In the wake of the Utøya massacre, the survivors’ utilization of health services was extensive both immediately and at longer-term. The grand majority received one or more types of primary health services both directly after the attack and the following year. Most survivors used specialized mental health services (MHS) in addition to the primary care based outreach. MHS utilization in the post-acute phase was more common in survivors who were injured, and those with high levels of posttraumatic stress, mental distress, and somatic symptoms, but differed little by sociodemographic characteristics.
Interpretation and comparison
The survivors’ high symptom levels and extensive utilization of MHS emphasize the severity of the attack. They further experienced an extended period of concern because of the trial and the high media coverage. The proactive outreach programme outlined that all survivors were assigned a contact person to organize screening assessments throughout at least a year. Yet one in six survivors reported that they did not have a contact person the first 4–5 months, while nearly half had no contact with the contact person 5–15 months after the attack. The high number of survivors without a contact person at T2 might represent a lack of continuity in the follow-up. Yet other health care practitioners might have performed the follow-up, as 95% of the survivors reported contact with at least one type of health services at T2. The recommendations were not mandatory; some municipalities may therefore not have provided contact persons. Furthermore, some survivors may have been proposed a contact person, and declined.
The utilization frequency and perceived usefulness was higher for MHS compared to primary care services. Since access to MHS usually occurs through referral from primary care services, survivors who received MHS may have had both a greater need for care and willingness to undergo therapy. Referrals to MHS often involve participation in an intervention lasting several weeks or months which requires higher consultation frequency. Due to proactive follow-up, the contact person and other primary care practitioners may have been more likely to interact with survivors who did not want or need health care. A previous study of the early proactive outreach after the Utøya attack found that survivors who did not use MHS the first 4–5 months were more likely to have had contact with the municipal crisis team or a contact person [
13]. Contrarily, in the current paper survivors who did not use MHS the following year were less likely to have had concurrent contact with the contact person; more than half had no contact with the contact person (Table
2). This may be of concern, considering that post-disaster psychopathology, such as PTSD, may have a delayed onset of more than six months [
24]. Besides, the survivors were at risk for potential retraumatization for a prolonged period due to the trial and the high media coverage [
25,
26]. Utilization of MHS was associated with utilization of the regular GP, which could be expected as the GP normally issues drug prescriptions, sick leaves, and referrals to MHS.
In contrast to prior findings, [
8] MHS utilization differed little by sociodemographic background, except that MHS utilization was higher among female survivors. Contrarily, MHS utilization differed significantly by impaired mental and physical health. This may indicate that a proactive outreach promotes that health care delivery primarily is based on needs rather than sociodemographic factors. Most survivors with clinical levels of PTSD or mental distress received MHS. In comparison, a minority of young survivors with severe posttraumatic stress reactions received counseling after the 1995 Oklahoma City Bombing and September 9/11 attacks [
5,
6]. Yet in our study one in five survivors who did not receive MHS had clinical levels of mental distress, and 14% had full or partial PTSD (Table
1). Among those who did not receive MHS and had clinical levels of mental distress and/or full or partial PTSD, there were five survivors who were not in contact with primary care services between T1 and T2. Hence the majority were in contact with primary care services. This could suggest a failure at the primary health care level to identify and meet the needs for treatment in an important minority of survivors. Contrary to former findings, [
5,
27] survivors with prior experience with MHS were not more likely to receive MHS after the Utøya attack. The proactive outreach may have rendered MHS more accessible also for survivors without prior experiences with MHS, since they did not have to initiate contact with treatment services themselves. Nonetheless, the consultation frequency was higher among survivors with predisaster MHS utilization.
Many survivors moved away from home to start at university or college shortly after the attack. Relocation was considered a potential risk factor for posttraumatic distress, as it could involve a loss of support from established social networks and family. Relocation was also considered as a potential risk factor for disruption of existing care or failure to initiate treatment; however, MHS utilization did not significantly differ by relocation. This could suggest that the MHS follow-up was maintained despite relocation.
The multivariate analysis showed that symptoms of depression/anxiety at T1 remained significantly associated with MHS utilization at T2 after adjustments (model 1). It is therefore possible that early symptoms of depression/anxiety after disasters indicate a need for prolonged treatment. It is also possible that the initial therapy was more successful at identifying and treating posttraumatic stress reactions than depression and anxiety. When we adjusted for symptoms at T2, only somatic symptoms remained significantly associated with MHS utilization (model 2). One possible explanation could be that somatization is an arduous aftereffect of long-term mental health problems after disasters [
28]. Furthermore, somatic ailments may have promoted counselling, and hence increased the likelihood for referral to MHS. The somatic symptoms could also be directly related to the terrorist attack, and potentially induce, maintain or worsen mental illness at long-term. Yet somatic symptoms remained significantly associated with MHS utilization when we added injuries to the independent variables in model 2 (data not shown). Somatic symptoms are associated with adverse psychosocial and academic consequences in adolescents [
29]. It is therefore important that health care practitioners address somatic symptoms also in disaster-survivors who are not physically injured. Moreover, it has been shown that the prevalence and co-occurrence of somatic and psychological symptoms in low income settings are similar to those in high income settings [
30]. Accordingly, the importance of assessing somatic symptoms in addition to psychological symptoms is likely to be pertinent also for low income settings.
A challenge with proactive outreach is to decide who should be included in the screening. The survivors in our study had been isolated on an islet, and may therefore have been easier to identify than survivors of other disasters. Yet the survivors were dispersed over a large number of municipalities in the entire country after the attack. The geographical dispersion disfavoured a centralized screen and treat response, which has recently showed promising results [
31]. Our study indicates that a proactive outreach is feasible also when survivors are geographically dispersed. External validity may nonetheless be limited by differences in how healthcare provision is organised and financed. Norway is a country with universal healthcare, therefore access to specialized health care may depend less on personal economy than in countries with insurance-based healthcare. Furthermore, the study might not be representative for low-resource settings. A proactive outreach can be resource-demanding. A key challenge in low income settings is the limited availability of mental health resources. In accordance with recent WHO guidelines, access to mental health inventions could be improved by integrating the delivery of psychotherapy by non-specialists, such as community health workers in primary care [
32]. A primary care based proactive outreach might thus be applicable also in low income settings. More research is needed to develop effective evidence-based outreach in low income settings, where the risk of disasters is highest [
33].
The unpredictability and chaotic circumstances of terrorism make it challenging to execute studies. It is therefore important that researchers in advance plan how to implement studies after terror attacks. A linkage to registers could contribute objective and accurate measures of survivors’ health and service utilization before and after the attack, and thus enable a prospective design with a baseline assessment.
Strengths and limitations
The current study contributes new insight into the long-term delivery of different types of health services to young survivors of terrorism. Prior research on disaster-related health service utilization is still limited, and has usually addressed adult survivors using a cross-sectional design, and not covered several services [
7,
8,
34]. Our study included data from in-depth interviews at two time points after the attack. The longitudinal perspective is essential to increase our understanding of how initial reactions and receipt of health care are related to later MHS utilization, and thus optimize post-disaster health care delivery. Furthermore, the Utøya shooting was geographically constricted to a small island where all survivors were exposed to a life-threatening event and could be identified. Former studies have commonly lacked information about the number and identity of directly affected survivors, and consequently met difficulties with selecting a representative sample. The clear definition of our study population may therefore have yielded more reliable estimates. Yet the study had several limitations. Our study included 57% of the survivors, and selection bias may have occurred. Participation did not significantly differ by age, gender, or geographic region of residence, but survivors who participated in T1 only scored higher on exposure. Moreover, survivors who participated at T2 only had more severe posttraumatic stress reactions, mental distress, and somatic symptoms. This may imply that non-participation was associated with poorer mental and physical health. However, survivors who participated at one wave did not significantly differ from two-wave participants with respect to MHS utilization. Study participation might have influenced health service utilization and recovery, as interviewers may have assisted in acquiring treatment for participants with unmet needs for help. Furthermore, the study lacked predisaster data and was based on self-reports, which could be inaccurate. Survivors might also have used health services due to concerns that were not or only partially related to the terrorist attack. Another potential limitation was the variance in the time of interview. T1 covered health service utilization from the attack until T1, which was mainly effectuated in November and December 2011, while T2 covered health service utilization in 2012. Eight survivors completed T1 early in 2012, of whom three reported MHS utilization at T2. Hence there was a potential overlap between the T1 and T2 measurement of MHS utilization for three survivors. Due to sample size considerations, we had to limit the number of independent variables; our multivariate analyses might therefore have missed relevant confounders. Finally, our analysis might have missed significant differences due to a relatively small sample size (type II error).