Religious Beliefs, PTSD, Depression and Resilience in Survivors of the 2010 Haiti Earthquake

Journal of Affective Disorders 190 (2016) 697–703

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Research report

Religious Beliefs, PTSD, Depression and Resilience in Survivors of the 2010 Haiti Earthquake Judite Blanc a,b,n, Guitele J. Rahill c, Stéphanie Laconi d, Yoram Mouchenik e a

Laboratory UTRPP, University of Paris, 13 Sorbonne Paris Cite, France State University of Haiti, Faculty of Humanities (UEH/FASCH)Avec Christophe, Impasse Le Hasard, Port-au-Prince, Haiti c School of Social Work College of Behavioral and Community Services University of South Florida, 13301 Bruce B. Downs, Blvd., MHC 1400, Tampa, FL, 336123807 United States d Psychopathology CERPP, EA-4156 University of Toulouse, 2 Jean Jaurès 5 Allées Antonio Machado, 31078 Toulouse, France e Transcultural Psychology, Laboratory UTRPP University of Paris, 13 Nord 99 Avenue Jean-Baptiste Clément, 93430 Villetaneuse, France b

art ic l e i nf o

a b s t r a c t

Article history: Received 7 August 2015 Received in revised form 12 October 2015 Accepted 16 October 2015 Available online 28 October 2015

Background: This study examines relationships between religious beliefs regarding the origin of the 2010 earthquake in Haiti and posttraumatic symptomatology as well as depressive symptoms and resilience among its survivors. Method: We used convenient sampling to recruit participants (n ¼ 167). They completed six scales, which had been translated into Haitian Creole, including measures such as the Earthquake Experiences Exposure (EEE), the Peritraumatic Distress Inventory (PDI), the Peritraumatic Dissociative Experience Questionnaire (PDEQ), the PTSD Checklist (PTSD-CL), the Beck Depression Inventory (BDI) and the Connor–Davidson Resilience Scale (CD- RISC) Results: Among our participants, 51% were male, (mean age¼30.5, SD ¼11.03), 92% (n ¼155) were believers in some sort of supernatural force and 65% (n ¼108) endorsed the earthquake as a natural phenomenon. There was significant difference in average scores at peritraumatic distress, PTSD symptoms and Resilience measures between those perceiving a divine origin and/or a punishment through the event and those who did not. Peritraumatic responses were best predictors for PTSD (β ¼.366, po .001) and Depression symptoms (β ¼.384, po .001). Voodoo adherents appeared to be vulnerable to depression, but reported superior resilience factors & 2015 Elsevier B.V. All rights reserved.

Keywords: Depression Haiti earthquake PTSD Religious beliefs Resilience

1. Introduction Several studies have highlighted a multitude of factors that are liable to influence the onset, severity and persistence of PostTraumatic Stress Disorders (PTSD) and depression among survivors of earthquakes. Among these factors are being female, age, previous psychological distress, traumatic exposure experienced during the event (Priebe et al., 2009; Qu et al., 2012; Tural et al., 2004; Zhang et al., 2011), proximity to the earthquake's epicenter (Dell’Osso et al., 2013), exposure to the memories of the earthquake (Goenjian et al., 2011; Najarian et al., 2011), and perceived social support (Altindag et al., 2005; Yu et al., 2010). Additional factors that have been linked to the experience of PTSD and depression in the aftermath of earthquakes include ethnicity and minority status (Kun et al., 2013; Xu and Song, 2011), human and material losses as a consequence of the event, post-traumatic n

Corresponding author. E-mail address: [email protected] (J. Blanc).

http://dx.doi.org/10.1016/j.jad.2015.10.046 0165-0327/& 2015 Elsevier B.V. All rights reserved.

adversities (Gigantesco et al., 2013), and spirituality and religiosity (Stratta et al., 2013). Moreover, the subjective negative interpretation of the disaster has also been identified as a risk factor for PTSD symptoms in children and adolescent survivors of an earthquake in Turkey (Hizli et al., 2009). Regarding the effect of subjective perception of a traumatic event such as an earthquake on the development of subsequent PTSD symptoms, the cognitive model of PTSD developed by Ehlers and Clark (2000) hypothesizes that patients who suffer from persistent PTSD may experience a variety of negative emotions that are contingent on their cognitive appraisal of the stressful incident. For example, self-statements such as “I attract trauma” or “I deserve that bad things happen to me” are likely to evoke or exacerbate subjective states of unease, anxiety or threat in the survivor. In addition, Ehlers and Clark (2000) underscored the key role that individual differences can play in the etiology of PTSD after a traumatic event. However, research on the psychological consequences of exposure to traumatogenic events such as earthquakes often limit their sample to the most at-risk survivors, to the exclusion of those who do not develop psychological

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disorders. The latter group has increasingly become a population of interest to researchers and clinicians who are interested in PTSD, depression and disasters. 1.1. Resilience, PTSD, depression and trauma There is a growing body of knowledge on resilience as a theoretical construct, but little consensus on how to operationally define the concept or on the optimal instrument to measure it. Still, scholars generally agree on the issue of resilience as a protective factor against trauma (Ahmad et al., 2010; Pietrzak et al., 2011). Early researchers on resilience focused on various factors, including the absence of psychiatric symptoms after a potentially traumatic event, coping strategies in reaction to a stressor, the level of self-esteem among survivors of trauma, the degree of perseverance and of perceived stress, and others (See for review Connor and Davidson, 2003). Resilience has been studied worldwide in various populations exposed to traumatic events, including in survivors of earthquakes (Karaırmak, 2010; Wang et al., 2010). For example, Pietrzak and colleagues examined potential links between psychological resilience (i.e., positive acceptance of change) and suicidal ideation in veterans of the American military. Psychological resilience was negatively related to veterans's contemplation of suicide, unless the individual screened positively for depression or PTSD in which case even post deployment social support did not diminish suicidal ideation (Pietrzak et al., 2011). 1.2. Religiosity/spirituality and resilience There is minimal agreement among researchers regarding how the concepts of religion, religiosity, and spirituality differ from each other. Despite this divergence, some authors view religion more as “institutionalized practices, beliefs, and authority structures linked to identifiable religious traditions” while others interchangeably describe religiosity and spirituality more in terms of “a personal quest for meaning, and experience of the transcendent, quasi-independent of institutionalized religion” (Day, 2010: 216). There is empirical evidence that some individuals who have experienced traumatic and stressful events try to face the adversity through the lenses of their religious beliefs (Chen and Koenig, 2006). Indeed, in a large population of adults and children exposed to the September 11th, 2001 attack of the World Trade Center of the United States, religious coping (prayer, religion, or spiritual feelings) was the second most cited (90%) way that adult survivors used to face trauma and stress-related symptoms (Schuster et al., 2001). Moreover, a close relationship was found between the level of spirituality (“belief in the sacredness of life, an interest in spirituality, search for meaning/purpose in life, discussions about the meaning of life with friends, thinking of spirituality as a source of joy, seeking out opportunities to help them grow spiritually”) and the ability of post-graduate Indian students to cope with stressors (Gnanaprakash, 2013). Beyond religiosity and spirituality, people impacted by trauma or adversity are more or less vulnerable to mental distress, and thus to PTSD, as indicated by the vulnerability-resilience model (Jakovljevic et al., 2012). Religious beliefs are central in the daily functioning of Haitian people, particularly in the area of government, socialization norms, and personal as well as communal well-being (World Health Organization, 2010). In the most recent national survey on mortality, morbidity and the use of health services (Enquête Mortalité, Morbidité et Utilisation des Services), Catholicism, inherited from early European settlers in Haiti, was the most frequently endorsed religious affiliation (39.1%). In contrast 53.1% comprised several other religions together, i.e., Protestants, Methodists, Adventists, and Jehovah’s Witnesses, and a mere 1% self-identified as voodoo adherents. (Cayemittes et al., 2013). The latter, voodoo,

transplanted to Haiti by former slaves whose traditional African beliefs and traditions persisted across the continents, has been consistently demonized since French colonization (Hurbon, 2005). Despite the adoption of western culture by a small portion of Haiti's population, the idea that a human being is a specific combination of “energy of all cosmic” prevails in Haitian existence and in the manner in which health and disease are conceptualized in Haitian culture. There is no separation in terms of organic and mental morbidity in Haitian culture. The concept of health implies a subjective “state of well-being” – of connection with the social environment that is connected with the non-human or physical environment (earth, plants, animals, air, strength of nature, etc.). The human environment comprises observable physical persons as well as ancestors and the spirits of humans who have transcended the physical world (invisible) as well as spiritual beings. In that context, disease is understood as a “state of discomfort” which can result, on the one hand from a conflict between different components of the self or of the “being”, or on the other hand from actions external to one's self, as in the case of action stemming from diverse environmental entities (Sterlin, 2006). Consequently, quickly after the unprecedented and devastating January 12, 2010 earthquake in Haiti which killed nearly 222,000 Haitians and displaced more than a million survivors in the capital of Port-au-Prince (United Nations, 2010), images of praying Haitians of various religions were splashed across media venues around the world (Llana, 2010). A survey conducted by O’Grady and colleagues (2012) in the aftermath of the earthquake among 104 adult survivors revealed “the majority of participants reported that their faith in a higher power increased following the trauma and that they felt a renewed interest in practicing their religion” (page 296). In the same context, there were reports of religious conflicts among Haitian believers from various sects and of violent animosity toward voodoo members whose beliefs and behaviors were purported to occasion the earthquake as divine retribution (Pierre-Pierre, 2010). Within months after the earthquake, estimates of PTSD symptomatology, associations between PTSD and resilience and between religious affiliation and practices were among variables measured in a sample of Christian university students in Haiti (Burnett and Helm, 2013). In that study, 34% of the sample (n ¼140) endorsed symptoms of PTSD, with females endorsing a greater number of PTSD symptoms than their male peers; Burnett and Helm (2013) also found that participants who endorsed more PTSD symptoms also reported less characteristics of being resilient. To our knowledge, no studies have added to knowledge regarding the types of relationships that exist between the religious perceptions that are prevalent among Haitians regarding the origin of the earthquake that instigated the conflicts against the minority Voodoo members, and mental health outcomes among survivors of the event. Thus, the goals of the present study were to: (1) examine the effect of religious beliefs on the interpretation of the origin of the 2010 Haiti earthquake two years after the disaster in a sample of adults from various religious backgrounds; (2) to explore potential links among survivors' religious beliefs, their peritraumatic responses and the severity of PTSD and depression symptoms; and (3) to evaluate associations of the aforementioned variables with survivors’ resilience.

2. Method This epidemiological cross-sectional study was conducted in April 2012 in a sample of 167 men and women in Port-au-Prince, one of the areas most affected by the 2010 earthquake. A Couple of days after the catastrophe, 19 million cubic meters of concrete and

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ruble littered the streets of this city; four thousand schools were damaged, 60% of state buildings and 80% of academic buildings were impacted. Most of the data were collected in a group setting, following delivery of information about the study and procurement of written or verbal (in case of preliteracy) consent to participate. This study was conducted in accordance with the 1989 revision of the Helsinki Declaration. 2.1. Participants Participants were recruited by the Primary author from local churches and schools in the west department of Haiti (Downtown Port-au-Prince, Canapé-Vert, two associations of Voodoo located in Bel-Air and Cité-Soleil and in suburbs and other adjacent regions of Port-au-Prince such as Pétion-ville, Delmas, Carrefour and Tabarre). Inclusion criteria were: males or females, aged 18 to 68 years old, who survived the earthquake of January 12, 2010 and who voluntarily read and signed the informed consent provided to them along with an accompanying information leaflet on the research project which was presented to them at the screening/ intake session. The exclusion criteria were: lack of mastery of one of the two official languages (Creole, French), and untreated pathologies that prevented voluntary, willful participation (major behavior disorders: agitation, delirium, straight verbal and/or physical aggressiveness). Other exclusion criteria included refusal to participate and not having been in Haiti at the time of the earthquake in January 2010. A final sample of 171 people took part in the study; four of them were not included in the final analysis because of missing data. The sample consisted of 86 men (51.5%) and 81 women (48.5%). The average age was 30 years and 6 months (SD ¼11.03), 79 (47.9%) participants reported having a university level, 29 (17.4%) were small business owners. Besides, 104 (52.3%) were single, 23 (11.6%) married and 29 (14.6%) in common-law relationships. 2.2. Procedure Due to the illiteracy problem in Haiti, questionnaires were administered collectively with the help of a dozen undergraduate level psychology professionals working at the “Centre de Psychotrauma de l’Unité de Recherche et d’Action Médico-Légale” (Psychotrauma Center of the Unit for Medical and Legal Action). Participant contamination of answers was minimized by insuring that individuals were sitting far enough apart that others could not see their responses. These professionals were experienced in psychological assessment and trained in human rights protection by the Unit for Medical and Legal Action. They received one-day training for the purpose of this study. The psychologist who coordinated the study previously translated the questionnaires into Haitian Creole and then the translation was edited and reviewed by the interviewers during training. In addition, under the supervision of the author of the CD-RISC, a bilingual health professional backtranslated the Creole version of this tool in English before the data collection. Inclusion criteria were verified during screening visits and at the time of questionnaire distribution prior to data collection.

699

2.4. Religious beliefs about the origin of the earthquake After the earthquake, Voodoo adherents and practitioners were scapegoated by many as being responsible for the occurrence of the earthquake, because of perceptions of inherent conflicts between their beliefs and practices and those prescribed by the Christian Bible. Thus, questions about the religious affiliation of participants and about their perception of the origin of the earthquake were added at the end of the questionnaire in order to assess their current understanding of the origin of the disaster. 2.5. Earthquake exposure experience The Earthquake Experience Questionnaire (EEQ) (Hizli et al., 2009) was administered to assess the degree of exposure to traumatic experiences during the earthquake. Composed of 54 items, it includes sections on objective and subjective experiences, losses, traumatic memories experienced, and changes in the living conditions of the individual as a consequence of the event. Traumatic factors including being trapped under the rubble, injuries, or participation in rescue efforts, material loss or loved one's death, for example, were reported as dichotomous yes/no variables. 2.6. Peritraumatic responses Peritraumatic dissociation was assessed with the Peritraumatic Dissociative Experiences Questionnaire (PDEQ) (Marmar et al., 2007), which is a self-administered 10-item questionnaire that measures the intensity of dissociative experiences observed during a traumatic event (e.g., “I had moments of losing track of what was going on”). Each item is rated on a 5-point scale, from 1¼ not true at all to 5 ¼extremely true. The total score vary between 10 and 50. The higher the score, the higher is the intensity of dissociation. A total score Z22 distinguishes those with a clinically significant peritraumatic dissociation from those who do not suffer from PD (Birmes et al., 2001). The PDEQ has been validated in several languages and has good convergent validity, as well as test–retest reliability and internal consistency (Birmes et al., 2005; Marmar et al., 2007). Peritraumatic distress was assessed using the 13-item self-report Peritraumatic Distress Inventory (PDI) (Brunet et al., 2001). Each item is rated on a Likert scale ranging from 0 ¼not at all to 4 ¼extremely true, with a total score ranging from 0 to 52. Higher scores indicate increased peritraumatic distress. In the present work, we used the cut off score of 13. 2.7. PTSD symptoms The PTSD Checklist Specific- (PCL-S) (Weathers et al., 1993) was used to assess PTSD symptoms in relation with the earthquake. Respondents were asked to rate each of the 17 DSM-IV-TR PTSD symptoms in the past month using 5-point Likert scale, ranging from 1 ¼not at all to 5 ¼extremely. A total symptom severity score (from 17 to 85) is obtained by summing the scores from each item. For the present study, we used a cut-off of 45 to indicate probable PTSD (Blanchard et al., 1996). The Cronbach's alpha of the Creole version of the PCL-S was 0.88 in our sample.

2.3. Socio-demographic questionnaires

2.8. Symptoms of depression

The socio-demographic questionnaires used in our study are based on the type of questionnaires employed by organizations that provide support to victims in the aftermath of traumatic events. The different sections assess the socio-demographic characteristics (marital status, education, etc.), and living conditions before and after the disaster or psychological support available.

To assess symptoms of depression, we administered the second edition and revision of the Beck Depression Inventory (BDI-II) (Bouvard and Cottraux, 2010), one of the most commonly used scales to evaluate depressive symptoms, such as feelings of sadness, ability to experience pleasure, pessimism, and other cognitive and affective states. The BDI consists of 21 statements and

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their total score reflects the severity of depressed mood. Each item is scored from 0 ¼absent to 3 ¼severe. Scores higher than 27 indicate a significant depressive symptomology. This cutoff score has been used in the present study. 2.9. Resilience factors Translated into several languages, the Connor–Davidson Resilience Scale (CD-RISC) is increasingly used internationally in evaluating resilience in relation to intense stressors within and across populations. It includes 25 items (e.g., “I can adapt to change”) rated on a 5-point Likert scale ranging from 0¼not at all to 4¼almost always. Participants endorse items from the previous month, or how he/she would react in a given situation. The total score ranges from 0 to 100, and a higher score reflects high resilience factor. The instrument has good psychometric properties, the validation study of the original version included five specific groups based on their average scores in the United States: current Population (80.7), patients seen in primary care (71.8), users of outpatient psychiatric care (68.0), participants with generalized anxiety disorder (62.4), and two groups of patients with PTSD (47.8 and 52.8) (Connor and Davidson, 2003). In the present work, we used the cut off score of 80 that reflects the average from current population reported by Connor and Davidson (2003). 2.10. Statistical analyses Statistical analyzes were performed using the 22th version of the Statistical Package for the Social Sciences (SPSS 22s, IBM). The Kolmogorov–Smirnov scores on the PDI, PDEQ, PCL-S, BDI-II and CD-RISC were not significant, thus it was possible to perform parametric tests with the data. We used descriptive statistics to present the sociodemographic characteristics of the group. Then, we used Student's t-test, kruskal Wallis test Pearson correlation matrices to explore bivariate association between socio-demographic characteristics, peritraumatic responses, religious beliefs, resilience factors with PTSD and Depression. Then, multiple regression analyses were performed to examine multivariate association among religious beliefs, peritraumatic responses, resilience factors and psychopathology. Statistical significance was set at p ¼0.05, the confidence interval at 95%.

3. Results 3.1. Descriptive statistics The sample consisted of 86 men (51.5%) and 81 women (48.5%), the average age was 30 years and 6 months (SD ¼11.03), 79 (47.9%) participants reported having a university level qualification, 29 (17.4%) were small business owners. Besides, 104 (52.3%) were single, 23 (11.6%) married and 29 (14.6%) in common-law relationships. 3.2. Traumatic exposure during the earthquake Among the participants, 18 (10.8%) reported having been under rubble on January 12, 2010, 132 (79%) had family members or friends who were trapped under the rubble, 151 (90.4%) reported having seen people seriously injured, 125 (74.9%) had relatives seriously injured, 73 (43.7%) participated in relief operations for victims and survivors, 153 (91.6%) had seen bodies of deceased persons, and 190 (83.8%) endorsed having heard of the death of loved ones, or having been seriously injured in the event.

Table 1 Average score for peritraumatic responses; trauma related psychopathology and resilience (N ¼167). Variables

Mean (SD)

Cut-off scores

Age PDI peritraumatic distress PDEQ peritraumatic dissociation PCL-S PTSD symptoms BDI-II depression symptoms CD-RISC resilience factors

30.6 (11.03) 22.59 (10.23) 13

Above ¼n (%) Below¼ n (%) 31 (18.6) 136 (81.4)

24.75 (8.88)

r 22

103 (61.7)

64 (38.3)

41.07 (14.34) 15.37 (12.17)

r 45 27

72(43.1) 33 (19.8)

95 (56.9) 134 (80.2)

47 (28.1)

120 (71.9)

66.46 (18.39) 80

Note. PDI¼ peritraumatic distress inventory; PDEQ ¼ peritraumatic dissociative experiences questionnaire; PCL-S ¼PTSD checklist-specific; BDI ¼beck depression inventory; CD-RISC ¼ Connor–Davidson resilience scale.

3.3. Religious beliefs and interpretation of the origin of the earthquake A total of 155 (92.8%) of the participants believed in the existence of God; 51 (30.5%) claimed to be Catholic, 34 (20.4%) Baptists and 38 (22.8%) Voodoo practitioners. For 108 (64.7%) participants, the earthquake was perceived as a natural phenomenon, while 39 (23.4%) reported not knowing the origin, and 15 (9%) ascribed a divine origin to the earthquake. As Table 1 illustrates, most participants had clinically significant levels of peritraumatic dissociation, as indicated by a mean score above 22 on the PDEQ. The majority of participants, 27 months after the event obtained scores of higher than 44 on the PCL-S, suggesting a severe intensity of PTSD symptoms. 3.4. Comparison between religious affiliation, peritraumatic responses, psychopathology and resilience Table 2 indicates significant statistical difference between male and female scores regarding peritraumatic responses (p¼ .004) and their current PTSD symptoms (p ¼.000). There was no link noted between subjects who received psychological support and their counterparts who did not for resilience factors (p ¼.633). With respect to mean scores of the population based on their religious affiliation, the level of peritraumatic dissociation, (p ¼.003), depression symptoms (p¼ .000), and resilience factors (p ¼.021) were higher among voodoo adherents. Finally, average scores for those perceiving a divine origin or a punishment through the event, were superior at peritraumatic distress, PTSD symptoms and Resilience measures. Table 3 shows significant and moderate positive correlations between peritraumatic responses (distress and dissociation) and symptoms of PTSD and depression. The symptoms of PTSD correlated positively with depression. Weak correlations were observed among age, peritraumatic reactions, depression and resilience factors. To explore the nature and strength of the relationship between religious beliefs peritraumatic responses and symptoms of PTSD and Depression, multiple linear regressions were performed. In both models of regression analysis of PTSD and depression, Religious affiliation, Earthquake's origin belief, Peritraumatic Distress, Peritraumatic Dissociation, Resilience factors were included at the same time. Results are summarized in Table 4. In model 1, Peritraumatic Distress was the best predictor for PTSD symptoms (β ¼ .366, p o.001) before religious affiliation (β ¼.155, p o.001) and peritraumatic dissociation (β ¼.221, p o.001). All the independent variables are included, together they accounted for

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701

Table 2 Comparison of subjects mean scores based on socio-demographic status, psychological support received and religious affiliation (N ¼ 167). Variables

PDI

p

PDEQ

p

PCL-S

p

BDI

p

CD-RISC

p

Sex M F Work Yes No Psychological support received Yes No Religion Catholic Protestant & others Voodoo Non- believers Voodoo member Yes No God responsible for the event Yes No Event was punishment Yes No

(n; mean; SD) (86; 20.4; 9.8) (81; 24.9; 10.19)

.004

(n, mean, SD) (86; 26.2; 8.5) (81; 26.3; 9.0)

.024

(n; mean; SD) (86; 37,2; 12,9) (81; 45.1; 14.6)

.000

(n; mean; SD) (86; 14.3; 11.9) (81; 16.5; 12.3)

.243

(n, mean, SD) (86; 67.0; 18.1) (80, 65.8; 18.7)

.670

.129 (28; 25.1; 11.2) (135; 21.9; 9.9)

.226 (135; 24.3; 8.2) (135; 24.3; 8.2)

.231 (36; 24.0; 9.1) (123; 21.6; 10.5)

.058 (36; 26.7; 7.6) (123; 23.5; 8.7)

.146 (51; 21.6; 9.8) (69; 22.4; 9.3) (38; 25.2; 12.2) (9; 17.4; 7.8)

.369

.287 (14; 25.5; 12.2) (149; 22.4; 10.0)

Table 3 Correlation matrices with demographic characteristics, peritraumatic responses, psychopathology and resilience (n¼ 167).

Age (a) Sex (b) PDI (c) PDEQ (d) PCL-S (e) BDI (f) CD-RISC (g)

Age

Sex

PDI

PDEQ

PCLS

BDI

CD-RISC

1

.167* 1

.160* .220** 1

.231** .174 * .699** 1

.120 .274** .523** .480** 1

.221** .091 .326** .422** .468** 1

.217**  .033 .086 .013  .076  .155* 1

Note. ** p o .01, * p o .05, (a) mean age, (b) sex, (c) peritraumatic distress at time of the earthquake, (d) peritraumatic dissociation at time of the earthquake, (e) ptsd symptoms, (f) depression symptoms, (g) resilience factors.

Table 4 Multiple regression analysis predicting symptoms of PTSD and depression (N ¼167). Variables

B

S.E

Bêta

t

p

Symptoms of PTSD Religious affiliation Earthquake's origin belief Peritraumatic distress Peritraumatic dissociation Resilience factors R2 df

 2.564 2.549 .514 .357  .019 .301 5

1.110 3.364 .128 .149 .053

 .155 .051 .366 .221  .024

 2.309 .758 3.996 2.400  .356

.022 .450 .000 .018 .722 .000

Symptoms of depression Religious affiliation Earthquake's origin belief Peritraumatic distress Peritraumatic dissociation Resilience factors R2 df

2.132 3.432 .033 .527  .136 .208 5

1.003 3.039 .116 .134 .048

.151 .081 .028 .384  .205

2.125 1.129 .282 3.922  2.827

.035 .260 .778 .000 .005 .000

30. % of the variance of PTSD symptoms. In model 2, Peritraumatic Disssociation was the best predictor for Depression symptoms (β ¼.384, p o.001) before resilience factors (β ¼.205, p r.005). All the independent variables are included, together they accounted

.000

.267

.025

.020 (38; 72.5; 19.5) (128; 64.6; 17.7)

.107 (15; 20.2; 12.2) (152; 14.8; 12.0)

.031 (14; 49; 15.4) (149; 40.3; 14.1)

.021 (50; 61.4; 18.5) (69; 66.1; 15.9) (38; 72.5; 19.5) (9; 70.6; 24.4)

(38; 22.3; 11.5) (129; 13.3; 11.6)

(15; 45; 15.6) (152; 40.6; 14.2)

(14; 29.7; 11.0) (149; 24.2; 8.5)

.000

.803

.045

.633 (36; 64.8; 14.2) (122; 66.4; 18.5)

(51; 13.6; 12.6) (69; 13.6; 10.9) (38; 22.3; 11.5) (9; 9.3; 10.6)

(38; 40.5; 15.0) (129; 41.2; 14.1)

(15; 29.1; 9.9) (152; 24.3; 8.6)

.010

.401

.002

.217 28 62,50 21,132 134 67,24 17,778

(36; 19.5; 13.1) (123; 13.6; 11.3)

(51; 43.8; 14.9) (69; 23.6; 8.2) (38; 28.7; 8.7) (9; 35; 6; 8.9)

(38; 28.7; 8.7) (129; 23.5; 8.6)

(15; 24.8; 12.0) (152; 22.3; 10.0)

.002

.003

.067

.671 (28; 13.5; 10.4) 135 15,57 12,451

(36; 47.7; 13.6) (123; 39.3; 14.0)

(51; 24.3; 9.2) (69; 23.6; 8.2) (38; 28.7; 8.7) (9; 17.4; 6.0)

(38; 25.2; 12.2) (129; 21.8; 9.4)

.011 (28; 4.3; 16.8) (135; 39.7; 13,6)

.016 (15; 77.3; 16.1) (151; 65.3; 18.2)

.095 (14; 20.5; 13.6) (149; 14.9; 11.8)

.119 (14; 73.7; 20.0) (148; 65.7; 18.3)

for 20. % of the variance of Depression symptoms.

4. Discussion To our knowledge, this is the first study to assess possible links between religious beliefs about the disaster's origin espoused by adult survivors of the 2010 Haiti earthquake, and peritraumatic responses, the prevalence of trauma related psychopathology and resilience factors. The majority of participants (64%) perceived the disaster as a natural phenomenon, in contrast to what was widely reported in the media shortly after the earthquake. The time that passed since the disaster and the data collection process may have contributed to this finding. Nevertheless, in contrast with Burnett and Helm (2013) from the examination of relationships among PTSD, resilience, religious orientation and religious practices in a sample of Haitian university students who survived the 2010 earthquake, our study indicates that perceiving the earthquake, as divine punishment was significantly associated with severe PTSD symptoms. This is in agreement with the vulnerability-resilience model highlighting that individual differences could accentuate psychopathological vulnerability. As hypothesized, and consistent with other studies involving survivors of earthquakes including in Haitian population (Cénat and Derivois, 2014; Priebe et al., 2009; Tulra et al., 2004; Xu and Song, 2011), symptoms of PTSD and depression were best predicted by peritraumatic responses experienced during the earthquake. The prevalence of PTSD was also higher among women as noted in some previous studies. Voodoo practitioners, a minority religious category, were quickly scapegoated as responsible for the “divine punishment” after the earthquake. Our results indicate that they appeared to be vulnerable to depression, but reported higher resilience factors. Such findings could be related to the animosity that they have been experiencing since the catastrophe (Pierre-Pierre, 2010). The mean resilience score of 66.4 on CD-RISC was close to that observed in Turkey (70.27) among survivors exposed to a series of earthquakes in 1999. A significant difference was noted between the mean scores obtained by the general population of the American validation study and those from the Turkish study

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(Karaırmak, 2010). This contrast in the scores of earthquake survivors and the general American population could be explained by the particular traumatic exposure and/or by the cultural differences between the groups. Similarly, there was a significant difference in the mean scores on the CD-RISC for survivors of the 2008 earthquake in Wenchuan, China, compared with a control group from the same country (Wang et al., 2010). Our findings suggest that depressive symptoms were associated with resilience, while a higher score for this contruct correlated positively with age. These are consonant with findings in two groups of Pakistani participants who had been exposed to the October 2005 earthquake that devastated Southeast Asia, killing more than 250,000. In that study, proximity to the epicenter, the death of a loved one, personal optimism, and more importantly, a high score of the CD-RISC (resilience) were significantly associated with lower levels of PTSD symptoms (Ahmad et al., 2010). Similar data were also corroborated by Pietrzak and colleague regarding the relation between resilience factors, depression and age in veterans of the United States Armed Forces (2011). Additionally, Min et al. (2013) contributed that “low spirituality” was an important risk factor for “lower-resilience” (CDRISC scores o25th percentile), severe trait anxiety was a predictor of low ( o25th percentile) and medium (scoresZ 25th percentile and o75th percentile) resilience. In our sample, the belief that the earthquake had a divine origin was predominant among those who obtained higher scores for resiliency factors measured by the CD-RISC. A possible explanation for this outcome could be the spiritual transformation noticed sometimes in populations affected by large-scale traumatic events. For example, O’Grady et al. (2012) observed in their post-earthquake survey including Haitian participants that spiritual transformation and posttraumatic growth themselves are positively correlated, suggesting the key role that spirituality might play in transforming a traumatic event from a moment of destructiveness to a moment of challenge and new perspective. Stratta and colleagues (2013) also noted that religiosity was a protective factor against traumatic consequences in an Italian community following a disaster. Nonetheless, they also noted a distinction between spiritual and religious dimensions and their impact: compared with a non-exposed group, a decline in “meaning or purpose to life” was detected in the earthquake victims evaluated. Our study has some limitations. First, the evaluation of the relationship between religious beliefs and perception of the origin of the earthquake was restricted to the label of affiliated religion, regardless of the degree of intrinsic spirituality, frequency of participation in group activities, and moments of individual prayers, etc. Another bias relates particularly to the retrospective measurement of peritraumatic responses (distress and dissociation) 27 months after the trauma. People with symptoms of severe PTSD may overstate the degree of distress or dissociation at the time of the event. These factors lead us to emphasize the importance of the establishment of more permanent infrastructures that can provide support for victims in the aftermath of traumatic event in the country, including evaluation of symptoms shortly after the event and longitudinally. Furthermore, additional studies and data collection in larger samples are needed to investigate more the effects of religiosity on the mental health of people exposed to trauma in Haiti. 4.1. Clinical implications There is a growing literature regarding the role of religion/ spirituality in adjustment to trauma; however very little of it applies to natural disasters. The present work highlighted, on the one hand, the possible impact of subjective negative perceptions of the 2010 earthquake in Haiti as a “curse,” on the severity of PTSD

symptomatology, and on the measured level of resilience two years after the disaster in a sample of adults from various religious groups; and on the other hand, our results indicate that depressive signs were prevalent among the voodoo practitioners who have been largely demonized due to their beliefs and religious practices, and whose proponents underwent several violent attacks shortly after the event. Finally, this study underscored the similarity in resilience scores for earthquake survivors in Haiti and their counterparts who experienced a similar disaster in Turkey. Consequently, our findings support the necessity for the implementation of culturally sensitive mental health programs in the aftermath of major natural disaster in the country.

5. Conclusion To conclude, our study revealed that there was significant difference in average scores at peritraumatic distress, PTSD symptoms and Resilience measures between those perceiving a divine origin and/or a punishment through the earthquake and those who did not. There was also an association between religious affiliation and severity of depressive symptoms and resilience factors, especially in the case of Voodoo adherents. Additional studies and data collection in larger samples are needed to investigate more the effects of religiosity on the mental health of people exposed to trauma in Haiti.

Conflict of interest statement The authors report no conflict of interest.

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