2011 Norway attacks:Longitudinal patterns and predictors of health care utilization among survivors of the Utøya massacre and their parents.

The study The objective of this study was to assess the reactions of the survivors of the terror attack at Utøya the 22nd of July, 2011, and their parents, their experiences with the post-terror outreach and the health services they received. This will provide knowledge that may contribute to better preparedness and response to future disasters and other traumatic events. The survey has a longitudinal design. Data collection was conducted with interviews at three time-points; 4-5 months, 14-15 months and 30-32 months after the attack. All survivors who were on the Utøya islet during the terrorist attack and were at least 13 years of age in 2011 were invited to participate. In the first round of interviews, 325 (66 %) of those who were at Utøya during the shooting participated, and seven youth who had been on the land side. The average age was 19 years. Moreover, there were 463 parents/caregivers who participated in interviews or filled out questionnaires. In the second wave of interviews, 285 (58 %) of those who were at Utøya participated; six people who had been on the land side; and 435 parents/caregivers. In the third round of interviews, 261 (53 %) of those who were at Utøya, five people from the land side, and 377 parents/caregivers participated. Participation was voluntary and informants could withdraw from the study at any time. Those who had reserved themselves from the study were not contacted for further inquiries. Interviews were conducted by trained personnel at the participants? home, or in an office nearby. If the participants indicated that they wanted or needed help, the interviewers helped them get in contact with the local support system. After each interview, a summary report with selected results was sent to all participants. In the third survey wave, we also asked all informants for consent to collect records from health registers. In the interview, we asked participants what they had experienced during the attack, and about their experiences with the outreach and support services after the event. Results The study has uncovered that those who were directly affected by the terrorist attack at Utøya had significant mental and physical reactions to the incident and the challenges they faced in the aftermath. At the second and third interview, the symptom load had somewhat abated, but it was still far above the expected symptom load in the general population. The parents of those who survived also reported strong reactions to the event. Following the terror attack, the Norwegian Directorate of Health recommended a proactive model of follow-up in the municipalities. According to this model, crisis teams were to immediately contact the survivors, and all survivors were to be assigned a fixed contact person in the municipality. These were to ensure continuity of follow-up, safeguard that standardized assessments of mental reactions were conducted throughout the first year, and help those affected to receive necessary healthcare. Many reported that they received early assistance from the crisis teams (87 %) and the contact person in the municipality (84 %), but in the second interview nearly half (45%) of the survivors had not had any contact with the contact person. Hence, the proactive follow-up did in many cases not last as long as recommended and it did not reach everyone. The study uncovered that there were geographical differences in the health assistance provided, whereby a lower proportion of survivors received proactive follow-up in Oslo compared to the rest of the country Furthermore, most parents reported contact with the municipal crisis team and the contact person. However, a lower proportion of parents who were divorced/separated or of non-Norwegian origin reported contact with the proactive outreach programme. The youths? and parents' mental and physical reactions generated a high need for assistance over several years, both from the municipal and the specialized health services. At the second interview more than 90% of the survivors reported contact with ?1 types of primary care services; and 68% with specialized mental health services. The statistical analyses showed that two factors were particularly influential with respect to mental health service utilization at the second interview: early symptoms of mental distress and concurrent somatic symptoms. Unmet healthcare needs, both with respect to mental and physical health problems, were associated with higher levels of posttraumatic stress, psychological distress, somatic symptoms and less social support. Two factors were particularly important for satisfaction: The overall organization and accessibility of healthcare. We have also published qualitative data from our study, asking survivors about their experiences with health services. Survivors called for more knowledge about trauma among professionals, more organized services and a long term outreach program.

Background Terrorism and disasters may impact physical and mental health of survivors and affected families, and constitute needs of long-term follow-up from municipal and specialized health services. Adequate access to interventions in muncipalities and specialized treatment is important to reduce trauma-related symptoms and prevent chronic health problems. Due to its unforeseen and devastating effects, terrorism and disasters constitute major challenges for health care services. Research provides limite d knowledge on utilization of health care services in the aftermath of terrorism and disasters, particularly for young survivors and their families and new empirical knowledge will aid developing adequate diaster response programs. Objective This study aims to quantify the increased need for municipal and specialized health services after terrorism and identify predictors of utilization of services. It will further assess whether access to health care was equitably distributed, if mental health services were provided to survivors with high levels of distress and needs, as well as users own perceptions of provided care. Methods A unique opportunity for investigation of longitudinal patterns of health care utilization is offered by our study of survivors and their parents following the 22. July terrorist attack at the Utøya Island in Norway. Clinical data from face-to-face interviews will be linked to register-data of utilization of health care services pre- and post terror. Predictors of use of health c are services will be identified for survivors and their parents. Scientific importance Longitudinal data of the patterns of health seeking in the aftermath of terrorism and disasters are lacking. Planning of adequate and evidence informed outreach is rel ying on research based on sound methods and reliable data sources.