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Impacts of the 2013 Floods on Families' Mental Health in Alberta: Perspectives of Community Influencers and Service Providers in Rural Communities.

Disasters result in great economic, social, and environmental upheaval, which has a detrimental impact on the physical, social, mental health, and well-being of individuals, families, groups, and communities. The 2013 flood in Southern Alberta, Canada, had a devastating impact; more than one hundred thousand people were evacuated in the city of Calgary and thousands of residents displaced in thirty communities. The flood was the result of heavy rainfall and thunderstorms that, coupled with rapid mountain snowmelt, contributed to rivers in the southern region of the province overflowing their banks (Fulton & Drolet, 2018). Catastrophic flooding resulted in the full or partial evacuation of thirty-two communities, representing about eighty thousand citizens, within a fifteen-hour period (Vroegop, 2014). The town of High River (located 40 km south of Calgary) was among the worst affected, with all thirteen thousand residents forced to evacuate. Disasters such as the 2013 flood in southern Alberta disrupt the lives of individuals, families, and entire communities at multiple levels. The floods in Southern Alberta particularly affected rural communities and created a sudden and substantial need for mental health services and resources.

The lack of availability of rural mental health resources has been a major challenge in Canada for many years (Ryan-Nicholls & Haggarty, 2007). Communities recover from floods slowly, and the prolonged recovery and rebuilding process can result in both acute and chronic psychological effects that may negatively affect every individual's development (Kronenberg et al., 2010; Osofsky, Osofsky, Weems, King, & Hansel, 2015). Mental health resources were recognized as lacking in these communities during the 2013 flood and were subsequently parachuted in by external agencies; however, this in turn created a new set of challenges surrounding the type of services and their proposed length of availability.

This article will highlight the importance of disaster mental health in rural communities from the perspectives of community influencers engaged in post-flood recovery. It will focus on rural communities as there was a notable concern regarding access to mental health services for residents from these communities following the flood, particularly among affected children, youth, and families. Community influencers include social workers, human service professionals, practitioners, and service providers who play a vital role in the delivery of services and programs in the wake of the disaster and during post-disaster long-term recovery. This article will also discuss several promising practices to promote the overall well-being and resilience of rural communities post-disaster.

Disaster Mental Health and Resilient Communities

Literature evidences that disasters result in major stressors and psychological trauma for affected individuals and communities (Arbour et al., 2017; Cretney, 2016; Drolet, McDonald-Harker, Fulton, & Iliscupidez, 2018; Math, Nirmala, Moirangthem, & Kumar, 2015). The World Health Organization (WHO; 1992) defined the term disaster as a severe disruption, ecological and psychosocial, which greatly exceeds the coping capacity of the affected community." Particularly in the face of disaster, promoting community mental health and well-being becomes a priority to sustain a resilient community. According to the United Nations Office for Disaster Risk Reduction (2017), resilience is defined as "the ability of a system, community or society exposed to hazards to resist, absorb, accommodate to and recover from the effects of a hazard in a timely and an efficient manner, including through the preservation and restoration of its essential basic structures and functions." Resilience often depends upon the adaptive capacities of an individual or a community in response to an adversity such as disaster (Norris, Stevens, Pfefferbaum, Wyche, & Pfefferbaum, 2008). The concepts of adaptation, coping, and resilience are interlinked with mental health. Numbers of mental health problems in disaster-affected populations tend to be two to three times higher than those for the general population (Math et al., 2015). Along with diagnosable mental health disorders, a disaster-affected community suffers anxiety, fear, trauma, and stress and thus requires an increased number of mental health facilities and resources in the community.

Rural Mental Health in Canada

More than six million Canadians, approximately 20 percent of the total population, live in northern and rural communities (Dyck & Hardy, 2013). According to the provincial government of Alberta, access to mental health resources often remains a concern for rural populations (Government of Alberta, 2015). Canadians living in rural and isolated areas face numerous barriers in accessing quality mental health services including stigma, lack of availability, lack of rural hospitals and available health care resources, lack of diversity in services, and lack of accessibility due to transportation challenges (Goodwin, MacNaughton-Doucet, & Allan, 2016; Sibley & Weiner, 2011). Consequently, most rural families including children and youth suffer various mental health issues (Starke et al.,

2015).

Following a disaster, children and youth, who are among the most vulnerable individuals, are affected in several ways. They suffer effects of relocation (Powell & Holleran-Steiker, 2015); school disruption (Deuchert & Felfe, 2015; Kousky, 2016; Taylor, Weist, & DeLoach, 2012); loss of possessions (Arbour et al., 2017); and physical and mental health concerns such as appetite loss, anxiety, depression, trouble sleeping, lack of memory and concentration, reduced school performance, and other behavioral issues (Kousky, 2016; Lai, La Greca, Auslander, & Short, 2013). Studies also suggest that, in comparison to younger children, older adolescents are more vulnerable to mental trauma post-disaster because they have a greater awareness and understanding of the significance and future impacts of a disaster (Masten & Osofsky, 2010; Osofsky et al., 2015). Any psychological and emotional symptoms need to be addressed as they can result in major depression and other mental health disorders and can be a serious threat to the overall mental well-being of the family and community.

Alberta Resilient Communities Project

The Alberta Resilient Communities (ARC) Research Project was undertaken to better understand the social, economic, health, cultural, spiritual, and personal factors that contribute to resilience among children, youth, and their families while empowering them and their adult allies and communities to enact resilience-building strategies (Drolet, Cox, & McDonald-Harker, 2016). The ARC project provided the authors with a better understanding of the perspectives, experiences, and challenges faced by rural communities in the aftermath of the 2013 floods. It included various activities piloted in collaboration with community influencers to build the capacities and resilience of children, youth, families, and communities in Southern Alberta post-flood (Drolet et al., 2016). Rural community influencers and service providers were asked about the specific needs of their communities, focusing on the impact of the flood on the mental health and well-being of rural residents including children and youth; about their successes and challenges; about how to build resilience in a post-flood environment; and about the role of services and programs in promoting long-term disaster recovery and well-being in the community.

Method

The study used a community-based participatory approach, which is defined as a collaborative approach that focuses on working in partnership with community members to share knowledge, collaboratively build capacities, and inform actions that address issues of concern to the community as a collective (Ohmer, Sobek, Teixeira, Wallace, & Shapiro, 2013). The intent in community-based research is to transform research from a process in which researchers act upon a community to answer a research question to one in which researchers work side by side with community members (Ohmer et al., 2013). An advisory committee was established including experts in disaster mental health and professionals working in the rural communities where research was to be carried out. The advisory committee worked in collaboration to plan the study recruitment, create the study guide, and plan and implement the program in the affected communities.

Sampling

Purposive and snowball sampling approaches were used to select thirty-seven community influencers and social service providers for the study. This sample represented a variety of organizations in Southern Alberta including Calgary, High River, Okotoks, and other small towns and rural communities within the municipal district of the Foothills. Social workers, mental health therapists, psychologists, teachers, community program managers and coordinators, child and youth care providers, newcomer settlement staff, and clergy members were recruited as key informants.

Procedure

After ethics approval was obtained from the university's research ethics board, an e-mail invitation including informed consent and study information was sent to all participants. Two reminder e-mails followed the original mailing. Recipients were encouraged to pass on information about the study to other colleagues, creating a larger number of participants. Participants were asked to contact the investigator if they agreed to participate in the study. They were informed that their participation was confidential and voluntary and that they could withdraw from the interview at any point without consequences. Before each interview, written consent was obtained from the participant, and investigator and participant agreed on a time and place for the meeting. The average length of each interview was forty-five to sixty minutes. Participants were asked a range of questions on such topics as their personal experiences; roles as service providers; perceived successes and challenges; service gaps; and policy recommendations based on their work with children, youth, and families following the 2013 flood. Following are some sample questions:

* What were some of the biggest success and challenges to date in terms of achieving your goals with respect to post-flood disaster recovery?

* What are the challenges associated with building resilience in post-flood environments, specifically while dealing with children and youth in the area?

* How is resilience understood and conceptualized by community organizations, social services, health agencies, and other stakeholders and do these understandings affect your work?

Each interview was digitally recorded and later transcribed verbatim for analysis by two research assistants. The transcripts were subsequently uploaded into NVivo 11.0 for analysis. Qualitative data analysis involved multiple iterations of thematic coding. Transcripts were coded line by line, and comparisons were drawn across interviews to identify resilience-related themes and meanings grounded within the data. In addition, reflective notes and comparisons with the existing literature were considered when creating themes. Themes were shared among the research team members to build consensus. Using NVivo 11.0 to digitally support the analytic process allowed for collaborative reading, coding, discussion, and visualization of the emerging nodes among the research team members.

Results

Findings have been divided into two subsections. The first section includes analysis of rich descriptions about the mental health and well-being of families following disaster and barriers to accessing mental health, such as lack of availability and limited resources, lack of understanding of rural context and needs, stigma, and transportation. The second section contains analysis of rich descriptions about various promising practices held in the community to enhance well-being and resilience in the affected rural communities.

Families' Mental Health and Well-Being

Post-disaster Mental Health and Recovery Needs of Families

The disaster caused major disruptions in the lives of children, youth, and their families and affected the whole community physically, economically, socially, and emotionally. People lost their houses and other valuable possessions and had to struggle to access the basic amenities of living (housing and economic, social, and health care resources) and to reconnect to the community as a whole. For families with children and youth, it was a major struggle to meet all of the needs of the family. Participants reported that families struggled to meet psychological and emotional needs of their children while dealing with other social and economic burdens and responsibilities following the flood disaster. Families faced major psychological pressures and mental health challenges. The majority of the participants mentioned that children and youth were the most vulnerable population and therefore needed increased support and assistance post-disaster. Most children and youth in the schools and community were found to be experiencing major anxiety and depression and therefore required additional attention and assistance.

Participants strongly expressed that, although supports were provided for the immediate relief of families, flood recovery is a lengthy process and therefore requires long-term resources and actions to be in place for the families and community. The stressors and pressures associated with disaster recovery were found to emerge over time, and thus mental health supports and resources were needed for the long-term. Families needed to be socially connected and required increased emotional support. One interview participant said,
Well we're still hearing from the schools that they have a lot to deal
with kids. Those are just anecdotal kinds of things, information that
we're hearing, that kids still need help in schools. And sometimes the
kids are asking for help or getting help from schools because the
parents still don't have the ability to address some of those emotional
needs for them, so they are getting outsourced.


Participants added that the community is still in recovery three years post-flood and youth are still going through multiple psychological and mental health issues. Some youth are homeless because their families moved to other cities and these youth decided to remain with their friends in the flood-affected community. These youth are experiencing enormous emotional turmoil and need services to enhance their well-being. Service providers reported that it is challenging to contact these youth in the community and to provide them adequate mental health and other support. According to one participant,
And in terms of that too, some of the youth homelessness, couch surfing
that I was being made aware of, sometimes families had moved away
because their house was gone, or they couldn't afford to rebuild and so
their oldest child was maybe in Grade 11 or 12 and maybe wanted to stay
behind and graduate. And so that was a big hurdle for I think service
providers was just that immediate impact of where those youth were left
standing.


Some of the participants explained that the disaster event also served as a reminder of the importance of mental health for families, especially for children and youth, and thus there is increased recognition of this important need within the community. A participant said,
so, my truth is that I don't believe we were serving the need well
enough before the flood. And now I think we did much, much better
post-flood. And I think because of that it exposed that there was a
whole lot more need anyways... And it just makes me wonder about, with
all that we know about mental health and the trends we are seeing in
our kids, we need to do better.


Barriers to Accessing Mental Health Services

In addition to the mental health and recovery needs of children and youth, participants also spoke of the barriers and challenges in accessing mental health programs and services within rural communities. These descriptions informed another major theme of the study.

Lack of Availability and Limited Resources

Most participants reported that it is difficult to access mental health services, especially in rural communities, due to lack of availability and resources. Counseling services were not easily accessible to the families. In some families, children and youth were suffering from acute mental health illnesses and needed specialized services, which were available only in the city. Participants said that, in view of the additional burdens and stressors post-disaster, it was difficult and seemed to be a low priority for families to take their children to urban areas in the city to access mental health services. As one of the participants indicated, "Certainly, there's a lot of people including youth coming in with general depression and anxiety, what it was with flood related, flood impact or not, relationship counselling was not easily accessible to them being rural." Participants felt that there were not enough counseling services and resources available in rural areas:
and this is my perception not based on any sort of expertise at all,
but there are so many resources in urban population versus what is
available for people in the rural populations, so I think that is why
you know just the need was perhaps spread out over a greater number of
agencies.


Lack of Understanding of Rural Context and Needs

Another challenge highlighted by community influencers was lack of understanding of the special needs of rural residents by urban service providers. Participants felt that rural residents have a different lifestyle in that they are more integrated and closer to their neighborhood. The needs for privacy and autonomy of rural residents are different from those of people living in cities and therefore need to be considered before planning and implementing any services. One of the participants added, "I would also say that the other piece is going from urban population to rural population there was a bit of a learning curve there, just generally the life style that is different." Participants suggested that there is a need to adopt a practice lens to identify and analyze things differently for people recovering from disaster in rural communities.

Stigma

Stigma was another major barrier to accessing mental health services in rural communities. Participants explained the need to create awareness and teaching around mental health issues and to identify ways to deal with those issues in creating a healthy and prosperous community. The following quote from a study participant describes stigma as a barrier in access to mental health services:
So I mean all the challenges that we have been dealing with
post-flood... [have] been under that umbrella obviously right and so...
[it's important to teach] that there should not be a stigma attached to
mental health and that it is ok to reach out and that it is ok to talk
about that.


To reduce stigma around mental health, participants suggested increasing awareness about mental health, especially among parents in the community, and encouraging parents and community members to use mental health and counseling services available in the community. Adults serve as a role model for the younger generation by using these services in the community and talking freely about mental health issues in the community. As one participant noted,
I think there is an opportunity too for adults to model asking for help
and that was a real challenge. I think that it is important for the
kids to say that "oh, it's ok if I go to counselling because my dad
goes for counselling" or "it's ok if I have to ask for help or go to
the food bank sometimes because they need that."


Transportation

Transportation was also identified as a major barrier to accessing services in rural areas. Due to inaccessibility of transport, families remain unable to access appropriate services as needed and therefore suffer multiple challenges. One of the participants highlighted this issue:
Rurally there is a major need for mental health services that they're
inaccessible, often require lots of transportation and what we see in
the rural areas is people often relapsing because they're getting
band-aid kind of treatments. We saw wonderful treatments that were
accessible for the first time ever. It felt like we could offer
supports while historically you knew you couldn't because of the
barriers.


Promising Practices to Enhance Well-Being and Resilience

In addition to discussing challenges and barriers to health and recovery post-disaster, participants were asked to share any promising practices that can assist or have assisted communities to recover and to describe how those practices promoted mental wellness in the community.

After the disaster, various practices were introduced in the community to promote mental wellness and ensure long-term recovery among children and youth. Among these practices were inclusion of child and youth voices in disaster recovery, a school-based Hearts and Minds program, and collective actions at the community level. Sustainability and continuous funding for these programs in the community remained major concerns among the participants, and therefore these topics were added as a major subtheme in this section.

Inclusion of Child and Youth Voices in Disaster Recovery

The majority of the participants identified listening to the voices of the children and youth as one of the promising practices in disaster recovery. Participants stressed that it was important to include concerns and suggestions of children and youth in post-disaster planning and implementation strategies. However, when asked to describe how this was taking place in the community, the majority of the participants were unable to identify how child and youth voices influenced disaster recovery processes or policies. One participant mentioned "making sure that there is a voice for schools and a voice into the schools." Some participants stated that these actions might be written at the policy level but were generally not happening in the real practice setting. As one participant said, "Having access to services for children and youth is important. At the policy level that is happening, but I don't see it happening in practice."

Participants emphasized that it is essential to include child and youth voices in the recovery process while planning and implementing various strategies or programs designed and intended for their benefit in the community. Because children and youth in rural communities have small neighborhoods and are therefore more connected to their surroundings and people, they acquire unique emotional and social needs and preferences. Participants felt that children and youth could be the best sources of information about their needs before and after disaster. One participant noted the need for policies to support this effort:
It is integral to ensure that children and youth are heard and
supported both within their families and communities at a policy level.
So, policies [are needed] that would support the child and youth within
the context of their family, within the context of the broader
community.
Another participant said,
This is our new council strategic plan... [it] is one way of the...
[town's] making it a priority to ensure that youth were consulted, and
youth were involved.... Something like this we have to consider either
at the council or at a community level when we are making decisions
about youth and children. Have we done youth consultation, they're part
of the check box, yeah?
We did a community Open House, but did we go out to the high schools?
... In the past our planning department... [has] done several focus
groups at high schools, but it should be done on a frequent basis. So,
they have the option to... [use] their different voice.


Community influencers emphasized specific strategies to involve children and youth in the policy development process, such as consultations with children and youth in the schools and other community spaces where they feel free to talk and engage in the discussions about their needs in the community:
I think we have the opportunity now to do some planning with youth
around at time of disaster. And children and youth at the time of
disaster, what are the supports and what does that look like?... How do
we set up a reception center where youth can have some meaningful
activities? Places where we could connect with children and youth which
is the key.... So, I think there is a lot more work to do. We need to
hear from youth to really shape our procedures, our policies, what our
reception centers look like, etc.


Participants suggested that involving youth in the future strategic plans and actions around disaster and recovery would empower them, build accountability and ownership, and make them equal partners in ensuring the well-being of the community as a whole. It is noteworthy that, in order to build resilience, especially among children and youth, the ARC project closely collaborated with social service and community agencies in the community who were engaged in fostering resilience among children and youth, which in turn assisted families and communities in participating in the recovery process following the flood. Community schools played a major role in promoting mental wellness among the children and youth in the community.

Hearts and Minds was one of the programs that was highly appreciated by the community. Hearts and Minds is a school-based program developed through a unique collaboration of federal and provincial disaster response initiatives in partnership with Alberta Health Services and the town of High River's two school divisions, Christ the Redeemer School Division and Foothills School Division. The Hearts and Minds team consisted of a program coordinator and four wellness coaches who worked closely with flood response family therapists and school staff. Hearts and Minds operated within eight schools, reaching a total of twenty-five hundred students in the community. Hearts and Minds staff used schools in the community to identify the mental health needs of children and youth through collaborative meetings with school staff and supports, to respond to family referrals, and to obtain direct identification through formal and informal check-ins with students. The program also addressed any unmet or base level needs, such as issues related to food or shelter, family abuse, or risky behavior.

The program focused on developing five social-emotional competencies among the children and youth as identified by the Collaborative for Academic, Social and Emotional Learning: self-awareness, self-management, social awareness, responsible decision making, and relationship skills. These competencies enabled children and youth to build resilience and mental well-being while reducing automatic or maladaptive responses to trauma. The Hearts and Minds team employed a variety of strategies and activities such as meditation, restorative justice circles, and one-to-one mentoring in an effort to promote healthy choices and strengthen social emotional skills. As one of the participants commented,
Hearts and Minds is often spoken [of] as using a relationship-based
approach, but also utilizing alternative out-of-the-box methods such as
music, drumming, and writing songs as a way to build and offer healthy
relationships and to model that and to teach people how to do that.


The program also provided direct referrals to Alberta Health Services to deal with complex or intense needs among children and youth. The Hearts and Minds program enabled children, youth, and families to connect with appropriate services through its interactions and relationships-based approach.

Study participants noted how the program created safe spaces to have difficult conversations and commented on the importance of starting that discussion: "just kids connecting and knowing that we are Hearts and Minds so just opening up the dialogue." They often discussed the strengths and resilience that children and youth possessed despite the hardships they faced. One of the participants said, "I am pretty amazed at how resilient they have all been I have to say that." Another participant commented on the Hearts and Minds program as a promising practice for children and youth:
The program that stands out for me as being a model that could be
implemented everywhere is the Hearts and Minds program.... For the
Hearts and Minds Program I have such awe and respect for their approach
and the innovative stuff and programs that they have done and the
results of their program.


The Hearts and Minds program was a big success and served as a promising practice to promote child and youth mental well-being in rural communities. Approximately 90 percent of children and youth in the town of High River received universal mental health services and approximately 20 percent received targeted mental health services through the Hearts and Minds program. Nearly all service providers appreciated the program and considered it as an essential service within rural communities for supporting the mental health and wellness of children and youth in both the short- and long-term disaster recovery processes. According to community influencers and service providers, the Hearts and Minds program was not limited to the schools but it slowly and gradually became part of the community culture. A participant commented,
Hearts and Minds, it was in the schools and I think it didn't become
like, Oh they're from Hearts and Minds and not the school and they're
just here to support post-flood people"--they became a part of the
community culture, right. So, it was okay to go and talk to them and
then I think too they were such a huge help to the community and all
those sorts of things.... And just as a support that was really handy
to have.


The Hearts and Minds program operated in collaboration with the schools and other social service agencies in the community.

Collective Actions at the Community Level

Participants also commented emphatically on the need for collective and collaborative actions at the community level in order to support the well-being of families and communities in rural areas. This informed another theme in the study.

Specifically, in rural communities where there are limited resources and supports, participants strongly believed that all agencies should collaborate on one common goal: to promote well-being and full recovery of the community post-disaster. As one participant said,
I think, and specific to youth and children, part of our mandate within
the clinic is certainly to support families, so we work very closely as
well with schools, with the Hearts and Mind program. I worked in a very
integrated way with the all of the community organizations serving all
demographics.


Another participant continued: "There... [are] a lot of players, lots of collaboration and the mandate is to assist with recovery and to help establish a continuum of mental health supports in schools in High River." Participants reported that the recovery work included collaboration with both government and nongovernment organizations:
We had a lot of NGOs, Samaritan's Purse, Red Cross, Women's Helping
Hands, World Renew, Mennonite Disaster Recovery--those were the five
big ones and again we couldn't have done it without them. And then
Alberta Health funded a number of positions primarily through
addictions and mental health.


Sustainability and Funding: A Major Concern

The majority of the participants appreciated the services and programs operating in the rural communities to foster their well-being and recovery. However, they all echoed major concerns and fears about the sustainability of these programs as well as the continuity of funds and resources from the government and other agencies. Thus, another major theme in the study was the need for sustainability and funding.

Participants emphasized that there is a need to recognize that recovery is a long-term process and that several years may be needed for the community to recover fully post-disaster. Immediate attention and efforts are therefore required to sustain and continue the programs and services needed to achieve successful outcomes and full recovery of the community. All the participants advocated for continuous support and funding to ensure accessible and available mental health supports and resources within the community. Participants supported the Hearts and Minds program; however, major concerns were expressed regarding its sustainability due to lack of funding from the government and other agencies in the community only three years after the flood. As one of the participants said,
My concern is that as flood recovery dollars and funding and positions
are ending, that we [are] starting to slide back. We need to be...
investing more resources and building that relationship too because
recovery is still happening within High River.


Nearly all participants voiced the need for continuous funding in the community post-disaster. The community was anxious and uncertain about whether the services would continue to be available in rural areas due to lack of funding. Service providers advocated for the continuity of mental health programs and services, especially for children and youth and to support families and the community as a whole. One individual commented on "how people were disheartened that Hearts and Minds, that they couldn't be funded to stay." Another participant said,
So that is a big worry for us, we have advocated to government, the
Town has advocated to government. Within our base instruction for
grants we don't get money specifically targeted for mental health....
We are seeing more kids with very complex mental health needs come into
our system. And so, the services especially for children in the rural
area, we don't have the same access as other urban cities... but yeah,
we are hoping, fingers crossed, that something will come through in
budget, but we have not heard anything as of yet.


Service providers who were interviewed also spoke about the frustration of having mental health funding available post-flood, but only to certain heavily flood-impacted rural areas, negatively affecting availability elsewhere:
I think that was a small piece of the frustration post flood was that
we served so many at-risk families and so many communities and all of a
sudden, we had the ability in particular [to serve] mental health needs
in comprehensive ways in High River, but those services were not
available to the folks we worked with in Okotoks and Turner Valley. And
so, they continued to have those rural barriers around--that was really
hard to see.


Sustainability often remains a major concern in developmental projects. Findings showed that disaster-affected rural communities require continuous support and effort to fully recover and thrive, especially for families with children and youth. The government and other agencies need to create sustainable and continuous funding options for various programs and services to help the community overcome disaster effects and to establish a meaningful and prosperous future for all.

Discussion

Findings highlight several valuable perspectives and experiences of community influencers during the post-disaster response in rural communities. Families in rural communities were affected by disasters in a variety of ways and suffered emotional and psychological trauma. They had difficulty managing multiple priorities post-disaster and had to struggle with multiple stressors; they needed counseling and other mental health services that were often not accessible to them.

Mental health was identified as a major area to be considered in the long-term post-disaster recovery period. Various barriers to accessing mental health services in rural areas were identified and prioritized for consideration by the community: lack of mental health facilities and services, lack of transportation facilities, stigma, lack of awareness about mental health, and inability of service providers to recognize and integrate the specific mental health needs of rural residents. Math and colleagues (2015) asserted that disaster mental health necessitates a paradigm shift from relief-centered post-disaster management to a holistic, multidimensional, integrated community approach of health promotion, disaster prevention, preparedness, and mitigation. This is consistent with the United Nations' Sendai Agreement (United Nations, n.d.).

Findings of our study strongly suggest that families need greater support and care post-disaster. Provision of and access to mental health services post-disaster are essential in building resilience and fostering healthy communities. There is a strong need to understand the unique interplay between the rural mindset and challenges to accessing mental health. Mental health issues seen in the rural community are often compared to urban examples, which may not be appropriate. Rural communities pose unique stressors that must be addressed, such as issues of privacy while living in closed neighborhoods, poverty, and community-specific needs of children, youth, and families (Holmes et al., 2017). Service providers need training to adopt a rural lens, understand community dynamics, and gain contextual knowledge (Dyck & Hardy, 2013). There is a strong need for collaboration between service providers and community representatives in decisions regarding rural health care programming and delivery. These community representatives have expert knowledge of their own communities and therefore the best insight into their community's particular mental health care needs (Dyck & Hardy, 2013).

Children, youth, and families should be equal partners in planning and implementation of programs and services. Most importantly, collaboration with schools to incorporate mental health care has been suggested as an effective way of targeting children and youth in the community (Starke et al., 2015). Findings point to certain promising practices that have supported children and youth, helping them to thrive and reconnect to themselves, others, and the community. These practices include the Hearts and Minds program, involvement of children and youth in planning and implementation of programs, and collective actions taken by the community in partnership with other agencies and government services.

School-based programs and activities are often seen as the best practices for promoting pro-social attitudes and behavior (Kousky, 2016; Masten & Osofsky, 2010; Osofsky et al., 2015). Previous studies have indicated that, unlike other mental health resources, school-based mental health interventions have the opportunity to reach all children and mitigate the post-disaster impact. School-based intervention programs should include post-adaptive coping strategies to better prepare children and youth for future disaster scenarios (Powell & Holleran-Steiker, 2015). The Hearts and Minds program, which was implemented in partnership with schools in the community, was much appreciated among both families and community influencers in rural communities. It provided safe spaces for children and youth to share their anxieties and fears post-disaster and enabled them to attain mental, emotional, and spiritual well-being. It offered universal mental health supports and services that helped children, youth, and families to cope effectively with the challenges experienced post-disaster and to develop and enhance social and emotional skills.

Participants expressed their concerns and fears about the discontinuation of the Hearts and Minds program due to lack of funding three years post-disaster. Previous studies have indicated that it takes around three to five years on average to counteract the detrimental mental health effects on children and youth following a disaster (Dai et al., 2016; Pfefferbaum, Jacobs, Griffin, & Houston, 2015). These studies substantiate the necessity of maintaining a school-based intervention program that has the ability to compensate for mental health resource gaps and help children, youth, and families cope with post-disaster effects and challenges.

Sustainability of the existing programs and services is a major challenge facing all the study participants. The lack of availability of mental health resources for the communities was compounded by funding constraints. Often funding was provided for a short time frame, which did not meet all of the needs of the residents and therefore created additional stress for local service providers. Local governments felt a need to create community resilience through greater public awareness about disaster preparedness (Cretney, 2016); nonetheless, the issue of limited resource availability for rural areas remains a concern.

Implications of the Study

The study implied that ensuring mental health and well-being post-disaster is essential in order to build a resilient and healthy community and that this effort requires additional attention, especially in rural areas where the resources are limited. Having a clear understanding of the context and needs of rural communities can guide us in future policy decisions and disaster preparedness. At a policy level, new approaches should be considered to support the mental health and well-being of rural residents and families post-disaster. Planned rehabilitation efforts should be culturally appropriate and targeted toward empowering affected communities to enhance their camaraderie and coping skills in the face of disaster (Math et al., 2015). Initiatives should embrace identifying and meeting the specific needs of rural communities using a lens appropriate to the local context, establishing personalized services that incorporate specific rural needs such as transportation or home visits, integrating the school system with the mental health system so that early intervention is possible, and fostering increased collaboration and partnership among different local and government agencies and services (Dyck & Hardy, 2013; Laycock & Caldwell, 2018). Community-based interventions should encourage increased participation and avoid stigmatization.

Strengths and Limitation of the Study

The study findings provide a rich description of the mental health needs of families in disaster-affected communities from a rural context. The study also highlights several promising practices, describing their successes and challenges in promoting post-disaster resilience. The rich data were collected in multiple rural communities and therefore findings can be contextualized in other similar settings. There is a possibility of socially desirable answers from the participants. Analytic rigor and reflexivity were maintained throughout the research process with consistent input from an expert research and advisory team.

Conclusion

Rural communities need extra support, care, and attention, and their voices need to be included in promoting families' mental health, resilience, and well-being. School-based programs and other collective actions are beneficial in promoting stronger, healthier, and more resilient rural communities. Sustainability of the programs is essential and therefore should be prioritized during the planning and implementation phases, especially in disaster-affected communities where lengthy recovery times are expected.

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Nasreen Lalani and Julie Drolet

Nasreen Lalani, PhD, MSN, RN, is postdoctoral research fellow in the Faculty of Social Work, University of Calgary Calgary, Canada. Julie Drolet, PhD, MSW, is professor, Faculty of Social Work, University of Calgary, Edmonton, Canada.

This project was funded by Alberta Innovates from 2015 to 2019.
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Author:Lalani, Nasreen; Drolet, Julie
Publication:Best Practices in Mental Health
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Date:Sep 22, 2019
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