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Journal of Mental Health
ISSN: 0963-8237 (Print) 1360-0567 (Online) Journal homepage: http://www.tandfonline.com/loi/ijmh20
Risk and resilience factors affecting thepsychological wellbeing of individuals deployed inhumanitarian relief roles after a disaster
Samantha K. Brooks, Rebecca Dunn, Clara A. M. Sage, Richard Amlôt, NeilGreenberg & G. James Rubin
To cite this article: Samantha K. Brooks, Rebecca Dunn, Clara A. M. Sage, Richard Amlôt, NeilGreenberg & G. James Rubin (2015) Risk and resilience factors affecting the psychologicalwellbeing of individuals deployed in humanitarian relief roles after a disaster, Journal of MentalHealth, 24:6, 385-413, DOI: 10.3109/09638237.2015.1057334
To link to this article: http://dx.doi.org/10.3109/09638237.2015.1057334
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J Ment Health, 2015; 24(6): 385–413! 2015 Taylor & Francis, LLC. DOI: 10.3109/09638237.2015.1057334
REVIEW ARTICLE
Risk and resilience factors affecting the psychological wellbeing ofindividuals deployed in humanitarian relief roles after a disaster
Samantha K. Brooks1, Rebecca Dunn1, Clara A. M. Sage1, Richard Amlot2, Neil Greenberg1, and G. James Rubin1
1Department of Psychological Medicine, King’s College London, London, UK and 2Emergency Response Department, Health Protection Directorate,
Public Health England, Microbial Risk Assessment and Behavioural Science, Porton Down, Salisbury, Wilts, UK
Abstract
Background: When disasters occur, humanitarian relief workers frequently deploy to assist inrescue/recovery efforts.Aims: To conduct a systematic review of factors affecting the psychological wellbeing ofdisaster relief workers and identify recommendations for interventions.Method: We searched MEDLINE� , Embase, PsycINFO� and Web of Science for relevant studies,supplemented by hand searches. We performed thematic analysis on their results to identifyfactors predicting wellbeing.Results: Sixty-one publications were included. Key themes were: pre-deployment factors(preparedness/training); peri-deployment factors (deployment length/timing; traumatic expos-ure; emotional involvement; leadership; inter-agency cooperation; support; role; demands andworkload; safety/equipment; self-doubt/guilt; coping strategies) and post-deployment factors(support; media; personal and professional growth).Conclusions: As well as role-specific stressors, many occupational stressors not specific tohumanitarian relief (e.g. poor leadership, poor support) present a significant health hazard torelief workers. Humanitarian organisations should prioritise strengthening relationshipsbetween team members and supervisors, and dealing effectively with non-role-specificstressors, to improve the psychological resilience of their workforce.
Keywords
Disaster, humanitarian relief, mental health,psychological impact, relief work
History
Received 25 March 2015Revised 12 May 2015Accepted 24 May 2015Published online 8 October 2015
Introduction
Humanitarian staff deployed overseas in crisis response roles
provide essential support for local populations. While many
emergency responders view work overseas positively
(Hibberd & Greenberg, 2011; Thoresen et al., 2009) some
return with psychological problems (Shah et al., 2007). The
Health and Safety Executive (2007) identified six primary
workplace stressors: work demands; control over work;
support; relationships; role and responsibilities and organisa-
tional change. These stressors can affect employees’ general
and psychological wellbeing. Similar factors may impact on
humanitarian relief workers, although their psychological
wellbeing may well be affected by a combination of
‘‘everyday’’ and role-specific stressors related to performing
challenging tasks in austere environments.
Research on military and civilian deployment following
conflict and civil emergencies has shown a typology of
stressors which have the potential to affect wellbeing (NATO/
EAPC, 2009). While deployment stressors, including threats
to safety and not feeling in control, are difficult to eliminate,
organisations can ensure that staff are properly informed
about them, so they can prepare accordingly. Stressors not
inherent to deployment, but equally detrimental to wellbeing,
may include an absence of role-specific training and poor
leadership/management practices (Williams & Greenberg,
2014). Strong evidence exists of the impact of leader
behaviours upon the mental health of military troops deploy-
ing on high-threat operations (Greenberg & Jones, 2011).
National Institute of Health and Care Excellence guide-
lines (NICE, 2009) for the mental wellbeing of employees
emphasises the importance of promoting a culture of partici-
pation, equality and fairness; flexible working; and a man-
agement style encompassing an open communication style
and provision of regular feedback. These guidelines may
equally apply to the field of humanitarian relief work.
Understanding which factors are most important in promoting
or impairing psychological wellbeing in humanitarian
responders is essential to prepare responders adequately for
the challenges they will face and to help where possible, avoid
exposure to major stressors and to develop interventions to
meet their needs during and after deployment.
In this systematic review we identify risk and resilience
factors which may predict psychological outcomes in
humanitarian relief workers, in order to identify recommen-
dations for interventions for reducing risk and fostering
resilience in disaster relief workers.
Correspondence: Dr. Samantha K. Brooks, Department of PsychologicalMedicine, King’s College London, Cutcombe Road, London SE5 9RJ,UK. E-mail: samantha.k.brooks@kcl.ac.uk
Regarding the terminology used in this review, it should be
noted that ‘‘resilience’’ – generally used to describe the
ability to recover from difficulties – is a term used in varying
ways by different authors, not all of whom describe how they
define the term. What does seem to be agreed upon is that
psychological resilience relates to the adaption of individuals
after trauma, and that certain ‘‘protective’’ factors may
influence the extent to which individuals adapt. Similarly,
‘‘wellbeing’’ may be variably defined in the literature. We
present the term simply as it has been used in the papers
themselves, but it must be considered that different authors
may have defined and measured it in different ways. We hope
that our description of ‘‘measures used’’ for each paper in
Appendix III gives an idea of how resilience and wellbeing
were defined for each paper.
Method
Selection of studies
We limited our search to the following inclusion criteria:
� primary research papers;
� published in peer-reviewed journals;
� English language and
� reporting on factors determining any psychological
outcomes (e.g. stress, wellbeing, mental health disorders,
resilience and personal growth) in humanitarian aid
workers or similar professions deployed to help with the
aftermath of a disaster.
No date restriction was employed.
Conducting the review
We composed a list of terms relevant to wellbeing, covering
both negative and positive health effects (Search 1). We used
the Emergency Events Database (EM-DAT) (Centre for
Research on the Epidemiology of Disasters, 2009) to assem-
ble a list of extreme events, which became Search 2. Our third
search included terms relating to relief work. The full strategy
can be seen in Appendix I.
One author (S.K.B.) conducted a free text literature search
using the databases MEDLINE�, Embase, PsycINFO� and
Web of Science. Resulting citations were downloaded to
EndNote� software version X7 (Thomson Reuters, New
York, New York, USA) and duplicate citations removed.
Based on the inclusion criteria, three reviewers (S.K.B., R.D.,
C.A.M.S.) evaluated the titles of citations for an initial
decision on inclusion or exclusion; irrelevant papers were
removed. Reviewers then screened abstracts for the remaining
citations to evaluate their relevance; any clearly not meeting
the inclusion criteria were excluded. Full-text copies of all
remaining citations were then obtained. Reviewers then read
these papers in their entirety and decided which to include.
We also searched reference lists of key papers for any which
may have been missed in initial searches.
Data extraction and quality appraisal
A standardised process was followed by extracting details
from relevant studies into pre-designed spreadsheets, includ-
ing: year of publication; country participants originated from;
study design; participants (‘‘n’’ and demographic data); type
of disaster and country deployed to; wellbeing outcomes and
how they were measured; predictive factors and how they
were measured; key results; conclusions and limitations.
Following repeated readings of the ‘‘key results’’ column of
our spreadsheet, we used thematic analysis to group predictive
factors into a typology. We accepted as ‘‘themes’’ topics
which had been identified by at least two studies.
We used the Qualitative Research Checklist developed by
the Critical Appraisal Skills Programme (2013) to appraise
qualitative studies’ quality. We assessed quantitative studies’
quality in three different areas: study design; data collection
and methodology and analysis and interpretation of results.
Quality assessment forms for quantitative studies were
designed for the purpose of this review, but informed by
existing quality appraisal tools (Drummond & Jefferson,
1996; Effective Public Health Practice Project, 2009; National
Institute for Health, 2014). Each study was given an overall
score as a percentage, based on the number of ‘‘yes’’
responses to the quality questions.
Results
A total of 5926 citations were identified. After screening,
61 papers remained appropriate for inclusion (see flow chart,
Appendix II). Methodological details for each included paper
are given in Appendix III.
Quality appraisal
The purpose of this review was to identify risk and resilience
factors in order to make recommendations for interventions,
rather than to evaluate the current state of the literature;
therefore, the results focus on the themes emerging from the
literature rather than on the methodological rigour and quality
of studies. However, we did carry out appraisal of the studies
to give an overview of the quality of existing literature.
Individual quality scores for each paper can be seen in
Appendix III.
Though the majority of studies were of high-quality, most
did not explore factors affecting psychological and personal
growth following disaster work in great depth, and the
majority of studies focused on negative outcomes.
Quantitative papers were generally of fairly high quality.
The data presented in Figure 1. show the results of the quality
appraisal.
The majority of papers scored highly, particularly for
methodology. No papers scored below 41% overall. The
median overall percentage was 85.7% (IQR¼ 71.4–93.3).
Figure 2 shows the number of qualitative papers scoring in
different percentage intervals for quality.
Quality of qualitative papers was more inconsistent. The
median score was 76.4% (IQR¼ 55.5–88.9); there were seven
lower-quality papers which scored below 60%. Although the
quality of papers included in the review was fairly high
overall, we found a lack of high-quality quantitative studies
specifically exploring the association between risk and
resilience factors and outcomes. Much of the available
research was qualitative, and many of the survey studies
included open-ended questions and so analysis became
thematic and qualitative in nature. Many quantitative studies
did not explore the association of variables with outcomes,
386 S. K. Brooks et al. J Ment Health, 2015; 24(6): 385–413
instead reporting for example the percentages of respondents
who reported various factors as ‘‘stressors’’. More in-depth
statistical analysis is needed, looking at the relationship
between potentially influential factors and psychological
outcomes. Further research on the themes identified in this
report is needed.
Themes
Table 1 presents an overview of the themes that emerged from
the literature, showing first author and year of publication for
each qualitative and quantitative study which looked at each
theme.
Our results have been grouped into three core themes: pre-,
peri- and post-deployment, with further sub-themes. The key
themes presented below were mentioned by at least two of the
papers included in the review. Appendix IV provides a full
description of which papers explored which themes, and what
they found. Socio-demographic factors are not focused on in
the report, though these are also detailed in Appendix IV.
Pre-deployment
Preparedness and training
Evidence suggested that appropriate training was needed to
equip all DRWs with the skills, knowledge and confidence to
operate under challenging conditions, particularly when they
are required to take control, make decisions and take up
positions of responsibility (Bjerneld et al., 2004; Yang et al.,
2010). Training individuals in how to work as a team in crisis
response environments and having teams train together pre-
deployment appeared to help facilitate collaborative
functioning (Wyche et al., 2011). Ensuring that team mem-
bers were provided with sufficient training and information to
enable them to be emotionally and cognitively ready for the
realities of their work was found to be protective and viewed
as valuable by disaster response workers (DRWs) (Hearns &
Deeny, 2007; Johnson et al., 2005; Wilson & Gielissen,
2004).
Peri-deployment
Deployment length and timing
Findings from Cardozo et al. (2005) indicated a strong
association for international DRWs between the number of
deployments and depression; the risk of depression was
highest on the first mission, decreased for the second and
reached a peak with five or more missions. However,
deployment length was inconsistently related to mental
health: a quantitative study by Perrin et al. (2007) found
that the risk of PTSD increased with the length of time spent
at the disaster site while qualitative reports suggested that
DRWs found shorter deployments more stressful because
workers lacked time to adapt to their surroundings (Bjerneld
et al., 2004).
Traumatic exposure
Unsurprisingly, many papers reported that traumatic exposure
was significantly linked to the mental health of disaster
workers. DRWs in an incident’s epicentre had significantly
higher rates of acute stress disorder, anxiety and depression
(Fullerton et al., 2004). Yokoyama et al. (2014) found that
nurses who witnessed more destruction and death during an
Figure 1. Results of quality appraisal:quantitative studies.
Figure 2. Results of quality appraisal:qualitative studies.
DOI: 10.3109/09638237.2015.1057334 Wellbeing of humanitarian relief workers 387
Table 1. Themes.a
Theme Qualitative evidence Quantitative evidence
Preparedness and training: Preparednessfor the multiple roles and tasks takenon by relief workers/Importance ofboth prior experience and pre-disastertraining
Bjerneld et al. (2004), Hearns & Deeny(2007), Johnson et al. (2005), Norris et al.(2005), Pulido (2012), Stuhlmiller (1994),Weber & Messias (2012), Wilson &Gielissen (2004), Wyche et al. (2011) andYang et al. (2010)
Hagh-Shenas et al. (2005), Lundin &Bodegard (1993), Paton (1994), Perrinet al. (2007), Thoresen et al. (2009),Thormar et al. (2013), Witteveen et al.(2007), and Wyche et al. (2011)
Deployment length and timing: Lengthand frequency of deployments/Whenthey were deployed
Bjerneld et al. (2004) Cardozo et al., (2005), Ehring et al. (2011),Eriksson et al. (2001), Holtz et al. (2002),Perrin et al. (2007), and Yokoyama et al.(2014)
Traumatic exposure: Exposure to death,destruction and grief, as well as toharassment, anger, aggression andassault from victims
Brandt et al. (1995), Putman et al. (2009),Stuhlmiller (1994), Ursano & McCarroll(1990), Wang et al. (2011) and Yang et al.(2010)
Alexander (1993), Cardozo et al., (2005),Chang et al. (2008), Dobashi et al. (2014),Durham et al. (1985), Fullerton et al.(2004), Holtz et al. (2002), Karanci &Acarturk (2005), Marmar et al. (1996),Paton (1994), Thoresen et al. (2009),Thormar et al. (2013), West et al. (2008)and Yokoyama et al. (2014)
Becoming emotionally involved:Secondary traumatisation/Over-identi-fication with victims/Emotionaldistancing
Berah et al. (1984), Brandt et al. (1995),Clukey (2010), Norris et al. (2005), Pulido(2012), Stuhlmiller (1994), Ursano &McCarroll (1990), Wang et al., (2011,2013) and Wyche et al. (2011)
Cetin et al. (2005), Chang & Taormina,(2011), Hodgkinson & Shepherd (1994),Paton (1994), Soliman et al. (1998),Thormar et al. (2013), Wyche et al. (2011)and Zhen et al. (2012)
Leadership: Relationships with super-visors, professional support from lea-ders and organisations/Importance of‘‘reward’’ and recognition in terms ofgood feedback
Bakhshi et al. (2014), Bjerneld et al. (2004),Cox (1997), Hearns & Deeny (2007),Johnson et al. (2005), Stuhlmiller (1994),Wang et al. (2011), Weber & Messias(2012), Wilson & Gielissen (2004), andWyche et al. (2011)
Alexander (1993), Biggs et al. (2014),Cardozo et al. (2005, 2012), Curling &Simmons (2010), Eriksson et al. (2009),Soliman et al. (1998), Thormar et al.(2013), Van der Velden et al. (2012) andWyche et al. (2011)
Inter-agency cooperation: Cultural differ-ences/‘‘Insider vs. outsider’’ dynamics
Berah et al. (1984), Cox (1997), Norris et al.(2005), Wyche et al. (2011) and Yanget al. (2010)
Hodgkinson & Shepherd (1994), Soliman &Gillespie (2011), and Wyche et al. (2011)
Social support: Organisational support/Support from co-workers and peersduring operation/Communication withhome
Bakhshi et al. (2014), Bjerneld et al. (2004),Hearns & Deeny (2007), Moynihan et al.(2005), Norris et al. (2005), Wang et al.(2011) and Wyche et al. (2011)
Biggs et al. (2014), Cardozo et al. (2012),Ehring et al. (2011), Eriksson et al. (2001,2009), Huang et al. (2013), Karanci &Acarturk (2005), Kasperen et al. (2003),Miles et al. (1984), Paton (1994), Van derVelden et al. (2012), West et al. (2008) andWyche et al. (2011)
Formal during- disaster support: Peersupport/Professional support/Counselling
Johnson et al. (2005), Moynihan et al. (2005)and Yang et al. (2010)
Curling & Simmons (2010)
Role: Role clarity, adapting one’s role andresponsibilities in a chaotic situation/Tasks
Bakhshi et al. (2014), Bjerneld et al. (2004),Moynihan et al. (2005), Norris et al.(2005), Pulido (2012), Wyche et al. (2011)and Yang et al. (2010)
Paton (1994) and Soliman et al. (1998)
Demands, workload and long hours:Workload, demands and exhaustion/Resources/Long hours
Bakhshi et al. (2014), Bjerneld et al. (2004),Cox (1997), Hearns & Deeny (2007),Norris et al. (2005), Putman et al. (2009),Stuhlmiller (1994), and Wang et al. (2011)
Biggs et al. (2014), Curling & Simmons(2010), Paton (1994), Putman et al.(2009), Soliman & Gillespie (2011),Thormar et al. (2013), and Yokoyamaet al. (2014)
Safety and equipment: Sense of personalvulnerability/Safety concerns/Concerns over equipment and facilities
Bakhshi et al. (2014), Clukey (2010), Hearns& Deeny (2007), Johnson et al. (2005),and Yang et al. (2010)
Huang et al. (2013), Karanci & Acarturk(2005), Kenardy et al. (1996), Marmaret al. (1996), Miles et al. (1984), Paton(1994), Perrin et al. (2007), and Thormaret al. (2013)
Self-doubt and guilt: Doubting one’s selfand actions/Guilt and blame
Bakhshi et al. (2014), Brandt et al. (1995),McCormack & Joseph (2013), Pulido(2012), and Stuhlmiller (1994)
Ehring et al. (2011), Marmar et al. (1996),Miles et al. (1984), and Wilkinson (1983)
Coping strategies: Negative coping/Talking and writing/Relaxation/Redefining experience in positive ways
McCormack & Joseph (2013), Norris et al.(2005), Stuhlmiller (1994), Wang et al.(2011, 2013), and Wyche et al. (2011)
Chang et al. (2008), Curling & Simmons(2010), Huang et al. (2013), Karanci &Acarturk (2005), Miles et al. (1984), Paton(1994), Wilkinson (1983), and Wycheet al. (2011)
Formal post-disaster support: Peer sup-port/Professional support/Counselling/Debriefing
Bakhshi et al. (2014), Bjerneld et al. (2004),Hearns & Deeny (2007), McCormack &Joseph (2013) and Stuhlmiller (1994)
Durham et al. (1985), Kenardy et al. (1996),Van der Velden et al. (2012) and Wu et al.(2012)
Media: Media coverage of disaster/Publicity
Bakhshi et al. (2014), Norris et al. (2005) Miles et al. (1984), Nishi et al. (2012), andPaton (1994)
(continued )
388 S. K. Brooks et al. J Ment Health, 2015; 24(6): 385–413
incident had lower mood, worse sleep and more intense
fatigue than nurses who had less traumatic exposure. Dealing
with dead bodies either as a primary role, or encountering
them in another way, appeared be a strong significant risk
factor for psychological distress and post-traumatic stress
responses (Dobashi et al., 2014). Exposure to local and
survivor hostility, lack of gratitude and aggression were
sources of stress in DRWs (Thormar et al., 2013; Wang et al.,
2011).
Becoming emotionally involved
Many studies reported participants becoming ‘‘emotionally
involved’’ (often over-involved) in the disaster, and secondary
or vicarious traumatisation (generally defined as experiencing
similar symptoms to trauma victims as a result of indirect
traumatic exposure via close contact with the survivors;
Figley, 1995) was common. Hodgkinson & Shepherd (1994)
found that workers with a high level of identification with
survivors had significantly more intrusive thoughts and scored
higher on an obsessive/compulsive scale. Many studies
reported DRWs repeatedly re-living the disaster experience,
feeling a sense of ‘‘knowing the victim’’ and imagining their
loved ones in such situations (Cetin et al., 2005; Paton, 1994;
Pulido, 2012; Soliman et al., 1998; Thormar et al., 2013;
Ursano & McCarroll, 1990).
Several studies’ results emphasised the need to keep
professional and psychological distance (Brandt et al., 1995;
Norris et al., 2005) and suppress grief (Wang et al., 2013).
Indeed several studies found that emotional distancing and
repression were used as coping strategies by relief workers
(Stuhlmiller, 1994; Wang et al., 2011). However, one
quantitative study (Zhen et al., 2012) showed that avoidance
of traumatic thoughts during a disaster was predictive of
traumatic stress, perhaps suggesting a need for acceptance
rather than avoidance.
Leadership
Poor leadership was described as including ad hoc planning
(Hearns & Deeny, 2007); poorly planned work and schedules
(Bjerneld et al., 2004); lack of guidance in terms of roles and
boundaries (Soliman et al., 1998) and a lack of concern for
staff’s welfare needs (Johnson et al., 2005). Poor organisa-
tional support was significantly associated with increased
likelihood of depression post-deployment in international
DRWs (Bjerneld et al., 2004; Cardozo et al., 2005), while
good organisational support and sensitive staff management
practices were demonstrated to contribute to the positive
occupational health of body handlers (Alexander, 1993).
Leaders who gave good feedback and were perceived as
recognising workers’ efforts were viewed more positively;
lack of recognition in efforts and feeling undervalued were
considered stressors (Cox, 1997; Curling & Simmons, 2010),
particularly for those working in small organisations (Weber
& Messias, 2012).
The effects of involvement and support from all levels of
management were also felt. Lack of coordination and
communication among government officials, employees and
volunteers led to frustration, job overload and stress (Bakhshi
et al., 2014; Wang et al., 2011; Weber & Messias, 2012),
while for some DRWs organisational headquarters were
perceived as not fully understanding the reality of the
worker’s environments (Hearns & Deeny, 2007) and were
viewed as being only involved superficially and for bureau-
cratic procedures (Wilson & Gielissen, 2004).
Inter-agency cooperation
Lack of inter-agency cooperation was also a stressor; several
studies noted tension and rivalry between agencies, secrecy of
information, cultural differences and ‘‘insider vs. outsider’’
dynamics (Berah et al., 1984; Hodgkinson & Shepherd, 1994;
Yang et al., 2010). Norris et al. (2005) reported local
professionals appearing to have a sense of ‘‘ownership’’
over the disaster; the involvement of ‘‘outsiders’’ was seen to
imply a lack of ability of the local community to self-manage
the situation leading to resentment unless they were seen as
playing a supporting role to local leadership.
Social support
Social support was predictive of wellbeing. After adjusting for
all other study variables, Cardozo et al. (2012) found that
social support was significantly associated with lower levels
of depression, psychological distress, burnout and lack of
Table 1. Continued
Theme Qualitative evidence Quantitative evidence
Personal and professional growth:Rewarding experience/Feeling ofhaving made a contribution/accom-plishment/Re-evaluation of self and themeaning of life/Increased understand-ing/Feeling more educated and able toassist in future relief work
Bakhshi et al. (2014), Berah et al. (1984),Moynihan et al. (2005), Putman et al.(2009), Shih et al. (2002), Wang et al.(2013), Yang et al. (2010) and Zinsli &Smythe (2009)
Alexander (1993), Cardozo et al. (2012),Chang & Taormina, (2011), Miles et al.(1984), Putman et al. (2009), Solimanet al. (1998), and Thoresen et al. (2009)
Socio-demographic characteristics andpre-/post-disaster experiences:Gender/Age/Ethnicity/Family andrelationships/Educational background/Pre-deployment mental health/Previous experience and exposure/Having a family member injured/Post-disaster life events
Putman et al. (2009) Cardozo et al. (2005, 2012), Dobashi et al.(2014), Ehring et al. (2011), Eriksson et al.(2001), Fullerton et al. (2004),Hodgkinson & Shepherd (1994), Holtzet al. (2002), Musa & Hamid (2008),Putman et al. (2009), Soliman et al.(1998), Thormar et al. (2013), West et al.(2008), Wilkinson (1983), Witteveen et al.(2007) and Zhen et al. (2012)
aSome studies used mixed-methods and therefore may appear in both columns.
DOI: 10.3109/09638237.2015.1057334 Wellbeing of humanitarian relief workers 389
personal accomplishment and greater life satisfaction.
Perceived social support from colleagues appeared to mitigate
the effect of traumatic exposure on symptoms of stress (Biggs
et al., 2014; Kasperen et al., 2003) and correlate with post-
traumatic growth (Karanci & Acarturk, 2005). Qualitative
studies showed that on return from their missions, DRWs
recommended that the pre-departure team building would
usefully foster resilience when in the disaster area (Norris
et al., 2005; Paton, 1994).
There were mixed findings regarding the impact of social
support from friends and family via communication with
home. Infrequent contact with family and perception of
communication facilities as poor were associated with stress,
depression and isolation (Bjerneld et al., 2004; Cardozo et al.,
2005; Hearns & Deeny, 2007; West et al., 2008). However,
another study (Bakhshi et al., 2014) found that contact with
friends and family could be stressful, as home-based loved
ones worried when they became aware of incidents through
media reporting.
Formal during-disaster support
During-disaster support (including support from peers and
professionals/counsellors) was generally viewed as desirable,
though often lacking. Many participants felt that there was a
lack of appropriate clinical and other supportive services
(Moynihan et al., 2005); one study found that occupational
health support and policies for non-uniformed workers were
not seen as equal to those provided for first responders/
uniformed services (Johnson et al., 2005). The availability of
on-site professional psychological counsellors or stress man-
agement workshops was generally seen as helpful (Curling &
Simmons, 2010; Yang et al., 2010).
Role
Although disaster workers may be assigned to specific roles
within the disaster response, lack of clarity around tasks and
role expectation was a considerable source of stress. Notably
role ambiguity appeared to be more problematic in the early
stages of disaster work due to the chaotic aftermath of
traumatic events; roles and tasks often appeared to ‘‘fall into
place’’ with time (Bakhshi et al., 2014). Employer and role
flexibility are considered essential in order to accommodate
for changing needs and to foster resilience (Paton, 1994;
Pulido, 2012; Wyche et al., 2011). A strong ‘‘chain of
command’’/line management structure was believed to reduce
confusion in such situations (Norris et al., 2005).
Demands, workload and long hours
The high demands of the job, in terms of workload,
complicated tasks and long hours were associated with
stress and poor wellbeing. Putman et al. (2009) found that
emotional exhaustion was a significant predictor of PTSD.
Soliman & Gillespie (2011) found that complicated tasks,
high expectations and excessive demands led to stress,
particularly when associated with inadequate resources.
Biggs et al. (2014) also reported that job resources played a
role in the stressor-strain process after unpredictable and
emotionally challenging work demands. Many papers
reported that time off while deployed was essential for
maintaining emotional stability and being able to distance
oneself from the work (Bakhshi et al., 2014; Stuhlmiller,
1994), limiting daily working hours and a need for adequate
staff-to-work ratios (Norris et al., 2005).
Safety and equipment
Many study participants felt concerned about personal safety,
poor living conditions and inadequate equipment: all could
induce a sense of vulnerability (Clukey, 2010; Hearns &
Deeny, 2007; Paton, 1994; Thormar et al., 2013; Yang et al.,
2010). Anxiety and PTSD symptoms were found to increase
in relation to not feeling enough safety measures were in place
and fearing for one’s own safety (Miles et al., 1984; Thormar
et al., 2013); however, contact with and reassurance from
seniors could be helpful in alleviating these fears (Bakhshi
et al., 2014). DRWs with PTSD were more likely to report
near-death experiences, severe injury or severe mental trauma
(Huang et al., 2013).
Self-doubt and guilt
Several studies found that DRWs commonly experienced
feelings of self-doubt, self-blame and guilt. Many participants
reported wanting to have done more to relieve suffering and
felt helpless, frustrated and reported themselves ‘‘failing’’
victims as they could not meet all of their needs (Miles et al.,
1984; Pulido, 2012; Wilkinson, 1983); blaming oneself for
not being able to help more was significantly associated with
increased psychological distress (Ehring et al., 2011).
McCormack & Joseph (2013) reported that workers doubted
their own actions, especially when having to prioritise their
own safety over others, which led to shame and fear of being
judged.
Coping strategies
Many studies reported on a range of coping behaviours
employed by DRWs. Negative coping strategies included
increased use of tobacco, alcohol, caffeine, tranquilisers and
medication (Curling & Simmons, 2010; Miles et al., 1984),
while positive strategies included talking, writing, massage
and deep breathing (Miles et al., 1984; Norris et al., 2005).
Other positive strategies included returning to work, finding
meaning and purpose in their life and work, and compart-
mentalising things outside of one’s control (McCormack &
Joseph, 2013; Wang et al., 2011; Wilkinson, 1983). Chang
et al. (2008) found that the strategies mentioned above
positively modified the effect of disaster related exposures on
psychiatric morbidity.
Post-deployment
Formal post-deployment support
Several studies reported poor re-adjustment into home,
society and work environments and a need for support
programmes (Bakhshi et al., 2014; Hearns & Deeny, 2007).
Lack of support, criticism, indifference, disinterest or
being told to ‘‘get on with life’’ by colleagues and family
members once home led to feelings of anger, betrayal,
disconnection and lack of validation, often leading to poor
390 S. K. Brooks et al. J Ment Health, 2015; 24(6): 385–413
reintegration (McCormack & Joseph, 2013). Some partici-
pants felt that their organisation should automatically pro-
vide debriefing, not only when requested (Bjerneld et al.,
2004). Group debriefings, however, were seen as stressful
(Stuhlmiller, 1994). Training in Trauma Risk Management
(TRiM; Greenberg et al., 2008) was reported by participants
as helpful post-disaster in one study (Bakhshi et al., 2014).
Media
Publicity and media coverage of the disaster were often
perceived as being stressful and post-disaster was reported to
be a significant stressor and trigger of disaster recall (Miles
et al., 1984; Paton, 1994). Criticism from the media was often
taken personally and participants suggested that training how
to deal with the media would be helpful (Bakhshi et al., 2014;
Norris et al., 2005).
Personal and professional growth
Several studies reported evidence of psychological growth,
with participants feeling they had, personally and profession-
ally, benefited from the experience. Many participants viewed
the experience as rewarding, in terms of feeling they had made
a contribution; personal accomplishment; and consequent
improved confidence and self-esteem, increased compassion,
and re-evaluation of the self and meaning of life (Bakhshi et al.,
2014; Soliman et al., 1998; Wang et al., 2013; Yang et al.,
2010). Humanitarian concern, work satisfaction and the feeling
of ‘‘giving back’’ were motivators. Levels of perceived
personal accomplishment were inversely related to PTSD
(Putman et al., 2009), and associated with higher levels of
resilience and lower levels of secondary trauma and burnout
(Chang & Taormina, 2011). However, one quantitative paper
(Cardozo et al., 2012) found that a reportedly ‘‘better’’
experience and more positive evaluation of work was signifi-
cantly associated with higher anxiety and burnout possible
from participants being overinvolved by working as a DRW.
Socio-demographic characteristics and pre-/post-deployment experiences
Several quantitative studies examined various socio-
demographic characteristics and experiences both pre- and
post-deployment as predictors of psychological outcomes.
The literature yielded mixed results on the effects of
demographic variables on psychological outcomes.
Generally, younger age was associated with poorer outcomes,
though there was more ambiguity surrounding other charac-
teristics. Details can be seen in Appendix IV.
Discussion
The results of this review suggest that factors before, during
and after deployment affect DRWs’ mental health. An
understanding of these factors is likely to be useful to
organisations that deploy DRWs in order to ensure they are
appropriately prepared for and supported on deployment as
well as cared for post-deployment to ameliorate the negative
impact of disaster work.
Pre-deployment DRWs are likely to benefit from being
prepared for the tasks they will undertake in the aftermath of a
crisis. Such training should be backed up by relevant
handbooks and guidelines for DRWs to refer to. An emotional
preparation component may be useful as part of this pre-
disaster training to develop resilience, possibly including
specific training to cope with exposure to tragedy. Workers
should also be prepared for potential hostility and lack of
gratitude from survivors. Training should also be evidence-
based and cover the range of psychological responses to
trauma and vicarious trauma management.
Evidence regarding the impact of the length and frequency
of deployments on workers’ mental health was inconsistent.
While some studies suggest longer deployments increased the
risk of adverse psychological health effects (Ames et al.,
2007; Hibberd & Greenberg, 2011; McCarroll et al., 2000),
possibly as a result of increased exposure to an accumulation
of highly challenging exposures, other findings on this topic
have been less consistent. Thus further research on the impact
of deployment length and frequency is required. However,
studies have shown that initial deployments are the most
challenging, and that first time deployees are particularly
vulnerable (Adler et al., 2005; Huffman et al., 1999). Being
deployed with a supportive and experienced team may
be a particularly important protective factor in these
circumstances.
Several studies report that DRWs can potentially become
‘‘emotionally involved’’ with their work placing them at risk
of over-identification with survivors and secondary trauma-
tisation. While distancing was often cited as a useful coping
strategy in the immediate aftermath, this is often difficult to
do and may lead to suppressed feelings surfacing at a later
time. Time to discuss and ‘‘make sense’’ of emotions after the
event would be useful. Wilson & Gielissen (2004) recom-
mended that a degree of secondary traumatisation is a
‘‘normal reaction to an abnormal situation’’. Thus becoming
emotionally involved should perhaps be something workers
learn to accept as ‘‘normal’’ and manage, rather than avoid.
Organisations could consider implementing this into training
programmes, perhaps drawing from the type of training and
supervision that therapists and counsellors have to help them
cope with potential secondary traumatisation (Wesson et al.,
2013).
Poor leadership was reported as a stressor in several
studies suggesting a need for leaders to be supportive, clear in
their directions and feedback and have good relationships with
their subordinates. DRW supervisors should be especially
adept at leading in challenging environments and be able cater
for their staff’s mental health needs. We suggest that
organisations establish training programs to enhance leader-
ship skills, ensuring supervisors are trained in management as
well as leadership. It is also important that leaders should be
appropriately experienced; similarly at least some members of
the team should be able to provide support and advice to
inexperienced workers. Lack of recognition of efforts was a
stressor; this provides some support for the effort-reward
imbalance model of occupational stress (Siegrist, 1996) which
suggests that a reciprocal relationship is needed between
effort (required to meet job demands) and rewards (in terms
of money, esteem, career opportunities, positive feedback or
feeling valued) at work. It may be that more focus on
‘‘reward’’ in terms of positive feedback from leaders could
bolster the wellbeing of employees.
DOI: 10.3109/09638237.2015.1057334 Wellbeing of humanitarian relief workers 391
Inter-agency cooperation was a frequent stressor, with
‘‘insider versus outsider’’ dynamics prevalent. Our findings
suggest that ‘‘outsiders’’ (i.e. those non-local deployed
DRWs) need to be seen as supporting local agencies rather
than competing with them. Efforts to minimise rivalries,
perhaps by encouraging different agencies to focus on joint
goals, may be helpful. Future research might consider
exploring various different groups of relief workers and
their relationships with local agencies; those with more
positive relationships could be examined in more detail to
ascertain exactly what constitutes a ‘‘good’’ inter-agency
relationship and how to best foster one.
We found that poor intra-team support was a risk factor for
poor mental health. This supports previous literature relating
to the psychosocial impact of individuals’ exposure to
adversity, conflict, violence and hardship, which suggests
strong social networks and support are important in fostering
resilience (Williams & Greenberg, 2014). Future studies
should investigate how best to build and maintain cohesion
between team members. There may be utility in ensuring that
pre-deployment skills and procedural training may also
provide opportunities for DRWs to learn effective ways of
helping and supporting their peers. Leaders should also be
aware of the benefits of fostering social support by
encouraging teamwork among workers.
Poor facilities to communicate with home can lead to
stress; however, communication with home can also be
stressful in itself due to family and friends being worried after
having seen dramatic media reports, and putting pressure on
workers to return home. This supports previous research such
as a study by Mulligan et al. (2012) of British military
personnel serving in Iraq and Afghanistan, who found that
difficulties communicating with home were associated with
PTSD symptoms and common mental disorders. Overall, it
appears that it would be helpful for adequate facilities for
communicating with home to be in place for those who do
wish to use them, and personnel could be taught specific
strategies for dealing with various mediums of communicat-
ing with friends and family.
Due to the unpredictable and ever-changing nature of
disaster roles, workers often reported lack of role clarity and
being put in positions of responsibility when they were not
expecting to be. Due to the nature of disaster relief work, it
may not be possible to ensure that roles are consistent and
clarified at all times, but managers and organisations can
ensure that personnel are helped to set, and reset, their
objectives as a deployment develops and to set as clear goals
for DRWs as possible.
We found evidence that the high demands of the job such
as workload and long hours, particularly when coupled with
lack of resources, had a negative psychological impact. The
job demands–resources model (Demerouti et al., 2001), which
categorises working conditions as demands (aspects requiring
effort or skills) or resources (aspects which may help to
achieve goals or lessen demands), may offer a useful
framework for identifying aspects of the work environment
needing to be better managed. The literature reviewed here
suggests that appropriate training and preparedness and
support from colleagues and management are particularly
valuable resources. Shift rotations and sharing of workload to
enable shorter exposure time would be beneficial where
possible. DRWs should be encouraged to take breaks without
feeling guilty, and to engage in recreation during breaks.
While shortening working hours may be challenging with
limited available manpower, if long hours are essential,
promoting camaraderie between team members so the risks
of work overload and long hours are minimised is especially
important.
Concerns about safety and equipment were also prominent
issues, with poor living conditions, inadequate equipment and
a sense of being in personal danger leading to feelings of
vulnerability. While DRWs cannot be guaranteed an entirely
safe working environment, our results suggest that organisa-
tions are likely to help their staff by taking steps to ensure that
their safety is being taken as seriously as it can be. Provision
of adequate supplies and equipment is essential for both
physical and psychological health. Ensuring that senior staff
are available to talk to and reassure workers about the steps
taken to ensure their personal safety may be helpful. The
safety of deployed workers can also be threatened by
harassment and violence from survivors. The current
‘‘Health Care in Danger’’ project (International Committee
of the Red Cross International Committee of the Red Cross,
2015) concerning the protection of deployed humanitarian
and healthcare personnel, aims to address this, proposing
development of a domestic legal framework to monitor and
protect the safety of deployed workers.
Feelings of self-doubt, guilt and blame were common:
doubting one’s self and actions can lead to self-blame, and
learning to view the experience as meaningful and drawing
from the positives are important. This often happens naturally
with time and distance from an incident but can be delayed
due to lack of support from colleagues, family members and
peers on return home; it is therefore essential that support
networks are in place when DRWs return home.
Provision of during, and post-disaster, support was viewed
as desirable though often lacking. There was, however, some
evidence which suggested immediate psychological debrief-
ing was unhelpful. This fits with National Institute for Health
and Care Excellence (NICE) guidelines for PTSD which state
that individual debriefing sessions focusing on the traumatic
incident should not be part of routine practice (NICE, 2005).
However, our findings suggest that most DRWs desired some
kind of post-disaster support. On return home, many partici-
pants reported needing time to adjust and re-integrate and felt
that support throughout this process would be helpful.
Participants of several studies noted a lack of validation and
support from peers on returning home, which could be
distressing: while organisations cannot wholly determine the
response of family members, friends and colleagues, they
could provide education or support to the family members
themselves or compensate for potential lack of support in this
area by ensuring that validation and support are provided by
managers. Post-mission support should encourage workers to
redefine their experience in positive ways, for example, using
it to find meaning and purpose in their life, re-evaluate one’s
self and goals or focus on the positives such as professional
growth. Thus, instead of non-evidence based psychological
debriefing, we suggest that DRWs who desire, or need,
support access it from organisationally aware psychological
392 S. K. Brooks et al. J Ment Health, 2015; 24(6): 385–413
support from line managers or possibly from in-house
counselling/therapists. TRiM (Greenberg et al., 2008), a
trauma-focused peer support system originating in the mili-
tary and since adopted by many organisations including
media companies, emergency services and the National
Health Service may also be a useful support mechanism.
TRiM has been found to be associated with reduced
sickness absence after a traumatic event and may lessen
some of the negative effects of high trauma exposure (Hunt
et al., 2013).
Finally, publicity and the media are often perceived as
being stressful, especially in terms of media criticism and
demands for information; over-exposure to the media may
also worsen the feeling of being emotionally involved. Over-
exposure to disaster media coverage should be avoided to
foster relaxation and allow workers to keep ‘‘distance’’ from
their work.
Results on the effect of socio-demographic or pre-disaster
factors on wellbeing were inconsistent, and do not appear to
imply that any particular screening processes would be useful.
This supports previous literature that there is little value in
pre-deployment screening processes based upon psychometric
testing or profiling. Brewin et al. (2000) suggest that the
extent to which traumatic exposure impacts on wellbeing
depends more on the availability of good social networks than
it does on the personal histories, attitudes and capacities of the
individuals, while Rona et al. (2006) suggest that screening in
the Armed Forces is not only ineffective but has the potential
to exclude perfectly capable and resilient candidates and
provide false reassurance that individuals will remain resilient
no matter what they are exposed to.
In summary, we found many non-disaster-specific occu-
pational stressors (such as overwhelming demands, limited
resources, lack of training, poor leadership and poor support
networks) that were relevant and amenable to modification.
While direct exposure to traumatic events is impossible to
prevent, training, preparedness and the support received
during and after the mission can be improved. Taken together,
the results of the review suggest that preparedness and support
are of particular importance, both of which can be improved
through good leadership.
Limitations
This review yielded mainly studies from North America.
Future reviews could consider translating foreign-language
papers to explore whether similar stressors are discussed.
The majority of the papers included in this review, which
were qualitative or cross-sectional. Concepts (such as ‘‘resili-
ence’’ and ‘‘wellbeing’’) may be defined differently by
different authors, and this should be kept in mind when
considering the overall findings.
Implications for researchers
More prospective and longitudinal studies are needed to
consider directionality of effects and clarify the influence of
stressors or protective factors. Further in-depth quantitative
considering the relationships between variables rather than
merely the numbers of participants citing certain events as
stressors would be useful.
Implications for DRWs
The results of this review demonstrate that the potential for
stress prevention measures to be incorporated into disaster
relief work. We have used the findings to develop a guideline
of recommendations for reducing risk and fostering resilience
in DRWs. Interventions which appear the most likely to make
a difference include:
� Systematic, educational training programmes pre-
deployment, emphasising both psychological and phys-
ical preparedness.
� Making appropriate guidelines, handbooks and policy
documents available, particularly for workers going on
their first deployment.
� Dedicated training programmes and management courses
for those in supervisory roles.
� Regular manager–employee feedback, ensuring that good
work is ‘‘rewarded’’ with positive feedback and
encouragement.
� Training to build and maintain cohesion between team
members, incorporating awareness of the psychological
challenges of humanitarian work.
� Establish and emphasise joint goals to encourage
teamwork.
� Training in effective ways of supporting other team
members.
� Other, perhaps less important but still potentially helpful
interventions might include:
� Increased communication with other agencies; encour-
agement to focus on a joint goal.
� Identification of personnel with poor support networks at
home; ensure this vulnerable group have good support
from professionals, both during and post-disaster.
� Additional training in skills for dealing with the media.
� Encouraging talking, sharing and other relaxing or
expressive outlets.
� Ongoing non-judgmental support groups allowing for the
sharing of experiences and opportunities for discussion
and education about emotional responses to disasters.
� Interventions to promote positive thinking and teach
appropriate coping strategies such as acceptance or
redefining the experience in positive ways.
� Education about the potential risks of the job and
training in relaxation, problem-solving and self-care
behaviours.
� Interventions aimed at improving psychosocial skills, e.g.
skills in supporting colleagues.
� Interventions aimed at improving self esteem and self
efficacy.
While certain disaster-related stressors cannot easily be
changed, such as exposure to traumatic events and developing
a degree of emotional attachment to victims/survivors,
organisations can work with their employees to ensure that
they are properly supported, their concerns are listened to and
they are taught evidence-based approaches to cope with their
anxieties.
Acknowledgements
The authors gratefully acknowledge Professor Til Wykes and
Dr. Alison Beck for their guidance on the search strategy.
DOI: 10.3109/09638237.2015.1057334 Wellbeing of humanitarian relief workers 393
Declaration of interest
Financial support from Service User Research Enterprise,
Institute of Psychiatry, King’s College London/National
Institute for Health Research Health Protection Research
Unit National Institute for Health Research Health Protection
Research Unit. N.G. runs a small company providing
psychological support to trauma-exposed organisations and
is President of the UK Psychological Trauma Society. The
research was funded by the National Institute for Health
Research Health Protection Research Unit (NIHR HPRU) in
Emergency Preparedness and Response at King’s College
London in partnership with Public Health England (PHE).
The views expressed are those of the author(s) and not
necessarily those of the NHS, the NIHR, the Department of
Health or Public Health England.
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DOI: 10.3109/09638237.2015.1057334 Wellbeing of humanitarian relief workers 395
Appendix I. Search strategy
Search: EMBASE 1980–2015; EMBASE 1974–1979; EMBASE Classic 1947–1973; Ovid Medline 1946–2015; PsycINFO 1806–2015; Web ofScience.
Search 1 (psychological wellbeing)
Well?being; anxiety; panic; post?traumatic stress; PTSD; stress; ‘‘mental health’’; depress*; neurosis; adjustment disorder*; distress; psychological;resilience; coping; ‘‘mental disorder*’’; ‘‘positive psychology’’; ‘‘satisfactory life’’; mindfulness; flourish; pleasure; flow; growth¼COMBINE WITH OR
Search 2 (disasters)
Anthrax; avalanche; avian influenza; bioterrorism; bird flu; blizzard; bomb*; chemical spill; Chernobyl; cyclone; drought; disaster*; earthquake;Ebola; emergenc*; explosion; fire; Fukushima; H1N1; H5N1; hurricane; industrial accident; landslide; massacre; mass killing; MERs; Middle Eastrespiratory syndrome; pandemic; nuclear radiation; radiological; SARs; severe acute respiratory syndrome; September 11th; shooting*; storm; swineflu; terroris*; Three Mile Island; tidal wave; tornado; tsunami; typhoon; volcanic eruption; volcano; World Trade Center.¼COMBINE WITH OR
Search 3 (humanitarian work)
Humanitarian; relief work*; ‘‘disaster aid’’; ‘‘disaster planning’’; ‘‘aid agencies’’; ‘‘aid agency’’; ‘‘emergency relief’’; ‘‘disaster relief’’; ‘‘disasterrecovery’’; ‘‘aid work’’*¼COMBINE WITH ORCombine Search 1 AND Search 2 AND Search 3LIMIT TO: Human studies, English language
Appendix II. Flow diagram
Records iden�fied through database searching
n = 5895
Addi�onal records iden�fied through other sources
n = 31
Total records foundn = 5926
Duplicates removedn = 2609
Titles screenedn = 3317
Abstracts screenedn = 1433
Full-text ar�cles assessed for eligibility
n = 162
Studies included in review n = 61
Excluded a�er �tle screening n =1884
Excluded a�er abstract screening n = 1271
Excluded a�er full-text screening
n = 91; Full text unavailable
n = 10
396 S. K. Brooks et al. J Ment Health, 2015; 24(6): 385–413
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DOI: 10.3109/09638237.2015.1057334 Wellbeing of humanitarian relief workers 397
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398 S. K. Brooks et al. J Ment Health, 2015; 24(6): 385–413
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(co
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DOI: 10.3109/09638237.2015.1057334 Wellbeing of humanitarian relief workers 399
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aN
ort
hS
eaO
ilE
xp
losi
on
&C
lap
ham
Rai
lC
rash
–U
K
So
cial
Rea
dju
stm
ent
Rat
ing
Sca
le;
Ho
pk
ins
Sy
mp
tom
Ch
eck
list
;P
sych
olo
gic
alW
ellb
ein
gS
cale
;m
od
ifie
dP
erso
nal
Har
din
ess
Sca
le;
Th
efo
llow
ing
wer
eas
ked
ina
stu
dy
spec
ific
ques
tio
nn
aire
wit
hso
me
qu
es-
tio
ns
form
edfr
om
lite
ratu
rere
sear
ch–
exp
erie
nce
s;ca
selo
ad;
stre
ss&
Co
pin
g;
So
cial
Su
pp
ort
;&
Em
plo
ym
ent
Ro
leIs
sues
Pip
erA
lph
aS
eaO
ilE
xp
losi
on
-9
mo
nth
s&
12
mo
nth
sC
lap
ham
Rai
lC
rash
–4
mo
nth
s&
12
mo
nth
s
73
.3
400 S. K. Brooks et al. J Ment Health, 2015; 24(6): 385–413
Ho
ltz
etal
.(2
002)
Cro
ss-s
ecti
on
al7
0H
um
anR
igh
tsW
ork
ers
Hu
man
Rig
hts
Dat
aC
oll
ecti
on
–K
oso
vo
Gen
eral
Hea
lth
Qu
esti
on
nai
re-2
8;
Ho
pk
ins
Sy
mp
tom
Ch
eck
list
-25
;H
arv
ard
Tra
um
aQ
ues
tio
nn
aire
(ad
apte
dfo
rtr
aum
aev
ents
inK
oso
vo
)
No
tre
po
rted
92
.9
Hu
ang
etal
.(2
013)
Cro
ss-s
ecti
on
al9
23
-5
5w
ith
PT
SD
&8
68
wit
ho
ut
wh
oac
tas
con
tro
lg
rou
p
Mil
itar
yre
scu
ew
ork
ers
Wen
chu
anE
arth
qu
ake
–C
hin
aC
lin
icia
nA
dm
inis
tere
dP
TS
DS
cale
du
rin
gst
ruct
ure
din
terv
iew
s;E
yse
nck
Per
son
alit
yq
ues
-ti
on
nai
re;
Tra
itC
op
ing
Sty
leq
ues
tio
nn
aire
;S
oci
alS
up
po
rtq
ues
tio
nn
aire
;&
self
-rep
ort
dem
o-
gra
ph
ics
ques
tio
nn
aire
18
mo
nth
s8
5.7
Joh
nso
net
al.
(2005)
Cro
ss-s
ecti
on
alw
ith
qual
ita-
tive
dat
aan
dan
alysi
s
11
14
retu
rned
surv
ey&
33
2fi
lled
inth
eo
pen
-en
ded
ques
tio
nin
the
surv
ey
Rec
over
yw
ork
ers
(reh
abil
itat
ion
&re
con
stru
ctio
n)
9/1
1W
orl
dT
rad
eC
entr
ed
isas
ter
US
AS
tud
ysp
ecif
icqu
es-
tio
nn
aire
–W
orl
dT
rad
eC
entr
eC
lean
-Up
&R
ecover
yW
ork
erH
ealt
hS
urv
ey
18
–3
6m
on
ths
62
.5
Kar
anci
&A
cart
urk
(2005)
Cro
ss-s
ecti
on
al2
00
10
0m
emb
ers
of
Ko
cael
iN
eig
hb
orh
oo
dD
isas
ter
Vo
lun
teer
sO
rgan
izat
ion
vs.
10
0co
ntr
ols
19
99
Mar
mar
a,T
urk
eyea
rth
qu
ake
Sy
mp
tom
Ch
eck
list
-4
0(S
CL
-40
);W
ays
of
Co
pin
gQ
ues
tio
nn
aire
;S
tres
sR
elat
edG
row
thS
cale
(SR
GS
)
4.5
yea
rs1
00
Kas
per
enet
al.
(2003)
Cro
ss-s
ecti
on
al2
13
UN
So
ldie
rs&
Rel
ief
Wo
rker
sA
idse
rvic
es&
mil
itar
yse
rvic
esin
Yu
go
slav
ia1
99
2–
19
96
Tra
um
aE
xp
osu
reQ
ues
tio
nn
aire
bas
edo
nU
nit
edN
atio
ns
Inte
rim
Fo
rce
InL
eban
on
stu
dy
;P
ost
-T
rau
mat
icS
tres
sS
cale
;Im
pac
to
fE
ven
tsS
cale
;S
tud
ysp
ecif
icS
oci
alN
etw
ork
Su
pp
ort
Qu
esti
on
nai
re
No
tre
po
rted
71
.4
(co
nti
nu
ed)
DOI: 10.3109/09638237.2015.1057334 Wellbeing of humanitarian relief workers 401
Co
nti
nu
ed
Ref
eren
ceD
esig
nP
arti
cip
ants
(n)
Occ
up
atio
nal
gro
up
Dis
aste
r/cr
isis
Mea
sure
sT
ime
of
mea
sure
-m
ent
po
st-d
isas
ter
Qu
alit
yap
pra
isal
sco
re(%
)
Ken
ard
yet
al.
(19
96
)L
on
git
ud
inal
19
5R
elie
fW
ork
ers
(in
clu
din
gem
er-
gen
cyse
rvic
esp
erso
nn
el,
dis
as-
ter
wo
rker
s)
19
89
New
cast
leea
rth
-qu
ake,
Au
stra
lia
Imp
act
of
Even
tS
cale
;G
ener
alH
ealt
hQ
ues
tio
nn
aire
27
,5
0,
86
&1
14
wee
ks
93
.3
Lu
nd
in&
Bo
deg
ard
(19
93
)
Lo
ng
itu
din
al5
0R
escu
eW
ork
ers
19
88
Arm
enia
nea
rth
qu
ake
Qu
esti
on
nai
rein
clu
din
gG
ener
alH
ealt
hQ
ues
tio
nn
aire
&Im
pac
to
fE
ven
tS
cale
Imm
edia
tely
afte
r;1
mo
nth
afte
r;9
mo
nth
saf
ter
60
Mar
mar
etal
.(1
99
6)
Cro
ss-s
ecti
on
al1
98
resc
ue
wo
rker
s;1
40
Bay
Are
aco
ntr
ols
;1
01
San
Die
go
con
tro
ls
Res
cue
Wo
rker
svs.
con
tro
lg
rou
ps
of
wo
rker
sle
ssh
igh
lyex
po
sed
toth
ed
estr
uct
ion
19
89
Lo
ma
Pri
eta
eart
hqu
ake
Inte
rsta
te8
80
free
way
coll
apse
Per
itra
um
atic
Em
oti
on
alD
istr
ess
Sca
le;
Per
itra
um
atic
Dis
soci
ativ
eE
xp
erie
nce
sQ
ues
tio
nn
aire
;S
tres
s-sp
ecif
ic&
gen
eral
sym
pto
mm
easu
res
No
tre
po
rted
86
.7
McC
orm
ack
&Jo
sep
h(2
01
3)
Qu
alit
ativ
e2
Hu
man
itar
ian
Aid
Wo
rker
sM
issi
on
sin
Rw
and
a,S
ud
an,
Sie
rra
Leo
ne,
Eas
tT
imo
r,B
urm
a,L
iber
ia,
Pak
ista
n,
and
the
So
lom
on
Isla
nd
s.
Inte
rvie
wN
ot
rep
ort
ed1
00
Mil
eset
al.
(19
84
)C
ross
-sec
tio
nal
54
Res
cue
Wo
rker
s:fi
refi
gh
ters
,n
urs
es,
emer
gen
cym
ed-
ical
tech
nic
ian
s,m
ort
icia
ns,
phys-
icia
ns
&o
ther
no
n-h
ealt
hca
rere
late
do
ccu
pat
ion
s
Co
llap
seo
fsk
yw
alk
sat
Hyat
t-R
egen
cyH
ote
lin
Kan
sas
Cit
y1
98
1
Ho
pk
ins
Sy
mp
tom
Ch
eck
list
;H
ealt
hA
sses
smen
tQ
ues
tio
nn
aire
;D
isas
ter
Per
son
al-
Ex
per
ien
tial
Qu
esti
on
nai
re;
Dis
aste
rP
erso
nal
-E
xp
erie
nti
alQ
ues
tio
nn
aire
2–
6m
on
ths
85
.7
Moy
nih
anet
al.
(20
05
)Q
ual
itat
ive
9C
risi
sC
ou
nse
llo
rs9
/11
Wo
rld
Tra
de
Cen
tre
dis
aste
rU
SA
Fo
cus
Gro
up
s1
9–
23
mo
nth
s5
5.5
Mu
sa&
Ham
id(2
00
8)
Cro
ss-s
ecti
on
al5
3H
um
anit
aria
nai
dw
ork
ers
rep
re-
sen
tin
g1
1re
lief
org
anis
atio
ns
Arm
edco
nfl
ict
inD
arfu
rP
rofe
ssio
nal
Qu
alit
yo
fL
ife
Qu
esti
on
nai
re;
Rel
ief
Wo
rker
Bu
rno
ut
Qu
esti
on
nai
re;
Gen
eral
Hea
lth
Qu
esti
on
nai
re(G
HQ
-28
)
No
tre
po
rted
64
.3
402 S. K. Brooks et al. J Ment Health, 2015; 24(6): 385–413
Nis
hi
etal
.(2
012)
Lo
ng
itu
din
al1
73
Dis
aste
rM
edic
alA
ssis
tan
ceT
eam
s2
01
1G
reat
Eas
tJa
pan
eart
hqu
ake
Imp
act
of
Even
tS
cale
;P
erit
rau
mat
icD
istr
ess
Inven
tory
1m
on
than
d4
mo
nth
s9
3.3
No
rris
etal
.(2
005)
Qu
alit
ativ
e3
4A
ffil
iate
dw
ith
var
i-o
us
org
anis
atio
ns
wh
ich
pro
vid
edm
enta
lh
ealt
hsu
pp
ort
/cri
sis
cou
nse
llin
g
Bo
mb
ing
of
the
Mu
rrah
Fed
eral
Bu
ild
ing
inO
kla
ho
ma
Cit
y,U
SA
in1
99
5
Inte
rvie
ws
7Y
ears
77
.7
Pat
on
(19
94
)C
ross
-sec
tio
nal
37
Fir
efi
gh
ters
&se
arch
&re
scue
char
ity
vo
lun
teer
s
Arm
enia
nea
rth
qu
ake
Imp
act
of
Even
tssc
ale
toget
her
wit
hsh
ort
sym
p-
tom
chec
kli
st;
8in
terv
iew
s
3m
on
ths
78
.6
Pu
lid
o(2
01
2)
Qu
alit
ativ
e2
6M
enta
lH
ealt
hC
lin
icia
ns
9/1
1W
orl
dT
rad
eC
entr
ed
isas
ter
US
AIn
terv
iew
s2
4m
on
ths
77
.7
Pu
tman
etal
.(2
009)
Mix
edM
eth
od
s:st
ud
y1
cro
ss-
sect
ion
alan
dst
ud
y2
qu
alit
ativ
e
Stu
dy
1:
13
7S
tud
y2
:2
6A
idW
ork
ers
Aid
mis
sio
nin
Gu
atem
ala
Fo
cus
gro
up
s;L
os
An
gel
esS
ym
pto
mC
hec
kli
st;
Mas
lach
Bu
rno
ut
Inven
tory
;S
urv
eyo
fC
hil
dre
n’s
Ex
po
sure
toC
om
mu
nit
yV
iole
nce
No
tre
po
rted
78
.6
Sh
ihet
al.
(20
02
)Q
ual
itat
ive
46
Nu
rse
vo
lun
teer
s9
–2
1T
aiw
anes
eea
rth
qu
ake
Inte
rvie
ws
No
tre
po
rted
88
.9
So
lim
anet
al.
(1998)
Cro
ss-s
ecti
on
al6
4O
utr
each
Wo
rker
s1
99
3Il
lin
ois
flo
od
Wo
rker
Per
cep
tio
nS
cale
&o
pen
-en
ded
qu
esti
on
sto
enco
ura
ge
com
men
ts
No
tre
po
rted
75
So
lim
an&
Gil
lesp
ie(2
011)
Cro
ss-s
ecti
on
al2
74
Rel
ief
So
cial
Wo
rker
sR
efu
gee
cam
ps
infi
ve
reg
ion
so
fth
eM
idd
leE
ast
(Jo
rdan
,L
eban
on
,S
yri
a,th
eG
aza
Str
ipan
dth
eW
est
Ban
k)
Su
rvey
–n
ot
stat
edN
ot
rep
ort
ed7
8.6
Stu
hlm
ille
r(1
994)
Qu
alit
ativ
e4
2M
ilit
ary
par
a-re
s-cu
ers;
fire
fig
ht-
ers;
tran
spo
rtat
ion
wo
rker
s;co
ron
erin
ves
tigat
ors
Oct
ob
er1
98
9ea
rth
-qu
ake
inS
anF
ran
cisc
o
Inte
rvie
ws
6m
on
ths
88
.9
Th
ore
sen
etal
.(2
009)
Cro
ss-s
ecti
on
al5
81
NG
Os,
po
lice
,jo
ur-
nal
ists
,h
ealt
hp
erso
nn
el,
min
is-
try
of
fore
ign
affa
irs,
trav
elag
enci
es,
20
04
So
uth
Eas
tA
sia
tsu
nam
iIm
pac
to
fE
ven
tsc
ale;
4st
ud
ysp
ecif
icqu
esti
on
so
nw
het
her
wo
rkw
asm
ean
ing
ful,
succ
essf
ul,
they
wo
uld
rath
ern
ot
9m
on
ths
10
0
(co
nti
nu
ed)
DOI: 10.3109/09638237.2015.1057334 Wellbeing of humanitarian relief workers 403
Co
nti
nu
ed
Ref
eren
ceD
esig
nP
arti
cip
ants
(n)
Occ
up
atio
nal
gro
up
Dis
aste
r/cr
isis
Mea
sure
sT
ime
of
mea
sure
-m
ent
po
st-d
isas
ter
Qu
alit
yap
pra
isal
sco
re(%
)
chap
lain
s,ai
rfo
rce
med
ics
hav
ed
on
eit
,an
dif
itm
ade
them
bet
ter
pre
par
edfo
rsi
mil
arsi
tu-
atio
ns
inth
efu
ture
;8
ques
-ti
on
so
nex
po
sure
;4
qu
esti
on
so
nco
nta
ct;
1qu
es-
tio
no
nh
aras
s-m
ent;
1qu
esti
on
on
reje
ctin
gv
ic-
tim
s;5
qu
esti
on
so
ntr
ain
ing
and
exp
erie
nce
Th
orm
aret
al.
(20
13
)L
on
git
ud
inal
50
6R
edC
ross
vo
lun
teer
s2
00
6ea
rth
qu
ake
inIn
do
nes
iaIm
pac
to
fE
ven
tsc
ale;
Ho
spit
alA
nx
iety
and
Dep
ress
ion
Sca
le;
Su
bje
ctiv
eH
ealt
hC
om
pla
ints
inven
tory
sco
rin
gsy
stem
;O
ccu
rren
cesu
b-
scal
eo
fT
rau
mat
icE
xp
osu
reS
ever
ity
Sca
le;
surv
eyd
esig
ned
for
this
stu
dy
6,
12
and
18
mo
nth
s1
00
Urs
ano
&M
cCar
roll
(19
90
)
Qu
alit
ativ
e5
0in
terv
iew
s;o
bse
rvat
ion
so
fover
40
0
Bo
dy
han
dle
rs:
ho
s-p
ital
and
fore
nsi
cp
ath
olo
gis
ts,
mil
itar
yb
od
yh
and
lers
,p
oli
ce/
fire
per
son
nel
,em
ergen
cym
ed-
ical
tech
nic
ian
s,R
edC
ross
dis
as-
ter
reli
efw
ork
ers
19
85
mil
itar
yai
rd
isas
-te
rin
New
-fo
un
dla
nd
Inte
rvie
ws
and
ob
serv
atio
ns
Du
rin
gth
ep
roce
ssan
dse
ver
alm
on
ths
ther
eaft
er
22
.2
Van
der
Vel
den
etal
.(2
01
2)
Lo
ng
itu
din
al5
11
1p
oli
ceo
ffic
ers,
35
fire
-fig
hte
rs,
4am
bu
lan
cep
er-
son
nel
and
1su
rgeo
n
20
10
Hai
tiea
rth
qu
ake
Sy
mp
tom
Ch
eck
list
90
(SC
L-9
0-R
);Im
pac
to
fE
ven
tsc
ale
Even
ing
bef
ore
dep
artu
re&
3m
on
ths
po
st-
dep
loy
men
t
92
.9
404 S. K. Brooks et al. J Ment Health, 2015; 24(6): 385–413
Wan
get
al.
(20
11
)Q
ual
itat
ive
25
Gra
ss-r
oo
tsg
over
n-
men
to
ffic
ials
invo
lved
ind
isas
-te
rre
lief
wo
rk
20
08
eart
hqu
ake
inC
hin
aIn
terv
iew
s1
0m
on
ths
88
.9
Wan
get
al.
(20
13
)Q
ual
itat
ive
25
Dis
aste
rR
elie
fO
ffic
ials
20
08
eart
hqu
ake
inC
hin
aIn
terv
iew
s1
0m
on
ths
10
0
Web
er&
Mes
sias
(20
12
)
Qu
alit
ativ
e3
2F
ron
t-li
ne
wo
rker
sre
pre
sen
tin
gn
on
-g
over
nm
enta
l,n
on
-pro
fit
com
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DOI: 10.3109/09638237.2015.1057334 Wellbeing of humanitarian relief workers 405
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406 S. K. Brooks et al. J Ment Health, 2015; 24(6): 385–413
Appendix IV
Themes and results: all studies
Theme Evidence
Pre-deploymentPreparedness and training DRWs need to prepare for the complex social, economic, mental and physical needs of
survivors and victims (Paton, 1994; Pulido, 2012; Stuhlmiller, 1994; Witteveen et al., 2007).Participants cited poor non-medical training and felt out of their depth when put in positions of
responsibility and asked to make decisions, lead projects and teach skills. Participantsworking outside of their main profession reported poor training and lack of handbooks,guidelines and policies to read. Deploying solely with inexperienced staff led to anxiety,stress, frustration and failure to execute the role adequately (Bjerneld et al., 2004).
Performing tasks atypical of the intended role predicted PTSD (Perrin et al., 2007).Training together as a team helped build a network and function collaboratively (Wyche et al.,
2011).Inexperienced volunteers scored more highly on intrusive thoughts, inability to control
emotions, depression and anxiety scales than experienced workers (Hagh-Shenas et al.,2005).
75% of workers felt that they needed more training and skills, and those who felt preparedmanaged better psychologically (Lundin & Bodegard, 1993).
Sufficient training and information to ensure emotional and cognitive readiness for the realitiesof disaster work was found to be protective and viewed as valuable by DRWs (Hearns &Deeny, 2007; Johnson et al., 2005; Wilson & Gielissen, 2004).
Films and speakers as part of training helped to adapt and prepare (Paton, 1994).More realistic rescue and recovery expectations, training on work tasks and specific
preparation for the mission were significantly associated with lower levels of stress(Thoresen et al., 2009).
Training and preparation is an inconsistently managed area across many organisations withinadequate preparation for what to expect, leading to anxiety and dissatisfaction(Norris et al., 2005; Thormar et al., 2013; Weber & Messias, 2012).
Peri-deploymentDeployment length and timing There was a strong association for international DRWs between the number of deployment
missions and depression; the risk of depression was highest on the first mission, decreasedfor the second and reached a peak with five or more missions, though the time period inwhich these occurred was unclear in the paper (Cardozo et al., 2005).
Probability of PTSD increased with longer duration of time worked at the disaster site (Perrinet al., 2007). Another study found no significant relationship between length of deploymentand PTSD severity (Eriksson et al., 2001).
Shorter deployments were more stressful as it took time for workers to ‘‘find their feet’’ andadapt to their surroundings (Bjerneld et al., 2004).
Staff working in a human rights organisation for more than six months were found to havehigher rates of non-specific psychiatric morbidity, anxiety and depression than those whohad worked with the organisation for less than six months (Holtz et al., 2002).
Longer deployments were strongly associated with lower anxiety and depression symptomlevels (Ehring et al., 2011).
Nurses who were dispatched within the first three weeks of the disaster experienced greaterpsychological suffering than those dispatched later (Yokoyama et al., 2014).
Traumatic exposure Workers directly exposed to the disaster itself had significantly higher rates of acute stressdisorder in the aftermath, significantly higher rates of depression at seven and 13 monthspost-disaster, and higher levels of PTSD 13 months post-disaster, compared to thoseworking off-site (Durham et al., 1985; Fullerton et al., 2004).
Workers experienced stress, anxiety and intrusive thoughts caused by the magnitude of deathand grotesqueness witnessed including recovering body parts, smelling burnt flesh and notknowing how to reply to victims asking if they were going to die (Brandt et al., 1995; Paton,1994; Putman et al., 2009; Thormar et al., 2013; West et al., 2008; Yang et al., 2010).
Local and victim hostility in the form of misunderstandings, displaced anger and lack ofgratitude were sources of general stress in DRWs (Thormar et al., 2013; Wang et al., 2011).
Although victim and local population contact could be very stressful, finding ways to comfortfamilies was viewed as making the work worthwhile (Stuhlmiller, 1994; Thoresen et al.,2009).
The prevalence of elevated anxiety was significantly greater in DRWs who witnessed torture(OR 3.0, 95% CI 1.1–81) or general hostility (OR 4.4, 95% CI 1.8–11.0) while being injureddue to an assault was a significant risk factor for PTSD and depression (Holtz et al., 2002).
There was more than a threefold significant increase in depression for DRWs who experiencedthreats to their life, as well as significant differences in non-specific psychiatric morbiditybetween DRWs who experienced threats to their life and those who did not (Cardozo et al.,2005).
At step one of a multivariate model, two exposure variables were uniquely associated withstress reactions for direct disaster exposure; witnessing traumatic experiences and having toreject victims in need of help. At step two, with ‘‘training’’ added to the model (a measure
(continued )
DOI: 10.3109/09638237.2015.1057334 Wellbeing of humanitarian relief workers 407
Continued
Theme Evidence
of preparation), they were no longer significant (Thoresen et al., 2009).Dealing with dead bodies either as a primary role, or encountering them in another way,
appeared be a strong significant (p50.01) risk factor for psychological distress and post-traumatic stress responses when compared to workers without such exposure (Dobashi et al.,2014).
Exposure to dead bodies was significantly associated with post-traumatic morbidity (Changet al., 2008); elevated anxiety and intrusive flashbacks, although in most individuals thissignificantly decreased over time (Alexander, 1993); greater psychological distress (Marmaret al., 1996); and remained significant even after adjusting for age, gender and previousPTSD (West et al., 2008).
Bodies of children (Ursano & McCarroll, 1990) and taking family members to identifymutilated bodies of loved ones were found to be particularly stressful experiences (Brandtet al., 1995).
Magnitude of death and destruction was reported as a stressor by 10 (48%) non-emergencyservice volunteers and 12 (75%) fire fighters. Death of young children was reported asstressor by 43% volunteers, 38% fire fighters (Paton, 1994).
Among disaster-area personnel, witnessed experiences most likely to be reported as ‘‘verystrainful’’ were seeing victims searching for next of kin (n¼ 48/23%) and seeing childrenwho were separated from family (n¼ 33/32%). In the disaster-area group, approximately 1in 3 (n¼ 57) rated personal contact with disaster victims who had suffered loss as ‘‘verystrainful’’ compared to approximately 1 in 5 (n¼ 29) of home-base personnel (Thoresenet al., 2009).
Becoming emotionally involved Secondary stress reactions included fatigue, sleep disturbance, grief and anger (Clukey, 2010).Workers with a high level of identification with survivors had significantly more intrusive
thoughts and scored higher on an obsessive/compulsive scale (Hodgkinson & Shepherd,1994).
Identification (sense of kinship) or emotional involvement with the deceased produced distress;working with the personal effects of the dead was particularly stressful as it tended to createa sense of ‘‘knowing’’ the victim (Cetin et al., 2005; Ursano & McCarroll, 1990).
Repeatedly hearing stories of trauma often led to re-living of the incident, over-identificationwith victims and an inability to separate oneself from those they were there to help, andinternalisation of their pain and suffering, leaving workers feeling emotionally affected(Paton, 1994; Pulido, 2012, Soliman et al., 1998; Thormar et al., 2013). This often led tofeelings of helplessness (Berah et al., 1984; Wyche et al., 2011).
Workers involved in certain tasks which may evoke emotional reactions to the victims, namelyproviding psychosocial support and food aid to affected communities, were more vulnerableto PTSD and depression (Thormar et al., 2013).
Workers found it stressful if they thought of family members and friends when seeing victimsand imagined seeing their loved ones in that situation (Berah et al., 1984).
Several authors emphasised the need to keep professional and psychological distance (Brandtet al., 1995; Norris et al., 2005) and to suppress grief (Wang et al., 2013).
Emotional distancing and repression were used as coping strategies (Stuhlmiller, 1994; Wanget al., 2011).
However, suppression and avoidance of traumatic thoughts was also predictive of traumaticstress (Zhen et al., 2012).
One study found that rescue workers were at low risk for secondary trauma, though those whodid experience this were also more likely to report burnout (Chang et al., 2011).
Leadership Poor leadership was described as including ad hoc planning (Hearns & Deeny, 2007); poorlyplanned and badly anchored work and schedules (Bjerneld et al., 2004); lack of guidance interms of roles and boundaries (Soliman et al., 1998) and an overall lack of concern forstaff’s welfare needs (Johnson et al., 2005).
Poor leadership acted as a stressor (Stuhlmiller, 1994; Wyche et al., 2011) particularly toinexperienced staff (Cox, 1997).
Lack of perceived support from leaders was related to greater psychopathology 18 monthspost-disaster; lack of support from the organisation in the aftermath was the strongestcontributor to depression (Thormar et al., 2013).
‘‘Poor or good’’ organisational support, rather than ‘‘excellent’’ support had a strongsignificant association with increased likelihood of depression post-deployment ininternational DRWs (Bjerneld et al., 2004; Cardozo et al., 2005).
Poor organisational support was associated with increased emotional exhaustion anddepersonalisation (Eriksson et al., 2009).
Perceived lack of organisational support pre-, mid- and post-deployment led to disappointment,reduced self-worth, anger and a sense of failed achievement. Despite the lack of support,many participants felt that a sense of loyalty and wanted to continue to work for them(Hearns & Deeny, 2007).
Supervisory support had a strong positive association with intrinsic job satisfaction,engagement, and work culture support, and a strong negative association with psychologicalstrain and turnover intentions (Biggs et al., 2014).
Field leader team cohesion was associated with lower risk for burnout in personal
(continued )
408 S. K. Brooks et al. J Ment Health, 2015; 24(6): 385–413
Continued
Theme Evidence
accomplishment (Cardozo et al., 2012).Participants felt frustrated with inexperienced leaders who were not used to being in a position
of such power and did not know how to handle it; they wanted experienced leaders (Clukey,2010).
Lack of coordination and communication among government officials, employees andvolunteers led to frustration, job overload and stress (Bakhshi et al., 2014; Wang et al.,2011; Weber & Messias, 2012).
Organisational headquarters were perceived as not fully understanding the reality of thesituation that workers were dealing with (Hearns & Deeny, 2007) and being only involvedsuperficially and for bureaucratic procedures (Wilson & Gielissen, 2004).
Good organisational support and sensitive staff management practices were shown tocontribute to positive occupational health (Alexander, 1993).
Organisational social support provision was largely reported to be positive, although someworkers felt that their supervisors were too busy to provide emotional support or they wouldfeel uncomfortable opening up to them (Bakhshi et al., 2014).
79% reported that they could rely on their superiors when they returned home and resumedtheir normal work. 98% also reported that they received a lot of appreciation and recognitionfor their work (Van der Velden et al., 2012).
Lack of recognition in efforts and feeling undervalued were considered stressors, particularlyfor those working in small organisations (Weber & Messias, 2012).
Feeling undervalued was reported to be in the top five stressors (Curling & Simmons, 2010).Workers sometimes reported a sense of invisibility and did not feel valued (Cox, 1997).
Inter-agency cooperation Local professionals appeared to have a sense of ‘‘ownership’’ over the disaster; ‘‘outsiders’’were seen as implying the local community was not able to manage the situation themselvesand tended to be resented unless they were seen as playing a supporting role to localleadership (Norris et al., 2005).
Lack of cooperation between agencies often meant different services operating in their ownareas on their own time schedules, and workers reported conflicts with other aid workersand having disparaging opinions of each other (Cox, 1997).
There were often tensions between local first responders and ‘‘outsiders’’, with differences inopinion between agencies hindering the provision of a quick and appropriate response(Wyche et al., 2011).
Moderate to considerable difficulties with other relief teams were attributed to two majorfactors: differing philosophies/frameworks and professional rivalry/jealousy (Berah et al.,1984). Inter-agency rivalry and secrecy of information was also noted by Hodgkinson &Shepherd (1994).
Cultural differences and communication difficulties were blamed for an inability to buildcollaborations with local responders, which became a barrier to productive work (Yanget al., 2010).
Even when agencies collaborated, this was of minimal help in reducing stress, suggesting thatthe intense nature of the role can make it distracting to engage with other agencies (Soliman& Gillespie, 2011).
Social support Social support was significantly associated with lower levels of depression (AOR 0.9; 95% CI0.84–0.95), psychological distress (AOR 0.9; 95% CI 0.85–0.97), burnout in lack ofpersonal accomplishment (AOR 0.95; 95% CI 0.91–0.98), and greater life satisfaction(p¼ 0.0213), even after adjusting for all other study variables (including age, gender,marital status, childhood trauma, non-government organisation experience) (Cardozo et al.,2012).
Perceived social support appeared to mediate the effects of high trauma exposure and PTSDseverity, although there was insufficient statistical data to confirm the strength of thisinteraction (Eriksson et al., 2001).
Many workers felt that informal ‘‘talking/sharing’’ was the most helpful way of dealing withdistressing thoughts and was significantly linked to lower levels of anxiety and depression(Ehring et al., 2011; Miles et al., 1984).
Social support was important for high trauma exposure in relief workers and there were nosignificant differences as to where this support came from. In UN soldiers involved indisasters, social support was important for low trauma exposure, but only friends andcolleagues were a significant buffer/moderator for post-traumatic stress symptoms(Kasperen et al., 2003).
Camaraderie within the team, mutual support, trust, understanding and cooperation amongcolleagues were perceived to be important (Bakhshi et al., 2014; Wang et al., 2011; Wycheet al., 2011).
Perceived work culture support appeared to mediate the effect of exposure to a natural disasteron job control, job demands, work strain, intrinsic job satisfaction, turnover intentions andwork engagement (Biggs et al., 2014).
It was suggested that the pre-departure period be used for team building to foster a resilientenvironment for when in the disaster area (Norris et al., 2005; Paton, 1994).
Having to live and work with colleagues could be a source of stress in itself if relationshipswere poor (Bjerneld et al., 2004).
(continued )
DOI: 10.3109/09638237.2015.1057334 Wellbeing of humanitarian relief workers 409
Continued
Theme Evidence
Perceived social support was significantly correlated with post-traumatic growth (Karanci &Acarturk, 2005).
Highly infrequent family contact was significantly associated with depression (West et al.,2008).
There was a significant association between perception of communication facilities as poor andnon-specific psychiatric morbidity and depression (Cardozo et al., 2005).
Lack of communication or poor facilities to communicate could be stressful (Bjerneld et al.,2004; Hearns & Deeny, 2007).
One study reported that participants found communication with home to be stressful due toloved ones being worried (Bakhshi et al., 2014).
During-deployment formal support Many participants felt that there was a lack of appropriate clinical and social services forsupport (Moynihan et al., 2005).
Occupational health support and policies for non-uniformed workers were not seen as equal tothose provided for first responders/uniformed services (Johnson et al., 2005).
When on-site psychological counselling sessions with professional counsellors or stressmanagement workshops were available, these were generally seen as helpful (Curling &Simmons, 2010; Yang et al., 2010).
Role Some non-managerial DRWs felt unexpectedly out of their depth when put in positions ofresponsibility and asked to make decisions, lead projects and teach skills when they werenot expecting to (Bjerneld et al., 2004).
Competing needs and demands often meant role diffusion and a need to adapt to multiple roles(Moynihan et al., 2005), which led to individuals having to modify their standard practices;at times this caused ethical and moral dilemmas (Yang et al., 2010).
59% rated clarity of service and rules and regulations of service delivery to be understandable(Soliman et al., 1998).
5% of volunteer workers experienced role uncertainty compared to 38% of fire-fighters (Paton,1994).
Role ambiguity appears to be more of a significant problem in the early stages of disaster work,but in many cases, roles and tasks soon fall into place (Bakhshi et al., 2014).
Employer and role flexibility is considered essential due to the nature of disaster work, in orderto accommodate for changing needs and to foster resilience (Paton, 1994; Pulido, 2012;Wyche et al., 2011).
A strong ‘‘chain of command’’/line management structure was believed to reduce confusion indisaster situations (Norris et al., 2005).
Demands, workload and long hours Job resources played a particular role in stressor-strain process after unpredictable andemotionally challenging work demands (Biggs et al., 2014).
Workers cited an inappropriate balance between workload and manpower – however, thisincreased team cohesion and spirit, as they needed to depend on each other, and likened theteam to a family (Hearns & Deeny, 2007).
Pressure and a perceived need to act quickly led to putting in long hours and neglecting normalactivities; participants believed hours worked per day should be limited, and adequatenumbers of staff were needed to reduce pressure on individuals (Norris et al., 2005).
A number of work hours per day were associated with poor subjective well-being and intensefatigue (Thormar et al., 2013; Yokoyama et al., 2014).
50% of fire-fighters and 19% of non-emergency service volunteers cited ‘‘being pushed to thelimit’’ as a stressor; however, only 1 (5%) volunteer and 4 (25%) fire-fighters reported‘‘exhaustion’’ as a stressor (Paton, 1994).
Complicated tasks, high expectations and excessive demands led to stress, particularly whenassociated with inadequate resources (Soliman & Gillespie, 2011).
Workers reported feeling exhausted and that they found the prolonged heavy workload, longhours and emotional exhaustion stressful (Bakhshi et al., 2014; Curling & Simmons, 2010;Paton, 1994; Wang et al., 2011).
Time off while on deployment was viewed as essential for maintaining emotional stability andbeing able to distance oneself from the work (Bakhshi et al., 2014; Stuhlmiller, 1994).
Simply taking breaks were not enough, as participants often felt that they were merely waitingfor their next shift; using the break to do some activity which helped take their mind offtheir work was useful, although some reported feeling guilty during time off and using it tohelp out informally (Bakhshi et al., 2014).
Safety and equipment Participants felt concerned about safety, poor living conditions and inadequate equipment andfacilities, which could lead to a sense of personal vulnerability (Clukey, 2010; Hearns &Deeny, 2007; Paton, 1994; Thormar et al., 2013; Yang et al., 2010).
Sustaining an injury on the job was a strong predictor of PTSD (Kenardy et al., 1996; Perrinet al., 2007).
Anxiety and PTSD symptoms increased in relation to not feeling enough safety measures werein place and fearing for one’s own safety (Miles et al., 1984; Thormar et al., 2013).
Near-death experiences and severe injuries occurring on the job were associated with PTSD(Huang et al., 2013).
Feeling personally threatened was associated with higher psychological distress (Marmar et al.,1996).
(continued )
410 S. K. Brooks et al. J Ment Health, 2015; 24(6): 385–413
Continued
Theme Evidence
Perceived severity of threat to life was correlated with post-traumatic growth (Karanci &Acarturk, 2005).
Participants felt that they lacked the appropriate personal protective equipment which was onlyprovided after complaints were made, which led to stress, anxiety and health complaints(Johnson et al., 2005).
Reassurance about safety from supervisors was helpful (Bakhshi et al., 2014).Self-doubt and guilt 24% of participants reported feeling ‘‘guilt’’ (Miles et al., 1984); workers who felt poorly
prepared for tasks were more likely to report feelings of guilt (Marmar et al., 1996). Workerswho had themselves been involved in the disaster often felt guilt at being alive when otherswere not (Wilkinson, 1983).
Participants reported wanting to have done more to relieve suffering and felt helpless,frustrated and that they were ‘‘failing’’ victims as they could not meet all of their needs(Miles et al., 1984; Pulido, 2012; Wilkinson, 1983).
Blaming oneself for not being able to help more was significantly associated with increasedpsychological distress (Ehring et al., 2011).
Workers doubted their own actions, especially when having to prioritise their own safety overothers, which led to shame and fear of judgment (McCormack & Joseph, 2013). It was alsocommon for workers to question their own capabilities (Stuhlmiller, 1994), and to fearmaking mistakes (Bakhshi et al., 2014).
Participants reported feelings of inadequacy and confusion and often felt that they did not‘‘deserve’’ to be there as they were unable to fix the situation or stop the suffering of victims(Brandt et al., 1995).
Staff felt more positive when they believed they had been helpful and felt appreciated bymembers of the public, but felt stressed if their work was not immediately beneficial to thepublic (Bakhshi et al., 2014).
Self-doubt and shame led to ‘‘narcissistic coping’’ including high-risk behaviours, poor self-care and becoming less compassionate to others (McCormack & Joseph, 2013).
Coping strategies 20% of respondents reported an increase in the use of tobacco or caffeine, 16% an increase intranquilisers, and 10% an increase in alcohol use (Miles et al., 1984).
Participants reported an increased reliance on alcohol, cigarettes, prescribed and non-prescribed medication and caffeine (Curling & Simmons, 2010).
Negative ways of coping such as evasion, fantasy, and repression led to a significantlyincreased likelihood of developing PTSD (Huang et al., 2013).
‘‘Talking and sharing’’ was seen as the most helpful way of coping with distressing thoughts(Miles et al., 1984; Wilkinson, 1983).
Other helpful coping mechanisms included writing, massage and deep breathing to fosterrelaxation (Norris et al., 2005).
For some occupations, such as military para-rescuers, a ‘‘press on’’, ‘‘do your job’’ strategywas used as a way to cope (Stuhlmiller, 1994).
Redefining the experience as a ‘‘realistic training exercise’’ or way of ‘‘skill building’’ wasuseful (Paton, 1994; Wyche et al., 2011), and remaining optimistic and appreciative of lifewere used as ways of coping (Wang et al., 2013).
Additional important coping strategies included dedication to work, finding a meaning in theirwork and goal/time management (Wang et al., 2011); active problem solving and self-reflection (Wyche et al., 2011); finding meaning and purpose in life through relief work(Wang et al., 2013); compartmentalising things they could not change, finding meaning andpurpose, re-evaluation of self-worth and re-connecting with the idea of the self as altruisticrather than bad (McCormack & Joseph, 2013).
Confrontive coping, distancing, seeking support, accepting responsibility, escape-avoidance,problem-solving and positive appraisal modified the effect of traumatic exposure on generalpsychiatric morbidity (Chang et al., 2008).
Fatalistic coping and problem-solving/optimistic coping approaches explained a largeproportion of variance in post-traumatic growth (Karanci & Acarturk, 2005).
Post-deploymentPost-deployment formal support Participants felt that the organisation should be responsible for providing debriefing and this
should be carried out automatically, not only when requested (Bjerneld et al., 2004).One-third of participants (n¼ 79) expressed a need for intervention within the first few weeks
following a disaster (Durham et al., 1985).Embassy workers felt that they had a lack of time to adjust to being back home and doing their
everyday work; this poor re-adjustment often led to feelings of ‘‘anti-climax’’ anddecreased motivation for normal work. However, those participants who were offered TRiMtraining found it helpful, and taking part in a qualitative study was also deemed helpful bymany, perhaps serving as a means for them to express their feelings and discuss theirexperiences (Bakhshi et al., 2014).
Participants felt that stress management and re-entry into home and society programmesneeded to be better (Hearns & Deeny, 2007).
Participants who had had a group debriefing reported that they felt that they were expected topublicly admit to vulnerabilities and acknowledge fears, which led to a fear of being seen asineffective; the debriefing also happened at the end of long work hours when they were
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Theme Evidence
exhausted, and listening to those less successful deflated the sense of accomplishment ofsuccessful rescuers (Stuhlmiller, 1994).
Debriefing had little effect on psychological distress (Kenardy et al., 1996).Technical and operational debriefing were reported positively, but participants felt that they
needed more contact with other workers involved in the disaster after returning home (Vander Velden et al., 2012).
Lack of support from peers post-disaster, including criticism, indifference, disinterest or beingtold to ‘‘get on with life’’ led to feelings of anger, betrayal, disconnection and lack ofvalidation, often leading to poor reintegration (McCormack & Joseph, 2013).
The ‘‘512 Psychological Intervention Model’’ (an intervention including debriefing onsymptoms of mental ill health, stress management and training in cohesion) was an effectivedebriefing method for rescue nurses, associated with a reduction in symptoms of PTSD,anxiety and depression (Wu et al., 2012).
Participants reported poor re-adjustment into home, society and work environments and a needfor support programmes (Bakhshi et al., 2014; Hearns & Deeny, 2007).
Media Exposure to media coverage of the disaster was the most common ‘‘trigger’’ of recall of thedisaster after the event (Miles et al., 1984).
Hours spent watching coverage of the disaster were related to PTSD (Nishi et al., 2012).Publicity was reported to be a stressor (Paton, 1994).Press attention left participants feeling they were working in the public view; criticism from the
media was taken personally; and demands for information from journalists increasedworkload (Bakhshi et al., 2014).
Participants felt training in skills for dealing with the media would be helpful (Norris et al.,2005).
Personal and professional growth Many participants viewed the experience as rewarding, in terms of feeling they had made acontribution; personal accomplishment and consequent improved confidence and self-esteem, increased compassion, and re-evaluation of the self and meaning of life (Bakhshiet al., 2014; Soliman et al., 1998; Wang et al., 2013; Yang et al., 2010).
The experience was generally seen as meaningful and fulfilling and workers were glad thatthey had experienced it (Alexander, 1993; Berah et al., 1984; Yang et al., 2010).
65% of participants felt that the experience had changed their lives in some way: for example26% saw life as more fragile and 15% felt more committed to living their lives fully (Mileset al., 1984).
96% of disaster-area personnel and 91% of home-base personnel reported their experience asmeaningful, and only 3% and 6% of disaster-area and home-base personnel, respectively,would rather have been without the experience (Thoresen et al., 2009).
77% of participants felt that their experiences had had a positive impact on their personal lives(Soliman et al., 1998).
Participants expressed satisfaction in having a sense of purpose and being able to educateothers and offer wisdom and skills (Zinsli & Smythe, 2009) and felt that they were makingimportant contributions to the relief effort (Moynihan et al., 2005).
Participants felt more connected to the community afterwards, and gained insights intoconceptual thinking about themselves and their professional work (Berah et al., 1984).
Humanitarian concern, work satisfaction and the feeling of ‘‘giving back’’ were motivators,and levels of perceived personal accomplishment were inversely related to PTSD (Putmanet al., 2009) and associated with higher levels of resilience and lower levels of secondarytrauma and burnout (Chang et al., 2011).
Participants felt that their experience led to a recognition of the transient nature of life; helpedthem develop a wish to lead a more significant life with more caring relationships; led to abetter appreciation of the value of their work and own self-worth; and that they felt‘‘touched’’ by seeing others’ altruism (Shih et al., 2002).
However, one paper found that a reportedly ‘‘better’’ experience and more positive evaluationof work was significantly associated with higher anxiety and burnout: this appears counter-intuitive, but it may be that the positive experience puts more responsibility on the worker ifthings do not go as planned (Cardozo et al., 2012).
79.7% of participants were satisfied with the effect on their professional growth; they alsofound a negative impact on workers if they felt their professional skills had not beenenhanced during their experience, though this finding must be interpreted cautiously as itmay be that those who felt more stressed were less likely to report professional growth(Soliman et al., 1998).
Participants felt that the experience had had a positive impact on their career (Bakhshi et al.,2014).
Participants felt that they gained a clearer concept of disaster care, enhanced knowledge ofsurvivors’ needs and enhanced ability to recognise factors hindering rescue operationswhich in turn strengthened professional competency, reinforced commitment to theprofession and led to positive life goals (Shih et al., 2002).
Socio-demographic and pre-deploymentcharacteristics
Age: Younger workers more likely to be depressed and anxious (Cardozo et al., 2005; Ehringet al., 2011; Thormar et al., 2013) and were at higher risk for acute stress disorder (Fullertonet al., 2004) and psychological complaints (Zhen et al., 2012). Another study found that
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depression was higher in younger workers but not to the point of significance (Wilkinson,1983). Older workers experienced less burnout and secondary stress (Musa & Hamid,2008). Two studies found no relationship between age and psychological outcomes(Eriksson et al., 2001; Hodgkinson & Shepherd, 1994).
Gender: One study reported females showed significantly higher levels of PTSD, mixedanxiety and depression, somatic symptoms and burnout (Ehring et al., 2011). Two studiesfound that males were more likely to have depressive symptoms (Holtz et al., 2002;Thormar et al., 2013). Females were more likely to report role clarity and positive effects ofthe experience (Soliman et al., 1998). Two studies found no significant relationship betweengender and psychological outcomes (Eriksson et al., 2001; Hodgkinson & Shepherd, 1994).
Ethnicity: Ethnicity was not found to predict PTSD (Putman et al., 2009).Education: Workers with social science educational backgrounds showed more positive
perceptions than those with other educational backgrounds (Soliman et al., 1998). One studyfound no correlation between educational level and psychological complaints (Zhen et al.,2012).
Family relationships: Married workers were more likely to develop acute stress disorder(Fullerton et al., 2004). Workers with children had significantly lower levels of PTSD anddepression (Ehring et al., 2011). Two studies found no association between marital statusand psychological outcomes (Hodgkinson & Shepherd, 1994; Zhen et al., 2012).
Having a family member injured in the disaster: Having a family member injured in theincident was associated with PTSD and depression when adjusted for age, gender and priorPTSD/depression history (West et al., 2008).
Previous experience/exposure: Greater previous disaster experience was significantlyassociated with higher levels of PTSD (Fullerton et al., 2004). Lifetime direct communityviolence exposure was significantly associated with PTSD, although lifetime indirectexposure was not (Putman et al., 2009). Outreach workers with longer experience in humanservices showed more positive perceptions with regards to the effects of service (Solimanet al., 1998).
Pre-deployment mental health: Previous psychiatric history was strongly associated withdepression and moderately associated with non-specific psychiatric morbidity (Cardozoet al., 2005). A history of mental illness contributed to increased risk of anxiety anddepression (Cardozo et al., 2012). Two studies found no association between psychiatrichistory and elevated symptoms post-disaster (Holtz et al., 2002; Wilkinson, 1983).
Post-disaster life events: The number of post-disaster life events was significantly associatedwith psychological wellbeing (Witteveen et al., 2007).
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