Haiti and the Earthquake

Abstract

For approximately 35 seconds on January 10, 2010, an earthquake measuring 7.0 on the Richter scale struck the small Caribbean nation of Haiti. This research used a preexperimental one-shot posttest to examine the incidence of posttraumatic stress disorder (PTSD) and associated trauma symptomatology from the earthquake experienced by a sample of adult Haitians who were living in temporary shelters located in “tent cities” in Port-au-Prince and a comparative group of displaced individuals who left the capital city and took up residence in the northern rural town of Terrier Rouge. Sixty-five (N-65) participants completed the Impact of Events Scale–Revised (IES-R) to assess the severity of trauma symptomology in the study groups. Data presented are comparisons between the groups on total IES-R scores and the measure subscales for intrusion, avoidance, and hyperarousal. Based on the scores on the measure for the comparison groups 4 months after the earthquake, the findings suggests that all participants in the study exceeded the threshold of an acute stress disorder and most likely experienced PTSD. Implications of using the data in future longitudinal studies on trauma in Haiti are also discussed.

Keywords

international field of practice mental health trauma

For approximately 35 seconds on January 10, 2010, an earthquake measuring 7.0 on the Richter scale struck the Caribbean nation of Haiti. The earthquake, which was the first in over 200 years, devastated and crippled the small underdeveloped country. Indeed, even before this disaster, Haiti was considered by most measures as being the poorest nation in the Western hemisphere. Although it is estimated that 76% of the population survives on less than US$2 a day, more than half (54%) lives in extreme poverty, living on less than US$1 a day (Taft-Morales & Drummer, 2007). In addition, 81% of the national population does not receive the minimum daily ration of food as defined by the World Health Organization (2010). In the simplest terms, 75% of Haitians are poor and over half, 4.5 million persons, are extremely poor (Taft-Morales & Drummer, 2007).

The impact of the earthquake socially, psychologically, and economically cannot be overstated. Although the tragedy affected the entire country of approximately 9 million persons, it is estimated that 25% of the national population was directly affected by the disaster. The majority of the devastation occurred in the capital city of Port-au-Prince, where approximately 300,000 people perished and over 2 million of its residents were displaced and left homeless (Haitian Conference, 2010). Moreover, it is estimated that 1.3 million people living in Port-au-Prince resided in temporary shelters or “tent” cities located throughout the city, while 600,000 of its residents fled to the rural areas of the country (Haitian Conference, 2010). Throughout the city, basic services including potable water, sanitation, and access to basic health care became woefully inadequate.

The purpose of the present study was to examine the psychological stress and emotional trauma experienced by residents of Haiti as a result of the earthquake. Specifically, this research examined the incidence of posttraumatic stress disorder (PTSD) and the associated trauma symptomatology experienced in a sample of individuals who resided in temporary shelters located in “tent cities” in Port-au-Prince and a comparative group of displaced individuals who left the capital city and took up residence in the northern rural town of Terrier Rouge. In addition, a secondary and longitudinal goal of the research activity was to use the data currently reported on as a baseline, which will be used as basis of comparison in future studies examining the long-term psychological effects and trauma associated with the earthquake.

Review of the Literature

Previous studies examining natural disasters suggest that earthquakes, which occur suddenly and often without warning, have serious economic and psychological effects on individuals and communities. Survivors of such disasters are faced with tremendous losses including the loss of personal and material possessions, the loss of social support systems and community resources, the loss of a community as well as the grief and loss associated with those loved ones who were either injured or perished (Madianos & Evi, 2010).

It is speculated that the emotional stress associated with such losses often exceeds an individual’s ability to cope. The overwhelming state of shock and grief along with the accumulation of these losses is known to create severe traumatic experiences that result in individual’s presenting symptoms of PTSD. Likewise, PTSD is one of the most common mental health outcomes after such disasters (Norris et al., 2002). In addition, a limited number of studies have empirically validated that exposure to natural disasters, like an earthquake, places individuals at risk for the development of PTSD (Galea, Nandi, & Vlahov, 2005). PTSD is characterized by the development of intrusion, avoidance, and hyperarousal symptoms following exposure to an extreme traumatic stressor (American Psychiatric Association, 2000). The occurrence of PTSD symptoms in individuals after natural disasters, particularly earthquakes, is documented within the literature.

In a review examining the psychological repercussions of earthquakes, Madianos and Evi (2010) evaluated the findings of 12 studies in four cities in Greece over the past 40 years. The authors discovered the large majority of survivors in all studies reviewed were found to have developed high levels of symptoms of PTSD. Wang et al. (2009) explored trauma symptomatology in Chinese survivors 3 months after the Sichuan earthquake that killed almost 70,000 people on May 12, 2008. These researchers also found the prevalence of PTSD to be almost 40% in a sample of individuals previously inhabitants of a town that was not only completely destroyed by the earthquake but where more than half of the residents perished. Similar studies have reported rates of PTSD in earthquake survivors, ranging from 23% to 60% (Cairo et al., 2010).

Likewise, studies have explored the mental health effects of natural disasters in the United States (Acierno et al., 2007; Mcmillen, North, & Smith, 2000; Weems et al., 2010), European countries (Altindag, Ozen, & Sir, 2005; Dekkers, Olff, & Naring, 2010; Madianos & Evi, 2010), Asian countries (Kun, Han, Chen, & Yao, 2009; Wang et al., 2009), and South America (Cairo, et al. 2010). However, little has been done to examine the effects of similar disasters on those living in countries located in the Caribbean. Individuals residing in poor developing nations, such as Haiti, are particularly vulnerable to the development of psychological distress and more likely to be adversely affected by such a natural disaster. Those nations with long-standing conditions of poverty including inadequate mental health care services suggest that recovering from the psychological stress and trauma associated with such disasters would be extremely difficult.

For example, a recent study found that in countries with similar infrastructure and human service deficiencies such as Haiti, natural disasters affect twice as many people and cause three times more deaths than similar events in other more affluent countries (Cairo et al., 2010). As well, susceptibility to PTSD has been demonstrated in bereaved individuals and those displaced by a disaster (Chen, Tan, & Liao, 1999; Kuo et al., 2003). Additionally, ethnic minorities (Wang et al., 2009) and individuals with a lower levels of educational attainment (Chou et al., 2007; Kilic et al., 2006) have been found to be more vulnerable to the development of PTSD after an earthquake.

Method

Procedures

The present study used a preexperimental, one-shot posttest design to examine the emotional and psychological stress in a sample of 65 (N = 65) Haitian individuals who experienced the earthquake on January 10, 2010 (Cook & Campbell, 1979). In early May 2010, approximately 4 months after the tragedy, the researchers traveled to Haiti. Accompanied by a guide and interpreter, they spent 2 days in Port-au-Prince and 5 days in the rural town of Terrier Rouge where they identified individuals to participate in the study. Those Haitians who volunteered as participants in the study completed a standardized brief measure of trauma symptomology, which was translated into Creole. In addition, the participants were interviewed and responded to three open-ended items that included “where were you when the earthquake struck,” “where are you living now,” and “are you able to get the health care you need.” Demographic information on the study participants that included age, gender, and living location was also collected. All protocols and procedures used in the research investigation were approved by the Human Subjects Review Board of the University of Georgia, in April 2010.

Study Participants

Of the N-65 Haitian adults who participated in the research study, 30 resided in the capital city of Port-au-Prince and were living in a temporary shelter located in one of the tent cities. The remaining 35 participants were physically present in Port-au-Prince during the earthquake but were subsequently displaced and relocated to Terrier Rouge, a small town in Northeastern Haiti. The study sites were chosen by the researchers as a matter of convenience. The researchers have traveled to Haiti on a number of occasions and have conducted studies previously in both Port-au-Prince and Terrier Rouge. Terrier Rouge is located approximately 90 miles north of Port-auPrince between Cape Haitian and the border of the Dominican Republic. Also, more than 300 individuals from Port-au-Prince relocated to Terrier Rouge after the earthquake. All participants in the study were identified via a snowball sampling technique (Rubin & Babbie, 1993). Accompanied by a Haitian interpreter, the researchers randomly approached individuals in both locales seeking potential participants for the study. The researchers explained the purpose of the study to those interested individuals who were then asked whether they would volunteer to participate in the research and whether they knew of others who would be willing to do so as well.

The researchers were particularly concerned about the psychological welfare and vulnerability of a potential participant in the study; particularly those individuals residing in the “tent” cities. In order to avoid imposing any additional stress or anxiety an individual may have been experiencing by having them sign a consent form, their participation in the study was agreed to verbally. In addition, all participants understood that they would not receive any financial incentives or honorarium for their participation. Due to high rate of illiteracy in the country of Haiti, the items on the standardized measure as well as the open-ended questions were read to the participants by the interpreter and the responses were recorded verbatim by the researchers.

In identifying participants for the study, the researchers were purposeful in their attempt to seek a diverse sample of individuals. Summarily, although the study participants ranged in age from 18 to 66 years, the majority (82%) were between 18 and 45 years old. A little more than half (59%) were female, while the remaining 42% were male (see Table 1).

Table 1.
Sample Demographics (N-65).

N %

Gender

Male 27 41.5

Female 38 58.5

Age

18–25 23 35.4

26–35 18 27.7

36–45 12 18.5

46–55 6 9.2

56–66 5 7.7

Over 67 1 1.5

Measures

Trauma symptomatology was measured using the Impact of Events Scale–Revised (IES-R) (Weiss & Marma, 1997). The IES-R is a self-report, rapid assessment scale designed to measure the current distress from exposure to a specific life event. The instrument corresponds with the symptom clusters delineated in the Diagnostic and Statistical Manual of Mental Disorders (Fourth Edition, Text Revision) for PTSD (American Psychiatric Association, 2000). The defining features of PSTD are a cluster of characteristic symptoms that are present following the exposure to, or knowledge of, an extreme traumatic event that involves actual or threatened violent death or serious injury to one’s self, family member, or close associate (American Psychiatric Association, 2000). In addition, the individual’s response to the event involves feelings of intense fear, helplessness, and horror, which results in clinically significant impairment and distress. The IES-R contains 22 items that comprise three subscales related to the symptom clusters of PTSD described earlier, intrusion, avoidance, and hyperarousal. Of the 22 items, 7 measure intrusive symptoms such as intrusive thoughts, nightmares, feelings, and imagery associated with an event, while 8 items assess related symptoms of avoidance such as numbing of responsiveness, avoidance of feelings, situations, and ideas. The final 7 subscale items measure symptoms of hyperarousal such as anger, irritability, heightened startle response, difficulty concentrating, and hypervigilance as well as reexperiencing the event in flashbacks.

Respondents are asked to rate each item on a Likert-type scale of 0 (not at all), 1 (a little bit), 2 (moderately), 3 (quite a bit), and 4 (extremely) according to how they had experienced a symptom related to the event, in past 7 days. Examples of scale items include, “I felt irritable and angry,” “I tried not to think about it,” “Pictures about it popped into my mind,” and “I felt as if it hadn’t happened or wasn’t real.” Responses to the 22 items on the IES-R are summed, which has a total scale score range of 0–88. Reportedly, individuals with IES-R scores greater than 24 have been shown to have clinically significant symptoms of PTSD (Askai et al, 2002; Derluyn, Broekaert, Schuyten, & Temmerman, 2004). The internal consistency of the IES-R and its subscales are well established in various study samples and is purported to be good, with Cronbach’s α scores ranging from .79 to .92 (Weiss & Marmar, 1997).

Due to the fact that the study was being conducted in Haiti, an English version of the IES-R and open-ended questions were translated into the native language of the country, Creole. Prior to the collection of data, both the measure items and questions were examined by a number of Haitian professionals who provided cultural suggestions to ensure that the IES-R would be interpreted correctly by the study participants. Noteworthy, the translated version of the IES-R used in the study also demonstrated good internal consistency for the total scale (α = .85) as well as the intrusion (α = .73), avoidance (α = .61), and hyperarousal (α = .74) subscales.

Data Analysis

Analyses of the data were conducted using SPSS Version 17. Univariate descriptive statistics and tests for strength of association were used to examine demographics variables, subgroup comparisons, and rates of PTSD symptomatology based on IES-R scale scores. In addition, tests of mean differences and analysis of the variance examined the total IES-R scale and subscale scores to assess the variations in PTSD symptomology between the participant study groups from Port-au-Prince and Terrier Rouge locales.

Results

An initial examination of the data revealed that even 4 months after the earthquake, the degree of traumatic stress experienced by many Haitians continued to be clinically significant and chronic, with measured scores well above the 24-point threshold for symptoms of PTSD. The mean IES-R score for the 65 participants as a whole was 52.74 (SD = 15.05), suggesting that those individuals sampled at the time of the assessment were experiencing clinically high levels of PTSD. In addition, there were no significant differences in IES-R scores based on the participants’ gender or age. Although the mean subscale scores on the IES-R for the study participants varied slightly, the most frequently reported symptoms were those in the hyperarousal cluster followed by symptoms in the intrusion cluster. For the total sample of participants, the mean IES-R subscale scores were as follows: intrusion M = 21.21 (SD = 6.67), hyperarousal M = 16.32 (SD = 5.88), and avoidance M = 15.15 (SD = 5.63), as indicated in Table 1.

Interestingly, the data revealed a statistically significant difference in the total scores on the IES-R as well as its subscales between participants in the study living in Port-au-Prince and those residing in Terrier Rouge. Those individuals residing in Terrier Rouge had significantly higher total scores on the IES-R (M = 61.69, SD = 8.47) when compared to the scores for the individuals in the group from Port-au-Prince (M = 42.3, SD = 14.37), t(45) = −6.47, p < .001. Table 2 presents the data comparisons on the total and subscale scores for the IES-R between the study groups from Port-au-Prince and Terrier Rouge.

Table 2.
IES-R Sample and Port-au-Prince and Terrier Rouge Group Comparison Scores.

Total Sample (N-65) Port-au-Prince (N-30) Terrier Rouge (N-35) Group Comparison

M SD M SD M SD t(df)

IES-R total 52.74* 15.05 42.3* 14.36 61.69* 8.47 −6.47(45)

Intrusion 21.21 6.68 16.97 6.16 24.85 4.69 −5.86(63)

Avoidance 15.15 5.63 10.87 5.08 18.83 2.76 −7.63(43)

Hyperarousal 16.32 5.88 14.43 6.70 17.94 4.56 .2.42(50)*

Note. df = degrees of freedom; IES-R = Impact of Events Scale–Revised; PTSD = posttraumatic stress disorder; SD = standard deviation.

p < .05. p < .001. Score exceeds clinically significant cutoff criteria (24) for symptoms of PTSD.

Likewise, comparisons in the data for the scores on the IES-R subscales between the groups revealed similar statistical differences. Study participants in the group from Terrier Rouge scored significantly higher on all three of the IES-R subscales when compared to the individuals residing in Port-au-Prince and are reported as follows. In a comparison of the mean scores for the intrusion subscale, the scores for the group from Terrier Rouge were higher (M = 24.86, SD = 4.69), when compared to the scores from the participants from Port-au-Prince (M = 16.97, SD = 6.16), with the difference being statistically significant, t(63) = −5.86, p < .001. The scores for the avoidance subscale were similarly higher for the Terrier Rouge group (M = 18.83, SD = 2.76), when compared to the scores for the participants from Port-au-Prince (M = 10.87, SD = 5.08), with the difference also being statistically significant, t(43) = −7.63, p < .001. Finally, the analysis of the scores for the comparison groups on the IES-R hyperarousal subscale was also found to be statistically significant. The mean hyperarousal subscale score for the group from Terrier Rouge was M-17.94 (SD-4.56), when compared to the scores for the participants from Port-au-Prince, M-14.43 (SD-6.7), which also indicated a significant difference, t(50) = −2.42, p < .05.

To lend a contextual frame of reference to the quantitative data, the study participants responded to three open-ended questions asking them to describe where they were during the earthquake, where they were living, and whether they could get health care. When the earthquake struck, most of the participants indicated that they were in some building, either at work or at home, while others indicated that they were riding in cars or walking on the street. Responses from the participants varied, when asked to describe where they were living 4 months after the earthquake. For example, some individuals stated they were living in places such as a “tent city,” “the street,” “under a tree,” or “wherever I can.” Finally, access to health care was identified as a significant problem, as the overwhelming majority of study participants indicated that they have little or no access to health care services.

Although anecdotal, comments from the participants varied that highlighting the stress and psychological trauma that many experienced. Many of the statements came as no surprise, considering the daily reminders of the disaster that remains. For example, with the many buildings in Port-au-Prince still standing but damaged beyond repair and abandoned 4 months post-earthquake, many expressed a constant fear of going into concrete buildings. Other individuals presented symptoms of heightened anxiety that were spiritual in nature by describing beliefs that they had been punished by God.

Discussion

This research examined the incidence of PTSD and associated trauma symptomatology experienced by Haitian adults who survived the earthquake that occurred on January 10, 2010. Participants in the study included 30 individuals who were currently living in temporary shelters located in tent cities in the capital city of Port-au-Prince, and a comparative group of 35 individuals who were initially displaced by the earthquake and took up residence in the northern rural town of Terrier Rouge. Participants in the study completed a brief measure of PTSD and trauma symptomology as well as responding to open-ended survey items. Analysis of the data examined mean scores on the measure for the total sample and between the two comparison groups.

It was not surprising that the data suggested that all the individuals who participated in the study experienced clinical and chronic symptoms of PTSD. Although IES-R is a rather nonrobust scale used to diagnose PTSD, the severity of the reported scores after 4 months suggests that the individuals who participated in the study are passed the threshold of an acute stress disorder and are most likely experiencing PTSD. In addition, although the scores on the IES-R indicated the pervasiveness of PTSD was high among the study participants and may be interpreted at face value, these results may also suggest a contagion effect of the trauma symptomology within the study population as a group overall. This seems reasonable particularly in Port-au-Prince, where the tent cities host large numbers of individuals (hundreds and thousands) who live in extremely close proximity to one another, in primitive temporary shelters.

Although no differences were found in the data between the age and gender of the participants for the measures, variations in the scores on the IES-R for the comparison groups from Port-au-Prince and Terrier Rouge were notable. As indicated in Table 2, the participants in the study group from Terrier Rouge had significantly higher total IES-R scale scores and higher scores for all three of the measure subscales, intrusion, avoidance, and hyperarousal.

Differences in the scores between the comparison groups suggest a number of conclusions. For example, the differences in the scores for the individuals in the respective groups by locale may indicate that being with others who have shared a similar traumatic experience may be more important than typical supportive networks of individuals who may not share the same understanding. Those individuals residing in Port-au-Prince may have more opportunities to debrief their traumatic experiences with one another, while those from the group who were displaced and took up residence in Terrier Rouge were perhaps reluctant to discuss their experiences with local residents and individuals who were not directly affected by the disaster.

Noteworthy, one of the most significant differences between the mean IES-R scores for the comparison groups was on the intrusion subscale (see Table 2). One one hand, those individuals in Port-au-Prince living in the tent cities are seemingly forced to confront their traumatic circumstances daily, when surrounded by the rubble and destruction that serve as constant reminders of the disaster. Conversely, those individuals who were displaced and now residing in Terrier Rouge are confronted with constantly thinking about the unpleasant memories of the traumatic event, causing an increase in their symptoms of intrusion. In other words, although the earthquakes devastation was out of sight, it was not out of mind. This was an unexpected finding as we assumed, because of the location, that those residing in Port-au-Price would demonstrate more symptoms of trauma than those in the group living in Terrier Rouge.

The context of how and when the research was conducted is important to mention. The research activity and the collection of data were conducted under considerable time constraints in conditions that were less than desirable. The extent of the devastation from the earthquake after just 4 months was overwhelming and would be analogous to examining the effects of a forest fire, while the fire is still burning. Arguably, long after the earthquake, the remains of the disaster (e.g., rubble and abandoned buildings) contribute significantly to the lingering and insidious symptoms of trauma.

Although this research found higher rates of PTSD than typically reported in other investigations on trauma, the small sample size in this research would preclude any broader generalization of the findings. In spite of the small sample size, however, this study is one of a few exploring the effects of trauma resulting from a natural disaster in the Caribbean and in the often overlooked country of Haiti. In addition, we hope that the data from this research may be a useful comparison in future studies on trauma in Haiti or perhaps other countries in the geographic region.

	N	%
Gender
Male	27	41.5
Female	38	58.5
Age
18–25	23	35.4
26–35	18	27.7
36–45	12	18.5
46–55	6	9.2
56–66	5	7.7
Over 67	1	1.5

	Total Sample (N-65)	Port-au-Prince (N-30)	Terrier Rouge (N-35)	Group Comparison
IES-R total	52.74***	15.05	42.3***	14.36	61.69***	8.47	−6.47(45)**
Intrusion	21.21	6.68	16.97	6.16	24.85	4.69	−5.86(63)**
Avoidance	15.15	5.63	10.87	5.08	18.83	2.76	−7.63(43)**
Hyperarousal	16.32	5.88	14.43	6.70	17.94	4.56	.2.42(50)*

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

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	Total Sample (N-65)		Port-au-Prince (N-30)		Terrier Rouge (N-35)		Group Comparison
	M	SD	M	SD	M	SD	t(df)
IES-R total	52.74***	15.05	42.3***	14.36	61.69***	8.47	−6.47(45)**
Intrusion	21.21	6.68	16.97	6.16	24.85	4.69	−5.86(63)**
Avoidance	15.15	5.63	10.87	5.08	18.83	2.76	−7.63(43)**
Hyperarousal	16.32	5.88	14.43	6.70	17.94	4.56	.2.42(50)*