Disasters can have physical, psychological, and social impacts on the affected population. Reference Lebowitz1–Reference Norris, Friedman and Watson3 Sudden and overwhelming social disorganization, such as displacements or deaths, induces social support disruptions, occupational and economic stress, and health problems. Reference Leon2–Reference Jacobs, Oosterbeek and Tummers5 All these factors make it difficult for disaster victims to return to their daily lives and influence individuals’ functionality after a disaster. Reference Hussain, Weisaeth and Heir6
After disasters, different factors create functional impairment and a poor quality of life. Reference Hussain, Weisaeth and Heir6–Reference Lee, Kim and Kim8 Disaster exposure can lead to negative physical health consequences, which cause deteriorated daily functioning. Reference Hu, Xu and Liu9 Disasters also directly give rise to injuries or physical illness Reference Salazar, Pesigan, Law and Winkler10–Reference Alderman, Turner and Tong13 through accidents that produce structural collapse Reference Salazar, Pesigan, Law and Winkler10 and can cause long-term health impacts. Difficulties in health care accessibility or shortages of basic needs lead to an increased prevalence of chronic diseases such as respiratory health, diabetes, and cancer among disaster victims. Reference Salazar, Pesigan, Law and Winkler10–Reference Allweiss14
Additionally, posttraumatic stress symptoms (PTSS), which frequently occur among disaster victims, Reference Leon2,Reference Hussain, Weisaeth and Heir6,Reference Neria, Nandi and Galea7 can lead to social maladaptation. Reference Druss, Hwang and Petukhova15,Reference Hu, Xu and Liu16 PTSS include intrusive re-experiencing, avoidance of trauma memories, disturbances in cognition and mood, and hyperarousal. Reference Mikolajewski, Scheeringa and Weems17 These symptoms are maladaptive and disabling and can severely impair the affected individuals’ psychosocial functioning and quality of life. Reference Hu, Xu and Liu16,Reference Liang, Cheng, Ruzek and Liu18 Likewise, posttraumatic stress disorder (PTSD) is frequently comorbid with depression and anxiety, which can delay recovery and worsen daily life functioning. Reference Hu, Xu and Liu16,Reference Xi, Yu and Yao19–Reference Momartin, Silove, Manicavasagar and Steel21
Research has indicated that PTSD severity is more associated with global functional impairment after trauma exposure than other specific aspects of traumatic experiences or physical injuries. Reference Miller, Wolf and Martin22 Subsequently, PTSD can be considered a mechanism for functional impairment observed after traumatic exposure. Reference Miller, Wolf and Martin22,Reference Wagner, Wolfe and Rotnitsky23 However, physical illness or concomitant mental disorders are frequently not included in the analyses, which could lead to bias in the variance of functional impairment assessments. Reference Miller, Wolf and Martin22
In the present study, we aimed to investigate the prevalence of PTSS and physical illness in a large sample of South Korean disaster victims 1 year after the occurrence of a natural disaster. Our goal was to compare social and work adjustments between individuals with PTSS and individuals with physical illness to examine the importance of PTSS in disaster victims’ functional impairment. To our knowledge, this is the first study that evaluated social and work maladjustments 1-year post-disaster in victims who present PTSS compared to those with physical illnesses.
Methods
Participants and Procedures
All the participants were selected and surveyed from the National Disaster Safety Research Institute list of disaster victims who were provided financial assistance from the Disaster Relief Donation Fund designated by the government from 2012 to 2017 in South Korea. This funding is government capital destined for humanitarian aid to assist and revive the economies of disaster victims. The types of disaster events experienced by the subjects included floods, typhoons, earthquakes, and fires and are detailed in Table 1. 24 The data were obtained over 5 months, from September 2017 to January 2018, through surveys that were stratified by sex and residence province. The study areas included Seoul, Incheon, Gyeonggi, Gangwon, Daejeon, Sejong, Chungbuk, Chungnam, Gwangju, Jeonbuk, Jeonnam, Jeju, and Daegu. Survey teams were established with a total of 60 people who were trained specifically for this research. Face-to-face interviews were performed to complete the questionnaires and clinical scales.
Table 1. Types of disaster events experienced by subjects
In total, 1822 individuals were surveyed, and 1659 completed the evaluation (response rate: 91.1%). Participants of ages between 19 and 69 who did not have physical or psychiatric illnesses before the disasters were selected for the study. Participants who presented missing data were excluded, giving a total of n = 988. Ethics committee approval was obtained for this study from the National Center for Mental Health, Seoul, South Korea (IRB File No. 11627-2019-31). Participation in the study was voluntary, and informed written consent was obtained from all participants.
Instruments
Data were obtained by a self-report questionnaire and clinically validated scales that included information related to demographic participant profile, characteristics of the disaster exposure, PTSD symptoms, general health, resilience, and work and social adjustments. The specific scales and questionnaires used are listed below.
Demographic and disaster exposure characteristics
Age, sex, education, and economic status were included as demographic characteristics. Education level was divided into elementary school or below, middle school, high school, and university studies. Economic status was divided into 5 groups depending on monthly income (Won): < 1 million, 1–3 million, 3–5 million, 5–7 million, > 7 million. Injury and the perceived life threat levels were assessed and divided into 3 groups: none, low injury, and high injury. Self-report questionnaires were used to assess the following variables: (1) prevalence and persistence of injuries and diseases after the disaster (short-answer rating), (2) physical damage after the disaster (multiple ratings), (3) scale of damage loss after the disaster (short-answer rating), (4) witnessed damage after the disaster (multiple ratings), (5) experienced life-threatening disaster (short-answer rating), (6) assisted identifying victims and persons (multiple ratings), (7) experienced separation after the disaster (multiple ratings), and (8) experienced moving residence after the disaster (multiple ratings).
Depression
Depression was assessed using the Korean version of the Patient Health Questionnaire depression module 9 (PHQ-9). Reference Kroenke, Spitzer and Williams25,Reference Choi, Choi and Park26 The PHQ-9 is a self-report questionnaire with 9 items that correspond to DSM-IV criteria for depressive disorders and measures symptom severity. Reference Kroenke, Spitzer and Williams25 Each item is scored on a 3-point Likert scale with a total score ranging between 0 and 27.
Posttraumatic stress symptoms (PTSS)
PTSS were assessed using the Impact of Event Scale–Revised Reference Weiss, Wilson and Tang27 —Korean version (IES-R-K). Reference Lim, Woo and Kim28 IES-R-K is a 22-item, 4-point Likert scale, ranging from 0 (“not at all”) to 4 (“extremely”), and assesses subjective distress in response to traumatic events during the previous week. Reference Weiss, Wilson and Tang27 The total score ranges from 0 to 88 and is divided into 3 subscales that evaluate intrusion (8 items), avoidance (8 items), and hyperarousal (6 items). Reference Weiss, Wilson and Tang27,Reference Beck, Grant and Read29 Higher scores correspond to more significant subjective distress. Reference Weiss, Wilson and Tang27,Reference Joseph30
Physical illness
The presence of physical illness was assessed by self-report questionnaires that included digestive system illnesses, chronic headaches, dental diseases, hypertension, obstetrics or gynecological illnesses, neoplasia, cerebral vascular disease, and others.
Resilience
Resilience was assessed using the Brief Resilience Scale (BRS), Reference Smith, Dalen and Wiggins31 which is a self-report questionnaire including 6 items to measure the capability to recover from difficulties. Each item is evaluated by participants, with 5 agreement levels—from 1 (“strongly disagree”) to 5 (“strongly agree”). Reference Smith, Dalen and Wiggins31
Work and social adjustments
Work and social adjustments were assessed using the Work and Social Adjustment Scale (WSAS), Reference Mundt, Marks, Shear and Greist32 which is a 5-item scale that assesses functional impairment attributable to an identified problem. Each item is rated on an 8-point Likert scale—from 1 (“not at all”) to 8 (“very severely”). Reference Mundt, Marks, Shear and Greist32 The total scores are interpreted as > 20 severe impairment and symptomatology, 10–20 significant impairment but less symptomatology, and < 10 subclinical presentation. Reference Mundt, Marks, Shear and Greist32
Statistical Analysis
For the statistical analysis, 3 groups were constructed based on PTSS and physical illness incidence 1-year post-disaster: (1) PTSS (-) physical illness (+); (2) PTSS (+) physical illness (-); and (3) PTSS (+) physical illness (+). A cross-sectional descriptive analysis was performed with the IBM Statistical Package for Social Sciences (SPSS; Armonk, NY) software. The mean, standard deviation, and range of variables were calculated as descriptive statistics. An analysis of variance (ANOVA) test was performed to compare the sociodemographic data, resilience, injury, perceived life threat level, and work and social adjustments in the 3 groups. A P-value of 0.05 was thought to be statistically significant. A post-hoc Bonferroni analysis was performed for the covariates (sex, age, education, injury, perceived life threat, and resilience) correction. Corrected means and standard deviations were re-calculated to compare social and work adjustments between the 3 groups. Likewise, a multiple comparison analysis was applied to confirm the differences between the 3 groups mentioned above. To evaluate the odds ratio for the associations with social/work adjustments in each group, we performed a multiple logistic regression using PTSS (-) and physical illness (-) as reference groups. To select potential covariates for the final model, a simple logistic regression was performed for each variable.
Results
Table 2 presents the prevalence of physical illness among participants 1-year post-disaster. A total of 305 (30.36%) participants presented post-disaster physical illnesses. The most prevalent physical illness was related to the musculoskeletal system (28.94%), followed by hypertension (18.84%), digestive system-related illnesses (12.33%), diabetes (8.56%), chronic headaches (5.99%), and dental health problems (5.65%). Other less prevalent illnesses were related to the cardiovascular system (3.77%), dermatology (3.77%), obstetrics and gynecology (2.05%), neoplasia (1.54%), cerebrovascular disease (1.54%), and urogenital system illnesses (1.03%). Differences in sociodemographic characteristics, the type of disaster exposure, mental health problems, quality of life, and work and social adjustments between the group PTSS (+) and the group PTSS (-) are illustrated in Table 3.
Table 2. Prevalence of physical illness 1-year post-disaster
Table 3. The result of chi-square test and ANOVA of sociodemographic, numeric variables in group based on the course of PTSS
*P < 0.05; **P < 0.01; ***P < 0.001.
From the total sample, 347 individuals presented PTSS. A greater proportion of the PTSS (+) group were women (56.4%) compared to the PTSS (-) group (43.6%): F1,987 = 7.21, P < 0.01. The mean age in the PTSS (+) group was higher (52.71 years) than in the PTSS (-) group (49.72 years): F1,987 = 3.18, P < 0.01. Among the PTSS (+) group, a significantly greater proportion of participants (12.5%) presented the lowest assessed income (< 1 million Won): F1,987 = 34.6, P < 0.001; and a lower proportion (14.4%) had completed the highest education level (> university): F1,987 = 11.3, P < 0.01, compared to the PTSS (-) group. Regarding the type of disaster exposure, the PTSS (+) group had significantly more exposure to anthropogenic disasters (11.8%) compared to the PTSS (-) group (5.3%): F1,987 = 13.3, P < 0.001. Furthermore, the PTSS (+) group presented a significantly higher proportion of injury experience (12.1%) compared to the PTSS (-) group (5.2%): F1,987 = 17.66, P < 0.001. There were no statistically significant differences between the PTSS (+) and PTSS (-) groups in alcohol and tobacco abuse rates.
Depression scores were significantly higher in the PTSS (+) group (20.7% presented moderate or severe scores) compared to the PTSS (-) group (8.8% presented moderate or severe scores): F1,987 = 15.61, P < 0.001. Likewise, the PTSS (+) group presented worse scores in sleep quality in the last month, while 8.2% of the PTSS (+) group participants scored “very bad” in this variable compared to 1.2% of the PTSS (-) group: F1,987 = 107.58, P < 0.001. Moreover, the PTSS (+) group experienced more physical illness (45.9%) than the PTSS (-) group (30.3%): F1,987 = 22.50, P < 0.001. The PTSS (+) group reported significantly worse scores in quality of life (20.07) compared to the PTSS (-) group (23.1): F1,987 = 10.65, P < 0.001. Similarly, work/social adjustment scores were worse in the PTSS (+) group (4.39) than in the PTSS (-) group (1.12): F1,987 = 13.61, P < 0.001.
Next, we present odds ratios for the associations between the constructed groups (based on the incidence of PTSS and physical illness in the year post-disaster, using PTSS [-] and physical illness [-] as reference groups) and sociodemographic characteristics, disaster exposure characteristics, alcohol and tobacco abuse, depression, sleep quality, physical illness, quality of life, and work and social adjustment variables. The results of the simple logistic regression are illustrated in Table 4.
Table 4. Simple logistic regression analysis (Reference group: PTSS [-] physical illness [-])
*P < 0.05; **P < 0.01; ***P < 0.001.
As sex, education, disaster type, injury exposure, and alcohol and tobacco abuse did not have significant associations in all 3 groups, they were excluded in the final logistic regression model (Table 5). Work and social maladjustments presented significant odds ratios in both the PTSS (+) physical illness (-) group (OR: 1.18, CI: 1.12–1.26, P < 0.001) and PTSS (+) physical illness (+) group (OR: 1.16, CI: 1.08–1.23, P < 0.001) but not the PTSS (-) physical illness (+) group.
Table 5. Multinomial logistic regression analysis (Reference group: PTSS [-] physical illness [-])
*P < 0.05; **P < 0.01; ***P < 0.001.
Discussion
To our knowledge, this is the first study that has compared social and work adjustments 1-year post-disaster between victims who had physical illnesses and those with PTSS. We found that groups who presented PTSS (+), regardless of whether they had physical illnesses, had a significant association with work and social maladjustments. Interestingly, this association was not found in the group that exclusively presented physical illnesses. Our results are consistent with previous research that has demonstrated that PTSD might mediate the association between disaster exposure, functional impairment, Reference Kroenke, Spitzer and Williams25 or quality of life. Reference Liang, Cheng, Ruzek and Liu18 Increased odds ratios of work and social maladjustments in individuals with PTSS have been strongly supported by different hypotheses in previous research. Reference Ribeiro, LaCroix and De Oliveira33–Reference Rodriguez, Holowka and Marx37 The hypotheses, detailed below, include clinical, social, and medical mediations of PTSS in work and social maladjustments. Reference Wagner, Wolfe and Rotnitsky23,Reference Ribeiro, LaCroix and De Oliveira33,Reference Solberg, Birkeland and Blix38
Solberg et al. reported clinical impacts due to dysphoric arousal symptoms and emotional numbing related to PTSD, which were associated with functional impairment over time. Reference Solberg, Birkeland and Blix38 Similarly, individual functionality decreased due to interpersonal social difficulties. Reference Ehlers and Clark39 Individuals who experience PTSS may avoid social interactions to elude traumatic experiences and increase safety. Reference Ribeiro, LaCroix and De Oliveira33,Reference Price, Gros and Strachan40 Additionally, their experience could lead to frustration and a loss of confidence in support networks. Reference Price, Gros and Strachan40 Combining these factors may adversely influence individual social attachment and decrease social support resources. Reference King, Taft and King34
Regarding medical impact, disaster exposure can lead to negative physical health consequences, which cause deteriorated daily functioning. Reference Hu, Xu and Liu9 Among the various factors aggravating physical health status, psychological trauma, such as experiencing disasters, may affect functioning. PTSD has been associated with the decline of good health habits and increased behaviors that could compromise health, such as the use of alcohol and other psychoactive substances. Reference María-Ríos and Morrow41 Finally, PTSD could affect immunocompetence due to neurochemical and physiological changes that accelerate aging in the epigenome and affect both the immune and inflammation systems. Reference Wolf and Morrison42 The experience of psychological trauma per se has been associated with increased self-reports of health problems, increased use of medication and medical consultations, and ultimately higher mortality rates. Reference Wagner, Wolfe and Rotnitsky23 Thus, psychological trauma after disasters may result in an even greater cost to individuals and health care systems than previously suspected. Reference Wagner, Wolfe and Rotnitsky23
In this research, other possible factors implicated in poor functional adjustment after a disaster, such as depression, sleeping disturbances, alcohol/tobacco use, and sociodemographic characteristics, were also examined. Reference Druss, Hwang and Petukhova15,Reference Xi, Yu and Yao19,Reference Stein, Walker and Forde43 Depression, considered one of the most impairing mental health disorders, Reference Druss, Hwang and Petukhova15 presented higher scores in all 3 groups and scored 4 points more in the PHQ-925 compared to the PTSS (-). Furthermore, more participants in the PTSS (+) group presented serious sleeping disturbances than in the PTSS (-) group. However, after adjusting for depression and sleeping disturbances as covariates, associations with social and work maladjustments remained in all PTSS groups but not in the PTSS (-) groups. Our results might indicate that PTSS (+) is independently associated with work and social maladjustments, even considering the effects of depression or sleep disturbances 1-year post-disaster.
Additionally, and contrary to expectations, no significant differences in alcohol and tobacco use were found between the PTSS (+) and PTSS (-) groups. As mentioned above, this result is inconsistent with previous research, which found substance use is increased in the presence of PTSD after a disaster. Reference María-Ríos and Morrow41 This could be explained by the survey responders withholding this information due to social stigmatization related to psychoactive substance use.
Finally, when comparing PTSS (+) and PTSS (-) groups globally, significant sociodemographic differences were evident without considering the presence of physical illnesses. The PTSS (+) group had a higher mean age (52.71 years), consistent with previous research, as anxiety disorders with a strong autonomic nervous system component like PTSD might be at their highest prevalence in adulthood. Reference Lenze and Wetherell44 Another significant difference was that the PTSS (+) group had a greater number of women. This is similar to Stein et al.’s results that demonstrated that women had a significantly increased risk of developing PTSD following exposure to traumatic events. Reference Stein, Walker and Forde43 Regarding additional sociodemographic differences, lower incomes and education were more likely to be related to the PTSS (+) group. These results indicate that older adults, women, and those with lower socioeconomic status are disadvantaged after a major disaster and more susceptible to social and work maladjustments.
Limitations
The current study has several limitations. First, the sample was assessed with self-reported questionnaires, which could lead to recall biases. Accordingly, the time distance between disaster experience and our assessment (in some cases, up to 5 years) could interfere with the reliability of the results. Likewise, due to the nature of surveys, short scales were used, which could result in less accurate information and the dismissal of other important variables, such as psychiatric comorbidities, loss of family, and social support. Finally, no survey was performed “pre-disaster” in this population, so it is difficult to measure the outcomes caused by the disaster. Moreover, the cross-sectional study design may limit the interpretations of the causal role of PTSS in work and social dysfunction; however, a multivariable analysis was performed to compensate for this limitation. Further research must be performed considering all these limitations to improve the consistency of the outcomes.
Conclusions
This research demonstrates the importance of considering PTSS in post-disaster assistance management. According to our results, individuals who present PTSS criteria after a disaster have worse social and work adjustments than those who present with physical illnesses. Considering that the global incidence of natural and human-made disasters remains persistently high and the importance of effective medical response, it is important to start focusing on PTSS presence in these victims.
Our results contribute by providing empirical evidence to identify the association between PTSS and related variables, as well as psychological interventions and mental health promotions necessary to improve disaster management effectiveness. Therefore, psychological support programs, including early screening and proper management of PTSS, could minimize social and work maladaptation after disasters.
Acknowledgments
This research was supported by the Establishment of Relief Services for Disaster Victims, National Disaster Management Research Institute, Republic of Korea. The support of this study by the National Center for Disaster and Trauma is also gratefully acknowledged.
