FY 2018 Bulletin, Issue 7

What we have learned fromthe Tagajo Disaster Survivors
Health Support ProjectMiyagi Disaster Mental Health CareCenterStem Center, Community Support Division
Public health nurse – Yumi Suzuki
Psychiatric social worker – Mebuki Sasaki
Public health nurse – Akemi Ozaki
Public health nurse – Yukie Oba
Doctor – Naru Fukuchi

Introduction
Fully one-third of the city of Tagajo was flooded during the Great East Japan Earthquake and Tsunami of2011. During the disaster, it was one of the hardest-hit regions in the country. From FY 2012 onwards, and atthe city’s request, the Miyagi Disaster Mental Health Care Center began providing health support to disasteraffected residents.
Disaster-affected municipalities have each developed their own unique disaster-victim support initiatives.
Some of the characteristic features of the methodology adopted by this city are that: it conducted several healthsurveys and used the results to identify individuals with health issues that needed to be followed-up on. The
city of Tagajo also deployed support teams made up of individuals from four different support organizations.
To ensure the smooth running of support activities, the Miyagi Disaster Mental Health Care Center team has
endeavored to develop a variety of support tools and systems. For example, proposing shifts to normal business
operations and suggesting measures, based on compiled resident support data, to help disaster victims. In thissection, we will look back on our work in this regard and discuss the characteristics of individuals who required
follow-up visits.
1. BackgroundThe city of Tagajo is located almost exactly in the middle of Miyagi Prefecture, along the coast. As of August
2018, it had a population of 62,365 and 26,839 households. In the Nara Period, it was the site of a large militarybase, and the history of that period lives on to this day, as ruins from that time can be found around the city. It
is a commuter town for Sendai, and every year many individuals move there.
Concerning post-disaster housing reconstruction, by the end of March 2011, the final outfitting of containertype temporary housing had already begun, in six different parts of the city, and move-ins had begun. Disasterpublic housing was built in four places inside the city as of December 2016 and move-ins were complete. Notlong after, in April 2017, the teardown of container-type temporary housing finished. In FY 2011, 1,402 households were living in Miyagi Prefecture private rented housing (prefectural public temporary housing) in thecity. By September 1, 2018, only 8 remained. These 8 households had all been affected by the disaster outsideof the city itself.
In the wake of the disaster, the city of Tagajo conducted several health surveys. Out of all the residents thatresponded, those who seemed to require support were designated “individuals requiring follow-up;” and thecity began to construct a support system to address their needs. Rather than just set up a support desk, supporters
made in-person visits to the homes of these individuals, took stock of the situation, and determined what typeof outreach support (if any) was necessary (Figure 1).
TagajoShiogama HealthCare Center

Center: Inter-supportercollaborations // Improving
support quality

Home nurses (until 2017)(Contract)
Public health nurses, nurses,
dietitians

Case conference(once weekly)

Determine whether to continue support based on support criteria・ Examine and share support
guidelines

Midorigaoka Hospital(until 2016)
Contract/medicalinstitutions

Miyagi Disaster Mental Health Care CenterDoctors, public health nurses, clinicalpsychologists, psychiatric social workers, andnurses, psychiatric social workers, and nurses

Figure 1. Disaster Survivors Health Support Team－ 109 －Parent-Child Survivors Camping Project

Early on in our support work, in FY 2013, many support organizations that were operating in the city were
doing so only because of the results of multiple health surveys. This sort of support system introduced a lot ofvariance into the health assessments of the city’s residents, and our conferences also started to take a lot oftime. At this point, we decided to set up disaster victims' support teams. To provide effective and efficient support, the MDMHCC drafted a set of “Support Withdrawal Criteria” (Table 1), enabling us to provide moreconsistent support to each supporter.
Table 1: Support Withdrawal Criteria① Regularly visits the hospital② Has someone they can seek out for counsel③ Has a relationship with a supporter, etc.
④ Is socially active(volunteering, clubs, etc.)⑤ Meets and interacts with friends, relatives, etc.

⑥ Has hobbies and pastimes(methods to reduce stress)⑦ Has a good relationship with their family⑧ Sleeps well
⑨ Eats well

⑩ Is in good physical health*These “Support Withdrawal Criteria” were drafted in FY 2013 by disaster victim support teams

2. Progress
Immediately after the Great East Japan Earthquake, the city began receiving support both from within andwithout the prefecture; it continued to develop its support initiatives, which included health surveys and homevisits, as it entered each new phase of the post-disaster reconstruction process. From FY 2013 to FY 2018, teams
continued to deploy support based on ① the “Health Survey of Miyagi Prefecture Private Rental Housing” (thePrefectural Temporary Housing Health Survey), and ② the “City Disaster Victim Survey,” administered to individuals requiring follow-up. Survey results were entered and tabulated by an external agency, that handed its
data over to the city at the end of every FY. Thus, individuals requiring follow-ups received support at thebeginning of the following FY.
Table 2: Progress of the Disaster Victim Health Support ProjectHealth Survey Deployment Status from FY 2013 – FY 2018
Circles indicate that the listed initiative was implemented that fiscal year.
Individuals requiring follow-up visits were given support the following year inaccordance with survey results.

PrefecturalTemporary Housing
Health Survey

×City Disaster
Victim Survey

×◆ Flagging criteria for individuals requiring follow-up① Prefectural Temporary Housing Health Survey: K6 score ≥ 13, drinking problems, stopping treatment② City Disaster Victim Survey: K6 score ≥ 13

3. Objectives
Multiple health surveys were combined to flag which individuals required follow-up visits, and we continue
to send out waves upon waves of supporters to home visits. Teams pointed out that “many individuals requiring
follow-up did not need any further support after the one visit,” and that “individuals requiring multiple support
visits should have certain common characteristics.” We thus endeavored to compare the cumulative survey andhome visit data, to reevaluate our support system.
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4. Methods(1) Subjects
The 241 individuals who required, and received, follow-up visits from support teams in FY 2017
became our subjects. They fell into the following three categories: ① individuals requiring follow-up
based on the FY 2016 Prefectural Temporary Housing Health Survey, ② individuals requiring followup based on the FY 2016 City Disaster Victim Survey, and ③ recipients of ongoing support from FY
2016. All individuals in all three of these categories had received and finished receiving support in FY
2017. Based on the characteristics of individuals who had required follow-ups in FY 2017, we analyzed
the characteristics of individuals who “finished receiving support after one visit” and those that “finished receiving support after two or more visits.”① FY 2016 “Prefectural Temporary Housing Health Survey”
The number of target households for this survey was 163; responses were obtained from 74
households (response rate: 45.4%) and were provided by a total of 152 individuals. Criteria used
to flag individuals requiring follow-up visits were: “K6 score ≥ 13;” “drinking problems;” and“stopped treatment” (Table 2). After excluding various system users and residents who had moved
out of the city, we were left with a total of 8 individuals requiring follow-ups, as our subjects.
② FY 2016 “City Disaster Victim Survey”
The number of target households for this survey was 5,027; responses were obtained from 3,023
of them (response rate: 60.1%); they were provided by a total of 7,417 individuals. The criterion
used to flag individuals requiring follow-ups was: “K6 score ≥ 13” (Table 2). After excluding various system users and residents who had moved out of the city, we were left with a total of 200individuals requiring follow-up visits, as our subjects.
③ Individuals requiring follow-up visits who needed continued support
We provided support to 33 people whose support programs had carried over from FY 2016.
(2) Support period
The support period for these individuals extended from April 1, 2017, to March 31, 2018. We tabulated all our results from April 1, 2018, to August 31, 2018.
(3) Methods
In this study, the 241 individuals whose support programs ended in FY 2017 were divided into twogroups: Group A comprised individuals who “finished receiving support after one visit,” whereas Group
B comprised individuals who “finished receiving support after two or more visits.” We then comparedthese two groups across the following categories.
Table 3: Compared attributes① Basic information (sex, age, living situation), family structure, profession, the effect of the disaster② Support impetus (K6 score ≥ 13, drinking problems, stopped treatment)③ Assessment status (physical health, mental health, living situation)④ Support status (physical health counseling, mental health counseling, use of and connection to social resources)⑤ Outcome

Determination of continuation or conclusion of support was made following the Support Withdrawal
Criteria (Table 1) created in FY 2013 by teams after they had examined the Group A and Group B cases.
Individuals that met more than one of these criteria had their support withdrawn. We held team caseconferences for all cases.
(4) Ethical considerations
This study was approved by the Miyagi Disaster Mental Health Care Center’s Ethics Committee
and was carried out with the necessary safeguards for personal information in place.
5. Results
Two hundred and forty-one individuals were selected as subjects for this survey; 194 of them were analyzed
and finished receiving their support in FY 2017. One hundred and forty-two fell into Group A, “finished receiving support after one visit” (73.6%), and 51 fell into Group B “stopped receiving support after two or more visits”(26.4%). Comparison results have been listed in Table 4. In both Group A and Group B, the percentages ofpeople who had “K6 score ≥ 13” or were “under treatment for physical illness” were high. Group B had higher
rates of “has received psychiatric care,” “difficulty sleeping,” and “financial issues.”－ 111 －Parent-Child Survivors Camping Project
Table 4. Subject Characteristics (Comparison of Group A and Group B)

Group A

Finished receiving support after onevisit
142 (74 men, 68 women)

Subjects

Group B

Finished receiving support after
two or more visits
51 (23 men, 28 women)

Mean age

60.6

61.4

Disaster damage (housecompletely destroyed)
Tsunami-affected area

40 (28.2%)

26 (51.0%)103 (72.5%)

36 (70.6%)

K6 score ≥ 13

139 (97.9%)

41 (80.4%)

Drinking problems

22 (15.5%)

10 (19.6%)

Under treatment for physical illness
Has received psychiatriccareDifficulty sleeping

107 (75.4%)

48 (94.1%)

13 (9.2%)

9 (17.6%)

16 (11.3%)

14 (27.5%)

Financial issues

14 (9.9%)

13 (25.5%)

Figure 2 depicts the actual support status of these individuals. The results of a comparison of Groups A andGroup B revealed that Group B had higher percentages of individuals supported by “physical health counseling,”“mental health counseling,” and “use of and connection to social resources” than Group A.
%
60.0

58.8%

50.0
40.0
30.0
20.0
10.00

Group A■ Physical health counselingGroup B

■ Mental health counseling■ Use of and connection to social resources

Figure 2. Results (Comparison of Support Status Between Group A and Group B)

The various combinations of support types that we considered are depicted in Figure 3. Group B had higher
percentages of individuals receiving the following support-type combinations: “physical health counseling andmental health counseling,” “physical health counseling and use of and connection to social resources,” “mental
health counseling and use of and connection to social resources,” and “physical health counseling and mental
health counseling and use of and connection to social resources.” The primary forms of health counseling wereas follows: in terms of physical health, many people were under treatment for high blood pressure and orthopedic
diseases and had been referred to doctors for health counseling. In terms of mental health, many were in counseling for depression, drinking, and sleep problems, and we provided listening support and close support, andthen referred them to psychiatric therapy. Individuals who ran into financial or employment difficulties when
they were undergoing physical or mental health counseling, were referred to independent counseling support
desks or welfare departments.

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80.0
70.0
60.0
50.0
40.0
30.0
20.0
10.00

Physical + mental

Physical + social

Mental + social

Physical + mental + social

Group A ■ Group B

Figure 3. Results (Group A and Group B Comparison of Multiple Support Types)

6．Discussion
Based on the results listed above, it is apparent that disaster victims who required follow-up visits received
a combination of physical health, mental health, and lifestyle (financial, employment, etc.) support. Thesemeasures appear to interact in complex ways.
Figure 4. The Importance of a Comprehensive Perspective in Disaster Victim Support

Collaboration withother organizations
Medicalcare

Health andwelfare

Finances
Living situation

Socialactivities

EmploymentIn addition to being aware of the usual medical, health, and welfare services that are available to disastervictims, supporters need to also obtain information on support systems and services that can cater to survivors’
housing-, social-, financial-, and employment-related needs and endeavor to share the information with eachdisaster victim. This information must be tailored to their needs, involve other organizations, and provide comprehensive support. Since both Group A and Group B included high percentages of subjects “under treatmentfor physical illness,” we believe that furnishing supporters with pertinent knowledge and support techniques
will facilitate the formation of victim-supporter relationships.

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There are limits to what one can deduce from tabulated health survey results. By conducting home visits, wewere able to learn several things, such as the necessity for psychiatric care and financial/employment-related
issues. Subjects' needs and issues became clearer after these visits. Health surveys have given us a chance tocome into contact with isolated individuals—like alcoholics and hikikomori—and with households struggling
with multiple latent issues—like being cut off from medical care and other support services. A K6 score of 13or greater as an index of mental health is a very useful tool that enables us to quickly ascertain the mental stateof a resident during a home visit. However, because both Group A and Group B had a high percentage ofindividuals with a K6 score ≥ 13, that score alone cannot be used to determine the need for continued support
or the severity of a particular individual’s issues.
Acknowledgments
This study was made possible thanks to the assistance of the employees and staff of the Tagajo Health andWelfare Department. Thank you so much for all of your help. Using the results compiled as part of this research
initiative, the city of Tagajo will hold a mental health promotion awareness project called the “Body HealthSalon” for disaster public housing tenants and nearby residents in FY 2018, and they will use a team-based
system therein. We hope that this summary of our work will prove useful in health support initiatives for victimsof future disasters.
The content of this manuscript was presented as “What we have learned from the Tagajo Disaster Survivors
Health Support Project” by Chika Chiba and Shu Kimura, public health nurses in the Division of Social Welfare,
Department of Health and Welfare at Tagajo City Hall, and the staff of the MDMHCC at the 9th Annual Meetingof the Tohoku Mental Health and Welfare Association in Yamagata on September 30, 2018.

References
1) Chika Chiba; Tagajo Disaster Victim Health Support Project: through inter-supporter collaboration．FY
2017 Miyagi Mental Health Care Forum．http: //miyagi-kokoro.org/media/files/%E8%B3%87%E6%96%99%EF%
BC%91%E3%80%80%E5%A4%9A%E8%B3%80%E5%9F%8E%E5%B8%82%E5%8D%83%E8%91%89%E6%B0%8F (5).pdf, accessed 2019.5.31.

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