Disaster literature widely documents that individuals exposed to large disasters with cascading effects that evolve overtime, such as hurricanes, are more likely to experience increased levels of stress, anxiety, depression, and post-traumatic stress disorder (PTSD) compared to unexposed individuals (1–9). More so, residents of the United States (U.S.) Gulf Coast often experience elevated levels of depression and anxiety in the immediate aftermath of a hurricane and continue to experience ongoing psychopathologies long after the storm (3, 4). Such psychopathology trends may be present due to Hurricane Harvey, likely the most devastating storm in the last decade. After its landfall on August 25, 2017, the storm destroyed more than 12,000 homes and affected 13 million people across five states: Texas, Louisiana, Mississippi, Tennessee, and Kentucky (10–12). The category 4 hurricane caused widespread flash flooding across most of Harris County, submerging a third of the Houston metropolitan area (13). Existing studies revealed that Texas residents affected by Hurricane Harvey reported poorer self-rated mental health post-storm compared to the national standards (14). Also, individuals who experienced personal or property loss due to the hurricane were more likely to develop mental health symptoms, including PTSD, after the storm (15).

Short- and long-term post-disaster outcomes can differ by individual’s social economic status (SES) and racial backgrounds (16). Older age, occupational status, marital status, acculturation level, and the extent of property damage have statistically significant effects on post-storm health outcomes (17). Poor acculturation among immigrants and extensive property damage negatively affect the outcomes, and they often continue to impede recovery long after the storm (17). Furthermore, immigrants are vulnerable to poor post-disasters recovery due to their limited capacity to prepare for and respond to disasters (18, 19). Often exhibiting low levels of language skills, social acculturation, and SES, immigrants are more prone to poor recovery, and poor physical and mental health outcomes post-disasters (2, 20–30). This is particularly true among Vietnamese Americans across the U.S., who in 2019, reported that 65% of those ages 5 or above experienced limited English proficiency (31).

Previous studies on Hurricane Katrina highlighted that Vietnamese Americans who experienced displacement, severe property loss, and trauma due to the storm experienced concerning prevalence of partial PTSD during the first year post-storm (32). They also had limited access to health care and medications after Hurricane Katrina. About 40% of those surveyed also reported difficulties in obtaining health care needs 1 year post-storm (33, 34). Similar trends may be present among Houston-area Vietnamese American residents affected by Hurricane Harvey, but there have been no data available. However, the safety net provided by high perceived social support and community embeddedness among this community may be helpful in their recovery process; yet such associations among Vietnamese Americans, who are often excluded in post-disaster research, remain underexplored.

Sociodemographic background, pre-disaster health status, event exposure characteristics, and social support factors are features that may be associated with the likelihood of mental health issue development after disasters among affected individuals (35). Existing studies documented the associations between high perceived social support and community embeddedness to better post-disaster outcomes (36–39). Helpful relationships may provide emotional, informational, and instrumental support to alleviate mental distress, reduce anxiety, and enhance feelings of security to help affected individuals navigate the altered landscape of daily life post-disaster (35, 40). For example, social support through social connections may benefit the appraisal process of stressors to help regulate the intensity of emotional reactions to disaster events and subsequently alter post-traumatic stress levels (41–43). The availability of a supportive environment through social relationships and community embeddedness may encourage individuals to express their thoughts and feelings without fears of judgements, fostering the validation of their emotions, to then enhance positive coping and self-efficacy for disaster recovery. The interaction between high self-efficacy and quality social support may further offset negative disaster consequences. Thus, social support may be a critical factor in post-storm recovery to distinguish between those who succumbs to disaster hardships and those who do not (44). More specifically, high perceived social support and social embeddedness – two dimensions of social support – are vital to successful disaster recovery (40, 45–47). Evidence supporting the association between high levels of social support and lower depressive symptoms is expansive within existing literature. However, such association among Vietnamese Americans within the disaster context remain scant, particularly those affected by Hurricane Harvey.

This study is set in the Houston metropolitan area, home to the second largest population of Vietnamese Americans (48). At the time of the study, little was known about the Vietnamese American experiences from Hurricane Harvey in 2017, the second costliest storm to mainland U.S. since 1990 (49). This study thus aims to examine the association between social support and depressive symptom development within a community in the Houston-area that was severely impacted by Hurricane Harvey. We hypothesized that a high level of social support was likely associated with reduced depressive symptom development among Vietnamese Americans post-Hurricane Harvey.

The mean depressive symptom score among participants was 5.94 (standard deviation [SD] = 4.84); more specifically, more than half of participants (52.50%) experienced five or more symptoms – the median number of symptoms – 1 year post-storm (not shown in Table 1). The mean SF-12 MCS was 32.63 (S.D. = 4.98) while the mean SF-12 PCS was 39.78 (S.D. = 10.15). Although 75.83% of participants experienced storm-related home damages, less than a quarter of participants experienced injuries or illnesses due to the storm (Table 1). The mean age of participants was 57 and 71.43% were below the age of 65. The distributions of sex and education level among participants were relatively even (Table 2). The mean monthly income among participants was $1,903 (not shown in Table 2) while the median monthly income was $1,500. Prior to Hurricane Harvey, 66.67% of participants had employment and the majority (70.00%) had consistent residency pre- and post-storm. The percentage of uninsured participants was high (34.17%) compared to the national percentage of uninsured Vietnamese Americans. Most participants (69.17%) had a routine physical exam within the last 12 months prior to the interview. About half of participants indicated a high level of acculturation.

Within Table 3, we presented the results to our models that examined the predictors of depressive symptom scores among the participants. Model 1 included only social support as measured by the LSSS to predict depressive symptom scores. We added socio-demographic characteristics in Model 2 to ensure that the observed association between social support and depressive symptom development was not confounded by factors such as income and acculturation, while Model 3 included Hurricane Harvey-related characteristics. In Model 4, we added SF-12 MCS and SF-12 PCS measures to assess if the observed association between social support and depressive symptomology was confounded by self-rated mental health and/or physical health after the hurricane.

Social support, consistently across all four models, had a negative association with the outcome, in which higher social support was associated with lower depressive symptom scores (p < 0.05). Higher education was significantly related to lower depressive symptom scores in both Model 2 and Model 3 (p < 0.05); it seemed protective against depression symptom development in Model 4 but without statistical significance (b = −0.82, p > 0.05). Pre-storm employment had a negative association with depressive symptom score in Model 2 (b = −2.46, p < 0.05) but became statistically insignificant in Model 3 and Model 4.

Those who sustained injuries or illnesses from the storm experienced almost four points higher depressive symptom scores compared to those that did not in Model 3 (b = 3.90, p < 0.01). However, storm injuries or illnesses lost its statistical significance in Model 4. High self-rated physical health (b = −0.24, p < 0.001) was a statistically significant predictor of depressive symptom score, in which higher physical health was associated with lower depressive symptom scores in Model 4. The results implied that the influence of storm-related injuries or illnesses on depressive symptom development following Hurricane Harvey was explained in part by the participants’ perception of overall physical health 1 year post-storm; therefore, sustaining injuries or illnesses from the storm rendered marginally statistical significance (p = 0.08) in Model 4.

Residency tenure and high acculturation level consistently showed negative, but statistically insignificant, associations with depressive symptom scores across models. Individual characteristics, including age, sex, income level, health insurance status, marital status, and religion were not associated with the outcome in any models.

We conducted multicollinearity assessments in Model 4 using the variance inflation factor (VIF) metric to examine the correlation and strength of correlation between the predictor variables in the models. None of the VIF values were high, while the mean VIF value was 1.39, which indicated that multicollinearity was not a concern. In addition, a correlation matrix revealed that predictor variables were not highly correlated to one another (not shown).

Our study results documented the protective impact that social support has on depressive symptom development post-Hurricane Harvey. The results confirmed our hypothesis that a high presence of social support lowers depressive symptom scores among Vietnamese Americans post-Hurricane Harvey, even when accounting for Hurricane Harvey-related home damages and storm-related injury or illness. More so, the negative association between social support and depressive symptom development remained when accounting for both post-storm self-rated mental and physical health.

Better physical health was associated with fewer depressive symptoms. High acculturation level indicated better assimilation into U.S. society and better knowledge of the English language which may be helpful for Vietnamese Americans to navigate recovery resource access; thus, mitigating post-storm distress. However, in our study, although high acculturation level decreased depressive symptom development, the association lacked statistical significance (b = −1.19, p > 0.05). Inconsistent with existing studies, marriage/partnership did not have a statistically significant protective relationship to psychological distress development post-storm (4, 6, 36, 64). Interestingly, despite statistical insignificance, home damages due to the storm did not elevate depressive symptoms among our participants like it did for Vietnamese Americans affected by Hurricane Katrina (32).

Our results emphasized that Vietnamese Americans could be vulnerable to the adverse impacts of natural disasters long after the storm. More than 1 year post-storm, depressive symptoms remained prevalent among participants. Prolonged depressive symptoms may contribute to negative long-term well-being and health outcomes among Vietnamese Americans impacted by Hurricane Harvey. Disaster-related pessimistic thoughts are linked to physical health problems, more specifically, existing studies revealed that enduring negative thoughts contribute to anxiety disorders and chronic illnesses such as cardiovascular diseases over long durations (65, 66). Thus, prolonged psychological distress may result in poor recovery to pre-storm well-being and health among Vietnamese Americans affected by the storm (44, 67). The implication is that negative thoughts post-disaster can be part of a pathway to poorer health and subsequently group health disparities. Our results also indicated that on average, Vietnamese Americans had lower self-rated mental and physical health outcomes post-storm compared to the national standards of 50 (SD = 10). The stress from rebuilding after the storm may have cascading health impacts among this subpopulation but unexplored in existing literature. Such results emphasize that Vietnamese Americans’ well-being, especially psychological distress, immediately and long-term post-storm should be considered in recovery efforts.

Our study was limited by a small sample size and participant recruitment from a list of only BPSOS-Houston clients, even though the selection was random. Thus, the sample may not necessarily be representative of all Vietnamese Americans in the area, some of whom might be lucky enough to not experience Hurricane Harvey. In addition, the cross-sectional data did not allow us to assess depressive symptoms and the health status of participants prior to the storm, which limited causal references regarding the storm’s impacts. Future research using larger samples and replication to Vietnamese Americans outside of the BPSOS-Houston network would build on the strengths of our study. Also, continued long-term follow-up using a longitudinal approach would be beneficial for better understanding of how social support is associated with post-storm psychological distress across time.

Overall, our study added to the limited literature on post-disaster outcomes and the positive impacts of social support among immigrants and within the Vietnamese Houstonian population. Despite cross-sectional data limitations, our study findings have significant policy implications as the U.S. Gulf Coast continues to experience increased prevalence of powerful hurricanes (68, 69). Our results suggest that mental well-being after hurricanes among Vietnamese Americans should be prioritized by public health practitioners and emergency management entities. Programs and services should focus on fostering mental well-being and mitigating psychological distress through the provision of social support and community cohesion resources. Better efforts to integrate Vietnamese Americans into the larger Houston-area community pre-storms would contribute to building social embeddedness which may be beneficial in preparation for additional future hurricane exposures. As future hurricanes are expected to be stronger and more prevalent, inclusive preparedness efforts are critical. Other immigrant groups with similar characteristics as Vietnamese Americans may share similar disaster vulnerabilities highlighted by our study.

The datasets presented in this article are not readily available because protection of participants’ privacy. Requests to access the datasets should be directed to MD, mdo@tulane.edu.

The studies involving human participants were reviewed and approved by the Institutional Review Board of Tulane University. The patients/participants provided their written informed consent to participate in this study.

NP: conceptualization, formal analysis, methodology, software, writing – original draft, writing – review and editing, and visualization. MD: conceptualization, data curation, funding acquisition, methodology, project administrations, supervision, and writing – review and editing. JD: project administrations and writing – review and editing. All authors contributed to the article and approved the submitted version.

This project was funded by the Tulane University’s Carol Lavin Bernick Faculty Grant and the Tulane Japan Friendship Award with MDo, MPH, MD, PH as Principal Investigator.

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.