Health Impact and Risk Factors Affecting South and Southeast Asian Women Following Natural Disasters: A Systematic Review

(1) Background: Following natural disasters, women have a higher prevalence of adverse physical and mental health outcomes. Given that the South and Southeast Asia regions are highly disaster prone, a review was undertaken to identify the potential health impact and key risk factors affecting women after disasters in the countries located in South and Southeast Asia regions. (2) Methods: A systematic literature search of four databases yielded 16 studies meeting the inclusion criteria. The review was conducted according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidance, between July 2008 and March 2021. (3) Results: The majority of studies reported women’s negative/poor mental health, identifying a significant association of socio-demographics, during disaster exposure, post-disaster, and pre-existing risk factors. The six most-cited influences on women’s mental health found in the reviewed literature were being female, adult age group, having no formal education, poverty or low economic status, poor physical health/physical injuries, and death of family members. Women’s health during the post-disaster period was generally reported as poor among all the countries of the South and Southeast Asia regions. (4) Conclusions: Appropriate social support and the availability of free healthcare access for women are warranted in disaster-affected areas. This review offers a valuable contribution to the knowledge of women’s health complications/challenges and associated risk factors related to disasters, essential for the development of strategies to help reduce this burden in the future. Further research is required on natural disasters to identify ways to reduce women’s health impacts after natural disasters, especially in the context of low-income and lower-middle-income countries.


Introduction
Natural disasters are adverse environmental events not directly attributable to human acts that create fear of injury, loss of property, and dislocation of residence. They include volcanic eruptions, earthquakes, floods, cyclones, droughts, and wildfires [1,2]. The Centre for Research on the Epidemiology of Disasters (2020) reported that over the past two decades, between 2000 and 2019, 7348 natural disasters were recorded, with the highest number (3068) occurring in Asia followed by America and Africa. In Asia, other than China, the most disaster-affected countries were in South and Southeast Asia, including India, the Philippines, Indonesia, and Bangladesh [3]. Additionally, in Pakistan in 2005 and Nepal in 2015, earthquakes killed 73,300 and 8969 people, respectively, causing massive injury and infrastructural damage, resulting in these being considered the world's two most dangerous earthquakes to date [3]. Other catastrophic disasters have occurred in South and Southeast Asia in recent times, namely the 2004 Indian ocean tsunami and the management efforts. The aim of the review was to identify and critique the evidence of the impact of natural disasters on the physical and mental health of women, and the underlying causes/risk factors affecting their health in the countries located in South and Southeast Asia regions. Through identification of the impact and risk factors, our study can assist and improve preparedness for disasters and the implementation of appropriate plans to potentially reduce the impact of disasters on women's health and wellbeing.

Protocol and Registration
The results of this study have been reported according to the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidance 2020 (Supplementary Materials, Table S1) [22]. The review protocol is registered with PROSPERO (registration no. CRD42019123809).

Inclusion Criteria
The inclusion criteria for the review comprised empirical peer-reviewed studies published between July 2008 and March 2021 to return contemporary evidence, reporting on South and Southeast Asian women's risk factors and physical and mental health outcomes following natural disasters, including women aged 18 years and above, and published in English.
Studies were excluded if they did not address the impact of natural disasters on women's health and studies that did not distinguish between health impacts of natural disasters and existing conditions.

Search Strategy
After auditing PROSPERO to avoid unnecessary repetition, a computerised search of four databases was conducted: ProQuest, ProQuest Health and Medicine, PubMed, and EBSCO. Table 1 illustrates search terms in four domains. natural disasters ("natural disasters" OR "natural disasters" OR "natural calamities" OR "natural calamity" OR flood OR floods OR flooding OR volcano OR volcanoes OR volcanic OR earthquake OR earthquakes OR cyclone OR cyclones OR hurricane OR hurricanes OR drought OR droughts OR tornado OR tornadoes OR landslide OR landslides OR mudslide OR mudslides OR ("wild fire" OR "wild fires" OR "wildfire" OR "wildfires" OR bushfire OR bushfires) South and Southeast Asian countries are identified based on the South Asian Association for Regional Cooperation (SAARC) and the Association of Southeast Asian Nations (ASEAN). The first author developed the search terms, selected databases, and conducted the initial search and screening process in consultation with a senior health librarian agreed upon by all authors. Keywords were searched connecting Boolean operators OR/AND. The searches were restricted to title, abstract, and subject due to a large number of studies obtained by the initial search. The search terms were modified for each database as necessary (Supplementary Materials, Table S2). In addition, a search in Google Scholar and the reference lists of the included studies were conducted for any additional references that could have been overlooked/missed during the database searches.

Data Extraction
The first reviewer (S.R.F.) extracted data using a standardised data extraction form and the second reviewer (L.E.) confirmed the extracted information. The data extraction form was developed using Joanna Briggs Institute manual [23] and grouped into three sections. The first section was related to characteristics of the studies such as the title, citation, authors, year of publication, and source of publication. The second section documented information on the methodology, study objectives, and demographics of the study participants. In particular, information related to the objectives, study design, study setting, type of participants, age, sex, type of data, data collection instrument, sampling procedure, sample size, and data analysis procedure were recorded in this section. The third section documented the main findings, limitations of the study, relevant additional information, and recommendations.

Quality Assessment
The quality of the 16 articles were assessed using the criteria of the Mixed Method Appraisal Tool (MMAT) [24], which is designed for the methodological quality appraisal of systematic mixed-method reviews and quantitative, qualitative and mixed-method studies. Two screening questions including the inclusion of a clear research question and data addressing the research question were used for all types of studies. The quantitative articles were assessed using the descriptive and non-randomised categories of the MMAT. The quality of the qualitative and mixed-method study was assessed using the qualitative and mixed-method categories of the MMAT, respectively. Each criterion carried one point in the assessment of a study, with a maximum score of 7 along with the points of 2 screening questions. As per this assessment tool, articles scoring 1-3 points were considered as "low quality", 4-5 as "medium quality", and 6-7 as "high quality". The quality assessment of the included studies was independently carried out by the lead author (S.R.F.) and another team member (M.S.I.).

Data Synthesis
Results of the review were synthesised using an integrated mixed-method synthesis approach to summarise all quantitative, qualitative, and mixed-method data into a single combined synthesis [25]. All data were analysed and integrated, and the results across all studies presented as a narrative summary. Although the majority of reviewed studies used a cross-sectional design, due to substantial differences among individual studies in terms of settings, samples, populations, context, health assessment tools, and outcome assessment statistical combination of results (meta-analysis) are not possible [26]. Therefore, all data were analysed and integrated, and the results across all studies are presented as a narrative summary.

Systematic Review Results
A total of 796 studies were found through electronic databases (n = 779) and hand searching (n = 17), of which 16 fulfilled the inclusion criteria after a full-text evaluation. All the articles were imported into EndNote library version X9. Two independent reviewers (S.R.F. and K.U.) involved in the study selection procedure, and disagreement was resolved in consultation with other team members. Figure 1 illustrates the PRISMA flow diagram with the evaluation and selection procedure of the chosen studies.

Study Characteristics
The study characteristics are outlined in Table 2. Of the studies included in this review, 14 (88%) were quantitative, 1 was qualitative, and 1 study used a mixed-methods design. The most common research method was the quantitative approach, which included 10 quantitative descriptive studies and four quantitative non-randomised studies. All the studies were conducted in lower-middle-income countries: Nepal (n = 6) [27][28][29][30][31][32], Pakistan (n = 4) [33][34][35][36], India (n = 2) [37,38], Indonesia (n = 2) [39,40], Sri Lanka (n = 1) [41], and Bangladesh (n = 1) [42]. Among these, Nepal and Bangladesh have recently risen up from low-income country status to lower-middle-income countries. The studies assessed exposure to disasters caused by three different types of natural disasters, most frequently, exposure to earthquakes (75%), tsunamis (19%), and cyclones (6%). Women represented almost two-thirds of the study populations presented in the studies. The majority of the studies (14/16) included disaster-affected men and women as the study participants and the other two reported women in particular. One study did not report the age range, although the study included adult community members [31]. Most of the studies (n = 8) were published between 2018 and 2019, one in 2020, and seven between 2010 and 2012.

Quality Assessment
The results of the quality appraisal are presented in Supplementary Materials, Table S3. The quality appraisal procedure resulted in 14 of 16 articles being rated as high quality and the other two medium quality. No studies were excluded based on the quality assessment scores. The mixed-method study was assessed as medium quality article as per the MMAT. This outcome was due to its failure to report the quantitative and qualitative methods of data collection distinctly, inconsistency between results, and the lack of a rationale for the need for a mixed-method study.

Mixed Method Synthesis
Based on our individual study aim's, an evidence table (see Table 3) was developed aggregating findings to synthesise aspects focused on the women's health impact and underlying risk factors following natural disasters. Table 3. Risk factors and health outcomes of women of selected studies.

Pre-disaster risk factors
Pre-disaster stress and exposure to violence, family adversities/conflict (secondary stressors) [28,29,41]; chronic illness [37,38,40] PTSD, CMD, poor physical health, depressive symptoms, psychosocial and mental health problems Exposure of family history of mental illness [29,38] PTSD 2 (13%) Low quality marital relationship [37]; poor socioeconomic background; history of substance use [38] PTSD, CMD 1 (7%) The quantitative, qualitative, and mixed method data were extracted and viewed to identify common themes among the retained studies. Three core themes were identified and are presented in Table 4. Association between physical and mental health -

Health Impact of Natural Disasters on Women
Three sub-themes were identified within the literature considering the variation of health outcomes. These include (i) physical health outcomes, (ii) mental health outcomes, and (iii) post-traumatic stress disorder. As mentioned, Table 3 illustrates the main risk factors affecting women's health that have been cited in this review.

Physical Health Outcomes
The findings from the review provide evidence that natural disasters have a direct impact on the physical health of women. Two studies conferred that women experienced physical injury and disability following earthquakes [27,39]. Among the included studies, a cross-sectional study conducted in Nepal, the most earthquake-affected area in South Asia, identified physical injury and disability as an outcome of earthquakes. A high percentage (80%) of the survivors had upper extremity injuries followed by lower extremity injuries (31%), head injuries, and miscellaneous injuries such as to the rib or clavicle. Multiple injuries and spine or spinal cord injuries were also seen in a significant percentage (62%) of participants. In the study by Bimali et al., (2018), the highest percentage (85%) of disability was observed in women even though there were more men included in the study [26]. Similarly, a prospective cohort study reported consistent and significant disability scores among injured women survivors in Indonesia [39]. Women with the highest disability scores reported pain and discomfort as negatively impacting their quality of life [39].

Mental Health Outcomes
The majority (n = 8) of retrieved studies strongly identified the association between depression, anxiety, and common mental disorder (CMD) in women following natural disasters [28,[31][32][33][34][35][36][37]42]. All these studies measured/observed significant scores of depressions (mean range of score 9.88-29.14), anxiety (10.97), and CMD (General Health Question score of 4 and above, mean score of distress 11.2) in disaster-affected participants using a variety of scales including the Depression Anxiety Stress Scale (DASS)-21, the Patient Health Questionnaire-9 (PHQ-9), the Beck Depression Inventory-II (BDI-II), the General Health Questionnaire (GHQ 12), and the Centre for Epidemiological Studies Depression Scale (CES-D). More than half of the reviewed studies (n = 10) associated with male and female participants revealed that women were more vulnerable in regard to negative psychological or mental health outcomes compared to men [27,[29][30][31][32][34][35][36][37][38]. For example, one study found that women had almost twice the rate of CMD than men, while women over 30 years of age had approximately two times greater odds of experiencing CMD than those younger than 30 years [37]. Most (n = 5) of these studies identified depression as a common illness in disaster-affected women followed by anxiety, CMD, and other psychosocial and mental health problems. In addition, higher mean of depressive symptoms (10.8 and 29.14, respectively) in women after natural disasters were confirmed by two specific studies on women [41,42]. The qualitative study observed psychosocial and mental health problems such as forgetfulness, tiredness, loss of concentration, restlessness, and isolation in older people, largely women, following an earthquake [28].

Post-Traumatic Stress Disorder (PTSD)
In addition to the reported mental disorders of anxiety, depression, and CMD, almost half of the studies reported that disaster-affected women are exposed to PTSD [29,30,32,35,36,38,40]. In post-disaster circumstances, PTSD is the highest recorded health issue compared to other mental health problems (i.e., depression, anxiety, CMD) for women documented through retrieved studies [29,30,32,35,36,38,40]. Studies used different recognised measures to determine the level of PTSD such as Clinician Administered PTSD Scale version 5, the standard PTSD symptoms checklist, the PTSD checklist civilian version (PCL-C), the Impact of Event Scale-Revised (IES-R), and the Traumatic Stress Symptoms checklist. Two studies showed intrusion symptoms for example (3.24 ± 0.71) were high among the 91% survivors with PTSD [30,40]. In addition, all these cross-sectional studies showed that females experienced a greater level of mental health complications related to PTSD compared to males after earthquakes and tsunamis in Nepal, Pakistan, and India [29,30,32,35,36,38,40].

Risk Factors Affecting Women's Health Following Natural Disasters
Our review identifies several types of risk factors for women's negative health outcomes in post-disaster circumstances. Four sub-themes are identified: (i) socio-demographic risk factors, (ii) disaster exposure, (iii) post-disaster factors, and (iv) pre-existing risk factors.

Disaster Exposure
Exposure to a disaster was the most notable risk factor for disaster-related health problems for any disaster survivor. Among the reported disaster variables throughout the literature, the most common (38%) recorded reasons for disaster-affected women's health adversities were physical injury and resource loss including financial, food, shelter, and property [28][29][30]32,35,[37][38][39]42]. Studies showed that these two disaster exposures are significantly associated with disability, depression, CMD, psychosocial and mental health problems, and PTSD [28][29][30]32,35,[37][38][39]42]. Studies (n = 5) from India and Pakistan showed humanitarian loss (i.e., death of family members, close relatives, or friends) and displacement (i.e., living in tent) as the second highest causes for women's PTSD and CMD after a disaster [29,[34][35][36][37][38]. Two studies from Pakistan found women who experienced disability and PTSD more likely remained at home during the earthquake [34,36]. The women in India [38] and Nepal [30] scored high levels of PTSD as they felt their lives were threatened and experienced panic during a disaster. Other causes of PTSD for these women were related to difficulty in communication, separation from family or when relatives were injured, and if they witnessed the death of family or community members [29,34,36,38]. In addition, and within the context of earthquakes, greater levels of anxiety and depression were recorded in Nepalese women who went to traditional healers as their source of health information [31], while Indonesian women recorded significant PTSD scores if they could not access public health centres [40].

Post-Disaster Risk Factors
Post-disaster risk factors were mostly associated with PTSD, anxiety, depression, and CMD, and psychosocial and mental health problems were evident in 63% of the reviewed studies. The most common (13%) post-disaster risk factors were loss of job or income generation activities, low social support, and negative religious coping [29,[36][37][38]. A study from Nepal showed that inadequate access to health care facilities due to poverty made women more vulnerable to anxiety and depression [31]. Women recorded significant depressive symptoms when they experienced poor physical health and became dependent on others, and although they survived, they lived with the fear of re-experiencing a disaster [32,33,41]. In addition, a study from Bangladesh revealed that depressive symptoms were dominant when women were the income-earner yet were unable to work due to physical injury or poor physical health [42]. Indian women recorded high PTSD scores associated with inadequate resources after a disaster, lack of mental health support systems, involvement in rescue work, and substance abuse [38]. Moreover, negative religious practices such as a feeling of being punished by God for one's sins or lack of spirituality was significantly associated with higher symptoms of depression and PTSD in Nepal and India [36,37]. The qualitative study also found that older women were blamed for the negative events in society, and this accusing practice severely affected their psychosocial and mental health [28].

Pre-Existing Risk Factors
Nearly half of the reviewed studies (n = 6) reported how pre-existing disaster factors of low and lower-middle-income countries impact women's health following natural disasters [28,29,37,38,40,41]. Studies showed Sri Lankan and Nepalese women more exposed to family adversities, stress and violence before disasters were generally vulnerable to PTSD, and poor physical, psychosocial, and mental health problems in postdisaster [28,29,41]. In addition, some studies (n = 4) identified those suffering from chronic illness and with a family history of mental illness were more vulnerable to developing PTSD and CMD [29,37,38,40]. In addition, CMD and PTSD in women was associated with low quality of marital relationships and history of substance use [37,38].

Association between Physical and Mental Health
Physical and mental wellbeing are interrelated-poor physical health affects mental health and vice versa. Studies (n = 2) presented direct correlation of physical and mental health, and some of the studies identified poor physical health (i.e., ill health, physical injury, and disability) as a significant risk factor for mental health problems after a disaster [39,41]. The prospective cohort study in Indonesia showed that injured earthquake survivors reported significantly higher proportions of severe complaints of co-morbidities (i.e., acute symptoms and chronic diseases) as compared to the non-injured survivors group. Among the injured group, the lowest average quality of life attribute (QLA) score was attributed to pain, depression, and anxiety throughout the study period [39]. However, the longitudinal Sri Lankan study of women described the existence of physical and mental health problems in an inverse relationship. After tsunamis, the average depressive symptoms showed a decline, whereas poorer physical health increased over the time of the study [41].

Discussion
The review identified a variety of physical and psychological health consequences after natural disasters and risk factors affecting women in South and Southeast Asia based on 16 empirical peer-reviewed research articles. The review included studies conducted among twenty SAARC and ASEAN countries. Fourteen were from South Asia, covering Nepal, Pakistan, India, Sri Lanka, and Bangladesh, and the remaining two were from Indonesia and the Southeast region. The studies showed that there are variations in disasters between countries, which is influenced by geography [3]. The review identified that Nepal-, Pakistan-, and Indonesia-based studies were primarily on earthquakes, while India-and Sri Lanka-based studies were on tsunamis, and cyclones were the focus of studies in Bangladesh. Although there is a difference in the type of disasters from country to country, the health impacts reported post-disasters are similar.
Our synthesis of the relevant published studies provided strong evidence for significant levels of health problems within disaster-affected women, which is consistent with previous evidence [11,43]. In support of the findings of other studies, the review showed that disability from injury can significantly impact women's physical health. For example, a high prevalence of pelvic fractures and inflammation among women were reported after the Wenchuan earthquake in China [44,45]. Due to these injuries, survivors lost their mobility and became dependent on others, which led them to experience a poorer quality of life [7,11,46]. These physical health vulnerabilities impact women's mental health and in the long term and can lead to the development of PTSD. The majority of reviewed studies (n = 13) also showed that women faced different types of mental health problems including PTSD, depression, CMD, and anxiety after disasters in accordance with the findings of prior studies in Iran, Japan, and the USA [11,47,48], and PTSD of women after the Haiti and Wenchuan earthquakes [17,18].
Disaster-affected women are often disadvantaged and vulnerable because of biological, physical, socio-demographic, cultural, and economic factors [11]. In the context of disasters, a total of 35 risk factors for negative health outcomes in women were explored and categorised under four groups (i.e., socio-demographic, disaster exposure, post-disaster, and pre-disaster/pre-existing). Six risk factors were dominant in six to ten studies and seven risk factors were explored in three or more studies. Similar to other studies, the review showed that socio-demographic factors such as adult/older age, having no formal education, severe economic status, divorced/widowed, and low social support were independent risk factors for health problems in most women [11,17,47]. Women's sociodemographic profile influences their economic resources, social status, social networks, and health behaviour. Therefore, not all women are vulnerable after a disaster, but women with a low socio-demographic profile reported health problems worldwide [10,11,17,47,48] The most reported disaster exposures affecting women's mental health were related to physical injury, resource loss (e.g., loss of food, property, damage house), and death of close family members. Higher post-traumatic symptoms were generally found to be worse for those with physical injury and the loss family members in the aftermath of disasters [49,50]. It is understandable that with loss of property, individuals face persistent financial problems and difficulties with living arrangements. In addition to these, loss of employment or income-generating activities constituted ongoing stress that could adversely affect mental health. In most cases, the affected women were too poor to pursue treatment and did not treat their diseases seriously [7,11]. Findings also indicated that being an income earner was a risk factor for post-disaster health problems, which was the opposite to other studies showing that economic inactivity was associated with increased rates of depression [51,52]. However, women found that their mental health was improved when their livelihood needs were met.
The majority of studies reported that post-disaster risk factors were relevant to coping strategies and disaster management systems of countries. Low social support is significantly associated with health problems after disasters whereas strong support from family and the community and access to health care facilities appear to safeguard people from the negative impact of traumatic events. The right support is also important for preventing mental disorders and helping individuals adapt to disasters. For instance, women affected by Hurricane Katrina benefitted from social support four years after the storm [53]. Some studies revealed, however, that women with poor socio-demographic backgrounds appeared to have a lower capacity of managing and coping with both pre-disaster and post-disaster situations [11,43]. Additionally, pre-existing family adversities, stress, chronic illness, and low-quality marital status potentially make women vulnerable to health problems.

Policy Implication
The review emphasises the implications of the effective emergency response and recovery in the post-disaster situation along with disaster preparedness and mitigation plans in the pre-disaster context. Both are essential for helping and improving the physical health, mental health, and wellbeing of women [54,55]. The most important issue is to mitigate the impact of disasters; disaster management should be preventive rather than responsive [55]. Therefore, pre-impact conditions, hazard mitigation, and preparedness efforts needed to be prioritised in policy and practice [54,56]. In addition, policies needed to prioritise effective interventions focusing on livelihood support to women to promote health and resilience after a disaster [55]. Social policies including building houses, roads, and river barriers are essential for disaster-prone residents of rural and remote communities. Older disaster victims are more at risk of negative health outcomes, evidenced by low social support, economic dependency, re-experiencing disasters, pre-existing chronic health conditions, and feelings of distress during a disaster [30,33,34,39,57]. Emotional support is identified as an important factor for promoting the health of elderly disaster victims [58]. Therefore, elders' health necessities must be considered with particular attention in disaster management policy.

Clinical Implications
This review highlights that overcoming the mental illness experienced by disasteraffected women requires urgent clinical attention and implication in the South and Southeast Asia region. The WHO (2007) recommended disaster mental health guidelines for disaster-prone countries, which are already implemented by developed countries such as the United States, Australia, and Japan [14,15]. In any health emergency situation, the role of emergency medical teams including doctors, nurses, and community health workers are essential to reduce deaths, disabilities, and diseases [59]. Clinicians and mental health professionals in communities receiving disaster survivors could facilitate individual disaster recovery through understanding their individual stressors and circumstances, which was found in this review. Disaster-affected individuals will benefit from the collaboration between disaster management and the healthcare sector. In disaster-prone countries, health professionals' active involvement in pre-disaster and during disaster health risk assessment and post-disaster recovery programmes can mitigate the health impacts of vulnerable populations, such as women. It is recommended that the availability of access to female health professionals can reduce mental illness. For example, following the Nepal earthquake, women who went to female community health workers reported lower anxiety and depression symptoms compared to those who went to other services [31].

Conclusions
Increasing natural disasters is a worldwide issue, and is associated with negative physical and mental health issues, particularly among women. The results of this systematic review suggest that the adverse impacts of natural disasters extend beyond the explicit consequences of other damages in terms of women's health. The findings of this review support the view that women's health problems are a result of a complex interplay between pre-disaster, disaster, and post-disaster factors. The most-cited risk affecting disaster survivors' health included being female, being from a poor socio-economic background, resource loss, humanitarian loss, negative coping, dependency, and loss of income. In the context of low-and lower-middle-income countries, improved communication plans need to be developed for disaster-prone residents, who need free access to health information/facilities. Future health policy and disaster management consultants need to consider how best to address various health problems and risk factors in the most effective way. In addition, policy should help unprivileged women of developing countries to recognise that a mental health problem exists, and to believe that seeking help may be beneficial in promoting their health and wellbeing. Facilitating women's capacity of managing and coping with both pre-disaster and post-disaster situations is crucial. Moreover, the identification of health impact and risk factors affecting women's health is essential for reducing the burden of health problems. Therefore, this research is an important step in synthesising some of these important factors and outlining possible suggestions for prevention, as well as affording guidance for future research.

Limitations
As with all reviews, there are inherent limitations in this study; hence, it is important to acknowledge the limitations of this review. First, reports, grey literature, and books, which may be based on primary data, were not included. Therefore, there is a possibility that these sources may have yielded additional results. Second, searches in additional databases without search parameters could gather more information which could strengthen the generalisability of the findings of this review. Third, some relevant studies may have been missed due to strictly following the inclusion criteria that focused on adult women. For example, no study was retrieved from the Philippines in this review, which is a significant disaster-affected country of Southeast Asia. Fourth, although reproductive health was included as a search term, no studies on women's reproductive health challenges after disasters were identified in this review that met the inclusion criteria. The majority of reviewed studies used a cross-sectional design, which may prevent researchers from making strong inferences about the causation of women's health impacts and risk factors reported in the studies, as the data observe the study population at only one point in time. The review did, however, identify women's health impacts following natural disasters, the prevalent risk factors, and the current knowledge gaps.

Recommendation for Future Research
A variety of the health assessment tools were used in the reviewed studies. A greater consistency in assessment tools used to examine the extent of physical and mental health difficulties may be beneficial for future research. We also recognise that further work is needed in this area, particularly in relation to research that yields high-quality evidence, such as studies that utilise non-probability sampling to enhance the quality of the work and the confidence in the evidence provided. Further qualitative and mixed method research needs to be carried out. More research related to the aim of this review was conducted in Nepal and Pakistan than the other countries; thus, more is generally known about the health impact and risk factors of these survivors. Notably, although Bangladesh is the fifth most disaster-affected country in the world [60] and records floods, cyclones, and riverbank erosions every year [12], only one study retrieved from Bangladesh identified women's mental health outcomes after disasters. Given the large number of disasters, there is a scarcity of disaster research focused on the health impact of disasters on women in Bangladesh.

Supplementary Materials:
The following are available online at https://www.mdpi.com/article/ 10.3390/ijerph182111068/s1, Table S1: Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidance 2020, Table S2: Search terms and search strategy for each database, Table S3: Risk of bias assessment.