Introduction: Mass casualty decontamination is an intervention employed by first responders at the scene of an incident involving noxious contaminants.  Many countries have sought to address the challenge of decontaminating large numbers of affected casualties through the provision of rapidly deployable temporary showering structures, with accompanying decontamination protocols.  In this paper we review decontamination guidance for emergency responders and associated research evidence, in order to establish to what extent psychosocial aspects of casualty management have been considered within these documents. The review focuses on five psychosocial aspects of incident management: likely public behaviour; responder management style; communication strategy; privacy/ modesty concerns; and vulnerable groups.

Methods: Two structured literature reviews were carried out; one to identify decontamination guidance documents for first responders, and another to identify evidence which is relevant to the understanding of the psychosocial aspects of mass decontamination.  The guidance documents and relevant research were reviewed to identify whether the guidance documents contain information relating to psychosocial issues and where it exists, that the guidance is consistent with the existing evidence-base.

Results: Psychosocial aspects of incident management receive limited attention in current decontamination guidance.  In addition, our review has identified a number of gaps and inconsistencies between guidance and research evidence.  For each of the five areas we identify: what is currently presented in guidance documents, to what extent this is consistent with the existing research evidence and where it diverges.  We present a series of evidence-based recommendations for updating decontamination guidance to address the psychosocial aspects of mass decontamination.

Conclusions: Effective communication and respect for casualties’ needs are critical in ensuring decontamination is completed quickly and effectively.  We identify a number of areas requiring further research including: identifying effective methods for communicating in an emergency; better understanding of the needs of vulnerable groups during decontamination; effective training for emergency responders on psychosocial issues, and pre-incident public education for incidents involving emergency decontamination.  It is essential that the psychosocial aspects of mass decontamination are not neglected in the pursuit of solely technical solutions.

Introduction
Extreme events and disasters, such as earthquakes and floods, cause distress and are associated with some people developing mental disorders. Primary stressors inherent in many disasters can include injuries sustained or watching someone die. The literature recognises the distress which primary stressors cause and their association with mental disorders. Secondary stressors such as a lack of financial assistance, the gruelling process of submitting an insurance claim, parents’ worries about their children, and continued lack of infrastructure can manifest their effects shortly after a disaster and persist for extended periods of time. Secondary stressors, and their roles in affecting people’s longer-term mental health, should not be overlooked. We draw attention in this review to the nature of secondary stressors that are commonly identified in the literature, assess how they are measured, and develop a typology of these stressors that often affect people after extreme events.

Methods
We searched for relevant papers from 2010 and 2011 using MEDLINE®, Embase and PsycINFO®. We selected primary research papers that evaluated the associations between secondary stressors and distress or mental disorders following extreme events, and were published in English. We extracted information on which secondary stressors were assessed, and used thematic analysis to group the secondary stressors into a typology.

Results
Thirty-two relevant articles published in 2010 and 2011 were identified. Many secondary stressors were poorly defined and difficult to differentiate from primary stressors or other life events. We identified 11 categories of secondary stressors, though some extend over more than one category. The categories include: economic stressors such as problems with compensation, recovery of and rebuilding homes; loss of physical possessions and resources; health-related stressors; stress relating to education and schooling; stress arising from media reporting; family and social stressors; stress arising from loss of leisure and recreation; and stress related to changes in people’s views of the world or themselves. Limitations in this review include its focus on studies published in 2010 and 2011, which may have led to some secondary stressors being excluded. Assumptions have been made about whether certain items are secondary stressors, if unclear definitions made it difficult to differentiate them from primary stressors.

Conclusions
This is the first review, to our knowledge, that has developed a typology of secondary stressors that occur following extreme events. We discuss the differing natures of these stressors and the criteria that should be used to differentiate primary and secondary stressors. Some secondary stressors, for example, are entities in themselves, while others are persisting primary stressors that exert their effects through failure of societal responses to disasters to mitigate their immediate impacts. Future research should aim to define secondary stressors and investigate the interactions between stressors. This is essential if we are to identify which secondary stressors are amenable to interventions which might reduce their impacts on the psychosocial resilience and mental health of people who are affected by disasters.

Corresponding Author: Dr Sarah Lock, Extreme Events and Health Protection, London, 151 Buckingham Palace Road, London, SW1W 9SZ. E-mail: [email protected]

Introduction
While most people who are involved in disasters recover with the support of their families, friends and colleagues, the effects on some people’s health, relationships and welfare can be extensive and sustained. Flooding can pose substantial social and mental health problems that may continue over extended periods of time. Flooding can challenge the psychosocial resilience of the hardiest of people who are affected.

Methods
The Health Protection Agency (HPA) undertook a review of the literature published from 2004 to 2010. It is intended to: assess and appraise the epidemiological evidence on flooding and mental health; assess the existing guidance on emergency planning for the impacts of flooding on psychosocial and mental health needs; provide a detailed report for policymakers and services on practical methods to reduce the impacts of flooding on the mental health of affected people; and identify where research can support future evidence-based guidance. The HPA identified 48 papers which met its criteria. The team also reviewed and discussed relevant government and non-government guidance documents. This paper presents a summary of the outcomes and recommendations from this review of the literature.

Results
The review indicates that flooding affects people of all ages, can exacerbate or provoke mental health problems, and highlights the importance of secondary stressors in prolonging the psychosocial impacts of flooding. The distressing experiences that the majority of people experience transiently or for longer periods after disasters can be difficult to distinguish from symptoms of common mental disorders. This emphasises the need to reduce the impact of primary and secondary stressors on people affected by flooding and the importance of narrative approaches to differentiate distress from mental disorder. Much of the literature focuses on post-traumatic stress disorder; diagnosable depressive and anxiety disorders and substance misuse are under-represented in the published data. Most people’s psychosocial needs are met through their close relationships with their families, friends and communities; smaller proportions of people are likely to require specialised mental healthcare. Finally, there are a number of methodological challenges that arise when conducting research and when analysing and comparing data on the psychosocial and mental health impacts of floods.

Conclusions
The HPA’s findings showed that a multi-sector approach that involves communities as well as agencies is the best way to promote wellbeing and recovery. Agreeing and using internationally understood definitions of and the thresholds that separate distress, mental health and mental ill health would improve the process of assessing, analysing and comparing research findings. Further research is needed on the longitudinal effects of flooding on people’s mental health, the effects of successive flooding on populations, and the effects of flooding on the mental health of children, young people and older people and people who respond to the needs of other persons in the aftermath of disasters.

Corresponding author: Carla Stanke
Address: Health Protection Agency
151 Buckingham Palace Road
London SW1W 9SZ
E-mail: [email protected]
Fax: 020 7811 7759
Telephone: 020 7811 7161