Post-traumatic stress disorder and its associated factors among survivors of 2015 earthquake in Nepal

Earthquakes cause significant stress and affect a substantial number of people in the world. The 2015 earthquake in Nepal was a dreadful disaster with a painful impact on many survivors. Three years after the disaster, affected people have yet to fully recover. This cross-sectional study emerged within the four selected most affected districts. The PTSD prevalence assessed using PCL-C (DSM-IV) criteria was remarkably high three years after the disaster.

Prevalence of the PTSD

The present study found that the prevalence of PTSD three years after a devastating earthquake is 18.9% among earthquake-affected adult survivors, which is consistent with previous studies done in Nepal on mental health problems nine months after the 2015 Nepal earthquake [5].

A study containing forty-six eligible articles showed the combined incidence of PTSD among survivors who were diagnosed, at no more than nine months after the earthquake, was 28.76%, while for survivors who were diagnosed at over nine months after earthquake the combined incidence was 19.48% [38]. This result shows the prevalence of PTSD remains high years later. A study on 1355 adults from the 2010 Haiti earthquake after 30 months (about 2 and half years) found the prevalence rates of PTSD was 36.75%, which is higher than our study [39]. The PTSD was measured by the clinician using life events checklist subscale [39].

Similarly, our prevalence rates are lower than the 40% rate three years after the Turkey earthquake. The epicenter was predominantly government-constructed housing. The study used the Traumatic Stress Symptom Checklist (TSSC), which included 17 DSM IV PTSD, 55.2% female, 33.4% male reported eighteen months after the Kashmir earthquake those people were living in tents, 28.5% reported 11 months after the 2015 Nepal earthquake, 23% reported 14 months after the epicenter of Turkey earthquake, 22.1% reported 8 months after the 2008 Wenchuan earthquake in China [10, 40,41,42,43].

Most long-term studies of prevalence of PTSD in disaster exposed survivors show that the prevalence of PTSD decreases with time [44]. In contrast, some studies show that there might be a rise in the prevalence of PTSD. In the years following exposure to the 2001 World Trade Center disaster, the prevalence of PTSD among firefighters was shown to increase over time, from 9.8% in the first year (2002) to 10.6% in the 4th year (2005) (p = 0.0001), using the same scale as ours [45].

A literature review shows that most researchers who studied PTSD rates occurred around three months after the earthquake [10]. Even after powerful quakes (Wenchuan), the prevalence rate of PTSD was seen lower than other reports in the short term, however, our study focused on the potential long-term effects after an earthquake. These differences may be explained by factors such as the loss of family, loss of property, loss of job, self-injury/buried, gender, strength of coping, type of exposure, location of the disaster and diagnosis measure (tools) of PTSD. Compared with current study results of Nuwakot (2016) the prevalence (24.10%) was found to be higher in the Nepal earthquake after 10 months, it might be because of the short duration after an earthquake than ours [2]. This is also supported by a study done in China after 9 month of an earthquake which found PTSD 24.2% by using DSM IV criteria [46].

A study done in the Sichuan and Shaanxi provinces of China, 2 earthquake-stricken areas, showed that the 1 –year prevalence of PTSD amongst 2080 adult survivors was 40.1% [8]. Three years after the same earthquake it was found that 10.3% of the respondents had PTSD [47]. Similarly, a population survey done among 1756 respondents aged 16–98 in the 1991 earthquake in Yu-Chi, Taiwan found that at 6 months and 3 years, the estimated rate of Post-traumatic Stress Symptoms (PTSS) was 23.8% and 4.4% respectively [48]. Likewise, another study (Turkey) showed PTSD prevalence dropped by the length of time after the earthquake [43]. However, some other studies suggest the prevalence of PTSD has not decreased as time goes on [42, 47, 49].

After an extensive literature review and comparing our results we conclude that many factors contribute to the prevalence of PTSD symptoms amongst earthquake survivors. Further comparison is limited due to lack of studies measuring the prevalence of PTSD among survivors three years after the earthquake in Nepal. We can also assume that variation may exist between magnitude of earthquake, assessment tools, type of study (qualitative, quantitative) and coping strategies adopted by individuals after a traumatic event.

In our study, there was a significant association (p = 0.003) with age group and PTSD. In the age group of 60 and above, participants had the highest prevalence of PTSD (28.8%). These findings were consistent with a study done in Dhading Nepal, 9 months after the earthquake where adolescents and the elderly were associated with a higher incidence of PTSD [5, 50]. Similarly, another study done in Nepal (2019) and other countries (China, 2011, 2013 and 2014, Tehran, 2017), revealed that the elderly were more likely to have PTSD compared to younger adult survivors [2, 8, 51,52,53,54]. Our result is also consistent with a study done by Bhat W. et al. where age was one of the best predictors of PTSD prevalence [55].

Although our study is consistent with most other studies, it was inconsistent with the findings done in Wenchuan one month after the earthquake, which revealed the prevalence of PTSD as in young and middle age adult was 78.8% [56]. One probable reason is the ‘burden perspective hypotheses’, which suggests that middle-aged adults experience poorer coping capacity than others because of their responsibilities to society (e.g. working) and to the family (e.g. often providing support to both children and parents), which can render them more psychologically vulnerable in the aftermath of the disaster [57, 58]. Older adults have a high coping mechanism according to socio-cultural structure (potential spiritual, religious beliefs), which is consistent with a study done by Palgi. Y. [59, 60]. Moreover, older people were reported to learn coping mechanisms from experience; also, older age was associated with less sensitivity, fewer negative beliefs, and decreased mood symptoms [61].

Gender difference in prevalence of PTSD was also noted in our study. Females were found to have a 1.6 times higher odds ratio of developing PTSD compared to males. This is consistent with a study done by Lama et al. [54].

Gender differences are also supported from previous studies done in Nepal (2018) and other countries (China, 2015, Pakistan, 2011, 2013, and China, 2013) [5, 53, 61,62,63,64,65,66]. A study by Shrestha after the 2015 Nepal Earthquake also revealed higher PTSD amongst female medical personnel [67]. Higher PTSD risk among women may be due to their stronger perceptions of threat and loss of control [2]. In addition, it is possible that women are more susceptible to negative events and tend to express their emotions more than males [5]. Literature even explains gender differences in neuro-endocrine response that may lead to higher risk of PTSD in women [68].

In our study, illiterate survivors were nearly 2 times more likely to have PTSD compared to literate survivors. This is consistent with a study in Wenchuan (2012), where PTSD was found to be 52.6% among respondents with a low level of education (primary and secondary) compared with a university degree (master's and bachelor's degree). Another survey result revealed that in Nepal, the prevalence of PTSD was 13.9% among literate survivors, while illiterate accounted for 38.1% [2, 50]. A lower education level may contribute to patients being less informedwhich may decrease confidence in both physical and mental recovery [2].

The results of the present study differs from a study conducted in Haiti and other countries (China, Pakistan) which showed that higher education increases levels of PTSD [39, 62, 65]. Our study also disagrees with studies by Contractor, AA and Khodadadi-H. et al. which found that participants with a high school education were more likely to have PTSD [69]. Their hypothesis for these results is that due to their increased level of education they may be moreinclined to worry about future consequences regarding earthquake than illiterate respondents.

Our study found that ethnicity also had an association with PTSD symptoms. In the current literature, ethnicity has not been consistently described as a risk factor associated with PTSD [37, 68].

In our study, the profession of respondents was also found to have an association with PTSD. This is supported by a study conducted in China 5 years after the earthquake in 2013 [62]. The major occupation of the people residing in Wenchuan, China was fish farming (aquaculture). It was impacted or destroyed by the 2008 earthquake, and, as a result, their source of income was affected [62]. Similarly, a study revealed psychological health disturbances were more common in farmers and farmworkers, conducted by Daghagh Yazd S et al. [70].

People engaged in other occupations where less likely to develop PTSD when compared with farmers or those engaged in agriculture. Our result was consistent with a study done by Mitsuaki Katayanagi et al. which revealed that after the Great East Japan Earthquake in 2011 nearly half of the farmers who were engaged in agriculture and fishery reported decreased income [71]. It is possible that these survivors had fewer resources in coping with the stress from the economic burden than those of other occupations [62]. This may resulted in a higher PTSD rate amongst farmers [62].

In our study perceived social support was associated with PTSD in both univariate and multivariate analysis (p < 0.001). In this study, participants with moderate social support had 70% lower odds of having PTSD compared to those with poor social support (AOR = 0.3, 95%CI: 0.2–0.5, p < 0.001). These findings are similar to findings by Asnakew S. et al. who found that participants with poor social support were 3.6 times more likely to develop PTSD than those with strong social support (AOR = 3.6, 95% CI from 2.0 to 6.7) [72]. Other research has shown that there is a possible positive effect of social support for the prevention of PTSD. Social support will not benefit everyone equally. Numerous confounding variables, including gender, previous experiences of violent trauma, and self-efficacy, appear to play a role [73]. Another study by Dai W et al in 2016 found that strong social support can not only protect individuals from mental disorders but also facilitate psychological recovery from disaster [38]. This variation could be due to differences in the study population, assessment methods and posttraumatic period.

Earthquake related variables and PTSD related information

This study showed that there is a significant association between PTSD prevalence and factors such as getting buried after an earthquake, death of a family member, and witnessing others who have been buried, injured ordied. This finding is consistent with other previous studies [39, 74].These are all autonomous factors for developing PTSD. Similarly, survivors with family member loss may undertake more negative traumaand endure greater economic and psychological pressure,which may contribute to a higher PTSD prevalence rate [75].

Another factor that was associated with the PTSD prevalence was participant house and property damage. Those who had medium to very high level damage to house and property were 5 times more likely to have PTSD compared to those with no or very less damage. A study in Dhadhing showed participants who had house completely damaged and loss of property had between 4 and 9 times higher odds of having PTSD [5].

Our study is consistent with numerous previous studies [5, 7, 8, 62, 76, 77]. It is a common association that increases the prevalence rate of PTSD and likely was confounded by the fact that none of the respondents were living in their previous houses three years after the earthquake. Their current way of living and surrounding environment may have caused a constant reminder to the patient of the earthquake. The temporary accommodation of the respondents has likely made an impact on the prevalence of PTSD.

According to Galea and colleagues’ studies, loss of private property (e.g. house) and experiencing economic loss (e.g. loss of job) are major stressors after a disaster [44].This is consistent with our study. In our study sample, over ninety percent of houses were damaged during the earthquake. With loss of houses and property, many survivors were faced with financial and social problems/barriers three years later.

Similarly, consistent with our findings, a study (Kun P. et al. 2009 and 2013) of PTSD concluded that female gender, being married, ethnicity, death of family members, and damaged personal property are associated risk factors [53, 64]. Guo J. et al. and Zhou X. et al. revealed that risk factors for PTSD included advanced age, female gender, buried in the earthquake, injured in the earthquake, witnessing someone get injured in the earthquake, witnessing someone get buried in the earthquake, and witnessing someone die in the earthquake. These findings are consistent with our study findings [10, 75].

Strength of the study

The study included a large sample of communities most affected by the 2015 earthquake in 4 districts of Nepal. A standardized and validated PCL-C scale was used to assess PTSD symptoms. All interviews were conducted by trained researchers. There was, therefore, little missing data.

Limitations of the study

Our study has some limitations. Our design is a cross-sectional study with data collected at a single time reference point. To better study the effects of time, additional time points would be helpful. This study is quantitative in nature. The findings would be stronger if it had been triangulated by qualitative (study) interviews. Similarly, we also could not assure that all participants properly disclosed their mental illness. Participants were asked if they were suffering from mental illness and/or if they were under medication as exclusion criteria. It is possible that some participants who responded no had an underlying mental illness. We also did not inquire about our respondents’ family income. Family history of psychiatric illness was also not asked.

Ideally, the questionnaire should be completed by the respondents, but many of the respondents were illiterate. Researchers had to verbally ask questions and record their responses. This may have introduced bias into the study. Although the self-administration of the questionnaire would be more preferable, our data collector might have faced difficulties in explaining the PCL-C questionnaire during data collection due to its difficulty in comprehension. Recall bias may have also been a limitation. Although widely used around the world, PCL-C is a screening measure for PTSD, not a diagnostic tool. The current study participants with a score of 50 or above greater were classified as having probable PTSD without a clinical interview.

留言 (0)

沒有登入
gif