Prevalence of Post Traumatic Stress Disorder (PTSD) among flood victims in Malaysia: Difference
between Kuala Lumpur and Kelantan
Chong Zhi Xiong1, Ho Jia Hao2, Chang Wing Liong3, Chong Wai Loon4,
Khong Siau Chenn5, Ing Shan Kai6, Maruzairi bin Husain7, Mohd Jamil bin Yaacob8
1,2,7,8
3,4,5,6
School of Medical Sciences, Universiti Sains Malaysia
Faculty of Medicine and Health Sciences, Universiti Putra Malaysia
1
Zhi Xiong Chong
School of Medical Sciences
Universiti Sains Malaysia
Jia Hao Ho
School of Medical Sciences
Universiti Sains Malaysia
Wing Liong Chang
Faculty of Medicine and Health Sciences
University Putra Malaysia
Wai Loon Chong
Faculty of Medicine and Health Sciences
University Putra Malaysia
Siau Chenn Khong
Faculty of Medicine and Health Sciences
University Putra Malaysia
Shan Kai Ing
Faculty of Medicine and Health Sciences
University Putra Malaysia
Maruzairi bin Husain
Psychiatrist, Dr
Department of Psychiatry
School of Medical Sciences
Universiti Sains Malaysia
Mohd Jamil bin Yaacob
Senior Consultant Psychiatrist, Prof
Department of Psychiatry
School of Medical Sciences
Universiti Sains Malaysia
Corresponding Author:
Zhi Xiong Chong / Chong ZX
School of Medical Sciences
Universiti Science Malaysia
Tel No: +60127705963
Email: zhixiong17c@yahoo.com
2
Abstract
Objective: The aims of the study were to determine the prevalence of PTSD among rural and urban residents
in flood prone area in Malaysia and the factors for the difference in prevalence of PTSD between rural and
urban areas. Design: This was a cross-sectional survey study involving a total number of 200 respondents
with 100 respondents each from rural and urban area. The research tool was Impact Event Scale-Revised.
Materials and methods: A chi-square test was performed to examine the relation between locality and
prevalence of PTSD. A Fisher-Exact test was performed to examine the relation between monthly income
and locality for respondents with PTSD while another similar test was performed to know the relation
between education level and locality for respondents with PTSD. Results: Results showed that 50% and 26%
of the respondents in rural and urban areas have PTSD respectively. The study showed significant
association between income and prevalence of PTSD [p<0.001]. There was also significant association
between education level and prevalence of PTSD [p<0.001]. Besides, significant association between
number of children in a household and prevalence of PTSD [p=0.012] was proven as well. However,
variables such as age and supports after flood did not show significant association with prevalence of PTSD
[p>0.05]. Among the three subscales of PTSD, the study highlighted that there was association between
intrusion and residential area [p<0.001]. Conclusion: The current findings suggested the need for the
government to assist the people in rural flood prone area by providing more financial supports. Nongovernmental organizations should also provide more counseling services to the flood victims to cope with
the stressful life after flood. People living in rural area should be given more chance in education to enhance
their problem coping ability.
Keyword: PTSD, flood, urban area, rural area, Impact Event Scale-Revised
Introduction
Disaster is a situation or event that meet at least one of the following criteria, 10 or more people are killed or
at least 100 people are affected or a call for international events or declaration of a state of emergency.1 It
occurs all over the world, since the past till the present, be it natural disaster or human accident disaster. Of
these, natural disaster is particularly striking recently, It peaks at the year 2002 (about 550 cases reported)
and remained at high level of 350 cases or more for the past 10 years as compared it to the year 1900, the
number of cases are less than 10.1
Flood turns out to be one of the main issues which happen in nearly every country. According to the EMDAT, the worst flood for the period 1900 to 2012 happened in China in July 1931 with a total of 3.7 million
people killed. In Malaysia, flood is listed 9 out of top 10 natural disasters which affect most people with the
worst flood in 3-Dec-1965 affecting 300 thousands of people.1
Flood causes great impact to the health of the Malaysian in a few ways such as it results in water-borne
diseases, physical problems, and psychological problems. Among psychological problem, posttraumatic
stress syndrome (PTSD) is one of most serious problems after a flood. Flood may affect rural and urban
areas, and the ways of the people coping with stress after the flood in respective areas may be different.
Prolonged exposure to stress and confrontation with physical loss caused by the calamity may play an
important part in its chronicity.2 Moreover, floods can lead to direct economic and property losses and result
not only in physical injuries and deaths but also in psychological injuries.3
3
Posttraumatic stress disorder (PTSD) is a common disorder among victims of various disasters such as
traffic accidents, violent crimes, hurricanes, earthquakes, and floods. PTSD is also a severe and complex
disorder precipitated by exposure to psychologically distressing events, and it is characterized by persistent
intrusive memories about the traumatic event, persistent avoidance of stimuli associated with the trauma,
and persistent symptoms of increased arousal. Early prediction for PTSD could benefit the prevention and
treatment of PTSD.4 Besides, a study has shown that posttraumatic stress disorder (PTSD) may mediate the
effects of trauma exposure on health outcomes.5
PTSD is a common mental disorder in flood victims, which implies the need for improved health services,
especially mental health services for this population.5 A study on adults in flood district in China shown that
a total of 2336 (9.2%) subjects were diagnosed as probable PTSD-positive individuals among a total of
25,478 study subjects.4 Seven independent predictive factors (age, gender, education, type of flood, severity
of flood, flood experience, and the mental status before flood) were identified as key variables in a risk score
model.4
Research aims and methods
Study aims
General objectives:

This study is designed to study the association between flood and prevalence of PTSD among
Malaysians in selected urban (Kuala Lumpur) and rural (Kelantan) communities in the country.
Specific objectives:


To study the prevalence of PTSD among rural and urban residents in flood prone area in Malaysia.
To determine the reasons for the difference in prevalence of PTSD between rural and urban areas.
Survey methods
A cross-sectional study was conducted from 15th September 2012 to 15th October 2012 at selected flood
areas in Penambang Village, Kelantan and Klang Valley, Kuala Lumpur in Malaysia. Kelantan represents
the rural area whereas Kuala Lumpur represents the urban area in the study.
Sampling population are Malaysian adults aged 20-59 who understand the questionnaire. (i.e. no language
barrier between the data collectors and the subjects), whose physical and mental health are sufficiently good
to participate in the research and who have faced at least one flood incident within one year from the study.
PS software was used to calculate the sample size by comparing 2 proportions. To detect the difference of
15% in prevalence of PTSD (P0 8.6% versus P1 23.6%) between 2 study groups with 80% power and alpha
0.05, 93 subjects were needed from urban flood areas and 93 subjects from rural flood areas. Taking 10%
dropout, 100 subjects were taken as the study units each from Kuala Lumpur and Kelantan respectively. P0
was determined from the study done by Wallace et al. 6
Study instrument was a questionnaire which comprised of 3 parts. The first part of the instrument was on
demographic information, which includes age, gender, ethnicity, religion and occupation. Second part of the
4
questionnaire aimed to assess the history of flood encountered and the ways in which the subjects copes with
the traumatic experience. For the third part, a validated questionnaire named the Impact of Event Scale –
Revised (IES-R) were adopted. The IES-R consists of 22 questions, 5 of which were added to the original
Horowitz (IES) to better capture the DSM-IV criteria for PTSD. 7, 8 The IES-R is intended to be used as a
screening tool, but not a diagnostic test for PTSD. It measures there of six DSM-IV criterias for PTSD; reexperiencing/intrusion, avoidance/numbing and hyperarousal.
The scoring system of IES-R:
 Avoidance Subscale = mean of items 5, 7, 8, 11, 12, 13, 17 and 22
 Intrusion Subscale = mean of items 1, 2, 3, 6, 9, 16 and 20
 Hyperarousal Subscale = mean of items 4, 10, 14, 15, 18, 19 and 21
 Mean IES-R score = sum of the above three scales
The maximum score on each of the three subscales is ‘4’, the maximum mean IES-R score is 12. Lower
scores are better. A total score of 33 or over from a theoretical maximum of 88 signifies the likely
presence of PTSD.7, 8
The questionnaire was translated into Malay language and back translated into English in which it was
reviewed by the Centre for Language and Translation of University of Science Malaysia.
Trained, briefed and well supervised researchers were used to control possible interviewer bias in different
localities. The data collection technique was a guided interview which took an average of 20 minutes to
complete. Only one adult was interviewed at each time to avoid clustering effect.
Data entry and statistical analysis was done using Stata statistical software version 11. The percent
prevalence of PTSD by locality was defined using descriptive statistics. A p-value of < 0.05 was considered
statistically significant.
Discussion
From the study, several associated factors were determined for the difference in prevalence of PTSD based
on locality.
Association between prevalence of PTSD and education is significant based on Fisher-Exact test. About 53%
and 15% of the rural PTSD respondents had primary and no education respectively while 40% of the urban
PTSD respondents had tertiary education. Lower education level results in higher prevalence of PTSD in
rural area.9 This may be due to lower stress coping ability with less education.
Association between prevalence of PTSD and monthly income is significant based on Fisher-Exact test.
Lower monthly income results in higher prevalence of PTSD in rural area. About 50% of the rural PTSD
respondents were classified under poverty line while 88% of the urban PTSD respondents had high monthly
income. This may be due to lower capability of the low income group to compensate for the loss during
flood.
5
Independent t-test showed significant difference in the mean score of intrusion subscale between rural and
urban respondents. Mean score for intrusion is higher for rural than urban respondents. Possible explanation
for this is that people in rural area have more free time and so they are more prone to re-experiencing the
flood. For the other two subscales of PTSD which are hyperarousal and avoidance, independent t-test
showed no significant difference in mean.
For other factors which showed significant association with locality such as ethnicity and religion, the
researchers have decided not to take it into consideration due to the geographical distribution of the
respondents, in which all respondents in rural area are Malay who is Muslim. Matching of respondents could
not be done due to the fact that most rural areas in Kelantan are populated by Malays (95% of the
population)10 and urban areas in Kuala Lumpur are multiracial.
The main challenge faced by the researchers is that there is still lacking of similar study on PTSD. This
makes it difficult to compare the findings found in this study with the findings from other study. However,
this study shall be one of the referencing sources for similar study in the near future.
There is no a single, universally accepted method to standardise flood. The flood prone area chosen are
based on the fact that they faced river flood which is caused by massive rainwater during monsoon season.
In order to combat the discrepancy between the prevalence of PTSD in relation to locality, some suggestions
are proposed by the researchers. The Malaysian Ministry of Rural and Regional Development should build
forts along the riverside of flood prone villages. The Malaysian Ministry of Housing and Local Government
should improve the drainage system in flood prone areas throughout the country. The Malaysian Fire and
Rescue Department should provide adequate, prompt and comfortable humanitarian services during flood.
Non-governmental organisations such as Mercy Malaysia should provide healthcare to the flood victims.
Medical students should volunteer themselves actively to raise the awareness and improve mental
preparedness of residents in flood prone areas. Medical students can also act as a psychological first-aider
right after the flood happened in the hope to reduce the susceptibility for the victims to develop PTSD.
Conclusion
In conclusion, low income and education level are the main factors which result in the significant difference
in prevalence of PTSD based on locality. Pre and post-flood interventions should be carried out by various
parties to reduce the prevalence of PTSD. The researchers hope that this study can draw the attention of the
society about the significance of the association factors in relation to PTSD prevalence.
6
References
1. Natural disasters based on country profile. EMDAT, the International Disaster Database. 2011.
Available: http://www.emdat.be/result-country-profile
2. Agnieszka S, Krzysztof M, Patryk P, et al. Picture of posttraumatic stress disorder among flood victims
correlated to scale of sustained loss. Archives of Psychiatry and Psychotherapy. 2007;4:37–44
3. Liu A, Tan H, Wen S, et al. An epidemiologic study of posttraumatic stress disorder in flood victims in
Hunan China. Can J Psychiatry. 2006;51(6):350-354
4. Huang P, Tan HZ, Liu AZ, et al. Prediction of posttraumatic stress disorder among adults in flood district.
BMC Public Health. 2010;10:207
5. Polusny MA, Ries BJ, Schultz, et al. PTSD Symptom Clusters Associated With Physical Health and
Health Care Utilization in Rural Primary Care Patients Exposed to Natural Disaster. J Traumatic Stress.
2008;21(1):75-82
6. Wallace AE, Weeks WB, Wang S, et al. Rural and urban disparities in health-related quality of life among
veterans with psychiatry disorders. Psychiatric Services. 2006;57:851–856
7. Weiss. DS. The Impact of Event Scale-Revised. In J. P. Wilson, & T. M. Keane (Eds.), Assessing
psychological trauma and PTSD. A practitioner's handbook. 2004;2:168-189
8. Impact of Events Scale- Revised (IES-R). 2002.
Available: http://serene.me.uk/tests/ies-r.pdf
9. Cardenas J, Williams K, Wilson JP, et al. PTSD, major depressive symptoms, and substance abuse
following September 11, 2001, in a Midwestern university population. Int J Emerg Ment
Health. 2003;5:15–28
10. Distribution of population. Department of Statistics, Malaysia. 2006.
Available: http://kelantan.gov.my/web/main.php?page=keluasankawasan
7
Result
Table 1: Sociodemographic information (n=200)
Variables
Percentage (%)*
Locality
Rural
Urban
1. Gender
Male
45
47
MaFemale
55
53
Female
2. Age group**
Adolescent
1
2
Young adult
48
73
Middle adult
43
25
Elderly
9
0
3. Ethnics**
Malay
99
19
Chinese
0
69
Indian
0
8
Others
1
4
4. Religion**
Islam
100
20
Christian
0
17
Buddha
0
43
Hindu
0
7
Others
0
13
5. Marital Status
Single
Married
6. Number of Children
staying together
0
1
2
>3
7. Education level**
None
Primary
Secondary
Tertiary
21
79
37
16
11
36
17
35
43
5
X2 value
Statistical
significant
0.363
0.547
-
<0.001
-
<0.001
-
<0.001
1.707
0.191
13.433
0.004
-
<0.001
-
<0.001
29
71
29
16
31
22
0
3
53
42
8. Monthly income**
Poverty line
Low income
Middle income
High income
27
5
13
1
7
19
2
31
*Percentage from residential area (%) =Number of subjects (n)
8
** Fisher Exact test is used instead of Chi-square test
Table 2: Association locality and prevalence of PTSD (n=200)
Variables
Locality
Urban
Rural
Frequency/%
PTSD
34
10
No PTSD
66
90
Chi value
p value
16.783
<0.001
A chi-square test was performed to examine the relation between locality and prevalence of PTSD. The
relation between these variables was significant, X2 (1, n=200) =16.783, p <0.001. Prevalence of PTSD is
higher in rural area compared to urban area.
Table 3: Association between monthly income and locality (n=22)
Monthly Income
Number of respondents (%)
Rural
Urban
Poverty Line
7 (50.00)
0
Low
6 (42.86)
1 (12.5)
Middle
1 (7.14)
0
High
0
7 (87.5)
*Fisher-exact Test, significant at p<0.001
p value*
< 0.001
A Fisher-Exact test was performed to examine the relation between monthly income and locality for
respondents with PTSD, n=22. The relation between these variables was significant, p<0.001.
Table 4: Association education level and locality (n=44)
Education level
No. of residents/ Percentage (n/%)
Rural
None
5 (14.71)
Primary
18 (52.94)
Secondary
9 (26.47)
Tertiary
2 (5.88)
*Fisher-exact Test, significant at p<0.001
Urban
0
0
6 (60)
4 (40)
p value*
<0.001
A Fisher-Exact test was performed to examine the relation between education level and locality for
respondents with PTSD, N=44. The relation between these variables was significant, p<0.001.
Table 5: Difference in mean score for intrusion component among respondents with PTSD of different
locality
t-test for Equality of Means
Locality n Mean
Std.
Deviation
t
Sig.
Mean difference
Mean score for
Rural 34 2.521
0.520
(2-tailed)
(95% CI)
intrusion
4.704
<0.001
0.807 (0.461, 1.153)
Urban 10 1.714
0.261
9
Mean intrusion score between rural and urban area is significantly different (p<0.001, 95% CI). The mean
(SD) intrusion score in rural area is higher than in urban area [2.521 (0.520) vs 1.714 (0.261)]. The mean
difference intrusion score between rural and urban area is between 0.461 and 1.153 marks by having 95%
confidence.
10