We identified and reviewed the abstracts of 257 papers published in 2010 or 2011. We could not obtain the full texts of four articles. Forty-two papers seemed potentially relevant to our review and we read and analysed the full texts. Thirty-two papers fulfilled our inclusion criteria 6-37
The papers reported research on a range of extreme events in a variety of countries (Table 1). The majority of papers reported on the impacts on the mental health of adults 7,8,10,11,12,13,14,16,18,20,24,25,26,27,30,31,32,34,35,37
. Others focused on adults and adolescents above the age of 15 years 19,22,28
, while nine reported research on children and adolescents aged between 4 and 17 years 6,9,15,17,21,23,29,33,36
Primary stressors, concurrent life events or secondary stressors
Usually, the focus of the research reported in the papers we read related to identifying and minimising the impacts of primary stressors.
One key problem within the studies reviewed was the lack of a definition, or the use of unclear definitions, for many of the secondary stressors. We found that researchers assessed secondary stressors using different methods or tools. The time between the occurrence of the index extreme event and the measurement of secondary stressors ranged widely from as little as one month to as long as four years. These features made it difficult for us to determine if a problem was a primary stressor, concurrent life event, or a secondary stressor.
Another challenge arose due to the blurred definitions and time boundaries between primary and secondary stressors. Some authors reported research on items such as ‘lost livelihood
or property destruction 16,19,24,37
. They measured these factors as part of ‘event-related traumatic events
’ alongside other experiences such as seeing people die, fearing for one’s life at the time of the event, or the severity of the disaster. Arguably, these circumstances are aspects of the extreme event and should, therefore, be considered as being among the primary stressors that stem directly from the event. However, as clearer definitions or explanations of these terms were not provided, and as the studies were conducted up to three years after the index event, they could also be seen as unresolved primary stressors or secondary stressors.
Similarly, daily or continuing stressors and other ‘negative life events
’ were measured in some research 7,9,14
. These events included changes to marital or family status, death of a spouse or family member, divorce, marriage, other family and work problems. Once again, the definition of these terms, and the variations in time intervals after the extreme event at which they were measured, were not clear. These occurrences could be either a direct consequence of, or exacerbated by the disaster, or be concurrent and unrelated. We have not included these events within our typology of secondary stressors.
A typology of secondary stressors
Table 2 summarises the results of our thematic analysis of the secondary stressors.
Although this table suggests clear distinctions between the different categories of secondary stressors, many of the stressors fall into more than one category in the typology. Different stressors may also interact and or act in a cumulative fashion to prolong distress or raise the risk of people developing mental disorders. None of the studies examined the pathways or inter-relationships between the primary and secondary stressors, or between different secondary stressors.
A variety of continuing economic problems may act as secondary stressors following extreme events. They include the loss of income 11,16,22
following loss of employment, and the loss of savings, emergency money or retirement security 11
through having to pay for repairs or recovery. Lack of financial assistance or support to help to improve people’s economic situations 30,34
or loss of financial credit 11
may well contribute to continuing distress and anxiety. These effects have been identified as occurring from as soon as ten weeks to as long as 32 months after an event. A ‘negative perceived impact on finances
’ increased the risk of people developing mental health problems up to six months after a flood in England 31
Loss of employment or ‘livelihood’ 6,10,16,19,22,27,28
, lack of stable employment 11
or employment assistance 10
, along with the loss of farmland 22
, business 16
or tools required for work 11
can also contribute to distress and mental health problems. Parents’ persisting loss of a job was associated with their children developing the symptoms of PTSD 18 months after a hurricane 6
A 'negative perceived impact on house values'
caused by a flood 31
was investigated as a potential secondary stressor. It was not found to have a significant impact on mental health outcomes in that study.
Stress arising from Problems with Compensation.
Problems with applications for financial assistance or compensation through insurers or loss adjustors were highlighted as secondary stressors. People may lack understanding of application processes and the roles, responsibilities and rights of the various parties 34,35
. Often, there is insufficient help or advice in making claims 30,34
, and, at times, conflicting information is given to applicants 35
or problems arise from ‘inconsiderate attitudes
Lack of compensation or insurance payments after an event may also contribute to psychological stress or mental disorders such as depression 16,35
. Secondary stressors include disputes with insurance companies, state grant lenders, and loan providers over applications that were not processed,or were delayed or denied 16,35
. There were reports of lack of satisfaction with insurance payouts 32
or refusals to re-insure properties in high-risk areas in the future 34
. There were also problems with affected people being restricted in purchasing new possessions by the terms of their policies or by a lack of available money 35
. These impacts on income and savings contribute further to future economic insecurity, especially in the event of people being affected by repeated disasters.
Stress arising from Recovery and Rebuilding Homes.
Recovery and rebuilding processes start soon after disasters and may continue for many years. There are numerous secondary stressors that can contribute to people’s distress and mental health problems. Many people lack understanding, information or advice about recovery processes 34,35
. There are reports of continuing lack of essential services such as gas, electricity and water supplies 7,31
and medical services 22
, which may present difficulties.
Often, people who are affected have to contend with continued house damage 6,13,16,19,22,24,37
and some live in temporary accommodation such as caravans or dormitories 16,18,20,22
. Other people experience lack of housing assistance 10
. People who are restoring their homes can come up against difficulties with building contractors. They include delays in the work being done, ‘inconsiderate attitudes’, giving homeowners no control over rebuilding and poor workmanship 35
. Lack of community participation or help in repairing and constructing homes can be a stressor for some people 30
Impact on life in general 28
, such as having to get on with one’s daily routine of work and managing one’s family while dealing with recovery and associated problems 14,35
, are also reported as secondary stressors.
Stress arising from Loss of Physical Possessions or Resources.
Many people experience the loss of their physical possessions and resources such as cars, furniture, home appliances and clothing 11,13,19
. The impact of replacing these items can be substantial, especially if there are delays in payouts from insurance policies or grants, and the sentimental value of some lost or damaged items may make them irreplaceable.
Health problems that have been measured in studies as potential secondary stressors include concerns about the health of self, family and friends 11,13,14,22,31
. Often, we found it difficult to determine if papers were describing new health problems caused specifically by the index event, or a continuation or exacerbation of pre-existing illnesses.
Other problems include lack of access to medical care 10,22
or prescription medication 10
. There are reports of people having problems in gaining access to psychological services such as counselling or therapy for carers, children or families 10
up to one or two years after an event.
Stress relating to Education and Schooling.
The negative impacts of disasters on schooling, study and tutoring have been studied. Some studies looked at the negative impacts on mental health of going to a new school 6
, being displaced from your ‘home university
and losing the opportunity for further education or training 11
. However, two of the papers we identified provided no further explanation of these terms and the lack of detail made it difficult to assess what particular concepts these studies measured 10,28
Stress arising from Media Reporting.
Media coverage after disasters is often extensive. One study 23
found that being exposed to negative media reports of ‘scary or sorrowful stories
’ one month after an earthquake increased the risk of depression and the demand for psychological counselling services.
Changes to the functioning of families following disasters can be problematic, both by eroding the protective or buffering effects that social support has on the effects of adversity, and also by introducing new forms of upsetting experiences. Secondary stressors studied in families include breakdown in relationships, reduced social support from a partner 31
, ‘inter-parental conflict
’, intimate partner abuse 12,26,29
, changes to marital status 14
and ‘negative impacts on family relationships
. Reduced levels of intimacy can occur and they have been measured as ‘negative impacts on sexual activity
or a loss of time spent with loved ones 11,14
Breakdown in household daily activities and functioning 11,14,15,17,28,36
that ordinarily provide stability and routine can also be a secondary stressor. Changes to the composition of households through loss of family members, or having additional family members or friends living with you for some time after an event 6
, further disrupts family life and the perceptions that people have of their families as unified.
A lack of ‘family resilience
’ has also been found to contribute to generating people’s perceptions of distress and mental disorders. The term ‘resilience
’ was used in two papers to describe the ability of families to talk about worries and problems and for members of families to help each other in times of need and adversity 30,36
. It was difficult to determine if a breakdown in resilience occurred as a result of the disaster impacting on otherwise functioning families and was, therefore, a secondary stressor, or if this was a pre-existing vulnerability.
A number of papers that we reviewed reported studies of the negative impacts of psychopathology (such as depression or PTSD) in parents on the emotional and mental health of their children. This can occur either directly 4,15,21,33
or through pathways such as poor parenting practice or verbal and physical abuse 15,17,29,33
Just as family support networks are important in helping people to cope with the stress of extreme events, so too are other social networks and social support. Disruption and breakdown of social networks and relationships with friends, work colleagues and the wider community all contribute as secondary stressors. These concepts have been reported in the literature as ‘negative impacts on friendship
’ or loss of companionship 11,24,28
, changes and disruptions to social networks 14,21,30,36
and lack of social capital 34
. Physical separation from family and friends 6
remains an important stressor even up to 18 months after an event.
Reduced levels of social support, loyalty and mutuality from parents, peers, teachers and the wider community have been highlighted as matters that contribute to mental disorders 7,11,13,15,18,19,20,21,23
. However, the definition of social support varies across the papers we reviewed. Some used validated tools to measure this concept, while others asked a single question or gave no further description of what this term encompassed.
Stress arising from Loss of Leisure and Recreation.
Disruption to leisure and relaxation activities 28
, lack of time for sleep 14
or of free time to spend with families and friends 11
can result from having to spend time and effort organising recovery and rebuilding. Pressure on time can contribute to any existing distress and mental health problems.
Stress related to changes in the view of the world or oneself.
Commonly after a disaster, people may have a range of psychological experiences and they too, may act as secondary stressors and contribute to distress or mental disorders. Psychological problems that have been studied include the feeling of loss of control and agency. Commonly, people may experience feeling reduced levels of independence 11,14
or value to others 11
and feel that they ‘lack control over their environment
’ or ‘predictability over their future
. Some people lose their aspirations for the future. They lack goal setting 11,14
, feel their lives have lost meaning or purpose 11
or they lack optimism about the future 14
Fear of recurrence of the extreme event is another significant issue for many people 22,23,35
especially, for example, when they experience aftershocks following earthquakes or heavy rain after floods.