ORI GIN AL PA PER

Mental health preparedness for natural disasters in Iran

Naghmeh Sadeghi Æ Mohammad H. Ahmadi

Received: 22 August 2006 / Accepted: 3 June 2007 / Published online: 3 July 2007� Springer Science+Business Media B.V. 2007

Abstract Appropriate emergency preparedness and response rely on social, economical,

cultural, and political infrastructures, which vary widely according to the level of the

development of each country. Mental health damages are among the consequences of

absence of such infrastructure, which have not been studied comprehensively till to date. In

most countries, planning for natural disasters and earthquakes has been mainly focused on

physical and economical impacts; however, lessons learnt from recent earthquakes in Iran

and other countries show that psychological impacts need to be considered more seriously.

The first responder to an emergency is really the affected community, which consequently

should be mentally prepared by appropriate training programs. These should include simple

psychosocial interventions developed for people with average level of education in a way to

be easily understandable and practicable. After the Bam earthquake, local community

volunteers have been selected and trained to provide post-disaster mental health services.

Keywords Mental preparedness � Mental health � Earthquake � Natural disaster �Psychological impact

1 Introduction

In order to appropriately cope with natural disasters, a well-planned, coordinated and

integrated effort is needed among different sectors, including governmental agencies,

N. Sadeghi (&)Disaster Management Department, Risk Management Research Center, International Institute ofEarthquake Engineering and Seismology (IIEES), No. 26, Arghavan St., North Dibajee, Farmanieh,P.O.box: 19395/3913, Tehran, Irane-mail: n.sadeghi@iiees.ac.ir

M. H. AhmadiRisk Management Research Center, International Institute of Earthquake Engineering and Seismology(IIEES), No. 26, Arghavan St., North Dibajee, Farmanieh, P.O.box: 19395/3913, Tehran, Iran

123

Nat Hazards (2008) 44:243–252DOI 10.1007/s11069-007-9150-1

financial stakeholders, multidisciplinary scientists, NGOs, and the public (Srivastava and

Gupta 2006). Alongside proper disaster management and post-disaster rehabilitation

activities, pre-disaster planning and preparedness are crucial. Studies of recent earthquakes

show the important role of mental health preparedness and its consideration in pre-disaster

planning.

The impact of earthquakes on a community is determined by several factors, such as,

the socio-economic situation, the level of psychological sensitivity, the degree of fear and

the frequency of earthquake in the area. Disasters not only cause deaths, physical injuries,

damages to infrastructures and economic losses, but also have a deep impact on the

population’s mental health (PAHO/WHO 2004). In general, disaster research has a key

social role in highlighting the long-term effects of such impacts, which in the past were

mostly overlooked and neglected (Robertson et al. 2002). Studies of Bam earthquake in

2003 confirm the importance of psychosocial interventions for earthquake victims (Iranian

Welfare Organization: Planning Committee 2004). Integrating risk reduction into national

development plans has an important role for creating a culture of prevention and

decreasing impacts of disasters (La Trobe and Venton 2003). Such national plans have to

include mental preparedness plans, particularly in Iran as one of the ten countries in the

world most prone to disasters.

Studies show that the local communities performed most of the rescue operations in the

first hours after Bam earthquake (Ministry of Health and Medical Education: Deputy for

Research 2003). Therefore, preparedness should be implemented through education for

non-specialized and ordinary people in a way to be easily understandable and practicable in

the community.

This paper shows results from investigations on mental health after disasters, summa-

rizes guiding principles, and discusses actions towards a community-based mental pre-

paredness.

2 Mental health in crisis situation

The mental state of victims after a disaster should be considered at three different

stages: the immediate reaction, the post-immediate phase and the delayed and long-term

sequel. The immediate phase may be associated with distressing symptoms accompa-

nying adaptive stress; symptoms of maladaptive stress, such as confusion, agitation,

panic flight, automatic behavior; and exceptionally, neurotic or psychotic reactions. The

post immediate phase may be characterized by a return to normal health, or by the

insidious onset of a Post-Traumatic Stress Disorder (PTSD) or PTSD-like syndromes.

The chronic phase may present persistence of PTSD or personality changes (Robertson

et al. 2002).

Table 1 shows the summary of World Health Organization (WHO) projections of the

prevalence of mental disorders before and after a disaster (WHO 2006).

In Iran, based on experience from previous natural disasters, the Ministry of Health and

Medical Education (MOH&ME) in cooperation with welfare organization has developed

an elaborate mental health program to provide the required care to traumatized victims and

help in stabilization and social rehabilitation. In the case of Bam, the number of deaths and

intensity of the destruction were so large, that all survivors required extensive psycho-

logical counseling and psychiatric treatment (Iranian Welfare Organization: Planning

Committee 2004). Based on early assessment, around 40% of the affected population

developed PTSD. This is more than twice the people that developed PTSD in the earth-

244 Nat Hazards (2008) 44:243–252

123

quake that stuck the northern provinces of Iran in 1990 (WHO 2004). Table 2 presents the

prevalence rate of psychosocial disorders after Bam earthquake in 2003.

In Yassini and Hosseini (2006), authors conduct a survey study and show a statistically

significant relationship between the incidence and severity of PTSD symptoms and loss of

family members. However, it shows that physical injuries, socio economic status and level

of education had no effect on the incidence or severity of PTSD symptoms. Incidence and

severity of PTSD symptoms in survivors who received psychiatric care following earth-

quake were also statistically significant (Yassini and Hosseini 2006).

The increase in PTSD prevalence in Bam earthquake with respects to previous earth-

quakes in Iran and also to international statistics indicates the necessity of considering this

issue much more in detail than before. The investigations in (Montazeri et al. 2005) show

that the rate of psychological distress among the survivors of Bam earthquake is three

times higher than that of the normal population. Table 2 also shows the gender differences

in psychosocial disorder incidence; for example, in females the rate of depression is higher

than that of males, however, the rate of addiction disorders is much lower. These differ-

ences should be considered in delivery interventions and care to each gender.

On the first day of the earthquake, the rescue operation was mostly performed by the

local community rather than by professional rescue and emergency teams. At Imam

Hospital in Bam, some people psychologically affected by the disaster made problems and

difficulties in prioritizing emergency operation. Due to a lack of proper training, aware-

ness, and preparedness, patients’ relatives were forcing physicians and nurses to first visit

and examine their injured persons with no life threatening injuries. A few violent incidents

towards medical staff were initiated by patients’ relatives (Ministry of Health and Medical

Education (MOHME): Deputy for Research 2003).

Following the Bam earthquake, the role of psychologists besides medical staff to help

people who are experiencing emotional shock and psychological disorders have been

reinforced.

3 Principles for mental health preparedness

In addition to human losses, recent natural disasters have resulted in significant impacts on

people’s health and mental health that could have been controlled by appropriate disaster

Table 1 Mental disorders: a summary of generic WHO projections after disaster

Disorders Before disaster 12-month prevalence(%)

After disaster 12-monthprevalence (%)

Severe mental disorders (Psychosis, severedepression, severely disabling form ofanxiety disorder)

2–3 3–4

Moderate or mild mental disorders (Mild andmoderate forms of depression and anxietydisorders, including PTSD)

10 20 (reduces to 15 withnatural recovery)

Severe or moderate psychological distress(No disorder)

No estimate 30–50 (reduces to unknownextent with naturalrecovery)

Mild psychological distress No estimate 20–40 (may resolve overtime)

Nat Hazards (2008) 44:243–252 245

123

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246 Nat Hazards (2008) 44:243–252

123

management (Pine 2006). In the absence of comprehensive and fundamental planning,

interventions might have unpredictable, unexpected and subsequently unacceptable con-

sequences.

Emergency planning requires coordinated team work involving different levels of

governmental and NGO agencies and organizations (FEMA 2006). Planning and prepara-

tion are also important when working as a Psychological First Aid (PFA) provider. The PFA

provides information that may help survivors cope effectively with the psychological im-

pacts of disasters. In general, PFA is designed to be provided by expert rescue teams, who

can provide early assistance to affected children, families and adults as part of an organized

disaster response effort. These providers can be part of a variety of response units such as

Community Emergency Response Teams (CERT). PFA providers need to be sensitive to

cultural, ethnic, religious and language diversity (National Child Traumatic Stress Network

and National center for PTSD 2005). In order to reduce the impacts of natural disasters on

the community, comprehensive plan should be structured in advance, so that each institute

and organization knows exactly its responsibility when needed. In order to achieve the best

result, this plan has to specify what action, by whom and when should take place.

WHO key principles on assisting populations exposed to extreme stressors are sum-

marized below;

1. Contingency planning: Before the emergency, national-level contingency planning

should include developing interagency coordination systems, designing detailed plans

for a mental health response and training of relevant personnel in indicated

interventions.

2. Assessment: Assessment should cover the socio-cultural context, available services,

resources, and needs.

3. Long-term perspective: The population is best helped by a focus on the medium and

long-term development of services.

4. Collaboration: Strong collaboration with other agencies will avoid wastage of

resources.

5. Integration into primary health care: Led by the health sector, mental health treatment

should be made available within primary health care to ensure access to services for

the largest number of persons.

6. Access to service for all: Setting up separate, vertical mental health services for special

populations is discouraged.

7. Through training and supervision: Training and supervision should be by mental

health specialists—or under their guidance to ensure lasting effects of training and

responsible care.

8. Monitoring indicators: Activities should be monitored and evaluated through key

indicators that need to be determined, if possible, before starting the activity (PAHO/

WHO 2004).

These principles should guide national programs for the prevention and mitigation of

the psychosocial consequences of disasters being developed in each country (Robertson

et al. 2002). Assessment is one of the most important actions to be taken urgently after a

disaster, to assign priorities in the coordinated efforts. Training in the pre-disaster period

plays a key role on mental preparedness. Provided services should be monitored through

essential indicators in order to ensure performance improvement.

In general, the following suggested steps have to be taken before developing national

mental health plans for disasters: review the country’s existing norms and legislation;

Nat Hazards (2008) 44:243–252 247

123

review national disaster-prevention and response plans in the ministry of health and related

organizations; review national mental health plans; compile existing documentation on the

topic; interview key players at the national and local levels and set up a multi-sector

working group. Contrarily to what can be believed, plans for mental health during disasters

need to be quite simple to be implemented in local communities, low-cost and resource

compatible (PAHO/WHO 2003). A comprehensive national plan should culminate to well-

defined and practical guidelines, with coordinated, directed and organized effort among

different organizations involved in the disaster management process in such a way that all

available resources and facilities can be applied as proportioned to the real occurrences.

Due to mental health preparedness importance, all planning should include mental

health preparedness and response to mitigate and prevent negative psychological conse-

quences (US Department of Homeland Security 2004; WHO 2003; Institute of Medicine

et al. 2003). Mental preparedness requires promoting public awareness in order to make the

community better prepared and mobilized to cope with natural disaster’s impacts. This

process needs necessarily participation of the communities, since communities understand

their own needs better, and they are more prompt to accept professional and technical

recommendations when these are convincing and non in conflict with their own percep-

tions and knowledge.

Severe disasters lead to the creation of impromptu community organizations that

mobilize to address gaps in response capacity or failure of existing systems to surge

adequately in situations where their resources are strained excessively. The tremendous

capacity of communities and their social networks and formal associations to respond to

crises is a resource that should be empowered by pre-disaster awareness raising and

training. Citizens should be made familiar with what to expect following a major disaster,

they should be made aware of their responsibility for mitigation and preparedness and they

should be trained in needed life saving skills with emphasis on decision making skills and

rescuer safety so that they are an extension of first responder services offering immediate

help to victims until professional services arrive. People will have to rely on each other’s

help in order to meet their immediate life saving and life sustaining needs (Department of

Homeland Security 2006). Communities are likely to know themselves and their capa-

bilities and resources better than most outside agencies or organizations (Landesman

2001). A community that is prepared for emergencies can rescue people rapidly and

provide life-saving first aid. Waiting and relying only on external assistance will result in

greater loss of life and more damage to the community (WHO South–East Asia Region

2006; Jackson and Cook 1999).

Although for each individual who is physically injured during a disaster there are more

than 200 people damaged psychologically, the ratio between the personnel who assist the

former and the latter is 20 to 1 (Robertson et al. 2002). These statistics show that health

care plan should be structured giving a higher priority to mental health issues.

Joint Commission on Accreditation of Healthcare Organizations (JCAHO) engages

communities in preparedness planning and exercises. JCAHO requires and sets standards

for preparedness activities including exercises, and interacts with communities in the area

of bioterrorism and disaster preparedness. The range of partners in preparedness should be

conceived broadly, to include local community, health care institutions, voluntary orga-

nizations, and others (Landesman 2001).

If a community wants to increase its response capability, particular groups of citizens

should be recruited and trained, so that in time of need, they can act as auxiliary

responders. These groups can provide immediate assistance to victims in their area,

organize spontaneous volunteers who have not had the training, and collect disaster

248 Nat Hazards (2008) 44:243–252

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intelligence that will assist professional responders with prioritization and allocation of

resources following a disaster (US Department of Homeland Security 2006).

All above considerations are confirmed by case studies, such as the Shang-An ICBDM

Project (Chen and Liu 2006), which also shows advantages of developing specific edu-

cational materials targeted at different community characteristics.

The Whittier Narrows earthquake in 1987 underscored the area-wide threat of a major

disaster in California. Further, it confirmed the importance of training civilians to meet

their immediate needs so that family members, fellow employees, and neighbors sponta-

neously tried to help each other. This was the case following the Mexico City earthquake

where untrained, spontaneous volunteers saved 800 people. However, 100 people lost their

lives while attempting to save others. Although it was a high price to pay, it could have

been prevented by appropriate training (Department of Homeland Security 2006).

The CERT program (National Child Traumatic Stress Network and National center for

2005) in the United States educates people about disaster preparedness for hazards that may

impact their area and trains them in basic disaster response skills and disaster medical

operations. The primary reason of CERT training is to give people the decision-making,

organizational, and practical skills to offer immediate assistance to family members,

neighbors, and associates while waiting for help. One of the important issues in CERT

training in order to prepare for emergency response is to understand the psychological

impact of a disaster on themselves and others (Department of Homeland Security 2006).

The purpose of a psychological training program is to reduce panic and anxiety of the

catastrophic events on the exposed community and to improve their disaster response skills.

Helping to maintain or reestablish customs, traditions, rituals, family structure, gender

roles, and social bonds is important in helping survivors cope with the impact of a disaster

(National Child Traumatic Stress Network and National center for PTSD 2005). Therefore

the training program needs to use traditional beliefs, customs, religion, poetry, folklore

literature and proverbs which are commonly used in the local community, to be more

effective.

Previous experiences have shown that theory is not sufficient, and that regular practical

exercises are the most efficient ways to rehearse adaptive reactions. In Japan, authorities

stage collective exercises every year on September 1 (the anniversary of the Tokyo

earthquake on 1923, which caused 200,000 deaths). On this day, schools and factories are

evacuated and relief exercises are practiced on the street. A specialized information and

training center has been created in Tokyo, and replicas of apartments have been mounted

on hydraulic jacks to simulate the shaking produced by an earthquake (Robertson et al.

2002).

Secondary prevention implies that the mental health and other disaster response workers

are able to identify subjects at risk after a disaster (Robertson et al. 2002). A variety of

information can help survivors manage their stress reactions, and deal more effectively

with problems. Such information includes; what is currently known about the unfolding

event, what is being done to assist them, what, where and when services are available, post-

disaster reactions and how to manage them, self-care and family care (National Child

Traumatic Stress Network and National center for PTSD 2005). Some researches and

authors believe that secondary prevention can be achieved by developing the resilience

capacity of the victims. As part of their education, survivors may be given an information

leaflet. Robertson et al. (2002) reported a high degree of satisfaction with a two-page

leaflet, entitled ‘‘Surviving Trauma’’ consisting of immediate symptoms, impact of trauma

on the environment, evolution of symptoms during the first months, how to help oneself

and places where help can be found.

Nat Hazards (2008) 44:243–252 249

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Collaboration with traditional healers is important since they can play an important role

in the local community by creating social support networks. When mental health care is

considered, it is very important that counselors and psychiatrists speak the native language,

even when the medical help is considered in general. Thus it is easier, more cost effective

and yielding to train volunteers from the population who are willing to work for the

aggrieved to identify those who need priority consultation by specialist doctors of whom

there is generally insufficient (Thirunavukarasu 2004).

4 Post Bam activities in Iran

General guidelines, such as WHO’s, need to be adapted by intermediary institutions to

local cultures and community traditions to be useful. The role of such organizations in Iran

is missing and although some limited efforts in some organizations are being conducted,

they are not integrated and coordinated to be applicable at the national level.

Nevertheless, MOHME with welfare organizations in Iran also applied local community

volunteers (‘hamyar’) in order to improve community mental health after Bam earthquake

in 2003. The planning committee of the Community Based Rehabilitation (CBR) con-

sultancy services placed psychosocial rehabilitation as a priority after earthquake. The size

of the city, unfamiliarity of the experts with the area and cultural conditions were the

reasons to use local community volunteers as welfare organization executive agents. Ex-

perts besides their other duties prepared educational pamphlets for such volunteers in order

to fulfill the screening phase appropriately. The volunteers were selected, organized and

trained and then sent to six psychosocial health stations. Provision of mental health aid was

organized in three levels; at the first level services were offered on place by the community

volunteers, at the second level services were provided by experts in psychology and

consultancy and at the third level help was given by psychiatrists and senior experts in the

headquarter. In each CBR psychosocial health station, psychologists with volunteers under

supervision of chief psychologist have been working. At the first level, the volunteers

duties were as follows: identification of the individuals with psychological disorders;

referring the identified cases to the station; distribution of the educational pamphlet among

families and earthquake victims; following up the correct way of consuming prescribed

drugs by patients; and holding the public educational sessions in mental health with

cooperation and supervision of mental health committee experts (Iranian Welfare Orga-

nization: Planning Committee 2004).

After the Bam earthquake, in Iran the main objective of community emergency pre-

paredness program is to bring communities together to prepare for natural disasters in a

participatory process. This is being achieved on the basis of the general principles dis-

cussed at Chapter 3.

Since 1991, education about earthquake preparedness in schools has being given a

special priority. There are almost 15,000,000 pupils and students in schools at different

levels. These can convey appropriate awareness further in the communities. In order to

create a deeper understanding of the safety culture at schools, the public education

department of International Institute of Earthquake Engineering and Seismology (IIEES)

has organized earthquake and safety programs with the objectives of improving disaster

skills, increasing earthquake preparedness and pursuing long-lasting training. Educating

children and youngsters on disaster preparedness at nursery, elementary, secondary and

high school levels has been developed on a national scale in Iran covering both urban and

rural areas. This has been achieved by including related materials in the textbooks,

250 Nat Hazards (2008) 44:243–252

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showing films, conducting ‘‘safety drills,’’ holding exhibitions and competitions, display-

ing paintings and posters in educational environments and using songs and games. ‘‘Safety

drills’’ are held every year on November 29. In coincidence with the ‘‘week of natural

disasters reduction,’’ the IIEES Public Education Department holds annually an educa-

tional workshop on ‘‘earthquake and safety’’ (International Institute of Earthquake Engi-

neering and Seismology 2006).

After the Bam earthquake, in cooperation with United Nations International Children’s

Emergency Fund (UNICEF) cooperation, welfare organization’s mental health committee

prepared an applicable educational pamphlet for intervention in crisis to improve the skills

of nursery school instructors to cope with psychosocial consequences of natural disasters in

children. An informative pamphlet with the aim of helping parents in order to cope with

their children’s fear also has been developed and distributed (Iranian Welfare Organiza-

tion: Planning Committee 2004).

5 Conclusions

Natural disasters cause deaths, diseases, injuries and economic loss and also have a deep

impact on the population’s mental health. In most countries, natural disaster planning has

been mainly focusing on physical and economical impacts; however, lessons learnt from

recent earthquakes in Iran and elsewhere indicate the importance of considering psycho-

logical impacts in disaster management planning.

In order to prevent long-term psychological impacts, communities must be prepared

mentally to cope with disasters and their unpredictability. Feeding the community with

knowledge and ability for coping with natural disasters on their own is essential. Training

is an important tool for ensuring community mental preparedness. The studies of the recent

earthquake in Iran show that local communities have done most of the rescue operations in

the first hours after the earthquake. Iran’s experience in applying local community vol-

unteers for providing mental health services after Bam earthquake was very positive.

Therefore, it is suggested to design an appropriate training program on psychological

issues for local volunteers, because they are familiar with cultures, customs and charac-

teristics of local communities and can provide better aid and more effective assistance.

Acknowledgement The authors would like to thank Dr. Aniello Amendolla and anonymous reviewers fortheir valuable comments and suggestions that greatly improved the presentation of this paper.

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