Long-term health and wellbeing of people affected by the 2002 Bali bombing

The 2002 Bali bombing resulted in the deaths of over 200 people, including 88 Australians and 35 Indonesians, making it the single worst act of terrorism to have affected either country.1 A further 209 people were injured, including 66 Australians who suffered severe burns and complex shrapnel wounds.2,3

Terrorism exposure may have significant long-term effects on the mental health and wellbeing of survivors. Post-traumatic stress disorder (PTSD) is the most common psychological condition observed in the aftermath of such events, but it often coexists with depression, functional impairment or substance misuse.4,5 Few studies have examined the long-term effects on terrorism survivors, although one large study found increases in PTSD between 3 and 5 years after the September 11 attacks.6,7 Risk factors included direct exposure (proximity, injury, witnessing horror), incident-related bereavement and low social support.

Bereavement that occurs in traumatic circumstances may have a considerable long-term impact on psychological distress and appears to slow the rate of recovery.8 Deaths involving deliberate violence are associated with higher prevalence of trauma conditions, depression and prolonged or “complicated” grief.8,9 Complicated grief is characterised by continuing separation distress and bereavement-related traumatic distress. While frequently comorbid with depression or PTSD, it is increasingly recognised as a distinct condition that is associated with persistent functional impairments and negative health outcomes, particularly among those bereaved through terrorism.9,10

The health and psychosocial effects of terrorism exposure have rarely been investigated beyond 3–4 years after such incidents.4,11 No studies have examined these effects among Australian survivors. Our aim was to examine the physical and mental health status of individuals directly affected by the 2002 Bali bombing, 8 years after the incident, and to determine demographic, exposure and loss-related correlates of these health outcomes.

Participants constituted a cross-sectional convenience sample of individuals who had experienced personal exposure and/or loss related to the 2002 Bali bombing and had current contact details listed with a New South Wales Ministry of Health therapeutic support program (Bali Recovery Program), where they had attended at least one consultation. Those who registered interest in response to a written invitation were contacted, given a description of the study, and asked for verbal consent. Professional interviewers from the NSW Health Survey Program completed computer-assisted telephone interviews between 9 July and 22 November 2010, excluding a period around the bombing anniversary (1–23 October). The validity of telephone-based interviews to assess stress and anxiety conditions has been demonstrated.12

Of 81 individuals contacted, 55 agreed to participate (68% of eligible respondents). The mean interval between the 2002 bombing and the interview was 7 years and 11 months (range, 7 y 9 m – 8 y 1 m). There were no significant differences between the respondents and the total Bali Recovery Program population in terms of mean age (P = 0.38) or male sex (P = 0.39).

Eight years after the first Bali bombing, a substantial proportion of this directly affected group were experiencing high levels of psychological distress and TSRS. These individuals, who had sought help, were also experiencing near-normal physical health, and their aggregate resilience score fell within a “high resilience” range observed in United States population estimates.17 Although a specific comparison group is not available, access to modern treatment methods and support may have promoted these positive long-term outcomes. Notably, experiential features of grief (eg, emptiness, difficulty moving on) were the only factors associated with reduced resilience, suggesting that early intervention with a specific focus on these factors may be indicated for such groups.10

Direct exposure to disasters is considered to have a dose–response effect. Factors such as proximity, injury and perceived threat to life are consistently associated with adverse mental health effects, but they are rarely examined beyond 3–4 years after terrorism incidents because of difficulty accessing affected cohorts.11 Eight years after the Bali bombing, a significant association was observed between incident-related physical injury and both psychological distress and functional impairment. These findings extend the current literature, showing that some of the most direct forms of exposure (proximity and injury) remain substantial risk factors at this extended time point.

Social support has a positive role in mental health and may foster recovery from trauma over time.21 We found that being in a marital or de facto relationship was the only demographic factor associated with distress in the respondent group, showing an inverse relationship with high psychological distress. Inverse relationships were also observed with the broader social support factors of high perceived family support and neighbourhood social connectedness.

The strength of our findings in relation to complicated grief variables appears to highlight important aspects of grief, as it relates to terrorism violence and loss. The ability to “make sense” of a loved one’s death is considered a central process of grieving.8 However, the irrational or meaningless nature of violent death, particularly through terrorism, has been found to interfere with this cognitive process for many survivors.22 Moreover, it is associated with more severe complicated grief, higher psychological distress and poorer physical health.23 While such mediating variables cannot be inferred in relation to our data, it is notable that complicated grief symptoms in this study were also associated with distress and poor physical health, as well as TSRS. Similarly, grief symptoms were also the only factors associated with significantly lower personal resilience. This suggests that among bereaved survivors of terrorism, grief maladaptation may represent a more significant long-term risk factor for health outcomes than incident exposure or post-event variables.

Our findings have implications for the support of people directly affected by terrorism. Complicated grief factors emerged as the strongest correlates of adverse physical and mental health status. Longer-term monitoring of survivor groups is indicated, including screening programs that incorporate grief-specific items. Previous short-term screening has effectively linked survivors with evidence-based care.10,24 However, case-finding from primary care pathways was poor, suggesting that outreach is required for longer-term initiatives.24 Significantly, 7 years after the September 11 attacks, registered individuals who had escaped the World Trade Center reported difficulty accessing physical and mental health care and often failed to connect long-term symptoms with their September 11 exposures.25

Our study has some notable strengths and several limitations. The sample ostensibly constitutes a traumatically bereaved population, with varying levels of direct incident exposure and use of clinical services. Respondents may represent a more seriously affected, but possibly better supported cohort than those who did not seek services from the program. This may limit generalisability of these findings to other survivor groups. This cross-sectional study can only determine significant associations at a single time point. No conclusions can be drawn regarding longitudinal health effects or their causes.

The response rate had the potential to introduce responder bias, although no significant differences in sex or age were found between the respondent sample and the total program population. Items from the complicated grief measure (ICG-R) examined a subset of symptoms only and cannot be considered to indicate syndrome-level complicated grief.

Importantly, this analysis presents the largest study sample to date of Australians directly affected by a single terrorist incident. In completing a quantitative analysis of their health status 8 years after a major bombing, it also represents, to our knowledge, the longest follow-up period of a terrorism-affected population reported in the literature.

4 Population comparison of prevalence estimates* of psychological distress† in the past month

* Bali Recovery Program 2010 weighted sample and New South Wales population weighted prevalence estimates (2010).15 † Measured using the Kessler Psychological Distress Scale. ‡ P < 0.05.