p u b l i c h e a l t h x x x ( 2 0 1 4 ) 1 e8
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Resilience and quality of life among Wenchuan earthquake survivors: the mediating role of social support J. Xu*, L. Ou Uncertainty Decision-making Laboratory, Sichuan University, Chengdu 610064, PR China
article info
abstract
Article history:
Objectives: To examine the extent social support mediates resilience and quality of life in
Received 31 August 2012
Wenchuan earthquake survivors.
Received in revised form
Study design: Originals.
26 September 2013
Methods: Self-report psychological questionnaires, the standard Chinese 12-item Short
Accepted 4 March 2014
Form (SF-12v2), the Resilience Scale for Adults (RSA), and the Social Support Rating Scale
Available online xxx
(SSRS) were used to interview a total of 2080 survivors from 19 counties in the 2008 Wenchuan Earthquake area. A regression analysis was conducted to evaluate the medi-
Keywords:
ating effect of social support on quality of life.
Quality of life
Results: Males and individuals with a higher level of education were found to have a better
Resilience
quality of life. The association between resilience and quality of life improved after social
Social support
support was included, suggesting that at least a part of this association was mediated by
Mediation analysis
the level of social support provided.
Wenchuan earthquake
Conclusions: This analysis highlighted that the level of resilience and quality of life after an earthquake was associated with the level of social support. This result has clear policy implications, and indicates that more focus needs to be placed on policies that aim for the provision of early mental health intervention and social support to improve the quality of life of earthquake survivors. ª 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction It is widely acknowledged that earthquakes are one of the most devastating natural disasters in the world.1,2 Studies have shown that earthquakes can significantly impair the quality of life (QOL) of survivors.3e6 It has been reported that earthquake survivors who experienced the pain of losing relatives suffered increased psychological stress,7 and
earthquake survivors’ QOL scores in earthquake affected regions were significantly lower than the general population.8 Resilience research has recently focused on factors which can explain unexpected positive outcomes and which have the ability to buffer the negative effect of trauma.9e13 Recent evidence has suggested that resilience plays a positive role in improving well-being and promoting psychological growth in adverse circumstances.14,15 Resilience can be viewed as a defense mechanism, which enables people to thrive in the face
* Corresponding author. Tel.: þ86 28 85418522; fax: þ86 28 85415143. E-mail address: [email protected] (J. Xu). http://dx.doi.org/10.1016/j.puhe.2014.03.002 0033-3506/ª 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Xu J, Ou L, Resilience and quality of life among Wenchuan earthquake survivors: the mediating role of social support, Public Health (2014), http://dx.doi.org/10.1016/j.puhe.2014.03.002
2
p u b l i c h e a l t h x x x ( 2 0 1 4 ) 1 e8
of adversity and thus improving the possibility that resilience may be an important target for long-term mental health recovery.16e19 Being resilient indicates that individuals have the ability to rebound mentally following a disaster.20e22 Therefore, research has recommended that there needs to be a health security approach focused on developing disaster resilience among people living in high risk environments to improve general health and reduce the effect of disasters and other crises.23 Social support has been seen to be a potential mediator for an individual’s mental health24e28 as it appears to have a positive effect on the adjustment of survivors after an earthquake. Studies have indicated that social support may mitigate the negative impact of earthquakes on people’s wellbeing29,30 and buffer individuals from the negative effects of stress following a trauma.31 A higher level of social support has been associated with psychological benefits (including reduced depression, anxiety et al.) in earthquake survivors.32 Based on this association between resilience, social support and QOL, it was hypothesized that (1) resilience has an effect on the survivors’ QOL after an earthquake; (2) social support is an important factor for increased QOL, and operates as a mediator between resilience and QOL. In order to test these assumptions, a survey (n ¼ 2080) was conducted in severely affected counties in Sichuan and Shanxi Provinces, China, one year after the 2008 Wenchuan earthquake. This earthquake struck Wenchuan on May 12, 2008, at a magnitude of 8.0 on the Richter scale with a maximum intensity of 11 . According to the Ministry of Civil Affairs, the earthquake resulted in 69,227 deaths, left about 4.8 million people homeless, and affected 15 million people living in the area. Survivors reported significantly lower scores in the QOL assessment,3 which provided a suitable context for the implementation of this study. Therefore, the aim of this study was to explore the associations between resilience and QOL, and the possible mediating influence of social support.
Methods Sample and procedure A cross-sectional survey of 2080 participants was conducted from May to September 2009 in severely affected counties. The counties were Dujiangyan, Pengzhou, Chongzhou, Shifang, Mianzhu, Jiangyou, Anxian, Pingwu, Beichuan, Jiange, Qingchuan, Hanyuan, Wenchuan, Lixian, Maoxian, Songpan, Lueyang, Heishui, and Xiaojin. These counties were selected because they had suffered more extensive damage as a result of the earthquake than other counties in the region. The inclusion criteria were as follows e having a high degree of exposure to the earthquake and experiencing the complete process of the earthquake e with a fair distribution of sex, age and place. In order to acquire complete survey data in these relatively underdeveloped areas, some participants with a higher level of education were chosen as these participants would be able to make full sense of the questionnaire. However, survivors with a lower level of education accounted for almost 50% of the sample. For those respondents with literacy
problems, group members read the questionnaires to them and noted down the answers. Survey teams were temporarily established with each group made up of two graduate students and a staff of the local Branch of the Association for Science and Technology. The teams participated in a five-day training program conducted by five specialists both from our project and other institutions. Before conducting the formal investigation, initial evaluations were carried out in four counties to test and consequently adjust the original questionnaire. All assessment forms were translated from English to Chinese and back-translated by a bilingual team of professionals. From July to September 2009, the trained groups were assigned to counties based on a previously arranged schedule. To ensure data confidentiality, it was guaranteed that none of the participants’ information would be revealed. Some inhabitants declined to participate in the interview as they were wary of such earthquake surveys and wished to avoid talking about the event. If this were the case, the next closest inhabitant was invited. A total of 2300 individuals were initially involved in this survey but 44 individuals were excluded, 137 were rejected, and 39 did not complete the questionnaire. Thus, 2080 completed the questionnaire, a response rate of 90.4%. To ensure privacy, interviewers and participants were encouraged to complete the questionnaires in private. There was daily supervision throughout the survey. In addition, face-to-face interviews and telephone interviews were also adopted in the study. The study was designed in accordance with the tenets of the Declaration of Helsinki and approved by the ethics committee of Sichuan University. The investigation complied with the principle of voluntariness.
Demographic characteristics Basic demographic characteristics included age, gender, education level, monthly income, and ethnicity. Age was divided into five groups: 18e24 (coded as 1), 25e34 (coded as 2), 35e44 (coded as 3), 45e54 (coded as 4), and 55e65 (coded as 5). Gender was coded as 1 (male) and 2 (female). The level of education was coded as; 1 (no degree), 2 (Bachelors level), 3 (Masters level), and 4 (Doctoral level). Four monthly income levels were coded as; 1 ¼
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
Resilience and quality of life among Wenchuan earthquake survivors: the mediating role of social support J. Xu*, L. Ou Uncertainty Decision-making Laboratory, Sichuan University, Chengdu 610064, PR China
article info
abstract
Article history:
Objectives: To examine the extent social support mediates resilience and quality of life in
Received 31 August 2012
Wenchuan earthquake survivors.
Received in revised form
Study design: Originals.
26 September 2013
Methods: Self-report psychological questionnaires, the standard Chinese 12-item Short
Accepted 4 March 2014
Form (SF-12v2), the Resilience Scale for Adults (RSA), and the Social Support Rating Scale
Available online xxx
(SSRS) were used to interview a total of 2080 survivors from 19 counties in the 2008 Wenchuan Earthquake area. A regression analysis was conducted to evaluate the medi-
Keywords:
ating effect of social support on quality of life.
Quality of life
Results: Males and individuals with a higher level of education were found to have a better
Resilience
quality of life. The association between resilience and quality of life improved after social
Social support
support was included, suggesting that at least a part of this association was mediated by
Mediation analysis
the level of social support provided.
Wenchuan earthquake
Conclusions: This analysis highlighted that the level of resilience and quality of life after an earthquake was associated with the level of social support. This result has clear policy implications, and indicates that more focus needs to be placed on policies that aim for the provision of early mental health intervention and social support to improve the quality of life of earthquake survivors. ª 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction It is widely acknowledged that earthquakes are one of the most devastating natural disasters in the world.1,2 Studies have shown that earthquakes can significantly impair the quality of life (QOL) of survivors.3e6 It has been reported that earthquake survivors who experienced the pain of losing relatives suffered increased psychological stress,7 and
earthquake survivors’ QOL scores in earthquake affected regions were significantly lower than the general population.8 Resilience research has recently focused on factors which can explain unexpected positive outcomes and which have the ability to buffer the negative effect of trauma.9e13 Recent evidence has suggested that resilience plays a positive role in improving well-being and promoting psychological growth in adverse circumstances.14,15 Resilience can be viewed as a defense mechanism, which enables people to thrive in the face
* Corresponding author. Tel.: þ86 28 85418522; fax: þ86 28 85415143. E-mail address: [email protected] (J. Xu). http://dx.doi.org/10.1016/j.puhe.2014.03.002 0033-3506/ª 2014 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Please cite this article in press as: Xu J, Ou L, Resilience and quality of life among Wenchuan earthquake survivors: the mediating role of social support, Public Health (2014), http://dx.doi.org/10.1016/j.puhe.2014.03.002
2
p u b l i c h e a l t h x x x ( 2 0 1 4 ) 1 e8
of adversity and thus improving the possibility that resilience may be an important target for long-term mental health recovery.16e19 Being resilient indicates that individuals have the ability to rebound mentally following a disaster.20e22 Therefore, research has recommended that there needs to be a health security approach focused on developing disaster resilience among people living in high risk environments to improve general health and reduce the effect of disasters and other crises.23 Social support has been seen to be a potential mediator for an individual’s mental health24e28 as it appears to have a positive effect on the adjustment of survivors after an earthquake. Studies have indicated that social support may mitigate the negative impact of earthquakes on people’s wellbeing29,30 and buffer individuals from the negative effects of stress following a trauma.31 A higher level of social support has been associated with psychological benefits (including reduced depression, anxiety et al.) in earthquake survivors.32 Based on this association between resilience, social support and QOL, it was hypothesized that (1) resilience has an effect on the survivors’ QOL after an earthquake; (2) social support is an important factor for increased QOL, and operates as a mediator between resilience and QOL. In order to test these assumptions, a survey (n ¼ 2080) was conducted in severely affected counties in Sichuan and Shanxi Provinces, China, one year after the 2008 Wenchuan earthquake. This earthquake struck Wenchuan on May 12, 2008, at a magnitude of 8.0 on the Richter scale with a maximum intensity of 11 . According to the Ministry of Civil Affairs, the earthquake resulted in 69,227 deaths, left about 4.8 million people homeless, and affected 15 million people living in the area. Survivors reported significantly lower scores in the QOL assessment,3 which provided a suitable context for the implementation of this study. Therefore, the aim of this study was to explore the associations between resilience and QOL, and the possible mediating influence of social support.
Methods Sample and procedure A cross-sectional survey of 2080 participants was conducted from May to September 2009 in severely affected counties. The counties were Dujiangyan, Pengzhou, Chongzhou, Shifang, Mianzhu, Jiangyou, Anxian, Pingwu, Beichuan, Jiange, Qingchuan, Hanyuan, Wenchuan, Lixian, Maoxian, Songpan, Lueyang, Heishui, and Xiaojin. These counties were selected because they had suffered more extensive damage as a result of the earthquake than other counties in the region. The inclusion criteria were as follows e having a high degree of exposure to the earthquake and experiencing the complete process of the earthquake e with a fair distribution of sex, age and place. In order to acquire complete survey data in these relatively underdeveloped areas, some participants with a higher level of education were chosen as these participants would be able to make full sense of the questionnaire. However, survivors with a lower level of education accounted for almost 50% of the sample. For those respondents with literacy
problems, group members read the questionnaires to them and noted down the answers. Survey teams were temporarily established with each group made up of two graduate students and a staff of the local Branch of the Association for Science and Technology. The teams participated in a five-day training program conducted by five specialists both from our project and other institutions. Before conducting the formal investigation, initial evaluations were carried out in four counties to test and consequently adjust the original questionnaire. All assessment forms were translated from English to Chinese and back-translated by a bilingual team of professionals. From July to September 2009, the trained groups were assigned to counties based on a previously arranged schedule. To ensure data confidentiality, it was guaranteed that none of the participants’ information would be revealed. Some inhabitants declined to participate in the interview as they were wary of such earthquake surveys and wished to avoid talking about the event. If this were the case, the next closest inhabitant was invited. A total of 2300 individuals were initially involved in this survey but 44 individuals were excluded, 137 were rejected, and 39 did not complete the questionnaire. Thus, 2080 completed the questionnaire, a response rate of 90.4%. To ensure privacy, interviewers and participants were encouraged to complete the questionnaires in private. There was daily supervision throughout the survey. In addition, face-to-face interviews and telephone interviews were also adopted in the study. The study was designed in accordance with the tenets of the Declaration of Helsinki and approved by the ethics committee of Sichuan University. The investigation complied with the principle of voluntariness.
Demographic characteristics Basic demographic characteristics included age, gender, education level, monthly income, and ethnicity. Age was divided into five groups: 18e24 (coded as 1), 25e34 (coded as 2), 35e44 (coded as 3), 45e54 (coded as 4), and 55e65 (coded as 5). Gender was coded as 1 (male) and 2 (female). The level of education was coded as; 1 (no degree), 2 (Bachelors level), 3 (Masters level), and 4 (Doctoral level). Four monthly income levels were coded as; 1 ¼
