Confiding in Family Members about Mental and Physical Problems Could Improve the Mental Health of Evacuees: The Fukushima Health Management Survey

doi:10.21203/rs.3.rs-3311955/v1

Background

After the Fukushima nuclear power plant accident in 2011, many victims experienced widespread evacuation away from their hometowns and family separation, affecting community social support. Affected individuals who have no one to communicate their concerns with could be at a high risk of psychological distress. Additionally, their families who provide guidance or encouragement are considered important sources of support. Therefore, we focused on evacuees confiding in family members and aimed to identify their relationship with psychological distress.

Methods

The study was a cross-sectional survey using a self-administered questionnaire for those aged ≥ 16 years. Poisson regression analysis was used to examine the association between psychological distress and having family members to confide in.

Results

The risk ratio (RR) by sex and age group was also examined. A regression analysis showed that the psychological distress of participants was significantly associated with having no family members to confide in, with an RR of 1.33 and a 95% confidence interval (CI) of 1.25–1.42. The RR by sex was 1.40 (95%CI:1.29–1.53) for women and 1.24 (95%CI:1.12–1.37) for men. Among the four age groups (16–25, 26–39, 40–64, and ≥ 65 years), RRs were generally higher in younger age groups (RR: 1.53, 1.88, 1.39, and 1.21; 95%CI: 1.12–2.07, 1.51–2.33, 1.25–1.54, and 1.10–1.33, respectively).

Conclusion

Among evacuees who had access to support, those who did not confide in their families were more likely to have mental health problems. Therefore, early identification of such high-risk individuals can help mitigate them.

community survey

confiding in family members

Fukushima nuclear disaster

high-risk approach

psychological distress

social resource

The Great East Japan Earthquake and the resulting Fukushima Daiichi Nuclear Power Plant accident occurred in 2011. Residents of the Fukushima prefecture experienced a massive evacuation and significant family separation, which affected residents’ social support structure (1). Communities with less capital and resources and with fewer associations between individuals and community organizations have been found to be less resilient to disasters (2, 3). Events that lead to evacuation can make it difficult for evacuees to find someone to share their problems or concerns with. In particular, evacuees who have no one to communicate their challenges experience psychological distress and drinking problems (4). Therefore, having someone to talk to is crucial (5). The individuals who can provide support are close family members, friends, and professional care providers; among them, family is the most important source of informal support both in everyday life and in crises (6). Although support from family members could be obtained incessantly without seeking (7, 8), natural disasters can have a detrimental effect not only on individuals but also on family relationships (9). Evacuees may find it challenging if they cannot confide in family members. In many disasters, families evacuate together and continue their post-disaster lives toward recovery (10, 11); however, in Fukushima prefecture, especially among the younger generation with children, there have been many cases of family separation, with only grandparents and fathers remaining in Fukushima owing to work, school, and radiation concerns(12, 13). Nevertheless, few studies have reported the importance of confiding in family members during disasters in the context of the association with mental health conditions.

We hypothesized that confiding in family members could more positively affect mental health among affected people than consulting with others. This study aimed to clarify the characteristics of the individuals and institutions with whom evacuees communicate their concerns, focusing on family members and the relationship between not confiding in family members and psychological distress. Hence, we used the 2016 data from the prefectural health survey named “the Survey on Mental Health and Lifestyle,” targeting residents aged ≥ 16 years in areas designated as evacuation zones owing to the Fukushima Daiichi Nuclear Power Plant accident. The data were used in a previous study (4), which successfully showed that individuals who had no one to confide in (11.2%) had a significantly higher prevalence of psychological distress and drinking problems and were considered to be high-risk individuals needing early support. Evacuees with no one to consult were more frequently of middle age (40–64 years; odds ratio [OR]: 1.30, 95% confidence interval [CI]: 1.16–1.46), male sex (OR: 2.46, 95% CI: 2.27–2.66), difficult economic situation (OR: 2.11, 95% CI: 1.96–2.27), and living alone (OR: 1.53, 95% CI: 1.39–1.68). Meanwhile, we considered that these findings needed to be reinforced with a more detailed analysis to clarify the differences based on whom individuals consulted or talked to, as well as whether individuals did so. Therefore, we examined the same data as in the previous study as a continuation.

2.1 Participants

This study is a cross-sectional survey, and the data used in this study were obtained from respondents aged ≥ 16 years from the 2016 Fiscal Year Fukushima Prefecture Mental Health Survey on Mental Health and Lifestyle conducted by Fukushima Medical University. The survey was commissioned by the Fukushima prefecture and covered approximately 180,000 residents aged ≥ 16 years living in municipalities encompassing evacuation-ordered zones. Between January and February 2017, we mailed a self-administered questionnaire using a self-addressed envelope. Details have been described in previous studies (14–17). There were 37,530 respondents (response rate: 20.4%), of whom 32,699 were included in the analysis after excluding those with incomplete data (Fig. 1).

2.2 Study variables

2.2.1 Availability of supporting individuals or organizations.

Having someone to consult was the main explanatory variable, which was assessed using the following yes/no question: “When you have a mental or physical problem, do you have someone you can consult with?” Those who responded that they had someone to consult were additionally asked to specifically select whom they communicated from a list of pre-prepared options using a multiple-response format. These options included family, friends/acquaintances, non-psychiatric clinics, local municipal consultation services, psychiatric clinics, colleagues, supervisors, home nursing care/home care service, prefectural consultation services, Fukushima Center for Disaster Mental Health, mental health and welfare centers, religious groups, and others. We defined the results as dichotomous according to whether or not the respondents answered that they confided in family members.

2.2.2 Psychological distress

The outcome variable, psychological distress, was assessed using the K6, a six-item standardized screening measure of non-specific psychological distress over the past 30 days (18, 19). The present study used a cutoff point of ≥ 5 points to identify significant psychological distress, which has been frequently used in previous studies (20–22).

2.2.3 Covariates

The demographic characteristics included in this study were age at the time of the survey, sex, employment status, financial circumstances, residence (inside or outside Fukushima prefecture), problem drinking, history of mental illness, history of lifestyle-related diseases (i.e., hypertension, diabetes mellitus, or hyperlipidemia), living alone, and disaster-related variables (i.e., separation from family members due to evacuation). Problems with drinking were evaluated using the Cut Down, Annoyed, Guilty, and Eye-opener (CAGE) questionnaire (23). Such problems were defined in participants aged ≥ 20 years, who responded “drinking (at least once a month)” as their current drinking frequency, and who had a CAGE score of ≥ 2 (23, 24).

2.3 Statistical design

First, we obtained baseline statistical data on the characteristics of the individuals and support organizations consulted by the participants (Table 1). Next, to explore the characteristics of those who did not confide in family members concerning their problems, we compared the sociodemographic characteristics, medical histories, disaster-related variables, psychological distress, and drinking problems using the chi-square or t-tests (Table 2). Then, we used Poisson regression analysis to examine the association between psychological distress (K6 scale; ≥5 points) as an outcome and having family members to confide in. Bivariate and multivariate analyses were performed after adjusting for sex and age. We adjusted for all covariates except for drinking problems and medical history and considered that living alone would have some effect on confiding in family members; therefore, we added these interaction terms and calculated the risk ratios (RRs; Table 3). Furthermore, we conducted multivariate analyses stratified by sex and four age groups (i.e., 16–25 years, 26–39 years, 40–64 years, and ≥ 65 years; Table 4). Statistical significance was set at p < 0.05. IBM SPSS Statistics for Windows (version 27; Armonk, NY, USA) was used for all the analyses.

Table 1

Characteristics of the individuals and organizations with whom participants communicate their problems
		Total (n = 32,699)
		n	(%)
Having someone to communicate with	Yes	29,049	(88.8)
	Family	25,300	(87.1)
	Friend/Acquaintance	14,309	(49.3)
	Non-Psychiatric Hospitals	7,608	(26.2)
	Local Municipal Consultation Services	6,794	(23.4)
	Psychiatric Hospitals	3,858	(13.3)
	Colleagues/Supervisors	2,982	(10.3)
	Home nursing care/Home care service	1,671	(5.8)
	Prefectural Consultation Services	1,591	(5.5)
	Fukushima Center for Disaster Mental Health	928	(3.2)
	Mental Health and Welfare Center	703	(2.4)
	Religious group	458	(1.6)
	Other	192	(0.7)
	No	3,650	(11.2)

Table 2

Characteristics of participants who have no family members to confide in concerning their problems
		Confide in family members				p*	Cohen's d/φ
		No (n = 3,749)		Yes (n = 25,300)
		n	(%)	n	(%)
Age	Mean (SD)	63.3	(16.7)	61.1	(17.6)	< 0.001	0.129
	16–25 years	167	(4.5)	1,166	(4.6)	< 0.001	0.056
	26–39 years	222	(5.9)	2,704	(10.7)
	40–64 years	1,210	(32.3)	8,237	(32.6)
	≥ 65 years	2,150	(57.3)	13,185	(52.1)
Sex	Men	1,825	(48.7)	10,523	(41.6)	< 0.001	0.048
	Women	1,924	(51.3)	14,777	(58.4)
Employment status	Employed	1,249	(35.5)	8,687	(36.1)	0.425	0.005
	Unemployed	2,274	(64.5)	15,348	(63.9)
Financial circumstances	Difficult	1,438	(39.6)	7,487	(30.5)	< 0.001	0.065
	Good	2,190	(60.4)	17,024	(69.5)
Place of living	Inside Fukushima prefecture	3,282	(87.5)	21,636	(85.5)	< 0.001	0.019
	Outside Fukushima prefecture	467	(12.5)	3,664	(14.5)
Drinking problem	Yes	254	(6.8)	1,310	(5.2)	< 0.001	0.024
	No	3,495	(93.2)	23,990	(94.8)
History of mental illness	Yes	722	(20.3	1,857	(7.6)	< 0.001	0.146
	No	2,841	(79.7)	22,625	(92.4)
History of lifestyle-related diseases	Yes	2,472	(67.5)	15,204	(60.6)	< 0.001	0.047
	No	1,192	(32.5)	9,874	(39.4)
Living alone	Yes	915	(25.7)	3,180	(13.0)	< 0.001	0.120
	No	2,652	(74.3)	21,374	(87.0)
Separation from family	Yes	1,182	(32.9)	7,535	(30.5)	0.004	0.017
	No	2,408	(67.1)	17,134	(69.5)
K6	< 5	1,833	(52.6)	15,911	(65.9)	< 0.001	0.092
	≥ 5	1,650	(47.4)	8,248	(34.1)
n (%), mean (SD), *p-values were determined by the chi-square test or t-test. SD, standard deviation

Table 3

Multivariate Poisson regression analysis showing RRs for the association between psychological distress and having family members to confide in for their problems
		Crude			Full-adjusted
		RR	95% CI	p	RR	95% CI	p
Confide in family members	Yes (Ref)	1.00	-		1.00	-
	No	1.39	1.32–1.46	< 0.001	1.33	1.25–1.42	< 0.001
Age*		1.01	0.998–1.02	0.097	1.01	0.996–1.02	0.154
Sex	Men (Ref)	1.00	-		1.00	-
	Women	1.16	1.11–1.21	< 0.001	1.16	1.11–1.21	< 0.001
Employment status	Employed (Ref)	1.00	-		1.00	-
	Unemployed	1.18	1.13–1.24	< 0.001	1.14	1.09–1.20	< 0.001
Financial circumstances	Good (Ref)	1.00	-		1.00	-
	Difficult	1.75	1.68–1.82	< 0.001	1.72	1.65–1.79	< 0.001
Place of living	Inside Fukushima prefecture (Ref)	1.00	-		1.00	-
	Outside Fukushima prefecture	1.15	1.09–1.21	< 0.001	1.10	1.03–1.16	0.002
Living alone	No (Ref)	1.00	-		1.00	-
	Yes	1.18	1.11–1.24	< 0.001	1.07	0.998–1.14	0.057
Separation from family	No (Ref)	1.00	-		1.00	-
	Yes	1.31	1.26–1.37	< 0.001	1.24	1.19–1.30	< 0.001
Confide in family members × Living alone**		1.43	1.30–1.58	< 0.001	0.95	0.83–1.09	0.457
Note. Poisson regression analysis was used to estimate relative risks and 95% confidence intervals (95% CI), simultaneously controlling for independent variables. Age defined in 10-year increments. *The interaction effect was not significant between “Confide in family members” and “Living alone” for full-adjusted. (RR, risk ratio; Ref, reference)

Table 4

Risk ratios for the association between psychological stress response and having family members to confide in using Multivariate Poisson regression analysis by age/sex group
		Men			Women			16–25 years			26–39 years			40–64 years			≥ 65 years
		RR	95% CI	p	RR	95% CI	p	RR	95% CI	p	RR	95% CI	p	RR	95% CI	p	RR	95% CI	p
Confide in family members	Yes (Ref)	1.00	-		1.00	-		1.00	-		1.00	-		1.00	-		1.00	-
	No	1.24	1.12–1.37	< 0.001	1.40	1.29–1.53	< 0.001	1.53	1.12–2.07	0.007	1.88	1.51–2.33	< 0.001	1.39	1.25–1.54	< 0.001	1.21	1.10–1.33	< 0.001
Age*		0.99	0.97–1.01	0.322	1.02	1.00–1.04	0.014		-			-			-			-
Sex	Men (Ref)		-			-		1.00	-		1.00	-		1.00	-		1.00	-
	Women		-			-		1.21	0.98–1.50	0.075	1.10	0.95–1.27	0.215	1.12	1.04–1.20	0.003	1.18	1.11–1.25	< 0.001
Employment status	Employed (Ref)	1.00	-		1.00	-		1.00	-		1.00	-		1.00	-		1.00	-
	Unemployed	1.18	1.10–1.27	< 0.001	1.12	1.05–1.20	< 0.001	0.94	0.77–1.16	0.579	1.08	0.94–1.242	0.270	1.19	1.11–1.28	< 0.001	1.40	1.28–1.54	< 0.001
Financial circumstances	Good (Ref)	1.00	-		1.00	-		1.00	-		1.00	-		1.00	-		1.00	-
	Difficult	1.82	1.70–1.94	< 0.001	1.65	1.57–1.75	< 0.001	2.04	1.67–2.50	< 0.001	1.69	1.48–1.92	< 0.001	1.63	1.53–1.75	< 0.001	1.75	1.64–1.86	< 0.001
Place of living	Inside Fukushima prefecture (Ref)	1.00	-		1.00	-		1.00	-		1.00	-		1.00	-		1.00	-
	Outside Fukushima prefecture	1.07	0.97–1.18	0.162	1.11	1.03–1.19	0.005	1.01	0.82–1.26	0.901	0.97	0.83–1.13	0.703	1.07	0.98–1.17	0.140	1.16	1.06–1.27	0.001
Living alone	No (Ref)	1.00	-		1.00	-		1.00	-		1.00	-		1.00	-		1.00	-
	Yes	1.05	0.94–1.17	0.370	1.07	0.98–1.16	0.144	1.11	0.87–1.43	0.398	1.51	1.22–1.87	< 0.001	1.10	0.981.23	0.122	0.99	0.90–1.09	0.828
Separation from family	No (Ref)	1.00	-		1.00	-		1.00	-		1.00	-		1.00	-		1.00	-
	Yes	1.23	1.15–1.32	< 0.001	1.25	1.18–1.33	< 0.001	0.96	0.78–1.19	0.713	1.16	1.22–1.877	0.042	1.19	1.11–1.28	< 0.001	1.32	1.24–1.40	< 0.001
Confide in family members × Living alone**		1.05	0.86–1.28	0.612	0.88	0.73–1.05	0.156	1.05	0.61–1.81	0.863	0.69	0.45–1.05	0.085	0.92	0.74–1.14	0.457	0.99	0.81–1.21	0.911
"Note. Poisson regression analysis was used to estimate relative risks and 95% confidence intervals (95% CI), simultaneously controlling for independent variables.
Age defined in 10-year increments. *The interaction effect was not significant between “Confide in family members” and “Living alone” for Full-adjusted. (RR, risk ratio; Ref, reference)

2.4 Ethical considerations

This study was approved by the Ethics Review Committee of Fukushima Medical University (No. 2020 − 239). We informed the participants in writing that their responses would not be published in any way that would identify them. Participants who answered the self-administered questionnaires consented to participate. This study was conducted in accordance with the tenets of the Declaration of Helsinki.

3.1 Characteristics of the individuals and organizations available for supporting evacuees

The results are summarized in Table 1. A total of 29,049 (88.8%) participants had someone to communicate their problems with. The main sources of support were family members (25,300 participants, 87.1%), followed by friends and acquaintances (14,309 participants, 49.3%), and medical institutions such as general physicians and surgeons (7,608 participants, 26.2%).

Table 2 shows the characteristics of participants who had no family members to confide in. Those who responded that they would not confide in family members were older men, in financial difficulty, living inside Fukushima prefecture, having a drinking problem, having a history of mental illness and lifestyle-related diseases, living alone, being separated from their family, and having higher psychological distress (K6 ≥ 5), compared to those who confided in family members.

3.2 Risk ratios for the association between psychological distress and having family members to confide in

Table 3 shows the RRs for the association between psychological distress and having family members to confide in, based on Poisson regression analysis. Multivariate Poisson regression analysis showed that the psychological distress of participants was significantly associated with having no family members to confide in (RR: 1.33, 95% CI: 1.25–1.42). An interaction term between “having family members to confide in” and “living alone” was included in the multivariate analysis; however, we found no significant association.

3.3 Analysis of the risk ratios for the association between psychological distress and having a family member to confide in by sex and age group

We analyzed the RRs for the association between psychological distress and having a family member to confide in by sex and age group using Poisson regression analysis (Table 4). Multivariate Poisson regression analysis adjusted for covariates stratified by sex for psychological distress and confiding in family members showed that women (RR: 1.40, 95%CI: 1.29–1.53) had a higher RR than men (RR: 1.24, 95%CI: 1.12–1.37). The RR values also varied by age group. The 26–39-year age group had the highest RR among the four groups (RR: 1.88, 95%CI: 1.51–2.33), followed by the 16–25-year (RR: 1.53, 95%CI: 1.12–2.07), 40–64-year (RR: 1.39, 95%CI: 1.25–1.54), and ≥ 65-year age groups (RR: 1.21, 95%CI: 1.10–1.33).

In addition, the presence of difficult financial circumstances was associated with psychological distress regardless of age and sex: 16–25 years (RR: 2.04, 95% CI: 1.67–2.50), 26–39 years (RR: 1.69, 95% CI: 1.48–1.92), 40–64 years (RR: 1.63, 95% CI: 1.53–1.75), ≥ 65 years (RR: 1.75, 95% CI: 1.64–1.86); men (RR: 1.82, 95% CI: 1.70–1.94); women (RR: 1.65, 95% CI: 1.57–1.75). Separation from family was also associated with psychological distress except for the 16–25-year age group: 26–39 years (RR: 1.16, 95% CI: 1.22–1.87), 40–64 years (RR: 1.19, 95% CI: 1.11–1.28), ≥ 65 years (RR: 1.32, 95% CI: 1.24–1.40); men (RR: 1.23, 95% CI: 1.15–1.32); women (RR: 1.25, 95% CI: 1.18–1.33). While unemployed status had a significantly negative effect on psychological distress for both men and women (RR: 1.18 and 1.12, 95% CI: 1.10–1.27 and 1.05–1.20, respectively), as well as 40–64 years and ≥ 65 years (RR: 1.19 and 1.40, 95% CI: 1.11–1.28 and 1.28–1.54, respectively), the association was not observed in younger people between the age of 16 and 39. Furthermore, we found that women living outside the Fukushima prefecture (RR: 1.11, 95% CI: 1.03–1.19) and those aged ≥ 65 years (RR: 1.16, 95% CI: 1.06–1.27) and 26–39 years living alone (RR: 1.51, 95% CI: 1.22–1.87) were significantly associated with psychological distress.

This study examined the individuals/institutions consulted by affected people during and after disasters and how the choices could affect their mental health, focusing on their family members. The results showed that those who did not confide in their families were more likely to suffer from psychological distress and were high-risk post-disaster evacuees, as were those who did not have anyone to confide in. According to the results, providing particular services for affected people who do not have family members to confide in is necessary.

The unexpected widespread evacuation of the Fukushima residents caused the separation of many original families and communities. There have been reports of such family breakups caused by great differences in health risk perception of radiation exposure, especially among families having young children (25–27). Additionally, the results suggest that women who did not confide in their families were more vulnerable to disaster stress, and this sex difference is supported by the findings of previous studies (28, 29). In contrast, the results of the analysis by age group were also interesting. The younger the age, the higher the RR of psychological distress among those who were unable to confide in their family members. This result indicates that the younger age group had higher risks of psychological distress when they did not confide in their family members concerning the troubles they faced. Compared to older individuals, younger individuals might be more strongly influenced by their parents and ties (30). In addition, according to the findings of this study, living alone was associated with high psychological distress only for adults aged 26–39 years, suggesting the negative impacts of separation from spouses. Regarding relationships with family members, based on another study (31), some individuals were unable to confide in their family members despite living with their families. Hence, public health nurses and other local care providers need to focus on the quality of actual family relationships (10) rather than consider whether affected people live with their families or not.

Meanwhile, difficult financial circumstances were found to be robust risk factors for psychological distress across different sexes and ages (1, 32). Families facing the financial burden of disasters have been reported to experience increased family conflict (33), and hence, attention should be paid to the financial circumstances of the evacuees. In addition, family separation was associated with psychological distress at the age of ≥ 26 years, with particularly higher RRs among older individuals. We should consider that the impact of family separation due to disasters is stronger among older individuals than younger ones. Furthermore, previous findings (34, 35) have shown that women and older individuals are at higher risk of psychological distress due to repeated shifting and leaving their hometowns (22, 36). This suggests that appropriate care, such as paying attention to the lack or loss of contact with family and community members (37, 38), is needed during and after disasters.

This study had several limitations. First, as this was a cross-sectional study, it was not possible to establish accurate causality. Therefore, there is a need to conduct a longitudinal study to establish a causal relationship. Second, as this study used self-reported data including, mental health conditions, it may be affected by “social desirability”; people might have had hesitation to disclose negative moods and/or emotions due to stigma or shame associated with psychiatric disorders. Third, the response rate in this study was approximately 20%, which may not be representative of the eligible population. Possible reasons for this low response rate could be the lack of time for participants to complete the questionnaire and the high burden on participants due to the length of the questionnaire (39). In addition, in a study examining the response bias in surveys administered after disasters, non-respondents had significantly higher rates of psychological distress than respondents (39). These findings suggest that the results of this survey may have underestimated the psychological distress of the evacuees. Despite these limitations, this is a new finding confirming that the availability of family members can be essential as a part of the whole support system to respond to initial mental health crises after disasters. Finally, in future studies, we will also need to consider the impact on mental health depending on other care resources that affected people could use during disasters.

Using large-scale epidemiological data (the Mental Health and Lifestyle Survey), we examined the association between not confiding in family members and psychological stress responses among affected people from the 2011 Fukushima nuclear disaster. We found that those who did not confide in their problems to their families were more likely to experience psychological stress responses and were a high-risk mental health group in the post-disaster period. Local supporters such as public health nurses, who are trying to care for evacuees directly, are required to understand with whom residents communicate their problems and consider the characteristics of family relationships by investigating whether they can confide in their family members regarding their concerns.

CAGE, Cut down, Annoyed, Guilty, and Eye-opener; CI, confidence interval; RR, risk ratio

Ethics approval and consent to participate

This study was approved by the Ethics Review Committee of Fukushima Medical University (No. 2020-239). We informed the participants in writing that their responses would not be published in any way that would identify them. Participants who answered the self-administered questionnaires consented to participate.

Consent for publication

Not applicable

Availability of data and materials

Requests to access the datasets should be directed to Naoko Horikoshi at [email protected].

Funding

This research was funded by the National “Health Fund for Children and Adults Affected by Nuclear Incidents” (Grant Number: n/a).

Conflicts of Interest

All authors declare no conflict of interest.

Author Contributions

Conceptualization, N. H. and M. M. (Masaharu Maeda); formal analysis, N. H.; project administration, M. M. (Masaharu Maeda) and S. Y.; writing —original draft preparation, N. H. and M. M. (Masaharu Maeda); writing —review and editing, N. H., M. M. (Masaharu Maeda), R. M., H. I., M. M. (Michio Murakami), and S. Y. All authors read and agreed to the published version of the manuscript.

Acknowledgments

We would like to thank the participants who responded the questionnaires.

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No competing interests reported.

Confiding in Family Members about Mental and Physical Problems Could Improve the Mental Health of Evacuees: The Fukushima Health Management Survey

Status:

Version 1

Abstract

Background

Methods

Results

Conclusion

Figures

1 Introduction

2 Materials and Methods