Health care needs, experiences, and satisfaction after terrorism: a longitudinal study of parents of survivors of the Utøya attack

BACKGROUND

There is scarce knowledge on the health care follow-up of parents of terror attack survivors. This study focused on the mothers and fathers of survivors and examined (1) their perceived health care needs relative to their psychological reactions, physical health problems (unmet health care needs), and adaptation to work; (2) whether sociodemographic characteristics, health problems and social support were associated with unmet health care needs; and (3) how unmet health care needs, sociodemographic characteristics, and experiences with health services associated with overall dissatisfaction during the health care follow-up.

METHODS

Interview and questionnaire data from three waves of the Utøya parent study were analyzed (n = 364). Chi-square tests and t- tests were used to compare unmet physical and psychological health care needs, sociodemographic factors and post-terror attack health reported by mothers and fathers. Logistic regression analyses were used to examine whether sociodemographic characteristics, unmet health care needs, and health care experiences were associated with overall dissatisfaction among mothers and fathers of the survivors during the health care follow-up.

RESULTS

Among the mothers, 43% reported unmet health care needs for psychological reactions, while 25% reported unmet health care needs for physical problems. Among the fathers, 36% reported unmet health care needs for psychological reactions, and 15% reported unmet health care needs for physical problems. Approximately 1 in 5 mothers and 1 in 10 fathers reported "very high/high" needs for adaptation to work. Poorer self-perceived health, higher levels of posttraumatic stress and anxiety/depression symptoms, and lower levels of social support were significantly associated with reported unmet psychological and physical health care needs in both mothers and fathers. Parents with unmet health care needs reported significantly lower satisfaction with the help services received compared to parents whose health care needs were met. Low accessibility of help services and not having enough time to talk and interact with health care practitioners were associated with overall dissatisfaction with the help received.

CONCLUSIONS

Our findings highlight that parents of terror-exposed adolescents are at risk of having unmet psychological and physical health care needs and thus need to be included in proactive outreach and health care follow-up programs in the aftermath of a terror attack.

The psychosocial aid response after the 22/03/2016 attacks in Belgium: a community case study

Introduction

After the terrorist attacks, early psychosocial care is provided to people considered at risk of developing mental health issues due to the attacks. Despite the clear importance of such early intervention, there is very few data on how this is registered, who is targeted, and whether target-recipients accept such aid.

Methods

Using registry data from the Centre General Wellbeingwork (CAW), a collection of centers in the regions Brussels and Flanders that provide psychosocial care, we examined the early psychosocial care response after the terrorist attacks of 22/03/2016 in Belgium.

Results

In total, 327 people were listed to be contacted by the CAW, while only 205 were reached out to (62.7%). Most were contacted within a month (84.9%), and were victims of the attacks (69.8%). Overall, the majority was female (55.6%).

Conclusion

Overall, target recipients were witnesses and survivors of the attacks, though a large proportion of people were not reached by the early outreach.

Post-what stress? A review of methods of research on posttraumatic stress during COVID-19

BACKGROUND

Post-traumatic stress (PTS) was extensively investigated during the COVID-19 pandemic. However, numerous researchers have raised concerns regarding the adherence of many of these studies to the diagnostic criteria for PTSD as outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM) or the International Classification of Diseases (ICD). This review aimed to provide insight into the methodology of research on PTS during the COVID-19 pandemic.

METHODS

Two independent reviewers examined a total of 1129 studies published between 1/01/2020 and 1/07/2023. The investigation focused on the scales employed to assess PTS, the diagnostic framework used (DSM or ICD), whether there was referral to an index-event in the PTS measurement and country where data collection took place.

RESULTS

Among the 1129 studies, 70.0% did not provide any indication of an index-event to which PTS symptoms were attributed. Only 11.3% of the studies explicitly indicated an index-event associated with the PTS symptoms. Furthermore, 54.1% of the studies utilized scales based on DSM-IV criteria. Finally, the majority of PTS-studies had data collections in China, United States and Italy.

CONCLUSION

A limited number of studies conducted during the COVID-19 pandemic reported use of an index-event in their PTS measurement. Furthermore, most studies used scales based on a previous iteration of the most used diagnostical system, namely the DSM. This delay in the implementation of new diagnostic criteria, may impair the clinical relevance of scientific studies.

Initiation of multiple-session psychological care in civilians exposed to the November 2015 Paris terrorist attacks

BACKGROUND

Terrorist attacks can induce post-traumatic stress disorder (PTSD) and depression, which require multiple-session psychological care (MSPC). This study aims at investigating MSPC initiation and associated factors.

METHODS

Data were collected from a web-based survey of civilians 8-12 months after their exposure to the November 2015 Paris terrorist attacks. Depression and partial and full PTSD were assessed using the Hospital Anxiety and Depression Scale and the PCL-5 checklist, respectively. Questionnaires collected data on socio-demographic variables, exposure to the attacks, psychological treatment history, social isolation, somatic problems, having received an outreach psychological support (OPS), consultations with a general practitioner, contact with an association for victims, MSPC initiation and, if not, reasons for not having initiated it. Logistic regressions were used to examine factors associated with MSPC initiation.

RESULTS

Among the 450 respondents, 154 reported having initiated a MSPC after the attacks. Of the 134 who provided the MSPC initiation date, 50% did so during the first month. Among the respondents with at least one of the considered psychological disorders, 53% declared not having initiated yet a MSPC. The primary three reasons for not having initiated a MSPC among people with PTSD were "did not feel the need", "it was not the right time to talk about it", and "not offered". For people with at least one psychological disorder, MSPC initiation was associated with the number of somatic problems, type of exposure (witness, threatened, indirectly exposed), prior psychological treatment, being a woman, being in a relationship, having consulted a psychiatrist or a psychologist, having received an OPS, and being in contact with association for victims.

CONCLUSION

The organization of adequate psychological care after a terror attack must take into account the need for healthcare that may emerge several months after the attack, and that witnesses seem less likely to receive MSPC than persons directly threatened despite their psychological disorder. Associations for victims and OPS seem to facilitate access to MSPC. Furthermore, our findings highlight the need to train physicians to screen for psychological disorders in persons exposed to terrorist attacks who present with somatic disorders.

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.

Terror leaves adolescents behind: Identifying risk and protective factors for high-school completion among survivors of terrorism

Terror exposure increases the risk of somatic and psychological health problems in survivors. Yet, knowledge of how such exposure affects survivors' ability to stay in school is lacking. This study examined whether exposure to the 2011 Utøya terrorist attack in Norway impacted survivors' ability to complete high school. Further, it aimed to identify important peri- and posttraumatic risk and protective factors. Interview data from the Utøya study, collected 4-5 months postterror, were linked to individual educational registry data for 265 survivors. Chi-square tests and ordinal logistic regression analyses were used to examine (a) high school completion among younger survivors (n = 185, age range: 13-18 years, 52.4% female) compared to both older survivors (i.e., who had the possibility of completing high school before the terror attacks; n = 80, age range: 19-21 years, 40.0% female) and the national average and (b) associations between high school completion and physical injury, posttraumatic stress symptoms (PTSS), somatic symptoms, and social support among younger survivors. Younger survivors were significantly less likely to complete high school on time. Among younger adolescents, physical injury, aOR = 0.36, 95% CI [0.16, 0.81]; higher-level PTSS, aOR = 0.54, 95% CI [0.33, 0.88]; and somatic symptoms, aOR = 0.51, 95% CI [0.29, 0.91], lowered the likelihood of on-time completion. Terror exposure in adolescence adversely affects long-term educational functioning in young survivors, which can severely hamper their future prospects. These findings reinforce the need for trauma-sensitive teaching and educator-provided support for adolescents exposed to trauma.

[Psychosocial responses to collective trauma]

Both man-made and natural disasters are societal concerns of actuality that can take a heavy toll on people's health and well-being. It is paramount to understand how to prevent or reduce adverse psychological and social consequences in affected individuals and communities. There is currently an intention of better coordination across Europe to improve the handling of such cross-border health threats. Still, more insight is needed on how different countries respond to their population's psychosocial needs in the wake of disasters. Substantial differences in European countries' psychosocial responses to large-scale terrorist attacks are herein highlighted for Norway, France and Belgium. These differences emphasize the need to improve and harmonize the monitoring, evaluation and research on the provision of post-disaster psychosocial care and support in order to strengthen our capacities to deal with future emergencies.

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.

PTSD and Partial PTSD among First Responders One and Five Years after the Paris Terror Attacks in November 2015

Following the Paris terror attacks in November 2015, a large number of first responders (FR) were mobilized and consequently were at risk of developing posttraumatic stress disorder (PTSD). Based on the ESPA 13 November survey, the objectives of this study were to 1) describe the prevalence of PTSD and partial PTSD in FR five years after the attacks, 2) describe the changes in PTSD and partial PTSD from one to five years after the attacks, and 3) examine factors associated with PTSD and partial PTSD five years after the attacks. Data were collected using an online questionnaire. PTSD and partial PTSD were measured using the Post-Traumatic Stress Disorder Checklist based on the DSM-5 (PCL-5). Gender, age, responder category, education level, exposure, mental health history, history of traumatic events, training, social support, concern about the COVID-19 epidemic, and somatic problems present after the attacks were all analyzed as potential factors associated with PTSD and partial PTSD using multinomial logistic regression. A total of 428 FR were included 5 years after the attacks, of which 258 had participated also 1 year after the attacks. Five years after the attacks, the prevalence of PTSD and partial PTSD were 8.6% and 22%, respectively. Presence of somatic problems after the attacks were associated with PTSD. Involvement in dangerous crime scenes was associated with a higher risk of partial PTSD. No awareness of psychological risks in the context of professional activity through specific training was associated with partial PTSD, in particular among participants aged 45 years or more. To mitigate PTSD for FR, monitoring mental health symptoms, providing mental health education, and providing treatment may be needed for several years after the attacks.

Threat through the Screen? Association between Proximity and/or Watching Media Coverage of a Terrorist Attack and Health

INTRODUCTION

After terrorist attacks, media coverage of the attacks is extensive. There are some indications that there is an association between watching the media coverage and certain health reactions, both mental and somatic. Most studies occur in the United States and often months after the initial attack. In the current study, we investigated the terrorist attacks in Belgium on 22 March 2016.

METHODS

An online cross-sectional survey was conducted one week after the attacks among the general population of Belgium. We measured hours of media watching of the terrorist attacks (hereafter media watching), adjusted scales of the Patient Health Questionaire-4 (PHQ-4) to measure mental symptoms and the Patient Health Questionaire-15 (PHQ-15) to measure somatic symptoms, proximity to Brussels (home, work and overall proximity) and background factors such as gender, age and level of education. Respondents were included if they answered the survey between 29 March 2016 and 5 April 2016.

RESULTS

A total of 2972 respondents were included. Overall, media watching was significantly associated with both mental symptoms (p < 0.001) and somatic symptoms (p < 0.001), while controlling for age, gender, level of education and proximity. Watching more than three hours of media was associated with more mental and somatic symptoms (p < 0.001). Compared to proximity, media watching was, in general, a better association. For geographical factors, watching more than three hours of media indicated equally high scores for mental symptoms and somatic symptoms as work proximity (p = 0.015) and overall proximity to the attacks (p = 0.024).

CONCLUSION

Media-watching is associated with acute health reactions after terrorist attacks. However, the direction of the relationship is unclear, as it might also be that people with health issues seek out more media.

Healthcare utilization after mass trauma: a register-based study of consultations with primary care and mental health services in survivors of terrorism

BACKGROUND

Knowledge on healthcare utilization after mass trauma is needed to strengthen the public health preparedness to such incidents. Using register-based data, this study had a unique opportunity to investigate how young survivors' use of primary care physicians (PCP) and mental health services (MHS) changed after a terrorist attack.

METHODS

We examined register-based data on PCP and MHS consultations among 255 survivors (52% male) of the 2011 Utøya youth camp attack in Norway 3 years before and after the attack, and their reason for encounter with the PCP according to the International Classification for Primary Care (ICPC- 2).

RESULTS

The PCP and MHS consultation rates (CR) were higher in female than male survivors both acutely and at long-term. The mean yearly CRs increased from 2.25 to 4.41 for PCP and 1.77 to 13.59 for MHS the year before and after the attack in female survivors, and from 1.45 to 3.65 for PCP and 1.02 to 11.77 for MHS in male survivors. The third year post-attack CRs for PCP were 3.55 and 2.00; and CRs for MHS were 5.24 and 2.30 in female and male survivors, respectively. Among female survivors, 76% consulted PCP and 12% MHS the year preceding the attack; post-attack 93% consulted PCP and 73% MHS the first year; decreasing to 87 and 40% the third year. Among male survivors, 61% consulted PCP and 7% MHS the year preceding the attack; post-attack 86% consulted PCP and 61% MHS the first year, and 67 and 31% the third year. As for PCP consultations, there was a particular increase in psychological reasons for encounter following the attack.

CONCLUSIONS

This study indicates that it is important to anticipate an increased healthcare utilization several years following mass trauma, particularly of MHS. Both PCP and MHS practitioners played important roles in providing healthcare for psychological problems in young survivors of terrorism in a country with universal and largely publicly financed healthcare and a gatekeeping system. The healthcare utilization could be different in countries with other health systems or psychosocial care responses to mass trauma.

Preparing for the unexpected: Comparing plans for post-terror health response in Norway and France

Background

How healthcare systems should respond to health and psychosocial needs in the population after terrorism is debated. Still, there has been recent interest for more coordinated health threat governance in Europe. Studies comparing approaches to health emergency contingency in different countries are thus needed. This poster will present a comparative study of how France and Norway planned for disaster follow-up prior to four major terrorist attacks, and how differences in the approaches can be understood.

Methods

National plans and guidelines from France and Norway, planning the response to mass casualty incidents relevant to four terrorist attacks in 2011, 2015 and 2016 were analyzed, by document analysis. Walt and Gilson's health policy model, focused on context, process, content and actors guided the analysis.

Results

The countries’ approaches were similar regarding identified target groups of prescribed measures and contents of some measures, however historical and systemic differences shaped approaches to post-terror needs. The countries deviated particularly on who the actors responsible for providing care were, and also the content of some measures. For instance, in France specialized mental health care were more involved in early psychosocial care than in Norway, where primary care approaches were more salient.

Conclusions

Contextual factors appear to affect how healthcare contingency is planned, and finding one approach applicable in all national contexts appears challenging. Still, the presentation will discuss the potential for identifying core elements for psychosocial and healthcare follow-up that can be relevant in different contexts.

Key messages

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.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-022-07691-2.

Remote training as a common tool for the different professionals involved in the acute phase after terror attacks across Europe: Perspectives from an expert panel

The acute response after a terror attack may have a crucial impact on the physical and psychological wellbeing of the victims. Preparedness of the professionals involved in the acute response is a key element to ensure effective interventions, and can be improved through trainings. Today in Europe there is a recognized lack of inter-professional and international trainings, which are important, among others, to respond to the needs and the rights of victims affected by a terrorist attack in another country than their home country. In this paper we report the perspectives of an expert panel composed by different categories of professionals on the possible role of interprofessional trainings provided remotely. The experts discussed the pertinence of remote trainings for professionals involved in the acute response of a terror attack, and highlighted their Strengths, Weaknesses, Opportunities and Threats (SWOT analysis). We concluded that, while remote trainings cannot replace in-person trainings, they may be useful to share knowledge about the role and the organization of the different categories of professionals, thus potentially improving response coordination, and to easily share good practices across professionals and countries.

Media Exposure and Post-traumatic Stress Symptoms in the Wake of the November 2015 Paris Terrorist Attacks: A Population-Based Study in France

The intense mass media coverage of the Paris terrorist attacks on November 13, 2015 exposed a majority of the French population to the attacks. Prior research has documented the association between media exposure to terrorism and post-traumatic stress symptoms (PTSS). The present study replicated and extended these findings in a French sample. A population-based sample (N = 1,760) was drawn from a national web-enabled panel in June 2016. Hours of attack-related media exposure (i.e., TV-watching, viewing internet images, engaging in social media exchanges) in the 3 days following the attacks were assessed. Multivariate regression models, adjusting for gender, age, direct exposure (i.e., witnessing in person or knowing someone injured or killed), residential area, social support, pre-attack mental health service utilization, and other adverse life events, examined the association between media exposure and PTSS (assessed using the self-report PCL-5). Compared to those reporting less than 2 hours of daily attack-related television exposure, those reporting 2-4 hours (β = 3.1, 95% CI = 0.8-5.3) or >4 hours (β = 4.7, 95% CI = 2.0-7.4) of media exposure reported higher attack-related PTSS. This finding was replicated with social media use: those with moderate (β = 3.2, 95% CI = 0.9-5.5) or high (β = 6.8, 95% CI = 1.9-11.7) use reported higher PTSS than those reporting no use. Subanalyses demonstrated that media exposure and PTSS were not associated in those directly exposed to the attacks. Results highlight the potential public health risk of extensive mass media exposure to traumatic events.

Use of mental health supports by civilians exposed to the November 2015 terrorist attacks in Paris

Background

The use of mental health supports by populations exposed to terrorist attacks is rarely studied despite their need for psychotrauma care. This article focuses on civilians exposed to the November 2015 terrorist attacks in Paris and describes the different combinations of mental health supports (MHSu) used in the following year according to type of exposure and type of mental health disorder (MHD).

Methods

Santé publique France conducted a web-based survey of civilians 8–11 months after their exposure to the November 2015 terrorist attacks in Paris. All 454 respondents met criterion A of the DSM-5 definition of post-traumatic stress disorder (PTSD). MHD (anxiety, depression, PTSD) were assessed using the PCL-5 checklist and the Hospital Anxiety and Depression Scale. MHSu provided were grouped under outreach psychological support, visits for psychological difficulties to a victims’ or victim support association, consultation with a general practitioner (GP), consultation with a psychiatrist or psychologist (specialist), and initiation of regular mental health treatment (RMHT). Chi-squared tests highlighted differences in MHSu use according to type of exposure (directly threatened, witnessed, indirectly exposed) and MHD. Phi coefficients and joint tabulations were employed to analyse combinations of MHSu use.

Results

Two-thirds of respondents used MHSu in the months following the attacks. Visits to a specialist and RMHT were more frequent than visits to a GP (respectively, 39, 33, 17%). These were the three MHSu most frequently used among people with PTSD (46,46,23%), with depression (52,39,20%), or with both (56,58, 33%). Witnesses with PTSD were more likely not to have RMHT than those directly threatened (respectively, 65,35%). Outreach support (35%) and visiting an association (16%) were both associated with RMHT (Phi = 0.20 and 0.38, respectively). Very few (1%) respondents initiated RMHT directly. Those who indirectly initiated it (32%) had taken one or more intermediate steps. Visiting a specialist, not a GP, was the most frequent of these steps.

Conclusion

Our results highlight possibilities for greater coordination of mental health care after exposure to terrorist attacks including involving GP for screening and referral, and associations to promote targeted RMHT. They also indicate that greater efforts should be made to follow witnesses.

Non-participation and attrition in a longitudinal study of civilians exposed to the January 2015 terrorist attacks in Paris, France

BACKGROUND

Non-participation and attrition are rarely studied despite being important methodological issues when performing post-disaster studies. A longitudinal survey of civilians exposed to the January 2015 terrorist attacks in Paris, France, was conducted 6 (Wave 1) and 18 months (Wave 2) after the attacks. We described non-participation in Wave 1 and determined the factors associated with attrition in Wave 2.

METHODS

Multivariate logistic regression models were used to compare participants in both waves with those who participated in the first wave only. Analyses were performed taking the following factors into account: socio-demographic characteristics, exposure to terror, peri-traumatic reactions, psychological support, perceived social support, impact on work, social and family life, and mental health disorders. Characteristics of new participants in Wave 2 were compared with participants in both waves using a chi-square test.

RESULTS

Of the 390 persons who were eligible to participate in the survey, 190 participated in Wave 1 (participation rate: 49%). The most frequently reported reason for non-participation was to avoid being reminded of the painful event (32%, n = 34/105). In Wave 2, 67 were lost to follow-up, 141 people participated, of whom 123 participated in Wave 1 (re-participation rate: 65%) and 18 were new. Attrition in Wave 2 was associated with socio-demographic characteristics (age, French origin) and location during the attacks, but not with terror exposure or mental health disorders. Compared with those who participated in both waves, new participants declared less social and psychological support since the attacks.

CONCLUSIONS

Attrition at 6 months was not associated with exposure to terror or mental health disorders, which indicates that any bias in future analyses on IMPACTS on mental health outcomes will be limited. Our findings suggest the importance of adapting similar surveys for people of foreign origin and of improving strategies to avoid attrition of younger people, for example by using social media, peers, and the educational environment. The present study also revealed that a high level of exposure to terror and a lack of social and psychological support after a terrorist event could impede individuals' participation in similar surveys in the short term.

Factors associated with PTSD and partial PTSD among first responders following the Paris terror attacks in November 2015

During the evening of 13 November 2015, the deadliest terror attacks in France in recent times occurred in the Paris area. Overall, 130 people were killed, 643 were physically injured and several thousands were psychologically impacted. Thousands of first responders, including health professionals, firefighters, affiliated volunteers and police officers were mobilized that night and during the subsequent weeks. The aims of our study were to measure the psychological impact on first responders in terms of post-traumatic stress disorder (PTSD) and partial PTSD as well as associated factors 12 months after the 13 November 2015 terrorist attacks. First responders who had intervened during the night and/or the aftermath of the terror attacks had the possibility of answering a web-based study 8-12 months after the attacks. They satisfied criterion A of the DSM 5 definition of PTSD. PTSD and partial PTSD were measured using the PCL-5. Gender, age, educational level, exposure, first responder category, mental health and traumatic event history, training and social support were all analysed as potential factors associated with PTSD and partial PTSD, using multinomial logistic regression. Overall, 663 participants were included in this analysis. Prevalence of PTSD in our sample went from 3.4% among firefighters to 9.5% among police officers and prevalence of partial PTSD from 10.4% among health professionals to 23.2% among police officers. Low educational level and social isolation were associated with PTSD and partial PTSD. Intervention on unsecured crime scenes and lack of training were associated with PTSD. Special attention should be given to first responders living in social isolation, those with low educational levels and those who intervene in unsecured crime scenes. Education and training about the potential mental health consequences of mass trauma intervention should be developed.

Returning to school after a terror attack: a longitudinal study of school functioning and health in terror-exposed youth

Terrorist attacks and mass shootings often involve youth. Knowledge is needed on how this may impact their health and functioning. This study investigates perceived academic performance and school wellbeing in 237 terror-exposed survivors of the Utøya youth camp attack according to their sociodemographic characteristics, health and mental health service (MHS) utilization. Semi-structured interviews were conducted after 4-5 and 14-15 months. The year following the attack, 143 (61%) survivors reported impaired academic performance and 66 (29%) impaired school wellbeing. Female survivors more often reported impaired performance. Non-Norwegian origin, being financially disadvantaged and less social support were associated with impaired wellbeing. Sleep problems, posttraumatic stress, anxiety/depression, somatic symptoms, and lower life satisfaction were associated with both impaired performance and impaired wellbeing. Survivors who had received MHS were more likely to report impaired or improved academic performance and school wellbeing. Higher age and posttraumatic stress reactions were associated with impaired academic performance after multivariate logistic regression adjustments for gender, somatic symptoms and social support. When additionally adjusting for impaired school wellbeing, age and impaired wellbeing were associated with impaired performance. Only posttraumatic stress reactions were associated with impaired wellbeing after similar adjustments. Non-Norwegian origin and being financially disadvantaged were not significantly associated with impaired wellbeing after adjusting for posttraumatic stress reactions, age and gender. Our findings demonstrate how a terrorist attack can considerably deteriorate young survivors' performance and wellbeing at school, which is associated with poorer health. Consequently, it is important to provide appropriate school support, and coordinate MHS with follow-up at school.

Factors associated with trace evidence analyses and DNA findings among police reported cases of rape

OBJECTIVE

The aim of this study was to examine the association between victim, suspect and assault characteristics and (1) forensic analysis of trace evidence, (2) detection of spermatozoa and (3) DNA match in police-reported cases of rape/attempted rape. In addition, we explored whether DNA findings were associated with legal outcome.

METHODS

We conducted a retrospective, descriptive study based on police-reported rapes and attempted rapes of women  ≥16 years of age in Sør-Trøndelag Police District throughout 1997-2010. Police data were merged with information from the Sexual Assault Centre (SAC) at St. Olavs University Hospital, Trondheim, Norway. We used binary and multivariable logistic regression for the comparisons.

RESULTS

We identified 324 victims (mean age 24 years). The police requested analysis in 135 (45%) of the 299 collected victim samples. The police decision to analyze was after adjustment associated with the victim being employed or under education, and a public venue, but not with interval from assault to sampling. Spermatozoa were detected in 79 (61%) of the analyzed cases, of which 71 were collected from victims within 24h. Interval from assault being <24h and reporting a penetrative assault remained associated with the findings of spermatozoa after adjustments. Forensic analyses of trace evidence collected from victim, suspect and/or venue disclosed matching DNA profiles in 57 (40%) of a total of 143 analyzed cases. Matching DNA profiles were associated with suspect being known to the victim and with the venue being private. A higher proportion of cases with a DNA match were prosecuted in court: 20 of the 29 cases prosecuted. However, despite a DNA match 35 cases were anyway dismissed because of insufficient evidence.

CONCLUSIONS

Although many of the associations in our study were expected, it is still important to report the actual numbers to gain insight into the importance of a DNA match in legal proceedings. A substantial proportion of cases with DNA match was dismissed because of insufficient evidence. To strengthen the justice response to sexual assault, it is essential to generate knowledge about the role of medico-legal evidence in such cases, and there are obviously other non-medical factors influencing the legal decisions.

Healthcare to parents of young terrorism survivors: a registry-based study in Norway

OBJECTIVES

To assess changes in parents' short-term and long-term primary and specialised healthcare consumption following a terrorist attack threatening the lives of their children.

DESIGN

Registry-based study comparing parental healthcare service consumption in the 3 years before and the 3 years after a terrorist attack.

SETTING

The aftermath of the Utøya terrorist attack. The regular, publicly funded, universal healthcare system in Norway.

INTERVENTION

Parents learning of a terrorist attack on their adolescent and young adult children.

PARTICIPANTS

Mothers (n=226) and fathers (n=141) of a total of 263 survivors of the Utøya terrorist attack (54.6% of all survivors 13-33 years, n=482).

MAIN OUTCOME MEASURES

We report primary and specialised somatic and mental healthcare service consumption in the early (0-6 months) and delayed (>6-36 months) aftermath of the attack, both in terms of frequency of services consumed (assessed by age-adjusted negative binomial hurdle regression) and proportions of mothers and fathers provided for (mean semiannual values). The predisaster and postdisaster rates were compared by rate ratios (RRs), and 95% CI were generated through bootstrap replications.

RESULTS

Frequency of primary healthcare service consumption increased significantly in both mothers and fathers in the early aftermath of the attack (mothers: RR=1.97, 95% CI 1.76 to 2.23; fathers: RR=1.73, 95% CI 1.36 to 2.29) and remained significantly elevated throughout the delayed aftermath. In the specialised mental healthcare services, a significant increase in the frequency of service consumption was observed in mothers only (early: RR=7.00, 95% CI 3.86 to 19.02; delayed: RR=3.20, 95% CI 1.49 to 9.49). In specialised somatic healthcare, no significant change was found.

CONCLUSION

Following terrorist attacks, healthcare providers must prepare for increased healthcare needs in survivors and their close family members, such as parents. Needs may present shortly after the attack and require long-term follow-up.

Does posttraumatic stress predict frequency of general practitioner visits in parents of terrorism survivors? A longitudinal study

Background: Life threat to children may induce severe posttraumatic stress reactions (PTSR) in parents. Troubled mothers and fathers may turn to their general practitioner (GP) for help. Objective: This study investigated frequency of GP visits in mothers and fathers of adolescent and young adult terrorism survivors related to their own PTSR and PTSR in their surviving children. Method: Self-reported early PTSR (4-5 months post-disaster) in 196 mothers, 113 fathers and 240 survivors of the 2011 Utøya terrorist attack were linked to parents' three years pre- and post-disaster primary healthcare data from a national reimbursement claims database. Frequency of parents' GP visits was regressed on parent and child PTSR, first separately, then in combination, and finally by including an interaction. Negative binominal regressions, adjusted for parents' pre-disaster GP visits and socio-demography, were performed separately for mothers and fathers and for the early (<6 months) and delayed (6-36 months) aftermath of the terrorist attack. Results: Parents' early PTSR were significantly associated with higher early frequency of GP visits in mothers (rate ratio, RR = 1.31, 95%CI 1.09-1.56) and fathers (RR = 1.40, 95%CI 1.03-1.91). In the delayed aftermath, early PTSR were significantly associated with higher frequency of GP visits in mothers only (RR = 1.21, 95%CI 1.04-1.41). Early PTSR in children were not significantly associated with an overall increase in GP visits. On the contrary, in mothers, child PTSR predicted significant decrease in GP visits the delayed aftermath (RR = 0.83, 95%CI 0.71-0.97). Conclusions: Our study suggests that GPs may play an important role in identifying and providing for parents' post-disaster healthcare needs. GPs need to be aware that distressed individuals are likely to approach them following disasters and must prepare for both short- and long-term healthcare needs.

Research participation after terrorism: an open cohort study of survivors and parents after the 2011 Utøya attack in Norway

Background

Reliable estimates of treatment needs after terrorism are essential to develop an effective public health response. More knowledge is required on research participation among survivors of terrorism to interpret the results properly and advance disaster research methodology. This article reports factors associated with participation in an open cohort study of survivors of the Utøya youth camp attack and their parents.

Methods

Overall, 490 survivors were invited to two semi-structured interviews that were performed 4–5 and 14–15 months after the attack. The parents of 482 survivors aged 13–32 years were eligible for a complementary study. The study had an open cohort design in which all of the eligible survivors were invited to both waves. Pearson’s Chi squared tests (categorical variables) and independent t tests (continuous variables) were used to compare survivors by participation.

Results

Altogether, 355 (72.4 %) survivors participated: 255 in both waves, 70 in wave 1 only, and 30 in wave 2 only. Compared with the two-wave participants, wave-1-only participants were more often non-Norwegian and reported higher exposure, whereas wave-2-only participants reported more posttraumatic stress, anxiety/depression, and somatic symptoms. In total, 331 (68.7 %) survivors had ≥1 participating parents, including 311 (64.5 %) with maternal and 243 (50.4 %) with paternal participation. Parental non-participation was associated with non-Norwegian origin, somatic symptoms and less social support. Additionally, paternal non-participation was associated with having divorced parents, and maternal non-participation was associated with higher age, not living with parents, posttraumatic stress and anxiety/depression symptoms.

Conclusions

Survivors with initial non-participation had more symptoms than did the other participants. Thus, an open cohort design in post-terrorism studies might improve the participation among survivors with higher morbidity. Because the factors associated with maternal and paternal participation differed, it is important to consider potential disparities in the selection of mothers and fathers when interpreting parental data.

Electronic supplementary material

The online version of this article (doi:10.1186/s13104-016-1873-1) contains supplementary material, which is available to authorized users.

Early postdisaster health outreach to modern families: a cross-sectional study

OBJECTIVES

This study investigated whether the early outreach programme following the Utøya massacre reached out to the parents of the young survivors. Additionally, we explored whether specialised mental healthcare services were provided to parents presenting elevated levels of PTSD and depression reactions.

DESIGN

Cross-sectional survey, face-to-face interviews and questionnaires.

SETTING

Norway, aftermath of the Utøya massacre, 4-7 months postdisaster.

BACKGROUND

Following the Utøya massacre, proactive early outreach programmes were launched in all municipalities that were affected, facilitating access to appropriate healthcare services.

PARTICIPANTS

A total of 453 parents of the Utøya survivors aged 13-33 years took part. Overall, 59.8% of the survivors were represented by one or more parent in our study.

MAIN OUTCOME MEASURES

Engagement with the proactive early outreach programme (psychosocial crisis teams and contact persons in the municipalities), utilisation of healthcare services (general practitioner and specialised mental healthcare services) and mental distress (UCLA PTSD-RI and HSCL-8).

RESULTS

A majority of the participants reported contact with the proactive early outreach programme (crisis team, 73.9%; and contact person, 73.0%). Failure of outreach to parents was significantly associated with non-intact family structure (crisis team: OR 1.69, 95% CI 1.05 to 2.72, p=0.032) and non-Norwegian origin (crisis team: OR 2.39, 95% CI 1.14 to 4.98, p=0.021). Gender of the parent was not significantly associated with failure of the outreach programme (p ≥ 0.075). Provision of specialised mental healthcare services was significantly associated with higher levels of PTSD (OR 2.08, 95% CI 1.55 to 2.79, p<0.001) and depression (OR 2.42, 95% CI 1.71 to 3.43, p<0.001) and not with the sociodemography (p ≥ 0.122).

CONCLUSIONS

Proactive early outreach strategies may be helpful in identifying healthcare needs and facilitating access to the required services in a population struck by disaster. Our findings prompt increased attention to the complexity of family structures in reaching out universally to modern families following a disaster.

Health service utilization after terrorism: a longitudinal study of survivors of the 2011 Utøya attack in Norway

Background

For effective organization of health services after terror attacks, it is vital to gain insight into survivors’ health service utilization. Following the 2011 Utøya mass shooting in Norway, a proactive outreach programme was launched to prevent unmet help needs. All survivors received health services during the first five months, yet an important minority were not proactively followed-up. This study assessed the prevalence of health service utilization and factors associated with mental health service utilization among the survivors 5–15 months after the attack.

Methods

The study comprised data from interviews using standardised questionnaires performed 4–5 (T1) and 14–15 (T2) months after the attack. Altogether 281 of 490 (57.3%) survivors answered questions on health service utilization at T2 and were included in this study. Users and non-users of mental health services were compared using Pearson Chi Square tests (categorical variables) and independent t-tests (continuous variables). Multivariate logistic regression analyses were conducted to examine the relationship between mental health service utilization at T2 and early (model 1) and concurrent (model 2) posttraumatic stress reactions, mental distress and somatic symptoms. Both models were adjusted for age, gender and predisaster utilization of mental health services.

Results

Altogether 267 (95.0%) of 281 survivors reported contact with health services at T2, including 254 (90.4%) with ≥1 types of primary care services; and 192 (68.3%) with mental health services. In bivariate analyses, mental health service utilization was associated with female gender, injuries, PTSD, mental distress, somatic symptoms, and sleep problems. After multivariate adjustments for early symptom levels (model 1), only mental distress remained significantly associated with mental health service utilization at T2 (OR 2.8, 95% CI 1.2-6.8). In the analysis adjusting for concurrent symptom levels (model 2), only somatic symptoms were associated with mental health service utilization (OR 4.4, 95% CI 1.8-10.8).

Conclusions

The high utilization of both primary and secondary health services among young survivors 5–15 months after the attack underscores the importance of allocating resources to meet the increased demand for services over a longer time period. The results further highlight the need to address somatic symptoms in disaster survivors who receive mental health services.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-015-0811-6) contains supplementary material, which is available to authorized users.

Intimate partner violence and cardiovascular risk in women: a population-based cohort study

BACKGROUND

A potential link between intimate partner violence (IPV) and cardiovascular disease (CVD) has been suggested, yet evidence is scarce. We assessed cardiovascular risk and incident prescription of cardiovascular medication by lifetime experiences of physical and/or sexual IPV and psychological IPV alone in women.

METHODS

A population-based cohort study of women aged 30-60 years was performed using cross-sectional data and clinical measurements from the Oslo Health Study (2000-2001) linked with prospective prescription records from the Norwegian Prescription Database (January 1, 2004 to December 31, 2009). We used age-standardized chi-square analyses to compare clinical characteristics by IPV cross-sectionally, and Cox proportional hazards regression to examine cardiovascular drug prescription prospectively.

RESULTS

Our study included 5593 women without cardiovascular disease or drug use at baseline. Altogether 751 (13.4%) women disclosed IPV experiences: 415 (7.4%) physical and/or sexual IPV and 336 (6.0 %) psychological IPV alone. Cross-sectional analyses showed that women who reported physical and/or sexual IPV and psychological IPV alone were more often smokers compared with women who reported no IPV. Physical and/or sexual violence was associated with abdominal obesity, low high-density lipoprotein cholesterol, and elevated triglycerides. The prospective analysis showed that women who reported physical and/or sexual IPV were more likely to receive antihypertensive medication: incidence rate ratios adjusted for age were 1.27 (95% confidence interval 1.02-1.58) and 1.36 (CI 1.09-1.70) after additional adjustment for education and systolic and diastolic blood pressure, respectively. No significant differences were found for cardiovascular drugs overall or lipid modifying drugs.

CONCLUSIONS

Our findings indicate that clinicians should assess the cardiovascular risk of women with a history of physical and/or sexual IPV, and consider including CVD prevention measures as part of their follow-up.

Intimate partner violence and prescription of potentially addictive drugs: prospective cohort study of women in the Oslo Health Study

OBJECTIVES

To investigate the prescription of potentially addictive drugs, including analgesics and central nervous system depressants, to women who had experienced intimate partner violence (IPV).

DESIGN

Prospective population-based cohort study.

SETTING

Information about IPV from the Oslo Health Study 2000/2001 was linked with prescription data from the Norwegian Prescription Database from 1 January 2004 through 31 December 2009.

PARTICIPANTS

The study included 6081 women aged 30-60 years.

MAIN OUTCOME MEASURES

Prescription rate ratios (RRs) for potentially addictive drugs derived from negative binomial models, adjusted for age, education, paid employment, marital status, chronic musculoskeletal pain, mental distress and sleep problems.

RESULTS

Altogether 819 (13.5%) of 6081 women reported ever experiencing IPV: 454 (7.5%) comprised physical and/or sexual IPV and 365 (6.0%) psychological IPV alone. Prescription rates for potentially addictive drugs were clearly higher among women who had experienced IPV: crude RRs were 3.57 (95% CI 2.89 to 4.40) for physical/sexual IPV and 2.13 (95% CI 1.69 to 2.69) for psychological IPV alone. After full adjustment RRs were 1.83 (1.50 to 2.22) for physical/sexual IPV, and 1.97 (1.59 to 2.45) for psychological IPV alone. Prescription rates were increased both for potentially addictive analgesics and central nervous system depressants. Furthermore, women who reported IPV were more likely to receive potentially addictive drugs from multiple physicians.

CONCLUSIONS

Women who had experienced IPV, including psychological violence alone, more often received prescriptions for potentially addictive drugs. Researchers and clinicians should address the possible adverse health and psychosocial impact of such prescription and focus on developing evidence-based healthcare for women who have experienced IPV.

Psychotropic drug use among women exposed to intimate partner violence: A population-based study

Aims: To investigate psychotropic drug use among women ever exposed to intimate partner violence (IPV) in relation to mental distress and sociodemographic, lifestyle and somatic health characteristics, and to assess whether drug use differed for physical and/or sexual violence compared with psychological abuse alone. Methods: Cross-sectional data from women aged 30—60 years were drawn from self-reported questionnaires in the Oslo Health study 2000—2001. Women reporting hypnotic, anxiolytic and/or antidepressant drug use in the previous four weeks were defined as users. Differences in psychotropic drug use by IPV exposure were examined by logistic regression analyses. Results: In total, 880 (14%) of 6,471 included women reported ever experiencing IPV; 494 (8%) reported physical and/or sexual IPV, and 386 (6%) reported psychological IPV alone. Physical and/or sexual IPV was significantly associated with use of all psychotropic drugs: hypnotics (odds ratio (OR) 2.28; 95% confidence interval (95% CI), 1.73—3.00); anxiolytics (OR 3.29; 95% CI, 2.43—4.44); and antidepressants (OR 2.72; 95% CI, 1.97—3.76). The associations remained significant for anxiolytics (OR 1.67; 95% CI, 1.14—2.45) and antidepressants (OR 1.50; 95% CI, 1.02—2.19) after adjusting for mental distress, sociodemographic, lifestyle and somatic health characteristics. Psychological IPV alone was associated with use of anxiolytics (OR 1.81; 95% CI, 1.20—2.75) and antidepressants (OR 2.38; 95% CI, 1.64—3.45). After adjustments the association persisted for use of antidepressants only (OR 1.64; 95% CI, 1.05—2.55). Conclusions: Women exposed to IPV were more likely to report use of psychotropic drugs, even after adjusting for mental distress. The study indicates that exposure to IPV; including psychological abuse should be evaluated as a possible source of distress when psychotropic drug treatment is considered.