (anxiety), 12.3% (PTSD), and 9.8% (drug abuse).
This study found a significant rise (1.5 to 2.5 fold) in the prevalence of all psychological
disorders, which is consistent with the literature. Women suffered more psychological
distress than men, but younger people suffered more mental illness than the elderly. In
general, all the psychological disorders were significantly predicted by higher exposure to
water level, injury, loss of a family member, financial help and loss of land, which is
consistent with previous findings. However, the influence of other factors (e.g., social
support, education level, coping strategy and previous trauma history) on the prevalence of
mental illness cannot be ignored. An in-depth understanding of these factors is vital in
planning mental health services and improving emergency preparedness programs,
especially among developing countries which have inadequate health infrastructure.
Seven recommendations for future research are derived from this study:
(1) Most of the previous studies have used a cross-sectional study design to assess the
impacts of flooding on mental health. Future studies should consider using a
cohort design.
(2) There is a need to assess the influence of social support, coping strategies and
medication and early intervention in the development of mental distress.
ASSESSMENT OF FLOOD RELATED MENTAL ILLNESS IN BANGLADESH Page iii

(3) Future studies should pay attention to the full spectrum of flood-related
psychological disorders.
(4) As most of the studies have assessed the immediate impacts of a flood event on
mental health, further studies are required on its long term impacts and intervention
strategies.
(5) Further research is needed for proper diagnostic criteria for different disorders so
that co-morbidity of the diseases can be well assessed.
(6) Researchers may compare flood related psychological illnesses between developed
and developing countries to evaluate common risk factors.
(7) Researchers should pay more attention to assessing the impacts of flooding on
suicide rates and post-flood drug abuse.
The findings of this study may help policy makers to improve early intervention and
screening programs and may also have significant public health implications in the control
and prevention of flood related mental illness in Bangladesh.
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Table of contents
Keywords ...................................................................................................................... i
Abstract ........................................................................................................................ ii
Table of contents .......................................................................................................... v
List of figures .............................................................................................................. ix
List of Tables................................................................................................................ x
List of Abbreviations................................................................................................... xi
Statement of original authorship ............................................................................... xiii
Acknowledgements ................................................................................................... xiv
Chapter 1: Introduction
1.1 Background ............................................................................................................ 1
1.1.1 Natural disaster and health .............................................................................. 1
1.1.2 Definition and types of flooding ..................................................................... 5
1.1.3 General scenario of flooding ........................................................................... 6
1.1.4 Floods and mental health in the world ............................................................ 7
1.1.5 Floods and mental health in Bangladesh....................................................... 10
1.1.6 Socio-demographic features of Bangladesh .................................................. 13
1.2 Aims and objectives ............................................................................................. 13
1.2.1 Research aims................................................................................................ 13
1.2.2 Specific objectives ........................................................................................ 13
1.3 Research questions ............................................................................................... 14
1.4 Significance and scope ......................................................................................... 14
Chapter 2: Literature Review

2.1 Overview .............................................................................................................. 15
2.2 Search strategy ..................................................................................................... 15
2.3 Mental health outcomes ....................................................................................... 17
2.3.1 Post-traumatic stress disorder/post-traumatic stress ..................................... 18
2.3.2 Depression/major depressive disorder/major depressive episode ................. 18
2.3.3. Anxiety disorder/ generalized anxiety disorder ........................................... 18
2.3.4 Drug abuse/substance abuse.......................................................................... 19
2.3.5 Other mental health impacts ......................................................................... 19
2.4 Floods and mental health in America and Europe ............................................... 19
2.5 Floods and mental health in the Asia-Pacific region ........................................... 20
ASSESSMENT OF FLOOD RELATED MENTAL ILLNESS IN BANGLADESH Page v
2.6 Floods and mental health studies from Australia ................................................. 22
2.7 Factors affecting the relation between flooding and mental illness ..................... 22
2.7.1 Socio-demographic variables ........................................................................ 22
2.7.2 Age ................................................................................................................ 22
2.7.3 Gender ........................................................................................................... 23
2.7.4 Socio-economic status ................................................................................... 24
2.8 Variables related to the nature of flood ................................................................ 24
2.8.1 Level/extent of exposure to flooding ............................................................ 24
2.8.2 Type and severity of flooding ....................................................................... 25
2.9 Disaster related impacts ....................................................................................... 25
2.9.1 Loss of loved one (s) ..................................................................................... 25
2.9.2 Physical injury ............................................................................................... 26
2.9.3 Loss of home or property damage ................................................................. 26
2.10 Social and psychological factors that mediated flood-related mental illness..... 27
2.10.1 Previous history of psychological trauma ................................................... 27
2.10.2 Previous psychiatric history ........................................................................ 27
2.10.3 Coping strategy ........................................................................................... 27
2.10.4 Co-morbidity ............................................................................................... 28
2.10.5 Social support .............................................................................................. 28
2.11 Research limitations and challenges .................................................................. 28
2.12 Knowledge gaps and future needs ...................................................................... 31
Chapter 3: Methods
3.1 Study design ......................................................................................................... 33
3.2 Conceptual framework ......................................................................................... 33
3.3 Study area ............................................................................................................. 34
3.4 Sampling procedure and study population ........................................................... 41
3.5 Interview schedule and fieldwork ........................................................................ 43
3.6 Data collection...................................................................................................... 44
3.6.1 Exposure assessment ..................................................................................... 44
3.6.1.1 Water level data ....................................................................................... 44
3.6.1.2 Injury data ............................................................................................... 44
3.6.1.3 Loss of family member(s) ....................................................................... 44
3.6.1.4 Financial help .......................................................................................... 44
ASSESSMENT OF FLOOD RELATED MENTAL ILLNESS IN BANGLADESH Page vi

3.6.1.5 Loss of property or land .......................................................................... 45
3.7 Confounding factors ............................................................................................. 45
3.8 Outcome assessment ............................................................................................ 46
3.8.1 Pre-flood mental health data ......................................................................... 46
3.8.2 Post-flood mental health data ........................................................................ 47
3.9 Definitions of assessed mental health disorder .................................................... 47
3.9.1 Post-traumatic stress disorder ....................................................................... 47
3.9.2 Depression ..................................................................................................... 48
3.9.3 Anxiety disorder ............................................................................................ 48
3.9.4 Drug abuse .................................................................................................... 48
3.10 Assessment of mental health disorder ................................................................ 48
3.11 Data management ............................................................................................... 52
3.11.1 Managing the data sets ................................................................................ 52
3.11.2 Missing data ................................................................................................ 52
3.12 Data analysis ...................................................................................................... 53
3.12.1 Descriptive analyses .................................................................................... 53
3.12.2 Multivariable analyses ................................................................................ 53
3.13 Validity and reliability of assessment tools ....................................................... 57
3.14 Ethics .................................................................................................................. 57
3.15 Summary ............................................................................................................ 57
Chapter 4: Results
4.1 Introduction .......................................................................................................... 59
4.2 Socio-demographic characteristics ...................................................................... 59
4.3 The association between flooding and mental health disorder ............................ 61
4.4 Statistical associations.......................................................................................... 63
4.4.1 Bivariate analysis .......................................................................................... 63
4.4.2 Logistic regression ........................................................................................ 68
4.4.2.1 Predictors of depression .......................................................................... 68
4.4.2.2 Predictors of anxiety ............................................................................... 74
4.4.2.3 Predictors of post-traumatic stress disorder ............................................ 78
4.4.2.4 Predictors of drug abuse .......................................................................... 82
ASSESSMENT OF FLOOD RELATED MENTAL ILLNESS IN BANGLADESH Page vii

Chapter 5: Discussions and conclusions
5.1 Summary .............................................................................................................. 86
5.2 An overview of the key findings of the study ...................................................... 86
5.3 Socio-demographic features between two survey populations ............................ 86
5.4 Unadjusted p-value vs. adjusted p-value .............................................................. 86
5.5 Depression ............................................................................................................ 87
5.5.1 Summary ....................................................................................................... 87
5.5.2 Predicting factors........................................................................................... 87
5.5.3 Associated socio-economic factors ............................................................... 88
5.5.4 Gender-based differences in the occurrence of depression ........................... 88
5.6 Anxiety ................................................................................................................. 89
5.6.1 Summary ....................................................................................................... 89
5.6.4 Gender-based differences in the occurrence of anxiety ................................ 91
5.7 Post-traumatic stress disorder............................................................................... 91
5.7.1 Summary ....................................................................................................... 91
5.7.4 Gender-based differences in the occurrence of PTSD .................................. 92
5.8 Drug abuse............................................................................................................ 93
5.8.1 Summary ....................................................................................................... 93
5.8.4 Gender-based differences in the occurrence of drug abuse........................... 94
5.9 Strengthens and limitations of the study .............................................................. 94
5.10 Directions for future research ............................................................................. 95
5.11 Overall implications for public health policy and intervention.......................... 97
5.12 Conclusions ........................................................................................................ 98
References ................................................................................................................ 100
Appendices………………………………………………………………………… 123
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List of Figures
Figure 1.1: Putative causal pathways linking climate change and mental health ........ 3
Figure 1.2: Number of coastal floods occurring worldwide ........................................ 6
Figure 1.3: Percentages of reported floods, worldwide, 1980-2013 ............................ 7
Figure 1.4: People killed by flooding from 1980-2013 in different
regions of the world ..................................................................................................... 8
Figures 1.5: Economic damages due to flooding from 1980-2013 .............................. 9
Figures 1.6: Occurrence of natural disasters in Bangladesh ...................................... 11
Figures 2.1: The process of selection criteria for the inclusion of
studies in the analysis ................................................................................................. 17
Figures 3.1: The conceptual framework for the analysis ........................................... 34
Figures 3.2: Flood affected districts of Bangladesh in 2011
including the study area ............................................................................................. 36
Figures 3.3: Average monthly temperature of district Sathkhira during 1990-2014.. 39
Figure 3.4: Average monthly rainfall of district Sathkhira during 1990-2014 .......... 39
Figure 3.5: Average number of rainy days of district Sathkhira during 1990-2014 .. 40
Figures 3.6: Average river flow from Sathkhira gauge station during 1990-2014 .... 40
Figure 3.7: Flow chart showing the adopted statistical analyses ............................... 56
Figures 4.1: Prevalence of mental health disorders in Upazila Tala .......................... 62
Figures 4.2: Scatter plot of significant interactions between age group and
unemployment status .................................................................................................. 69
Figures 4.3: Scatter plot of significant gender*water level at home interactions ...... 71
Figures 4.4: Scatter plot of significant gender*injury interaction.............................. 71
Figure 5.1: Model outlining significant factors related with
post-flood mental illness ............................................................................................ 99
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List of Tables
Table 3.1: Features of severely affected areas during 2011 floods in Bangladesh .... 35
Table 3.2: Flood damages during 2011 floods in Sathkhira district .......................... 37
Table 3.3: Geography and weather of Upazila Tala................................................... 38
Table3.4: Weather and level of flooding during the floods 2011 .............................. 41
Table 3.5: Patient health questionnaire-9 ................................................................... 49
Table 3.6: Generalized anxiety disorder-7 ................................................................. 50
Table 3.7: PTSD checklist-civilian version (revised and tested in the pilot study) ... 51
Table 3.8: Drug abuse screening test-10 .................................................................... 52
Table 3.9: Missing values in pre and post flood mental health survey ...................... 53
Table 4.1: The prevalence of mental health disorders among pre and
post-flood groups (n=2500)........................................................................................ 60
Table 4.2: Socio-demographic characteristics of Upazila Tala.................................. 61
Table 4.3: Distribution of mental illness associated with different
water levels of Upazila Tala ....................................................................................... 63
Table 4.4: Gender-based differences in the distribution of socio-economic
and outcome variables (pre-flood) ............................................................................. 65
Table 4.5: Gender-based differences in the distribution of socio-demographic
and exposure variables (post-flood) ........................................................................... 66
Table 4.6: Gender-based differences in the distribution of exposure and
outcome variables (Post-flood groups) ...................................................................... 67
Table 4.7: Socio-economic predictors of pre-flood depression ................................. 70
Table 4.8: Major risk factors of post-flood depression .............................................. 73
Table 4.9: Socio-economic predictors of pre-flood anxiety ....................................... 75
Table 4.10: Major risk factors of post-flood anxiety ................................................. 77
Table 4.11: Socio-economic predictors of pre-flood PTSD ....................................... 79
Table 4.12: Major risk factors of post-flood PTSD ................................................... 81
Table 4.13: Socio-economic predictors of pre-flood drug abuse ............................... 83
Table 4.14: Major risk factors of drug abuse ............................................................. 85
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List of Abbreviations
HEQ - Hurricane Exposure Questionnaire
IPCC - Intergovernmental Panel on Climate Change
IES-R - Impact of Event Scale (Revised)
ICMBD - International Classification of Mental Health, Behavioural Disorder
IMH - Institute of Mental Health
MDD - Major Depressive Disorder
MD- Manic Disorder
MCS - Mental Component Score
MDE - Major Depressive Episode
NWS-PTSD - National Women's Study Post Traumatic Stress Disorder module
OECD - Organization for Economic Co-operation and Development
PTSS-10 - Post Traumatic Stress Scale
PWI-SF - Psychological Well Being Index-Short Form
PSLES - Presumptive Stressful Life Events Scale
PD - Panic Disorder
PDGBV- Post Disaster Gender Based Violence
PTSD - Post-Traumatic Stress Disorder
PHQ-9 - Patient Health Questionnaire-9
PAPA - Pre-school Psychiatric Assessment
PCA - Principle Component Analysis
PANAS-C - Positive and Negative Affect Schedule-Child
QOL - Quality Of Life
RCADS - Revised Children Anxiety and Depression Scale
RSES - Rosenberg Self-Esteem Scale
RCMAS - Revised children’s Manifest Anxiety Scale
SCID-IV- Structured Clinical Interview for DSM-IV
SEQ - Social Experiences Questionnaire
SRCM - Self-Report Coping Measure
SASRQ - Stanford Acute Stress Reaction Questionnaire
STAIC-T - State Trait Anxiety Inventory for Children
SSSCA - Social Support Scale for Children and Adolescents
STAI-T - State–Trait Anxiety Inventory for Children—Trait version
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SRQ-20 - Self Reporting Questionnaire-20
SQD - Screening Questionnaire for Disaster Mental Health
SLIPSS-A - Sri Lankan Index of Psychosocial status- Adult version
SSS - Social Support Scale
UNOSAT - United Nation’s Operational Satellite Application Technology
USAID - United States Agency for International Development
WHO - World Health Organization
WMO - World Meteorological Organization
ZRDS - Zung Self Rating Depression Scale
ASSESSMENT OF FLOOD RELATED MENTAL ILLNESS IN BANGLADESH Page iv

Statement of original authorship
I have not submitted the work contained in this thesis to meet requirements for an award at
this or any other higher education institution. To the best of my knowledge and belief, the
thesis contains no material previously published or written by another person except where
due reference is made.
Signature: QUT Verified Signature

Date: July 2015
ASSESSMENT OF FLOOD RELATED MENTAL ILLNESS IN BANGLADESH Page v

Acknowledgements
I would like to thank my supervision team, Prof. Shilu Tong, Dr. Sue Naish and Dr. Sam
Toloo for their tremendous support during my master study. Shilu made sure I always
stayed on track and encouraged me to work hard. His academic advice and prompt
comments on my written work were highly valuable for my study. I will be forever
thankful for his patience, flexibilities and support throughout the journey of this Master’s
program. Sue and Sam spent endless hours to comment on my thesis and gave me support
and advice.
I would also like to thank Dr. Michelle Gatton for her valuable advice which helped me to
improve my statistical knowledge.
I would like to acknowledge the School of Public Health and the Institute of Health and
Biomedical Innovation, QUT, for the support provided during my research.
I would also like to acknowledge the Directorate General of Health Service (DGHS),
Dhaka, Bangladesh for permitting me access to the survey data needed to do the analysis.
ASSESSMENT OF FLOOD RELATED MENTAL ILLNESS IN BANGLADESH Page vi

Chapter 1: Introduction
1.1 Background
1.1.1 Natural disaster and health

Natural disasters impact on many people throughout the world. The material and financial
consequences of natural disasters have been extensively documented (CRED, 2010;
WMO, 2011). Floods may cause direct physical harm and fatalities due to drowning and
acute trauma (Li et al., 2007; Brunkard et al., 2008; Yeo and Blong et al., 2010); injuries
(Schnizler et al., 2007; Zahran et al., 2008) and toxic exposure (Fox et al., 2009; Cox et al.,
2008). However, the pattern of fatalities differs between developed and under developed
countries depending upon socio-economic and cultural factors (Alderman et al., 2012).
During flooded conditions, and in the aftermath, there is a potential risk of transmission of
faeco-oral diseases due to lack of clean water and sanitation (Ahern et al., 2005). Many
studies that have assessed post-flood water-borne disease outbreaks found increased cases
of cholera (Sidley, 2008), diarrhoeal diseases (Abaya et al., 2009; Schwatz et al., 2006),
cryptosporidiosis (Katsumata et al., 1998), poliomyelitis (Van et al., 2002), rotavirus (Fun
et al., 1991), typhoid and paratyphoid (Vollard et al., 2004), and hepatititis A and E
(Watson et al., 2007; Aggarwal and Krawczynski., 2000). Similarly, upper-respiratory
tract infection is the most common type of infection that may occur after floods (Diaz,
2004). Carrol et al. (2010) found that flu-like symptoms such as throat infections, coughs
and generalized fatigue were more common among flood-affected people after the 2005
floods in England. Besides upper respiratory problems, skin rashes and earache were
common among the flood victims (Reacher et al., 2004). Vector borne diseases such as
malaria outbreaks were reported after flooding due to areas being waterlogged (Abaya et
al., 2009). However, other studies also emphasized a chronic impact of flooding such as
malnutrition (Del Ninno and Lundberg et al., 2005). A large number of research studies
have been conducted on flood-related water borne diseases in Bangladesh (Kunii et al.,
2002; Siddique et al., 1991; Fun et al., 1991), while only one study has assessed flood-
related mental health issues (Dunkin et al., 1993).
Chapter 1: Introduction Page 1

In contrast, the short and long-term psychological consequences of disaster experiences are
largely unknown. Victims of disasters typically experience serious emotional breakdowns
prior to, during, or immediately following a disaster. The effects of traumatic events on
people’s mental health can be chronic, extensive and sustained (Nurse et al., 2010).
Disasters such as earthquakes, tropical cyclones, floods and volcanic eruptions have
claimed approximately 3 million lives worldwide during the past 20 years, have adversely
affected the lives of at least 800 million people, and have cost more than $50 billion in
property damage (CRED, 2011).
In general, natural disasters impact more heavily on poorer countries than on wealthy ones
(Anderson, 1991). For example, more than 3,000 deaths per disaster occur in low income
countries compared with the average of 500 deaths per disaster that occur in high income
countries (CRED, 2011). The poor are usually at higher risk due to their inability to afford
proper housing structures and mental health services. They generally live along coastlines
where hurricanes, storm surges, or earthquake generated tidal waves often strike, or they
live on flood plains subject to inundation. Sometimes they are forced to live in sub-
standard housing built on unstable river banks or slopes that are susceptible to landslides,
or close to industrial sites (Anderson, 1991).
Climate change has become an increasing global concern, where more frequent, long
lasting and severe weather extremes affect human health (WHO, 2014; IPCC, 2014).
These weather extremes create a variety of health impacts (Aharn et al., 2005, Noji et al.,
2005) ranging from the immediate effects of physical injury and morbidity and mortality
through to potentially long lasting impacts on mental health (Haines et al., 2006). Different
aspects of climate change may affect mental health through direct and indirect pathways,
leading to serious mental health problems. The direct impact of climate change includes
frequent exposure to physical injury during floods or storms, which elevate the rates of
acute anxiety disorder. Indirect impacts include more frequent and/or severe damage to
peoples’ homes and physical infrastructure; which may elevate a victim’s anxiety and
mood disorder (Berry et al., 2010). Berry et al. described the direct and indirect pathways
of climate change impacts on mental health (Figure 1.1). With the changing climate, the
frequency and intensity of all the natural disasters, especially heat waves and flooding will
increase (WHO, 2011). The prevalence of mental illness will increase with the increasing

frequency and severity of flooding. According to Berry et al. (2010) direct impacts of
disasters such as fires, extreme heatwaves and burns may impair physical health which
may lead to mental illness. On the other hand, following disasters, trauma related to the
event or community disruption such as loss of livelihood, poverty, isolation or
displacement may cause acute/chronic mental illness. Therefore, it is important to assess
the potential impacts of socio-demographic and economic factors on mental illness so that
strategies for early intervention and control of mental health problems can be put into
place.

Mental health disorders are an emerging global health concern, and along with
neurological disorders and substance use, constitute 36% of the global burden of disease,
surpassing the incidences of cardiovascular disease and cancer (WHO, The global burden
of disease: update 2010).
Mental health can be defined as:-
Mental health is defined as a state of well-being in which every individual realizes

his or her own potential, can cope with the normal stresses of life, can work
productively and fruitfully, and is able to make a contribution to her or his
community (WHO, 2014).
‘During a person’s lifetime, different traumatic experiences can produce significant

adverse mental health consequences’ (Turner and Lloyd, 1995). Post-traumatic stress has
been positively associated with a range of psychological disorders (McMillan et al., 2002).
A considerable body of research has accumulated suggesting that there is a close link
between individual exposure to different traumatic events and psychological disorders.
These events include sexual abuse (Browne and Finkelhor, 1986; Burnam et al., 1988;
Green, 1993; Stein et al., 1988; Yama, Tovay and Fogas, 1993), physical violence and
abuse (Bryer, Miller, and Krol, 1987; Holmes and Robins, 1988), parental death and
parental divorce (Brawn and Harris, 1978; Brown, Harris and Bifulco, 1986; Barnes and
Prosen, 1985; McLeod, 1991), parental psychopathology and substance abuse (West and
Prinz, 1987) and natural disasters (Navarro et al., 2014; Marshall et al., 2014; Scheeringa
et al., 2008). Previous studies (Bland et al., 1996) show that major adverse experiences
associated with trauma may have long term impacts on mental health outcomes (Harris et
al., 1986; Harris, Brown, and Bifulco, 1990; Kessler and Magee, 1994; McLeod, 1991).
Natural disasters like floods, tornadoes, cyclones, drought and earthquakes may change the
psychological and social behaviour of the affected community (Logue et al., 1981).
Generalized panic disorder (frequent attacks of terror), bipolar disorder, suicide and
paralysing trauma rarely occur after major disasters because people need long term
exposure to psychological trauma to generate these above mentioned disorders, and
survivors quickly recover from the initial shock. However, anxiety, neuroses and
depression may occur in spite of the length of time from the onset of the emergency (Noji

et al., 2005). The consequences of exposure to a disaster have not been fully addressed in
the literature in terms of mental health (Alderman et al., 2012).
Yet experiencing a disaster is often one of the single most serious traumatic events a
person can endure, and this experience can have both short and long term effects on mental
health and functioning, such as dissociation, depression and post-traumatic stress disorder.
For example, victims of the Mexico floods in 1999 suffered depression 6 months after the
event, and post-traumatic stress disorder 2 years after the event (Norris et al., 2004).
1.1.2 Definition and types of flooding
There are many definitions of flooding (WHO, 2014). According to the WHO flooding is
defined as:-
An increase of water that has a significant impact on human life and well-being.
When normally dry land is inundated partially or completely by the water that has
escaped from a lake, a river, a creek or any other natural watercourse, whether or not
altered or modified; or any reservoir, canal, or dam, this can cause flooding
(Geoscience Australia, 2015).
There are several types of floods: flash floods, riverine (fluvial) floods and storm-
surge (coastal) floods, single event floods, multiple event floods and seasonal floods
etc. (WMO, 2014).
In Bangladesh, people suffer from flash floods when excessive rainfall occurs in the
neighbouring hills and mountains of India (Mirza, 2002). Riverine floods cause
excessive damage to property and loss of life when major rivers reach their flood
peaks simultaneously (Mirza, 2002), during the June to September monsoon season
(NAPA, 2005). Riverine floods have caused the most devastating floods in
Bangladesh in 1974, 1980, 1984, 1987, 1988, 1998 and 2004. Storm surge floods
which typically happen in large estuaries, extensive tidal flats, and low-lying islands
occur frequently in Bangladesh. Storm surges caused by tropical cyclones cause
widespread damage to property and loss of life in the affected area (Mirza, 2002).
These floods are not the result of rainfall but of sea water being pushed inland by
strong cyclonic wind.

In 2011, the south-west coastal regions of Bangladesh suffered from severe riverine
flooding due to excessive rainfall in those area in the months of June to August.
1.1.3 General Scenario of Flooding

Flooding is the most common and frequently occurring natural hazard (WHO, 2011).
Many countries around the world often suffer from flooding events. From 1999 through to
2009, floods were the most frequent type of natural disaster statistically, accounting for
more than one-third of all disasters occurring in that decade (CRED, 2011). From 2000 to
2009, more than 65% of all natural disaster victims lived in Asia (e.g., China, India,
Pakistan and Bangladesh) and Africa (e.g., Kenya, South Africa and Tanzania). Figure 1.2
shows the overall number of coastal floods which occurred during 1950 to 2009.
Global coastal flooding by decade

1950-1959
1960-1969
Period of time
1970-1979
1980-1989
1990-1999
2000-2009
0 5 10 15 20 25 30 35
Number of coastal flooding
Figure 1.2: Number of coastal floods occurring world-wide.

Source: OECD coastal flooding report; 2011.
Regionally, the major natural disasters occurring in Asia were 15 per year, in Latin
America and Africa 10 per year, in North America, Europe, and Australia, one each per
year (Noji et al., 2005). The data demonstrates that Asia was the most natural disaster
prone part of the world, whether or not the disasters in a region were measured by
economic loss and/or by the numbers of deaths and injuries (WMO, 2013). A projected
sea level rise could threaten the livelihood of millions of poor rural people living in the
low-lying areas of the Asia-Pacific region. Figure 1.3 shows the percentages of reported
floods in different regions of the world.
Percentages of floods of all natural disasters

50
45
40
Percentages of floods
35
30
25
20 %
15
10
5
0
Africa America Asia Europe oceania
Affected region
Figure 1.3: Percentages of reported floods of all natural disasters in world regions,
1980-2013. (Source: EMDAT, accessed on 2nd July 2014).
1.1.4 Floods and mental health in the world
Floods are the most frequent and intense type of disaster in both developed and developing
countries, with recent events occurring in the United Kingdom, the United States of
America, Australia, South East Asia, Europe and Africa (Ahern et al., 2005). The adverse
human health consequences of flooding are complex and extensive: these include
drowning, injuries and an increased incidence of common mental disorders (Hajat et al.,
2003). The disease burden following a flood event ranges from psychopathology
(depression, anxiety disorder and substance abuse) to physical injury and systemic illness
(Cook et al., 2008). It is accepted that floods take a heavy toll on the mental health of the
people involved, those who mostly live in developing countries where the capacity to deal
with the event is extremely limited (WHO, 2001). Most of the studies on the impacts of
flooding on mental disorders are from high or middle income countries like Australia,
Poland, the United Kingdom and the United States (Ahern et al., 2005). There is only one
study from Bangladesh which found changes in childrens’ behaviour after a flood (Durkin
et al., 1993).
The decade 2001-2010 was the second wettest since 1901. Floods have been the most
frequently experienced extreme events over the course of this decade. Eastern Europe was
particularly affected in 2001 and 2005, India in 2005, Africa in 2008, Asia (notably
Pakistan, where 2000 people died and 20 million were affected) in 2010, and Australia,
also in 2010 (WMO, 2013). During the decade 2001-2010, more than 370,000 people died
as a result of extreme weather and climate conditions, including heat waves, cold spells,
drought, storms and floods (CRED, 2013). According to the 2011 Global Assessment
Report, the average population exposed to floods every year increased by 114% globally
between 1970 and 2010, a period in which the world’s population increased by 87% from
3.7 billion to 6.9 billion.
In the past decade (2002-2011), about 2.2 billion people in the Asia-Pacific region were
affected by disasters and almost 750,000 were killed (WMO, 2011). The number of deaths
in the region during this period is almost four times higher than the number of deaths
during the previous decade, i.e., 1992-2001 (EMDAT, 2014). The number of disaster
related fatalities is higher in this region due to dense populations, geographical features
(low-lying coastal areas), low resources and the poor infrastructure in place to deal with
the natural disasters (IFAD, 2014). Figure 1.4 shows the number of deaths due to floods in
different regions of the world.
People killed by floods between 1980-2013

8000000
7000000
Number of people killed
6000000
5000000
4000000
3000000
2000000
1000000
0
Africa Americas Asia Europe Oceania
Affected region
Figure 1.4: Number of people killed by flooding from 1980-2013 in different regions of
the world. (Source: EMDAT, accessed on 2nd July, 2014).

Coastal flooding causes substantial economic losses leading to increase emotional distress
among the victims. Figure 1.5 shows the economic damage due to flooding from 1980-
2013 in different regions of the world.
Economic Damage due to flooding

450000000
400000000
Economic damage (000 $)
350000000
300000000
250000000
200000000
150000000
100000000
50000000
0
Africa Americas Asia Europe Oceania
Affected Region
Figure 1.5: Economic damage due to flooding from 1980-2013

(Source: EMDAT, accessed on 2nd July 2013).
Like most disasters, flooding can lead to loss of life and property damage, with a
significant impact on public health that can extend far beyond recovery. In terms of
physical losses, floods account for 40% of property damages from all natural disasters
(Alexander, 1993). Despite increased levels of preparedness however, deaths, diseases,
and injuries continue to occur in affected communities. Flood exposure has been
associated with significantly increased incidences of mental disorders such as anxiety,
depression, post-traumatic stress disorder and suicide (Biswas and Mukhopaddhay, 1999;
Ahern et al., 2005; Mason et al., 2010). The disorder most commonly found in people
exposed to flooding is post-traumatic stress disorder (PTSD) (Breslau, Chase and
Anthony, 2002; Norris, 2005; Mason et al., 2010). The symptoms include sleep
disturbance, emotional numbing, avoidance and exaggerated arousal (American
Psychiatric Association, 2002). Disaster related experiences such as bereavement, threat of
death, loss of a loved one, property damage changes to socio-economic and family status
(loss of family, financial crisis and job loss) may all act as cumulative stress indicators
which may be associated with increased psychological distress (Hobfall, 2001; Verger et
al., 2003). The groups vulnerable to the health impacts of flooding are the elderly,
disabled, children, women, ethnic minorities and those from low-income countries (Hajat

et al., 2003). Over the past 40 years, a number of epidemiological studies have examined
the psychological consequences of disasters. Most have shown that disasters can contribute
to mental disorders (Bromet and Dew, 1995; Acierno et al., 2007; Kessler et al., 2006).
Evidence shows that 20%–25% of people affected by natural disasters are vulnerable to
developing mild to severe forms of psychological illness as a result of the traumatic event
(WHO, 2010).
1.1.5 Floods and mental health in Bangladesh

Bangladesh is one of the countries which has been significantly affected by natural
disasters. Figure 1.6 shows that about 272 natural disasters affected Bangladesh from 1970
to 2014, out of which 79 were floods (Bangladesh Meteorological Department, 2014).
Most of the floods occurred in the north-west, central, north-east and some parts of south-
east regions of Bangladesh which lies on the downstream part of three major river basins,
namely the Ganga, the Meghna and the Brahmaputra Rivers (Bangladesh Meteorological
Department, 2014). These floods have caused devastation in Bangladesh throughout
history, especially during the years 1966, 1974, 1985, 1988, 1998, 2008 and 2011
(Bangladesh Meteorological Department, 2014). Extreme events such as floods, droughts
and cyclones directly and indirectly affect the health of people almost every year. Several
studies have predominantly concentrated on water-borne diseases in Bangladesh due to
their frequent outbreaks during the post–flood periods (Siddique et al., 1991; Fun et al.,
1991; Kunii et al., 2002). However, only one study (Durkin et al., 1993) has examined the
effects of floods on children. Their results have demonstrated a significant change in
children’s’ behaviour following a flood. Nevertheless, the psychological impacts of floods
on the adult population of Bangladesh are still unknown.

Natural disasters in Bangladesh
Landslides
Epidemic
Type of the disaster
Earthquakes
Draught
Floods
Extreme Temp.
Mass mov. Wet
Storm
0 20 40 60 80 100 120 140

Number of occurence
Figure 1.6: Occurrence of natural disasters in Bangladesh from 1970-2014 (EMDAT,

2014).
The association between flood related mental illness and socio-economic positions is
unclear. The relationship between socio-economic factors and flood related mental illness
can be well observed after the comparison of the prevalence rates of mental illness among
flood affected people in different areas of Bangladesh. Therefore, further studies are needed
to evaluate the psychological consequences of flood affected people in different socio-
economic groups in Bangladesh.
1.1.6 Socio-demographic features of Bangladesh

Bangladesh is one of the most densely populated countries in the world (1076/km2) with a
small land area of 147,570 km2 and a total population of 158,799,518 (Bangladesh Bureau
of Statistics, 2015). It lies in the tropics in an enormous delta formed by three mighty
rivers, the Ganges, the Brahmaputra and the Meghna. Bangladesh is bordered on the west,
north, and east by a land frontier with India, and in the southeast, by a short land and water
frontier with Burma (Myanmar). On the south is a highly irregular deltaic coastline which
contains many rivers and streams, which all flow into the Bay of Bengal (CEGIS, 2015).
The combined effects of these geographical features significantly affect the weather in
Bangladesh. The country’s climate is subtropical monsoon. Countries like Bangladesh

which lie within the Ganges-Brahmaputra-Meghna basin will suffer an increase in rainfall
during the monsoon period, and this is predicted to be 4%-8% by the 2020s and 9%-10%
by the 2050s (Tanner et al., 2007). The combined total rainfall catchment of these rivers is
about 1.74 million km² and the amount of water coming through Bangladesh varies from
less than 5,000 cubic metres per second in the driest period (March-April) to 80,000-
140,000 m³/s in late August to early September. Therefore higher rainfall outside
Bangladesh in the monsoon season is likely to lead to more frequent and severe floods
originating in the swollen river (Alam, 2004). About 60% of the land area is fertile low
land (<6 metres above sea level) with an average river gradient of 6cm/km in the delta, so
Bangladesh is extremely vulnerable to large volumes of water flowing down these rivers
leading to riverine and other types of flooding. Bangladesh is at extreme risk because of
climate change due to its high hazard rivers, low-lying coastal margin and rapid population
growth, which includes a large proportion of highly vulnerability groups of people (IPCC,
2007).
Bangladesh is an economically unstable, over-populated country. Around 24% of the

population lives below the poverty line. When extensive flooding affects the rural areas
people lose whatever small assets they have and suffer from lack of work and loss of
income. In the future, it is highly likely that Bangladesh will suffer from more extreme
weather events such as heat waves, floods, cyclones, landslides, tornados and earthquakes
(IPCC, 2007).
Exposure and vulnerability are dynamic; varying across temporal and spatial scales and
depending on socio-economic, demographic, cultural, institutional governance and
environmental factors (CRED, 2011). Both individuals and communities are vulnerable to
flood-related psychological illnesses based on inequalities expressed through levels of
socio-economic status, pre-flood health status, and level of exposure, flood related losses
as well as age, gender and other demographic characteristics.
During the 2011 floods, 34 out of 64 districts were affected by riverine floods.
(Bangladesh Bureau of Statistic, 2012). During June-August of 2011 riverine floods struck
in different parts of Bangladesh. Due to excessive rainfall, the nearby rivers and tributaries
burst their banks and flooded the catchment areas. The coastal areas of Sathkhira, Khulna
and Jessore were severely flooded during this period. In this study, Upazila Tala, a county

in the Sathkhira district was selected for a study of flood related mental health issues.
Upazila Tala was selected because >67% of the people were affected by severe flooding
(>6 feet), therefore the prevalence of psychological illness caused by the severity of
flooding can be assessed. Most people in Upazila Tala are farmers/fieldworkers and are of
low socio-economic status. After the 2011 floods, there was been a marked change in the
socio-economic and demographic characteristics, which may have increased the
prevalence of mental health disorders. As Upazila Tala is a coastal area, most of the
farmers lost their land because of landslides and became unemployed, which may have
increased their stress levels. To evaluate the significant relationship between socio-
economic conditions and exposure factors and flood-related mental illness in the coastal
areas of Bangladesh, Upazila Tala was selected. This area has the typical socio-economic
features similar to other low-lying coastal areas of Bangladesh.
Therefore, this is the first study to evaluate flood-related mental illness in the adult
population in Bangladesh. In this study, four common mental health disorders are assessed
including drug abuse. Only one previous study was found (North et al., 2004) that
estimated flood-related drug abuse but that particular study did not find any significant
relation to flooding. Previous studies did not use any baseline data or previous records to
assess post-flood psychological illness. In this population based study, this researcher used
pre-flood baseline information to assess flood related mental illness. As very few studies
have been undertaken in the poorest countries (such as Bangladesh, Sri Lanka and
Pakistan), more studies in this region are needed. In this study, the relationship between
socio-economic and exposure factors and psychological outcomes was assessed in order to
gain a better understanding of the risk factors of flood-related mental illness in Bangladesh.
1.2 Aims and Objectives
1.2.1 Research Aims
The study aims to assess the impact of floods on mental health in Bangladesh.
1.2.2 Specific objectives

 To evaluate the association between flooding and mental illness among the people
from a flood affected area in Bangladesh.

 To find out the association between socio-economic and exposure factors and
mental illness.
1.3 Research Questions

• Is there any association between flooding and mental health among the affected
people of a coastal region of Bangladesh?
• Do socio-economic and exposure factors have any association with the prevalence
of psychological disorders?
• Is there any gender based difference in the occurrence of flood related mental
illness?
1.4 Significance and Scope

It is anticipated that more frequent and intense weather events will occur in Bangladesh as
climate change proceeds. These events will result in increased deaths, injuries and disease
in poor, low-lying and heavily populated areas (IPCC, 2013). The complexity of social,
environmental and psychological dynamics during an emergency cannot be
underestimated. Floods are the most common natural disaster in Bangladesh but the
psychological effects of flooding are still not clear. In this project, a severely affected
coastal area of Bangladesh is selected as a study site to find the association between
flooding and the prevalence of mental illness, as well as to explore the association between
socio-economic and exposure factors and the prevalence of flood related mental illness. As
little is known about the health consequences of flooding, it is important to find out the
mental health impacts of flooding in Bangladesh. It is hoped that the outcome of this study
will provide an improved understanding of the relationship between socio-economic
positions and flood related psychological distress, which may help to improve mental
health policy in disaster management programs.

Chapter 2: Literature Review
2.1 Overview
The primary objectives of this research are to assess the impacts of floods on mental health
among people living in the severely affected coastal region of Bangladesh. Bangladesh is a
poor, densely populated and humid country in the Asia-Pacific region. Although the health
impacts of flooding have been investigated in previous studies (Schwartz et al., 2006;
Shimi et al., 2010; Carrol et al., 2010), the psychological impacts have not been well
addressed in any country of the Asia-Pacific region, particularly Bangladesh. A few
studies have researched post-traumatic stress disorder after the flood events, but the
impacts of other mental health issues are still unknown (Amstadter et al., 2009; Kar et al.,
2007). Therefore in this current study, the literature on floods and mental health has been
critically reviewed to gain an improved understanding of the impacts of post flooding
mental illness.
2.2 Search Strategy

A systematic literature search has been conducted to identify relevant studies on flood
related mental illness. Electronic databases including MEDLINE (via EBSCOhost),
Science Direct, Web of Science and Pub Med were searched. Literature searches were
conducted in March 2012 with no date or language restriction. The databases were
searched with the following key words or MeSH terms: ‘mental health’ and/or ‘flooding’
‘mental illness’ and/or ‘natural disaster’ and/or ‘tornado’ and/or ‘cyclones’ and/or ‘tidal
waves’, ‘tsunami’ and/or ‘flash flood ‘and/or ‘post flooding health effect’ and/or ‘social
disruption’, ‘Asian flooding’ and/or ‘determinants’. All the publications obtained through
the literature search were assessed based on the titles and abstracts. The following selection
criteria were applied prior to the selection of articles for inclusion.
Primary inclusion criteria:

Only flood related health studies were included where flooding occurred as a single event
(flash or coastal or riverine floods) or as an effect of other events (hurricane, cyclone,
tornado and tsunami). Studies related to other disaster/ life-time trauma were excluded.
Chapter 2: Literature Review Page 15

The pattern and severity of flood related mental illness may differ when floods
followed other events such as hurricanes, cyclones, typhoons or tsunamis (Fernandez
et al., 2015). All relevant papers were included in the literature review.
Selection criteria:
1. Only post flooding mental health studies were selected. Other health impacts of
floods (e.g. infectious diseases, parasitic diseases), emergency preparedness,
statistical modelling of risk, exposure assessment methods, strategy to improve
community support and co-morbidity assessments were excluded.
2. Data collection methods: epidemiological studies (e.g. Paranjothy et al., 2011;
Fredman et al., 2010) including survey questionnaires were included, but clinical
studies were excluded.
The initial search generated 489 potentially relevant references (Figure 2.1). After
removing duplicates and studies related to other natural disasters based on a review of the
abstracts, 163 studies were deemed to be potentially appropriate for primary inclusion.
Upon further review, 65 references not meeting inclusion criteria 1 were excluded. The full
texts of all remaining flood studies were analysed. Thirty-three studies were excluded
based on selection criteria 2. Finally, 65 studies were included in this analysis. Full texts of
all relevant papers were obtained, and critically reviewed.
Additionally, the literature was also obtained from relevant government agencies on floods
and mental illnesses in Australia (Figure 2.1).

Figure 2.1: The process of selection criteria for the inclusion of studies in this
analysis.
2.3 Mental health outcomes

The major mental health disorders that have been analysed in the previous studies
are:
a. Post-traumatic stress disorder (PTSD)
b. Major depressive disorder (MDD)
c. Major depressive episode (MDE)
d. Anxiety disorder
e. Panic disorder (PD)
f. Generalized anxiety disorder (GAD)
g. Post-traumatic stress (PTS)
h. Psychological distress

i. Substance abuse
j. Suicidality
The possible impact of floods on each of these conditions is described in the following
section.
2.3.1 Post-traumatic stress disorder/post-traumatic stress
A number of papers (n=29) have considered post-traumatic stress disorder (PTSD) as the
dominant form of psychopathology that is associated with natural disasters (Ahern et al.,
2005; Sprang et al., 2009; Mills et al., 2007; Kumar et al., 2006). PTSD symptomology is
complex in nature and includes some of the major symptoms of other psychological
disorders (DSM-IV). Most of the previous studies have only assessed PTSD among people
who have been the victims of floods people using the single diagnostic tool. However,
some of the studies have used the same diagnostic tool that diagnoses PTSD for all other
psychological disorders, which will underestimate the prevalence of other mental illnesses
and subsume the symptoms as PTSD. This may lead to a higher prevalence of PTSD than
other disorders (Murray et al., 2011).
2.3.2 Depression/major depressive disorder/ major depressive episode

After post-traumatic stress disorder, the second most common mental illness among
people living in flood affected areas is depression or major depressive disorder (MDD).
During an extensive search only 18 studies were found accounting for depression or
MDD. Most of the studies show a high prevalence of depression after the event (Kar et al.,
2007; Tells et al., 2009; Amstadter et al., 2009). As there is no clear-cut evidence of
difference between the symptoms of MDD and MDE (major depressive episode), previous
studies have assessed these as a single entity (depression) using the same diagnostic tools
(Ruggiero et al., 2009). Likewise, MDE was also considered as MDD in this study.
2.3.3 Anxiety disorder/generalized anxiety disorder
18 out of 52 studies measured anxiety or generalized anxiety disorder along with PTSD
(Chae et al., 2005; Achierno et al., 2007; Tunstall et al., 2006; Madrid et al., 2008; Galea et
al., 2007). Some previous studies found the high occurrence of post-flood anxiety disorder.
In most of the studies (Ruggiero et al., 2009; Acierno et al., 2007; Weems et al., 2007)
anxiety was measured using the generalized anxiety disorder diagnostic tool.

2.3.4 Drug Abuse/substance abuse
To reduce distress following a disaster people may start to take illegal or non-prescribed
medication. Several studies have assessed post-disaster mental disorders, but only one of
them has measured post flooding drug abuse (North et al., 2004). These researchers tried to
assess the course of the substance abuse (drug and alcohol abuse) along with other
psychological disorders, but found no new substance abuse cases following the floods. In
this study, drug abuse was measured using the drug abuse screening tool (DAST-10) but
alcoholism was not included.
2.3.5 Other mental health impacts
Only one paper from Vietnam has included panic disorders (PD) along with other
mental health disorders [15]. About 9.3% of victims suffer panic disorder after a
flood. Some of the other papers have registered mental illness as being emotional or
psychological distress or aggressive behaviour without classifying into a disorder
(Sauza et al., 2007; Durkin et al., 1993; Fewtrell et al., 2008). Only one study has
investigated suicidality (Anestario et al., 2008).
2.4 Floods and mental health in America and Europe

Following the selection criteria, a total of 44 studies from America and Europe were
identified which demonstrated the relationship between floods and mental health
(See Appendix A, Table A.1 for details). Most of the studies from the USA (28 out
of 31) assessed people’s mental health after American hurricanes and three studies
assessed mental health after floods. The majority (n=37) of the papers reviewed
considered a population sample of adults affected by floods (Acierno et al., 2007;
Kessler et al., 2006; Green et al., 1990). Most of the studies (n=31) were cross-
sectional in nature (Kessler et al., 2006; Mills et al., 2007; Stimpson, 2006). The
timing of the studies, relative to the flood event, varied from data collected pre-event
to data collected zero to two weeks to 8 years after flooding (Kessler et al., 2006;
Acierno et al., 2007). However, the vast majority fell between six months and 24
months post event (Acierno et al., 2007; Scheeringa et al., 2008). Twenty-two out of
31 studies from the USA assessed post-traumatic stress disorder and found a
significant increase in the prevalence rate after a flood event (Scheeringa et al., 2008;
Pina et al., 2008). The highest rate, i.e. 50.5%, was found among populations of
people affected by Hurricane Katrina in the USA (Sprang et al., 2009). Very few
studies have researched PTSD, anxiety and depression as one study (Acierno et al.,
2007; Galea et al., 2007) and these have found a significant increase in the
prevalence rate.
Ten studies assessed the mental health impacts of flooding in the UK (Paranjothy et
al., 2011; Tunstall et al., 2006; North et al., 2004, Fredmen et al., 2010; Mason et al.,
2010; Fewtrell et al., 2008; Carroll et al., 2008; McMillen et al., 2002; Solomon et
al., 1990; Bennet et al., 1970). The prevalence of post-traumatic stress disorder after
the UK’s 2007 floods was 39.5% of cases in flooded groups versus 21.1% in the
control groups (Paranjothy et al., 2011). Tunstall et al. (2006) found anxiety in 55%,
mild depression in 14%, moderate depression in 9% and severe depression in 5% of
the sample after the 1998 floods in England.
Goenjian et al. (2001) found severe levels of post-traumatic stress disorder and
depression among the affected adolescents after Hurricane Mitch which affected
Nicaragua and Honduras in 1998.
A significant rise in PTSD was found after the 1997 floods in Southern Poland
(Strelau et al., 2005).
Norris et al. (2004) found that PTSD was higher (24.1%) among the study sample
than a baseline sample after the 1999 Mexican floods. Similarly, post flooding PTSD
was higher after the 1992 floods in France (Verger et al., 2003).
One study from Germany (Nitschke et al., 2006) found higher PTSD among a group
of people who had experienced a flood, but found no significant alteration in the
prevalence of anxiety and depression.
2.5 Floods and mental health in the Asia-Pacific region

18 studies demonstrated a relationship between floods and mental illness in the Asia-
Pacific region during 1993- 2013 (See Appendix a Table A.2 for details).
Five studies were from China and India (Liu et al., 2006; Huang et al., 2010; Li et al.,
2010; Feng et al., 2007; Tan et al., 2004; Telles et al., 2009; Kar et al., 2007; Kumar et al.,
2006; Kar et al., 2004; Kar et al., 2007). In China, all the studies concentrated on the 1998
flood in Hunan and found 8.6% to 11.1% cases of PTSD among the flood affected people
(Liu et al., 2006; Huang et al., 2010; Li et al., 2010; Feng et al., 2007; Tan et al., 2004). Liu

et al. (2006) found a significant association with age, gender and flood type with the
prevalence of PTSD symptoms (Table 2.2). Kar et al. (2004) assessed psychological
impacts after the Orissa floods 1999 in India and found a higher prevalence of PTSD,
anxiety and major depression disorder, 44.3%, 57.5% and 52.7%, respectively. They re-
assessed psychological disorders 18 months after the event and the prevalence of these
disorders was still high among the adolescent group (the prevalence of PTSD, major
depressive disorder and anxiety disorder were 26.9%, 17.6% and 12%, respectively).
Similarly, PTSD was high (12.7%) in Tamil Nadu after the 2004 flood (Kumar et al.,
2006).
Two studies from Sri Lanka assessed PTSD among tsunami-affected people in the coastal
region in 2004 (Fernando, 2008; Neuner et al., 2006). PTSD was significantly higher both
in adults and children after the tsunami. Similarly, after the tsunami in the Aceh province
in Indonesia, the prevalence of severe emotional distress was 83.6% and depressive
symptoms were 77.1% (Souza et al., 2007). The prevalence of PTSD was 4.18 times
higher than the baseline group among the affected group in Aceh one year after the event
(Frankenberg et al., 2004).
Chae et al. (2005) interviewed affected people from the Gangwon province of South
Korea in 2002 and found significant higher scores for PTSD, anxiety and depression.
Fifty-three percent of the sample had mild depression, 17% severe depression and 22%
had PTSD in Garisan-ni, Inje-gun and Gangwon-do provinces in Korea after the 2006
floods (Hoe et al., 2008).
Amstadter et al. (2009) collected 4 wave data from the Da-Nang floods in Vietnam in
2006 and the post typhoon prevalence of post-traumatic stress disorder was 2.6%, major
depressive disorder was 5.9%, panic disaster was 9.3% and generalized anxiety disorder
was 2.2%.
From Bangladesh, only one study was found that assessed behavioural changes among 2
to 9 year old children after the 1998 floods (Durkin et al., 1993). Before the flood, 16% of
the children in the study were found to have wet their beds; post flood, this increased to
40.4%.

Compared to America and Europe, and despite the frequent occurrence of floods, very few
studies were found on the psychological effects of floods in the Asia-Pacific region. So the
psychological outcomes due to flooding in the Asia-Pacific region are still not clear.
2.6 Floods and mental health studies from Australia

Only three relevant flood studies were found that related to Australia (See Appendix a
Table A.3 for details). Prince (1978) assessed psychological disorders among people who
had been flooded and found the psychological impact following floods was 14.1% higher
among women below 65 years of age than men. The study assessed general psychological
distress as an overall health impact of floods without specifying a psychological disorder.
Similarly, Abraham et al. (1976) found that psychological disturbance was more
prominent than physical disturbance among a group of people who had experienced a
flood. Turner et al. (2012) assessed the health of Brisbane residents after the 2011 floods
and found 22% of the sample was at high risk of psychological distress directly affected by
the floods.
2.7 Factors affecting the relation between flooding and mental illness
2.7.1 Socio-demographic variables
The literature review has demonstrated that a range of demographic variables are
associated with the mental health effects of floods, for example, age, gender, education and
socio-economic status. In multivariate analysis, not all studies found that the same set of
variables were associated with PTSD and other psychological disorders. However, older
age, female gender, lower education, and low income appear to be the demographic factors
that are consistently reported to be associated with PTSD.
2.7.2 Age
The majority of papers reviewed in this study considered population samples of adults
affected by a particular flood. A few papers (Madrid et al., 2008; Durkin et al., 1993;
Acheron et al., 2007) sampled specific populations: ten (15%) addressed people aged
under 18 worldwide; four studies were from the particular affected region; two were
conducted in evacuation shelters after hurricane Katrina; one specifically sampled ethnic
minorities; one assessed patients evacuated from a heart centre; and one looked at a school
mental health clinic.

Madrid et al. (2008) found that school based health centres in Louisiana were called upon
to provide increased mental health services among children after hurricane Katrina, which
occurred in August 2005. 53% of the respondents reported an increase in the prevalence of
mental illness. Anxiety and adjustment problems were higher among the students who
were displaced during the hurricane. Nearly half of the parents who were involved in the
study have developed some new emotional or behavioural problems. Vigil et al. (2005)
compared the mental health condition of adolescents (12 to 17 years old) 2 months after
hurricane Katrina. Adolescents exposed to and displaced by the event show a higher
prevalence of depression, anxiety, fear, self-injury and social withdrawal and symptoms of
distress than the control group. Galea et al. (2007) also estimated mental health conditions
in young people and found a higher risk of anxiety-mood disorders after hurricane Katrina.
Acierno et al. (2007) specifically studied the mental health impact of hurricane Katrina
among older groups (61+ years old). They compared the psychopathology of older people
with the younger adult group. Older adults showed fewer symptoms of posttraumatic
stress disorder (PTSD), generalized anxiety disorder (GAD) and major depressive disorder
(MDD). They found that significant predictors of these mental disorders were social
support, health problems, and prior trauma history. Females may have higher rates of
depression and GAD. But in older groups almost all predictors were the same except
female gender, but were related to lower income for PTSD. Exposure variables were more
prominent in the older group.
Only four studies observed children of 3 to 15 years after hurricane Katrina (Hensley et al.,
2008; Pina et al., 2008; Scheeringa et al., 2008; Weems et al., 2009). They found that
children were the group most vulnerable to mental illness and the prevalence of PTSD was
high (37%, 23.9%, 15.7% and 41%, respectively).
2.7.3 Gender
Women have been found to have a higher risk of developing mental illness, especially
PTSD after flooding (Mills et al., 2007, Sprang et al., 2009; Tobin et al., 2005; Verger et
al., 2003; Liu et al., 2006; Kumar et al., 2006). Many of the studies showed that female
gender was a significant predictor of mental illness. Liu et al. (2006) assessed the mental
impacts among the flood affected villagers of Hunan, China. 8.6% of the sample were
diagnosed with PTSD two years after the flood. One of the significant risk factors was
being female (OR 1.12; 95% CI, 1.04 to 1.21). Feng et al. (2007) found that females

suffered more PTSD than males (10.2% female vs. 8.2 % males) after the same flood. On
the other hand, Cooker et al. (2006) did not find any significant relationship between
gender and mental illness. Amstadter et al. (2009) also did not find that gender was a
significant risk factor for PTSD after typhoon Xangsane in Vietnam.
2.7.4 Socio-economic status

Limited resources within low income countries make it difficult to prepare for floods, as
often resources to build a sea defence or other counter-measures do not exist in areas that
are at risk of flooding caused by rising sea–levels (Haines et al., 2006). Many studies have
taken socio-economic conditions as a potential confounder and found significance
(Solomon et al., 1990; Verger et al., 2003; Kumar et al., 2006; Kar et al., 2004). Solomon
et al. (1990) assessed the psychological impact of flooding in Saint Louise, UK, and Puerto
Rico and found people with low income (n=37) had higher psychological stress than
others (F=1 8.24, d= 1, P =.001). As Kumar et al. (2006) evaluated, after the floods in
Tamil Nadu in 2004, individuals with no income had a higher risk of developing PTSD
than those with a higher income (OR=2.93, 95% CI=1.25-6.86). On the other hand, Kar et
al. (2004) found that middle class people had a higher prevalence of PTSD symptoms than
lower class people (OR=2.3, 95% CI, 1.2-4.1).
Huang et al. (2010) found that illiteracy gave a higher probable positive rate of PTSD
(24.9%) as compared with 3.1% for those with high school education. Some other studies
from the Asia-Pacific region found that poor education is a vulnerability factor for post-
flood mental illness due to lack of awareness (Kar et al., 2004; Hoe et al., 2008).
2.8 Variables related to the nature of flood

According to the literature, the characteristics of floods have a significant impact on
people’s mental health. A number of studies found a significant relationship between the
nature of floods and mental illness (Logue et al., 1979; Liu et al., 2006).
2.8.1 Level/ extent of exposure to flooding

A higher intensity of psychological disorders was concentrated among people who are
directly exposed to flooding than non-exposed people (Russoniello et al., 2002; Logue et
al., 1979). The level and duration of exposure were significantly associated with the
presence of PTSD symptoms and could be used as a predictor of the intensity of PTSD

symptoms that the people experienced during the event (Strelau et al., 2005). Goenjian et
al. (2001) found that the highest level of exposure had the highest level of PTSD RI scores
among adolescents of severely affected areas (total: mean=58.6, SD=12.8) than those in
less affected areas (total: mean=27.9, SD=13.7) after the floods in Nicaragua.
Coker et al. (2006) examined the people who were evacuated after hurricane Katrina. They
found that people were more than twice as likely to report moderate to severe PTSD
symptoms (OR= 2.4, 95% CI, 1.0-6.2, P < 0.005).
2.8.2 Type and severity of flooding

The type of flood may determine its severity. The effects of flash floods differ from
riverine floods in China. Liu et al. (2006) assessed the prevalence of mental illness among
a flood-affected group in Hunan, China. The prevalence of PTSD was higher among the
people who suffered from flash floods. They found flood type to be a significant predictor
of the event (flood type: OR=3.12, 95% CI [2.76-3.52]). Tan et al. (2004) assessed the
mental impact of flooding in a sample of three classified groups. They compared the
prevalence of mental illness and found the higher risk among collapsed groups rather than
among the soaked group (collapsed vs. control group: -5.81 [-3.59,-8.02]) and soaked vs.
control group [-3.66 (-1.11, -6.21)]. No such study is found from western regions.
2.9 Disaster related impacts

2.9.1 Loss of loved one (s)
In general, families who lose their loved ones may need more emotional support. In
addition to the physical, social and economic stability losses that affect most disaster
victims, this group must cope with the grief that attends the loss of a loved one (Noji,
1996). If family or friends have been killed or were missing, post disaster stress among
these people is significantly higher than in others (Coker et al., 2006). The death toll due to
riverine flooding may be not as high as other disasters like an earthquake, a tsunami or a
hurricane. Most of the studies found a positive relation between disaster and loss of life,
especially after hurricane Katrina (Coker et al., 2006; Neuner et al., 2006; Dewaraja et al.,
2006; Souza et al., 2007). Dewaraja et al. (2006) also reported that witnessing the death of
a child, elderly relative, neighbour or friend predicted a diagnosis of PTSD. Neunar et al.
(2006) did zero level correlation between PTSD and loss of a family member and found it
to be a significant predictor of PTSD.

2.9.2 Physical injury
Injuries are common during flood events as people try to save themselves. In the aftermath
of a flood, injuries are likely to occur as victims try to return to their homes to clean up the
damage and debris. Electrocution, burns, gas leaks or other injuries may occur along with
minor lacerations, and other wounds sustained during the cleaning up procedures. Most of
the studies described physical injury as a positive predictor of post flooding mental illness,
especially PTSD (Mills et al., 2007; Coker et al., 2006; Solomon et al., 1990; Strelau et al.,
2005; Frankenberg et al., 2004). Galea et al. (2007) reported that hurricane related stress of
physical injury or illness (OR=2.8, 95% CI [1.2-6.6]) and physical adversity (OR=7.9,
95% CI [3.2-19.7]) are associated with increased odds of PTSD. Frankenberg et al. (2004)
assessed physical injury as a stressor of mental illness among the affected people of
Indonesia and found a significant relation with PTSD (OR=1.23, 95% CI [0.60-1.85]).
2.9.3 Loss of home or property damage

From 1980 to 1985, approximately 160 flood related events occurred worldwide, in which
almost 20,000,000 people were left homeless (WMO, 1995). In terms of physical losses,
floods account for 40% of property damage from all natural disasters (Alexander, 1993).
Floods accounted for around $4 million dollars per year in economic losses in the USA
(NRC, USA annual report; 1994). Several studies found that people who lost property due
to a flood had a higher risk of developing mental illness (Scheeringa et al., 2008; Wealde
et al., 2008; Tobin et al., 2005; Carroll et al., 2008; Frankenberg et al., 2004). Wealde et al.
(2008) examined loss of property or damage as a risk factor for ASD and PTSD. They
found that exposure to threat and loss of property contribute significantly as a predictor of
these mental disorders (F [1.68] =34. 29, p<. 001). Continued disrepair of a damaged
home and property predicted stable elevated level of PTSD throughout the 2 year period
after hurricane Katrina (OR =2.71, 95% CI [1.04-7.04]) (Weems et al., 2009). But it is not
clear that this significance is due to its individual contribution or if it is part of an
accumulation of general exposure to the event.

2.10 Social and psychological factors that mediated flood-related mental
illness
2.10.1 Previous history of psychological trauma
Some studies show that people affected by disaster may have had some traumatic
experience in their lives which may aggravate the post disaster mental stress (Vernberg et
al., 1996; Hoe et al., 2008; Strelau et al., 2005; Amstadter et al., 2009). Hoe et al. (2008)
assessed affected people in Korea who are directly affected by flooding every year and the
prevalence rate of mild depression was 53%, severe depression 17% and PTSD 22%. The
odds ratio of previous trauma exposure was significant (OR=0.76, 95% CI [0.21-2.12]).
Amstadter et al., (2009) did a bivariate analysis and found that previous experience of
trauma was a significant risk factor for PTSD after a typhoon in Vietnam (OR =7.07, 95%
CI [2.06-4.33]).
2.10.2 Previous psychiatric history

Mental health status before any disaster like a flood appeared repeatedly as a predicting
factor in many studies (Mills et al., 2007; Tobin et al., 2005; Verger et al., 2005 Kar et al.,
2004, Amstadter et al., 2009). Kar et al. (2004) estimated the prevalence of psychological
disorders after the Orissa flood in 2000. The prevalence of post-traumatic stress disorder
was 44.3%; anxiety disorder 57.5% and depression 52.7%. People with positive
psychiatric history were more likely to develop a post-flood psychiatric disorder.
Amstadter et al. (2009) found that previous traumatic history with a prevalence of 46.5%
in the same population was a significant factor for all the psychiatric illness in bivariate
analyses, but it lost significance for generalized anxiety disorder in multivariate regression.
2.10.3 Coping strategy

A negative coping strategy may increase the chance of developing mental illness following
a disaster. Coping behaviour is different depending upon age, gender, socio-economic
status, and social support of the affected group of people. Vernberg et al. (1996) examined
568 school age children 3 months after hurricane Katrina and found that a negative coping
strategy acts as a potential risk factor for PTSD. Terranova et al. (2009) also established
the effect of a negative coping strategy with the prevalence of PTSD following Katrina
[R2=0.33, F (5,146) =14.191]. Children might be particularly at risk because they have not
yet developed adult coping strategies and do not yet have the life experiences to help them
understand what has happened to them. In addition, most young children depend on

routine and consistency in their environment, relationships, and home life for a sense of
security and identity.
2.10.4 Co-morbidity
Most studies looked at special diagnoses, but some concentrated on co-morbidities. Norris
et al. (2004) examined the co-morbidity between PTSD and MDD after the Mexican flood
of 1999. There was a substantial degree of co-morbidity between PTSD and MDD, and
those victims who have both disorders do not vary over time. The average prevalence of
MDD among people who had PTSD was 23.4% compared to 4.4 % who do not have
PTSD. Acierno et al. (2007) investigated the prevalence of major psychological disorders
and their risk factors after hurricane Katrina in Florida 2004. PTSD general was 3.6%;
PTSD hurricane was1.4%; GAD was 5.5% and MDE was 6.1%. On the other hand, many
previous studies failed to show true co-morbidity. Acute somatic disorder (ASD) acts as a
predictor for PTSD after hurricane Katrina (Mills et al., 2007).
2.10.5 Social support

Many studies support the view that social support is strongly correlated with PTSD and
other mental health conditions following a disaster (Weems et al., 2007; Pina et al., 2008;
Ruggiero et al., 2009; Feng et al., 2007; Vernberg et al., 1996). The level of support helps
to predict PTSD. Weems et al. (2004) found that social support was negatively related to
the brief symptom inventory score, suggesting that better social support acts as a protective
factor against the mental health impacts of flooding and other disasters.
There are many different forms and ways of measuring social support. PTSD was
associated with total support (OR=0.8, 95% CI [0.78-0.82]), subjective support (OR=0.48,
95% CI [0.44-0.52]), and support utilization (OR=0.53, 95% CI [0.49-0.57]) after the
floods in Hunan, China in 1998 (Feng et al., 2007), although not with objective support.
Low availability of social support on the other hand can be a risk factor for PTSD. Acierno
et al. (2007) found from bivariate and multivariate analysis that low social support 6
months prior to a hurricane was a risk factor for PTSD (OR=7.92, 95% CI [1.54-40.63]).
2.11 Research limitations and challenges

Any research in a disaster field is a challenge for the researchers, because mental health
research is particularly difficult to conduct due to a scarcity of reliable standard indicators;

the diverse nature of diagnosis; social stigma; a raised level of stress and the subjective
nature of the data. The literature review shows a substantial number of methodological
complexities and challenges during the conduct of the research on the psychosocial impact
of flooding. They include:
• Different definitions: There is no universally accepted statement about the

definition used in different mental health research. The researcher may use the
same and different terms to explain people’s experiences, responses and mental
illness (Weems et al., 2007; Nurse et al., 2011).
• Wide range of methodologies: Different range of methodologies and

understandings used in various studies that were scrutinized (Galea et al., 2005,
Kessler et al., 2005).
• Broad and compound range of mental disorders: Mental disorders are broadly
assessed and described in different research. It is very complex to give proper
understandings of the disorders based on different literature (Murray et al., 2011).
• Different diagnostic tools: Due to an absence of universal screening tools,

researchers are prone to using different diagnostic tools appropriate for their
sample (Madrid et al., 2008; Fredman et al., 2010, Prince, 1978). They are not
properly comparable nor adequately validated for the purpose for which they are
used.
• Complexity in the classification of the nature of floods: The nature and type of
floods differ in various regions. The previous literature review shows the
difficulties in classifying floods and the population that was exposed to it (Liu et
al., 2006).
• Proper understandings of the scale of the event: The severity of the event should be
properly described to better understand the impact of the event. It is important to
realize that people may find it difficult to separate the immediate effect of flooding
from subsequent events and their effects. This was the case after hurricane Katrina,
where widespread flooding followed devastating winds (Liu et al., 2006, Tan et al.,
2004).
• Categorization of natural hazards: When the event involves more than one
element, for example, when the primary hazard is wind, which provokes a
secondary hazard, a flood, it is difficult to explain exposure stressors. When a
series of events occurs, the effects are compound, overlapping, additive and short,
medium and long term (Mimura et al., 2011).
• Logistic challenges: Research programs rely upon the health and social
infrastructure of a country. Floods can cause destruction of the health management
system, including health data systems. To conduct research, organizing a new
strategy involving a local community is quite challenging. Organizing an efficient
research team with limited funding is difficult (Murray et al., 2011).
• Self-reporting questionnaires as an epidemiological method: Most of the studies

rely on self-reporting questionnaires rather than clinical interviews due to time and
resource limitations. Self-reporting may cause over reporting or under reporting of
cases which need further clinical assessment for proper diagnosis (Scheeringa et
al., 2008).
• Cross-sectional study design: Most of the previous studies are cross-sectional in

nature. These studies proceed without data regarding people’s pre-event health
status. So, the effect recorded in those literatures may be the result of pre-existing
disorders, exacerbated disorders or new disorders (Kumar et al., 2006; Kar et al.,
2007; Telles et al., 2009).
• Different cut-off thresholds: In different studies different cut-off thresholds are

used as diagnostic tools. The cut-off values were not properly interpreted in their
studies to show how they classified the mental health symptoms in different
categories. This makes it difficult to compare reported prevalence rate of those
studies (North et al., 2004; Vigil et al., 2008).
• Measurement of exposure level: It is hard to define or measure exposure in many

disasters. Impact measurement is easier than measurement of exposure due to the
complexities of the issue. Several studies assessed the level and the type of the
exposure among the sample population and show the association between
exposure data and mental impacts of flooding (Acierno et al., 2007; Hensley et al.,
2008).
• Recall bias: Measurement of flood-related stresses are retrospective, personal and

subjective in nature. This increases the chances of recall of past experiences being

influenced retrospectively by people’s recent and current experiences and
psychosocial functioning (Kessler et al., 2008).
• Defining the population at risk: Previous studies show that it is quite difficult to
define the ‘population at risk’ or construct a scientifically rigorous sampling frame
for a standard study of a population or to conduct cohort studies. The sampling
frame and study population have an impact on the generalizability of the results
(Nurse et al., 2011).
• Different statistical models: Different statistical models are used in different

studies. Therefore, it is difficult to compare the statistical outcomes of different
methods (Coker et al., 2006; Nurse et al., 2011).
• Potential confounders: Many studies investigating mental health impacts of floods

have not included any or very limited confounding factors in their analysis (North
et al., 2004; Fewtrell et al., 2008; Fredman et al., 2010; Prince et al., 1998; Carroll
et al., 2008; Strelau et al., 2005).
2.12 Knowledge gaps and future research needs

• Research from low-income Asian countries: Most previous studies were from high
income countries such as the USA and Europe, with very few studies from the
Asia-Pacific region. Only one study was undertaken in Bangladesh, which
assessed the violence of parents on children following flooding (Durkin et al.,
1993).
• Substance abuse and suicidality: Only one study assessed post-flood prevalence of
suicidality (Kessler et al., 2006) and drug abuse (North et al., 2004). The
prevalence of post disaster substance abuse from the Asia-Pacific region is yet to
be investigated.
• Future research into the influence of social support and post flood socio-economic
destruction in the development of mental distress is needed.
• Long term impacts of flooding: Many studies were undertaken on the immediate
impacts of flooding on mental health, but studies were lacking on the long-term
impacts and its principal causes. Future research could be conducted on the
psychosocial experiences of the populations in short, medium and long term
periods following flooding.
• Coping strategies of different age population: The response and impacts of
flooding on different age population may vary depending on the different coping
strategies of the community. Future research is needed for better understanding of
the different coping strategies on the nature and magnitude of mental health
problems.
• Longitudinal study: Most of the previous studies are cross sectional; hence, the
longitudinal impacts of flooding should be assessed.
• Proper definition and understandings of psychosocial problems: Further research

can help by providing definitions of psychological disorders, psychological needs
that are agreed upon and approved internationally. Scientifically acceptable
understandings of flood related mental illness definitions are needed.
• Development of an international system is required for the cross comparison of

different findings.
• Validated improved instrument: The instruments used should be well validated and
include separate diagnostic criteria for different disorders. Most of the previous
research used criteria which are more reliable for PTSD rather than for other
disorders. Further research should focus on diagnostic criteria for different
disorders so that co-morbidity of the diseases can be well assessed.

Chapter 3: Methods
3.1 Study design

This study used data collected by the Directorate General of Health Services (DGHS) of
the Ministry of Health and Family Welfare (MOH&FW), Government of Bangladesh. The
data contained two independent cross-sectional surveys to assess the prevalence of mental
illness before and after the flood which occurred in June 2011. The first survey was
conducted during July–December 2010, and the second survey during July–December
2011. The independent variables included in this study were flood exposure factors such as
water levels in homes during flooding, injury, loss of family member, social support or
financial help and loss of land or damage to the property due to flooding. The dependent or
outcome variables include: post-traumatic stress disorder (PTSD), anxiety, depression and
drug abuse. Socio-demographic factors (age, gender, chronic illness, marital status,
employment status and monthly income) are potential confounders. The study did not
examine the issue of suicide because the number of cases (<2%) was not sufficient to
assess the actual causes of this trauma (IMH report, Bangladesh 2012).
3.2 Conceptual framework

Constructing a mental health impact pathway diagram is complex but is important in order
to better understand of the problem. The conceptual framework of this study is constructed
based on the review of the literature (Berry et al., 2010; Few, 2007), but it is not a causal
model per se. Social vulnerability to flood related mental illness is composed of a mix of
biological factors, socio-economic factors and exposure factors, and the corresponding set
of resources needed to deal with mental illness.
As described in Chapter 2, floods and poor socio-economic conditions may adversely
influence people’s mental health status. They act as potential stressors of mental illness. In
the analysis, this study quantified the prevalence rate of mental disorders after floods and
the influence of a range of secio-demographic variables on the relationship between floods
and mental health. Figure 3.1 illustrates the conceptual framework for the analysis, which
includes key independent and dependant variables and a range of confounding factors.
Chapter 3: Methods Page 33

Socio-economic factors
1. Marital status
2. Employment status
3. Monthly income Exposure factors
Biological factors 1. Water level at home
1. Gender 2.Injury
2. Age group 3. Loss of family member
3. Chronic illness 4. Financial help
5. Loss of land or property
Mental illness
Figure 3.1 The conceptual framework for the analysis.
3.3 Study area

Bangladesh is a densely populated (964/km2) country in South-East Asia with a land area
of 147,570 km2 (Bangladesh Bureau of Statistics, 2014). The country has a tropical
climate, and within its borders is the largest delta in the world, formed by three large
rivers: the Ganges, the Brahmaputra and the Meghna. Bangladesh is situated at the
interface of two different environments surrounded by the Bay of Bengal to the south and
the Himalayas to the north (Agarwala, 2003). This peculiar geographical location along
with very low and flat topography (flood plain >80%) brings not only long lasting
monsoons but also catastrophic natural disasters such as floods, cyclones, tidal waves and
landslides (Ali., 1999). The low level of economic development, population density and
poor infrastructure along with its geographic features and the impact of climate change
makes the country extremely vulnerable to flooding (Agarwala, 2003).
In 2011, the south-west region of Bangladesh was affected by severe riverine floods.
Heavy monsoon rains caused several major rivers to burst their banks, displacing
thousands and affecting nearly a million people in all (IRIN, 2011). Approximately 34
districts were flooded (out of 64) in 2011 (UNOSAT, 2011) (Figure 3.2). Three coastal
regions of Bangladesh, namely Sathkhira, Khulna and Jessore, were the worst flood
affected districts (Table 3.1). The total number of affected households was 181,759.
Approximately 152,034 householders were taken to temporary shelters while many others
were forced to live out in the open with no shelter at all.
Table 3.1 Features of severely affected areas during 2011 floods in Bangladesh
Upazila No. of No. of No. of No. of Affected
villages Households people children Roads
affected Affected affected (km)
Satkhira Tala 230 36375 165805 31502 115
Satkhira Sadar 236 40124 160500 30495 20
Kolaroa 136 8068 32320 6464 48
Debhata 122 20035 58500 11115 465
Ashasuni 242 5222 9840 1869 45
Kaliganj 253 7250 32400 6480 35
Satkhira 1 22000 97000 18430 160

Paurashava
Khulna Paikgacha 123 19594 96011 28607 556
Jessore Keshabpur 78 12937 63388 19148 78
Manirampur 61 10154 49752 15027 52
Total 1482 181759 765516 169137 1574
Source: Uttaran, 2012

A total of 115,408 houses were damaged and 31,679 hectares of crop land were flooded
(Disaster Management Bureau, Bangladesh) (Table 3.2). In this study, data were obtained
from Upazila Tala (Sathkhira) which was severely affected during the 2011 floods in
Bangladesh (Figure 3.2). The county divisions in Upazila are similar to those found in
some western countries.

Flooded area
River bank erosion
Upazila
Tala of
District
Sathkhira
Figure 3.2: Flood affected districts of Bangladesh in 2011 including the study area.
(Source: Bangladesh Meteorological Department, 2014).

Table 3.2 Flood damages during 2011 floods in Sathkhira district
Sathkhira Damage Affected No. of No. of Tube Commodities
Upazila House Crop Embankment schools & Lives people well price
land (km) colleges stock lived in Increased
(hectare) affectedtemporary
shelter
Tala 31617 5990 10 35 354235 36375 152 10-15%
Sathkhira 30515 395 0 0 20819 40124 15 10-15%

sadar
Kolaroa 6512 1100 4.5 18 21500 8068 35 10-15%
Debhata 11580 195 6.58 8 14359 20035 95 10-15%
Ashashuni 1914 0 39 71 12685 5222 266 10-15%
Kaliganj 6515 203 0 0 8325 7250 19 10-15%
Sathkhira 18590 1600 0 13 29835 22000 8 10-15%

Paurashava
Total 115408 31679 72.08 352 809593 152034 2748
Source: Uttaran, 2012.
In Shatkhira, approximately 1,220 villages and 556,365 people were affected by floods
and approximately 139,074 households were moved to temporary shelters (Uttaran,
updated September, 2011).
Tala is located between 22°45' and 22°75' north latitude and between 89°15' and 89° 25'
east longitude. It occupies an area of 132.88 m2. It has 47,394 households and a population
of 299,820. Table 3.3 shows geographical and general weather conditions of UpazilaTala.

Table 3.3 Geography and weather of Upazila Tala
Region Tala
District Sathkhira
Area 132.9 m2
Population 299,820
Households 47,394
Density 1,900/m2
Location 22 045 N 89 0 15 E
Avg. annual Temp. 26°C
Avg. annual Rainfall 1655 mm
Driest month December with 5 mm
Most precipitation (Avg) July with 389 mm
The flood season is the rainy season or monsoon season when most of the region’s average
rainfall occurs. Using the Koppen climate classification for tropical climates, a wet season
is defined as a month when average rainfall is more than 60 mm (updated world Köppen-
Geiger climate classification map, 2015). Widespread flooding may occur as a result of
excessive rainfall. The flood season in tropical countries may vary from March to
September of any year. From March to September in a typical year, Bangladesh
experiences major flooding, as the monsoon season arrives, the major rivers and their
tributaries reach their peak, and the Himalayan snow melts. The frequency of flooding in
Bangladesh usually starts to increases with excessive rainfall during the month of May and
decreases gradually from August (BMD, 2015).
Sathkhira is situated in the south-west coastal region of Bangladesh. The average monthly
temperature and rainfall in this area varies between 19°C and 30°C and 8mm and 353mm,
respectively (Figure 3.3-3.4). The highest rainfall usually occurs during the months of June
to September with an average of 14-19 rainy days (Figure 3.5). Sathkhira lies within the
catchment area of the Ichamati River and the Kobadak River. The average river flow as
measured from the nearby Sathkhira gauge station varies between 3.88 mPWD and 4.56

mPWD during the months of June to August (Figure 3.6). The overall river flow during
the wet season is usually above the danger levels which often cause flooding.
Table 3.4 shows the weather conditions and level of flooding in Upazila Tala. The overall
maximum temperature (31°C), rainfall (345mm-562mm) and river flow (4.13mPWD-
4.57mPWD) in Upazila Tala in 2011 were higher than in the previous years during the
months of June-August in 2011, which lead to severe riverine flooding.
Average monthly temperature of

Sathkhira
35
30
25
20
Celsius
15
10
5
0
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
Figure 3.3: Average monthly temperature of district Sathkhira during 1990-2014.

Average monthly rainfall of Sathkhira

400
350
300
250
mm
200
150
100
50
0
Figure 3.4: Average monthly rainfall of district Sathkhira during 1990-2014.

(Source:Bangladesh Meteorological Department, 2015).

Average number of rainy days of
Sathkhira
20
15
days
10
0
Figure 3.5: Average number of rainy days of district Sathkhira during 1990-2014.
Average river flow of Sathkhira

6
4
Danger level: 3.96
mPWD
0
Figure 3.6: Average river flow from Sathkhira gauge station during 1990-2014.

Table 3.4 Weather and level of flooding during the 2011 floods
Region Tala
Mean Temp.
June 28.9
July 27.8
August 28.4
Max. Temp.
June 31.4
July 30.6
August 31.5
Precipitation (mm)
June 345.4
July 562.1
August 352.1
River flow (mPWD)
June 4.13
July 4.57
August 4.32
Sea level pressure (hpa)
June 1003.5
July 1002.6
August 1002.5
Water lodgement level 2-8 feet (>67% of households flooded with >6 feet water)
Water lodgement period 20-45 days
Severity of flooding Severe
3.4 Sampling procedure and study population

During July 2010 to December 2010, a baseline regional mental health prevalence survey
(face to face interviews) was conducted by the Directorate General of Health Services
(DGHS) (under the Ministry of Health and Family Welfare of the Government of
Bangladesh) using pretested structured questionnaires administered to Bengali speaking
adults aged ≥15 years. The DGHS systematically collected mental health data as part of
their health surveillance practice. The survey covered the south-west coastal regions of
Bangladesh, namely Sathkhira, Jessore, Khulna and Barisal. They randomly selected these
areas because the incidence of mental disorder was higher in the past decades (DGHS,
2014). This type of mental health survey is carried out occasionally as a part of the
surveillance process. But for the first time in this survey, they employed four different
scoring systems for the assessment of four different mental illnesses after a pilot study.
Therefore, the assessment of mental illness was more accurate than in any previous survey.
A total of 25,470 people (selected by randomly sampling) were interviewed during the
baseline survey. The response rate of the total baseline sample (n=25470) was 85%
(calculated from the total number of fully completed questionnaires divided by the total
number of people approached for the interview×100).
In June 2011, Bangladesh experienced a major flood in many parts of the country
(Bangladesh Disaster Management Bureau, 2011). Therefore, a second mental health
prevalence survey was conducted between July 2011 and December 2011 to assess the
effects of flood among its victims in the coastal regions. The post-flood regional surveys
were conducted in the flood affected counties of Sathkhira, Jessore and Khulna, where
baseline surveys were conducted 6 months before the event to assess the mental health
impact of flooding. The study population for this post-flood survey was reduced to 17,000
(selected by random sampling). The response rate of the total post-flood sample
(n=17,000) was 79%.
Both surveys were conducted by local, regional health practitioners, who were familiar
with the location and the people and who were employed by DGHS. DGHS trained and
appointed these health practitioners who conducted face to face interviews. Both
questionnaires included questions about socio-demographic circumstances and validated
measurement of mental health conditions, including depression, anxiety, PTSD and drug
abuse. The post-flood survey contained additional questions pertaining to flood exposure.
During the baseline survey, a stratified randomized sampling method was used to select
study participants from the south-west coastal region of Bangladesh which covers the
districts of Sathkhira, Khulna, Jessore, and Barisal. The population was divided into
different small strata based on gender, age and residence area (village), after which
respondents were chosen from each stratum. DGHS randomly selected 10 out of 16
Upazilas (counties) from coastal regions. The authority sampled 75% of the Upazilas of
the selected districts and 75% of the villages in the selected Upazilas and 75% of the
households in the selected villages.
During the post-flood survey, the stratified randomized sampling method was again used
to select study participants from the severely affected coastal regions (Sathkhira, Jessore
and Khulna). Firstly, DGHS randomly selected six out of the ten Upazilas which were

surveyed during the baseline survey. Secondly, by using a systematic sampling approach,
the authority randomly sampled 50% of the Upazilas of the selected districts, 50% of
villages in the selected Upazilas and 50% of the households in the selected villages. Face
to face interviews were conducted for self-assessment (including mental health
measurement tools) using structured questionnaires (in Bengali). The main objective of the
second survey was to ascertain the prevalence of PTSD, depression, anxiety and drug
abuse among the flood affected victims. The participants were included in the study based
on the following criteria:
• Aged 15 years and older

• Directly exposed to floods
• Permanent residents of the selected villages
The following exclusion criteria were applied:
• Residents with previous mental illness

• Residents with previous history of other stressful events
For the purpose of this study, data was obtained for UpazilaTala. In total, 2,500 people
were included in each of the pre and post-flood surveys. Data from different levels of
exposure (<2 feet to >6 feet) were analysed to understand the relationship between the
severity of flooding and mental illness.
3.5 Interview schedule and fieldwork

Initially, the appropriateness and applicability of survey questionnaires and four self-
assessment health scales (patient health questionnaire-9, Kroenke et al., 2010; generalized
anxiety disorder-7, Lowe et al., 2008; short form of PTSD checklist-civilian version,
McDonald et al., 2010; drug abuse screening test, Yudko et al., 2007) were tested for use
with flood victims through a series of six focus groups. Interview schedules were
developed in two phases: pre-flood and post-flood surveys. Three months before the pre-
flood survey, DGHS tested the questionnaires with health scales through pilot interviews
with 72 respondents and through 11 in-depth interviews carried out by the clinician. Only
one adult was interviewed at each address and the questionnaire took, on average, about 30
minutes to complete during the pre-flood survey and about 50 minutes during the post-
flood survey.

3.6 Data Collection
3.6.1 Exposure Assessment
3.6.1.1 Water level data
Data regarding the water level at residents’ homes following the flood was obtained
for the period July 2011 to December 2011. For the purpose of this study, residents
were classified as “flooded” if the floor of the house was under water during the
flood. Exposure to flooding was recorded based on the water level at the home (<2
feet=1, 2-4 feet=2 and >6 feet=3). The length of time the water remained in the home
was not included in this study. The data were requested from Upazila Tala, where
more than 67% of the households were flooded >6 feet water in their home.
3.6.1.2 Injury data
The survey included information regarding the number of injuries sustained during
flooding. Individual households were asked whether they had been injured during the
flood or not (yes=1, no=0). Most of the people of Upazila Tala are illiterate. They are
unable to assess the type and severity of any injury they sustained. Therefore data related
to the type of the injury were not included in the survey.
3.6.1.3 Loss of family member(s)

The questionnaire also included the occurrence of death/s in the family. Previous studies
demonstrate that deaths are associated with the mental health impacts of flooding (Souza et
al., 2007; Neuner et al., 2006). Data on the number of death/s per family were included and
verified by the regional health records. Only accidental cause of death, such as drowning,
electrocution or snake bite was included. Missing people or those who had been swept
away by the flood were excluded because sometimes these people can be rescued/found
elsewhere and reported later.
3.6.1.4 Financial help

Information on the financial help provided by government and non-government
organizations was obtained. The impacts of social support on mental health outcome of
flood victims need to be considered as most of the previous studies found that social
support is an important predictor of mental health (Vernberg et al., 1996; Pina et al., 2008).
This study also selected financial help as a predictor, particularly because this study group
belongs to the extremely low income region in Bangladesh. Even though the information
on the actual amount of money was not indicated due to institutional regulations,
information was obtained on whether victims received any financial help (help received
=1, help not received=0).
3.6.1.5 Loss of property or land

Loss of property or damage may impact on post-flooding mental health (Frankenberg et
al., 2004; Tobin et al., 2005). Information on the damage caused to the property including
homes, land and personal goods was obtained (e.g. damage to the house structure, loss of
crops, damage to furniture and loss of cattle). The severity of damage was not included in
this study. The impacts were measured according to people’s self-assessment of damage
(loss of property or damage=1, no loss of property or damage=0).
3.7 Confounding factors

Socio-demographic factors that could be associated with psychological outcomes were
identified in the literature review (section 2.3). Age group, sex, marital status, occupation,
monthly income and previous health status were considered as potential confounding
factors. Other potential confounding variables identified in the literature review were
education, previous mental health condition, previous traumatic event, living conditions,
coping strategy and smoking. The pre and post-flood survey conducted by the Directorate
General of Health Services did not ask information about these variables in their
questionnaire. The sampling criteria excluded people with previous mental health
disorders and experience of previous traumatic events. The relationship between other
potential confounders such as living conditions, education, coping strategy and mental
disorders have been more thoroughly investigated previously (Hoe et al., 2008; Vigil et al.,
2008; Terranova et al., 2009; Pina et al., 2008).
Age groups
Previous studies have found significant relations between age groups and post flooding
mental illness (Ruggiero et al., 2009; Liu et al., 2006; Hoe et al., 2008; Souza et al., 2007).
However, previous studies only focused on a single age group such as children (below 18
years old), adults (18+ years old) or the elderly (61+ years old). In this study, the
researcher investigated the association between different age groups (15-19, 20-24, 25-29,
30-49, 50-59, 60-64 and 65+ years) and post-flood mental illness.

Gender
Most of the previous studies have observed that women were more vulnerable to post
flooding mental illness (Amstadter et al., 2009; Neuner et al., 2006; Frankenberg et al.,
2004; Kar et al., 2007). In addition to possible confounding effects, this study examined
whether there is any interaction between gender and exposure variables on post-flood
mental illness.
Marital status
This study included data on two groups: married (code=1) and unmarried (code=0). The
number of divorced or widowed respondents was negligible, so they are not counted as a
separate group. These respondents were added along with the unmarried group as they do
not have a life partner. This study assessed whether marital status confounded the
association between floods and mental health.
Occupation
As the sample was collected from remote villages of the coastal region, most of the people
were farmers or field workers. Detailed information on their actual occupation was not
included. To assess their socio-economic status, data was collected on their employment
status: employed (code=1) or unemployed (code=0).
Monthly income
Monthly income was categorized into three groups: <2000 taka (code=0), 2000-4000 taka
(code=1), >4000 taka (code=2). Data on monthly income were obtained from both
employed and unemployed, however unemployed people had no regular income.
Previous health status

Previous health status was coded with the two categories: chronic illness (code=1) and no
chronic illness (code=0). However, data on the type of chronic illness (e.g. heart disease,
kidney disease, diabetes mellitus) were not available.
3.8 Outcome Assessment

3.8.1 Pre-flood mental health data
Non-identifiable pre-flood health data (i.e., six months before the floods) from July 2010
to December 2010 were obtained from the Directorate General of Health Services of
Bangladesh, who has conducted a pre-flood health survey, including mental health
conditions of people in the most flood-prone areas in the coastal region in Bangladesh.
Pre-flood health data provides a brief picture of the prevalence rates of mental disorders of
people in different socio-economic backgrounds. The study included 2,500 households in
Upazila Tala. This study used these data because it is important to measure the prevalence
of mental illness before a flood event for a proper evaluation of post-flood mental stress.
The data on the individuals of each household included the following variables:
Age groups (15-19, 20-24, 25-49, 50-59, 60-64, 65+ yrs), gender, chronic illness, marital
status (unmarried, married), employment status (unemployed, employed) and monthly
income (<2000, 2000-4000, > 4000 taka). Those who have been diagnosed with mental
illness/stress in the pre-flood survey were not included in the study as previous mental
illness can be chronic in nature and act as predictors of new cases.
3.8.2 Post-flood mental health data

Non-identifiable post-flood mental health data (i.e., for six months after the floods) were
collected from the Directorate General of Health Services, Dhaka, Bangladesh. The data
were collected from the same population of Upazila Tala, where this researcher has
previously obtained pre-flood data. Post-flood data also included a total of 2,500
households from Upazila Tala. The surveys were conducted among the same population,
but the respondents (pre and post-flood) might not be the same individuals. Post-flood data
included the individual data and additional information on exposure variables as follows:
floodwater level in the home (<2, 2-6, >6 feet), injury, loss of a family member, financial
help and loss of land or property damage.
3.9 Definitions of assessed mental health disorders

A number of mental illnesses or disorders were included in this study as follows:
a. Post-traumatic stress disorder (PTSD)
b. Depression
c. Anxiety disorder
d. Substance/drug abuse
3.9.1 Post-traumatic stress disorder (PTSD)

PTSD is an anxiety disorder that affects some people after seeing or living through a
dangerous or traumatic event. When in danger, it is natural to be afraid. This fear triggers
many split second changes in the body to defend against the danger in order to avoid it.
This “fight or flight” response is a healthy reaction meant to protect a person from harm.

But in PTSD, this reaction is changed or damaged. People who have PTSD or may have
PTSD feel stressed or frightened even when they’re no longer in danger.
3.9.2 Depression
Depression is a common mental disorder, characterized by sadness, loss of interest or
pleasure, feelings of guilt or low self-worth, disturbed sleep or loss of appetite, feeling of
tiredness and poor concentration.
3.9.3 Anxiety Disorder

Anxiety is a normal human emotion that everyone experiences at times. Many people feel
anxious or nervous when faced with a problem at work, before taking a test or making an
important decision. Anxiety disorders, however, are different. They can cause distress that
interferes with the person’s ability to lead a normal life.
3.9.4 Drug Abuse

Drug abuse is a persistent and ever growing problem. In DSM-IV, 'drug abuse' is defined
as a 'maladaptive pattern of use indicated by continued use despite knowledge of having a
persistent or recurrent social, occupational, psychological or physical problem that is
caused or exacerbated by the use [or by] recurrent use in situations in which it is physically
hazardous'.
3.10 Assessment of mental health disorder

Four predominant mental health disorders were assessed after the flood event. The pre and
post-flood mental health surveys assessed the prevalence of mental health disorders among
the people living in the flood affected region. Single households were surveyed using a
pre-tested questionnaire. The assessment was carried out using different screening tools
based on DSM-IV criteria. As discussed in Chapter 2, DSM-IV has some diagnostic
criteria set for different mental health conditions. The appropriateness of the manual was
well established in different mental health studies (Paranjothy et al., 2011; Wealde et al.,
2008). In this study, the four predominant mental illnesses were investigated; these are
depression, anxiety, post-traumatic stress disorder (PTSD), and substance abuse or drug
abuse. The survey questionnaire was based on four screening tools: a patient health
questionnaire (PHQ-9), generalized anxiety disorder (GAD-7), short form of PTSD
checklist- civilian version (PCL) and drug abuse screening test (DAST-10).

Patient health questionnaire
Depression was assessed using the PHQ-9, a well validated, highly sensitive instrument for
identifying current and past depression that additionally corresponds to the diagnosis of
MDD (major depressive disorder) as described in the DSM-IV (Anasterio et al., 2008;
Kroenke et al., 2001; Brody et al., 1998). The sensitivity and specificity ranged from 0.77
to 0.88 and 0.88 to 0.94, respectively (Kroenke et al., 2001; Gilbody et al., 2007;
Wittkampf et al., 2007). The respondents were asked if they had experienced any of the
symptoms nearly each 2 weeks prior to the flood. Each symptom related to depression was
examined and diagnosed using the PHQ-9 (Tunstall et al., 2006, Paranjithy et al., 2011).
Respondents with a score between 1-4 were diagnosed as having minimal depression; 5-9
having mild depression; 10-14 having moderate depression; 15-19 having moderately
severe depression and 20-27 having severe depression, respectively.
Table 3.5 Patient Health Questionnaire-9

Questions Not at all Several Half of the Nearly
days day everyday
1. Little interest or pleasure in doing 0 1 2 3
things
2. Feeling down, depressed or 0 1 2 3
hopeless
3. Trouble falling, staying asleep or 0 1 2 3
sleeping too much
4. Feeling tired or having little energy 0 1 2 3
5. Poor appetite or overeating 0 1 2 3
6. Feeling bad about yourself 0 1 2 3
7. Poor concentration 0 1 2 3
8. Try to hide from people or like to 0 1 2 3
stay alone
9. Suicidal thought 0 1 2 3
Generalized anxiety disorder

In this study, GAD-7 was used for brief measurement of anxiety disorder based on DSM-
IV criteria, as it is a reliable and valid self-reporting measure for anxiety in the general
population (Lowe et al., 2008). Specifically, results from a principle component analysis
reveal that the uni-dimensional questionnaire of GAD-7 is capable of assessing anxiety
disorder in different ages and genders (Lowe et al., 2008). The internal consistency of the
GAD-7 was excellent (Cronbach’s α =0.92) (Lowe et al., 2008). Each individual in the

household was asked about how often during the last 2 weeks, they had been bothered by
each of the 7 core symptoms of anxiety. Respondents with a score between 5-9 were
diagnosed as having mild anxiety; 10-15 having moderate anxiety and >15 having severe
anxiety, respectively.
Table 3.6 Generalized anxiety disorder-7

Questions Not at all Several Half of Nearly
days the day everyday
1. Feeling nervous, anxious 0 1 2 3
2. Continuous is worrying 0 1 2 3
3. Worrying too much about different 0 1 2 3
things
4. Trouble relaxing 0 1 2 3
5. Being so restless that it is hard to sit still 0 1 2 3
6. Becoming easily annoyed or irritable 0 1 2 3
7. Feeling afraid that something bad will 0 1 2 3
happen
Short form of PTSD checklist-civilian version

The PTSD checklist has a different number of questions based on DSM-IV, based on four
different criteria: re-experience of symptoms, persistent avoidance of symptoms, and
persistent avoidance of stimuli and persistent symptoms of increased arousal.
The PCL-C is the most commonly used PTSD self-reporting questionnaire, and it has been
used extensively as a PTSD screening test, a diagnostic tool, and an estimator of PTSD
prevalence in the general population. It is a 17 item measure of the DSM-IV symptoms of
PTSD, which can be used in both clinical and research applications (McDonald et al.,
2010). It was modified and revised to fit in the questionnaire to screen the flood affected
people. For a cut-off point of 18, sensitivity and specificity were ranged from 86 to 91 and
95 to 99, respectively. The criterion which does not give a clear view of PTSD was not
included in the study.

Table 3.7 PTSD checklist-civilian version (revised and tested in the pilot study)
Questions Not Moderate Very-
at al Mild Severe severe
During flooding, did you experience or 1 2 3 4 5
witness serious injury or death, or the
threat of injury or death?
During the flood did you feel intense 1 2 3 4 5
fear, helplessness, and/or horror?
Do you regularly experience intrusive 1 2 3 4 5
thoughts or images about the event?
Do you sometimes feel like you are re- 1 2 3 4 5
living the event or that it is happening
all over again?
Do you have recurrent nightmares or 1 2 3 4 5
distressing dreams about the traumatic
event?
Do you try to avoid activities, people, or 1 2 3 4 5
places that remind you of the traumatic
event?
Do you feel that your future will not be 1 2 3 4 5
"normal" -- that you won't have a
career, marriage, children, or a normal
life span?
Do your symptoms interfere with 1 2 3 4 5
normal routines, work or school, or
social activities?
Do you often feel jumpy or startle 1 2 3 4 5
easily?
Scoring
A total symptom severity score (Range=9-45) was obtained for PTSD by summing the
scores of the 9 questions. The cut-off point for PTSD is 18. Respondents with a score
between 9-20 were diagnosed as having mild PTSD; 21-32 moderate PTSD and 33-45
severe PTSD, respectively.
Drug Abuse Screening Test

DAST was developed to provide a convenient instrument for assessing the extent of
problems related to drug misuse. The total DAST score yields a quantitative index of
problem severity. The DAST score is highly reliable and has only a minimal chance of
response style biases of denial and social desirability (Skinner, 1982). The sensitivity and
specificity of the test used in this study population ranged from 78% to 86% and 94% to
96%, respectively. It is a 10 item screening tool used for drug abuse study. Individual
households were asked about their general health/behaviour including drug abuse. In this

study, individuals were asked if they had experienced any symptoms of substance use
during the previous 6 months. Respondents with a score 0 were interpreted as having no
drug abuse; 1-2 having a low level of drug abuse; 3-5 having a moderate level of drug
abuse and 6-8 having a substantial level of drug abuse, respectively.
Table. 3.8 DAST-10

Questions : Yes No
Have you used drugs other than those required for medical reasons? 1 0
Do you abuse more than one drug at a time? 1 0
Are you unable to stop using drugs when you want to? 1 0
Have you ever have blackouts or flashbacks as a result of drug abuse? 1 0
Do you ever feel guilty or bad about your drug use? 1 0
Do your spouse/parents ever complain about your involvement with drugs? 1 0
Have you engaged in illegal activities in order to obtain drugs? 1 0
Have you neglected your family because of your use of drugs? 1 0
Have you ever experienced withdrawal symptoms (feel sick) when you 1 0
stopped taking drugs?
Have you had medical problems due to use of drugs? (e.g. hepatitis, bleeding, 1 0
memory loss, convulsions)
3.11 Data Management

3.11.1 Managing the datasets
The different measuring score for four different mental illness conditions, socio-economic
data and exposure data were used in this study, so that individual mental health conditions
were assessed for every adult individual.
3.11.2 Missing data

Descriptive statistics were used to confirm whether the missing data occurred randomly or
in a systematic pattern. Table 3.9 present the missing data on the socio-economic and
exposure variables of Upazila Tala. There were few missing values in the survey records,
except for financial help where 7% of the records (175 out of 2500 participants) were
missing. “The mental health data” did not have any data missing.
This study imputed missing values for financial help from the post-flood data set based on
a regression model. The number of missing values is so small that the chance of bias is
negligible.

Table 3.9 Missing values in pre and post flood mental health survey
Variables Pre-flood Post-flood
n % n %
Gender 9 0.4 9 0.4
Age group 12 0.5 12 0.5
Marital status 0 - 0 -
Employment 3 0.1 3 0.1
Monthly income 11 0.4 11 0.4
Chronic illness 4 0.2 4 0.2
Water level at home 2 0.1
Loss of loved one 9 0.4
Injury 0 -
Financial help 175 7
Loss of land 4 -
3.12 Data analysis

• The difference in the prevalence of each mental health disorder pre and post-flood
in Upazila Tala was assessed using the Pearson chi-square test.
• Socio-economic and exposure variables were plotted for each individual mental
health index to discover potential risk factors.
3.12.1 Descriptive analyses

Descriptive analyses of the socio-demographic and exposure variables and mental illness
were conducted as outlined below:
• Examination of the distribution of each variable.
• Descriptive statistics were calculated for each variable.
• Pearson chi-square with Phi and Cramer V test was used to assess the bivariate
association between the socio-demographic and the exposure variables. Phi and
Cramer V tests were used to examine the association between variables (nominal
by nominal or nominal by ordinal). This study used non-parametric tests, as the
exposure variables were not normally distributed.
3.12.2 Multivariable analyses

The multivariable logistic regression model has been extensively used to assess the
predictors of post flood mental illness (Paranjothy et al., 2011; Abramson et al., 2008,
Stimpson et al., 2008; Li et al., 2010; Kumar et al., 2006). Most of these studies have used
univariate analyses (Paranjothy et al., 2011; Kar et al., 2007) to examine the distribution of

each variable followed by bivariate analyses (Fredman et al., 2010; Achirno et al., 2007;
Mills et al., 2007) to determine the significant association between variables. Then
multivariable logistic regression analyses were used to measure the associated risk factors.
Multivariable logistic regression can be used when the dependent variables are categorical
variables. In this study all four dependant variables are categorical variables (no
depression=0, depression=1) which justified the use of logistic regression analyses.
Hence, analyses were conducted to assess the impact of flooding on psychological
outcomes using multivariable logistic regression to evaluate the potential predictors of
mental illness following a flood event. Clinical scoring of mental disorder was used to
categorize the cases. All the independent variables (both socio-economic and flood
exposure variables) were assessed for each dependent variable (anxiety, depression, PTSD
and drug abuse) using forwarded stepwise regression analyses. The logit coefficient and
95% confidential intervals were measured. The statistical significance level was fixed at
5%. Each variable was added to the model step by step to assess the individual impact of
the factors to the model.
Multivariable logistic regression model

All analyses were carried out using the Statistical Package for the Social Sciences (SPSS)
(Version 21.0). Figure 3.7 shows the overall statistical analyses adopted in this study to
assess the flood-related mental illness. Scale scores were calculated for the GAD-7, PHQ-
9, PCL-9 and DAST-10 according to the guidelines given in the manual. Cut-off scores
were used to assess whether a participant could be classified as having a psychiatric
disorder or not.
All socio-economic and exposure variables were tested for mutlicollinearity by variance
inflation factor (VIF). If the score of VIF is higher than 10, that means there is a chance of
higher multicollinearity. To reduce the effect of multicollinearity in regression analyses,
only variables with VIF score <10 were entered into the model as independent variables.
The Bonferroni correction method was used to adjust the significance level for each
regression model. To reduce the likelihood of the false-positive results, the overall p-value
was adjusted for multiple significance testing.

Pre-flood
The predictor variables were entered into the model forward stepwise (Figure: 3.7). In the
first step, the gender of the participants was entered. Then all other socio-economic
variables were added into the model. Variables that were entered in the pre-flood model
included gender, marital status, employment status, monthly income and whether or not
the participant had a chronic illness. The individual predictor was checked for
multicollinearity before being entered into the model.
All the variables were included in the model and then significant risk factors of mental
illness were identified.
The significance level of each pre-flood model was adjusted for multiple significant testing
using the Bonferroni method. The overall adjusted p-value for the pre flood model was
0.01 (α1=α/k). From the post-hoc analyses, (adjusted p-value=unadjusted p-value*numbers
of comparison tests in pairs) p-value of each predictor was reduced to the significance
level of 0.01.
Post-flood
All the variables that were found statistically significant in the pre-flood regression model
were entered in step 1 of the post-flood regression model (Figure 3.7). To assess the
potential predictors of each flood-related mental health disorder, all the exposure variables
were added to the model forward stepwise (water level at home, injury, loss of loved one,
financial help and loss of land). All the socio-economic factors, along with exposure
variables were checked for multicollinearity before entering into the model. Similarly, like
the pre-flood model, interactions between socio-economic and exposure variables were
assessed in the model.
To evaluate the gender-based difference in the occurrence of mental health disorders, at the
final step of the model an interaction term was also included to assess any interaction
between gender and exposure variables on post-flood mental illness.
Similarly to the pre-flood model, the significance level of each post-flood model was
adjusted for multiple significant testing using the Bonferroni method. The overall adjusted
p-value for the pre-flood model was 0.005 (α1=α/k). From the post-hoc analyses, p-value
of each predictor was reduced to the significance level of 0.005.

Figure 3.7: Flow chart showing the adopted statistical analyses.

3.13 Validity and reliability of assessment tools
Constructive validity and reliability of the all assessment tools (translated to Bengali) for
measurement of mental illness were checked in the pilot study. Principal component
analyses were used to assess the factor structure in a set of variables (Floyd and Widaman,
1995). All the assessment tools were used in previous studies and found structurally sound
for a mental health study (McDonald et al., 2010). In this study, validity and reliability was
re-assessed for the study population as follows:
• Principal component analysis was conducted to assess the constructive validity

(Appendix Table B1-B4).
• Chronbech’s alpha over piloted instruments was calculated to evaluate the inter
reliability of the tools (Appendix table B5).
All analyses were conducted using SPSS software (version 21). (Please see the Appendix
B for details of principal component analyses and Chronbech’s alpha).
3.14 Ethics
The questionnaires were anonymous and contained non-identifiable data. Ethical approval
was granted by the Queensland University of Technology (QUT) Human Research Ethics
Committee (ethical number:1300000357). Approval was also provided by the Directorate
General of Health Services, which is under the Ministry of Health and Family Welfare
(MOH&FW) of the Government of Bangladesh to obtain the data.
3.15 Summary
This chapter presented the research methods applied in this study. It included sections on
research design, study area and population, data collection procedures, instruments/survey
tools used, as well as evidence of their reliability and validity and the statistical analyses
employed. This is a cross-sectional study in nature. In this study, data were collected from
pre and post-flood mental health surveys conducted by the Directorate General of Health
Services. Study participants were identified by randomized sampling procedure during
both study periods (pre-flood and post-flood). The questionnaires (including measuring
tools) were tested by the pilot study before being administered in the field survey. All
participants were interviewed with a questionnaire comprising four validated instruments
and a socio-demographic and flood exposure questionnaire. These 4 instruments included
the patient health questionnaire, generalized anxiety disorder, PTSD checklists-civilian

version and drug abuse screening test. These instruments had acceptable reliability and
validity. Data were obtained from December 2010 to November 2011 (pre-flood health
survey from December 2010 to May 2011 and post-flood mental health survey from June
2011 to November 2011). Statistical analyses were performed using SPSS software.
Descriptive analyses of each variables and regression analyses were used to analyse the
data and answer the research questions.

Chapter 4: Results
4.1 Introduction
In this chapter, firstly the socio-demographic characteristics of the participants before and
after the floods is presented. Then, I examined whether there is any association between
flooding and mental health disorders, and also assessed the distribution of each mental
disorder associated with different water levels of exposure. Finally, bivariate and
multivariate analyses were conducted to test the research hypotheses.
4.2 Socio-demographic characteristics

Table 4.1 shows the socio-economic characteristics of participants in Upazila Tala. Before
the flood, 75% of the participants were male; 34% were aged 15-24 years, 32% were 25-
49 years and 34% were 50 years and above. Most (70%) were married and nearly half
(47%) were employed. Among the respondents, 42% earned <2000 taka, 34% earned
between 2000-4000 taka and 23% earned >4000 taka per month. Around a quarter of the
participants reported having a chronic illness.
After the flood, only 51% of the participants were male; 31% were aged 15-24 years, 38%
were 25-49 years and 31% were 50 years and above. 60% of the respondents were married
and only 36% were employed. Around 63% had a monthly income of <2000 taka,
whereas 20% had earned between 2000-4000 taka and 17% had earned >4000 taka. Only
11% of the participants reported having a chronic illness. During the flood, 18% had <2
feet, 29% had between 2-6 feet and 53% had >6 feet of water in their homes. Only 2%
participants lost family members and 16% were injured during the event. 67% of the
residents received financial help and around 72% lost their land or property due to
landslides during the flood.
During the flood, most of the participants to this study were affected directly or indirectly.
The socio-economic condition of the respondents was significantly changed after the
flood, especially their employment status and monthly income.
Chapter 4: Results Page 59

Table 4.1 Socio-economic characteristics of Upazila Tala
Pre flood Post flood Pearson χ2 P value
Variable Number % Number %
Gender 302.7 0.001
Male 1872 74.9 1278 51.1
Female 628 25.1 1222 48.9
Age group
15-19 446 17.8 251 10.0 300.7 0.001
20-24 404 16.2 518 20.7
25-29 352 14.1 459 18.4
30-49 442 17.7 475 19.0
50-59 380 15.2 290 11.6
60-64 190 7.6 299 12.0
65+ 286 11.4 208 8.3
Marital status
Married 1759 70.4 1513 60.5 101.3 0.001
Unmarried 741 30.0 987 39.5
Employment
Employed 1177 47.1 902 36.1 131.2 0.001
Unemployed 1323 52.9 1598 63.9
Monthly Income
<2000 taka 1062 42.5 1574 63.0 487.2 0.001
2000 taka-4000 taka 854 34.2 490 19.6
>4000 taka 584 23.4 436 17.4
Chronic illness
Yes 606 24.2 280 11.2 427.3 0.001
No 1894 74.8 2220 88.8
Water level at home
<2 feet 455 18.2
2-6 feet 722 28.9
>6 feet 1323 52.9
Loss of loved one
Yes 54 2.2
No 2446 97.8
Injury
Injured 402 16.1
Not injured 2098 83.9
Financial Help
Got help 824 33.0
No help 1676 67.0
Loss of land / property
Yes 1801 72.0
No 699 28.0

4.3 The association between flooding and mental health disorder
The difference in the prevalence of mental health disorders among pre and post-flood
groups was calculated with a one-way Pearson chi-square test. Table 4.2 shows the
prevalence of each mental illness among pre and post-flood groups in the Upazila Tala.
Table 4.2 The prevalence of mental health disorders among pre and post-flood groups
(n=2500)
Mental Pre-flood Post-flood Pearson χ 2 P value
disorder
No Mild Moderate Severe No Mild Moderate Severe
(%) (%) (%) (%) (%) (%) (%) (%)
Depression 2081 230 110 79 1804 170 314 212 187.7 0.004
(83.2) (9.2 ) (4.4) (3.2) (72.2) (6.8) (12.5) (8.5)
Anxiety 2229 95 134 42 2100 92 192 116 50.1 0.04

(89.1) (3.8) (5.4) (1.7) (84) (4.8) (6.7) (4.5)
PTSD 2377 45 52 30 2193 85 143 79 84.2 0.003

(95.1) (1.8) (2.1) (1.0) (7.7) (3.4 ) (5.7) (3.1)
Drug Abuse 2363 30 67 40 2256 45 37 161 87.0 0.001

(94.5) (1.2) (2.7) (1.6) (90.2) (1.8) (1.5) (6.4 )
Out of 2,500 participants in Upazila Tala, 2,081 (83.2%) did not suffer from depression
(non-case) pre-flood, while 419 (16.8%) had some symptoms. Among these depression
cases, 9.2% had mild depression, 4.4% had moderate depression and 3.1% had severe
depression. After the flood, the number of depression cases increased from 419 (16.8%) to
696 (27.8%) with the increase of severity (6.8% had mild depression, 12.5% moderate
depression and 8.5% severe depression). The results of the Pearson chi-square test showed
that there is a significant association between flooding and depression in Upazila Tala
(χ 2=187.69; p<0.004).
Before the flood, 2,229 (89.2%) did not suffer from anxiety (non-case), while 271 (10.8%)
had some symptoms. Among the pre-flood anxiety cases, 3.8% had mild anxiety, 5.4%
had moderate anxiety and 1.7% had severe anxiety. After the flood, the number of anxiety
cases increased from 271 (10.8%) to 400 (16%) with the increase of severity (4.8% had
mild anxiety, 6.7% moderate anxiety and 4.5% severe anxiety). The results of the Pearson
chi-square test showed that there is a significant association between flooding and anxiety
in Upazila Tala (χ 2=50.11; p<0.04).

Before the flood, 2,377 people (95.1%) did not have PTSD (non-case) while only 123
(4.9%) had some symptoms. Among the pre-flood PTSD cases, 1.8% had mild PTSD,
2.1% had moderate PTSD and 1.0% suffered from severe PTSD. After the flood, the
number of PTSD cases increased from 123 (4.9%) to 307 (12.3%) with the increase of
severity (3.4% had mild PTSD, 5.7% moderate PTSD and 3.2% severe PTSD). The results
of the Pearson chi-square test showed that there is a significant association between
flooding and PTSD in Upazila Tala (χ 2=84.71; p<0.003).
Before the flood, 2,363 (94.5%) had not abused drugs (non-case) while only 137 (5.5%)
had some symptoms. Among the pre-flood drug abuse cases, 1.2% had mild drug abuse,
2.7% had moderate drug abuse and 1.6% suffered severe drug abuse. After the flood, the
number of drug abuse cases increased from 137 (5.5%) to 244 (9.8%) with the increase of
severity (1.8% had mild drug abuse, 1.5% moderate drug abuse and 6.5 % severe drug
abuse). The results of the Pearson chi-square test showed that there is a significant
association between flooding and drug abuse in Upazila Tala (χ 2=86.97; p<0.001).
Mental illness in Tala

800
700
600
Number of cases
500
400
Pre-flood
300
Post-flood
200
100
0
Depression Anxiety PTSD Drug abuse
Type of the mental illness
Figure 4.1: Prevalence of mental disorder pre and post-flood in Upazila Tala (Statistical
significant difference: p<0.01).
Table 4.3 shows the association between different levels of water exposure and mental
health disorders. The proportion of mental health disorder was higher at the higher level of
water in home (i.e. at 2-6 feet and >6 feet compared to <2 feet). For example, the relative
risk for depression at 2-6 feet of water exposure was 1.83 times (95% CI; 1.43-2.35)
higher than < 2 feet water in the home. When people were exposed to > 6 feet of water in

the home, the relative risk for depression was 2.12 times (95% CI; 1.68-2.67) higher than
<2 feet water in the home. Similarly, the relative risk for anxiety was also higher at higher
water level than lower level of exposure (2-6 feet vs < 2feet: 1.59, 95% CI; 1.11-2.27); >6
feet vs <2 feet: 2.4, 95% CI; 1.74-3.32). The relative risk for PTSD was also higher at
higher water level in the home (2-6 feet vs <2 feet: 1.48, 95% CI; 1.03-2.14); >6 feet vs <2
feet: 1.7, 95% CI; 1.21-2.38). Similarly, the relative risk for drug abuse was higher at
higher level of water than <2 feet water in the home (2-6 feet vs < 2feet: 1.78, 95% CI;
1.14-2.80); >6 feet vs <2 feet: 2.18, 95% CI; 1.43-3.30).
Table 4.3 Distribution of mental illness associated with different water levels of Upazila Tala
Mental <2 feet 2-6 feet >6 feet Pearson χ2 P value
disorder
No depression 386 (21.4) 521 (28.9) 897 (49.7) 48.9 <0.001

Depression 69 (9.9) 201 (28.9) 426 (61.2)
Relative Risk 1.00 1.83 (1.43-2.35) 2.12 (1.68-2.67)
No Anxiety 417 (19.9) 626 (29.8) 1057 (50.3) 40.3 <0.001

Anxiety 38 (9.5) 96 (24) 266 (66.5)
Relative Risk 1 1.59 (1.11-2.27) 2.4 (1.74-3.32)
No PTSD 418 (19.1) 635 (29) 1140 (52) 10.3 <0.006

PTSD 37 (12.1) 87 (47.5) 183 (59.6)
Relative Risk 1 1.48 (1.03-2.14) 1.7 (1.21-2.38)
No drug abuse 431 (19.1) 654 (29) 1171 (51.9) 130.0 <0.001
Drug abuse 24 (9.8) 68 (27.9) 152 (62.3)
Relative Risk 1 1.78 (1.14-2.80) 2.18 (1.43-3.30)
4.4 Statistical associations
4.4.1 Bivariate analysis

Chi-square tests with cross tabulation were conducted to explore the association between
socio-economic factors and exposure variables. Variables that were associated with each
psychological outcome at p≤ 0.2 were then selected for entering into multivariable logistic
regression analyses. To control for type I errors, predictor variables in these regressions
were required to attain p ≤ 0.01 to be considered statistically significant (Appendix C). As
there is a significant change in the socio-demographic characteristics between survey
groups (pre-flood male respondents were 75%, which reduces to 51% post flood) the
association between gender and other socio-economic and exposure factors were assessed
by the chi-square test. Cross tabulation also provided the distribution of each risk factor for

different genders. These result were used to assess the gender-based difference in the
occurrence of mental illness.
Table 4.4 shows the gender-based differences in the distribution of socio-economic and
outcome variables among the pre-flood group. Out of 2,500 respondents of the pre-flood
survey, 74.9% were male and 25.1% were female. Males were significantly older than
females. Significantly more males were married, more were employed, and had less
monthly income and less chronic illness than females. Males had more chance of
developing anxiety and used more drugs, but had fewer chances of developing PTSD and
depression than females.
Phi and Cramer’s V test indicated the significant association between gender and other
socio-economic and exposure variables. The score of phi and Cramer V test score varies
between 0 and 1 and did not show the direction of the associations between variables.

Table 4.4 Gender-based differences in the distribution of socio-economic and outcome
variables (pre-flood group)
Variables Total respondents (2500) Phi and Cramer V P value
Gender Male Female
74.9% 25.1%
n(1872) n(628)
Age group
15-19 (446) 15.8% 26.2% 0.2 0.001
20-24 (404) 14.8% 22%
25-29 (323) 12.9% 21.7%
30-49 (329) 16.9% 12.1%
50-59 (347) 17.1% 9.5%
60-64 (179) 8.4% 5.3%
65+ (267) 14.2% 3.2%
Marital Status
Married (1759) 65% 47.8% 0.2 0.001
Unmarried (741) 35% 52.2%
Employment status
Employed (1177) 58.7% 43.9% 0.3 0.05
Unemployed(1323) 41.3% 56.1%
Monthly income
<2000 taka (1062) 55.5% 23% -0.4 0.001
2000-4000 taka (854) 31.2% 47.1%
>4000 taka (584) 13.4% 29.9%
Chronic illness
Yes (606) 21.7% 31.8% -0.1 0.001
No (1894) 78.3% 68.2%
Depression
Yes (419) 10.1% 36.5% -0.4 0.001
No (2081) 89.9% 63.5%
Anxiety
Yes (271) 18.8% 8.4% 0.2 0.001
No (2229) 81.2% 91.6%
PTSD
Yes (123) 2.3% 12.8% -0.3 0.001
No (2377) 97.7% 87.2%
Drug abuse
Yes (137) 6.3% 3.2% 0.2 0.001
No (2363) 93.7% 96.8%
Table 4.5 shows the gender-based differences in the distribution of socio-economic

variables among the post-flood group. Around 51% of the total respondents were male and
49% were female. Post flood, males were significantly older than females, more
employed, had less monthly income and less chronic illness. Phi and Cramer’s V test
showed the significant association between gender and other socio-economic variables.

Table 4.5 Gender-based differences in the distribution of socio-economic variables (post-
flood group)
Gender Male Female
51.1% 48.9%
n(1272) n(1222)
Age group
15-19 (251) 10.7% 18.3% 0.1 0.01
20-24 (518) 22.1% 29.2%
25-29 (459) 16.7% 22.1%
30-49 (475) 20.3% 14.6%
50-59 (290) 12.2% 6.7%
60-64 (299) 10.3% 5.6%
65+ (208) 7.6% 3.4%
Marital Status
Married (1513) 59.2% 56.1% 0.0 0.11
Unmarried (987) 40.8% 43.9%
Employment status
Employed (902) 51.8% 34.3% 0.2 0.001
Unemployed (1598) 48.2% 65.7%
Monthly income
<2000 taka (1574) 75.2% 58.2% -0.3 0.001
2000-4000 taka (490) 17.6% 28.4%
>4000 taka (436) 7.2% 13.4%
Chronic illness
Yes (280) 10.3% 14.1% -0.0 0.09
No (2220) 89.7% 85.9%
Table 4.6 shows the gender-based differences in the distribution of exposure and outcome
variables among the post-flood group. Males had suffered more injuries, more loss of land,
received more financial help and faced more loss of a loved one than females. On the other
hand, females were more exposed to higher levels of water (>6 feet) than males. After the
flood, males had suffered significantly more anxiety, used more drugs, but had less PTSD
and depression than females. As gender-based differences were more evident in this study,
the associations between gender and other factors are presented in this chapter. (See more
details in appendix C).

Table 4.6 Gender-based differences in the distribution of exposure and outcome variables
(post-flood group)
Gender Male Female
51.1% 48.9%
n (1272) n (1222)
Water level at home
<2 feet (455) 22.2% 14% -0.1 0.01
2-6 feet (722) 29.7% 23.8%
>6 feet (1323) 48.1% 62.2%
Injury
Yes (402) 21.8% 10.6% 0.0 0.001
No (2098) 78.2% 89.4%
Loss of loved one
Yes (54) 2.6% 1.7% 0.0 0.08
No (2446) 97.4% 98.3%
Financial help
Yes (824) 34% 31.8% 0.0 0.11
No (1676) 66% 68.2%
Loss of land
Yes (1801) 74.8% 65.1% 0.1 0.01
No (699) 25.2% 34.9%
Depression
Yes (696) 18% 45.4% -0.3 0.001
No (1804) 82% 56.6%
Anxiety
Yes (400) 21.3% 10.5% 0.4 0.02
No (2100) 78.9% 89.5%
PTSD
Yes (307) 3.7% 20.4% -0.4 0.04
No (2193) 47.4% 42.5%
Drug abuse
Yes (244) 14.8% 4.5% 0.5 0.01
No (2256) 85.2% 95.4%

4.4.2 Logistic Regression
In the pre-flood regression model, a total of six predictors were entered into the model
(gender, marital status, employment status, monthly income and chronic illness) for each
dependent variable (anxiety, depression, PTSD and drug abuse).
After the flood, along with the significant pre-flood socio-economic factors, five flood
exposure variables were entered into the logistic regression model (water level in the
home, injury, loss of loved one, financial help and loss of land) for each dependent
variable (anxiety, depression, PTSD and drug abuse).
4.4.2.1 Predictors of depression

Pre-flood
Of the total 2,500 participants, 419 had depression before the flood. As Table 4.7 shows, in
step 1, gender was entered into the model. Nagelkerke R2=0.15, suggesting that only 15%
of the variance in caseness (i.e. having the disorder) was explained by this model. Then all
other socio-economic variables were entered into the model step by step to assess the
significant impact of each variable on the prevalence of depression. The addition of socio-
economic status made a significant improvement to the model fit (Nagelkerke R2=0.32),
suggesting that 32% of the variance in caseness was explained by the model. Additionally,
the factors having a high VIF score were included in the final model using an interaction
term. In this model, age group*employment status was entered, which made a significant
improvement to the model fit (Nagelkerke R2=0.43).
The odds of having pre-flood depression was associated with gender (female: OR=2.45,
95% CI [1.19-5.13]), age group (30-49 yrs. vs 65+ yrs.: OR=1.34, 95% CI [1.02-2.98]),
marital status (married: OR=1.46, 95% CI [1.07-3.67]), employment status (unemployed:
OR= 2.31, 95% CI [1.21-3.90]) and monthly income (<2000 taka vs. >4000 taka:
OR=2.17, 95% CI [1.51-5.81]. The age group (30-49 yrs)*unemployment status
interaction was significantly associated with depression. Figure 4.2 shows that younger
(25-49 yrs) and unemployed respondents had significantly higher risk of developing
depression than the employed older groups (>50 years) (OR=3.11, 95% CI [2.27-4.41].

Age group*unemployment status
6
25-49 yrs, 5.45
Odds ratio of depression 5
Unemplyment,
4 3.53
3
2 65+ yrs, 1
15-24 yrs, 0.87 Ref group
1
50-64 yrs, 0.55
0
0 1 2 3 4 5 6 7
Age group*unemployment
Figure: 4.2 Scatter plot of significant interactions between age group*unemployment

status.
Adjustment for multiple significant testing
The Bonferroni method was used to adjust the significance level for each regression
model. As multiple tests were performed on the same data set, there were chances of type-I
errors. To reduce the likelihood of the false-positive results, the overall p-value was
adjusted for multiple significant testing.
In the regression analyses, to adjust for the multiple testing, the significance level (p-value)
was reduced using the Bonferroni correction method. According to the Bonferroni test, the
overall adjusted p-value for the pre flood model was 0.01 (α1=α/k). From the post-hoc
analyses, (adjusted p-value=unadjusted p-value*numbers of comparison tests in pairs) p-
value of each predictor was reduced to the significance level of 0.01.

Table 4.7 Socio-economic predictors of pre-flood depression (n=2500)
Step Predictors B SE Odds ratio Wald χ 2 P value R2
(95% CI) Unadjusted Adjusted
1 Gender 0.15
Female 1.21 0.41 2.45 (1.19-5.13) 14.88 0.003 0.006
2 Age group 0.19

65+ yrs. - - Ref. Group - - -
15-19 yrs. -0.47 0.22 0.56 (0.37-1.85) 0.53 0.47 0.89
20-24 yrs. -0.27 0.13 0.67 (0.21-1.36) 1.55 0.37 0.92
25-29 yrs. 0.63 0.17 1.29 (1.07-3.57) 9.45 0.04 0.28
30-49 yrs. 0.45 0.19 1.34 (1.02-2.98) 9.49 0.003 0.01
50-59 yrs. -0.56 0.12 0.34(0.45-1.73) 3.78 0.21 0.87
60-64 yrs. -0.31 0.05 0.59 (0.19-1.67) 3.31 0.23 0.86
3 Marital status 0.22

Married 1.15 0.32 1.46 (1.07-3.67) 11.21 0.002 0.004
4 Employment 0.31
Unemployed 1.16 0.21 2.31 (1.21-3.90) 11.68 0.004 0.008
5 Monthly income 0.37

>4000 taka - - Ref. Group - - -
<2000 taka 1.47 0.34 2.17 (1.51-5.81) 20.45 0.003 0.009
2000-4000 taka 0.37 0.31 1.44 (1.09-3.34) 8.89 0.04 0.12
6 Chronic illness 0.32

Yes -1.06 0.47 0.18 (0.07-1.89) 6.67 0.37 0.76
7 30-49 yrs*unemployment 1.34 0.31 3.11 (2.27-4.41) 10.45 0.003 0.01 0.43
Post-flood
Of the total 2,500 participants, 696 suffered from depression after the flood. Table 4.8
shows that when all the significant predictors of pre-flood depression were entered in the
first step of the model, only 31% of the variance in caseness (i.e. having the disorder) was
explained by this model (Nagelkerke R2=0.31). Then all the exposure variables were
entered into the model step by step. The addition of exposure variables made a significant
improvement to the model fit (Nagelkerke R2=0.49), suggesting that 49% of the variance
was explained by the model. Then, age group*employment status was included in the
model which also improved the model fit (Nagelkerke R2=0.51). Additionally, interaction
terms between gender and significant exposure variables were added into the model which
made significant improvement in the model (Nagelkerke R2=0.59).

Post flood depression was significantly associated with the water level in the home (>6
feet vs. <2 feet: OR=4.89, 95% CI [3.98-7.13]) and injury (OR=2.27, 95% CI [1.32-3.90]).
Post flood depression was more common in females (OR=4.67, 95% CI [2.49-8.17]),
married (OR=3.71, 95% CI [1.52-6.82]) and lower-income people (<2000 taka vs. >4000
taka: OR=4.73, 95% CI [3.91-6.17]). Figure 4.3-4.4 shows that the female* >6 feet water
in the home (OR=5.56, 95% CI [4.78-7.34]) and female*injured (OR=3.67, 95% CI [2.12-
6.27]) interactions significantly increased the impact of flooding on depression.
Gender*water level
6 Female*>6 feet,
5.56
Odds ratio of depression
5 >6 feet, 4.89

Female*2-4
4 feet, 4.11 2-4 feet, 3.65
3
2
<2 feet, 1
1
Ref. group
0
0 1 2 3 4 5 6
Gender*Water level
Figure 4.3: Scatter plot of significant gender*water level at home interaction.
Gender*injury
4
3.5
Odds ratio of depression
female*injury,
3 3.67
2.5
Injury, 2.27
2
1.5
No injury,1
1
Ref group
0.5
0
0 0.5 1 1.5 2 2.5 3 3.5
Gender*injury
Figure 4.4: Scatter plot of significant gender*injury interaction.

Goodness of fit
The goodness of fit of each model was assessed by the Nagelkerke R2 tests. All the
individual variables were included into the model stepwise and checked for model fit
(Table 4.7-4.8). Individual factors which reduce the R2 (chronic illness; R2=0.32) was not
entered into the post-flood model. The overall Nagelkerke R2 increased significantly from
pre-flood to post-flood model (0.43 to 0.59) respectively.

According to the Bonferroni test, the overall adjusted p-value for the post-flood model was
0.005 (α1=α/k). From the post-hoc analyses, p-value of each predictor was reduced to the
significance level of 0.005.

Table 4.8 Major risk factors of post-flood depression (n=2500)
Step Predictors B SE Odds ratio Wald χ2 P value R2
1 Gender 0.31
Female 1.25 0.15 4.67 (2.49.-8.17) 24.16 0.001 0.002
1 Age group
65+ yrs. - - Ref. Group - - -
15-19 yrs. -0.31 0.10 0.68 (0.32-1.89) 3.11 0.28 0.66
20-24 yrs. -0.26 0.13 0.76 (0.36-1.67) 3.73 0.31 0.62
25-29 yrs. 0.55 0.13 1.26 (1.03-1.82) 7.78 0.001 0.007
30-49 yrs. -0.12 0.06 0.88(0.40-1.54) 4.67 0.56 0.92
50-59 yrs. -0.21 0.04 0.77 (0.21-1.41) 2.56 0.44 0.88
60-64 yrs. -0.22 0.09 0.80 (0.56-1.49) 1.43 0.34 0.78
1 Marital status
Married 1.51 0.06 3.71 (1.52-6.82) 18.91 0.001 0.002
1 Employment
Unemployed 1.02 0.19 3.53 (2.91-4.89) 15.61 0.004 0.008
1 Monthly income
>4000 taka - - Ref. Group - - -
<2000 taka 1.23 0.18 4.73 (3.91-6.17) 14.35 0.001 0.003
2000-4000 taka 0.56 0.34 1.72 (1.05-2.83) 6.15 0.004 0.01
2 Water level at home 0.45

<2 feet - - Ref. Group - - -
2-6 feet 2.04 0.43 3.65 (2.32-6.92) 18.87 0.01 0.03
>6 feet 3.23 0.21 4.89 (3.98-7.13) 24.27 0.001 0.003
3 Loss of loved one 0.42

Yes 0.79 0.34 1.17 (0.67-1.75) 6.10 0.47 0.89
4 Injury 0.47
Injured 0.82 0.27 2.27 (1.32-3.90) 8.80 0.002 0.004
5 Financial helps 0.47

Yes -0.65 0.47 0.33 (0.15-1.18) 20.73 0.33 0.87
6 Loss of land 0.49
Yes 0.82 0.27 4.27 (2.32-8.90) 18.80 0.004 0.008
7 25-29 yrs*unemployment 1.19 0.28 3.29 (1.67-5.56) 15.02 0.001 0.01

0.51
8 Female*>6 feet water 1.24 0.14 5.56 (4.78-7.34) 27.89 0.001 0.006 0.59
level at home
8 Female*injured 1.09 0.47 3.67 (2.12-6.27) 24.32 0.001 0.004
8 Female*loss of land 1.34 0.23 4.91 (3.66-5.98) 39.12 0.003 0.01

4.4.2.2 Predictors of anxiety
Pre-flood
Of the total 2,500 participants, 271 had anxiety (non-case) before the flood. As the table
4.9 shows in step 1, gender was entered into the model. Nagelkerke R2=0.12, suggesting
that only 12% of the variance in caseness (i.e. having the disorder) was explained by this
model. Then all other socio-economic variables were entered into the model step by step to
see the significant impact of each variable on the prevalence of anxiety. The addition of
socio-economic status made a significant improvement to the model fit (Nagelkerke
R2=0.27), suggesting that 27% of the variance in caseness was explained by the model.
Additionally, the factors having a high VIF score were included in the final model using a
significant interaction term. In this model, age group*employment status was entered, which
had made significant improvement to the model fit (Nagelkerke R2=0.31).
The odds of having a pre-flood anxiety was significantly associated with gender (Male:
OR=1.86, 95 % CI [1.12-4.63]), age group (25-29 yrs. vs. 65+ yrs: OR= 0.57, 95% CI
[0.37-0.82]; 30-49 yrs. vs. 65+ yrs: OR=1.38, 95% CI [1.15-1.75], 50-59 yrs. vs. 65+ yrs.:
OR=0.57, 95% CI [0.31-0.94], employment status (unemployed: OR=2.13, 95% CI [1.07-
3.75]) and monthly income (<2000 taka vs. >4000 taka: OR=2.23, 95% CI [1.44-5.51].
The age group (30-49 yrs)*unemployment status interaction was significantly associated
with anxiety. Younger and unemployed groups developed more anxiety than the older
employed groups (age group (30-49 yrs)*unemployment: OR=2.51, 95% CI [1.56-4.11]).
Scatter plots for this interaction term are similar to depression.

According to the Bonferroni test, the overall adjusted p-value for the post flood model was
0.01 (α1=α/k). From the post-hoc analyses, p-value of each predictor was reduced to the
significance level of 0.01.

Table 4.9 Socio-economic predictors of pre-flood Anxiety (n=2500)
1 Gender
Male 0.81 0.12 1.86 (1.12-4.63) 12.14 0.004 0.008 0.12
2 Age group 0.16

65+ yrs. - - Ref. Group - - -
15-19 yrs. -0.35 0.18 0.65 (0.32-1.77) 3.06 0.37 0.59
20-24 yrs. -0.31 0.12 0.63 (0.55-1.12) 3.32 0.23 0.61
25-29 yrs. -0.47 0.17 0.57 (0.37-0.82) 3.69 0.001 0.01
30-49 yrs. 0.35 0.09 1.38 (1.15-1.75) 7.62 0.001 0.01
50-59 yrs. -0.31 0.13 0.57 (0.31-0.94) 3.56 0.001 0.01
60-64 yrs. -0.25 0.16 0.78 (0.71-1.38) 0.007 0.35 0.85
3 Marital status 0.12

Married -1.15 0.23 0.12 (0.07-1.28) 15.90 0.43 0.86
4 Employment 0.21
Unemployed 1.56 0.33 2.13 (1.07-3.75) 9.21 0.003 0.006

>4000 taka - - Ref. Group - - -
<2000 taka 1.04 0.18 2.23 (1.44-5.51) 27.28 0.004 0.01
2000-4000 taka 0.77 0.16 1.57 (1.09-4.98) 11.34 0.02 0.06
6 Chronic illness 0.23

Yes -0.88 0.22 0.15 (0.10-1.23) 13.46 0.17 0.54
7 30-49 yrs*unemployment 1.11 0.21 2.51(1.56-4.11) 12.45 0.001 0.01 0.31
Post-flood:
After the flood, 400 respondents suffered from anxiety. Table 4.10 shows that when all
the significant predictors of pre-flood anxiety were entered in the first step of the model,
only 29% of the variance in caseness (i.e. having the disorder) was explained by this model
(Nagelkerke R2=0.29). Then all the exposure variables were entered into the model step by
step. The addition of exposure variables made a significant improvement to the model fit
(Nagelkerke R2=0.41), suggesting that 41% of the variance in caseness was explained by
the model. Then, age group*employment status was included in the model which also
improved the model fit (Nagelkerke R2=0.43). Additionally, interaction terms between
gender and significant exposure variables were added in the model which made significant
improvement in the model fit (Nagelkerke R2=0.53).

Post-flood anxiety was significantly associated with the water level at home (>6 feet vs. <2
feet: OR=5.58, 95% CI [4.71-7.11]), loss of loved one (OR=3.17, 95% CI [1.29-6.79]) and
loss of land (OR=4.21, 95% CI [2.90-6.52]). Post-flood anxiety was more common in
males (OR=3.98, 95% CI [1.46-6.87]), younger age group (30-49 yrs. vs. 65+ yrs.:
OR=1.43, 95% CI [1.05-2.71], unemployed (OR=3.67, 95% CI [1.4-5.51] and lower-
income people (<2000 taka vs. >4000 taka: OR=4.73, 95% CI [2.84-8.10]. The
gender*loss of loved one (OR=4.15, 95% CI [2.89-8.81]) and gender*loss of land
(OR=5.61, 95% CI [3.67-9.91]) interactions significantly increased the impacts of flooding
on anxiety (the scatter plots for anxiety are similar to those for depression so they are not
included here).
Goodness of fit
Similarly to depression, the goodness of fit of each model was assessed by the Nagelkerke
R2 tests. All the individual variables were included into the model stepwise and checked
for model fit (Table 4.9-4.10). Individual factors which reduce the R2 (Marital status: R2
=0.12, Chronic illness: R2=0.23) were not entered into the post-flood model. The overall
Nagelkerke R2 increased significantly from the pre-flood to the post-flood model (0.31 to
0.53) respectively.

According to the Bonferroni test, the overall adjusted p-value for the post flood model was
0.005 (α1=α/k). From the post-hoc analyses, the p-value of each predictor was reduced to
the significance level of 0.005.

Table 4.10 Major risk factors post-flood Anxiety (n=2500)
(95% CI) unadjusted adjusted
1 Gender 0.29
Male 1.01 0.13 3.98 (1.46.-6.87) 19.76 0.001 0.002
1 Age group
65+ yrs. - - Ref. Group - - -
15-19 yrs. -0.33 0.15 0.67 (0.31-1.04) 3.34 0.11 0.77
20-24 yrs. -0.21 0.12 0.63 (0.23-1.21) 1.70 0.44 0.88
25-29 yrs. -0.41 0.12 0.59 (0.47-1.02) 4.45 0.34 0.78
30-49 yrs. 0.55 0.14 1.43 (1.05-2.71) 9.41 0.001 0.007
50-59 yrs. -0.27 0.13 0.57 (0.32-1.94) 4.56 0.13 0.91
60-64 yrs. -0.31 0.12 0.68 (0.64-1.16) 1.25 0.27 0.89
1 Employment
Unemployed 1.23 0.11 3.67 (1.74-5.51) 16.32 0.002 0.004
1 Monthly income
>4000 taka - - Ref. Group - - -
<2000 taka 2.89 0.21 4.73 (2.84-8.10) 24.68 0.001 0.003
2000-4000 taka 0.89 0.41 1.89 (1.28-4.42) 10.15 0.01 0.03

2-6 feet 1.23 0.34 2.19 (1.21-4.98) 9.54 0.04 0.1
>6 feet 2.21 0.41 5.58 (4.71-7.11) 27.81 0.001 0.005
3 Injury
Yes 0.54 0.21 1.36 (0.63-2.28) 7.67 0.34 0.68 0.34
4 Loss of loved one

Yes 1.23 0.45 3.17 (1.29-6.79) 18.19 0.003 0.003 0.38
5 Financial helps
No -1.25 0.32 0.23 (0.05-1.27) 14.46 0.26 0.52 0.37
6 Loss of land
Yes 1.12 0.34 4.21 (2.90-6.52) 27.45 0.002 0.004 0.41
8 Male*>6 feet water at home 1.34 0.47 5.81 (4.15-8.34) 25.78 0.003 0.01 0.53
8 Male*loss of loved one 1.03 0.41 4.15 (2.89-8.81) 24.89 0.001 0.004
8 Male*loss of land 1.89 0.37 5.61 (3.67-9.91) 30.71 0.001 0.004

4.4.2.3 Predictors of PTSD
Pre-flood
Of the 2,500 participants, only 123 respondents had PTSD before the flood. As the table
4.11 shows in step 1, gender was entered into the model. Nagelkerke R2=0.06, suggesting
that only 6% of the variance in caseness (i.e. having the disorder) was explained by this
model. Then all other socio-economic variables were entered into the model step by step to
assess the significant impact of each variable on the prevalence of PTSD. The addition of
socio-economic status made a significant improvement to the model fit (Nagelkerke
R2=0.23), suggesting that 23% of the variance in caseness was explained by the model.
Additionally, the factors having a high VIF score were included in the final model using an
interaction term. In this model, age group*employment status was entered, which made a
significant improvement to the model fit (Nagelkerke R2=0.27).
The odds of having pre-flood PTSD was associated with gender (Female: OR=2.94, 95%
CI [1.66-5.19]), age group (25-29 yrs vs. 65+ yrs: OR=1.29, 95% CI [1.22-3.21]; 30-49
yrs vs. 65+ yrs: 1.43, 95% CI [1.02-3.18]; 50-59 yrs vs. 65+yrs: 0.67, 95% CI [0.35-0.98],
employment status (unemployed: OR=1.19, 95% CI [1.00-1.75]), monthly income (<2000
taka vs. >4000 taka: OR=3.69, 95% CI [2.12-6.67]) and chronic illness (Yes: OR=2.03,
95% CI[1.14-4.36]). The age group (25-49 yrs)*unemployment status interaction had
significant association with pre-flood PTSD (OR=1.56, 95% CI [1.11-1.96]) that means
the younger (25-49 yrs) unemployed group suffered from more PTSD than elderly (>50
yrs) employed groups.

According to the Bonferroni test, the overall adjusted p-value for the pre flood model was

Table 4.11 Socio-economic predictors of pre-flood PTSD (n=2500)
(95% CI) unadjusted adjusted
1 Gender
Female 0.67 0.29 2.94 (1.66-5.19) 16.42 0.004 0.008 0.06
2 Age group
65+ yrs. - - Ref. Group - - - 0.09
15-19 yrs. 0.34 0.14 0.52 (0.27-1.75) 2.12 0.27 0.79
20-24 yrs. -0.29 0.13 0.68 (0.41-1.66) 2.19 0.26 0.92
25-29 yrs. 0.76 0.14 1.29 (1.22-3.21) 10.29 0.004 0.02
30-49 yrs. 0.52 0.20 1.43 (1.02-3.18) 8.26 0.005 0.03
50-59 yrs. 0.38 0.07 0.67 (0.35-0.98) 7.55 0.001 0.007
60-64 yrs. -0.35 0.11 0.67 (0.39-1.76) 2.35 0.31 0.72
3 Marital status
Married 0.17 0.32 1.18 (0.62-2.25) 6.26 0.33 0.66 0.08
4 Employment
Unemployed 1.11 0.34 1.19 (1.00-1.75) 7.21 0.001 0.002 0.17
5 Monthly income
>4000 taka - - Ref group - - - 0.21
<2000 taka 1.15 0.52 3.69 (2.12-6.67) 19.46 0.004 0.01
2000-4000 taka 2.55 0.44 1.98 (1.12-4.78) 11.78 0.03 0.09
6 Chronic illness
Yes 0.80 0.34 2.03 (1.14-4.36) 13.57 0.003 0.006 0.23
7 25-49 yrs *unemployment 1.02 0.23 1.56 (1.11-1.96) 9.81 0.001 0.01 0.27
Post-flood
Of the total 2,500 participants, 307 respondents had PTSD after the flood. Table 4.12
shows that when all the significant predictors of pre-flood PTSD were entered into the first
step of the model, only 32% of the variance in caseness (i.e. having the disorder) was
explained by this model (Nagelkerke R2=0.32). Then all the exposure variables were
entered into the model step by step. The addition of exposure variables made a significant
in caseness was explained by the model. Then, age group*employment status was included
in the model which also improved the model fit (Nagelkerke R2=0.51). Additionally,
interaction terms between gender and significant exposure variables were added to the
model, which made significant improvement in the final model fit (Nagelkerke R2=0.62).

Post-flood PTSD was significantly associated with the water level in the home (>6 feet vs.
<2 feet: OR=4.78, 95% CI [3.62-6.89], injury (injured: OR=2.81, 95% CI [1.98-5.33]) and
loss of land (OR=4.15, 95% CI [2.71-8.32]). Post-flood PTSD was more common in
females (OR=3.91, 95% CI [2.15-7.29]), unemployed (OR=3.43, 95% CI [2.78-5.11]) and
lower income people (<2000 taka vs. >4000 taka: OR=4.52, 95% CI [3.53-6.10]. Age
group (30-49 yrs)*unemployment status was significant for post-flood PTSD (OR=3.61,
95% CI [1.63-5.93]). Similar to the pre-flood statistics, younger unemployed people had
more PTSD than elderly employed people. The female*>6 feet water in the home
(OR=6.24, 95% CI [3.89-8.46]), female*injured [(OR=3.43, 95% CI (2.59-5.21)] and
female*loss of land (OR=5.12, 95% CI (3.33-9.89]) interactions significantly increased the
impact of flooding on PTSD.
Goodness of fit
Similarly like other disorders, the goodness of fit of each model was assessed by the
Nagelkerke R2 tests. All the individual variables were included into the model stepwise
and checked for model fit (Table 4.11-4.12). Individual factors which reduce the R2
(Marital status: R2=0.08) were not entered into the post-flood model. The overall
Nagelkerke R2 increased significantly from the pre-flood to the post-flood model (0.27 to
0.62) respectively.

According to the Bonferroni test, the overall adjusted p-value for the post-flood model was

Table 4.12 Major risk factors of post-flood PTSD (n=2500)
1 Gender
Female 1.07 0.33 3.91 (2.15-7.29) 21.67 0.002 0.004 0.32
1 Age group
65+ yrs. - - Ref. Group - - -
15-19 yrs. -0.22 0.13 0.82 (0.38-1.46) 0.85 0.34 0.68
20-24 yrs. -0.24 0.10 0.91 (0.29-1.31) 2.19 0.45 0.75
25-29 yrs. -0.35 0.17 0.78 (0.58-1.36) 1.41 0.36 0.77
30-49 yrs. 0.66 0.11 1.74 (1.15-3.96) 9.06 0.004 0.02
50-59 yrs. -0.25 0.12 0.59 (0.71-1.39) 1.01 0.43 0.86
60-64 yrs. 0.19 0.08 1.19 (0.73-1.59) 2.96 0.22 0.69
1 Employment
Unemployed 1.02 0.35 3.43 (2.78-5.11) 21.89 0.003 0.006
1 Monthly income
>4000 taka - - Ref. Group - - -
<2000 taka 0.84 0.52 4.52 (3.53-6.10) 25.60 0.001 0.003
2000-4000 taka 1.15 0.41 2.79 (1.41-5.07) 15.15 0.01 0.03
1 Chronic illness
Yes 0.67 0.27 3.05 (1.89-6.67) 18.91 0.004 0.008
2 Water level at home

<2 feet - - Ref. Group - - - 0.39
2-6 feet 1.24 0.31 2.16 (1.27-4.46) 12.34 0.03 0.09
>6 feet 1.56 0.13 4.78 (3.62-6.89) 20.89 0.001 0.003
3 Loss of loved one

Yes 1.45 0.21 2.51(1.35-5.86) 15.46 0.004 0.008 0.41
4 Injury
Injured 0.88 0.40 2.81 (1.98-5.33) 14.70 0.001 0.002 0.43
5 Financial helps
Yes -0.85 0.39 0.07 (0.02-1.12) 6.68 0.45 0.90 0.39
6 Loss of land
Yes 1.12 0.25 4.15 (2.71-8.32) 24.66 0.001 0.004 0.47
8 Female*>6 feet water at 1.22 0.32 6.24 (3.89-8.46) 39.56 0.001 0.005 0.62
home
8 Female*loss of loved one 0.89 0.27 3.78 (2.63-5.61) 18.45 0.003 0.01
8 Female*injured 0.72 0.34 3.43 (2.59-5.21) 20.98 0.001 0.004
8 Female* loss of land 1.34 0.45 5.12 (3.33-9.89) 31.67 0.001 0.004

4.4.2.4 Predictors of drug abuse
Pre-flood
Of the total 2,500 participants, only 137 respondents had symptoms of drug abuse before
the flood. As the table 4.13 shows in step 1, gender was entered into the model.
Nagelkerke R2=0.09, suggesting that only 9% of the variance in caseness (i.e. having the
disorder) was explained by this model. Then all other socio-economic variables were
entered into the model step by step to see the significant impact of each variable on the
prevalence of drug abuse. The addition of socio-economic status made a significant
in caseness was explained by the model. Additionally, the factors having a high VIF score
were included in the final model using a significant interaction term. In this model, age
group*employment status was entered, which had made significant improvement to the
model fit (Nagelkerke R2=0.37).
The odds of having a pre-flood drug abuse was significantly associated with gender (Male:
OR=2.80, 95% CI [1.34-5.36]), age group (20-24 yrs. vs. 65+ yrs.: OR=1.47, 95% CI
[1.21-3.97]; 50-59 yrs. vs. 65+ yrs.: OR=0.38, 95% CI [0.16-0.81]), marital status
(married: OR=2.69, 95% CI [1.24-4.89]), employment status (unemployed: OR=1.51,
95% CI [1.02-1.91) and monthly income (<2000 taka vs. >4000 taka: OR=1.88, 95% CI
[1.04-3.27]). Age group (20-24 yrs)*unemployment status was significantly associated
with pre-flood drug abuse that means younger unemployed groups used more drugs than
elderly employed groups (OR=2.12, 95% CI [1.67-2.78]).

According to the Bonferroni test, the overall adjusted p value for the pre-flood model was

Table 4.13 Socio-economic predictors of pre-flood drug abuse (n=2500)
1 Gender
Male 1.03 0.09 2.80 (1.34-5.36) 16.45 0.004 0.008 0.09
2 Age group 0.12

65+ yrs. - - Ref. Group - - -
15-19 yrs. -0.33 0.14 0.79 (0 .55-1.14) 1.52 0.33 2.31
20-24 yrs. -0.28 0.11 1.47 (1.21-3.97) 2.51 0.001 0.01
25-29 yrs. -0.22 0.15 0.59 (0.84-1.19) 0.95 0.37 2.17
30-49 yrs. 0.41 0.12 0.99 (0.36-1.86) 6.50 0.66 4.62
50-59 yrs. -0.29 0.14 0.38 (0.16-0.81) 1.18 0.001 0.01
60-64 yrs. 0.27 0.08 0.71 (0.56-1.58) 3.09 0.39 2.73
3 Marital status
Married 1.31 0.21 2.69 (1.24-4.89) 13.32 0.001 0.002 0.15
4 Employment
Unemployed 1.12 0.22 1.51 (1.02-1.91) 14.45 0.001 0.002 0.19

>4000 taka - - Ref. Group - - -
<2000 taka 1.23 0.48 1.88 (1.04-3.27) 8.91 0.003 0.009
2000-4000 taka 1.84 0.42 2.98 (1.13-4.96) 12.85 0.001 0.003
6 Chronic illness
Yes 0.56 0.29 1.24 (0.75-2.22) 13.96 0.47 0.94 0.30
Post-flood
After flooding, 224 respondents had used drugs. Table 4.14 shows that when all the
significant predictors of pre-flood drug abuse were entered into the first step of the model,
only 31% of the variance in caseness (i.e. having the disorder) was explained by this model
(Nagelkerke R2=0.31). Then all the exposure variables were entered into the model step by
step. The addition of exposure variables made a significant improvement to the model fit
(Nagelkerke R2=0.47), suggesting that 47% of the variance in caseness was explained by
the model. Then, age group*employment status was included in the model which also
significantly improved the model fit (Nagelkerke R2=0.49). Additionally, interaction terms
between gender and significant exposure variables were added in the model which made
significant improvement in the final model fit (Nagelkerke R2=0.57).

Post-flood drug abuse was significantly associated with the water level in the home (>6
feet vs. < 2 feet: OR=5.57, 95% CI [3.33-8.61]), financial help (no: OR=1.78, 95% CI
[1.78-5.77]) and loss of land (OR=4.56, 95% CI [2.91-8.32]). Post-flood drug abuse was
more common in males (OR=5.48, 95% CI [4.49-9.14]), married (OR=3.28, 95% CI
[1.43-5.93]), unemployed (OR=3.34, 95% CI (1.14-5.78)]) and lower income people
(<2000 taka vs. >4000 taka: OR=3.29, 95% CI [2.56-5.61]). Similarly like the pre-flood
statistics, the age group (20-24 yrs)*unemployment status significantly associated with
post-flood drug abuse that means younger unemployed groups used more drugs than
elderly employed groups (OR=2.12, 95% CI [1.67-2.78]). The male* no financial help
(OR=4.88, 95% CI [2.91-8.12]) and male*loss of land (OR=5.27, 95% CI [4.78-7.21])
interactions significantly increased the impact of flooding on the prevalence of drug abuse.
Goodness of fit
The goodness of fit of pre and post-flood model was assessed by the Nagelkerke R2 tests.
All the individual variables were included into the model stepwise and checked for model
fit (Table 4.13-4.14). Individual factors which reduce the R2 (Chronic illness: R2=0.32)
were not entered into the post-flood model. The overall Nagelkerke R2 increased
significantly from the pre-flood to the post-flood model (0.37 to 0.57) respectively.

According to the Bonferroni test, the overall adjusted p value for the post- flood model was

Table 4.14 Major risk factors of post-flood drug abuse (n=2500)
1 Gender 0.31
Male 1.67 0.19 5.48 (4.49-9.14) 28.21 0.001 0.002
1 Age group
65+ yrs. - - Ref. Group - - -
15-19 yrs. -0.17 0.09 0.86 (0.47-1.53) 0.82 0.45 0.95
20-24 yrs. 0.51 0.18 1.61 (1.03-2.91) 7.35 0.003 0.02
25-29 yrs. -0.30 0.13 0.71 (0.31-1.67) 1.56 0.31 0.77
30-49 yrs. -0.32 0.14 0.66 (0.44-1.61) 2.78 0.48 0.86
50-59 yrs. 0.67 0.19 1.22 (0.37-1.89) 4.38 0.47 0.89
60-64 yrs. -0.24 0.22 0.77 (0.41-1.29) 1.28 0.31 0.67
1 Marital status
Married 1.37 0.33 4.28 (2.43-8.16) 24.71 0.003 0.006
1 Employment
Unemployed 1.05 0.39 3.34 (1.14-5.78) 17.77 0.002 0.004
1 Monthly income
>4000 taka - - Ref. Group - - -
<2000 taka 1.34 0.32 3.29 (2.56-5.61) 18.32 0.001 0.003
2000-4000 taka 1.45 0.22 1.39 (1.13-3.37) 9.58 0.02 0.06

2-6 feet 1.37 0.47 3.90 (1.53-5.38) 18.29 0.004 0.01
>6 feet 1.54 0.37 5.57 (3.33-8.61) 27.46 0.001 0.003
3 Loss of loved one

Yes -0.54 0.21 0.44 (0.21-1.45) 9.67 0.28 0.56 0.31
4 Injury
Injured 0.67 0.37 1.34 (0.57-3.69) 12.12 0.37 0.84 0.31
5 Financial helps
No 1.45 0.29 3.45 (1.78-5.77) 17.78 0.002 0.004 0.42
6 Loss of land
Yes 1.39 0.35 4.56 (3.65-7.11) 24.34 0.002 0.004 0.47
8 Male*>6 feet water at 1.52 0.40 6.78 (4.12-8.98) 41.42 0.004 0.01 0.57
home
8 Male*no financial help 1.67 0.41 4.88 (2.91-8.12) 28.89 0.001 0.004
8 Male* loss of land 1.56 0.31 5.27 (4.78-7.21) 49.56 0.001 0.004

Chapter 5: Discussion and conclusions
5.1 Summary
This chapter summarizes the key findings of the study; explains the results; discusses its
strengths and limitations, describes the future research directions and draws conclusions.
5.2 An overview of the key findings of the study

This study assessed flood-related mental illness among flood-affected people of Upazila
Tala in Bangladesh using a multivariable logistic regression model. Overall, the prevalence
of post flood mental health disorders increased significantly among the victims of that area
and was strongly associated with exposure variables, including floodwater levels in the
home, injury, loss of a family member, financial help and loss of land.
5.3 Socio-demographic features between two survey populations

There are significant changes in the characteristics of two survey populations, before and
after the floods. During the pre-flood survey, around 75% of the population were male,
which decreased to 51% after the floods. After the flood, most of the victims lost their
houses and their work. Some males went to other areas to look for employment. As the
post-flood survey was conducted immediately after the event, interviewers knocked on
every door seeking adult participants, which may explain why more females were included
in the post-flood survey than in the pre-flood survey. Due to this limitation the results may
show more cases with mental illness among the female respondents, but as the model
includes interaction terms between gender and significant exposure variables, the impact
of sampling bias is minimised. Similarly, the survey was conducted in the same area
(Upazila Tala) but does not ensure that the same individual was surveyed before and after
the flood. Therefore, the results of this study need to be interpreted cautiously.
5.4 Unadjusted p-value vs adjusted p-value

In this study, we used Bonferroni adjustment for multiple testing, which reduced the
chance of type-I errors (false-positive results). On the other hand, it might increase the
chance of type-II errors (false-negative results). Individual predictors for each
psychological disorder were discussed at the significance level of p≤0.01 instead of the
conventional p≤0.05. If we used the unadjusted p-values, most of the predictors were
Chapter 5: Discussions and Conclusions Page 86

significantly associated with each psychological illness. Thus, the approach adopted in this
study is prudent and conservative.
5.5 Depression
5.5.1 Summary
Unlike previous studies, in this study the number of cases of depression is higher than the
number of cases of PTSD. Because of their lower standard of living people in flood prone
areas always suffer from higher stress levels. When exposed to a flood, they feel more
depressed, think more about the devastating losses and worry about their livelihood, which
may increase their stress levels. Some previous studies have also found significant
associations between flooding and depression. Post-flood, depression varies from 5.9% to
53% (Amstadter et al., 2009; Hoe et al., 2008) among the victims of different population
worldwide. In this study, a total of 419 cases (16.76%) are estimated to have depression in
Upazila Tala before the flood, while this increased significantly to 696 cases (27.84%) after
the flood.
5.5.2 Predicting Factors

Multivariable regression analysis has shown the significant flood-related predictors of
depression. As in the results shown in Chapter 4, (Table 4.8) water level in the home and
injury were strongly associated with the prevalence of depression among the flood victims.
Paranjothy et al. (2001) found the higher water levels are significantly associated with
depression symptoms among the victims of the 2007 floods in England. In this study,
victims who had higher levels of water in their homes suffered more depression than those
with lower levels of water in their homes. Victims flooded with >6 feet water suffered 3.98
to 7.13 times more depression than those who had <2 feet of water in their homes, which is
consistent with other studies (Mason et al., 2010; Paranjothy et al., 2011). Victims who
were injured during the flood suffered from 1.32 to 3.90 times more depression than those
who did not sustain an injury. As a limited number of studies from the Asia-Pacific region
have assessed depression, it is difficult to compare the potential risk factors. However,
similar to the other psychological disorders, it is evident that flooding has a significant
impact on the prevalence of depression. In the coastal region of Bangladesh, most of the
people are of low socio-economic status. They may suffer from day to day stress in
maintaining their livelihood. With limited resources, the government cannot help them to
improve their living standards. After the flood these people are helpless. Being exposed to

higher levels of water in their homes, they may always be frightened. Dealing injuries
when they are unable to leave their may make them even more worried. As a result of
higher exposure and injury, they may suffer from more serious levels of depression. As no
previous studies have assessed post-flood depression in Bangladesh, this study can be used
as baseline information for future studies. The results of this study may help policy makers
to plan depression prevention programs among the most vulnerable people, including
measures to improve the post-flood evacuation and rehabilitation processes, and to give
more financial support to reduce the psychological impact of flooding.
5.5.3 Associated socio-economic factors
In this study, a number of socio-economic factors were significantly associated with

depression before a flood. Being from lower socio-economic status, respondents were
more prone to develop depression than others. Socio-economic factors such as being
female, marital status and low income significantly increased the risk of post flood
depression (Table 4.8). Most of the previous studies reported that more females (Mason et
al., 2010; Paranjothy et al., 2011) have developed depression than males after a flood. In
this study, females had 2.49 to 8.17 times more risk of developing post-flood depression
than males and married people had 1.52 to 6.82 times more risk of suffering depression
than unmarried victims. In the literature, little information is available on the relationship
between marital status and flood-related depression. In Tala, respondents with low income
(<2000 taka) had a higher risk of developing depression than those with high income
(>4000 taka) after the flood. They have 3.91 to 6.17 times more risk of developing
depression than the high-income group (>4000 taka), which is consistent with other studies
(Kar et al., 2007; Stimpson et al., 2006).
People from low socio-economic status are more vulnerable to depression. When exposed
to a flood, they may fail to cope with their losses and are likely to develop depression.
5.5.4 Gender-based difference in the occurrence of depression

The results of this study show that 62.2% of the total female respondents (1,222) were
exposed to >6 feet of water in their home. The gender*water level interaction term is
statistically significant, meaning that the association between the water level in the home
and depression varies with gender. Females had a significantly higher risk of develop
depression when they were exposed to a higher level of water (OR=5.56, 95% CI [4.78-
7.34]). In spite of females having fewer injuries (10.6% vs. 21.8%) they have a higher risk
of developing depression than males. Females had a higher risk of developing post-flood
depression when they were injured (OR=3.67, 4.89, 95% CI [2.12-6.27].
Females living in the coastal area of Bangladesh usually earn more than males. The
government and non-government organisations in Bangladesh have developed income
generation schemes for women (e.g., micro-credit scheme), to encourage rural women to
participate in different economic activities and increase their income. With this financial
and technical support, they are able to have their own fisheries and poultry farms near their
homes. By selling their produce, it is likely that they will earn more than males. As they
stay at home more than males, they are at higher risk of being flooded. When they are
exposed to higher levels of floodwater in their homes, and when they are injured, they may
become more worried about their losses and therefore suffer more depression.
5.6 Anxiety
5.6.1 Summary
This study confirms the high occurrence of post-flood anxiety disorder using GAD-7.
Anxiety always co-exists with depression and other psychological disorders. In this study,
anxiety is seen as a separate entity, but the chances of co-morbidities are not excluded.
Post-flood anxiety varies from 2.2% to 57.5% (Amstadter et al., 2009; Kar et al., 2004)
among the victims of different populations worldwide. In this study, a total of 271 cases
(10.86%) are estimated to suffer from anxiety in the studied coastal region before the
flood, while this increased significantly to 400 cases (16%) after the flood.
5.6.2 Predicting Factors

Regression analysis has shown that flooding is significantly associated with anxiety. As
the results show in Chapter 4, (Table 4.10) water level in the home, loss of a loved one and
loss of land were all strongly associated with the prevalence of anxiety among the flood
victims. Very few studies have assessed the water level in the home/level of exposure as a
predictor of anxiety (Mason et al., 2010; Carrol et al., 2008). No studies have assessed loss
of a family member as being a significant factor of anxiety. In this study, anxiety is
significantly associated with higher levels of water in the home. Victims who had higher
levels of water in their homes suffered more anxiety than those who experienced lower
levels of water. Victims flooded with >6 feet water suffered 4.71 to 7.11 times more
anxiety than those with <2 feet water in their homes. Victims who lost a family member

had 1.29 to 6.79 times more anxiety than those who did not suffer any such loss.
Respondents who lost their property/land developed 2.90 to 6.52 times more anxiety than
those who did not face such loss, which is consistent with other studies (Paranjothy et al.,
2011; Caroll et al., 2008). Due to limited existing research on flood-related anxiety, it is
hard to compare the impact of potential factors of anxiety. Continuously worrying about
different things with poor coping strategies may increase people’s stress levels. Prolonged
and sustained levels of stress may lead to anxiety disorders. Anxiety disorder is one of the
important flood related psychological disorders, but has received less attention in previous
studies, especially in the south-east region of Bangladesh. The significant outcome of this
study may draw the attention of future researchers. The results of this study may help to
focus on one of the world’s most vulnerable groups of people and early detection of flood-
related anxiety. Helping the victims cope with flood-related losses may prevent long term
anxiety disorder.

Socio-economic factors such as being male, being in a younger age group, being
unemployed, and having a low monthly income significantly increased the risk of post-
flood anxiety (Table 4.10). In some previous studies, females are significantly associated
with having anxiety disorders (Acierno et al., 2007; Mason et al., 2010). However, in this
study, males are 1.46 to 6.87 times more at risk of developing anxiety than females when
they are exposed to floods. Unlike previous studies (Aceirno et al., 2007; Mason et al.,
2010) in this study, respondents between 30 and 49 years of age are 1.05 to 2.71 times
more prone to developing anxiety than the older group following a flood. Unemployed
people were 1.74 to 5.51 times more at risk of developing anxiety than employed people
after a flood, which is consistent with other studies (Kar et al., 2004;). Galea et al. (2007)
found an association between lower income and higher anxiety level among the victims of
hurricane Katrina in the USA in 2005. Similarly, in this study, respondents with low
income (<2000 taka) had 2.84 to 8.10 times more risk of developing anxiety than the
higher-income group (>4000 taka). Males between 30 and 49 years of age, being
unemployed and having a low monthly income had significantly higher risk of developing
anxiety when exposed to a flood. With limited resources available, they may feel more
nervous and confused in dealing with flood-related losses, and may suffered more anxiety.

5.6.4 Gender-based difference in the occurrence of anxiety
The results of this study show that males (2.6%) lost more family members than females
(1.7%). Males had a significantly higher risk of developing post-flood anxiety when a
family member died (OR=4.15, 95% CI [2.89-8.81]). Around 75% of the total number of
males in this study had lost their land or faced property damage during the flood. They had
a significantly higher risk of developing anxiety when they lost land (OR=5.61, 95% CI
[3.67-9.91].
Most of the males living in Upazila Tala are farmers/fieldworkers. When they lose their
land due to a flood and become unemployed, they may experience more emotional
distress, explaining why they feel more anxiety.
5.7 Post-traumatic stress disorder

5.7.1 Summary
PTSD is the most prevalent psychological disorders related to flooding. Some previous
flood studies have also assessed PTSD and found significant associations with flooding.
Post-flood PTSD varies from 2.6% to 62.5% (Amstadter et al., 2009; Scheeringa et al.,
2008). In this study, a total of 123 cases (4.9%) are estimated to have PTSD in the studied
coastal region before the flood, while this increased significantly to 307 cases (12.3%)
after the flood.
5.7.2 Predicting factors

Regression analysis has shown that exposure factors significantly increased the prevalence
of post-traumatic stress disorder. Among the exposure factors, water level in the home,
injury and loss of land were significant predictors of post flood PTSD (Table 4.12). In this
study, victims who had higher levels of water in their homes suffered more PTSD than
those who experienced lower levels of water in their homes, which is consistent with
previous findings (Goenjian et al., 2001; Mason et al., 2010). Victims flooded with >6 feet
water suffered 3.62 to 6.89 times more PTSD than those with <2 feet water in their homes.
People who were injured (Mills et al., 2007; Soloman et al., 1990) and lost their
land/property (Wealde et al., 2008; Tobin et al., 2005) significantly developed more PTSD
than others. In this study, injured people suffered 1.98 to 5.33 times more PTSD than those
who were not injured during the flood. Similarly, people who lost their land had 2.71 to
8.32 times more PTSD than those who did not face such loss. Compared to other studies, it

is evident that flooding has significantly increased the number of cases of PTSD in Upazila
Tala. People are unable to assess the onset and severity of the event and may get confused
and startled by the sudden impact of the flood. Continuous flashbacks along with the
devastating losses may increase their stress levels, which then leads them to develop
PTSD. The result of this study may help policy-makers to improve PTSD prevention
strategies of the disaster preparedness program. With the help of early screening and
intervention programs, health workers can reduce the frequency and severity of PTSD
cases.

Most of the people of Tala belong to lower socio-economic classes. Being victims of poor
economic conditions, they continually suffer from stress. When exposed to floods they are
traumatised. Socio-economic factors such as being female, being unemployed and having
a low monthly income significantly increases the risk of post-flood PTSD (Table 4.12).
Women have been found to have a higher risk of developing PTSD after a flood (Liu et al.,
2006, Kumar et al., 2006). In this study, females had 2.45 to 7.29 times more risk of
developing PTSD than males. Those who were unemployed (Kar et al., 2004) and who
had a low income (Solomon et al., 1990; Kumar et al., 2006) had a higher risk of
developing post-flood PTSD than employed and higher-income people. In Tala,
unemployed people had 2.78 to 5.11 times more risk of developing PTSD than employed
people after the flood. The significant interaction (age group*employment status) also
proves that younger and unemployed people had 1.63 to 5.93 times more risk of
developing PTSD than elderly and employed groups. Respondents with low income had a
higher risk of developing PTSD after the floods than those with higher income. People
with low income (<2000 taka) suffered 2.83 to 9.10 times more PTSD than those with
higher income (>4000 taka). Consistent with other studies, being female, unemployed and
having a low income may increase the risk of developing post-flood PTSD. Along with
flashbacks and nightmares of the traumatic event, they may feel more helpless due to their
poor economic condition, which may delay their recovery process.
5.7.4 Gender-based difference in the occurrence of PTSD

The results of this study show that most of the female respondents were exposed to higher
levels of water in their homes. Females had significantly higher risk of developing PTSD
when they were exposed to higher levels of water (OR=6.24, 95% CI [3.89-8.46]). In this

study, females had a significantly higher risk of developing PTSD when they were injured
(OR=3.43, 95% CI [2.63-5.61]. In Upazila Tala, around 65% of the female respondents
lost their land during the floods. The gender*loss of land term is significant, meaning that
females had a significantly higher risk of developing PTSD when they lost their land
(OR=5.12, 95% CI (3.33-9.89]).
Women may experience more shock at the sudden and severe onset of flooding. They
have to maintain the family responsibilities and carry out refurbishment work. Along with
the daily life stresses, periodic flashbacks of traumatic events may lead them to suffer
higher levels of PTSD.
5.8 Drug abuse

5.8.1 Summary
This study has assessed drug abuse to see the increased rate of drug abuse among flood
victims. Only one previous study has assessed drug abuse (North et al., 2004), but no
significant new cases were found after the great mid-western floods of 1993. Based on a
survey, alcoholism was not included in this study. In Tala, a total of 137 cases (5.7%) are
estimated to have drug abuse symptoms in the studied coastal region, while this increased
significantly to 244 cases (9.8%) after the flooding.
5.8.2 Predicting factors

Similar to other psychological disorders, drug abuse is significantly predicted by exposure
factors. Among the exposure variables, after level in the home, financial help and loss of
land all strongly increased the prevalence of drug abuse among the flood victims (Table
4.14).
Similarly to other mental health disorders, victims who had higher levels of water in their
homes used more drugs than those who experienced lower levels of water. Victims
flooded with >6 feet of water used 3.33 to 8.61 times more drugs than those who
experienced <2 feet of water. Respondents who did not receive financial help used 1.78 to
5.77 times more drugs than those who received financial help. Similarly, people who lost
their land used 2.91 to 8.32 times more drugs than those who did not suffer such loss. Due
to lack of studies on drug abuse, it is difficult to compare the potential risk factors.
However, similar to the other psychological disorders, it is evident that flooding is
significantly associated with drug abuse. After a flood, victims may be disheartened by
financial losses. Receiving no financial help from government and after losing their
land/property, they may suffer from emotional distress. As a result, they may start to take
an increased number of illegal drugs in order to try to reduce their worries and tension.
This is the first study that found a significant relation between flooding and drug abuse in
the coastal region. The results of the study may help policy makers to focus on flood
related drug abuse and improve their prevention policy to reduce the number of cases of
such abuse.

Among the socio-demographic variables, being male, marital status, unemployment and
low monthly income significantly increased the risk of post-flood drug abuse (Table 4.14).
After a flood event, males were 4.49 to 9.14 times more prone to use drugs than females.
In this study, married people were 2.43 to 8.16 times more at risk of using drugs than
unmarried people. Unemployed people were 1.14 to 5.78 times more at risk of using drugs
than unemployed people after a flood. Respondents with a lower income used more drugs
after the flood than those with a higher income. People with a low income (<2000 taka)
used 2.56 to 5.61 times more drugs than those with a higher income (>4000 taka).
5.8.4 Gender-based difference in the occurrence of drug abuse

The results of this study show that 14.8% of the total male respondents had used drugs
after a flood event and only 34% of the males received financial help. As a result, males
had a significantly higher risk of using drugs when they did not receive financial help
(OR=4.88, 95% CI [2.91-8.12]). Similarly, males faced significantly more loss of land
than females. In this study, males had a significantly higher risk of becoming drug users
when they lost their land (OR=5.27, 95% CI [4.78-7.21].
As males are more responsible for the household income, they are more outgoing. They
may have easier access to illegal drugs than females. On the other hand, due to cultural and
religious norms females are forbidden from taking drugs. When males are exposed to a
flood, they may feel more distressed about their losses and therefore use more drugs.
5.9 Strengths and limitations of the study

This study has several strengths. It is the first study that comprehensively assesses the
flood-related mental illnesses of an adult population in Bangladesh. Socio-demographic
and flood exposure factors are included in this study. Data were obtained from pre and

post-flood surveys conducted by DGHS in Upazila Tala, which was severely flooded.
Secondly, this study included PTSD, depression, anxiety and drug abuse. Only two studies
are identified from the Asia-Pacific region that have observed these disorders together (Kar
et al., 2004; Chae et al., 2005). Kar et al., (2004) assessed socio-economic and exposure
factors and found a significant association between higher levels of exposure, loss of
property, death of a family member and psychological disorder, which is consistent with
our study. They found no gender based differences in the occurrence of anxiety and PTSD.
However, in this study, females suffered more depression and PTSD than males, which
may reflect the vulnerability of females in Bangladesh to disasters (Paranjothy et al., 2011;
Mason et al., 2010). This is the first study from the Asia-Pacific region which has
measured flood-related drug abuse among the local population using a diagnostic tool.
Assessment tools are well validated during the pilot study and are re-assessed in this study.
The limitations of this study also need to be acknowledged. Firstly, all the probable cases
were diagnosed with self-rated questionnaires. Self-assessment may cause recall bias,
which may underestimate or overestimate the number of mental health cases. Secondly, as
the samples were collected from the same area before and after the flood, to a small extent,
overlapping of the sample may be inevitable. Thirdly, the survey design was inappropriate
for collecting random samples with similar socio-economic characteristics, which may
affect the assessment of potential risk factors. In this study, multivariate logistic regression
was used to assess flood related mental illness. Fourthly, as this is not a cohort study and
two different cross-sectional surveys’ for data collection were used before and after the
floods, a direct comparison between pre and post-flood psychological illness at the
individual level is not feasible in this study. Finally, this study mainly included some the
socio-economic factors, along with exposure factors. Other factors like education level,
previous history of psychological trauma, medication history, social support, coping
strategy and co-morbidity may also be associated with mental health illness after a flood.
However, such information is not available in this study.
5.10 Directions for future research

Future research should pay attention to the following areas:
1) Most of the previous studies have used a cross-sectional study design to assess the
mental health impacts of flooding. Future studies using a cohort design are needed.

2) Most of the studies have assessed the immediate impacts of flooding on mental
health, hence studies are required on the long-term impacts and their principal
causes.
3) The impact of flooding has focused on anxiety and depression along with PTSD.
Future studies should pay attention to the full spectrum of psychological disorders
related to flooding (e.g., suicide).
4) Researchers may compare flood-related psychological illness between developed
and developing countries to assess common and different risk factors among
different regions.
5) Future research into the influence of social support, coping strategies and early
intervention and medication in the development of mental distress are needed to
improve the mental health strategy of the disaster preparedness program.
6) Most of the previous studies have used the criteria which are more reliable for
PTSD rather than for other disorders (Sprang et al., 2009; Mills et al., 2007;
Kumar et al., 2006). Hence, further research should develop proper diagnostic
criteria for different disorders so that co-morbidities of the diseases can be well
assessed.
7) Most of the studies have used logistic regression analyses (Paranjothy et al., 2011),
two ways ANOVA (Telles et al., 2009), x2 analyses (Terranova et al., 2009) to
assess the relationship between flooding and mental illness. Future studies may use
different modelling approaches such as the structural equation model (SEM),
factor analyses, classification and regression tree analyses (CART) to examine the
mental health impacts of flooding.
8) Future surveys should use an improved and simpler form of questionnaire based
on DSM-IV criteria for self-assessment, especially for lower income countries
where most of the people are illiterate. In the future, proper multi-stage stratified
sampling design or quota sampling should be used to select a sample of similar
socio-economic and demographic characteristics. In the case of longitudinal
studies, it is very important to know what proportion of each gender falls into
different categories such as age, marital status, and educational status. Then the
researcher can collect a sample with the same proportions as the total population at
a different point in time to assess the long-term psychological illness at the
individual level.

5.11 Overall implications for public health policy and intervention
Mental, neurological, and substance use disorders make a substantial contribution to the
global burden of disease (GBD, 2011). Among non-communicable diseases they account
for 28% of DALYs which is more than the proportion of cardiovascular disease or cancer.
This study assessed the relation between floods and mental health and found potential
predictors of mental illness. This will help in public health intervention planning and
implementation in order to control and prevent flood related mental illness.
As this study focused on the most vulnerable group of people suffering from psychological
disorders, the disaster preparedness program in Bangladesh as well as other developing
countries may upgrade their strategies. The policy makers may assess the risk factors and
improve their early intervention and surveillance programs. They can focus on the
population at risk to minimize the number of cases of mental disorders.
In remote and rural areas, it is necessary to strengthen mental health care and
psychological consultation facilities, in order to control and prevent mental illness. The
disaster preparedness program must include mental health services along with emergency
first aid services. Emergency mental health nurses or social workers may be able to assess
the probable cases and refer them to a psychiatrist. This will reduce the number of long
term psychological cases.
Health education and health promotion are vital in increasing mental health knowledge
among the rural population. Education regarding disaster management and early
forecasting will help people to improve their coping strategy.
In flood prone areas, the government, public health emergency services and other relevant
agencies need to provide necessary support to the local communities, as well as health care
to reduce the financial burden of families and to cope with the mental health problems
resulting from financial crises. Post-flooding psychological intervention and occupational
rehabilitation are strongly needed to reduce long term mental illness.

5.12 Conclusions
This study examined the impacts of flooding on mental health conditions among the
vulnerable population of the coastal area of Bangladesh. Figure 5.1 shows the model
outlining the significant predictors of post-flood mental illness. Flooding may directly or
indirectly affect mental health (Berry et al., 2010). In this study, after the 2011 floods in
Upazila Tala, people suffered injury, and lost their land or property. The most victims of
Upazila Tala were from a lower socio-economic background. After a flood they suffered
from major socio-economic changes, possibly becoming unemployed, losing their land or
having a low level of monthly income. Maintaining their lives with limited resources and
coping with flood-related losses was extremely difficult for them. They expected some
financial help or support from the government, however, very few actually received any
financial support. As a result, many of these people suffered more grief, emotional distress,
numbness and eventually develop a mental illness.
The prevalence of psychological disorders increased significantly after the flood. The
analyses show that exposure factors such as water levels in the home, injury, loss of a
family member, loss of land and financial support were among the major predictors of
psychological illness. Victims with higher water exposure (>6 feet) suffer more
psychological distress. People who lost a family member, were injured, lost their land and
received no financial support from the government were more prone to developing mental
illness. Regarding socio-economic factors, females with depression and anxiety and males
with anxiety and drug abuse, being of a younger age, being unemployed and having a low
monthly income significantly increased the risk of flood related psychological disorders.
Overall, in this study most of the exposure factors (e.g. water level in the home, injury, loss
of land, and no financial help) were associated with post-flood mental illness. As this is the
first study of such a kind from Bangladesh, the results of the study may help policy-makers
to improve the mental health strategies among flood-affected areas.
It is important to target interventions for the most susceptible groups in order to use the
health resources in an efficient manner. These findings may have a significant public
health implication in the control and prevention of flood-related mental illness in
Bangladesh.

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APPENDIX A
Table A.1: Studies from America and Europe on the impacts of floods on mental health (From newest to oldest studies from 2011-1970)
Author, year Location Study design Sample and Screening Outcome Confounders Main result
and year study period tools adjusted for
of flood
Statistics Estimate P value
Paranjothy et al., South Retrospective 3-6 months post GHQ-12, Sleeping Age, gender, Univariate Psychological Not
2011 Yorkshire cross-sectional flood 2265 GAD-7, disorder (27.1% existing analysis distress (OR 2.5, Given
and individuals was PHQ-9, cases vs. 14.7% medical followed by 1.8-3.4), anxiety
Worcester surveyed PTSD-CL controls), heart problems and multivariable (OR 1.8, 1.3-2.7)
shire; palpitations employment logistic depression (OR
2007 (33.9% cases vs. status. regression 2.0, 1.3-2.9) and
15.1% controls), PTSD (OR 3.2,
PTSD (39.5% 2.0-5.2).
Cases vs. 21.1% CI (95%).
controls).
Fredmen et al., Saint Retrospective 205 Woman DIS, Significant Not mentioned Bivariate Indirect <0.05
2010 Louis, cross-sectional responded to Disaster association analysis association both
Missouri, interview 9 Supplement between threat and harm
UK; 2009 months after the , DAS, threat/harm and (direct effect=0.
event PTSD PTSD 09, P<. 05). Loss
module symptoms. (standardized
indirect effect= -.
07, p<. 05) with
PTSD.
Appendices Page 123

Mason et al., UK flood; Retrospective Flood affected HTQ-R, 27.9% had Gender, age Binary == 17.116, 𝑃 <0.001
2010 2009 cross- households were CSQ, PTSD, 24.5% and health logistic < 0.001
sectional surveyed 6 HSCL-25, anxiety and status. regression
months DSM-IV 35.1%
following the depression.
floods.
Ruggiero et al., Florida Retrospective 1452 adults NWS- 3.6% of the Older age and Logistic Older age Varied
2009 hurricane, cross-sectional were telephoned PTSD,SCI participants met monthly regression (OR=3. 1),
USA; in Florida D-IV, the criteria for income. extreme fear
2004 counties. PTSD, 6.1% (OR=1. 9), low
(MDE), &5. 5% social support
(GAD). (OR=1. 7).MDE
(OR=5. 0).
Terranova et al., Hurricane Retrospective 152 six grade HURTE, Almost all Older age and analysis Hurricane <0.001
2009 Katrina, cohort students were PTSD psychosocial ethnicity. exposure×
USA; participating in checklists, and behavioural negative coping
2005 the survey 1.5 EATQ, adjustment R2=. 33, F
months and 8 SEQ, variables were (5,146) =14. 191;
months after the SRCM, significantly PTSD symptoms
storm HICUPS, associated with B=. 47; SE B =.
respective- PTSD. 08; β=.48
-ly.
Sprang et al., Hurricane Retrospective 167 evacuees PTSD PTSD (50.5%) Gender, race, Logistic Exposure and <0.001
2009 Katrina; cross-sectional were surveyed checklist- was marital status regression female gender are
Louisville after the event civilian significantly and significant for
Kentucky, version related exposure employment predicting PTSD
USA; (PCL), intensity and status. ((8) =13. 26; P=.
2005 BRIEFCOP may be altered 103
E by avoidant
coping.
Appendices Page 124

Anastario et al., Hurricane Retrospective Total 420 PHQ-9 GBV increased Age, race, Logistic and GBV increased <.10
2009 Katrina; cross-sectional female from marital status Poisson 3.2% (F (1, 416)
Louisiana respondents 4.6/100,000/day and income. regression = 1.1; P =0. 31);
and were surveyed to analysis lifetime GBV
Mississip during the year 16.3/100,000/da increased
pi 2006 and 2007 y in 2006, and 8.4%,from 35.3%
USA; remained in 2006 to 43.7%
2005 elevated In 2007; F (1,
10.1/100,000/da 416) = 2.9; P
y in 2007. =0.09.
Taft et al., Summer Retrospective 205 female adult PTSD Higher PTSD Age, sex and Chi-square χ2 (12, N = 199) <0.05
2009 flooding cross-sectional flood module, was associated marital status. test = 22.69, p<. 05,
of victims who DAS, CTS with higher
Mississip were physical and
pi river; representative of psychological
USA the flood Aggression
1993 population in victimization,
Monroe County, poorer
Illinois and St. relationship
Louis, Missouri adjustment and
higher physical
and
psychological
aggression
perpetration.
Harville et al., Hurricane Retrospective 102 women of EPDS, Women with Age, Spearman PTSD-K & <.001
2009 Katrina cross-sectional southern PTSDCL, severe gender, race, correlation-n PTSD-G
and Louisiana BRS experience marital status correlated by
hurricane telephoned in during the event and education 0.72; p <0.001
Gustav; 2006 and 2007 scored higher on level. and depression-G
USA mental health by 0.47; p<0.001
2005 scales.
Appendices Page 125

Abramson et al., Hurricane Retrospective 1077 people MCS More than half Age, sex, race, Multivariate No significant Varied
2008 Katrina; cross-sectional were of the baseline marital status, regression changed in follow
Mississip interviewed 6 to cohort and monthly up from baseline
pi 12 months and follow up shows income and cohort due to
USA. 23 months after significant birth place. socio-
2005 the event. mental distress. demographic
factors.
Scheeringa et al., Hurricane Retrospective 70 preschool DEQ, PTSD rate was Age, gender analysis The PTSD rate <.01
2008 Katrina, cross sectional going children PAPA & 62.5% for those and ethnicity. stayed vs.
New aged (3-6) was DIS stayed in the evacuated group
Orleans; assessed in 2006 city & 43.5% Z (70) =1. 90, p
USA for those who =<. 05. SAD z
2005 are evacuated. (68) =1. 87, p=<.
The PTSD rate 05 one sided.
among
caregivers was
35.6% of which
47.6% new to
post Katrina.
Fewtrell et al., Utley& Retrospective 108 households Not Psychological No analysis YLD scores for Not
2008 Devonshir cross sectional from Utley and mentioned distress was mental distress
given
e, 186 households found to were greater than
UK. from dominate the for the combined
1998 Devonshire Park overall health physical
impacts. symptoms; 0.582
(Utley) &0.332
(Devonshire)
Appendices Page 126

Pina et al., Hurricane Prospective 46 youths of DSM-IV, Positive reaction Age and analysis Average PTSD <.01
2008 Katrina, cross sectional New Orleans 6 RCADS, between gender. severity score
USA; to 7 months CCSC, FSS helpfulness from 19.78 (SD=
2005. after the storm. professional 10.70) Extra-
support sources familial support
and PTSD. (β=-0.98, t = 3.57,
p <.01),
professional
support (β=1. 63,
t =3. 69,
p<.01), and
avoidant coping
(β=. 80,
t=3. 06, p <. 01)
Madrid et al., Hurricane Retrospective 43 mental health Not Significant rise Not analysis Significant rise of Not
2008 Katrina cohort practitioners of mentioned of anxiety as mentioned psychological given
2005 and school based well as other symptoms on
hurricane health centres mental illness Likert scale (1-
Rita were invited for among the 3)Anxiety 2.20;
2005; the survey. displaced adjustment 1.90;
USA students Depression 1.70;
Vigil et al., Hurricane Retrospective 81 adolescents F-COPES, Psychological No Cohen’s d, Distress score at P<. 01
2008 Katrina; cross-sectional surveyed were RSES, IES- distress was followed by (79) = 2.93, p
USA; involved 50 R, partly mediated regression =.01,
2005 Katrina survivors RCMAS, by family d=.68Mobilizing
2 months CES-D coping strategy coping as a
following the predictor (Z =2.
event. 22, p =. 05) And
Depression (Z =1.
91, p =. 06).
Appendices Page 127

Anastario et al., Hurricane Retrospective 194 women PHG-9 46.9% of Not mentioned Logistic Sleep <0.1
2008 Katrina; cross-sectional from travel woman had regression dysregulation
Louisiana trailer park GBV among 1.5 %( 95%CI
and interviewed in which 17.5% 1.2-5.1) appetite
Mississip May 2006. experienced loss (OR 3.8,
pi PDGBV. 95%CI=1. 4-
USA 10.3), low self-
2005; esteem, 2.3%
(95%CI=1. 2-
4.6), Suicidal
ideation by
2.7 %( 95%CI=1.
1-6.7)
Waelde et al., North Retrospective 131 persons SASRQ, The loss and Age, sex, Hierarchical Exposure to threat <0.05
2008 Carolina, longitudinal initially and 74 PCL-C threat exposure marital status, regression (F (1, 68=5.05)
USA; persons were race and and loss (F (1,
2007 completed one significantly occupation. 68=34.29,) were
year follow up. associated with significant for
ASD and PTSD. ASD.
Stimpson et al., Iowa Prospective 1735 adults CES-D Seeking help Gender, age, Multivariate Odds of seeking <.001
2008 flooding, cohort were sampled at was associated race, education logistic help among flood
USA; second wave out with exposure to and income regression exposure (OR=1.
1993 of 2406 first floods, race, level. 58; 95% CI= 1.33
wave data 60 economic –1.87; P<0.001)
days after hardship, urban
flooding. residence and
social support.
Appendices Page 128

Carroll et al., Carlisle Retrospective 14 men and 26 Not Every Not mentioned Not included The danger of the Not
2008 floods; longitudinal women were mentioned respondent of event, property mention
UK sampled 10-13 the study damage, ed
2005 months after the reported varying displacement,
flood. degree of disruption and
anxiety and living condition
stress attributing increased
it floods directly psychological
or indirectly. distress
Acierno et al., Florida Retrospective 1452 adults over NWS- Significant rise Female and Bivariate Post hurricane <1.0
2007 counties, cross sectional 18 years was PTSD of PTSD, GAD, elderly people analysis PTSD 3.6%,
USA; telephoned 6-9 Module for MDD among with previous followed by GAD 5.5%, MDE
2004 months after a PTSD, affected people health multivariate 6.1%
hurricane in DSM-IV problems logistic
2004 for GAD significantly regression
and MED associated
with
depression.
Weems et al., Hurricane Retrospective 52 youths of DSM-IV, No significant No Hierarchical PTSD 95% <0.05
2007 Katrina, longitudinal New Orleans STAIC-T, differences in regression mean diff = –
USA who were pre- RCADS, mean scores for 7.0, 2.9,
2005; hurricane PANAS-C pre and post Cohen’s d=0.
surveyed (5 to 7 Katrina PTSD 16; GAD 95%
months after the symptoms, CI mean diff
event) RCADS-GAD = - 0.9,1.2,
symptoms and Cohen’s d =-
RCADS-MD 0.04; and MD
symptoms. 95% CI, mean
Diff = –1.1, 2.6,
Cohen’s d = 0.16.
Appendices Page 129

Mills et al., Hurricane Retrospective Evacuees at the ASDS 38% to 49% will Female and Bivariate Life is treating <0.05
2007 Katrina cross sectional emergency based on met PTSD black people analysis (OR=1. 37; 95%
USA shelter house DSM-IV criteria 2 years significantly followed by CI=1. 08, 1.75),
2005 was surveyed 12 post disaster. affect PTSD multivariate Female (OR=4.
days after the level. logistic 08;95%CI=1.
event regression 45,11.48), Injury
(OR =2.
75;95%CI=1.05,7
.11), psychiatric
history(OR=5.
84,95%CI=1.
92,17.80)
Galea et al., Hurricane Retrospective 1043 residents K-6 Pre-hurricane Age, income Logistic Anxiety in pre p<.001
2007 Katrina; cross sectional of the affected screening residents had level and regression hurricane group,
New area were scale 49.1%anxiety- living analysis 49.1%, than the
Orleans telephoned 6-7 mood disorder situation. 40- reminder sample
USA months after the (30.3% 59 years old (26.4%; Z=5. 0;
2005 hurricane. estimated with lower p<. 001). PTSD in
Prevalence of income had pre hurricane
PTSD) significant group was higher
compared with impact on (30%) than the
26.4% (12.5% PTSD. sample (12.5%;
PTSD) in the Z=4. 1; P<. 001.
remainder
sample.
Wang et al., Hurricane Retrospective 1043 displaced K-6 scale 31% of Age, gender, Logistic Significant <0.001
2007 Katrina, cross-sectional and non- respondents had race, marital regression increase of
USA displaced adults evidence of a status. seeking help after
2005 are telephoned mood or anxiety hurricane
in 2006 disorder
at the time of
the interview.
Appendices Page 130

Tunstall et al., 30 varied Retrospective 983 adults GHQ-12 Anxiety 55%; Age, gender Paired t= -24.74; df=793 <0.001
2006 locations cross- interviewed as for mild depression, and previous sample t test; N = 507, R2 =0.
of sectional a flooded psychologi 14%; moderate health status. multivariate 26, R2 adj. = 0.24
England sample & 527 cal distress; depression, 9% regression
& Wales: adults at risk PTSS scale and severe
UK sample in 2002 for PTSD depression 5%.
1998
Kessler et al., Hurricane Retrospective Baseline survey K6 scale Estimated Age, sex, analysis 11.3% after <0.001
2006 Katrina, cross sectional during 2001- mental illness race, income, versus 6.1%
USA 2003 (n=826) was doubling employment before; c²1= 10.9
2005 adults; post after the status, marital and mild
Katrina 1043 hurricane, but status and moderate mental
adults the prevalence education illness
interviewed the of suicidality status. (19.9% after
same area in was very low. versus 9.7%
2006. before; c²1 =
22.5;
Coker et al., Hurricane Retrospective 124 evacuees of Impact of Moderate Gender, race, Linear PTSD among 0.5
2006 Katrina cross sectional Houston shelter event scale (38.6%) to marital status regression injured, afraid to
Gulf house 3 weeks severe (23.9%) and chronic die, saw someone
coast; after the event post-traumatic illness. to die was
USA stress disorder double(OR=2. 4;
2005 symptoms. 95%CI=1. 0-6;
p=0. 5)
Stimpson et al., Iowa Prospective 1735 adults CES-D Flooding is Age, gender, Standardized Depression <0.01
2006 1993; cohort were sampled at significantly race, education coefficient (R2=. 381) and
USA second wave out associated with and income change in the
of 2406 first depressive level. sense of control
wave data 60 symptoms (β=0. (R2=. 415)
days after 089; p<0.001)
flooding. but not with a
sense of control.
Appendices Page 131

Nitschke et al., Floods in Retrospective 147 patients of HADS, Anxiety and Age, gender, Spearmen PTSS-10 scale <0.01
2006 Elbe and and the Dresden PTSS-10, depression and race. correlation (mean=23. 91,
Medlau in prospective heart centre IES-R, shows no range 10-52),
2002; were surveyed 1 SCID, significant Depression
Germany month after and alteration. PTSD subscale (mean
a follow up was higher than 13, 11; range 11-
study 6 months the general 16).
after the event. population
(8.5% vs.
6.7%;p< 0.05)
Strelau et al., Southern Retrograde 5 samples were DSM- Trauma and No Linear Emotional <.0.05
2005 Poland; longitudinal taken, including IV,FCB-TI, emotional regression reactivity (F=62.95
(a)
1997 562 females reactivity ,
before and after essentially R=0.38;R2=0.14;p
flooding. contributed as a artial
predictor of correlation=0.38)
PTSD trauma
(F=26.31(a);
R=0.25,R2=0.
06;partial
correlation=
0.25) significant
with PTSD.
Tobin et al., Great Retrograde Iowa Not 74% of the Age, gender, Logistic Female, mental <0.02
2005 Midweste cohort metropolitan mentioned cohort shows mental health regression health status,
rn floods, area was significant status, year of physical health
USA; surveyed 4 symptoms of education and status, flood
1993. months after the PTSD in the health status. damage and poor
flooding. A affected area. education are
similar study significant
was done in predictors of
Missouri. PTSD
Appendices Page 132

Fried et al., Hurricane Retrograde Medicaid Not Significant No Least square Number of visits Varied
2005 Floyd, Longitudinal recipients were mentioned impact of regression to the OPD and
North interviewed 14 hurricane Floyd psychiatrist
Carolina; months before on mental health increases
USA and 12 months and medication significantly 12
1999; after the event. expenses. months after the
flooding.
North et al., Missouri, Retrospective 162 adults DSM-III-R PTSD rates No analysis Intrusive <.001
2004 UK cross sectional interviewed 4 were 22% recollections
1998 months and 16 during early (58%), insomnia
months after the study and 16 % (51%), difficulty
flooding at follow up in concentration
respectively. study. (48%) and
Irritability (48%)
=13.17; df=1; p<.
001)
Norris et al., Mexico Retrograde 561 adults were CIDI PTSD was Religion, Linear PTSD; (1, N = <0.001
2004 floods; Longitudinal interviewed highly (24%) education regression 561) were 65.42,
1999 6,12,18 and 24 significant level, at Wave 1; 37.95,
months after the among the occupation and at Wave 2; 27.97,
flooding wave1 study marital status. at Wave 3; and
sample. 13.57, at Wave 4.
P <0.001.
Verger et al., Flood in Retrospective 500 samples DSM-IV PTSD score was No PCA analysis PTSD was <0.001
2003 south- cross-sectional were surveyed significantly significantly
eastern during the higher among higher among the
France; month of June the flooded area women, poor
1992 and July 1997 in than non- income and
France. flooded area. previous
psychiatric
history
respectively.
Appendices Page 133

McMillan et al., Saint. Retrospective 162 adults were DSM-III-R 38%met criteria Not mentioned analysis =12.27, df=1.p=. .001
2002 Luis area, cross sectional interviewed for a post-flood 001
Great psychiatric
Midwest, disorder. 22%
UK; PTSD, 20%
1993 MDD
separately.
Russoniello et North Retrospective 218 fourth grade CPTS-RI Children with Age, sex and analysis Female PTSD Varied
al., 2002 Carolina, Cohort students flooded home race. M=37. 5&
USA interviewed 6 were 3 times SD=16. 4;
1999 months after more likely to flooded vs. Non
hurricane Floyd report symptoms flooded M=39. 1
than those vs. 31.6 &
whose homes SD=16. 1vs 14.6
were not
flooded.
Goenjian et al., Hurricane Retrospective 158 adolescents HEQ, The severity Female are Multiple Highest level of <0.01
2001 Mitch, cross-sectional were surveyed 6 PTSD level of post- significantly stepwise exposure had the
Nicaragua months after the reaction traumatic stress higher impact regression highest level of
and hurricane. index for and Depression on PTSD PTSD RI scores
Honduras; children, found among score. (total: mean=58.
1998 DSS the adolescents 6, SD=12. 8)
of the affected
cities.
Vernberg et al., Hurricane Retrospective 568 elementary PTSD Approximately Age, race and Not Exposure to <.001
1996 Andrew cross-sectional school-age reaction 30% of the gender. mentioned Traumatic Events,
struck children 3 index for children Child
Dade months after children, Reported mild, Characteristics,
County, Hurricane HURTE, 26% moderate, Social Support,
Florida, Andrew were SSSCA, 25% severe, and and Coping were
USA; surveyed. Kid COPE 5% very severe related to
1992. symptoms psychological
symptoms.
Appendices Page 134

Green et al., Buffalo Retrospective 120 adults are SCID for Decreased No analysis Overall severity <.005
1990 creek dam cross sectional survivors of DSM-III symptoms were (F=9. 67,
collapse, dam collapse 14 noted in all df=1/74, p<. 005)
west years after the areas, although
Virginia, event. significant
USA; symptoms
1988; remained in
about one-
quarter of the
survivors.
Solomon et al., Saint Retrospective From Saint DSM-III-R Some of No ANCOVA Money problem <.001
1990 Louis UK cross-sectional Louis 543 adults the common analysis of N = 37, F = 1,
1982; and from Puerto stressful events covariance 8.24, df= 1, P
Puerto Rico 912 adults related more =.001) evacuation
Rico were surveyed 1 closely to PTSD (N=153, F = 6.93,
floods, and 2 years after symptoms than DF = 1, P=.
1985 respectively. did the 0087), Injury (N
extraordinary = 95, F = 4.41,
events. DF = 1, P =.
0363), upsetting
event (N = 79, F
= 24.38, DF = 1,
P <. 000l) in the
Saint Louis area.
Phifer et al., South- Prospective 2937 STAI-T for Psychological Age, sex, analysis Depression, F <.001
1989 eastern panel respondents anxiety, symptoms marital status, (1,184) =8. 03,
Kentucky, interviewed CES-D for among adults education and p<. 005, β=. 17,
USA; primarily depression were affected by occupation. anxiety, F (1,185)
1981 personal loss =7. 21, P<. 008,
and community β=. 15,
destruction. accounting for
2.2% to 2.8% of
the variance of
post flood
Appendices Page 135

measure.
Logue et al., Wyoming Retrospective 748 households Not Emotional No Not Not described <.001
1979 Valley, Cohort in Kingston and mentioned distress was & mentioned
Pennsylva 755 households 79% among the
nia, in the adjoining flood victims,
USA; town for 5 years whereas only
1972 duration after 53% of the non-
the flood flooded group
for more than 6
months.
Bennet et al., Bristol Prospective 316 flooded and Not A number of Not mentioned analysis = 7.57, 𝑝 < 0.01 < 0.01
1970 floods; cross sectional 454 not flooded mentioned patients were
UK persons were referred for
1968 surveyed 12 psychiatric care
months before whose
and 12 months symptoms dated
after the flood from the floods.
Appendices Page 136

Table A.2: Studies from Asia-Pacific region on the impacts of floods on mental health
Author, year Location Study design Sample and Screening Outcome Confounders Main result
and year of study period tools adjusted for
flood
Huang et al., Hunan, Retrospective 2000 DSM-IV 9.2% of the Age, gender, Logistic Risk scores for -
2010 China. 1998 cross-sectional individuals total subject education level regression PTSD with a cut
surveyed in was of a value of 65
Hunan. diagnosed is =107
with
probable
PTSD.
Li et al., Hunan, Retrospective 3698 families DSM-IV 4.7% of the Age and Multivariable Father PTSD <0.001
2010 China. 1998 cross-sectional were total children gender. logistic positive
interviewed and 11.2% of regression (OR,3.0;95%CI,2.
who is total parents 0,4.4), Mother
affected by were PTSD positive
flood in 1998. diagnosed (OR 4.0;95% CI,
with PTSD. 3.0,6.4)
Amstadter et al., Da Nang, Retrospective Four wave data SRQ- Post typhoon Age, gender and Bivariate Previous health <0.001
2009 Vietnam. cohort collected with 20,DSM- prevalence of religion analysis history (χ2= 1.41;
2006 797 participants IV,NWS- PTSD was OR = 1.83, CI =
at wave 4 from PTSD 2.6%, MDD 0.66 -5.13), female
the affected 5.9%, PD (χ2= <1; OR = 0.79,
area. 9.3% & GAD C I = 0.32 -1.91),
2.2%. trauma history (χ2
=12.90; OR =7.07,
CI = 2.06-4.33),
high exposure (χ2 =
6.18; OR=3.08,
CI=1.21).
Appendices Page 137

Telles et al., Bihar, India. Retrospective 1289 persons SQD People over Age and sex. Two way PTSD score in 60 <0.001
2009 2008 cross-sectional were assessed 60 years old ANOVA years than age
one month had higher between 15-20
after the event. PTSD and years higher (post
depression hoc analysis LSD,
rate than the 19% higher), 21-
other age 30(post hoc
group. analysis LSD,
12%higher), and
31-50 (post hoc
analysis LSD,
15% higher).
Fernando et al., Tsunami, Retrospective 170 adults SLIPPS-A, Significantly Age, gender analysis Significant PTSD <0.005
2008 southern cross-sectional were assessed PCL-C PTSD was level = 7.72, 𝑝 <
province of by the detected by 0.005
Srilanka, instrument of SLIPPS-A
2004 the affected scoring
area. system.
Hoe et al., Garrison-Ni, Retrospective 83 of 160 SF-36-K, 53% of the Age, gender, Logistic Male (OR=0. 64), Varied
2008 Inje-gun, cross-sectional residents of BDI, sample had smoking regression Age below 45
Gangwon- the affected MMPI- mild history, level years (OR=0. 35),
do, Korea. area were PTSD, IES- depression, of education. trauma (OR=0.
2006 assessed R. 17% severe 76), smoker
during April to depression (OR=3. 47), poor
July 2006. and 22% had education (OR=8.
PTSD. 85) were
significant factors
for depression.
Appendices Page 138

Feng et al., Hunan, Retrospective 25478 DSM-IV 9.7% of the Age. gender Logistic Social support <0.001
2007 China.1998. cross-sectional individuals total subjects regression (odds ratio [OR]
were have PTSD. 0.80, 95%
interviewed in confidence
2000 from the interval
affected area. [CI], 0.78–0.82),
subjective support
(OR 0.48, 95%CI,
0.44–0.52), and
support utilization
(OR 0.53,
95%CI, 0.49–
0.57).
Souza et al., Aceh Retrospective 262 samples HSCL The Age, marital Logistic Death in the Not
2007 province, cross-sectional were collected prevalence of status and regression family (OR) =1, mention
Indonesia.20 from barracks severe income level. 68(95%CI=1. 02- ed
04 and camps in emotional 2.80). Younger
Aceh distress was individuals (OR)
province. 83.6% and =0. 97 (95%CI=0.
depressive 95-0.99).
symptoms
were 77.1%.
Kar et al., Orissa, India. Retrospective 180 DSM-IV The Age, gender, Chi-square More females <0.001
2007 1999 cross-sectional adolescents prevalence of education level test (58.3%) than
were PTSD, major and socio- males (39.6%)
interviewed 18 depressive economic Reported startle
months after disorder, status. reactions
the event. Anxiety (χ2: 3.75, def: 1,
disorder p: 0.053. Guilty
were 26.9%, feeling in female
17.6% and vs. Male (51.7%
12% vs. 18.8%, χ2:
respectively. 12.4, def: 1, p:
0.000).
Appendices Page 139

Kar et al., Orissa, India. Retrospective 447 children ICMBD PTSD was Age, gender, Binary High exposure 4.1 <0.001
2007 1999 cross-sectional and present in education level logistic (95% CI, 2.3-7.2),
adolescents 30.6% of the and socio- regression middle socio
were taken as children and economic economic status
a sample from an additional status 2.3(95%CI, 1.2-
the affected 13.6% had 4.1) were
area. sub- significant
syndromal determinants of
PTSD. PTSD.
Neuner et al., Coastal Retrospective 264 children PTSD-RI The Age, gender Linear Zero order <0.05
2006 region of cross-sectional of affected prevalence of and previous analysis correlation for
Srilanka. area 3 to 4 tsunami trauma history. age, female,
2004 weeks after related PTSD previous
tsunami. was between traumatic
14% to39% exposure, family
member loss after
the tsunami
was.09, 0.5.0.38,
0.19 respectively.
Kumar et al., Tamil Retrospective 515 HTQ 12.7% of the Socio- Multivariate No family <.01
2006 Nadu,India. cross-sectional individuals subject was economic logistic income ([OR] =2.
2004 were surveyed diagnosed variables and regression 93; 95% CI=1.
2 months after with PTSD. female with no 25-6.86), Women
the tsunami. income ([OR] =2. 83;
significantly 95% CI=1. 36-
affect PTSD 5.91), Personal
level. injury [OR] =2.
81, 95% CI=1.
25-6.32) higher
PTSD.
Appendices Page 140

Liu et al., Hunan, Retrospective A total of DSM-IV 8.6% of the Age, gender, Multiple Female (OR <0.05
2006 China. cross-sectional 33340 subjects sample had and flood type logistic 1.12; 95% CI,1.04
1998-1999 were the and flood regression to 1.21),older age
interviewed symptoms severity. (OR 2.42; 95%
from the that met the CI, 2.05 to
affected area diagnostic 2.85),flood type
in 1998-1999. criteria for (OR 3.12;95% CI,
PTSD. 2.76 to 3.52),
flood severity
OR 4.05;95% CI
3.55 to 4.62)
Chae et al., Gangwon Retrospective 585 PWI- The Not mentioned ANOVA Anxiety after <0.001
2005 province, cross-sectional individuals are SF.GHQ- significant floods were
South selected from 60,ZRDS,S higher score 21.3% and PTSD
Korea.2002 the affected TAI, for PTSD, was 39.5%.
area during anxiety and
December depression
2002 to among the
February flood
2003. affected
group.
Kar et al., Orissa, India. Retrospective 540 SRQ, IES, Posttraumati Age, sex, Not Illiterate <0.01
2004 1999 cross-sectional individuals CSI, PTSS, c stress socio- mentioned (SRQ=84. 5),
were selected HADS, disorder was economic Unemployed
as a sample PSLES, found in status and (SRQ=82. 1),
from affected Hopelessne 44.3%; education unmarried
villages in ss scale. anxiety level. (SRQ=80. 9),
2000. Disorder in psychiatric
57.5% and history (SRQ=73.
depression in 7) had
52.7%. significantly
predict mental
illness.
Appendices Page 141

Tan et al., Dongting Retrospective 494 adults for GQOLI-74, The QOL Age and Multiple Mean difference <0.001
2004 Lake area, cross-sectional collapsed SSS was poorer in occupation. linear in QOL score at
China.1999 group, 473 soaked group regression 95%CI for
adults for (58.4), psychological
soaked group especially in health in
and 773 adults collapsed collapsed vs.
in the control group (55.1) Control group -
group were and then in 5.81 (-3.59,-8.02)
selected. the control and soaked vs.
group (59.5). Control group -
3.66 (-1.11, -
6.21).
Frankenbeg et Aceh Retrospective 20500 adults PTSD PTSR score Gender and Multivariate Female 0.80 <0.01
al., province and cross-sectional were checklist was higher age was analysis (95%CI, 0.55-
2008 Sumatra, interviewed in for among the significantly 1.10), 15-29
Indonesia. 2005 and civilians. respondents related with Years age 0.74
2005 2006. of highly PTSR. (95%CI, 0.53-
affected area. 0.95), injures
1.23(95% CI,
0.60, 1.85), loss
of kin 3.20 and
property damage
4.81 were
significantly
related with
PTSR.
Durkin et al., Dhamrai, Prospective 162 2-9 years Richman 40% children Age and Logistic The prevalence of <0.001
1993 Bangladesh, cross sectional old child was Child were gender. regression aggressive
1988. evaluated in Behavior reported behaviour
1989. checklist Have ‘‘very increased from 0-
aggressive’’ 10% and 34%
behaviour developed post
significantly flood enuresis.
(p<0.001)
Appendices Page 142

Table A.3: Studies from Australia that shows the impact of floods on mental health
Author ,year Locatio Study design Sample and Screening Confounders Main result
n and study period tools Outcome adjusted for
year of
flood
Turner et al., Brisbane, Retrospective Postal survey K-6,PCL- Distress Age, sex, Not mentioned Increased -
2012 Australia cohort involving 3000 civilian increased 1.9 property type, psychological
2011 adults of the version, times and current health, distress 1.9
affected area of GSQS probable employment and ((1.1,
Brisbane in July PTSD in 2.3 education level. 3.5),PTSD 2.3
2011. times. ((1.2, 4.5)
Prince, 1978 Brisbane Retrospective 246 flooded and Not Psychological Age and sex Not mentioned Difference >0.001
flood; cohort 194 non flooded mentioned impact more male versus
1974 families are significant female =
interviewed among women 14.3708; 𝑝 >
between April- (< 65 years) 0.001.
June 1974. old than man.
Abraham et Brisbane Case control 738 cases and 581 Not Significant-t Age and sex Not mentioned No detailed <0.01
al., 1978 floods, controls mentioned mental
Australia interviewed disturbances in
1974. both sexes.
Appendices Page 143

APPENDIX B
Principal component analyses for validity testing of assessment tools

The organization had used Principal component analyses to see the validity of the
assessment tools for different psychological disorders. These tools are internationally
approved and based on DSM-IV criteria. As all the assessment tools were translated into
Bengali the organization had used Principal component analyses over pilot study to see the
validity of the translated questionnaire. In this study, the validity of the questionnaire re-
assessed to see the validity of the questionnaire (validity may be changed due to larger
sample size).
The cumulative % of each assessment tool of principal component analyses were more
than 65% (cut-of value) that means these tools can significantly determine the
psychological disorders.
Table 1 show that 4 out of 7 questions of GAD-7 scored for 84.74% of the cases
(Cumulative %).
Table B.1 PCA for Generalized Anxiety Disorder-7
Component Initial Eigen values Extraction some of the squared loadings
Total % of Variance Cumulative % Total % of Variance Cumulative %
1 2.1 30.6 30.6 2.1 30.6 30.6
2 1.5 21.1 51.8 1.5 21.1 51.7
3 1.3 18.7 70.4 1.3 18.7 70.4
4 1.0 14.3 84.7 1.0 14.3 84.7
5 0.9 12.6 97.3
6 0.2 2.6 99.9
7 0.0 0.1 100.0
Bartlett test shows significance level <0.05.
Table B.2 show that 5 out of 9 questions of PHQ-9 scored for 93.97% of the cases.
Appendices Page 144

Table B.2 PCA for Patient Health Questionnaire-9
1 2.3 30.8 30.8 2.3 30.8 30.8
2 1.7 20.5 51.3 1.7 20.5 51.3
3 1.7 18.5 69.8 1.7 18.5 69.8
4 1.5 15.4 85.2 1.5 15.4 85.2
5 1.2 8.8 94.0 1.2 8.8 94.0
6 0.4 2.5 96.9
7 0.4 2.0 98.4
8 0.1 0.8 99.3
9 0.0 0.7 100.0
Bartlett test shows a significance level <0.005
Table B.3 show that 4 out of 9 questions of PCL-9 scored for 91.63% of the cases.
Table B.3 PCA for PTSD Checklist-9

1 3.2 40.8 40.8 3.2 40.8 40.8
2 2.8 25.2 66.0 2.8 25.2 66.0
3 1.3 19.3 82.3 1.3 19.3 82.3
4 1.0 9.3 91.6 1.0 9.3 91.6
5 0.6 4.6 95.3
6 0.1 3.3 98.6
7 0.0 0.8 99.4
8 0.0 0.6 99.9
9 0.0 0.1 100.0
Bartlett test shows a significance level <0.005.
Table B.4 show that 4 out of 10 questions of DAST-10 scored for 83.39% of the cases.
Table B.4 PCA for Drug abuse Test-10
Total %of Variance Cumulative % Total % of Variance Cumulative %
1 3.8 37.7 37.7 3.8 37.7 37.7
2 2.2 21.8 59.5 2.2 21.8 59.5
3 1.3 13.1 72.7 1.3 13.1 72.7
4 1.1 10.7 83.4 1.1 10.7 83.4
5 1.0 9.9 93.3
6 0.3 3.5 96.8
7 0.1 1.5 98.3
8 0.1 0.8 99.2
9 0.0 0.5 99.7
10 0.0 0.3 100.0
Bartlett test shows a significance level <0.001.
Appendices Page 145

The reliability of the assessment tools also re-assessed to see the impact of population size
with the cut off value of 60%
Table B.5 Reliability score of Assessment tools

Chronbach’s alpha GAD- PHQ- PCL- DAST-
7 9 9 10
Pilot study 0.86 0.88 0.81 0.82
Study Population 0.70 0.85 0.90 0.72
Appendices Page 146

APPENDIX C
Bivariate analyses was conducted to see the strength of association between socio-
economic and exposure factors with psychological outcome to detect the significantly
related factor to enter into the multivariable regression analyses.
Table C.1 Bivariate analyses for all variables (Pre flood group)
Variable Age Marital Employment Monthly Chronic Depression Anxiety PTSD Drug
group status income illness abuse
Age group - 0.23*** 0.30** 0.12* 0.91*** 0.24** 0.16* 0.13* 0.23*
Marital status - 0.22*** 0.32** 0.47*** 0.16 -0.18* -0.02 0.11*
Employment - 0.25* 1.00*** -0.04* -0.01 -0.01 -0.05*
Monthly income - 0.76*** 0.34** 0.12* 0.17* 0.22*
Chronic illness - 0.37** 0.24* 0.20* 0.09
Depression - 0.26* 0.22* 0.18*
Anxiety - 0.26** 0.25**
PTSD - 0.23*
Phi and Cramer's V test: p*<0.05, p**<0.01, p***<0.001
Table C.2 Bivariate analysis for all variables (Post-flood group)
Variable Age Marital Employment Monthly Chronic Depression Anxiety PTSD Drug
group status income illness abuse
Age group - 0.30*** 0.35*** 0.14*** 0.94*** 0.19* 0.23* 0.20* 0.08
Marital status - 0.61*** 0.13** 0.29*** 0.004 0.25* 0.14* 0.27*
Employment - 0.02*** 0.23*** 0.01 0.13 0.27* 0.21*
Monthly income - 0.37*** 0.42* 0.39* 0.51* 0.18
Chronic illness - 0.37* 0.20* 0.39* 0.21*
Depression - 0.27* 0.36* 0.29*
Anxiety - 0.20** 0.38*
PTSD - 0.24*
Appendices Page 147

Table C.3 Bivariate analysis between socio-demographic and exposure variables
Water level at Loss of loved one Injury Financial helps Loss of land
home
Age group 1.22 0.45* 0.22* 0.15* 0.13*
Marital status 0.27*** 0.12 0.35* 0.37** 0.27*
Employment 0.11*** 0.20* 0.58** 0.36* 0.27*
Monthly income 0.19* 0.35* 0.65* 0.85*** 0.47*
Chronic illness 0.25* 0.42* 0.74** 0.21*** 0.22*
Table C.4 Bivariate analysis of all variables (Post-flood group)

Variable Loss of Injury Financial Loss of Depression Anxiety PTSD Drug
loved one help land abuse
Water level at home 0.31*** 0.20*** 0.33*** 0.29*** 0.002 0.21* 0.02 0.07
Loss of loved one - 0.34*** 0.21*** 0.09*** 0.20* 0.27* 0.24* 0.35*
Injury - 0.62*** 0.27*** 0.16* 0.34** 0.30* 0.31*
Financial Help - 0.14*** 0.28* 0.31* 0.29* 0.38*
Loss of land - 0.28* 0.20* 0.19 0.16
Depression - 0.57* 0.16* 0.29*
Anxiety - 0.10* 0.18*
PTSD - 0.24*
Appendices Page 148

Flood-Related Mental Illness in Bangladesh

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ASSESSMENT OF FLOOD RELATED

Submitted in fulfilment of the requirements for the degree of

School of Public Health

Queensland University of Technology

Post-traumatic stress disorder

Socio-economic and exposure factors

Multivariable logistic regression

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Chapter 2: Literature Review

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due reference is made.

Signature: QUT Verified Signature

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1.1.1 Natural disaster and health

Chapter 1: Introduction Page 1

Chapter 1: Introduction Page 2

Chapter 1: Introduction Page 3

Mental health can be defined as:-

Mental health is defined as a state of well-being in which every individual realizes

‘During a person’s lifetime, different traumatic experiences can produce significant

Chapter 1: Introduction Page 4

1.1.2 Definition and types of flooding

Chapter 1: Introduction Page 5

1.1.3 General Scenario of Flooding

Global coastal flooding by decade

Figure 1.2: Number of coastal floods occurring world-wide.

Percentages of floods of all natural disasters

1.1.4 Floods and mental health in the world

People killed by floods between 1980-2013

Chapter 1: Introduction Page 8

Economic Damage due to flooding

Figure 1.5: Economic damage due to flooding from 1980-2013

Chapter 1: Introduction Page 9

1.1.5 Floods and mental health in Bangladesh

Chapter 1: Introduction Page 10

0 20 40 60 80 100 120 140

Figure 1.6: Occurrence of natural disasters in Bangladesh from 1970-2014 (EMDAT,

1.1.6 Socio-demographic features of Bangladesh

Chapter 1: Introduction Page 11

Bangladesh is an economically unstable, over-populated country. Around 24% of the

Chapter 1: Introduction Page 12

1.2 Aims and Objectives

1.2.1 Research Aims

1.2.2 Specific objectives

Chapter 1: Introduction Page 13

1.3 Research Questions

1.4 Significance and Scope

Chapter 1: Introduction Page 14

2.2 Search Strategy

Primary inclusion criteria:

Chapter 2: Literature Review Page 15

Chapter 2: Literature Review Page 16