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Evaluation of a resilience intervention for Filipino displaced survivors of Super Typhoon Haiyan Maria Regina Hechanova
Received 1 January 2018 Revised 5 May 2018 Accepted 5 May 2018
Department of Psychology, Ateneo de Manila University, Quezon City, The Philippines
Pierce S. Docena
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Division of Social Sciences, University of the Philippines Visayas Tacloban College, Tacloban City, The Philippines
Liane Peña Alampay and Avegale Acosta
Department of Psychology, Ateneo de Manila University, Quezon City, The Philippines
Emma E. Porio
The Department of Sociology and Anthropology, Ateneo de Manila University, Quezon City, The Philippines
Isabel E. Melgar
Department of Psychology, Ateneo de Manila University, Quezon City, The Philippines, and
Rony Berger
Department of Emergency Medicine, Ben-Gurion University of the Negev, Tel Aviv, Israel Abstract
Disaster Prevention and Management Vol. 27 No. 3, 2018 pp. 346-359 © Emerald Publishing Limited 0965-3562 DOI 10.1108/DPM-01-2018-0001
Purpose – The purpose of this paper is to evaluate the effect of a community-based resilience intervention for Filipino displaced survivors of Super Typhoon Haiyan. Design/methodology/approach – The researchers used a quasi-experimental and mixed-method design comparing a treatment group with a control group across three time periods: before, immediately after, and six months after the intervention. Findings – Results showed significant improvements in survivors’ anxiety scores and resilience scores compared to those who did not undergo the program. However, although there was an increase in adaptive coping of participants immediately after the program, there was a reduction in adaptive coping behaviors for all groups six months after the program. Focus group discussions revealed this might be due to significant environmental challenges among displaced survivors. Research limitations/implications – A limitation of the study was the lack of randomization and a small sample size due to attrition. Practical implications – The study highlights the positive effects of culturally adapted group interventions. Social implications – The results suggest the importance of a systemic approach to enabling the recovery of displaced survivors in developing countries. Originality/value – This study provides evidence for a resilience intervention developed in a low-middle income country in Southeast Asia. Keywords Disaster, Resilience, The Philippines, Typhoon disaster, Displacement Paper type Research paper
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The development and evaluation of disaster interventions is particularly relevant in countries located within the Pacific Ring of Fire. A study reported that in the past 100 years, nine of the ten worst natural disasters occurred in Asian countries (Udomratn, 2008). One of these countries is the Philippines, a country that is frequently hit by earthquakes and as many as 10-20 typhoons a year (Conde, 2004). In 2013, Super Typhoon Haiyan struck several provinces in the central Philippines, resulting in over 6,000 deaths and affecting 16 million people. Six months post-disaster, there were still two million survivors without adequate housing and 26,000 displaced survivors (Internal Displacement Center, 2014). Given the devastation, the World Health Organization (2014) estimated that 80,000 Haiyan survivors were at risk for mental health disorders and called for urgent scaling up of mental health and psychosocial support (MHPSS) interventions. Although there is increasing evidence on the role of MHPSS interventions in buffering the impact of trauma on mental health (Felix and Afifi, 2015), there is a dearth of culturally nuanced resilience interventions in low- and middle-income countries (LMICs). This study therefore seeks to address this gap by evaluating a community-based resilience intervention for displaced survivors in the Philippines. Resilience The conceptualization and study of resilience has evolved in various disciplines, such as ecology and psychology, which are concerned with the adaptation and recovery of complex systems when faced with major threats. Social scientists in particular have investigated how individuals, families, and communities cope with or recover from the harmful effects of severe adversity (Masten and Narayan, 2012). In psychology, the history of resilience research is closely tied to clinical psychopathology and developmental science. For instance, pioneering resilience research emerged from the traumatic experiences of children who experienced the Second World War; with respect to natural disasters, the collapse of the dam in Buffalo Creek, West Virginia in 1972, and the Australian Bushfire of 1983, provided early insights into the longitudinal course of recovery and resilience from mass-traumatic events (Masten, 2014). This study examines resilience from this psychological lens, which in earlier conceptions was defined as the “ability to maintain relatively stable, healthy levels of psychological and physical functioning as well as the capacity for generative experiences and positive emotions” (Bonanno, 2004, pp. 20-21). Recent perspectives, however, view resilience from multiple levels and as a process rather than an outcome. The resilience activation framework (Abramson et al., 2015) suggested that the resilience of a system (whether that in an individual, family, community, or organization) is a function of its ability to maintain, re-establish or acquire human, social, economic and political capital that will enable recovery. In other words, social support from family and other social networks activates resilient attributes of individuals and their communities. Reich (2006) suggested three principles of psychological resilience: control, coherence, and connectedness. Control relates to the belief that one has the personal resources needed to rebuild their lives. Coherence has to do with enhancing meaning, direction, and understanding so as to create order and structure in one’s life. Finally, connection is about enhancing connectivity in order to build one’s social capital (Reich, 2006). This psychological conception of resilience is affirmed by a study in a flood-prone rural Philippine community where people’s capacity to cope was dependent on the strength of their livelihood and social network (Gaillard et al., 2008). There is support for the importance of resilience in post-disaster contexts in enabling well-being. For example, a study among oil spill survivors conducted four-and-a-half years after the disaster found that individual resilience was negatively related to mood disturbance and depressive symptoms and positively associated with psychological well-being and overall health quality of life (Buckingham-Howes et al., 2017).
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Resilience interventions Recognizing the importance of resilience has led to a growing number of psychosocial interventions to build resilience. The majority of these interventions have been implemented in high-income countries (HICs) and are founded on cognitive-behavioral therapy (CBT). For example, Skills for Psychosocial Recovery (Berkowitz et al., 2010) was designed to help survivors hone skills in information and prioritization, problem solving, identifying positive activities, managing reactions, helpful thinking, and promoting healthy connections. A self-help online program called My Disaster Recovery (Steinmetz et al., 2012) builds adaptive coping skills. Resilience and Coping Intervention for college students aims to improve levels of stress and depression and increase coping skills and hope (Houston et al., 2017). The World Health Organization (2016) also launched Problem Management Plus, an individual intervention utilizing problem-solving therapy and behavioral strategies that aims to address psychological and practical problems through modules on managing stress and problems, strengthening social support, and staying well and planning for the future (Hamdani et al., 2017). The IASC (2007) guidelines in providing MHPSS advocate that interventions should be contextually relevant and culturally sensitive. However, the majority of resilience interventions were designed and applied in HICs and are not necessarily accessible in LMICs with limited resources. In addition, there is a lack of literature on psychological interventions for disasters in Southeast Asia. This study therefore seeks to contribute to the global literature on disaster prevention and management by evaluating a resilience intervention for Filipino displaced survivors of Super Typhoon Haiyan. Katatagan: a resilience intervention for Filipino survivors The design process for the creation of Katatagan began with a needs analysis of Super Typhoon Haiyan survivors. Three months after Typhoon Haiyan, the Psychological Association of the Philippines brought together psychologists from various regions that were affected by the disaster to discuss their needs. The needs analyses revealed somatic, emotional, cognitive, and behavioral symptoms typical of disaster survivors. Beyond these, Filipino disaster survivors narrated spirituality-related outcomes such as questioning the presence of God or believing that the disaster was a punishment from God. Other vulnerabilities included a lack of resources, poor inter-agency coordination, and “turf wars” among government institutions. Survivors also reported slow delivery of services and a lack of information among survivors on how to access these services. In the hardest-hit areas, the basic survival needs of survivors were still not met six months post-disaster (Hechanova et al., 2015). Aside from vulnerabilities, local psychologists also noted protective factors among disaster survivors, including the Filipino’s generally positive disposition and sense of humor amidst adversity. Other protective factors cited were strong family and community support and the presence of extended families (Hechanova et al., 2015). The Filipino value of bayanihan or mutual assistance is strongly felt post-disaster as survivors help each other survive, rebuild their homes, and recover resources (Hilhorst et al., 2015). Survivors reported that social support from families and neighbors made them stronger and allowed them to address difficulties in sourcing their basic needs. In addition, spirituality and faith-based community activities were central in restoring survivors’ ability to recover (Holden et al., 2017; Porio, 2016). Post-disaster mental health interventions in the Philippines have mostly entailed individual or group-based counseling, psychosocial processing, and psychological first aid that are provided by mental health professionals. Moreover, there is no evidence-based community-based disaster resilience intervention conducted by paraprofessionals (Hechanova et al., 2015). Local psychologists had initially examined the Skills for Psychological Recovery (Berkowitz et al., 2010). The skills developed in some modules appeared to be consistent with the needs of Filipino survivors (e.g. managing reactions,
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problem solving, promoting positive activities). Other capacities, such as building social connections, were less critical to adapt and include in the program, given the already strong social relationships in Filipino communities. In addition, modules required adaptation for survivors with low education and literacy levels. Given this, an intervention named Katatagan (the Filipino term for strength or resilience) was designed with Filipino survivors’ psychosocial needs, vulnerabilities, and protective factors in mind (Hechanova et al., 2015). The intervention used the five-part model in CBT as its theory of change. This model focuses on modifying a person’s cognitions, emotions, behaviors, physical activities, and environment to enable their positive adaptation to their adverse conditions (de Terte et al., 2009). Katatagan was designed considering key aspects of the Filipino culture and context such as the use of small groups and the acknowledgment of the role of family, community, and spirituality as a recovery capital of Filipino disaster survivors. Anticipating that many survivors may not be able to read or write, the intervention utilized methods such as narratives and creative and physical activities. A critical barrier in providing MHPSS interventions is the dearth of mental health professionals in the Philippines (the ratio of psychologists to Filipinos is 1:100,000). Thus, the intervention was designed as a small-group intervention delivered by trained paraprofessionals (Hechanova et al., 2015). The aim of Katatagan is to help survivors hone adaptive coping skills by enabling them to reflect on and change their maladaptive cognitions, emotions, behaviors, physical activities, and environment (Hechanova et al., 2015). It consists of six structured modules. The first module, Finding and Cultivating Strengths, draws from positive psychology principles. The goal of the module is to enhance self-efficacy of survivors by helping them identify their sources of strength using the metaphor of a vinta (a Filipino sea vessel). The second module, Managing Physical Reactions, seeks to help participants manage posttraumatic stress symptoms by teaching them coping and mindfulness skills. Mindfulness skills are also reinforced in subsequent modules. The third module, Managing Thoughts and Emotions, aims to help survivors manage negative cognitions by using skills in reframing and thought substitution. The fourth module, Engaging in Positive Actions, focuses on positive actions and aims to help survivors reflect on what they can do to help themselves cope. The module, Seeking Solutions and Support, focuses on providing problem-solving skills. In recognition of the Filipino’s interdependent culture and the protective factors of family and community, participants are also asked to identify their sources of support using a social map. The final module, Moving Forward, asks participants to reflect on their journey to recovery and allows for meaning making. It seeks to provide survivors a sense of hope by helping them dream and plan for the future. Based on the protective factors of survivors, each module ends with a prayer and/or song (Hechanova et al., 2015). A pilot study of the program was conducted among college student survivors of Super Typhoon Haiyan in Tacloban by psychology faculty members who participated in the design of the intervention. The modules were implemented among groups of six to seven students and lasted for about a month, with each group meeting once or twice a week. A quasi-experimental study using a control group showed a significant reduction in their posttraumatic stress, anxiety, and depressive symptoms compared to those who did not go through the intervention (Flores et al., 2014). However, the limitation of the pilot study was its lack of follow-up data. In addition, the pilot program was facilitated by psychologists and not by trained paraprofessionals (Hechanova et al., 2015). The present study This study sought to address the gap in evidence-based resilience interventions in LMICs and make three contributions to the literature on disaster prevention and management. First, it
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utilized a quasi-experimental and longitudinal design to provide a more robust assessment of the efficacy of the program. Second, in keeping with the goal of focused non-specialized interventions, it sought to examine the effectiveness of the resilience intervention when delivered by trained paraprofessionals. Third, it focused on displaced survivors who were still living in temporary resettlement areas a year-and-a-half after the disaster. In line with Hobfoll et al.’s (2007) suggestion that resilience interventions should aim to facilitate positive adaptation and promote emotional well-being, the researchers focused on evaluating three outcomes: level of anxiety, adaptive coping, and resilience. More specifically, we hypothesized that among displaced survivors: H1. Participants of the resilience program will report a greater decrease in anxiety compared to those who did not undergo the program.
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H2. Participants of the resilience program will report a greater increase in adaptive coping compared to those who did not undergo the program. H3. Participants of the resilience program will report a greater increase in individual resilience compared to those who did not undergo the program. Beyond testing the aforementioned hypotheses, we also obtained qualitative data from participants to understand how their lives have been changed post-disaster, how they coped with the adverse conditions brought about by the disaster, and what resources were helpful in facing post-disaster life challenges. Method Research design and participants The study employed a mixed methods design and was conducted in one of the temporary resettlement sites for Haiyan survivors in Tacloban City, the Philippines. Using a quasi-experimental design, intervention groups were compared to a comparison group who did not undergo the program. Although randomized controlled trials are considered more rigorous tests of intervention outcomes, such designs are often not feasible or practical in LMIC settings, especially in a post-disaster environment (Masten and Osofsky, 2010). Out of 200 bunkhouse residents recruited for the study, 96 participants volunteered to participate in the program. These adults were randomly assigned to two groups (G1, n ¼ 48 and G2, n ¼ 48), using a table of random numbers. As the intervention was administered in small groups, G1 and G2 were further divided into six groups of eight participants. One facilitator handled two groups per intervention arm. The G1 participants went through the program in April 2015, whereas the G2 participants went through the program in May 2015. In total, 12 G1 and 2 G2 participants were unable to continue attending because of employment and relocation; hence, only data from 82 adults in the intervention groups were obtained. The no treatment comparison group (G3) was composed of the 104 adults who did not volunteer to participate in the program. However, by the time G3 participants were contacted for the post-test assessment, only 38 were available to answer the survey (refer to Figure 1 for the flow of participants and assessment times). Table I provides a description of the characteristics of the three groups. Assessments were conducted in four time points across nine months (Figure 1). Time 1 (March 2015) provided baseline measures for participants in G1, G2, and G3. Time 2 (May 2015) assessed the post-intervention effects on G1 participants, two weeks after the program, and pre-intervention assessments for G2. Time 3 ( June 2015) assessed for G2 post-intervention effects two weeks after the program and one-month follow-up for G1. In Time 4 (December 2015), follow-up assessments were conducted on the G1 and G2 participants, and the G3 comparison group. The primary analysis of this study compares the change across time for G1 and G2, who underwent the program, against G3 who did not undergo any intervention.
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Baseline assessment, n = 200 (Time 1)
Consented to participate in Katatagan, n = 96
Declined to participate in Katatagan No-treatment comparison group (G3), n =118
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Random assignment
Waiting/Delayed intervention arm (G2) n = 48
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Immediate intervention arm (G1) n = 48
Intervention
Dropped out, n = 7
Second pre-test measures, n = 48 (Time 2)
Post-test measures, n = 41 (Time 2)
Intervention
Follow-up measures, n = 36 (Time 3)
Second follow-up, n = 36 (Time 4)
Lost to follow up, n=5
Posttest measures, n = 46 (Time 3)
Follow-up, n = 46 (Time 4)
Dropped out, n = 2
Lost to follow up, n = 66
Posttest, n = 38 (Time 4)
The qualitative aspect of the study involved two follow-up focus group discussions (FGDs) among 16 participants (8 participants per FGD) to understand the challenges related to post-disaster life in the resettlement bunkhouses. The FGDs were conducted after the follow-up surveys were administered. Participants were invited and conveniently sampled from both participants and non-participants of Katatagan. Measures Structured interviews were conducted using instruments measuring anxiety, adaptive coping, and resilience. These scales were translated to Waray, the local language in the region. Except for the adapted Brief Cope, translation of the scales was done by one of the authors, who was a native speaker and checked by other Waray-speaking colleagues. The Waray version of Brief Cope was taken from another project that translated and back-translated several scales for use in research among disaster survivors.
Figure 1. Flow diagram of participants and assessment time
DPM 27,3 Variables Age (years)
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Table I. Baseline demographic and outcome scores
Group 1 (N ¼ 36) Immediate treatment M(SD)
Group 2 (N ¼ 46) Delayed treatment M(SD)
Group 3 (N ¼ 118) No treatment M(SD)
36.14 (11.05)
37.38 (13.04)
34.05(12.07)
Gender Male Female
8 (22.2%) 28 (77.8%)
5 (10.9%) 41 (89.1%)
47 (39.8%) 71 (60.2%)
Civil status Married Single Widowed Separated
23 (63.9%) 7 (19.4%) 4 (11.1%) 2 (5.6%)
34 (73.9%) 7 (15.2%) 5 (10.9%)
65 (55.1%) 41 (34.7%) 4 (3.4%) 8 (6.7%)
8 (17.4%) 1 (2.2%) 25 (54.3%) 12 (26.1%) 4.93 (2.20) 11.87 (1.95) 2.42 (0.41) 2.89 (0.43) 2.35 (0.71)
37 (31.4%) 10 (8.5%) 40 (33.9%) 31 (26.3%) 4.45 (2.71) 11.57 (2.64) 2.30 (0.39) 2.88 (0.40) 2.45 (0.65)
Education Tertiary Vocational Secondary Primary Household size Length of stay (months) Anxiety Coping Resilience
6 (16.7%) 0 19 (52.8%) 11 (30.6%) 4.11 (2.08) 11.83 (2.33) 2.33 (0.35) 2.90 (0.39) 2.46 (0.57)
0
Anxiet. The 20-item state subscale (Form Y-1) of the State-Trait Anxiety Inventory for Adults (Spielberger et al., 1983) was used to measure displaced survivors’ anxiety. Participants were asked to indicate how much they felt (1 ¼ not at all to 4 ¼ very much so) the given statements at the time of the interview. The anxiety measure’s internal consistency reliability during the pre-test, post-test, and follow-up ranged from α ¼ 0.73 to 0.78. Adaptive coping. To measure how participants coped with the challenges they encountered after the disaster, the researchers developed a coping instrument adapting the positive items from the Brief Cope survey (Carver, 1997) and added items that were specific to the coping skills taught in the program (e.g. “I’ve been reminding myself of my strengths,” “I’ve been doing relaxation exercises,” and “I’ve been setting goals for the future”). The modifications resulted in a 22-item scale that asked respondents to rate how frequently (1 ¼ I have not been doing this at all to 4 ¼ I have been doing this a lot) they have been applying certain coping strategies. Higher scores indicate more frequent use of adaptive coping strategies. The coping measure’s internal consistency reliability during the pre-test, post-test, and follow-up ranged from α ¼ 0.74 to 0.88. Individual resilience. A ten-item version of the Connor-Davidson Resilience Scale was used to measure the ability of the participants to cope with adversity (Campbell-Sills and Stein, 2007; Connor and Davidson, 2003). Participants rated items on a scale from 0 (not true at all) to 4 (true nearly all the time), with higher scores reflecting greater resilience. This scale has been previously applied to displaced populations (Suarez, 2013). The internal consistency reliability of this measure during the pre-test, post-test, and follow-up ranged from α ¼ 0.70 to 0.77. FGD guide. The semi-structured FGD focused on the following questions/issues: effects of Super Typhoon Haiyan and flooding, the survivors’ responses and sources of support immediately after the typhoon and at present, coping mechanisms of self, family, and community after the typhoon, and their initiatives toward building long-term adaptive capacity and/or community resilience.
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Procedure To ensure consistency in delivery, three paraprofessional facilitators were trained by a research team member to run the program. The facilitators were female, in their early 20 s with undergraduate degrees in psychology. To ensure quality delivery of the modules, three psychology faculty members who had previously facilitated Katatagan served as coaches to the facilitators. They observed at least two sessions and provided feedback to facilitators. For the data gathering, student researchers were trained to conduct household interviews using the translated instruments. After an orientation on the study, community members were invited to participate in the study. Those who volunteered were asked to sign an informed consent form. The interviewer then proceeded to orally administer the survey. Respondents received Php100 (about US$2) as a token for their participation in the study. After the interviews were conducted, respondents were invited to sign up to participate in the intervention. Analysis Mixed analysis of variance (ANOVA) was used to analyze changes over time in the anxiety, adaptive coping, and resilience scores of G1 and G2, who underwent the program, and G3 or the no-treatment comparison group. Mixed ANOVA allows for tests of differences between independent groups (i.e. the group who underwent Katatagan vs the group who did not) but also within group, as participants have been assessed on the relevant outcomes repeatedly at different time points or before and after program exposure. A critical parameter is the interaction between group (the between factor) and time (the within factor) which, if statistically significant, would suggest that changes in an outcome variable from baseline to post-intervention differ for the group exposed to Katatagan vs the comparison. Bonferonni post-hoc tests were also applied to examine pairwise differences across different time points. Results Baseline demographic and outcome scores Table I presents the baseline demographic and outcome scores of the participants. Participants were mostly female (70 percent), married (61 percent) with ages between 18 and 70 years old (M ¼ 35.19, SD ¼ 12.15). Almost all participants were Catholic/Christian (99 percent). The participants’ household size ranged from 1 to 17 persons with a median of three persons per household (M ¼ 4.51, SD ¼ 2.49). At the time of the baseline survey, they had been in the resettlement site for 1-18 months (M ¼ 11.69, SD ¼ 2.43). Comparison of the characteristics of the treatment and control groups showed a greater proportion of females among the participants than among non-participants. There was a larger proportion of college-educated and vocational-trained individuals among the non-participants. However, the average baseline scores of G1, G2, and G3 on the outcome measures were not significantly different at baseline. All groups had moderate scores in anxiety, adaptive coping, and resilience. Preliminary analyses: immediate intervention (G1) vs delayed intervention (G2) at T2 Changes in outcome scores in the intervention groups were first compared. Mixed ANOVA revealed no significant differences in anxiety, adaptive coping, and individual resilience scores. Data from the two intervention groups (G1 and G2) were combined and compared to the no-treatment group (G3). Katatagan intervention groups (G1 and G2) vs no-treatment comparison (G3) Baseline measures at T1 were compared to post-intervention T4 (seven and six months after intervention for G1 and G2, respectively). Using mixed ANOVA, results showed significant
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changes in anxiety and individual resilience scores across time, and significant interactions between time and intervention vs non-intervention groups (see Table II). Anxiety. There was an interaction between Time and Group, albeit marginally significant and small in effect size, indicating that change in anxiety scores over time was conditional on whether participants were in the intervention group or comparison group, F (1, 105) ¼ 3.89, p ¼ 0.05, Z2p ¼ 0.036. The intervention groups manifested lower anxiety scores at post-test compared to the comparison group, whose anxiety scores did not considerably change. Scores across time showed that anxiety was lowest immediately after the intervention and increased somewhat over time. However, anxiety scores six months after were still significantly lower than before participants went through the intervention. Adaptive coping. There was no Time by Group interactions in adaptive coping. Examining the smaller patterns of change within the intervention group within T1-T4 time span, adaptive coping had a small but significant increase from T2 to T3, F (2.79, 192.6) ¼ 5.87, p ¼ 0.001, Z2p ¼ 0.078, or two weeks after the delayed arm received intervention, but decreased significantly six months after, suggesting that there were positive changes which were not sustained (see Table III). Individual resilience. There was a small but significant interaction between Time and Group, indicating that the intervention groups had larger increases in individual resilience scores at T4 compared to the no-intervention group F (1, 105) ¼ 4.68, p ¼ 0.03, Z2p ¼ 0.043 (see Table II). Scores across time showed that resilience scores increased significantly across the different time periods (see Table III).
df
Table II. Descriptive statistics and mixed ANOVA results for intervention groups vs no treatment comparison
Table III. Katatagan group differences across time in anxiety, coping, and resilience scores
Z2p
F
p
Intervention (G1, G2) (N ¼ 70) T1 T4 M (SD) M (SD)
Comparison (G3) (N ¼ 37) T1 T4 M (SD) M (SD)
Anxiety Time 1, 105 4.25** Time × group 1, 105 3.89*
0.039 0.04 0.036 0.05
2.37 (0.41)
2.18 (0.37)
2.26 (0.31)
2.25 (0.35)
Adaptive coping Time 1, 105 3.10 Time × group 1, 105 0.13
0.029 0.08 0.001 0.72
2.89 (0.41)
2.82 (0.48)
2.88 (0.39)
2.77 (0.46)
Resilience Time 1, 105 8.76*** 0.077 0.004 Time × group 1, 105 4.68*** 0.043 0.03 2.34 (0.63) 2.72 (0.61)* 2.52 (0.68) 2.58 (0.50) Notes: *Significant time × group interaction when compared to no treatment comparison group, p ¼ 0.05; **significant effect of time, po 0.05; ***significant time × group interaction when compared to no treatment comparison group, p o0.05
F
df
Z2p
p
Anxiety 7.33 3, 207 0.096 o0.001 Adaptive coping 5.87 2.79, 192.60 0.078 0.001 Resilience 8.47 3, 207 0.109 o0.001 Note: *Significantly different from Time 1 at p o0.05
T1 M(SD)
T2 M(SD)
T3 M(SD)
T4 M(SD)
2.37 (0.41) 2.89 (0.40) 2.34 (0.63)
2.32 (0.39) 2.92 (0.35) 2.49 (0.56)
2.18 (0.39)* 3.05 (0.39)* 2.63 (0.56)*
2.18 (0.37)* 2.82 (0.48) 2.72 (0.61)*
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Themes from FGDs with survivors The FGD results that were conducted after six months (T4) revealed that participants reported attempts at adaptive coping such as managing thoughts and emotions, either by thought stopping (I do not dwell on what happened) or self-talk (I have to make myself strong so we will live!). However, they also reported difficulties in the lack of basic needs because the temporary resettlement area had limited potable water, food, livelihood, and electricity. Water was particularly problematic as the community only had one water source and water came in trickles. Residents had to line up at all hours of the day to get water they needed to survive. They also had to deal with issues of crowding in their makeshift homes and environmental degradation of the site. Security was also an issue as crime was rampant and snakes abound. Survivors coped by giving and providing social support. Moreover, the resettlement site was far from their workplace or school, and transportation to and from their location was expensive. Many residents, in fact, traveled to the city during the week to become informal settlers there only to return to their resettlement community on weekends or occasionally. Given these difficulties, survivors reported relying on their faith. However, there was also a sense of helplessness as the national government agency that had originally managed the site had pulled out their camp management staff. The community was supposed to have been turned over to the local government but there was no one assigned to help manage the camp. Residents also had no information on plans for permanent relocation that was promised by the government. Discussion This study evaluated a resilience intervention program that aimed to strengthen the resilience, adaptive coping, and well-being of displaced disaster survivors. Results suggest that the intervention decreased anxiety and increased resilience of displaced disaster survivors compared to those in the comparison group. Although previous studies have shown the effectiveness of group-based interventions among children (Barron et al., 2013; Berger et al., 2012; Giannopoulou, et al., 2006; O’Donnell et al., 2014) and displaced adolescent survivors (Bolton et al., 2007), there is a dearth of studies on evidence-based interventions for adult survivors. Thus, a major contribution of this study is that it presents evidence that the Katatagan program can enhance emotional well-being and the resilience of displaced adult survivors. Furthermore, in keeping with the advocacy of IASC (2007), it provides evidence of the effectiveness of a resilience intervention delivered by trained lay facilitators. In line with IASC guidelines for MHPSS interventions to be contextually relevant and culturally sensitive (IASC, 2007), another contribution of this study is that the intervention was designed for a Southeast Asian and LMIC setting. Although there was an improvement in adaptive coping immediately after the intervention, post-follow-up scores decreased suggesting that the short-term positive changes in adaptive coping were not sustained over time. One possible explanation for this was the grim and uncertain state of their resettlement community. The FGDs revealed the lack of clear plans, access to basic needs, schools and social services, employment opportunities and general poverty – all of which may have limited their adaptive behaviors. These results support previous studies in the Philippines that the impact of natural calamities is compounded by environmental degradation, inadequate infrastructure, and poor delivery of social services to survivors of disasters (Porio, 2014; Holden et al., 2017), including insecure land and housing, high-risk locations, and lack of organization (Carcellar et al., 2011). Moreover, the results mirror findings of other studies among displaced disaster survivors such as limited job opportunities, poor housing conditions, lack of electricity and water, poor sanitation and health facilities, confinement in small spaces, and increased criminality (Waas et al., 2003).
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The results thus reinforce the importance of understanding the resilience of displaced disaster survivors from an ecological perspective. Studies among displaced survivors highlight the importance of enhancing employment skills and livelihood opportunities. Moreover, family interventions, family therapy, and parenting skills may be important means to strengthen the resilience especially of young survivors (Chen et al., 2016). However, beyond providing for survivors’ needs, Abramson et al. (2015) suggested that individual resilience interventions need to be linked to broader community resilience activities and partnership that may serve to activate and sustain adaptive behaviors. Thus, beyond individual interventions, community resilience interventions can engage members in collaborative planning (Gagnon et al., 2016). Unfortunately, a study among resettlement communities in the Philippines suggests that they tend to be agency or donor driven rather than owner driven. This approach fails to develop residents’ initiative and ability to rebuild their lives and their community. In contrast, owner-driven approaches that harness the participation of beneficiaries empower them and enable faster psychological recovery by providing a sense of control (Santiago et al., 2018). The use of citizenry-based and development-oriented approaches has been adopted by some non-profit organizations in the Philippines such as the Citizen’s Disaster Response Center that advocate that vulnerable sectors are the main actors in disaster response and not merely victims who need assistance. Thus, what is critical is partnering with people’s organizations in disaster preparation, emergency relief, and rehabilitation (Delica,1993). People’s organization driving the recovery processes in post-disaster situations have been shown by several case studies in Visayas and Mindanao to be more responsive and sustainable (Holden et al., 2017). Moreover, because developing countries are disproportionately affected by climate-related disasters, there has been an increasing call for integrated climate change adaptation and climaterelated disaster risk reduction and management strategies (de Leon and Pittock, 2017). Limitations and future directions for research A major limitation of the study was that the intervention and comparison groups were not randomly assigned to treatments (RCT). Another challenge was sample attrition because of the migration of residents out of the resettlement area and the inability to locate them. For example, it is possible that movement out of the community was a form of problem solving and thus a manifestation of adaptive coping. Possible systematic bias in the results may have been minimized if we had conducted an intention-to-treat (ITT) analysis, but the missing data were too substantial and possibly nonrandom. Given several issues in the evaluation design, researchers should validate the effectiveness of the Katatagan intervention in other sites and with larger samples, using RCT and an ITT analysis. It must be noted that conducting evaluation research post-disaster, and in a poor and unstable community, presents real constraints that eclipse scientific rigor. This first effort informs future researchers about what is possible in intervention research in such challenging environments. Limitations notwithstanding, the study provides initial evidence of the effectiveness of a group-based resilience intervention facilitated by trained lay community facilitators post-disaster. One implication for this is the value of training paraprofessionals in the community who can provide mental health interventions. The Inter-Agency Standing Committee (2007) classified MHPSS interventions into four types: basic services and security; family and community supports; focused non-specialized interventions; and specialized services. The Inter-Agency Standing Committee Reference Group for Mental Health and Psychosocial Support in Emergency Settings (2010) proposed that focused non-specialized interventions are important during the recovery phase after basic needs have already been met. However, our findings reveal that displaced survivors still struggle with meeting their basic needs two years after the disaster. Thus, even as the study shows that the resilience intervention Katatagan leads to positive outcomes on
anxiety and resilience of Filipino survivors, the results highlight the need for an ecological approach in order to sustain adaptive coping of survivors. The above findings suggest that resilience interventions like the Katatagan model be part of a more integrative model of development and disaster risk reduction (Curato, 2018). Moreover, integrative and/or convergent approaches to recovery and resilience need to be institutionally embedded in climate and disaster resilience programs (Porio, 2018).
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Corresponding author Maria Regina Hechanova can be contacted at:
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