Prevalence and predictors of posttraumatic stress disorder, anxiety, depression, and burnout in Pakistani earthquake recovery workers
Introduction
Natural disasters, such as earthquakes, floods, or hurricanes are prevalent traumatic events around the world. Earlier research has shown that in a substantial subgroup of survivors, natural disasters can lead to emotional disorders, including posttraumatic stress disorder (PTSD), other anxiety disorders, and depression (Norris et al., 2002, Neria et al., 2008). There is increasing recognition that not only the general population but also rescue workers engaged in disaster relief are at risk of developing disaster-related emotional problems (Benedek et al., 2007). This group typically includes not only professional fire fighters, military personnel, police officers, search-and-rescue teams, and medical personnel, but also volunteer rescue workers without any formal training. Earlier studies have estimated the prevalence of PTSD in earthquake relief personnel to lie between 20% and 25% (Chang et al., 2003, Guo et al., 2004, Ozen and Sir, 2004, Hagh-Shenas et al., 2005), with one study even reporting a prevalence as high as 43% (Soldatos et al., 2006). As only a subgroup of disaster relief workers develops PTSD, it appears important to identify risk factors or predictors of this disorder. However, only few studies to date have investigated predictors of PTSD in earthquake relief workers and few of these variables have been replicated. Preliminary evidence suggests that PTSD is related to being a volunteer rescuer (vs. a professional) (Guo et al., 2004, Hagh-Shenas et al., 2005), having a longer job experience (among professional rescuers) (Chang et al., 2003, Chang et al., 2008), high levels of identification with the dead and their families (Cetin et al., 2005), use of avoidant coping strategies (Chang et al., 2003), and high levels of anxiety sensitivity (Hagh-Shenas et al., 2005).
It is important to note, however, that all published studies to date have focused on individuals involved in the immediate response to disasters during the emergency relief phase. To our knowledge, it has not been investigated yet whether disaster recovery workers deployed later-on for rehabilitation and reconstruction also show a higher risk of emotional disorders. After large-scale natural disasters, such as earthquakes, a large number of professional rehabilitation and reconstruction workers are deployed to disaster regions for months or even years. Investigating the prevalence of emotional problems in this group appears relevant for a number of reasons. First, a substantial subgroup of professionals involved in disaster recovery can be expected to have already lived in or close to the affected region when the disaster struck, which may have led to disaster-related PTSD in some individuals. Second, as part of their job, disaster rehabilitation and reconstruction workers are exposed to the consequences the disaster had on the population. In addition to being exposed to destroyed houses, destroyed infrastructure, injured people, and dead bodies, disaster recovery workers often also have to repeatedly listen to disaster survivors' stories of their experience of the disaster and its impact on their lives, which may lead to secondary traumatization (Boscarino et al., 2004, Byrne et al., 2006). Finally, disaster recovery workers often experience high levels of work stress, such as high work load, long working hours, and being away from home, which may increase risk for depression or burnout. Burnout is a response to chronic work stress characterized by a number of symptoms; however, ‘emotional exhaustion’, defined as the draining of emotional resources, is usually regarded as the key factor (Maslach and Jackson, 1986, Schaufeli et al., 2001).
The current study aimed to investigate the prevalence and predictors of PTSD, depression, anxiety, and burnout in rehabilitation and reconstruction workers following the 2005 earthquake in Northern Pakistan. On 8 October 2005 at 8:50 am local time, an earthquake of magnitude Mw = 7.6 hit the North-West Frontier Province (NWFP) and Azad Jammu and Kashmir (AJK) regions of Pakistan. It was one of the most deadly earthquakes in the recent history of the subcontinent, which left more than 73,500 people dead, half a million homeless, and countless without livelihoods. In January 2006, the Earthquake Rehabilitation and Reconstruction Program (ERRP) funded by the World Bank was launched with the aim to reconstruct housing and the community physical infrastructure as well as support social mobilization, which was supplemented by funds from the International Fund for Agriculture (IFAD) and the German Reconstruction Credit Institute (KfW). The Pakistan Poverty Alleviation Fund (PPAF) was selected as an implementing partner for the ERRP. The current study was conducted among employees of this organization.
Section snippets
Participants
Data were collected on a nearly complete sample of earthquake recovery workers employed by the Pakistan Poverty Alleviation Fund's (PPAF) Earthquake Rehabilitation and Reconstruction Program. All 278 individuals in active duty at the time of the study were approached and invited for participation. The response rate was 96%, resulting in a final sample of N = 267 individuals (for demographic data see Table 1). Participants fell into three groups differing in professional background and tasks. The
Prevalence of traumatic experiences
Participants' answers to the TESS showed that a large majority of participants (76%) had been exposed to the earthquake themselves and that 45.7% had thought they were going to die during the event. In addition, a majority of participants had to spend the night somewhere other than home after the earthquake (64.4%) and a substantial subgroup of participants needed shelter (41.9%) and food and water aid (39.3%), had to deal with their home being damaged (37.1%) or even had to relocate (30%).
Discussion
The aim of the current study was to investigate the prevalence and predictors of emotional problems in a nearly complete sample of earthquake recovery workers. Results showed that a substantial subgroup of recovery workers reported high levels of emotional problems. More than 40% of participants showed clinically relevant levels of PTSD and approximately 20% of participants showed clinically relevant levels of depression and anxiety. Levels of burnout were overall low. Earlier studies have
Acknowledgments
We would like to thank the Pakistan Poverty Alleviation Fund (PPAF), especially Mr Kamran Akbar and Mr Yasir Jawad for their invaluable support. We are also grateful to Dr Muhammad Ali Mahmood for providing the back-translation of the questionnaires.
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