Is family functioning a mediator in the relationship between the severity of exposure to the 2015 earthquake and PTSD symptoms among the children living in Kathmandy, Nepal?

Abstract

Background: Natural disasters provide a unique opportunity to study variations in children's responses to an acute stressor. There is evidence that substantial numbers of children in earthquake affected areas experience disaster related symptomatology lasting for one month and sometimes up to one year after the acute stressor event. Identifying the pre- and post-disaster factors influencing children's response to a natural disaster is essential for expanding the current understanding of children's responses towards traumatic events. A growing number of studies are now examining children's post-earthquake distress within the context of the family. Specifically, the family unit has been constantly linked with a wide range of outcomes among children. The impact of disasters such an earthquake among children may be best understood by examining the family context within which children interact. However, there is little known about the role of the family and their context in adverse situations. Psychosocial support provides resources to families to cope with adversity and may promote family resilience but the integrated role of social support with family function, stressors and stress reactions is largely unknown. The objectives of the study were therefore to estimate the prevalence of post-traumatic stress disorder (PTSD) symptoms among earthquake affected children and to explore the mediating role of family functioning in the effects of severity of exposure to the earthquake on PTSD symptoms of the children in the presence of psychosocial support. Methods: A community-based, cross-sectional study using a multi- stage cluster sampling technique was conducted in Kathmandu district of Nepal. Three out of six suburban municipalities and two out of five urban municipalities were randomly chosen. Among those selected municipalities 10 wards were selected by population proportionate to size. At the next stage, 20 households from each selected ward were randomly selected. Within these households all eligible children aged 7-16 years were selected. The total sample size was 800 children. The During and After Earthquake Exposure Questionnaire (DAEEQ), Family Assessment Device (FAD), Child PTSD Symptoms Scale (CPSS), and psychosocial support questionnaire were used to elicit data on severity of exposure to the earthquake, family functioning, PTSD symptoms and psychosocial support, respectively. Multi group structural equation modelling was used to explore the structural relationships between PTSD symptoms, family functioning and level of exposure to the earthquake. Results: Among the 800 children surveyed, three children had no symptoms of PTSD, 48.5% had mild PTSD symptoms and 51.1% had moderate to severe PTSD symptoms. Children going to lower secondary school (p=0.012), Muslim religion (p=0.008) and those with a low level of psychosocial support (p=0.003) had a higher prevalence of PTSD symptoms compared to their counterparts. Severity of exposure to the earthquake was positively associated with PTSD symptoms (B-0.24, p<0.01) among children receiving low psychosocial support. There was a negative association between severity of exposure to the earthquake and family dysfunction (B=-0.36, p<0.01) however family functioning had no association with PTSD symptoms. No significant indirect effect of family functioning was found on PTSD in the original sample but there was a significant indirect effect in the bootstrapped sample (95% CI -0.125, -0.112). Among children with high psychosocial support there was no significant association between severity of exposure with PTSD and family functioning. The indirect effect of family functioning with PTSD symptoms was not significant based on the original sample and the bootstrapped sample. However, family functioning was directly and positively associated with PTSD symptoms (B-0.17, p<0.01). Conclusion: About half of the study children had moderate to severe PTSD symptoms one year after the 2015 Kathmandu earthquake. Psychosocial support had a significant role on family functioning. A significant negative indirect effect of family functioning was found among the children receiving low social support. Enhancing the role of family functioning or fortifying effective family function in low social support areas may help to reduce the adverse mental outcomes among children. Psychosocial support should be considered while developing interventions for children affected by disasters.