Healthcare Access and Rehabilitation Challenges Two Decades Post-Tsunami: A Qualitative Study from South Andaman, India

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Two decades later, this study was undertaken to qualitatively explore the long-term lived experiences of survivors concerning healthcare access, rehabilitation quality, and the subsequent resilience mechanisms that emerged in South Andaman. Methods This research employed a qualitative, phenomenological design using secondary thematic analysis of data from a larger project. Twenty-two tsunami survivors (N = 22), aged 18 years and above, were recruited via purposive and snowball sampling to ensure diversity across gender, location, and socio-economic status. In-depth, semi-structured interviews (IDIs) were conducted between March and August 2024 in Hindi, Bengali, or local dialects until data saturation was achieved. Transcripts were analyzed using Braun and Clarke’s six-phase thematic analysis framework , supported by NVivo software. Methodological rigor was ensured through independent coding and peer-checking. Ethical clearance was obtained from the Institutional Ethics Committee (ANIIMS/IEC/2024/23). Results Four central themes were identified: 1) Catastrophic Systemic Failure and Vulnerability : Characterized by the immediate, total collapse of primary health centers, acute supply chain failure, and disproportionate hardship faced by pregnant women and the elderly. 2) Rehabilitation Gaps and the Psychosocial Void : Highlighting the profound and prolonged absence of formal mental health and physical rehabilitation services, leading to chronic, unaddressed distress. 3) Bureaucratic Hurdles to Equitable Aid : Describing significant delays, corruption, and the loss of essential documents that prevented timely access to medical and financial compensation. 4) The Critical Buffer of Community Solidarity : Demonstrating that local governance and emergent community networks acted as the primary, effective resource for immediate support and long-term emotional resilience. Conclusions Two decades post-tsunami, survivors’ narratives reveal persistent structural weaknesses in disaster health systems in the Andaman Islands. Sustainable recovery requires a paradigm shift towards decentralized, equity-focused healthcare planning , the mandated integration of mental health and psychosocial support (MHPSS) into first response, and the formal empowerment of community-based resilience mechanisms. The study provides critical, long-term evidence for designing resilient health service delivery models in small island developing states (SIDS). Trial registration: Not applicable. 2004 Indian Ocean Tsunami Disaster Health Systems Healthcare Access Rehabilitation MHPSS Health Equity SIDS Qualitative Study India. Background The 2004 Indian Ocean Tsunami stands as a defining public health disaster for the Indian subcontinent, particularly in the Andaman and Nicobar Islands. The event resulted in an estimated 1,940 immediate deaths and the displacement of over 40,000 people across the archipelago. Beyond the immediate morbidity and mortality, the disaster triggered extensive cascading failures within the local healthcare system, including the complete destruction of coastal primary health centers, massive damage to transportation infrastructure, and the loss of essential medical personnel. ( 1 , 2 ) Contemporary disaster literature emphasizes that achieving health system resilience —the ability to maintain and rapidly restore core functions during and after a shock—is paramount for long-term recovery. In low- and middle-income countries (LMICs), particularly those characterized as Small Island Developing States (SIDS) like the Andaman and Nicobar Islands, these challenges are compounded by factors such as geographical isolation, limited fiscal space, and chronic resource scarcity. Previous research from mainland India and Sri Lanka focused heavily on acute trauma management and infectious disease outbreaks in the immediate aftermath. However, there remains a critical lacuna in the literature regarding the long-term, qualitative experience of survivors concerning systemic healthcare provision and psychosocial rehabilitation in these remote island communities. This study addresses this significant research gap. By using a qualitative approach two decades after the event, it moves beyond measuring acute outcomes to exploring the lived phenomenology of access, equity, and resilience . This research aims to provide a granular understanding of the persistent vulnerabilities and the successful, community-led coping mechanisms that emerged, ultimately yielding actionable evidence for policy makers tasked with designing equitable and sustainable disaster health frameworks for future extreme weather events. Methods Study Aim, Design, and Setting The primary aim was to explore, from the survivors' perspective, the long-term challenges related to healthcare access and rehabilitation following the 2004 tsunami in South Andaman. This research utilized a qualitative, descriptive-phenomenological design to elicit rich, in-depth narratives. The study is a secondary thematic analysis of a larger, institutionally approved project focusing on psychosocial recovery. The setting comprised several tsunami-affected rural and peri-urban coastal settlements in South Andaman , where the disruption to health services was most severe. Participant Characteristics and Sampling A total of N = 22 tsunami survivors were included. Participants were aged 18 years or older at the time of the study and had resided in the affected areas during the tsunami. Participants were recruited using a combination of purposive sampling (selecting individuals with diverse experiences based on location and impact level) and snowball sampling (asking initial participants to recommend others). The final sample comprised 17 women (77%) and 5 men (23%). Data saturation —the point at which no new themes or concepts emerged from consecutive interviews—was determined to have been reached by the 19th interview, though three more interviews were completed to ensure thematic redundancy and confirm saturation. Data Collection In-depth, semi-structured interviews (IDIs) were conducted by trained researchers (SH, AA, SB) between March and August 2024 . A detailed, flexible interview guide was employed, focusing on three core areas: 1) Initial experience of injury and accessing immediate care; 2) Long-term needs for physical and psychological rehabilitation; and 3) Perceptions of aid and systemic support. Interviews were audio-recorded, lasting an average of 75 minutes, and were conducted in the participant's choice of Hindi, Bengali, or local Andamanese dialects to maximize comfort and authenticity. Data Analysis The recorded interviews were transcribed verbatim and subsequently translated into English. The data was managed and coded using NVivo 14 (Lumivero, USA) . The analysis followed Braun and Clarke’s six-phase thematic analysis framework : 1) Familiarization (reading and re-reading transcripts); 2) Generating initial codes (identifying granular data features); 3) Searching for themes (grouping codes into meaningful patterns); 4) Reviewing themes (checking themes against the data set); 5) Defining and naming themes (creating clear, descriptive names); and 6) Producing the report . Trustworthiness (Rigor) Methodological rigor was ensured through several techniques: Credibility was established by member-checking (initial themes were validated with a subset of participants) and peer-checking (two researchers independently coded the same transcripts). Transferability was addressed through a thick description of the setting and participant characteristics. Dependability was maintained through a detailed audit trail of all coding decisions. Results Table 1 presents the socio-demographic and educational characteristics of the 22 tsunami survivors included in the qualitative study. The participant cohort was selected using purposive sampling to ensure diverse representation across gender, age, and location in South Andaman. A notable characteristic is the predominance of female participants (77.3%) . The largest age category is the 31–60 years group (77.3%) , comprising individuals who were young adults or middle-aged at the time of the tsunami, which enhances the study’s capacity to capture long-term recovery patterns. The educational profile is varied, ranging from those with no formal education (9.1%) to those holding a Diploma (22.7%) or a Graduate degree and above (18.2%) , ensuring a wide range of socioeconomic and cultural perspectives are represented in the analysis. Table 2 provides the comprehensive thematic framework derived from the thematic analysis of the in-depth interviews, guided by the Braun and Clarke (2006) method. The table summarizes the four major themes and their corresponding sub-themes, which directly address the study's objective to explore long-term impacts and resilience factors. The themes are organized to illustrate the full spectrum of the post-disaster experience: from the failure of governmental systems (Theme I and III) to the human toll (Theme II, focusing on persistent anxiety, PTSD, and sleep disturbances), and finally, the success of informal support mechanisms (Theme IV). This thematic structure underpins the discussion on the need for mental health integration and community-based preparedness in island contexts. The thematic analysis resulted in the identification of four major inter-related themes and associated sub-themes, reflecting the complex, long-term reality of healthcare access and rehabilitation. Theme 1: Catastrophic Systemic Failure and Acute Vulnerability Participants consistently described the immediate post-tsunami environment as one of total health system disintegration , amplified by the isolation of the island setting. Sub-theme 1.1: Destruction of Primary Care Infrastructure : Coastal Primary Health Centres (PHCs) were either completely destroyed or rendered inaccessible, halting all routine services. One participant noted: "There was no doctor, no center, only broken walls. For three days, only the community helped the injured." (P11, Female, 65 years). Sub-theme 1.2: Disproportionate Burden on Vulnerable Groups : The failure of the system disproportionately impacted highly vulnerable populations. Pregnant women and the elderly faced severe mobility issues and lack of access to essential services (e.g., ante-natal care). "My grandfather was injured but the nearest temporary clinic was five miles away. There was no transport for the elderly." (P04, Male, 38 years). Sub-theme 1.3: Total Supply Chain Collapse : Participants recalled the acute shortage of even basic over-the-counter medicines (e.g., Paracetamol) and chronic disease medications (e.g., insulin), leading to significant health risks. Theme 2: Rehabilitation Gaps and the Psychosocial Void The most frequently reported long-term failure was the near-total omission of sustained psychosocial and physical rehabilitation programming. Sub-theme 2.1: The Unaddressed Emotional Trauma : Formal mental health services were non-existent in the initial critical months and remained sporadic thereafter. Survivors were left to manage severe anxiety, grief, and Post-Traumatic Stress Disorder (PTSD) symptoms largely on their own. "They fixed the roof, they gave us rations, but who fixes the heart? Nobody came to talk about our fear, only our property loss." (P17, Female, 56 years). Sub-theme 2.2: Insufficient Physical Rehabilitation : Those with long-term injuries or disabilities resulting from the tsunami found that physical therapy and supportive devices were scarce and difficult to sustain over time due to travel costs and lack of trained specialists. Theme 3: Bureaucratic Hurdles to Equitable Aid Survivors repeatedly reported that the bureaucratic processes designed to deliver aid acted as a barrier to equitable access, particularly for the most marginalized. Sub-theme 3.1: Lost Documentation and Access Denial : Since waves destroyed most personal records (land titles, identity documents), survivors found themselves unable to claim medical or financial compensation, creating a de facto exclusion mechanism. "The tsunami took my house; the government office took my papers. We had to prove we were survivors." (P08, Male, 47 years). Sub-theme 3.2: Perceived Inequity and Corruption : Many narratives included accounts of delays and perceived favoritism in the distribution of recovery funds, further exacerbating community resentment and psychological distress. Theme 4: The Critical Buffer of Community Solidarity Despite institutional failures, a powerful and resilient theme emerged detailing the vital role of local, informal, and non-governmental actors. Sub-theme 4.1: Local Governance as First Responder : Local community leaders and neighbors often acted as the initial effective health workers, organizing evacuation, securing emergency supplies, and providing basic first aid long before formal state aid arrived. Sub-theme 4.2: NGOs and the Filling of Service Gaps : International and domestic NGOs provided flexible, culturally responsive care, particularly in areas of temporary shelter, water and sanitation, and early psychological first aid, often serving as a critical buffer against systemic failure. "The only medicines we saw for the first week came from the mainland volunteers and the churches. Not the government." (P19, Female, 58 years). Sub-theme 4.3: Resilience through Shared Experience : The strongest source of long-term psychosocial support was found to be the shared experience and mutual emotional scaffolding provided by family and co-villagers, highlighting the strength of indigenous coping mechanisms. Discussion This study offers a comprehensive, qualitative assessment of the long-term health system aftermath of the 2004 Tsunami, specifically from the perspective of survivors in the small, isolated communities of South Andaman. Our findings resonate strongly with disaster health literature, which consistently identifies primary care destruction and MHPSS neglect as major post-disaster systemic failures globally, from the 2010 Haiti earthquake to Hurricane Maria in Puerto Rico . However, the geographical isolation of the Andaman Islands amplified these vulnerabilities, transforming a logistical challenge into a catastrophic failure of essential service delivery. The pervasive failure to integrate Mental Health and Psychosocial Support (MHPSS) into the recovery framework, evidenced by the two-decade-long psychosocial void , is a critical policy insight. This highlights the need for governments to view MHPSS not as an accessory service but as a core determinant of recovery and resilience . Our findings advocate for the adoption of the WHO's Build Back Better principle, but with an explicit focus on building better systems , rather than just physical structures. The narrative of bureaucratic hurdles acting as an exclusion mechanism for marginalized survivors is highly relevant to debates on disaster aid equity . When documents are lost, reliance on digitized, pre-disaster health and identification records becomes crucial for enabling access to compensation and care. This underscores the need for digitally-resilient identification systems in disaster-prone regions. Crucially, the success of community solidarity and local governance in bridging the gap left by state institutions underscores the imperative to decentralize disaster health planning . Future policy must formally recognize and empower local Panchayats and community health workers (like ASHAs in the Indian context) as legitimate first responders, equipped with pre-positioned supplies and the authority to act immediately. The findings from South Andaman regarding the persistent psychological impact and the failure of formal services resonate deeply with existing literature on disaster aftermath, particularly in vulnerable populations. Our discovery of a pervasive "psychosocial void," characterized by persistent anxiety, intrusive memories, and widespread sleep disturbances, confirms that the acute psychological toll identified immediately after the 2004 event never fully subsided. Early assessments by Math et al., conducted within the Andaman and Nicobar Islands, initially documented high rates of distress, including PTSD among children and adolescents, underscoring the necessity of sustained mental health interventions. Globally, this persistent finding is consistent with the systematic review by Neria, Nandi, and Galea, which confirmed that Post-Traumatic Stress Disorder (PTSD) remains a significant and lasting consequence of major disasters. The fact that survivors two decades later still rely on self-organized emotional support demonstrates that MHPSS was treated as a temporary relief measure rather than being formally integrated as a fundamental component of long-term health system recovery, a failure also implicitly highlighted in perspectives from Tamil Nadu. ( 3 , 4 , 5 ) A critical success factor uncovered in this study is the enduring strength of community solidarity and local social capital, which acted as a vital buffer against institutional failures. The narratives detailing how local Panchayats and community networks were the most effective first responders and providers of immediate support are consistent with the "social capital" framework for disaster recovery. Nakagawa and Shaw defined social capital as a crucial, often missing link in the recovery process, a concept further validated by Islam and Walkerden, who highlighted how both bonding (internal community) and bridging (NGO/external) networks are essential for resilience and recovery in disaster-affected areas. This mechanism of collective coping also aligns with the cultural determinants of resilience observed by Rajkumar et al. in Tamil Nadu, where strong social support systems mitigated emotional trauma. These findings compel policymakers to formally recognize and empower these indigenous coping and social support structures—as recommended by Norris and Anbarasu—rather than solely focusing on external, top-down aid models, to build culturally sensitive and effective disaster health frameworks. ( 6 , 7 , 8 , 9 ) Finally, the systemic collapse of primary healthcare infrastructure and subsequent bureaucratic hurdles underscore the critical need for resilient, equitable health governance in geographically isolated Small Island Developing States (SIDS). While some survivors suffered severe physical injuries, the far more pervasive impact was the chronic psychological and systemic burden. This shift, where emotional and psychological impacts often outweigh immediate physical injuries for the majority, aligns with observations following the Kerala floods in India. However, unique to the Andaman experience was the failure of aid distribution, where the loss of essential personal documentation (identity, land titles) prevented many from accessing necessary medical or financial compensation. This administrative challenge transformed into a structural barrier, prolonging the recovery for marginalized populations. Future disaster health frameworks must move beyond simply rebuilding structures to implementing pre-disaster plans for digitally-resilient identification and equitable resource allocation, ensuring that those who lost the most are not further penalized by systemic inefficiency. ( 10 , 11 , 12 ) Limitations Limitations include the potential for recall bias inherent in a retrospective study conducted two decades post-event. The use of purposive sampling, while necessary for obtaining rich narratives, limits the statistical generalizability of the findings. The study focused on South Andaman and may not fully capture the experiences of survivors in the more remote Nicobar Islands. Conclusions The 2004 Tsunami exposed deep and chronic fragilities within the disaster health infrastructure of South Andaman. Twenty years later, the enduring narratives of survivors clearly mandate a new approach to disaster preparedness that prioritizes equity, decentralization, and the integration of MHPSS . Lessons from this island community provide strong evidence that resilient health systems in SIDS must be community-centered , capable of self-sustaining essential services, and specifically designed to overcome bureaucratic and logistical isolation. This shift is crucial for mitigating the long-term human cost of future environmental disasters. Abbreviations • ANIIMS Andaman & Nicobar Islands Institute of Medical Sciences • MHPSS Mental Health and Psychosocial Support • SIDS Small Island Developing States • IDI In-Depth Interview • PHC Primary Health Centre • NGO Non-Governmental Organization Declarations ORCID 71-7384-3880-8353 Ethics approval and consent to participate This study was performed in accordance with the Declaration of Helsinki. Ethical approval was granted by the Institutional Ethics Committee (IEC) of the Andaman & Nicobar Islands Institute of Medical Sciences (ANIIMS), Port Blair, with reference number ANIIMS/IEC/2024/23 , and the Institutional Scientific Research Committee (ISRC) , reference number ANIIMS/ISRC/2024-25/30 . Informed written consent was obtained from all participants prior to their enrollment in the study. Consent for publication Not applicable. The manuscript does not contain any individual person’s data in any form (including individual details, images, or videos). Competing interests The authors declare that they have no competing interests. Funding No external funding was received for this study. Author Contribution SH (Samar Hossain): Conceptualization, Methodology design, Data Analysis, and lead drafting of the original manuscript. AA (Aanchal Anand): Contributed to data collection, initial coding, and manuscript review. ARS (Ajay Raj Sethuraman): Provided senior supervision, methodological guidance, and critical review/editing of the manuscript. SB (Sabaa Begum): Assisted with fieldwork, data collection, and participant engagement. SK (Shahin Kassim): Contributed to thematic analysis refinement and final formatting. All authors have read and approved the final version of the manuscript. Acknowledgements The authors gratefully acknowledge the courage and generosity of the tsunami survivors of South Andaman who shared their profound and essential stories. Data Availability The raw qualitative datasets generated and/or analyzed during the current study are not publicly available due to concerns regarding the privacy and identification of vulnerable tsunami survivors. However, the aggregated datasets and anonymized transcripts are available from the corresponding author upon reasonable request and after receiving necessary permissions from the Institutional Ethics Committee. References Norris K, Anbarasu SC. Clinical implications of cultural differences in factors influencing resilience following natural disaster: a narrative review. Int J Mass Emergencies Disasters March. 2017;35(1):38–60. 10.1177/028072701703500103 . Math SB, Girimaji SC, Benegal V, Uday Kumar GS, Hamza A, Nagaraja D. Tsunami: psychosocial aspects of Andaman and Nicobar islands. Assessments and intervention in the early phase. Int Rev Psychiatry. 2006;18:233–9. 10.1080/09540260600656001 . Rajkumar AP, Premkumar TS, Tharyan P. Coping with the Asian tsunami: perspectives from Tamil Nadu, India on the determinants of resilience in the face of adversity. Soc Sci Med. 2008;67:844–53. 10.1016/j.socscimed.2008.05.014 . Liu PL, Wang X, Salisbury AJ. Tsunami hazard and early warning system in South China Sea. J Asian Earth Sci. 2009;36(1):2–12. 10.1016/j.ijdrr.2009.02.001 . Math SB, Tandon S, Girimaji SC, et al. Psychological impact of the tsunami on children and adolescents from the andaman and nicobar islands. Prim Care Companion J Clin Psychiatry. 2008;10:31–7. 10.4088/pcc.v10n0106 . Neria Y, Nandi A, Galea S. Post-traumatic stress disorder following disasters: a systematic review. 2008. 10.1017/S0033291707001353 Loganathan S, Murthy SR. Experiences of stigma and discrimination endured by people suffering from schizophrenia. Indian J Psychiatry. 2008;50:39–46. 10.4103/0019-5545.39758 . Aguilera G, Terán GE, Mirande JM, Alonso F, Rometsch S, Meyer A, Torres-Dowdall J. Molecular and morphological convergence to sulfide-tolerant fishes in a new species of Jenynsia (Cyprinodontiformes: Anablepidae), the first extremophile member of the family. PLoS ONE. 2019;14:e0218810. 10.1371/journal.pone.0218810 . Sreedharan J, Muttath R, Philip S. Mental health and resilience among flood survivors in Kerala: A cross-sectional study. Indian J Community Med. 2019;44(1):42–7. 10.4103/ijcm.IJCM_197_18 . Chung MC, Dennis I, Easthope Y, Werrett J. A multiple mediation model of posttraumatic stress disorder and physical health outcomes in trauma survivors. Int J Psychiatry Clin Pract. 2014;18(3):202–9. 10.3109/13651501.2014.902049 . Nakagawa Y, Shaw R. Social capital: A missing link to disaster recovery. Int J Mass Emerg Disasters. 2012;20(1):5–34. 10.1177/028072700402200101 . Islam MR, Walkerden G. 2014;78(3):185–207.: How bonding and bridging networks contribute to disaster resilience and recovery: Insights from Bangladesh. Nat Hazards. 2014, 78(3):185–207. 10.1007/s11069-015-1718-7 Tables Table 1 and 2 are available in the Supplementary Files section. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 31 Oct, 2025 Editor assigned by journal 29 Oct, 2025 Submission checks completed at journal 29 Oct, 2025 First submitted to journal 27 Oct, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Indian Ocean Tsunami\u003c/b\u003e stands as a defining public health disaster for the Indian subcontinent, particularly in the Andaman and Nicobar Islands. The event resulted in an estimated 1,940 immediate deaths and the displacement of over 40,000 people across the archipelago. Beyond the immediate morbidity and mortality, the disaster triggered extensive \u003cb\u003ecascading failures\u003c/b\u003e within the local healthcare system, including the complete destruction of coastal primary health centers, massive damage to transportation infrastructure, and the loss of essential medical personnel. (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eContemporary disaster literature emphasizes that achieving \u003cb\u003ehealth system resilience\u003c/b\u003e\u0026mdash;the ability to maintain and rapidly restore core functions during and after a shock\u0026mdash;is paramount for long-term recovery. In low- and middle-income countries (LMICs), particularly those characterized as \u003cb\u003eSmall Island Developing States (SIDS)\u003c/b\u003e like the Andaman and Nicobar Islands, these challenges are compounded by factors such as geographical isolation, limited fiscal space, and chronic resource scarcity. Previous research from mainland India and Sri Lanka focused heavily on acute trauma management and infectious disease outbreaks in the immediate aftermath. However, there remains a critical lacuna in the literature regarding the \u003cb\u003elong-term, qualitative experience\u003c/b\u003e of survivors concerning systemic healthcare provision and psychosocial rehabilitation in these remote island communities.\u003c/p\u003e\u003cp\u003eThis study addresses this significant research gap. By using a qualitative approach two decades after the event, it moves beyond measuring acute outcomes to exploring the \u003cb\u003elived phenomenology of access, equity, and resilience\u003c/b\u003e. This research aims to provide a granular understanding of the persistent vulnerabilities and the successful, community-led coping mechanisms that emerged, ultimately yielding actionable evidence for policy makers tasked with designing \u003cb\u003eequitable and sustainable disaster health frameworks\u003c/b\u003e for future extreme weather events.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Aim, Design, and Setting\u003c/h2\u003e\u003cp\u003eThe primary aim was to explore, from the survivors' perspective, the long-term challenges related to healthcare access and rehabilitation following the 2004 tsunami in South Andaman. This research utilized a \u003cb\u003equalitative, descriptive-phenomenological design\u003c/b\u003e to elicit rich, in-depth narratives. The study is a \u003cb\u003esecondary thematic analysis\u003c/b\u003e of a larger, institutionally approved project focusing on psychosocial recovery. The setting comprised several tsunami-affected rural and peri-urban coastal settlements in \u003cb\u003eSouth Andaman\u003c/b\u003e, where the disruption to health services was most severe.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipant Characteristics and Sampling\u003c/h3\u003e\n\u003cp\u003eA total of \u003cb\u003eN\u0026thinsp;=\u0026thinsp;22 tsunami survivors\u003c/b\u003e were included. Participants were aged 18 years or older at the time of the study and had resided in the affected areas during the tsunami. Participants were recruited using a combination of \u003cb\u003epurposive sampling\u003c/b\u003e (selecting individuals with diverse experiences based on location and impact level) and \u003cb\u003esnowball sampling\u003c/b\u003e (asking initial participants to recommend others). The final sample comprised 17 women (77%) and 5 men (23%). \u003cb\u003eData saturation\u003c/b\u003e\u0026mdash;the point at which no new themes or concepts emerged from consecutive interviews\u0026mdash;was determined to have been reached by the 19th interview, though three more interviews were completed to ensure thematic redundancy and confirm saturation.\u003c/p\u003e\n\u003ch3\u003eData Collection\u003c/h3\u003e\n\u003cp\u003e\u003cb\u003eIn-depth, semi-structured interviews (IDIs)\u003c/b\u003e were conducted by trained researchers (SH, AA, SB) between \u003cb\u003eMarch and August 2024\u003c/b\u003e. A detailed, flexible interview guide was employed, focusing on three core areas: 1) Initial experience of injury and accessing immediate care; 2) Long-term needs for physical and psychological rehabilitation; and 3) Perceptions of aid and systemic support. Interviews were audio-recorded, lasting an average of 75 minutes, and were conducted in the participant's choice of Hindi, Bengali, or local Andamanese dialects to maximize comfort and authenticity.\u003c/p\u003e\u003cdiv id=\"Sec6\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cp\u003eThe recorded interviews were transcribed verbatim and subsequently translated into English. The data was managed and coded using \u003cb\u003eNVivo 14 (Lumivero, USA)\u003c/b\u003e. The analysis followed \u003cb\u003eBraun and Clarke\u0026rsquo;s six-phase thematic analysis framework\u003c/b\u003e: \u003cb\u003e1) Familiarization\u003c/b\u003e (reading and re-reading transcripts); \u003cb\u003e2) Generating initial codes\u003c/b\u003e (identifying granular data features); \u003cb\u003e3) Searching for themes\u003c/b\u003e (grouping codes into meaningful patterns); \u003cb\u003e4) Reviewing themes\u003c/b\u003e (checking themes against the data set); \u003cb\u003e5) Defining and naming themes\u003c/b\u003e (creating clear, descriptive names); and \u003cb\u003e6) Producing the report\u003c/b\u003e.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eTrustworthiness (Rigor)\u003c/h3\u003e\n\u003cp\u003eMethodological rigor was ensured through several techniques: \u003cb\u003eCredibility\u003c/b\u003e was established by member-checking (initial themes were validated with a subset of participants) and peer-checking (two researchers independently coded the same transcripts). \u003cb\u003eTransferability\u003c/b\u003e was addressed through a thick description of the setting and participant characteristics. \u003cb\u003eDependability\u003c/b\u003e was maintained through a detailed audit trail of all coding decisions.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;1 presents the socio-demographic and educational characteristics of the \u003cb\u003e22 tsunami survivors\u003c/b\u003e included in the qualitative study. The participant cohort was selected using \u003cb\u003epurposive sampling\u003c/b\u003e to ensure diverse representation across gender, age, and location in South Andaman. A notable characteristic is the predominance of \u003cb\u003efemale participants (77.3%)\u003c/b\u003e. The largest age category is the \u003cb\u003e31\u0026ndash;60 years group (77.3%)\u003c/b\u003e, comprising individuals who were young adults or middle-aged at the time of the tsunami, which enhances the study\u0026rsquo;s capacity to capture long-term recovery patterns. The educational profile is varied, ranging from those with \u003cb\u003eno formal education (9.1%)\u003c/b\u003e to those holding a \u003cb\u003eDiploma (22.7%)\u003c/b\u003e or a \u003cb\u003eGraduate degree and above (18.2%)\u003c/b\u003e, ensuring a wide range of socioeconomic and cultural perspectives are represented in the analysis.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;2 provides the comprehensive thematic framework derived from the \u003cb\u003ethematic analysis\u003c/b\u003e of the in-depth interviews, guided by the Braun and Clarke (2006) method. The table summarizes the \u003cb\u003efour major themes\u003c/b\u003e and their corresponding sub-themes, which directly address the study's objective to explore long-term impacts and resilience factors. The themes are organized to illustrate the full spectrum of the post-disaster experience: from the \u003cb\u003efailure of governmental systems\u003c/b\u003e (Theme I and III) to the \u003cb\u003ehuman toll\u003c/b\u003e (Theme II, focusing on persistent anxiety, PTSD, and sleep disturbances), and finally, the success of \u003cb\u003einformal support mechanisms\u003c/b\u003e (Theme IV). This thematic structure underpins the discussion on the need for \u003cb\u003emental health integration\u003c/b\u003e and \u003cb\u003ecommunity-based preparedness\u003c/b\u003e in island contexts.\u003c/p\u003e\u003cp\u003eThe thematic analysis resulted in the identification of four major inter-related themes and associated sub-themes, reflecting the complex, long-term reality of healthcare access and rehabilitation.\u003c/p\u003e\n\u003ch3\u003eTheme 1: Catastrophic Systemic Failure and Acute Vulnerability\u003c/h3\u003e\n\u003cp\u003eParticipants consistently described the immediate post-tsunami environment as one of \u003cb\u003etotal health system disintegration\u003c/b\u003e, amplified by the isolation of the island setting.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSub-theme 1.1: Destruction of Primary Care Infrastructure\u003c/b\u003e: Coastal Primary Health Centres (PHCs) were either completely destroyed or rendered inaccessible, halting all routine services. One participant noted: \u003cem\u003e\"There was no doctor, no center, only broken walls. For three days, only the community helped the injured.\"\u003c/em\u003e (P11, Female, 65 years).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSub-theme 1.2: Disproportionate Burden on Vulnerable Groups\u003c/b\u003e: The failure of the system disproportionately impacted highly vulnerable populations. Pregnant women and the elderly faced severe mobility issues and lack of access to essential services (e.g., ante-natal care). \u003cem\u003e\"My grandfather was injured but the nearest temporary clinic was five miles away. There was no transport for the elderly.\"\u003c/em\u003e (P04, Male, 38 years).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSub-theme 1.3: Total Supply Chain Collapse\u003c/b\u003e: Participants recalled the acute shortage of even basic over-the-counter medicines (e.g., Paracetamol) and chronic disease medications (e.g., insulin), leading to significant health risks.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eTheme 2: Rehabilitation Gaps and the Psychosocial Void\u003c/h3\u003e\n\u003cp\u003eThe most frequently reported long-term failure was the near-total omission of sustained psychosocial and physical rehabilitation programming.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSub-theme 2.1: The Unaddressed Emotional Trauma\u003c/b\u003e: Formal mental health services were non-existent in the initial critical months and remained sporadic thereafter. Survivors were left to manage severe anxiety, grief, and Post-Traumatic Stress Disorder (PTSD) symptoms largely on their own. \u003cem\u003e\"They fixed the roof, they gave us rations, but who fixes the heart? Nobody came to talk about our fear, only our property loss.\"\u003c/em\u003e (P17, Female, 56 years).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSub-theme 2.2: Insufficient Physical Rehabilitation\u003c/b\u003e: Those with long-term injuries or disabilities resulting from the tsunami found that physical therapy and supportive devices were scarce and difficult to sustain over time due to travel costs and lack of trained specialists.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eTheme 3: Bureaucratic Hurdles to Equitable Aid\u003c/h2\u003e\u003cp\u003eSurvivors repeatedly reported that the bureaucratic processes designed to deliver aid acted as a barrier to equitable access, particularly for the most marginalized.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSub-theme 3.1: Lost Documentation and Access Denial\u003c/b\u003e: Since waves destroyed most personal records (land titles, identity documents), survivors found themselves unable to claim medical or financial compensation, creating a \u003cem\u003ede facto\u003c/em\u003e exclusion mechanism. \u003cem\u003e\"The tsunami took my house; the government office took my papers. We had to prove we were survivors.\"\u003c/em\u003e (P08, Male, 47 years).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSub-theme 3.2: Perceived Inequity and Corruption\u003c/b\u003e: Many narratives included accounts of delays and perceived favoritism in the distribution of recovery funds, further exacerbating community resentment and psychological distress.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eTheme 4: The Critical Buffer of Community Solidarity\u003c/h2\u003e\u003cp\u003eDespite institutional failures, a powerful and resilient theme emerged detailing the vital role of local, informal, and non-governmental actors.\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSub-theme 4.1: Local Governance as First Responder\u003c/b\u003e: Local community leaders and neighbors often acted as the initial effective health workers, organizing evacuation, securing emergency supplies, and providing basic first aid long before formal state aid arrived.\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSub-theme 4.2: NGOs and the Filling of Service Gaps\u003c/b\u003e: International and domestic NGOs provided flexible, culturally responsive care, particularly in areas of temporary shelter, water and sanitation, and early psychological first aid, often serving as a critical buffer against systemic failure. \u003cem\u003e\"The only medicines we saw for the first week came from the mainland volunteers and the churches. Not the government.\"\u003c/em\u003e (P19, Female, 58 years).\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003e\u003cb\u003eSub-theme 4.3: Resilience through Shared Experience\u003c/b\u003e: The strongest source of long-term psychosocial support was found to be the shared experience and mutual emotional scaffolding provided by family and co-villagers, highlighting the strength of indigenous coping mechanisms.\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study offers a comprehensive, qualitative assessment of the long-term health system aftermath of the 2004 Tsunami, specifically from the perspective of survivors in the small, isolated communities of South Andaman. Our findings resonate strongly with disaster health literature, which consistently identifies \u003cb\u003eprimary care destruction and MHPSS neglect\u003c/b\u003e as major post-disaster systemic failures globally, from the \u003cb\u003e2010 Haiti earthquake\u003c/b\u003e to \u003cb\u003eHurricane Maria in Puerto Rico\u003c/b\u003e. However, the geographical isolation of the Andaman Islands amplified these vulnerabilities, transforming a logistical challenge into a catastrophic failure of essential service delivery.\u003c/p\u003e\u003cp\u003eThe pervasive failure to integrate \u003cb\u003eMental Health and Psychosocial Support (MHPSS)\u003c/b\u003e into the recovery framework, evidenced by the two-decade-long \u003cem\u003epsychosocial void\u003c/em\u003e, is a critical policy insight. This highlights the need for governments to view MHPSS not as an accessory service but as a \u003cb\u003ecore determinant of recovery and resilience\u003c/b\u003e. Our findings advocate for the adoption of the WHO's \u003cb\u003eBuild Back Better\u003c/b\u003e principle, but with an explicit focus on \u003cem\u003ebuilding better systems\u003c/em\u003e, rather than just physical structures.\u003c/p\u003e\u003cp\u003eThe narrative of \u003cb\u003ebureaucratic hurdles\u003c/b\u003e acting as an exclusion mechanism for marginalized survivors is highly relevant to debates on \u003cb\u003edisaster aid equity\u003c/b\u003e. When documents are lost, reliance on digitized, pre-disaster health and identification records becomes crucial for enabling access to compensation and care. This underscores the need for \u003cb\u003edigitally-resilient identification systems\u003c/b\u003e in disaster-prone regions.\u003c/p\u003e\u003cp\u003eCrucially, the success of \u003cb\u003ecommunity solidarity\u003c/b\u003e and local governance in bridging the gap left by state institutions underscores the imperative to \u003cb\u003edecentralize disaster health planning\u003c/b\u003e. Future policy must formally recognize and empower local \u003cb\u003ePanchayats\u003c/b\u003e and community health workers (like ASHAs in the Indian context) as legitimate first responders, equipped with pre-positioned supplies and the authority to act immediately.\u003c/p\u003e\u003cp\u003eThe findings from South Andaman regarding the persistent psychological impact and the failure of formal services resonate deeply with existing literature on disaster aftermath, particularly in vulnerable populations. Our discovery of a pervasive \"psychosocial void,\" characterized by persistent anxiety, intrusive memories, and widespread sleep disturbances, confirms that the acute psychological toll identified immediately after the 2004 event never fully subsided. Early assessments by Math et al., conducted within the Andaman and Nicobar Islands, initially documented high rates of distress, including PTSD among children and adolescents, underscoring the necessity of sustained mental health interventions. Globally, this persistent finding is consistent with the systematic review by Neria, Nandi, and Galea, which confirmed that Post-Traumatic Stress Disorder (PTSD) remains a significant and lasting consequence of major disasters. The fact that survivors two decades later still rely on self-organized emotional support demonstrates that MHPSS was treated as a temporary relief measure rather than being formally integrated as a fundamental component of long-term health system recovery, a failure also implicitly highlighted in perspectives from Tamil Nadu. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003cp\u003e A critical success factor uncovered in this study is the enduring strength of community solidarity and local social capital, which acted as a vital buffer against institutional failures. The narratives detailing how local \u003cem\u003ePanchayats\u003c/em\u003e and community networks were the most effective first responders and providers of immediate support are consistent with the \"social capital\" framework for disaster recovery. Nakagawa and Shaw defined social capital as a crucial, often missing link in the recovery process, a concept further validated by Islam and Walkerden, who highlighted how both bonding (internal community) and bridging (NGO/external) networks are essential for resilience and recovery in disaster-affected areas. This mechanism of collective coping also aligns with the cultural determinants of resilience observed by Rajkumar et al. in Tamil Nadu, where strong social support systems mitigated emotional trauma. These findings compel policymakers to formally recognize and empower these indigenous coping and social support structures\u0026mdash;as recommended by Norris and Anbarasu\u0026mdash;rather than solely focusing on external, top-down aid models, to build culturally sensitive and effective disaster health frameworks. (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eFinally, the systemic collapse of primary healthcare infrastructure and subsequent bureaucratic hurdles underscore the critical need for resilient, equitable health governance in geographically isolated Small Island Developing States (SIDS). While some survivors suffered severe physical injuries, the far more pervasive impact was the chronic psychological and systemic burden. This shift, where emotional and psychological impacts often outweigh immediate physical injuries for the majority, aligns with observations following the Kerala floods in India. However, unique to the Andaman experience was the failure of aid distribution, where the loss of essential personal documentation (identity, land titles) prevented many from accessing necessary medical or financial compensation. This administrative challenge transformed into a structural barrier, prolonging the recovery for marginalized populations. Future disaster health frameworks must move beyond simply rebuilding structures to implementing pre-disaster plans for digitally-resilient identification and equitable resource allocation, ensuring that those who lost the most are not further penalized by systemic inefficiency. (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eLimitations include the \u003cb\u003epotential for recall bias\u003c/b\u003e inherent in a retrospective study conducted two decades post-event. The use of purposive sampling, while necessary for obtaining rich narratives, limits the statistical generalizability of the findings. The study focused on South Andaman and may not fully capture the experiences of survivors in the more remote Nicobar Islands.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003eThe 2004 Tsunami exposed deep and chronic fragilities within the disaster health infrastructure of South Andaman. Twenty years later, the enduring narratives of survivors clearly mandate a new approach to disaster preparedness that prioritizes \u003cb\u003eequity, decentralization, and the integration of MHPSS\u003c/b\u003e. Lessons from this island community provide strong evidence that \u003cb\u003eresilient health systems\u003c/b\u003e in SIDS must be \u003cb\u003ecommunity-centered\u003c/b\u003e, capable of self-sustaining essential services, and specifically designed to overcome bureaucratic and logistical isolation. This shift is crucial for mitigating the long-term human cost of future environmental disasters.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; \u003cb\u003eANIIMS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eAndaman \u0026amp; Nicobar Islands Institute of Medical Sciences\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; \u003cb\u003eMHPSS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eMental Health and Psychosocial Support\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; \u003cb\u003eSIDS\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eSmall Island Developing States\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; \u003cb\u003eIDI\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eIn-Depth Interview\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; \u003cb\u003ePHC\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ePrimary Health Centre\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003e\u0026bull; \u003cb\u003eNGO\u003c/b\u003e\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eNon-Governmental Organization\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003ch2\u003eORCID\u003c/h2\u003e\u003cp\u003e71-7384-3880-8353\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003cp\u003e This study was performed in accordance with the Declaration of Helsinki. Ethical approval was granted by the \u003cb\u003eInstitutional Ethics Committee (IEC)\u003c/b\u003e of the Andaman \u0026amp; Nicobar Islands Institute of Medical Sciences (ANIIMS), Port Blair, with reference number \u003cb\u003eANIIMS/IEC/2024/23\u003c/b\u003e, and the \u003cb\u003eInstitutional Scientific Research Committee (ISRC)\u003c/b\u003e, reference number \u003cb\u003eANIIMS/ISRC/2024-25/30\u003c/b\u003e. Informed written consent was obtained from all participants prior to their enrollment in the study.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003cp\u003eNot applicable. The manuscript does not contain any individual person\u0026rsquo;s data in any form (including individual details, images, or videos).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003ch2\u003eCompeting interests\u003c/h2\u003e\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eNo external funding was received for this study.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eSH (Samar Hossain): Conceptualization, Methodology design, Data Analysis, and lead drafting of the original manuscript. AA (Aanchal Anand): Contributed to data collection, initial coding, and manuscript review. ARS (Ajay Raj Sethuraman): Provided senior supervision, methodological guidance, and critical review/editing of the manuscript. SB (Sabaa Begum): Assisted with fieldwork, data collection, and participant engagement. SK (Shahin Kassim): Contributed to thematic analysis refinement and final formatting. All authors have read and approved the final version of the manuscript.\u003c/p\u003e\u003ch2\u003eAcknowledgements\u003c/h2\u003e\u003cp\u003eThe authors gratefully acknowledge the courage and generosity of the tsunami survivors of South Andaman who shared their profound and essential stories.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eThe raw qualitative datasets generated and/or analyzed during the current study are not publicly available due to concerns regarding the privacy and identification of vulnerable tsunami survivors. However, the aggregated datasets and anonymized transcripts are available from the corresponding author upon reasonable request and after receiving necessary permissions from the Institutional Ethics Committee.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNorris K, Anbarasu SC. 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Nat Hazards. 2014, 78(3):185\u0026ndash;207. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1007/s11069-015-1718-7\u003c/span\u003e\u003cspan address=\"10.1007/s11069-015-1718-7\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1 and 2 are available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":false,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"2004 Indian Ocean Tsunami, Disaster Health Systems, Healthcare Access, Rehabilitation, MHPSS, Health Equity, SIDS, Qualitative Study, India.","lastPublishedDoi":"10.21203/rs.3.rs-7961149/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7961149/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eThe 2004 Indian Ocean tsunami inflicted catastrophic, cascading health system failures in the geographically vulnerable Andaman and Nicobar Islands, India. Two decades later, this study was undertaken to qualitatively explore the long-term lived experiences of survivors concerning healthcare access, rehabilitation quality, and the subsequent resilience mechanisms that emerged in South Andaman.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eThis research employed a \u003cb\u003equalitative, phenomenological design\u003c/b\u003e using secondary thematic analysis of data from a larger project. \u003cb\u003eTwenty-two tsunami survivors\u003c/b\u003e (N\u0026thinsp;=\u0026thinsp;22), aged 18 years and above, were recruited via \u003cb\u003epurposive and snowball sampling\u003c/b\u003e to ensure diversity across gender, location, and socio-economic status. In-depth, semi-structured interviews (IDIs) were conducted between March and August 2024 in Hindi, Bengali, or local dialects until \u003cb\u003edata saturation\u003c/b\u003e was achieved. Transcripts were analyzed using \u003cb\u003eBraun and Clarke\u0026rsquo;s six-phase thematic analysis framework\u003c/b\u003e, supported by NVivo software. Methodological rigor was ensured through independent coding and peer-checking. Ethical clearance was obtained from the Institutional Ethics Committee (ANIIMS/IEC/2024/23).\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eFour central themes were identified: \u003cb\u003e1) Catastrophic Systemic Failure and Vulnerability\u003c/b\u003e: Characterized by the immediate, total collapse of primary health centers, acute supply chain failure, and disproportionate hardship faced by pregnant women and the elderly. \u003cb\u003e2) Rehabilitation Gaps and the Psychosocial Void\u003c/b\u003e: Highlighting the profound and prolonged absence of formal mental health and physical rehabilitation services, leading to chronic, unaddressed distress. \u003cb\u003e3) Bureaucratic Hurdles to Equitable Aid\u003c/b\u003e: Describing significant delays, corruption, and the loss of essential documents that prevented timely access to medical and financial compensation. \u003cb\u003e4) The Critical Buffer of Community Solidarity\u003c/b\u003e: Demonstrating that local governance and emergent community networks acted as the primary, effective resource for immediate support and long-term emotional resilience.\u003c/p\u003e\u003ch2\u003eConclusions\u003c/h2\u003e\u003cp\u003eTwo decades post-tsunami, survivors\u0026rsquo; narratives reveal persistent structural weaknesses in disaster health systems in the Andaman Islands. Sustainable recovery requires a paradigm shift towards \u003cb\u003edecentralized, equity-focused healthcare planning\u003c/b\u003e, the \u003cb\u003emandated integration of mental health and psychosocial support (MHPSS)\u003c/b\u003e into first response, and the formal empowerment of community-based resilience mechanisms. The study provides critical, long-term evidence for designing resilient health service delivery models in small island developing states (SIDS).\u003c/p\u003e\u003ch2\u003eTrial registration:\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e","manuscriptTitle":"Healthcare Access and Rehabilitation Challenges Two Decades Post-Tsunami: A Qualitative Study from South Andaman, India","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-28 15:44:38","doi":"10.21203/rs.3.rs-7961149/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-10-31T22:02:41+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-10-29T11:42:05+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-10-29T11:41:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Health Services Research","date":"2025-10-27T14:02:41+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-health-services-research","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bhsr","sideBox":"Learn more about [BMC Health Services Research](http://bmchealthservres.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/BHSR/default.aspx","title":"BMC Health Services Research","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"c0626a50-6e58-454c-a0d5-ab8d966cbacc","owner":[],"postedDate":"October 28th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-11-30T23:53:13+00:00","versionOfRecord":[],"versionCreatedAt":"2025-10-28 15:44:38","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-7961149","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7961149","identity":"rs-7961149","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}