Health status of adolescents in the Tibetan plateau area of western China: 6 years after the Yushu earthquake

Not only can natural disasters cause a devastating loss of life, homes, and livelihoods in an instant, they can also impose lingering threats to the physical and mental health of the survivors who must cope with post-disaster adversities for many years [1, 2]. Moreover, earthquakes are one of the most severe forms of natural disaster. Among developing countries, China is one of the most affected by natural disasters. A catastrophic earthquake, registering 7.1 on the Richter scale, struck Yushu, China, at 7:49 am on April 14, 2010, causing 2698 deaths and 12,135 injuries. The epicenter of the earthquake, Yushu, is a county in the Yushu Tibetan Autonomous Prefecture in the southernmost Qinghai province, with an average elevation of 4493 m. The total population of Yushu has been reported to be 311,000 (in 2007), of which Tibetans accounted for 97%, and the agricultural and animal husbandry population accounted for 70% [3].

There is an emerging literature on the health status of earthquake survivors [4‐7], with some studies contending that severe earthquakes/disasters can cause long-lasting physical and mental health problems [8]. Previous studies have assessed the impact of disasters in terms of mortality, morbidity, depression, posttraumatic stress disorder (PTSD), and the health-related quality of life (HRQoL) within a 1–36-month period following the disaster [9‐15]. Most of these studies have focused on adults; only a few have examined the health status of child survivors [16, 17]. Moreover, no previous study has evaluated the health status of child survivorsseveral years after an earthquake.

Child survivors are a vulnerable population whose health status is sensitive to external adverse events such as earthquakes. Several studies focusing on child survivors have shown that the HRQoLdecreases over time. Enabling children who have survived disasters to achieve and maintain the same standards of health as other children and adolescents is a goal of the international community [18].

In particular, for relatively remote plateau areas like Yushu, the health status of child and adolescent survivors should be continuously considered. Therefore, the present study aimed to assess the health status, and associated determinants, of child survivors in the epicenter of the Yushu earthquake(the undeveloped Tibetan plateau area, Northwest China) 6 years after the event, to provide evidence-based suggestions for specific long-term health interventions in such vulnerable populations.

Experiencing a disastrous earthquake can result in long-term mental and physical impairment among adolescent survivors [17, 26].The present study examined the health status, both in terms of physical and mental health, of adolescent survivors 6 years after the Yushu earthquake. We found that adolescent survivors of the Yushu earthquake had worse PCS and MCS scores compared to those for the general adolescent population in China [21].

With regard to the physical health status of adolescent survivors, being trapped and injured during the earthquake were found to be risk factors with a strong negative association to physical health. While a large number of studies have focused on the mental health problems of survivors [27‐30], research on the relationship between exposure to disaster events and survivors’ physical health is relatively limited. A previous study found that post-earthquake rescue policies could directly affect the promotion of PCS scores in survivors [31]. However, additional studies have suggested that disaster events have little impact on survivors’ physical health [27].For example, the results of the study by Adams and Boscarino suggested that exposure to the World Trade Center disaster did not have severe consequences for the physical well-being of adults 1 year after the attacks [32]. In other previous studies, poor housing conditions (such as living in temporary shelters and a lack of clean water and food) were reported to have a negative association with physical health 1-18 months after the disaster [6, 33, 34]. Our findings surprisingly show that even after a fairly long period of 6 years, being trapped and injured during the earthquake still had a strong negative association with physical health. These results may be related to dysfunction and movement disorders caused by the earthquake injury, such as amputations, becoming crippled, and so on. Overall, the results suggest that long-term follow-up for earthquake-related injuries and relevant measures should be developed to promote recovery.

In the present study, earthquake escape training was shown to have a positive association with physical health. Community emergency preparedness/engagement is critical for effective rescue, and earthquake escape training an important measure to enhance community emergency preparedness/engagement [35, 36]. Earthquake-related health education and promotion can bring positive changes to populations in areas at high risk for earthquakes. An improved level of knowledge and consequent preparedness are far more promising than the “treat when sick” strategy [37].

With regard to the psychological health status of adolescent survivors, being afraid and losing family members during the earthquake corresponded to lower MCS scores. These negative factors have been identified in previous cross-sectional studies with greater exposure to the events surrounding the disaster associated with poorer psychological well-being [5, 17]. Moreover, the results of the present study are consistent with previous studies demonstrating that children who felt intensely scared during a disaster were more likely to have poor psychological health status and were more likely to develop symptoms of PTSD, depression, and anxiety [38, 39]. In addition, our results indicated that although 6 years had passed, the students’ emotional memory of the Yushu earthquake was still clear. As suggested in previous studies, experiencing the loss of family members as a result of the earthquake may have aroused intense fear, which was closely related to negative psychological changes [40‐43]. Since disaster-related psychological sequelae may last for many years, appropriate actions should be taken to minimize potential negative impacts. A regular, long-term psychological intervention program should be established to improve the mental health conditions of survivors in earthquake-affected areas.

On the other hand, we found that receiving psychological counseling was associated with higher MCS scores. This result provides a comforting message, suggesting that appropriate psychological interventions can be effective in improving the mental health of survivors. In the presentstudy, psychological counseling included counselingimmediately after the disaster or several days tomonths later, either in individual or group settings, and to any extent. A wide variety of studies have appealed for more attention to the mental health of survivors [44‐46]. However, few studies exist on how to implement and assess the effectiveness of psychological interventions.

It is noteworthy that, in addition to the above earthquake exposure factors, two demographic characteristics also had a strong association with the MCS score: the adolescents’ grade level and whether they were living with their parents. A higher grade level and living with parents were positively associated with MCS scores. A previous study focusing on resilience reported the opposite result (i.e., junior grade 1 students hadnotably higher resilience scores compared to those of senior grade 1 students, which was attributed to senior grade 1 students facing great pressure to perform well in academics and meet the high expectations of parents) [47]. Since the population living in the Yushu area is scattered, the two investigated schools were boarding schools; thus, the students were usually living in the school. The lower grade students had just started the school’s collective life. Therefore, we speculate that the impact of grade level on the MCS score might be due to low-grade students not yet adapting to the school atmosphere and living situation. Regarding the association between living with parents and MCS scores, China has been undergoing rapid urbanization in the past few decades and one out of ten individuals is a migrant, moving from rural to urban areas to seek employment opportunities. Therefore, a considerable number of participants had left the rural area, and were not living with their parents. Evidence from studies in various countries suggests that a stable family environment contributes to the healthy development of children [48‐53]. In addition, negative impacts such as unhealthy behaviors [54], adverse emotions [55], and poorer psychosocial health [56] have been documented in left-behind children.

In conclusion, the results of the present study help to expand our knowledge regarding the health status of child survivors 6 years after the Yushu earthquake. The results suggest the importance of greater vigilance and long-term attention to the children who lived in the rural plateau area and were most affected by the earthquake. This study provides important information regarding monitoring the long-term course of physical and mental health recovery of adolescents after earthquakes, and is of great significance for public awareness and the sensitivity towards those who were the most affected. Specific care, earthquake escape training, and long-term psychological interventions should be provided to adolescent survivors with relatively low health status, including those who were injured in the earthquake and those who were not living with parents.