Social Support and Mental Health after the Disaster
Tohoku J. Exp. Med., 2014, 234, 241-247

241

Social Support Improves Mental Health among the Victims
Relocated to Temporary Housing following the Great East Japan
Earthquake and Tsunami
Shihoko Koyama,1 Jun Aida,1 Ichiro Kawachi,2 Naoki Kondo,3 S V Subramanian,2Kanade Ito,1 Gen Kobashi,4 Kanako Masuno,5 Katsunori Kondo6,7 and Ken Osaka1,8
1

Department of International and Community Oral Health, Tohoku University Graduate School of Dentistry,
Sendai, Miyagi, Japan2
Department of Social and Behavioral Sciences, Harvard School of Public Health, Boston, Massachusetts, USA
3
Department of Health and Social Behavior, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
4
Research Center for Charged Particle Therapy, National Institute of Radiological Science, Chiba, Chiba, Japan
5
Department of Global Health Policy, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
6
Center for Well-being and Society, Nihon Fukushi University, Nagoya, Aichi, Japan
7
Center for Preventive Medical Science, Chiba University, Chiba, Chiba, Japan
8
International Research Institute of Disaster Science, Tohoku University, Sendai, Miyagi, JapanThe victims of the Great East Japan Earthquake and Tsunami have been forced to live in temporary
housing, mainly by two different methods of resettlement: group allocation that preserved pre-existing local
social ties and lottery allocation. We examined the effects of various factors, including the resettlement
methods and social support, on mental health. From February to March 2012, we completed a crosssectional survey of 281 refugees aged 40 years or older, who had lost their homes in the tsunami and were
living in temporary housing in Iwanuma city. Psychological distress of the victims was assessed using the
Kessler Psychological Distress Scale (K6) that consists of six self-reported items. Participants were also
asked whether they had provided or received social support during this time. Participants were categorized
as “providing social support” if they listened to someone else’s concerns and complaints, or “receivingsocial support” if they have someone who listened to their concerns and complaints. After adjusting for age
and sex, multiple log-binomial regression analysis showed that participants without social support had ahigher risk of psychological distress. Group allocation victims were more likely to receive social support
than those who underwent lottery allocation. However, the resettlement approach did not significantly
correlate with distress. Other factors associated with a higher risk of psychological distress were a youngerage (55 or younger), living with either 3 people or 6 or more people, and having a lower income. The
present results suggest that social support promotes the mental health of disaster victims.
Keywords: disaster victims; psychological distress; resettlement approach; social support; the Great East Japan
Earthquake and Tsunami
Tohoku J. Exp. Med., 2014 November, 234 (3), 241-247. © 2014 Tohoku University Medical Press
The tsunami caused the destruction of more than 390,000
homes, forcing survivors to resettle into temporary housing.
The disaster also caused physical and mental health problems (Moriyama and Kaga 2013; Ochi et al. 2013; Tuerk et
al. 2013; Yamashita and Shigemura 2013) and disasterrelated stressors (Shultz et al. 2013).
Residents of temporary housing face enormous psychological strain in coping with the loss of family, friends,
and relatives; physical injury; changing living environments; loss of property and jobs; and the disruption ofsocial networks. Because the coastal areas of Japan are at a

Introduction
Disasters are an increasing public health concern (Noji2005; Limpakarnjanarat and Ofrin 2009); in 2010 alone,
there were 373 disasters around the globe, causing around
296,800 deaths (Centre for Research on the Epidemiology
of Disasters: http://www.emdat.be/). The National Police
Agency of Japan (https://www.npa.go.jp/archive/keibi/biki/
higaijokyo_e.pdf) reported on March 11, 2011 that theGreat East Japan Earthquake and Tsunami killed more than
15,000 people (with an additional 2,600 reported missing).

Received June 19, 2014; revised and accepted October 16, 2014. Published online November 8, 2014; doi: 10.1620/tjem.234.241.
Correspondence: Shihoko Koyama, Department of International and Community Oral Health, Tohoku University Graduate School of
Dentistry, 4-1 Seryo-machi, Aoba-ku, Sendai, Miyagi 980-0872, Japan.
e-mail: shihoko-koyama@umin.ac.jp

241

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S. Koyama et al.

higher risk of future tsunamis, local governments haverestricted many victims from rebuilding their houses, andhave instead created various plans to rebuild towns for thevictims; these include developing new towns on mountainsides or building higher bases for new towns along thecoasts. However, because these recovery plans will takeseveral years to complete, victims are forced to live in temporary houses for an extended period. Being forced into
temporary housing following a disaster has been documented as an important factor that determines how survivors recover (Yzermans et al. 2005; Neria et al. 2008;
Uscher-Pines 2009; Tomiyasu et al. 2013; Tanimura et al.
2014).
Recent studies have highlighted the importance ofsocial ties in disaster recovery (Nakagawa and Shaw 2004;
Aldrich 2010; Tomiyasu et al. 2013; Xin et al. 2013;
Tanimura et al. 2014). Aldrich (2011, 2012) showed that
communities rich in social capital recovered more quickly
after disasters. In addition, interpersonal connectedness is
considered a key factor for mental health recovery in the
short and middle terms after disasters (Hobfoll et al. 2007).
In contrast, the disruption of social relationships among
victims due to the disaster can exacerbate secondary traumas (Long and Wong 2012).
Following the earthquake and tsunami, Japanesemunicipal governments quickly began to build temporary
housing structures. Two main methods were adopted toresettle victims into temporary housing. In the first
approach, the victims were randomly allocated to temporary housing as housing became available, using a lottery
system (lottery allocation). In the alternative approach, thelocal authorities attempted to preserve local social ties bymoving members of a community together into the same
flat of housing (group allocation). The former method ismore straightforward for local governments from an operational perspective, but has the drawback of disrupting social
ties within communities. In contrast, the latter approachpreserves community ties (Tomiyasu et al. 2013), butinvolves longer delays to ensure that housing can be provided for everyone; furthermore, group allocation requires
a considerably greater effort on the part of local governments. To our knowledge, no study has examined the effectof these two resettlement methods on the social support andmental health of survivors. Accordingly, our study sought
to determine the impact of these resettlement approaches onsocial support and mental health, accounting for sociodemographic factors, among the relocated victims living in
temporary housing in Miyagi, one year after the earthquake
and tsunami.

Methods
Study setting
The present cross-sectional study was conducted in Iwanuma
city as part of the Japan Gerontological Evaluation Study (JAGES)
Project (Kondo 2010; Takeuchi et al. 2013). The JAGES project is an
ongoing prospective cohort study investigating the social and behav-

ioral factors associated with the loss of health. Iwanuma was a fieldsite of the JAGES project. It is a coastal municipality in the Miyagi
prefecture, about 50 km south of Sendai and 80 km west of the epicenter of the 3.11 earthquake (Ishigaki et al. 2013). Iwanuma suffered tremendous damage from the Great East Japan Earthquake andTsunami, with 180 people killed by the tsunami (Ishigaki et al. 2013)
and 48% (29 km2) of land inundated by seawater (Geospatial
Information Authority of Japan: http://www.gsi.go.jp/common/
000060371.pdf). Iwanuma city government exerted large efforts forgroup allocation for the disaster victims. The survey was conducted
between February 27 and March 3, 2012. The study subjects werelocal residents aged 40 years or older who had lost their homes in thetsunami and were still living in temporary housing. Out of the original JAGES baseline sample, 504 subjects met the inclusion criteria
and 376 (72.8%) participated in our questionnaire survey. Although
missing responses on the Kessler Psychological Distress Scale (K6)
(Kessler et al. 2002, 2003), mental health outcome composed by 6questions, were imputed using the average score on the remaining K6
items, data from a further 95 subjects were excluded because of no
responses to the K6 scale. Thus, the total number of subjects in theseanalyses was 281.
The study protocol was approved by the Research Ethics
Committee of Tohoku University, Graduate School of Dentistry. All
participants provided informed consent.
Outcome variable
The outcome variable, psychological distress, was assessedusing the K6 scale. It consists of six self-reported items that assess
the symptoms of serious psychological distress. The K6 has beenused to screen for anxiety and other mood disorders. Specifically, thescale asks respondents how frequently they have experienced symptoms of psychological distress (e.g., “feeling so sad that nothing cancheer you up”) during the past 30 days. Responses to each item arerecorded using a five-point Likert scale (0 = “all of the time,” 1 =“most of the time,” 2 = “some of the time,” 3 = “a little of the time,”and 4 = “none of the time”); the scores for each item are then summed
to produce an overall score ranging from 0 (“no distress”) to 24(“maximum distress”). A score of 13 points or higher on the K6 isconsidered equivalent to a score of less than 60 on the Global
Assessment of Functioning (GAF) scale, according to previous
research (Kessler et al. 2003). Therefore, we used this cutoff score of
13 as the definition of serious psychological distress. We used theJapanese version of the K6, which was developed through a standard
back-translation procedure and has been validated (Furukawa et al.
2008). The internal consistency reliability (Cronbach’s alpha) for the
K6 total score in our sample was 0.92.
Predictor variables
Two main resettlement approaches were used by municipal
authorities: (1) victims were resettled en masse according to co-residence in the same communities before the earthquake and tsunami(group allocation) and (2) victims were randomly allocated to temporary housing (lottery allocation). We asked subjects to report themethod of allocation (group or lottery allocation) in the questionnaire.
Social support was measured using two items: “Do you have someone who listens to your concerns and complaints?” (categorized as‘receiving social support’) and “Do you listen to someone else’s concerns and complaints?” (providing social support).
In addition, we inquired about sociodemographic factors,

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Social Support and Mental Health after the Disaster
comorbid health conditions, and other risk factors for serious psychological distress. Demographic factors included sex, age, marital status, and number of people living together. Age was grouped intoquartiles: 55 years or younger, 56-62 years, 63-71 years, and 72 years
or older. Marital status was classified into five groups: married, widowed, divorced, never married, and other. The number of people living in the same temporary housing was categorized into six groups:
living alone (answered 0 or 1) and 2, 3, 4, 5, or 6 people or more. For
socioeconomic factors, participants were also asked about theirannual household income and job status. Income was categorized as< ¥1000000, ¥1,000,000-1,999,999, ¥2,000,000-2,999,999,¥3,000,000-3,999,999, and ≥ ¥4,000,000. Job status was categorized
into six groups, as follows: 1 employment was not affected by theearthquake; 2 unemployed by the earthquake and still unemployed; 3
unemployed by the earthquake, but re-employed in the same occupation; 4 unemployed by the earthquake, but re-employed in anotheroccupation; 5 unemployed before and after the earthquake (e.g.,
retired, homemaker); and 6 unemployed before the earthquake, but
now employed. Current medical treatment and activities of daily living (ADL) were included as health status indicators. Current medical
treatment was assessed using the question: “Are you receiving hospital-based treatment for any condition?” Subjects could answer “yes”
or “no.” ADL was assessed with a single item: “Can you walk, take abath, and use the toilet without assistance?” The answer was dichotomized into “no disability” and “some disability.”
Statistical analysis
To determine the associations between the resettlement
approach and social support variables, cross-tabulation and chi-squareanalyses were performed. Multiple log-binomial regression analysis
was then used to examine the associations between each variable andserious psychological distress (Barros and Hirakata 2003). In the initial models, sex and age were adjusted to examine how the resettlement approach and social support variables were associated with serious psychological distress (subjects with a K6 score of ≥ 13). In themultivariate adjusted model, we included all variables simultaneously.
Missing answers for predictor variables were added into the models
as dummy variables.
The significance level was set at 5% (two-tailed). We used
STATA SE version 12.1 (Stata Corp., College Station, TX, USA) for
all analyses.

Results
A total of 281 subjects were included in the present
analyses. Even one year after the disaster, 101 subjects(35.9% of all respondents) were experiencing serious psychological distress, defined as scoring 13 points or higher
on the K6. Table 1 shows the descriptive statistics. The
prevalence of serious psychological distress among respondents who underwent group versus lottery allocation was
34.9% and 40.7%, respectively ( p = 0.361). Respondents
who reported higher psychological distress tended to bewithout social support, be younger, be receiving some formof medical treatment, and have a lower annual householdincome.
Fig. 1 shows the association between the resettlement
approach and the presence of social support. Respondents
who experienced group allocation to temporary housing

were more likely to both provide social support to others
and to receive social support, compared with the respondents who underwent lottery allocation (receiving social
support: p = 0.003, providing social support: p = 0.050).
To examine the association between the resettlement
approach and social support variables, age- and sexadjusted log-binomial regression models were used (Table
2, age- and sex-adjusted model). Table 2 excluded missing
variable. We found that the resettlement approach was not
significantly associated with serious distress. However,
respondents who reported that they were not receiving orproviding social support were 2.50 and 1.93 times more
likely to have serious psychological distress, respectively,
compared with those who were receiving or providing
social support. Other covariates partially explained theassociation between social support and mental health in themultivariate model. Factors associated with a higher risk ofserious psychological distress were a younger age (55 oryounger), living with either 3 people or 6 or more people,
having other marital status, receiving medical treatment,
and having a lower income.

Discussion
In the present study, we found that even one year after
the disaster, 35.9% of refugees living in temporary housing
reported serious psychological distress. Survivors who
underwent group allocation to temporary housing (and werethus living in proximity to people who were their neighbors
before the disaster) were significantly more likely to report
receiving social support than those who underwent lottery
allocation. Moreover, respondents who were receivingsocial support showed significantly lower psychologicaldistress, although the resettlement approach was not significantly associated with distress.
Relocation due to disasters has been found to be an
important health and social insolation risk factor for survivors, according to previous research (Yzermans et al. 2005;
Neria et al. 2008; Uscher-Pines 2009; Tanimura et al. 2014).
The present results suggest that the method of resettlement
to temporary housing is an important predictor of access tosocial support. Relocation to temporary housing together
with pre-disaster community members was significantly
associated with higher social support. Thus, group resettlement appears to preserve the pre-disaster social networks ofcommunity members. Previous research has shown thatsocial support is a key variable for reducing psychologicaldistress in the aftermath of disasters (Galea et al. 2006;
Neria et al. 2008; Kun et al. 2009; Nandi et al. 2009;
Kikuchi et al. 2014; Ootsuka 2014). For future disaster
preparedness, government authorities should take note of
the findings of the present study.
Resettlement approach did not show a significant association with distress, despite it being associated with social
support; however, participants who had experienced group
allocation were less likely to report serious psychologicaldistress than those who were randomly allocated (34.9% vs.

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S. Koyama et al.
Table 1. Sociodemographic characteristics of the study sample (n = 281).

Age
≤ 55
56-62
63-71
≥ 72
Missing
Sex
Male
FemaleMissing
Number of people living together
0, 1 (alone)
2
3
4
5
≥6
Missing
Marital status
MarriedWidowedDivorced
Never married
Other
Current medical treatment
Receiving some treatment
Not receiving any treatment
Missing
ADL (activities of daily living)
Without disability
Some disability
Missing
Relocation
Group allocation
Random allocation
Unknown & Missing
Annual household income< ¥1,000,000¥1,000,000-1,999,999¥2,000,000-2,999,999¥3,000,000-3,999,999≥ ¥4,000,000
Missing
Job status
Job status 1
Job status 2
Job status 3
Job status 4
Job status 5
Job status 6
Missing
Receiving social support
Yes
No
Providing social support
Yes
No
Missing*Chi-square test.

No. of respondents% of respondents with serious
psychological distress

68
70
60
63
20

45.6
34.3
38.3
27.0
30.0

0.241

128
151
2

32.8
39.1
0.0

0.226

37
105
51
42
24
20
2

32.4
39.0
41.2
28.6
25.0
45.0
0.0

0.504

175
52
21
21
12

34.9
34.6
23.8
47.6
58.3

0.255

184
90
7

39.7
27.8
42.9

0.145

249
14
18

35.3
42.9
38.9

0.820

195
27
59

34.9
40.7
37.3

0.361

42
59
48
27
27
78

59.5
47.5
27.1
33.3
14.8
28.2

< 0.001

79
54
22
11
73
8
34

31.6
44.4
40.9
27.3
35.6
25.0
35.3

0.764

250
31

34.0
51.6

0.054

203
62
16

33.0
41.9
50.0

0.212

p value*245Social Support and Mental Health after the Disasterp = 0.003

p = 0.050

100%
90%
80%
70%
60%
50%

No
Yes

40%
30%
20%
10%
0%
Group allocation

Lottery
allocation

Group allocation

Lottery
allocation

Receiving social support

Providing social support

n = 222n = 212Fig. 1. Relationship between relocation methods and receiving/providing social support (p values for chi-square test).

40.7%). This contradictory result might be explained by alack of statistical power because of a smaller sample size.
In addition, in temporary housing, volunteers and local government officials were available to offer support to victims,
often organizing various events and visiting victims seeking
support. It is possible that our questionnaire did notaccount for such support, which may explain the non-significant association between the resettlement approach andmental health.
Even one year after the disaster, a substantial numberof subjects (35.9%) in our study reported mental healthproblems, defined as scoring 13 points or higher on the K6
scale. Among the general population of Japan, only 2.3%scored 13 or higher on the K6 scale (Sakurai et al. 2011).
However, our survey coincided with the anniversary of thedisaster, during which television and newspaper reports
memorialized the victims of the earthquake and resultant
tsunami. Previous studies have reported an increased prevalence of health problems after the broadcasting of pastdisasters (Yzermans et al. 2005; Beaudoin 2007).
Therefore, media attention might have increased the psychological distress of subjects in the current study, meaningthat our results may overestimate the prevalence of psychological distress. An expert review concluded that therequirements for mental health recovery in the short andmiddle terms after disasters included: (1) a sense of safety,(2) calmness, (3) a sense of self- and community efficacy,(4) connectedness, and (5) hope (Hobfoll et al. 2007). All
respondents in our study lost their houses in the tsunami,
and some of the respondents also lost their jobs. Moreover,because of the future tsunami risk, victims have not yet
been allowed to rebuild their homes in the same coastal

areas in which they had lived before the disaster. Recovery
plans that promote economic security and enhanced hope,especially for younger generations, are now desperately
needed.
In the present multivariate analysis, the social support
variables did not show any significant associations with distress. Therefore, there may be mediating factors explaining
the association between social support and psychologicaldistress. In the model, people who were aged 55 or younger
showed a 26.95 times higher risk of mental distress. People
in this age group tended to have jobs, incomes, family
members, and social support. Although these factors protect mental health, after adjusting for them in the model,
younger people showed the highest risk of experiencing
psychological distress. This may be because younger people live with their children and have to rebuild their homes.
In a previous study, income and anxiety were found to be amajor cause of insomnia after a disaster (Misawa 2014).
Younger respondents tended to have more anxiety about
their future, which caused psychological distress. In fact,
we asked participants about their anxiety regarding thefuture, and 58.8% of younger people reported strong anxiety. In the 56-62, 63-71, and 72 or older age groups, therates of strong anxiety reported were 48.6%, 48.3%, and27.0% of participants, respectively.
This study has some limitations that should be noted.
First, the number of subjects was relatively small, decreasing the robustness of our estimates and the stability of themodel after adding various variables. Second, our survey
did not inquire about seriously distressing life events, suchas the death of friends or family members during the disaster.

246

S. Koyama et al.
Table 2. Odds ratios (95% confidence intervals) for respondents with serious psychological distress (n = 281).
Age & sex adjusted

Multivariate adjusted

2.33 (1.12-4.87)
1.46 (0.69-3.07)
1.83 (0.85-3.94)

26.95 (6.51-111.64)
7.32 (2.17-24.66)
4.02 (1.35-11.98)

1.39 (0.84-2.29)

1.59 (0.81-3.13)

1.39 (0.61-3.16)
1.25 (0.49-3.16)
0.65 (0.24-1.75)
0.56 (0.17-1.84)
1.66 (0.53-5.27)

3.13 (0.97-10.13)
4.16 (1.15-15.05)
1.27 (0.32-4.97)
1.51 (0.28-8.09)
6.81 (1.24-37.42)

1.28 (0.58-2.83)
0.49 (0.17-1.47)
1.76 (0.66-4.66)
3.22 (0.92-11.27)

2.54 (0.89-7.23)
0.26 (0.06-1.04)
1.48 (0.37-5.91)
4.40 (1.02-19.00)

2.20 (1.20-4.03)

2.73 (1.27-5.86)

1.80 (0.54-5.93)

1.60 (0.39-6.58)

1.29 (0.55-2.98)
1.58 (0.72-3.47)

0.65 (0.22-1.95)
1.22 (0.46-3.29)

2.50 (1.13-5.52)

2.59 (0.95-7.08)

1.93 (1.03-3.63)

1.38 (0.63-3.02)

12.89 (3.55-46.81)
7.07 (2.06-24.24)
2.64 (0.73-9.47)
3.01 (0.78-11.66)

6.68 (2.41-18.56)
3.87 (1.48-10.15)
1.48 (0.52-4.17)
1.33 (0.43-4.13)

2.59 (1.16-5.80)
2.00 (0.72-5.57)
0.83 (0.20-3.52)
1.87 (0.84-4.19)
0.83 (0.15-4.61)

1.89 (0.71-5.09)
2.74 (0.81-9.26)
0.67 (0.11-3.97)
1.31 (0.48-3.54)
0.61 (0.08-4.74)

Age (ref: ≥ 72)
≤ 55
56-62
63-71
Sex (ref: Male)
FemaleNumber of people living together (ref: 0, 1, alone)
2
3
4
5
≥6
Marital status (ref: Married)
WidowedDivorced
Never married
Other
Current medical treatment (ref: Not receiving any treatment)
Receiving some treatment
ADL (ref: Without disability)
Some disability
Relocation methods (ref: Group allocation)
Random allocation
Unknown
Receiving social support (ref: Yes)
No
Providing social support (ref: Yes)
No
Household-annual income (ref: ≥ ¥4,000,000)< ¥1,000,000¥1,000,000-1,999,999¥2,000,000-2,999,999¥3,000,000-3,999,999
Job status (ref: Job status 1)
Job status 2
Job status 3
Job status 4
Job status 5
Job status 6

Acknowledgments
The study was supported in part by the Japan Associationof National Universities and the Earthquake Disaster Reconstruction and Revitalization of Japan Support Program at theInstitute for Disaster Reconstruction and Regeneration Researchand Grant-in-Aid for Scientific Research (B) (KAKENHI
24390469) from the Japan Society for the Promotion of Science.
The funding bodies had no role in the study design, data collection and analysis, decision to publish, or preparation of themanuscript. The authors thank Drs. Rika Ootsuka, Noriko

Kawashima, Yuki Noguchi, Shin Yoshinaka, Ritsuko Wako,
Shintaro Wakaguri, and Kenji Takeuchi for data collection andproviding us with helpful comments on the research.

Conflict of Interest
The authors declare no conflict of interest.

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