Development of a method for analysing victims of the Great East Japan Earthquake using the International Classification of Functioning, Disability and Health (ICF): part I proposal for the disaster ICF

Abstract

Thirteen years have elapsed since the Great East Japan Earthquake of March 2011. Approximately 30,000 evacuees remain. Various reconstructions in the disaster area are currently ongoing. More than 20 years have been taken to complete the decommissioning the nuclear reactors. This study aims to develop a method for studying and following up on the health and health-related states of the victims and the disaster area using the International Classification of Functioning, Disability and Health (ICF). We adopted two newspapers with adequate personal information from the interviewees and qualitatively analysed the content of interviews of 1,910 victims (1,116 male and 794 female; age range: 1–98). The responses of each interviewed victim were coded into three components of ICF (Body Functions, Activities and Participation and Environmental Factors). We obtained 7,812 ICF codes describing the victims’ conditions and the disaster area. Of these, 55 high-frequency codes were quantitatively selected. They characteristically represented suffering caused by different elements of the calamity: the earthquake, the tsunami and the nuclear power plant accident. We noted the shortcomings of ICF during disasters, developed a new method, proposed the idea of a ‘disaster ICF’ in the process and discussed its applications.

Impact Statement

Massive natural disasters, such as earthquakes, tsunamis, floods, eruptions, typhoons (cyclones, hurricanes) and tornados, occur all over the world every year. These events are reported immediately by the media. Such news is generally covered for a few days or weeks at most, so many audiences are becoming less concerned about victims. However, as many victims suffer for several months or years at least, they need long-term support; in particular, health and health-related. A new system, for victims and supporters (including professionals and general citizens) to share information to restore their normal daily lives, is required. To address the need, the use of the International Classification of Functioning, Disability and Health (ICF) is effective as a standardised common language. We have developed a new method for analysing various conditions of disaster victims and areas using ICF codes.

Keywords:

• Disaster ICF
• earthquake
• newspaper interview
• nuclear power plant accident
• tsunami

Reviewing Editor:

• Joe Thomas
• Institute of Health and Management
• Australia

Subjects:

• Qualitative and mixed methods
• Social Psychology
• Hazards & Disasters
• Education
• Social Work
• Health & Society
• Nursing
• Social Work and Social Policy

1. Introduction

1.1. Damage from the disaster

The Great East Japan Earthquake occurred at 14:46 on 11 March 2011 (Figure 1). The magnitude-9.0 earthquake induced a massive tsunami, which demolished a nuclear power plant and consequently led to widespread radioactive contamination. This catastrophe thus caused three types of disasters within a short period of time. Three prefectures in particular (Iwate, Miyagi and Fukushima Prefectures) were especially seriously damaged. Unfortunately, Fukushima Prefecture was affected by all three calamities (Cabinet Office, Government of Japan, 2011; National Police Agency, Government of Japan, 2011).

Figure 1. Epicentre and main disaster area. The Great East Japan Earthquake (magnitude 9.0) occurred at 14:46, on 11 March 2011.

The human casualties comprised deaths (15,854/15,900 (March 2012/March 2023)), missing people (3,155/2,523), disaster-related deaths (1,479/3,789), evacuees (343,935/30,884) and temporary housing occupants (123,723/4).

Thirteen years after the disaster, evacuees still number approximately 30,000, and the number of disaster-related deaths is still rising. The work of decommissioning the nuclear reactors is still ongoing, and will take more than 20 years to complete (Reconstruction Agency, Government of Japan, 2024a).

Given these conditions, we should continue to monitor the state of the victims and the disaster area. However, no effective and unified follow-up method has yet been identified. This study addresses this shortcoming by using an internationally accepted classification system of the World Health Organization (WHO) to develop such a method.

1.2. ICF

The International Classification of Functioning, Disability and Health (ICF) was adopted in 2001 by WHO. According to the WHO, ‘The overall aim of the ICF classification is to provide a unified and standard language and framework for the description of health and health-related states’ (ICF Manual; WHO, 2008, p. 3). Information about health and healthcare provides a standardised common language to be used worldwide across a range of disciplines.

ICF organises health information in two parts (WHO, 2008, pp. 11–13). Part 1 addresses human functioning and the disability and comprises three components: Body Functions, Body Structures and Activities and Participation. Positive features of these components are expressed as functioning, and negative ones are expressed as disability. Part 2 addresses Contextual Factors and comprises two components: Environmental Factors and Personal Factors. Positive factors are defined as Facilitators, and negative ones are expressed as Barriers. Personal Factors have not yet been classified in ICF.

As shown in Figure 2 (WHO, 2008, p. 23), these components interact in two directions. Each component has several domains, and each domain has several category codes. Therefore, the health and health-related states of individuals are expressed by category codes and their qualifiers, as seen in Table 1. This study mainly focused on second-level category codes. Percentages of qualifiers denote the extent of an impairment, a problem, a difficulty, a barrier or a facilitator. The different users are required to be calibrated percentages according to their domains (WHO, 2008, pp. 272–273).

Figure 2. Interactions between the components of ICF. Individual health and health-related states are expressed by the ICF components. Source: ICF Manual (WHO, 2008, p. 23).

Table 1. Structure of ICF codes.

Category level^1 Qualifier^2	Part 1: Functioning and disability						Part 2: Contextual factors
	Body functions (b)		Body structures (s)		Activities and participation (d)		Environmental factors (e)
	Physiological or psychological functions of body systems		Anatomical parts of the body		Activity: Execution of a task or action by an individual Participation: Involvement in a life situation		Physical, social and attitudinal environment
First-level^1	b1–b8^1		s1–s8		d1–d9		e1–e5
Total	8		8		9		5
Second-level (example)	b167	Mental functions of language	s730	Structure of upper extremity	d450	Walking	e110	Products or substances for personal consumption
Total	115		56		128		74
Third-level (example)	b1670	Reception of language	s7300	Structure of upper arm	d4500	Walking short distances	e1100	Food
Total	341		165		329		182
Fourth-level (example)	b16710	Reception of spoken language	s73000	Bones of upper arm	None		None
Total	61		92		0		0
First qualifier^2	Extent or magnitude of impairment		Extent or magnitude of impairment		Extent of performance problem		Extent of barrier
	xxx.0	No impairment (0–4%) ^2	xxx.0	No impairment (0–4%)	xxx.0	No difficulty (0–4%)	xxx.0	No barrier (0–4%)
	xxx.1	Mild impairment (5–24%)	xxx.1	Mild impairment (5–24%)	xxx.1	Mild difficulty (5–24%)	xxx.1	Mild barrier (5–24%)
	xxx.2	Moderate impairment (25–49%)	xxx.2	Moderate impairment (25–49%)	xxx.2	Moderate difficulty (25–49%)	xxx.2	Moderate barrier (25–49%)
	xxx.3	Severe impairment (50–95%)	xxx.3	Severe impairment (50–95%)	xxx.3	Severe difficulty (50–95%)	xxx.3	Severe barrier (50–95%)
	xxx.4	Complete impairment (96–100%)	xxx.4	Complete impairment (96–100%)	xxx.4	Complete difficulty (96–100%)	xxx.4	Complete barrier (96–100%)
	xxx.8	not specified	xxx.8	not specified	xxx.8	not specified	xxx.8	barrier, not specified
	xxx.9	not applicable	xxx.9	not applicable	xxx.9	not applicable	xxx.9	barrier, not applicable
							Extent of facilitator
							xxx + 0	No facilitator (0–4%)
							xxx + 1	Mild facilitator (5–24%)
							xxx + 2	Moderate facilitator (25–49%)
							xxx + 3	Substantial facilitator (50–95%)
							xxx + 4	Complete facilitator (96–100%)
							xxx + 8	facilitator, not specified
Second qualifier	None		Nature of impairment		Extent of capacity limitation		None
			xxx.x0	No change in structure	xxx.x0	No difficulty (0–4%)
			xxx.x1	total absence	xxx.x1	Mild difficulty (5–24%)
			xxx.x2	partial absence	xxx.x2	Moderate difficulty (25–49%)
			xxx.x3	additional part	xxx.x3	Severe difficulty (50–95%)
			xxx.x4	aberrant dimensions	xxx.x4	Complete difficulty (96–100%)
			xxx.x5	discontinuity	xxx.x8	not specified
			xxx.x6	deviating position	xxx.x9	not applicable
			xxx.x7	Qualitative changes in structure
			xxx.x8	not specified
			xxx.x9	not applicable

Personal Factors are not classified in the ICF. The official ICF updates for 2011–2018 are included.

¹ First-, second-, third- and fourth-level categories are denoted by one to two digits that are underlined.

² Each qualifier is expressed by a percentile figure. Source: ICF Manual (WHO, 2008) (totaled by author).

Applying ICF concepts to this disaster, we found that the actual conditions of existing victims were mainly as follows: (a) Some victims were not in good Health condition prior to the disaster; (b) Some victims experienced disruptions in Body Functions because of mental exhaustion, physical injury or aggravated chronic disease; (c) Some victims were limited in their Activities because of a lack of teaching materials, difficulty going out or other impediments to normal daily life; (d) Some victims experienced restricted Participation because they had lost their offices, schools or communities; (e) Some victims’ material, human or social Environmental Factors deteriorated because their homes were destroyed or they were separated from family members or neighbours; and (f) Some victims’ Personal Factors, based on sense of value, life history and lifestyle, had changed.

According to ICF’s intended uses, (a) ICF addresses not only people with disabilities but all people and (b) ICF is also used by sectors such as labour, education, social policy and ecology (WHO, 2008, pp. 6–7). Therefore, ICF can be used to evaluate natural disaster victims and to produce a realistic depiction of the health of individual victims.

The advantages of ICF as a tool are as follows: (a) The individual health conditions of victims can be described in a consistent manner to make sustainable individual support easier (sustainability of support); (b) When the victims receive various forms of support from abroad, the labelled ICF codes offer an easy-to-use common language for providers (internationalisation of support); (c) It simplifies the extraction, editing and storage of large volumes of data on victims (forming a database of victims); and (d) The health-field-oriented ICF can be spread over other fields as a practical sample (versatility and flexibility of ICF).

1.3. Related studies and reports

1. Various studies have examined the health conditions of victims of natural disasters. For example, Reinhardt et al. (2011) examined the role of health-related rehabilitation in natural disaster (1970–2010) relief by reviewing the literature and called for a systematic assessment and measurement of disability after a natural disaster. Martin (2015) studied Superstorm Sandy in 2012 and suggested that studying psychological and health problems after a natural disaster can be useful for assisting individuals and communities. Amatya et al. (2017) reviewed the importance and the role of rehabilitation services for victims and listed 18 perspectives for future catastrophes. Two of them are listed here: ‘Build local volunteer/carer programmes (including family members, community, etc.)’ and ‘Increase public awareness and education about disability and rehabilitation’. Sone et al. (2016) conducted a self-report questionnaire survey on 959 victims of this disaster and suggested that the prevention of social isolation might lead to precautions being taken against psychological distress after a natural disaster. Iwasa et al. (2019) researched the posttraumatic growth (PTG) of 796 residents of Fukushima using a questionnaire method and suggested that the recovery from radiation anxiety might lead to positive psychological adjustment and PTG.

   These sources described several relevant ways to advance a victim’s physical and mental rehabilitation and assess how it should be developed.

2. Several studies concerning the application of ICF to natural disasters have been published: Rauch et al. (2011) analysed the rehabilitation needs of 18 victims with spinal cord injuries in the Haiti Earthquake in 2010 and developed a tool using the second-level codes of the ICF with qualifiers. Okawa and Ueda (2008) reported the implementation of ICF in national legislation and policy in Japan. One of the nine items listed was prevention after natural disasters. Okawa (2013) researched the life functions for 1,785 victims, aged 65 years and over, in the Niigata-Chuetsu Earthquake in 2004 and for 12,652 victims in the population of Minami-Sanriku-Machi (Miyagi Prefecture) in this disaster. Tatsuki (2015) classified the functional needs of 41 victims with disabilities in this disaster according to the ICF first-level codes without qualifiers and examined them using cluster analysis and correspondence analysis methods.

   The above studies made use of ICF components; however, they did not mention the imperfection in detail in the use of ICF under the disaster. Moreover, they tend to focus chiefly on the disabled and the aged, and contrast with this study with respect to the research population. A rare study concerning an artificial disaster was published; Seltser et al. (2003) presented three hypothetical case studies of terrorist attacks’ victims, tracking their functional status, and suggested that ICF was applicable to human disasters.

3. Various problems in this disaster concerning support for victims have been reported: (a) Several serious errors in the judgement of individuals, institutions and organisations in the aftermath were revealed, and the information-communication systems for domestic peoples, foreigners and foreign governments were insufficient (Japan Society for the Promotion of Science, Social scientific research committee on the Great East Japan Earthquake, 2015); (b) Several support and service systems for various and changing needs in the evacuation centres were unsatisfactory (Cabinet Office, Government of Japan (Disaster Management), 2012); and (c) Several acceptance systems for overseas’ support were confused (Cabinet Office, Government of Japan (Disaster Management), 2012; Ministry of Foreign Affairs, Government of Japan, 2012). The people concerned could effectively identify and improve these problems using ICF as a standardised common language.

1.4. Purpose

The purpose of this study is to: (a) qualitatively examine the content of newspaper interviews with victims of the Great East Japan Earthquake of 2011, (b) select the appropriate ICF codes to reflect the various responses of each interviewed victim, (c) develop a method for analysing the victims’ life and health conditions using these codes; and (d) discuss the applications of this method.

Our motive for this study is to contribute to the support of victims, recovery of the disaster area and preparation for future disasters.

2. Method

2.1. Data sources

2.1.1 Adopted media

Various mass media, such as TV, radio, internet, newspapers and magazines, have reported the images of victims. Newspapers were selected in this study because of their superior balance of impartiality, availability and preservation. In addition, newspapers depicted a large number of victims.

In Japan, newspapers have gained higher credibility than other media (Ministry of Internal Affairs and Communications, Japan, 2012; World Values Survey, 2010), and they have had generally large circulations (The Japan Newspaper Publishers & Editors Association, 2023). Uchida et al. (2015) researched the objectivity and the emotionality about TV and newspaper coverage of the tsunami and the nuclear power plant accident, and described how the newspaper articles sought to convey neutral information to maintain objectivity.

We required four items (full name, sex, age and a photograph) for each interviewed victim for definitive identification. We used these items as essential personal information to ensure high reliability as a data source. The Asahi Shimbun (AS; 2011), a national paper, and Fukushima Minpo (FM; 2011), a local paper, met those requirements, and then both were adopted as a media data source. The period of serialisation and the number of interviewed victims employed were from the middle of March 2011 to the beginning of June 2011 (approximately 13 weeks), for a total of 1,910 victims; 1,027 were identified in AS and 883 in FM. Approximately 13% of the victims were included without photographs out of consideration for their personal privacy. Demographic details are shown in Table 2. The three-month sampling period was adopted because AS had finished a serial interview article at that time, and the victims frequently faced difficult problems during the first three months after the disaster (Susato, 2015).

Table 2. Newspaper interviewees.

Items	AS^1					FM^2	Total: AS + FM
	Iwate	Miyagi	Fukushima	Others	(Subtotal)	Fukushima
Period (2011)	—	—	—	—	17 March–10 June	19 March–9 June	17 March–10 June
Number of interviewees	291	297	361	78	1,027	883	1,910
Sex (male/female)	176/115	167/130	213/148	48/30	604/423	512/371	1,116/794
Range of age (male)	7–87	6–88	6–89	8–86	6–89	1–92	1–92
Range of age (female)	5–87	8–92	4–92	12–78	4–92	2–98	2–98
Average age (male/female)	53.0/49.1	49.7/49.4	49.0/45.4	52.6/50.7	50.6/48.0	48.5/43.6	49.6/46.0
Photograph of face (male/female)	150/97	151/120	178/124	44/25	523/366	439/330	962/696
Photograph percentage (male/female)	85.2/84.3	90.4/92.3	83.6/83.8	91.7/83.3	86.6/86.5	85.7/88.9	86.2/87.6
Average of number of Japanese characters^3	138.0	145.7	131.8	96.7	134.9	88.7	113.6

¹ The Asahi Shimbun (AS, national newspaper). AS has local columns for Iwate, Miyagi, Fukushima and other prefectures.

² Fukushima Minpo (FM, local newspaper).

³ Approximately 10 Japanese characters are equivalent to 5 words in English.

2.1.2 Characteristics of data source

We used the following method of data collection: The reporters interviewed the victims shortly after the events occurred, and they then wrote the articles. We observed and analysed their articles. The interviews in newspapers were probably non-structured and consisted of spoken data covered as a real-world story of the disaster. Such data were not intended to be published for reuse in ICF coding. Thus, the interviewees must never have anticipated that their thoughts and experiences would be analysed here. The data source was unrelated to the ICF.

The first limitation concerns whether the descriptions of interviews were representative of all victims’ situations (exhaustiveness and authenticity of data source) and whether the interviewees in the articles reflected all victims’ samples (representativeness of victims). The second limitation concerns whether those data were the secondary data for us, and we were not involved in the collection and processing of the primary data. Therefore, we were unable to plan a cohort study (panel survey).

2.2. Procedure

Our general procedure was as follows: (a) qualitatively examine the content of newspaper interviews; (b) select appropriate ICF category codes (second- or third-level) from the health and health-related states of victims (with no limit to the number of codes) and evaluate the ICF qualifier (these steps are referred to as coding and were carried out by hand); (c) quantitatively examine the ICF codes obtained through coding to extract high-frequency codes; and (d) select several appropriate interview responses and indicate them in a table.

2.3. Method of coding

1. After the personal attributes of victims were defined in terms of Personal Factors, the responses were qualitatively analysed and coded to document the parts of speech used. In this study, nouns and verbs were the focus. For example, in the response ‘My family members support each other’, the key words ‘family’ (noun) and ‘support’ (verb) were extracted. These words and parts of speech were then labelled with the most appropriate ICF category code. Code e310 [Immediate family] and code d660 [Assisting others] are applicable to the response.

   In general, one minimum unit of analysis (word or phrase) corresponds to one category code. However, two cases sometimes occur. Case 1: one unit is expressed by several codes. For example, ‘Our house was swept away’ may have code e110 [Products], e165 [Assets] and e525 [Housing]. Case 2: several units are expressed by one code. For example, ‘I feel really sad, so I don’t sleep well at night’ may have only code b134 [Sleep]. These codes were decided based on the context.

   If the response was complex, the victim’s main idea was identified from the whole response. The main idea means a summary of one’s thought and behaviour about the whole response, that is to say, a theme of the response. Conversely, the main idea could be determined from the broader context of the article. The parts of speech were then reviewed in detail. The main idea was classified into eight categories: Self and Family member, Neighbour and Community, Administration and Government, Supplies and Facilities, Information, Rule and Procedure, Evacuation centre and Temporary housing and Others. For example, if an interviewee said distinctly, ‘I’m getting along nicely with neighbours every day in the shelter’, the main idea belonged to the category Neighbour and Community.

2. The concept of strengths was used to complement ICF codes. Strengths refer to human potential, unused ability, acquired skill, strong will and favourable environment, among others. Strengths perspective is ‘an orientation in social work and other professional practices that emphasizes the client’s resources, capabilities, support systems, and motivations to meet challenges and overcome adversity’ (Barker, 2014). We define strengths as a trait of the victim that enables the victim to improve his/her condition and to promote the recovery of the damaged area. A person who attempts to support a victim would be more effective in understanding the victim’s various difficulties and in assisting his/her challenges by using his/her strengths (i.e. strengths perspective). Park et al. (2005) investigated the relationship between various character strengths and life satisfaction among 5,299 adults based on internet samples. They showed 24 different character strengths (e.g. hope, zest, gratitude, love, curiosity). In this study, the victim’s strengths were identified in his/her response. The obtained 34 strengths were categorised into three parent categories (Resources, Natures and Capabilities) and were ramified into 11 subcategories (Family, Character, Efforts, etc.).

   The relationship between main idea, strengths and ICF code is explained as follows. When a victim stated, ‘I lost everything in the tsunami. So, I’m very sad. But I never give up!’, (a) The main idea is ‘I lost everything’, and the category is Self and Family member. The related ICF codes are e165 [Assets] and e310 [Immediate family]. (b) The strengths is ‘I never give up!’, and the parent category is Natures and its subcategory is Positivity. The related ICF code is b130 [Energy and drive functions]. The word ‘Tsunami’ (e230) is a cause of the main idea, and the word ‘Sad’ (b152) is a consequence of it.

3. In addition to the original definition, the following six codes were specifically defined to apply to this disaster:

   1. Code d710 [Basic interpersonal interactions]. This code was used when victims said, ‘Thanks’ for any support, encouragement or help from others.

   2. Code d720 [Complex interpersonal interactions]. This code was used when victims mentioned any form of enlightenment, philosophy, introspection or maxim (e.g. ‘The life of man is a winter’s day and a winter’s way’).

   3. Code d940 [Human rights]. This code was used to indicate victims who were treated unreasonably or unfairly.

   4. Code d998 [Community, social and civic life, other specified]. This code was assigned to any action or emotion such as insistence, demand, complaint, protest, vanity, pessimism in evacuation life or frequent moves to other evacuation sites.

   5. Code e445 [Individual attitudes of stranger]. Distress caused by rumours was recognised as an environmental factor that acts as a barrier to victims. Therefore, when victims mentioned ‘distress caused by rumours’ or a similar term, this code was used.

   6. Code e598 [Services, systems and policies, other specified]. This code was assigned to any announcement of information concerning nuclear accidents, relief supplies, recovery and so on.

As this study emphasised an observation, an observational study guideline, STROBE statement (STROBE; 2024), was referred to.

2.4. Example of coding

An example of our coding is shown in Table 3. By referring to several actual victims, a victim and an interview response are composed by the author. The response of Mrs Suzuki was related to the category codes (note: the meaning of each category code is given in Table 4). Each qualifier was determined by the author’s judgement based on the victim’s personal attributes (sex, age, occupation, address, etc.), sentence structure (parts of speech, style, dialect, etc.) and Japanese history, culture and customs. Therefore, different qualifiers could be chosen depending on the analysts’ sensibilities, values and background knowledge. The author’s judgement on the coding involved a researcher bias (or observer bias). To reduce this bias, the coding was repeated five times over three years. Each coding, from the second to the fifth coding, was carried out by the author under blinding conditions to avoid being influenced by the former coding and to maintain consistency in the coding, and then the fifth coding was finally used.

Table 3. Example of ICF coding.

Interviewee: Mrs Suzuki, 73 years old, unemployed, lived by the seaside, and evacuated to a gymnasium, interviewed two weeks after the disaster
Response^1	ICF category code (second-level)
	Body Functions	Body Structures	Activities and Participation	Environmental Factors
When the earthquake^*1 hit, I was in my house. I escaped^*2 quickly. My husband^*3 was swept away in his office, and he has been missing since. There is nothing around to mark our house^*4. I’m in the evacuation centre^*5 with neighbours^*6. But I get sad and uneasy^*7 when I’m alone. I haven’t taken a bath^*8 in a long time. I hope a temporary house^*9 is built soon.	b130.1^*7	unknown	d450.8^*2	e165.8^*4 e230.4^*1 e310.8^*3 e325 + 2^*6 e525 + 1^*5 e525 + 3^*9 e580.2^*8

The harm to a hypothetical victim and corresponding ICF codes with qualifiers are presented. Applicable words or phrases in Response¹ for the ICF category codes are underlined, and the same superscript letters (*1–*9) are used for each code.

Table 4. Total number of ICF codes based on newspaper interviews.

Second-level category codes: things or phenomena	AS^1					FM^2	Total: AS + FM
	Iwate	Miyagi	Fukushima	Others	(Subtotal)	Fukushima
Body Functions
b126 Temperament and personality functions	4	9	8	5	26	15	41
b130 Energy and drive functions	3	1	1	0	5	11	16
b134 Sleep functions	1	1	5	1	8	7	15
b749 Muscle functions, other specified and unspecified	3	2	2	3	10	3	13
Others	3	3	8	0	14	16	30
(Subtotal)	14	16	24	9	63	52	115
Activities and Participation
d450 Walking	0	3	8	0	11	10	21
d570 Looking after one’s health	11	17	11	1	40	79	119
d610 Acquiring a place to live	3	6	7	1	17	18	35
d650 Caring for household objects	2	1	15	0	18	34	52
d660 Assisting others	52	47	72	14	185	170	355
d710 Basic interpersonal interactions	28	32	35	4	99	162	261
d720 Complex interpersonal interactions	16	14	17	4	51	22	73
d750 Informal social relationships	15	28	22	10	75	97	172
d760 Family relationships	20	11	12	2	45	51	96
d845 Acquiring, keeping and terminating a job	53	56	69	8	186	82	268
d850 Remunerative employment	20	12	16	3	51	5	56
d855 Non-remunerative employment	37	29	19	3	88	59	147
d865 Complex economic transactions	4	2	5	1	12	0	12
d920 Recreation and leisure	9	6	14	1	30	102	132
d940 Human rights	18	24	113	8	163	193	356
d998 Community, social and civic life, other specified	49	62	100	14	225	126	351
Others	10	10	2	2	24	27	51
(Subtotal)	347	360	537	76	1,320	1,237	2,557
Environmental Factors
e110 Products or substances for personal consumption	11	18	17	10	56	27	83
e115 Products and technology for personal use in daily living	15	26	21	5	67	34	101
e120 Products and technology for personal indoor and outdoor mobility and transportation	12	16	14	4	46	21	67
e125 Products and technology for communication	1	2	2	3	8	2	10
e130 Products and technology for education	4	5	0	0	9	4	13
e135 Products and technology for employment	28	24	11	6	69	7	76
e140 Products and technology for culture, recreation and sport	5	8	2	1	16	2	18
e165 Assets	191	183	93	37	504	229	733
e230 Natural events	149	169	116	46	480	214	694
e235 Human-caused events	2	5	143	5	155	193	348
e310 Immediate family	142	139	158	21	460	456	916
e315 Extended family	24	16	23	5	68	73	141
e320 Friends	21	20	23	4	68	33	101
e325 Acquaintances, peers, colleagues, neighbours and community members	54	89	81	14	238	362	600
e330 People in positions of authority	2	3	6	4	15	31	46
e335 People in subordinate positions	10	10	11	2	33	6	39
e340 Personal care providers and personal assistants	16	17	15	3	51	86	137
e350 Domesticated animals	8	6	28	3	45	46	91
e355 Health professionals	0	3	2	1	6	8	14
e360 Other professionals	8	14	0	1	23	11	34
e398 Support and relationships, other specified	18	14	9	1	42	22	64
e425 Individual attitudes of acquaintances, peers, colleagues, neighbours and community members	1	2	5	0	8	3	11
e445 Individual attitudes of strangers	3	1	16	0	20	4	24
e520 Open space planning services, systems and policies	2	0	1	0	3	2	5
e525 Housing services, systems and policies	53	74	49	21	197	142	339
e530 Utilities services, systems and policies	28	36	7	7	78	16	94
e535 Communication services, systems and policies	7	5	1	0	13	0	13
e540 Transportation services, systems and policies	8	11	6	3	28	6	34
e545 Civil protection services, systems and policies	0	1	1	0	2	3	5
e565 Economic services, systems and policies	3	2	5	1	11	0	11
e570 Social security services, systems and policies	9	11	27	5	52	25	77
e575 General social support services, systems and policies	1	5	1	1	8	4	12
e580 Health services, systems and policies	12	17	10	4	43	26	69
e585 Education and training services, systems and policies	4	5	2	0	11	5	16
e598 Services, systems and policies, other specified	7	11	26	3	47	47	94
Others	4	5	0	0	9	1	10
(Subtotal)	863	973	932	221	2,989	2,151	5,140
Total	1,224	1,349	1,493	306	4,372	3,440	7,812

The interviewees were 1,910 disaster victims. Their responses (words and phrases) corresponded to the ICF category codes. Multiple codes per response were allowed.

¹ The Asahi Shimbun (AS, national newspaper).

² Fukushima Minpo (FM, local newspaper).

3. Results

The main results are described in this chapter; several detailed results are referred to in the Discussion section.

3.1. ICF codes

High-frequency category codes from the newspaper interviews are shown in Table 4. This table presents the content of victims’ concerns: what they wanted to say and do. In the table, AS articles were classified into four columns: Iwate, Miyagi, Fukushima Prefecture and Others. Their articles in the column are denoted by such terms as ‘AS-Iwate’.

In Table 4, there were four category codes from Body Functions, 16 from Activities and Participation and 35 from Environmental Factors for a total of 55 category codes. No interview responses for Body Structures were selected. As most interviewees were healthy individuals, severely disabled people scarcely appeared. They seemed to be in the hospitals, so the interviewers, who were probably non-medical professionals, were unable to interview them directly.

The total number of codes in AS was 4,372 and that in FM was 3,440 for a total of 7,812 codes. The number of interviewees of AS was 1,027, and that of FM was 883, so the ratio between both was 1:0.86. The number of interviewees of AS-Iwate was 291; that of AS-Miyagi was 297 and that of AS-Fukushima was 363, so the ratio was 0.81:0.82:1. Those ratios were considered in the analysis. The number per interviewee of AS was 4.3 codes (= 4,372/1,027); that of FM was 3.9 codes (= 3,440/833) and that of the average of both was 4.1 codes.

The main points observed were as follows (note: for ease of reference, for example, the representation ‘(T4-1)’ means ‘referring to Table 4 and numbered as 1’):

• (T4-1) The most common codes were the following: 916 codes of e310 [Family], 733 of e165 [Assets], 694 of e230 [Natural events], 600 of e325 [Acquaintances], 356 of d940 [Human rights], 355 of d660 [Assisting] and 351 of d998 [Community];

• (T4-2) Code d570 [Health]: The number of FM (79 codes) was larger than the number of AS (40);

• (T4-3) Code d710 [Basic interactions]: FM (162) was larger than AS (99);

• (T4-4) Code d845 [Job]: AS (186) was larger than FM (82);

• (T4-5) Code d920 [Recreation]: FM (102) was larger than AS (30);

• (T4-6) Code d940 [Human rights]: AS-Fukushima (113) and FM (193) were much larger than AS- Iwate (18) and AS-Miyagi (24);

• (T4-7) Code d998 [Community]: AS-Fukushima (100) and FM (126) were larger than AS-Iwate (49) and AS-Miyagi (62);

• (T4-8) Code e165 [Assets]: AS (504) was larger than FM (229);

• (T4-9) Code e230 [Natural events]: AS (480) was larger than FM (214);

• (T4-10) Code e235 [Human events]: AS-Fukushima (143) and FM (193) were much larger than AS-Iwate (2) and AS-Miyagi (5);

• (T4-11) Code e325 [Acquaintances]: FM (362) was larger than AS (238).

As the details of following codes were referred to in the Discussion section, they are listed here:

• (T4-12) Code e340 [Care providers]: In AS and FM (a total of 137 codes): volunteer (134);

• (T4-13) Code e355 [Health professionals]: In AS and FM (14): doctor (3), nurse (3) and nursery school teacher (2);

• (T4-14) Code e360 [Other professionals]: In AS and FM (34): Self-Defense Forces (27), fire department (3) and police (2);

• (T4-15) Code e580 [Health services]: In AS and FM (69): bathing (42).

3.2. Qualifiers of codes

The qualifiers of those codes in Table 4 are shown in Table 5. The chief observations can be summarised by the following seven points, concerning a large number of qualifiers:

Table 5. Total number of ICF qualifiers based on newspaper interviews.

Qualifiers	AS^1					FM^2	Total: AS + FM	Major codes (total)
	Iwate	Miyagi	Fukushima	Others	(Subtotal)	Fukushima
Body Functions
bxxx.0	0	1	1	0	2	1	3
bxxx.1	2	6	4	1	13	13	26	b126 (18)
bxxx.2	5	2	7	3	17	14	31	b126 (14)
bxxx.3	1	0	2	2	5	5	10
bxxx.4	1	3	2	0	6	0	6
bxxx.8	5	4	8	3	20	19	39	b749 (12)
bxxx.9	0	0	0	0	0	0	0
(Subtotal)	14	16	24	9	63	52	115
Activities and Participation
dxxx.0	28	39	29	7	103	240	343	d570 (81), d920 (77), d750 (61)
dxxx.1	15	21	23	5	64	50	114
dxxx.2	18	31	60	9	118	125	243
dxxx.3	16	13	22	3	54	12	66
dxxx.4	82	83	205	17	387	249	636	d940 (288), d845 (138), d998 (83)
dxxx.8	188	173	198	35	594	561	1,155	d710 (256), d998 (255), d855 (141)
dxxx.9	0	0	0	0	0	0	0
(Subtotal)	347	360	537	76	1,320	1,237	2,557
Environmental Factors
exxx.0	7	5	1	3	16	2	18
exxx.1	6	11	7	2	26	14	40
exxx.2	17	37	23	16	93	47	140
exxx.3	25	38	20	19	102	27	129
exxx.4	414	436	411	95	1,356	655	2,011	e230 (693), e165 (373), e235 (348)
exxx.8	49	53	52	15	169	90	259
exxx.9	0	0	0	0	0	0	0
exxx + 0	1	1	2	2	6	2	8
exxx + 1	5	3	2	0	10	6	16
exxx + 2	7	18	17	5	47	69	116
exxx + 3	21	33	21	2	77	39	116
exxx + 4	259	286	297	45	887	1,020	1,907	e310 (854), e325 (422), e315 (109)
exxx + 8	52	52	79	17	200	180	380	e165 (143), e525 (77), e325 (57)
(Subtotal)	863	973	932	221	2,989	2,151	5,140
Total	1,224	1,349	1,493	306	4,372	3,440	7,812

The interviewees were 1,910 disaster victims. Their category codes were linked to the dedicated qualifiers.

¹ The Asahi Shimbun (AS, national newspaper).

² Fukushima Minpo (FM, local newspaper).

• (T5-1) Qualifier bxxx.1 [Mild impairment] and bxxx.2 [Moderate impairment] in Body Functions: the number of codes b126 [Temperament] was large (a total of 32 codes);

• (T5-2) Qualifier dxxx.0 [No difficulty] in Activities and Participation (AP): d570 [Looking health] (81), d920 [Recreation] (77) and d750 [Informal relationships] (61);

• (T5-3) Qualifier dxxx.4 [Complete difficulty] in AP: d940 [Human rights] (288), d845 [Acquiring job] (138) and d998 [Community] (83);

• (T5-4) Qualifier dxxx.8 [Not specified] in AP: d710 [Basic interactions] (256), d998 [Community] (255) and d855 [Non-remunerative employment] (141);

• (T5-5) Qualifier exxx.4 [Complete barrier] in Environmental Factors (EF): e230 [Natural events] (693), e165 [Assets] (373) and e235 [Human-caused events] (348);

• (T5-6) Qualifier exxx + 4 [Complete facilitator] in EF: e310 [Immediate family] (854), e325 [Acquaintances] (422) and e315 [Extended family] (109);

• (T5-7) Qualifier exxx + 8 [Facilitator, not specified] in EF: e165 [Assets] (143), e525 [Housing services] (77) and e325 [Acquaintances] (57).

3.3. Interview responses

In Table 6, each ICF category code row, which was selected from Table 4, lists one victim’s personal attributes, interview responses (note: the average percentages of quotations from the original interview articles are approximately 40%) and qualifiers. Each interview response included various ICF codes. Nevertheless, only one code was listed. Our intention for the listing was to exemplify how we selected an applicable code from varied interview content. When the whole image of the victim was depicted, several codes were necessary, as in the case of Mrs Suzuki.

Table 6. ICF codes based on interview responses and their qualifiers.

Category codes^1	Victim			Date (2011), Newspaper^3	Response^4	Qualifier^5
	Sex^2	Age	Occupation
Body Functions
b130	Energy and drive functions
b1300	F	48	-	16 May, AS	My oldest daughter escaped to the nearest community centre, but she was turned away from going upstairs. So she was washed away by a tsunami, I heard. Her death has left a vacuum in my heart since that day, even after two months have passed.	E/M	[ .0 .1 .2 .3 .4 .8 .9 ]
b134	Sleep functions
b1343	M	65	Farmer	26 March, FM	My wife and I escaped in a hurry by driving a light lorry after we saw the tsunami coming. I saw our house floating in the rear view mirror. I’d lost my house, so concerns for the future make me sleep poorly every night.	E/M	[ .0 .1 .2 .3 .4 .8 .9 ]
Activities and Participation
d450	Walking
d4501	M	73	-	22 March, FM	Walking my dog is my chore. I maintain my health every day.	P	[ .0 .1 .2 .3 .4 .8 .9 ]
						C	[ ‥0 ‥1 ‥2 ‥3 ‥4 ‥8 ‥9 ]
d750	Informal social relationships
d7501	F	47	School staff	18 March, AS	To all people in Japan, let us pick your brains! Tell us how the people in evacuation centres can live together peacefully without quarrelling.	P	[ .0 .1 .2 .3 .4 .8 .9 ]
						C	[ ‥0 ‥1 ‥2 ‥3 ‥4 ‥8 ‥9 ]
d845	Acquiring, keeping and terminating a job
d8451	M	73	Fisherman	21 March, AS	Two boats for farming kombu (a kind of kelp) and scallops were swept away, and my house was too. I can’t cultivate them again at my age.	P	[ .0 .1 .2 .3 .4 .8 .9 ]
						C	[ ‥0 ‥1 ‥2 ‥3 ‥4 ‥8 ‥9 ]
d940	Human rights
d940	F	17	High school student	8 June, AS	I know irresponsible writings and sayings about Fukushima are spreading on the web and through rumours. I don’t want it to be said that ‘women in Fukushima can’t marry’.	P	[ .0 .1 .2 .3 .4 .8 .9 ]
						C	[ ‥0 ‥1 ‥2 ‥3 ‥4 ‥8 ‥9 ]
Environmental Factors
e165	Assets
e1651	M	27	Farm staff	10 April, AS	Our vineyard, office and winery were flooded with the seawater.	B	[ .0 .1 .2 .3 .4 .8 .9 ]
						F	[ +0 + 1 +2 + 3 +4 + 8 ]
e235	Human-caused events
e235	M	29	Company employee	5 April, AS	I’m concerned about the effect of radioactive contamination on children.	B	[ .0 .1 .2 .3 .4 .8 .9 ]
						F	[ +0 + 1 +2 + 3 +4 + 8 ]
e340	Personal care providers and personal assistants
e340	M	75	Retired	16 April, FM	During our long evacuation, we really appreciate the volunteers’ help such as with meals and cares.	B	[ .0 .1 .2 .3 .4 .8 .9 ]
						F	[ +0 + 1 +2 + 3 + 4 + 8 ]
e350	Domesticated animals
e350	M	50	-	30 May, AS	Just after the earthquake hit, I’d run away with my rabbit in a paper bag. I lost my job, and my house was completely swept away. But I always feel at rest when I hold my rabbit.	B	[ .0 .1 .2 .3 .4 .8 .9 ]
						F	[ +0 + 1 +2 + 3 +4 + 8 ]
e425	Individual attitudes of acquaintances, peers, colleagues, neighbours and community members
e425	M	77	President of residents’ association	19 March, AS	Twenty-odd evacuees are staying in the evacuation centre. They are becoming irritable, so some quarrels such as disputes over food have erupted.	B	[ .0 .1 .2 .3 .4 .8 .9 ]
						F	[ +0 + 1 +2 + 3 +4 + 8 ]
e445	Individual attitudes of strangers
e445	M	64	Fisherman	14 April, AS	When the tsunami hit, I went out fishing to be safe. But I’ve stopped fishing because of the risk of the damage caused by rumour about the nuclear power plant accident.	B	[ .0 .1 .2 .3 .4 .8 .9 ]
						F	[ +0 + 1 +2 + 3 +4 + 8 ]
e545	Civil protection services, systems and policies
e5450	M	70	Retired	9 April, FM	We are encouraged by the officers who patrol regularly and ask us about our problems and complaints.	B	[ .0 .1 .2 .3 .4 .8 .9 ]
						F	[ +0 + 1 +2 + 3 +4 + 8 ]
e575	General social support services, systems and policies
e5750	M	72	-	20 March, AS	As I’m disabled, I use a wheelchair. So even if I can return, I can’t clean debris from my house on my own.	B	[ .0 .1 .2 .3 .4 .8 .9 ]
						F	[ +0 + 1 +2 + 3 +4 + 8 ]

Fourteen interviewees were selected from among 1,910 disaster victims. Their personal attributes, responses, category codes and qualifiers were listed.

¹ Category codes are the lowest subcategory codes.

² M: male; F: female.

³ The Asahi Shimbun (AS, national newspaper); Fukushima Minpo (FM, local newspaper).

⁴ Applicable words or phrases and qualifiers for the ICF category codes and their qualifiers are underlined.

⁵ E/M: extent/magnitude; P: performance; C: capacity; B: barrier; F: facilitator.

For Activities and Participation, we were able to evaluate all the first qualifiers for Performance. However, we were unable to determine most of the second qualifiers for Capacity (i.e. without assistance qualifiers) from content of the interview articles; thus, we represented them as ‘xxx.8’.

3.4. Main ideas of responses

The main ideas of interviewed responses are shown in Table 7. The following are the three most common observations:

Table 7. Total number of main ideas based on interview responses.

Category of main ideas	AS^1		FM^2
	Main ideas	Percentage	Main ideas	Percentage
Self and Family member	570	55.5	457	51.8
Neighbour and Community	218	21.2	271	30.7
Administration and Government	95	9.3	60	6.8
Supplies and Facilities	39	3.8	16	1.8
Information	22	2.1	19	2.2
Rule and Procedure	5	0.5	0	0.0
Evacuation centre and Temporary housing	69	6.7	48	5.4
Others	9	0.9	12	1.4
Total	1,027	100.0	883	100.0

The interviewees were 1,910 disaster victims. The main ideas (themes) of their responses were classified into 8 categories.

¹ The Asahi Shimbun (AS, national newspaper).

² Fukushima Minpo (FM, local newspaper).

• (T7-1) The most common main idea was the category Self and Family member, and it had 570 pieces in AS (its percentage rate was 55.5%) and 457 pieces in FM (51.8%);

• (T7-2) In the category Neighbour and Community: AS (218 pieces, 21.2%) and FM (271, 30.7%);

• (T7-3) In Administration and Government: AS (95, 9.3%) and FM (60, 6.8%).

3.5. Strengths of victims

The total of strengths of interviewed victims in the newspapers is shown in Table 8 (note: some victims had several strengths or were without strengths). The following are the six most common observations:

Table 8. Total number of strengths based on interview responses.

Parent category	Subcategory	Strengths	AS^1					FM^2	Total: AS + FM
			Iwate	Miyagi	Fukushima	Others	(Subtotal)	Fukushima
Resources	Family	Bonds	133	134	187	28	482	460	942
		Relationship	12	8	10	3	33	55	88
	Close people	Friends	13	17	20	1	51	23	74
		Acquaintances	0	1	2	0	3	2	5
		Peers	7	2	4	1	14	11	25
		Neighbours	4	22	4	4	34	3	37
		Pets	4	2	5	0	11	1	12
	Home	House	19	14	8	4	45	0	45
	Business	Shop, Office	6	1	1	1	9	1	10
		Clients	8	5	4	0	17	2	19
(Subtotal)			206	206	245	42	699	558	1,257
Natures	Character	Modesty	8	16	12	0	36	21	57
		Discipline	6	8	12	4	30	14	44
		Pride	4	3	2	0	9	1	10
		Positivity	4	3	2	0	9	48	57
		Introspection	8	5	6	2	21	5	26
		Independence	5	5	3	1	14	9	23
		Responsibility	8	11	6	1	26	7	33
		Vocation	8	4	2	0	14	4	18
		Leadership	3	2	0	1	6	4	10
	Contribution	Service	39	33	19	2	93	60	153
		Altruism	2	1	1	0	4	9	13
		Gratitude	4	1	7	0	12	12	24
		Piety	2	2	5	0	9	5	14
	Attitude	Sympathy	7	3	6	1	17	5	22
		Care	10	14	17	3	44	51	95
		Thanks	38	39	40	10	127	213	340
		Sociability	1	0	5	0	6	13	19
	Community	Hometown affection	53	39	51	11	154	54	208
		Righteous indignation	1	5	27	3	36	29	65
		Justice	0	2	7	0	9	1	10
(Subtotal)			211	196	230	39	676	565	1,241
Capabilities	Efforts	Diligence (worker)	73	66	62	18	219	67	286
		Diligence (student)	19	13	22	3	57	69	126
	Technique	Originality	2	4	1	0	7	1	8
	Incentive	Dream	9	5	4	0	18	1	19
(Subtotal)			103	88	89	21	301	138	439
Total			520	490	564	102	1,676	1,261	2,937
Without strengths			11	15	30	14	70	67	137

The interviewees were 1,910 disaster victims. Strengths (individual good traits and favourable environment) of their responses were hierarchically classified. Multiple strengths per response were allowed.

¹ The Asahi Shimbun (AS, national newspaper).

² Fukushima Minpo (FM, local newspaper).

• (T8-1) The most common strengths had 942 items in Bonds, 340 in Thanks, 286 in Diligence (worker), 208 in Hometown affection and 153 in Service;

• (T8-2) In the parent category Resources: Neighbour (3 items), Pets (1), Shop (1) and Client (2) in FM were less than those in AS;

• (T8-3) In Natures: Thanks in FM (213) was larger than in AS (127);

• (T8-4) In Natures: Righteous indignation in AS-Fukushima (27) and FM (29) were larger than in AS-Iwate (1) and AS-Miyagi (5);

• (T8-5) In Capabilities: Dream in FM (1) was less than in AS (18);

• (T8-6) Interviewed victims without strengths were 7.2% (= 137/1,910) of those interviewed; AS-Fukushima (30) and FM (67) were larger.

4. Discussion

4.1. Data analysis

(1) Codes

The comparison between AS and FM in Table 4 suggested the following interpretations: (a) Many interviewees of AS-Iwate and AS-Miyagi had more interest in economic life (T4-4, -8); (b) By contrast, many interviewees of AS-Fukushima and FM had more interest in human beings (T4-2, -3, -5, -6, -7, -11); (c) In addition, they had more concern for the nuclear power plant accident, as well as the damages of the earthquake and the tsunami (T4-9, -10); and (d) Various people supported them (T4-12, -13, -14, -15).

We can summarise the analysis as follows: (a) Over 90% drowned in the tsunami (National Police Agency, Government of Japan, 2011); (b) Extensive houses and belongings were swept away; (c) Numerous victims were evacuated for extended periods and suffered distress from rumours about the nuclear power plant accident; (d) Disaster-related information was complicated by the co-occurrence of three simultaneous disasters; and (e) These incidents reflected the number of ICF codes, and these codes characterised the calamity.

(2) Qualifiers

The qualifiers in Table 5 were unevenly distributed; in particular, xxx.4 (worst), xxx + 4 (best) and xxx.8 (unknown) were larger. If newspaper articles had more information, the distribution of their qualifiers could be more spread out. A new scale of qualifier is needed for an existent data source.

(3) Responses

Table 6 expresses victims’ earnest thoughts and serious problems. There is an important point to elaborate: How do you convey their experiences using ICF?

According to the above-mentioned descriptions ((1)–(3)), (a) all people were given attention, instead of only the disabled and the aged people (a total of 1,910 interviewees); (b) in Environmental Factors, the study obtained the positive (facilitators; a total of 2,543 codes) as well as the negative (barriers, a total of 2,597 codes) aspects; and (c) many second-level category codes were selected (a total of 55 codes). These results cosiderably differed from those of other studies (Section 1.3).

(4) Main ideas

The number of main ideas in the category Self and Family member in Table 7 was large (T7-1), and the category Neighbour and Community also had a high number (T7-2). The content of both categories involved private matters such as safety and worry about people to whom one was close. The category Administration and Government had a lower number than the above two categories (T7-3), and its content included public matters such as criticism and demands on the authorities.

How much the victim’s honne (real intention or true thought) was expressed in his/her main idea needs attention. We speculate that every victim’s personal information was widely known; thus, his/her critical responses on the inside (e.g. neighbours and community members) and the outside (e.g. municipalities and organisations) were restricted for fear of reprisal. To find doubtful data, the discussion on biases initiated by the interviewer (reporter), the interviewee (victim) and the researcher (author) is needed here.

(5) Strengths

An analysis of strengths suggests the following interpretations: Many victims in Fukushima unwillingly left their hometowns due to the nuclear power plant accident, so that their Resources were fewer (T8-2); their anger and complaints were considerable (T8-4); and then they were depressed. Thus, they were obliged to obtain various forms of support (T8-3). To answer the expectation of the supporters, they desired above all to work at once for their families and hometowns (T8-1). Nevertheless, given hard realities, some of them were unable to achieve their dreams of the future (T8-5), and their strengths did not appear (T8-6).

The following two aspects should be carefully observed: (a) To what degree the victim’s strengths as determined by a researcher are different from his/her conscious strengths; and (b) To what degree his/her individual strengths were exploited. However, we are unable to solve the matter of the differences and their use in this study.

4.2. Analysis methods

Two qualitative methods were used in this study. In interviews with the evacuees, we adopted the text mining (TM) for analysis of parts of speech, and the grounded theory approach (GTA) for analysis of the context and of victim support.

The part-of-speech tagging (Ignatow & Mihalsia, 2018) in TM corresponds to ICF code selection in this study. The underlined word or phrase in each response in Table 6 means the ICF code has been tagged. We attempted questioning, one of the types of strategies in GTA (Corbin & Strauss, 2015), on the interview with Mrs Suzuki in Table 3. For example, we posed the following questions:

• If she ran away by herself, would she still have enough strength in her leg?

• If she used a car, did anyone share the car?

• How did she accept her husband’s death and loss of her past life?

• Did she have other family members, relatives or familiar friends?

• Did she lack sleep or feel tired because of grief and anxiety?

• Did she get along well with neighbours and did they cheer each other up in the evacuation centre?

• Was she able to maintain friendly relationships with other victims she did not know?

• Did she experience any difficulties bathing?

• Did she have other reasons for living in temporary housing, such as concerns for privacy, noise, toilet accessibility or homesickness?

Such questioning is useful for supporting evacuees concretely and widely.

A strategy of thinking about the various meanings of a word was also useful in selecting the category codes and qualifiers. For example, some words uttered frequently by victims, such as unease, patience and information, are both vague and potentially significant, and the meaning of a sentence is likely to be complicated. Therefore, it is important to understand the main idea of the victim’s response, as already mentioned.

4.3. Proposal for a ‘disaster ICF’

WHO describes the ICF as ‘a multipurpose classification designed to serve various disciplines and different sectors’ (WHO, 2008, p. 6). In general, an advantageous multipurpose use is not always fully guaranteed to be an individual use; therefore, some modifications to the original framework are necessary for specific applications. ICF is typically applied to one’s life and environment under peaceful conditions. In the event of a natural disaster, both the condition of a disaster area and that of an individual victim should be discussed. Thus, a ‘disaster ICF’ concept can be introduced. The following are three relevant points for implementing this concept:

1. How does ICF capture the conditions of the victim and the area? It is important to specify the time, place and state to capture this accurately. The post-disaster period and the lives of new communities that emerge in evacuation centres or temporary housing would be essential factors in the use of a disaster ICF. For example, the response of Mrs Suzuki in Table 3 depicted three-time frames: the day the disaster occurred, the day of her return home to see her house and the present. She had thus experienced three different lifestyles. One’s life would be affected in terms of grief, survivor’s guilt (including posttraumatic stress disorder (PTSD)) and rebound (including PTG).

2. Who uses the disaster ICF to examine the victim and the area, and how? It is important to specify the users and their purpose to discuss the question. The regular ICF is generally used by health or welfare professionals to support those with disabilities (professional’s perspectives). In contrast, the disaster ICF could be used to determine both one’s own condition (victim’s perspective) and the conditions of others (other victims’ perspective), because several disaster situations could require both self- and mutual help. Ideally, victims can support more troubled victims (e.g. those who have suffered physical, mental or economic misfortune).

3. Which codes express the conditions of the victim and the area? An effective selection method is expected. An ICF Core Set is defined as ‘a selection of categories from the full ICF classification …’ (Bickenbach et al., 2012). Thus, the ICF codes listed in Table 4 could be called the disaster ICF core sets and serve as the basic codes in the disaster ICF code family. These codes characterise various disaster situations. However, the basic codes do not always provide a rigid framework. Some of the codes should be replaced with different ones reflecting actual disaster type, area affected and other relevant details. Moreover, the codes of Body Structures excluded from this study should be added, and each code should be set according to the time phase.

From the above discussion, we propose that a disaster ICF should be introduced into the natural disaster environment. We can define the primary aim of the disaster ICF as identifying support needs for victims and affected areas. Several other studies tend to focus chiefly on the person, while the disaster ICF is focused on in the areas as well.

4.4. Potential problems with the use of the ICF

When the disaster ICF is used, the present ICF code system has shortcomings, which we describe here.

(1) Subcategories

Parent categories do not always have subcategories. For example, a parent category [Natural event] in Environmental Factors has a code e230; however, it has no subcategory. If the disaster ICF is applied, the code e230 could contain the following subcategories: earthquake, tsunami, typhoon (cyclone, hurricane), flood, tornado and eruption, among others.

The parent category code e165 [Assets] has regular subcategories: e1650 [Financial assets], e1651 [Tangible assets], e1652 [Intangible assets], e1658 [Assets, other specified] and e1659 [Assets, unspecified]. The victims mentioned concrete examples of many kinds of assets. Therefore, in this study, we modified the parent category code to allow more detailed analysis by marking the code with the object’s initial. The code e165 was further refined as follows: e165M (Money, a total of 7 responses), e165V (Valuables/documents, 14), e165G (Goods/products, 23), e165H (Houses/buildings, 526), e165S (Shops/stores, 74), e165W (Works/factories/mills, 19), e165F (Field/farms, 30), e165B (Fishing Boat/ships, 40). Twenty-four parent categories in 55 major category codes in Table 4 had their special subcategories. When the disaster ICF is used, users thus need to develop a complementary coding system in advance.

(2) Selecting codes

The selection of ICF codes is not always clear-cut. ICF has several general rules of coding. Some of those rules are disputable, in particular, ‘When assigning codes, the user should not make an inference …’ (WHO, 2008, pp. 274–276). However, the user cannot always obey those rules when the disaster ICF coding applies. This can be illustrated by the code ‘distress caused by rumours’. If a 40-year-old man reported himself as suffering from distress caused by rumours, one would infer that his business was affected. Therefore, codes d845, d850, e565 and e570 could be selected. If a 10-year-old boy reported this, however, he would more likely be affected in his school and home life (e.g. through bullying, truanting, social withdrawal). Thus, codes b126, b134, d750, d760, d920, d940, e130, e140, e310, e320, e325, e330, e425, e575 and e580 could be inferred and selected. As both these victims have different Personal Factors, their degrees of hardship cannot be measured on the same scale. Therefore, the number of codes and categories to select should not be limited. Because the disaster ICF emphasises support for victims, this support should be planned thoroughly without the unselecting codes as enough as possible. An explicit inference is necessary in cases in which the inferred code is distinguished, for example, when the code ‘b134?’ is used. When the code is determined, the code ‘b134!’ is denoted.

In addition, causality may be examined by inference. For example, distress caused by rumours is sometimes related to human rights. The response of a 17-year-old schoolgirl in column code d940 [Human rights] in Table 6 was caused by irresponsible rumours (code e445 [Individual attitudes of strangers]). Therefore, one must exercise one’s imagination and discretion in selecting codes. However, competence for doing so varies among individuals. Criteria must thus be developed to guide users through the code-selecting system.

(3) Qualifiers

The use of qualifiers is also problematic. The ICF guidelines specify that ‘The ICF codes are only complete with the presence of a qualifier … Without qualifiers, codes have no inherent meaning’ (WHO, 2008, p. 27). However, we have different views on the use of qualifiers. In a disaster setting, it is possible for one to transmit health information by using a category code without a qualifier. It is rather difficult for anyone except a professional or skilled person to use qualifiers precisely, especially for Body Functions and Body Structures. If ICF coding obliges us to use qualifier coding, the use of the disaster ICF would slow down or be limited in cases of victim-to-victim use (i.e. mutual help) or support from abroad. It is very important to share ICF information, which aims to connect victims and their supporters. The category codes comprise the minimum and simplest ICF information, and the usability of the ICF takes precedence over rigid adherence to its form. It is also possible to establish a framework for support using qualifierless codes.

The advantage of codes with qualifiers is that changes in the health condition of victims who have been traumatised or evacuated for long periods can be reflected as a change in the qualifier. Therefore, an evaluation criterion with both an absolute and a relative time axis should be set in advance. Moreover, the priority of and correlation among the codes should be established based on the degree and the change in one’s health condition.

(4) Ethical education

Newspaper interviews reveal the identities of individual victims. Even if a victim was anonymous or used a pseudonym, a reader could search the internet and identify him/her from internet content. Consequently, the data in our analysis could cause larger problems. Even if the analysis was nonjudgemental, the interviewees could be judged on one reading of the published study. Accordingly, analysts and users should keep in mind that the analysed ICF codes consist of any personally identifying information.

When teaching health and welfare using the ICF is practiced, the following risk should be noted. More cases could lead to a more results-oriented approach and promote exaggeration by stretching the definition of codes. The following harmful effects to students can result: (a) They could become inquisitive and violate victims’ privacy out of their personal interest and innocence; (b) They could have preconceptions and prejudices about the coding, such as from similar cases encountered in the past; (c) They could be insensitive to victims’ mental anguish, particularly in those who are facing death; and (d) They could fall into patterns of paternalism due to many of their vocations. Users thus need to definitely explain the evaluation system to students.

National Child Traumatic Stress Network and National Center for PTSD (2006) published a method of providing psychological support for those experiencing the aftermath of disaster or terrorism. They noted some behaviour to avoid and stated, ‘Do not make assumptions about what survivors are experiencing or what they have been through. Do not pathologize. Do not talk down to or patronize the survivor’. Supporters should acquire these implored behaviours as their basic attitudes. Users need to develop an ethical coding system and a talent training system.

(5) Deaths

The number of responses referring to death in the interview articles are as follows: ‘died’ (AS, 2 responses; FM, 0), ‘passed away’ (AS, 46; FM, 6), ‘sacrificed’ (AS, 1; FM, 0), ‘swept away’ (AS, 16; FM, 0), ‘killed’ (AS, 0; FM, 0), ‘remains’ (AS, 9; FM, 0), ‘corpse’ (AS, 0; FM, 0), ‘missing’ (AS, 29; FM, 11) and ‘can’t reach’ (AS, 10; FM, 5). The percentage of total responses was 11% (= 113/1,027) of AS and 2.5% (= 22/883) of FM. The figure of FM was much smaller than that of AS.

The following would be the main reasons for this difference: (a) the difference in coverage policy between the national newspaper and the local newspaper (e.g. informing the nationals as much as possible about real things that happened vs. serving as a ‘dedicated message board’ for the community and gathering ‘small talks’ for the locals); and (b) the intentional biases between the interviewer and the interviewee (e.g. interviewers pretending not to ask victims to give vivid accounts of their experiences vs. interviewees avoiding answering questions about their miserable experiences). Several interviewees compared this disaster with their experiences of past calamities (AS, 13; FM, 0) and World War II (AS, 5; FM, 3). Death is a delicate interview subject; however, it should be considered in the disaster ICF

When a victim died in several months or years after the occurrence, his/her death is sometimes categorised according to specific causes. A ‘disaster-related death’ is defined according to whether a victim dies not by direct causes (e.g. collapse of a structure, fire, tsunami) but by indirect causes (e.g. falling sick because of the long evacuation time, worsening chronic illness, stress, strain). From March 2011 to March 2023, a total of 3,789 victims died (Iwate, 470; Miyagi, 930; Fukushima, 2,333; others, 56) (Reconstruction Agency, Government of Japan, 2024b).

Two hundred fifty-two victims died by suicide from March 2011 to December 2023 (Iwate, 59; Miyagi, 64; Fukushima, 119; others, 10) (Ministry of Health, Labour and Welfare, Government of Japan, 2023). Fukushima residents have suffered large numbers of both disaster-related deaths and deaths by suicide. Maeda et al. (2018) reported that Fukushima residents, including evacuees from the nuclear power plant accident, have suffered from various psychosocial problems, leading to increases in both alcohol abuse and suicide.

The relationship between the large number of suicides and code e310 [Immediate family] in FS in Table 4 was meaningful. If the cause were intertwined with a family affair, the following things could happen: (a) Some victims felt gloomy about the future of their families; (b) They cried out for help from others except for family; (c) They were eager to do something for their families but did nothing; and (d) Some of them grew desperate and, thus, took their own lives. A victim mentioned the behaviour of other survivors: ‘I’ve exhausted myself overworking. But some people who just lost their family members are the first to chop firewood, carry hot water and offer other services to the evacuees with a smile’ (78-year-old male, AS-Iwate, 3 April). Such behaviour, which is occasionally encountered in one’s daily life, would be explained by defence mechanism, stress (e.g. coping, burnout) and need (e.g. need-hierarchy theory).

WHO (2017) asks the media professionals for responsible reporting on suicide and presents the 12 guiding principles. One such principle is ‘Do apply caution when interviewing bereaved family or friends’. The guideline could be applied to the case in which the ICF user came into contact with other family members of the person who committed suicide or suffered a disaster-related death.

At present, ICF has no code relevant to the death; however, the symptom of death could be expressed by the gradation of the negative qualifier evaluated. After a person’s death, his/her individual code will vanish; however, the death will affect others’ codes. The disaster ICF needs the concept of death.

5. Conclusion

We developed a new method of capturing and analysing the conditions of disaster victims and areas of the Great East Japan Earthquake 2011 using ICF codes.

In Part I, the responses of 1,910 victims gathered from newspaper interview articles were examined, and a total of 7,812 codes from 55 kinds of major category codes were obtained. These codes characterised various real images of this disaster. We proposed disaster ICF as a concept, that is, a dedicated ICF to natural disasters. The use of the disaster ICF would specifically contribute to the support and recovery of various victims and affected areas. As a way of complementing ICF coding, the term main idea, meaning the keystone of each response, was introduced. As an approach that emphasised each victim’s resources, nature and capability to recover his/her condition effectively, the concept of strengths was used. Five potential problems with the use of the original ICF were listed: the improvement of subcategories, the establishment of the code selection systems, the flexibility in qualifier evaluation, the regard for ethical education and the comprehension of deaths in disaster conditions. When the users adopt the disaster ICF, they should address these problems.

In Part II, the applicability of the disaster ICF is discussed.

About the author

Shin-ichi Susato, Doctor of Engineering. Certified Social Worker.

The author was engaged in the design and production of mechatronic products in private companies. He also taught electronics and computer science in technical schools. He has conducted research on anthropometry (the measurement of human physical dimensions, which is used in physical anthropology and ergonomics [human factors]) and on goniometry (the measurement of joint motion range and used in orthopaedic surgery and rehabilitation medicine) in his academic life. He has been examining a new development in the field of health and welfare by making use of his knowledge and experience in engineering, medicine and sociology.

Disclosure Statement

No potential conflict of interest was reported by the author(s).

Data availability statement

Each newspaper interview article is available on the following newspaper publisher databases (written in Japanese): The Asahi Shimbun, http://www.asahi.com/information/db/; Fukushima Minpo, https://www.minpo.jp/cdrom). The ICF coding datasets produced by the author are not shared to maintain the privacy of interviewees.

Additional information

Funding

The author received no funding for this study.