The short-term impact of terrorism on public mental health: an emergency primary care approach.

BACKGROUND: Terrorist attacks commonly have mental health consequences for those directly affected. Existing research is, however, divided when it comes to how and whether terrorist attacks affect the general population's mental health. There is a need for studies investigating a broader range of mental health reactions to understand more about how different groups of the population are affected by terrorist attacks, while also illuminating important systemic factors. METHODS: In this study we investigated whether there was any change in the number of consultations with out-of-hours emergency primary care for psychological reactions in association with the 2011 terrorist attacks in Norway. Data covering the entire Norwegian population's primary care contacts in 2008-2013, where the reason for encounter was coded as psychological concerns or psychiatric disorders, were studied. A time series intervention analysis, using ARIMA modelling, was used to estimate whether there was indeed a change in healthcare utilisation associated with the terrorist attacks. RESULTS: The analysis uncovered an increase in contacts with emergency primary care by the overall population for mental health concerns associated with the terrorist attacks. When divided into groups according to geographical proximity to attacks, no significant change was found in the area closest to the attack in Oslo, whereas an increase was found for the rest of the country. There was also heterogeneity across different age groups. An increase was found among youths, young adults, and middle-aged people, but not the other age groups, and an increase was found for both men and women. CONCLUSIONS: These findings highlight the need for primary care services to be prepared to meet mental health reactions in the general population when planning for healthcare provision in the aftermath of terrorism. Simultaneously, it should be noted that needs may vary across different groups of the population.

Preparing for the unexpected: a comparative study of policies addressing post-terror health reactions in Norway and France.

BACKGROUND: In the wake of terrorist attacks, protecting the health and psychosocial wellbeing of those affected and the general population, are important tasks for the healthcare system. The responses to such emergencies are often complex, including different phases and many actors, and may unveil insufficiencies that incite reforms to existing systems. Recently, initiatives have been promoted to strengthen cooperation and coordination regarding the governance of health threats in Europe. Comparative research is requested on how states prepare for health emergencies such as terrorist attacks. This study investigated how governments in two European countries with universal health coverage prepared to address the civilian population's health needs after terrorist attacks, and the factors that contributed to shaping their chosen approach. METHODS: Utilizing document analysis and Walt and Gilson's model for the analysis of health policy, national plans for post-terror health responses in Norway and France were studied with a focus on context, process, content, and actors. RESULTS: Whereas target groups for psychosocial care and certain measures were similar in both cases, the contents of prescribed policies and the actors responsible for enacting them differed. One of the most distinct differences was to what extent specialized mental healthcare was relied upon to provide psychosocial follow-up in the emergency phase. In the French approach, specialized mental healthcare practitioners, such as psychiatrists, psychologists and psychiatric nurses, provided early psychosocial support. In contrast, the Norwegian approach relied on interdisciplinary primary care crisis teams in the local municipalities to provide early psychosocial support, with further involvement of specialized mental healthcare if this was considered necessary. Historical, political, and systemic differences contributed to the variation in the countries' responses. CONCLUSIONS: This comparative study highlights the complexity and diversity of health policy responses to terrorist attacks across countries. Moreover, challenges and opportunities for research and health management in response to such disasters, including possibilities and potential pitfalls for the coordination of this work across Europe. An important first step could be to map out existing services and practices across countries to better understand if and how common core elements for psychosocial follow-up might be implemented internationally.

Psychosocial care responses to terrorist attacks: a country case study of Norway, France and Belgium.

BACKGROUND: The international terrorism threat urges societies to invest in the planning and organization of psychosocial care. With the aim to contribute to cross-national learning, this study describes the content, target populations and providers of psychosocial care to civilians after terrorist attacks in Norway, France and Belgium. METHODS: We identified and reviewed pre- and post-attack policy documents, guidelines, reports and other relevant grey literature addressing the psychosocial care response to terrorist attacks in Oslo/Utøya, Norway on 22 July 2011; in Paris, France on 13 November 2015; and in Brussels, Belgium on 22 March 2016. RESULTS: In Norway, there was a primary care based approach with multidisciplinary crisis teams in the local municipalities. In response to the terrorist attacks, there were proactive follow-up programs within primary care and occupational health services with screenings of target groups throughout a year. In France, there was a national network of specialized emergency psychosocial units primarily consisting of psychiatrists, psychologists and psychiatric nurses organized by the regional health agencies. They provided psychological support the first month including guidance for long-term healthcare, but there were no systematic screening programs after the acute phase. In Belgium, there were psychosocial intervention networks in the local municipalities, yet the acute psychosocial care was coordinated at a federal level. A reception centre was organized to provide acute psychosocial care, but there were no reported public long-term psychosocial care initiatives in response to the attacks. CONCLUSIONS: Psychosocial care responses, especially long-term follow-up activities, differed substantially between countries. Models for registration of affected individuals, monitoring of their health and continuous evaluation of countries' psychosocial care provision incorporated in international guidelines may strengthen public health responses to mass-casualty incidents.

Trust After Terror: Institutional Trust Among Young Terror Survivors and Their Parents After the 22nd of July Terrorist Attack on Utøya Island, Norway.

In the aftermath of terrorist attacks and disasters, public institutions play an important role in re-establishing safety and justice. However, little is known about the importance of institutional trust for victims' potential for healing in the aftermath of mass trauma. This study examines levels of post-terror trust in the police and in the justice system among young survivors from the 2011 Utøya terror attack and their parents. Furthermore, it investigates how institutional trust develops over time among directly affected populations, and whether it is associated with psychological distress. 325 survivors and 463 parents were interviewed face-to-face at wave one (4-5 months post-terror) and 285 survivors and 435 parents at wave two (14-15 months). Levels of institutional trust in victims were compared to general population data from the European Social Survey adjusted for age, gender, and ethnic background. Measures included trust in the police and justice system, post-traumatic stress reactions, anxiety and depression, and quality of life. Trust in the police among survivors and parents was higher than or comparable to trust levels in the general population at wave one, but decreased for survivors and parents at wave two. Trust in the justice system was higher among those directly affected than in the general population, and increased from wave one to wave two. Levels of institutional trust were negatively associated with distress for survivors in both waves and for parents in wave two. Levels of institutional trust were positively associated with perceived quality of life in parents and survivors. Directly affected groups' institutional trust differed from that of the general population following the terrorist attack, although being directly affected did not necessarily imply weakened institutional trust. This study found trust to be institution specific, however, trust in institutions changed with time, and the passing of time might be an important factor in better understanding whether trust will generalize across institutions or not. Institutional trust was negatively associated with psychological distress. This finding highlights the potential for institutions to create a healing post-disaster environment.

Psychosocial care for hospitalized young survivors after the terror attack on Utøya Island: A qualitative study of the survivors' experiences.

OBJECTIVE: The objective of the study was to explore hospitalized youths' experiences with psychosocial care in the hospital after the shooting on Utøya Island, Norway, in 2011. METHODS: 17 hospitalized youths were interviewed face-to-face 30-31 months after the attack. The interviews were analysed using interpretative phenomenological analysis (IPA). The initial reading and coding of the interviews was carried out inductively. To explore the emphasis placed on everyday conversation and ordinary interaction detected during the initial reading, the text was re-read while bearing in mind concepts from the research field of sociology concerning the therapeutic potential in commonplace conversations and situations. RESULTS: The youths highlighted the need for health care workers to embrace essential aspects of their past, present and future. Therefore, three overarching categories emerged related to 1) Remembering the past, 2) Dealing with the present and 3) Preparing for the future. For each temporal category, two related subcategories were identified: Past:Engaging in the trauma narrative; Understanding the trauma reminders; Present: Bringing back normalcy; Being there; Future: Supporting confidence; Instilling trust. CONCLUSIONS: For the youths in the current study, talking with the hospital staff about their traumatic experiences was mostly perceived as positive and linked to various helpful outcomes. In addition to engaging in the trauma narrative, the staff needed to comprehend and address how the traumatic experiences and the hospitalization resulted in the survivors' extended fear and changed appraisals about the world and themselves. Having the time to stay physically and mentally close to the youths and engage in everyday interaction was crucial in rebuilding their sense of safety and bringing back normalcy. The hospital staff played a significant role in strengthening the survivors' confidence in own capabilities and trust in others. The different professionals in the hospital contributed to various aspects of psychosocial care, and both trauma-focused interventions and commonplace conversations and actions were emphasized as important and meaningful approaches.