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JAMA Netw Open
JAMA Netw Open
JAMA Network Open
2574-3805
American Medical Association

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10.1001/jamanetworkopen.2024.11413
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Research
Research Letter
Online Only
Public Health
Sociopolitical Factors and Mental Health Following the Turkey-Syria Earthquake
Sociopolitical Factors and Mental Health Following the Turkey-Syria Earthquake
Sociopolitical Factors and Mental Health Following the Turkey-Syria Earthquake
Hou Wai Kai PhD 1 2
Tao Tiffany Junchen MPhil 1 3
Li Crystal Jingru MSocSc 1
Wong Evon Lam BSc 1
Saral Aysuhan Tuba PhD 4
Liu Huinan PhD 1 5
Galea Sandro MD MPH DrPH 6
1 Centre for Psychosocial Health, The Education University of Hong Kong, Hong Kong SAR, China
2 Department of Psychology, The Education University of Hong Kong, Hong Kong SAR, China
3 Department of Psychological Science, University of California, Irvine
4 Department of International Education, The Education University of Hong Kong, Hong Kong SAR, China
5 Department of Special Education and Counselling, The Education University of Hong Kong, Hong Kong SAR, China
6 School of Public Health, Boston University, Boston, Massachusetts
Article Information

Accepted for Publication: March 13, 2024.

Published: May 15, 2024. doi:10.1001/jamanetworkopen.2024.11413

Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2024 Hou WK et al. JAMA Network Open.

Corresponding Author: Wai Kai Hou, PhD, Department of Psychology, The Education University of Hong Kong, 10 Lo Ping Rd, Tai Po NT, Hong Kong SAR, China (wkhou@eduhk.hk).
Author Contributions: Dr Hou had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis. Dr Hou and Ms Tao are joint first authors.

Concept and design: Hou, Tao, Liu, Galea.

Acquisition, analysis, or interpretation of data: Hou, Tao, Li, Wong, Saral.

Drafting of the manuscript: Hou, Tao.

Critical review of the manuscript for important intellectual content: All authors.

Statistical analysis: Hou, Tao, Liu.

Obtained funding: Hou.

Administrative, technical, or material support: Hou, Tao, Wong, Saral, Galea.

Supervision: Hou, Galea.

Conflict of Interest Disclosures: Dr Galea reported serving on the board of Sharecare. No other disclosures were reported.

Funding/Support: This work was supported by Research Grants Council, University Grants Committee, Hong Kong SAR, China (grant No. 18600320 to Dr Hou).

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Data Sharing Statement: See Supplement 2.

Additional Contributions: We would like to thank all the respondents who participated in this study. We would also like to thank all the individuals who made significant contributions to the data collection.

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Copyright 2024 Hou WK et al. JAMA Network Open.
https://creativecommons.org/licenses/by/4.0/ This is an open access article distributed under the terms of the CC-BY License.
jamanetwopen-e2411413.pdf

This survey study evaluates the association between sociopolitical factors and mental health following the 2023 Turkey-Syria earthquake.
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pmcIntroduction

Large-scale natural disasters like the 7.8-magnitude Turkey-Syria earthquake on February 6, 2023, can be followed by substantial mental health consequences.1 The impact of these events can be modified by ongoing stressors of financial strain,2 political turmoil, and civil unrest.3,4 This study aims to investigate the associations between earthquake exposure and subsequent probable psychiatric conditions and whether and how these associations differed across socioeconomic status, assets, and political concerns surrounding the Turkish presidential election in May 2023.

Methods

A nationally representative Turkish sample was recruited through TGM Research’s internet panel. Participants completed an online survey from September to October 2023 (75.9% response rate). This study followed the American Association for Public Opinion Research (AAPOR) and Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) reporting guidelines and was approved by the Education University of Hong Kong institutional review board. Upon giving their informed consent, respondents reported earthquake exposure (proximity to epicenter and displacement, housing destruction, physical disability, and bereavement), sociodemographics (including ethnicity, assessed in this study to reflect diversity), assets, and concerns about political destabilization.

Primary outcomes were probable depression, anxiety, and posttraumatic stress disorder (PTSD) assessed by the Patient Health Questionnaire (α = .90), Generalized Anxiety Disorder scale (α = .92), and the abbreviated PTSD Checklist (α = .89). We described the prevalence of probable psychiatric conditions (greater than validated clinical cutoffs).

Logistic regression and path analyses examined the associations between earthquake exposure and probable conditions and whether and how the associations differed across different levels of sociopolitical factors (at the .05 significance level). The eMethods in Supplement 1 provides additional information.

Results

The 7585 respondents were mostly aged 18 to 29 years (3172 respondents [41.8%]) and 30 to 44 years (2916 respondents [38.4%]); 3613 (47.6%) were women, 1238 (16.3%) were of non-Turkish ethnicity, and 6347 (83.7%) were of Turkish ethnicity. Prevalence of current (ie, past month) probable psychiatric conditions was 44.2% for depression (3349 respondents), 31.0% for anxiety (2353 respondents), and 47.7% for PTSD (3619 respondents). The Table summarizes respondents’ sociodemographics and the peri-earthquake and sociopolitical associations of probable psychiatric conditions. Higher levels of exposure (ie, internally displaced, physical disability, or bereavement), younger age, female sex, low income, tertiary education or above, being nonmarried, Turkish ethnicity, and concerns about political destabilization were positively associated with probable conditions. Odds ratios ranged from 1.25 (95% CI, 1.11-1.42) for being nonmarried to 3.16 (95% CI, 2.13-4.69) for having a disability due to this earthquake. The Figure displays stronger associations of earthquake exposure with probable psychiatric conditions among respondents with lower compared with higher socioeconomic status (path coefficients ranged from 0.12; 95% CI, 0.01-0.24 to 0.91; 95% CI, 0.78-1.04), low compared with high assets (path coefficients ranged from 0.34; 95% CI, 0.21-0.46 to 0.89; 95% CI, 0.76-1.02), and concerns about political destabilization compared with none (path coefficients ranged from 0.46; 95% CI, 0.06-0.86 to 0.92; 95% CI, 0.78-1.06), controlling for age, sex, and ethnicity.

Table. Peri-Earthquake and Sociopolitical Associations of Probable Psychiatric Conditionsa

Variables	Respondents, No. (%)	Probableb	
Depression (n = 3349)	Anxiety (n = 2353)	PTSD (n = 3619)	
OR (95% CI)	P value	OR (95% CI)	P value	OR (95% CI)	P value	
Sociodemographics								
Age, y								
45 or above	1497 (19.74)	1 [Reference]	NA	1 [Reference]	NA	1 [Reference]	NA	
30-44	2916 (38.44)	1.39 (1.22-1.58)	<.001	1.52 (1.32-1.76)	<.001	1.40 (1.23-1.59)	<.001	
18-29	3172 (41.82)	2.18 (1.89-2.52)	<.001	2.28 (1.95-2.67)	<.001	2.14 (1.86-2.47)	<.001	
Sex								
Male	3972 (52.37)	1 [Reference]	NA	1 [Reference]	NA	1 [Reference]	NA	
Female	3613 (47.63)	1.51 (1.36-1.67)	<.001	1.48 (1.32-1.65)	<.001	1.71 (1.54-1.89)	<.001	
Employment								
Employed	5579 (73.55)	1 [Reference]	NA	1 [Reference]	NA	1 [Reference]	NA	
Dependent	1566 (20.65)	0.99 (0.87-1.13)	.92	0.96 (0.83-1.10)	.54	0.86 (0.79-1.02)	.10	
Unemployed	440 (5.80)	1.15 (0.92-1.43)	.23	1.01 (0.79-1.27)	.97	0.818 (0.65-1.02)	.08	
Monthly household incomec								
Nonlow income	6198 (81.71)	1 [Reference]	NA	1 [Reference]	NA	1 [Reference]	NA	
Low income	1387 (18.29)	1.27 (1.11-1.46)	<.001	1.34 (1.16-1.55)	<.001	1.10 (0.95-1.26)	.20	
Education level								
Tertiary or above	5286 (69.69)	1 [Reference]	NA	1 [Reference]	NA	1 [Reference]	NA	
Secondary or below	2299 (30.31)	0.97 (0.87-1.08)	.54	0.97 (0.86-1.09)	.59	0.95 (0.85-1.06)	.35	
Marital status								
Married	4063 (53.57)	1 [Reference]	NA	1 [Reference]	NA	1 [Reference]	NA	
Single, divorced, or widowed	3522 (46.43)	1.30 (1.16-1.46)	<.001	1.25 (1.11-1.42)	<.001	1.04 (0.93-1.16)	.53	
Assetsd								
High	4590 (60.51)	1 [Reference]	NA	1 [Reference]	NA	1 [Reference]	NA	
Low	2995 (39.49)	1.04 (0.93-1.16)	.53	0.95 (0.84-1.07)	.36	0.93 (0.84-1.04)	.21	
Ethnicity								
Non-Turkish	1238 (16.32)	1 [Reference]	NA	1 [Reference]	NA	1 [Reference]	NA	
Turkish	6347 (83.68)	0.99 (0.86-1.13)	.86	1.35 (1.16-1.56)	<.001	0.99 (0.86-1.13)	.86	
Earthquake exposure								
Proximity and displacemente								
No displacement within nonaffected provinces	6097 (80.38)	1 [Reference]	NA	1 [Reference]	NA	1 [Reference]	NA	
No displacement within affected provinces	934 (12.31)	1.05 (0.90-1.22)	.54	1.08 (0.91-1.26)	.38	1.33 (1.15-1.55)	<.001	
Displaced within affected provinces	331 (4.36)	1.57 (1.17-2.10)	.002	1.41 (1.05-1.89)	.02	1.98 (1.46-2.67)	<.001	
Displaced from affected to nonaffected provinces	223 (2.94)	1.36 (0.94-1.97)	.11	1.69 (1.17-2.44)	.01	2.42 (1.63-3.61)	<.001	
Housing destruction								
No	7214 (95.11)	1 [Reference]	NA	1 [Reference]	NA	1 [Reference]	NA	
Yes	371 (4.89)	1.15 (0.84-1.58)	.39	1.27 (0.93-1.73)	.14	1.19 (0.85-1.66)	.31	
Physical disability								
No disability	5747 (75.77)	1 [Reference]	NA	1 [Reference]	NA	1 [Reference]	NA	
With disability not due to this earthquake	1651 (21.77)	2.36 (2.10-2.66)	<.001	2.28 (2.02-2.57)	<.001	2.32 (2.06-2.61)	<.001	
With disability due to this earthquake	187 (2.47)	3.16 (2.13-4.69)	<.001	3.05 (2.13-4.36)	<.001	2.94 (1.90-4.54)	<.001	
Bereavementf								
No loss	5991 (78.98)	1 [Reference]	NA	1 [Reference]	NA	1 [Reference]	NA	
Loss of nonclose contact	1384 (18.25)	2.10 (1.84-2.40)	<.001	1.74 (1.52-1.99)	<.001	2.10 (1.84-2.41)	<.001	
Loss of close contact	210 (2.77)	2.01 (1.46-2.77)	<.001	1.87 (1.37-2.55)	<.001	1.68 (1.22-2.33)	.002	
Concerns about political destabilization								
No	5407 (71.29)	1 [Reference]	NA	1 [Reference]	NA	1 [Reference]	NA	
Yes	2178 (28.71)	1.65 (1.48-1.83)	<.001	1.96 (1.75-2.20)	<.001	1.59 (1.42-1.77)	<.001	
Abbreviations: NA, not applicable; OR, odds ratio; PTSD, posttraumatic stress disorder.

a Descriptive analyses were unweighted; logistic regressions were weighted.

b Probable depression was defined as a score of 10 or above on the 9-item Patient Health Questionnaire; probable anxiety was defined as a score of 10 or above on the 7-item Generalized Anxiety Disorder scale; probable PTSD was defined as a score of 14 or above on the 6-item PTSD Checklist—Specific Version.

c Low monthly household income was defined as 11 499 Turkish lira (approximately US $382) or below, with reference to the net minimum wage in effect in July 2023.

d Assets were defined as high (ie, high savings or property ownership) or low (ie, low savings and no property ownership). High and low savings were defined based on the cut-off of 160 000 Turkish lira (approximately US $5964) based on Turkish census data.

e The affected 11 provinces were Adana, Adiyaman, Diyarbakir, Elaziğ, Gaziantep, Hatay, Kilis, Kahramanmaraş, Malatya, Osmaniye, and Şanliurfa.

f Close contacts included partners, children, parents, and siblings; nonclose contacts included distant relatives, friends, and others.

Figure. Associations Between Earthquake Exposure and Probable Psychiatric Conditions

Associations are shown by level of SES, assets, and concerns about political destabilization. PTSD indicates posttraumatic stress disorder; SES, socioeconomic status.

Discussion

This nationally representative survey reported high prevalence of current probable depression, anxiety, and PTSD (31.0%-47.7%) 7 months after the 7.8-magnitude earthquake and the political turmoil of the presidential election. Consistent with prior evidence,3,5 earthquake exposure was positively associated with probable psychiatric conditions. The positive earthquake-outcome associations were 2 times stronger among those with lower socioeconomic status and fewer assets, suggesting that in mass traumatic events, disadvantaged populations are more likely to experience disproportionally more adverse mental health consequences relative to those with more resources.2,4,5 Concerns about the ready availability of relief services3 might explain the observed positive association between fear of political destabilization and psychiatric conditions.6

The limitations of this study are the cross-sectional design and self-report measures of earthquake exposure and probable psychiatric conditions. Notwithstanding these limitations, this study highlights the role that mass traumatic events, coupled with socioeconomic and political factors, play in mental health. These observations suggest that disaster relief needs to proactively focus on populations with fewer resources and aim to restore lost resources during mass traumatic events. These findings also highlight the importance of political stability in the postdisaster context as a pathway to mitigate adverse mental health consequences of these events.

Supplement 1. eMethods.

eReferences.

Supplement 2. Data Sharing Statement
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References

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