Introduction
Events that occur unexpectedly and negatively affect people’s lives are defined as natural disasters.Reference Datar, Liu and Linnemayr1 Many disasters that cannot be directly attributed to human actions, such as earthquakes, hurricanes, floods and volcanic eruptions, can cause people to die, be injured, and suffer financial losses and fear.Reference Fatema, East and Islam2 One of these major disasters occurred in the Kahramanmaraş province of Turkey on February 6, 2023. The city experienced 2 major earthquakes of magnitude 7.8 and 7.6 on the same day. After the earthquake, a state of emergency was declared in 11 provinces, including Gaziantep. Approximately 50 000 people lost their lives with these earthquakes, which are described as the disaster of the century.Reference Bahar and Çuhadar3–Reference Terzi and Dundar5
Earthquakes, which are described as impressive natural events, can cause a chain of effects that significantly affect the lives of individuals through death and injuries.Reference Mavrouli, Mavroulis and Lekkas6 Major traumas can occur after earthquakes and people can be negatively affected both physically and psychologically. For example, a systematic review examining research conducted after the Great East Japan Earthquake in 2011 clearly revealed the effects of the earthquake. It has been observed that individuals affected by the earthquake experienced significant psychological problems in the following years, and post-traumatic anxiety, depression, and stress disorders have been determined to occur. Likewise, it has been determined that physical health changes such as eating and sleeping disorders are also experienced.Reference Harada, Shigemura and Tanichi7 Health care workers are among the work groups most exposed to traumatic events as a result of natural disasters such as earthquakes. With this study, we aimed to measure the anxiety levels of health care professionals after the earthquake and the possible effects of this anxiety level on perceived stress and work-family conflict were evaluated.
Theoretical Framework
Stress is a concept introduced by Selye.Reference Selye8 First, it was expressed as the body’s nonspecific response to any harmful stimulus.Reference Koolhaas, Bartolomucci and Buwalda9 Subsequently, stress was defined as factors that pose a threat to people’s psychological and/or physical homeostasis. It has been stated that these elements may appear as real or perceived threats.Reference Andreou, Alexopoulos and Lionis10 This study focused on perceived stress.
With perceived stress, individuals’ situations in their lives are evaluated and their stress levels are revealed.Reference Cohen, Kamarck and Mermelstein11 High perceived stress level can bring about many negativities. For example, research shows that as perceived stress increases, health care workers’ subjective well-being levels,Reference Atanes, Andreoni and Hirayama12 job satisfaction levels,Reference Munnangi, Dupiton and Boutin13 and physical activity participation levelsReference Jonsdottir, Rödjer and Hadzibajramovic14 decrease.
It is extremely important to know the negative effects that perceived stress can have. However, it is also extremely critical to identify situations that lead to increased stress, which has become an important part of our daily lives. Many events experienced in recent years have negatively affected the perceived stress levels of health care professionals. For example, a study conducted in Saudi Arabia revealed that the Middle East Respiratory Syndrome Coronavirus (MERS-CoV) process creates stress in health care workers.Reference Khalid, Khalid and Qabajah15 Studies conducted in Spain,Reference Khalid, Khalid and Qabajah15 Bahrain,Reference Jahrami, BaHammam and AlGahtani16 Turkey,Reference Boran, Boran and Korukcu17 and ItalyReference Babore, Lombardi and Viceconti18 have stated that the COVID-19 epidemic increased the perceived stress levels of health care workers. Studies on both MERS-CoV and COVID-19 have shown that risks such as working too hard for health care professionals and contracting the disease increase perceived stress. However, major natural disasters such as earthquakes can cause great trauma to health care workers and negatively affect their mental health. For example, after the major earthquake in Nepal in 2015, it was observed that health care workers encountered tragic events and their stress levels increased significantly.Reference Shrestha19 With a similar approach, this study aimed to measure the level of anxiety caused by the major earthquake in Turkey and to examine whether it affected the perceived stress levels of health care professionals. In this context, the following hypothesis was developed:
Hypothesis 1. As earthquake anxiety increases, the perceived stress levels of health care professionals also increase.
Work-family conflict is defined as a type of inter-role conflict that occurs when the demands of work and family roles are incompatible. It is also known as work-family intervention.Reference Byron20 There are 2 different forms of work-family conflict: work interference with family and family interference with work.Reference Byron20 This distinction is important because both types of interventions have different outcomes and antecedents.Reference Zhang, Griffeth and Fried21 This study focuses on the dimension of work’s interference with the family.
Conflict between work and family, which are expressed as the basic areas of life, has quickly found its place in organizational studies today. Negative work attitudes caused by work-family conflict are shown as the main reason for this situation.Reference Boyar, Maertz and Mosley22 For example, many studies have revealed evidence that as work-family conflict increases, the job satisfaction levelReference Yang, Liu and Liu23 and organizational commitment levelReference Arisi-Nwugballa24 decrease in health care professionals.
Especially in recent years, many factors such as traditional gender, changing roles regarding housework, and the decrease in single-income families have been effective in the emergence of the field of work-family conflict.Reference Byron20 In their study, Eby, et al.Reference Eby, Casper and Lockwood25 grouped these factors that cause work-family conflict under 3 headings: work area, non-work area, and individual-demographic variables. Factors such as stress and schedule flexibility are job field variables. Non-work domain variables include factors such as marital problems, children’s ages, and family wishes. Individual-demographic variables include factors such as income, gender, education, and personality characteristics.
When any natural disaster occurs, health care professionals may face some indecision. This situation may affect the capacity of the patient staff and there may be a great conflict about whether to come to work or not. In a study conducted to evaluate the reactions of health care professionals after major fires, it was determined that participants were undecided between work and family. In this process, it has been revealed that one of the important factors affecting employees’ decision to work is family vulnerability, and employees experience tension due to the feeling of responsibility towards the family and the institution.Reference Davidson, Sekayan and Agan26 A similar result was obtained in the study conducted on nurses after Hurricane Floyd. It has been observed that nurses see themselves as disaster victims and are torn between work and family responsibilities.Reference French, Sole and Byers27 A similar approach was taken with this study, it was aimed to examine the effect of earthquake anxiety on the level of work-family conflict and the following hypothesis was developed.
Hypothesis 2. As earthquake anxiety increases, the work-family conflict levels of health care professionals also increase.
Methods
Study Design and Participants
It is a cross-sectional study using a self-administered questionnaire. We did not have any prior predictions about the prevalence of earthquake anxiety among health care professionals in Turkey. Effect size d = 0.15; power 0.95; Considering the type 1 error (α) as 0.05 and the number of predictive variables as 3, it was calculated that the total sample size should be 119. In this context, surveys were distributed to 170 health care workers and 150 of them answered. The overall response rate was determined as 88.23%. The surveys consist of 4 sections: socio-demographic questions, earthquake anxiety scale, perceived stress scale, and work-family conflict scale.
Definitions of Variables
Earthquake anxiety
Each natural disaster can have different effects on individuals’ lives depending on the situation. The impact of an earthquake on people in a developed country will be different than in a developing country. This earthquake in Turkey, which is among the developing countries, had deep effects on people both materially and spiritually. Taking these differences into consideration, a short scale of 5 questions was created by the authors, using the literature, to measure post-earthquake anxiety.Reference Bal and Akgül28–Reference Wald, Jaiswal and Marano33 The questions in the scale are as follows: (1) I don’t feel safe; (2) My concerns about the future of my life increased; (3) I constantly feel like I should spend more time with my loved ones; (4) I feel tired and restless all the time; (5) I have hesitations in changing my location and using different physical structures (such as houses, tunnels, and bridges). Opinions were taken from experts in the field to test content validity. Responses were scored on a 5-point Likert scale (ranging from 0 = never-4 = very often). The cut-off value of the scale was calculated as 2.90. In the next process, explanatory and confirmatory factor analyses were used to test the construct validity. As a result of the explanatory factor analysis, the Barlett Test value was 200.751 (P < 0.001) and the Kaiser-Meyer-Olkin (KMO) sampling adequacy was 0.71. Likewise, the explanation rate of the total variance was determined as 51.17%, and 5 statements regarding the scale were collected under 1 factor. In the confirmatory factor analysis, it was determined that the goodness of fit values (CMIN/SD = 1.818; NFI = 0.97; TLI = 0.96; IFI = 0.98; CFI = 0.98; RMSEA = 0.074; P < 0.05).Reference Sun34 Finally, in terms of reliability, the internal consistency (Cronbach Alpha) coefficient was found to be at a good level (α = .76).
Perceived stress
The scale developed by Cohen, et al.Reference Cohen, Kamarck and Mermelstein11 was used to measure the perceived stress level. There are 8 statements in the scale. Responses were scored on a 5-point Likert scale (ranging from 0 = never-4 = very often). The cut-off value of the scale was calculated as 1.94. The Turkish validity and reliability study of the scale was conducted by Bilge, et al.Reference Bilge, Öğce and Genç35 Previous studies have shown that the scale shows strong internal consistency.Reference Bilge, Öğce and Genç35, Reference Dökme Yağar and Yağar36 Similarly, in this study, the internal consistency coefficient (Cronbach Alpha) was determined to be acceptable (α = .61).
Work-family conflict
The scale developed by Netemeyer, et al.Reference Netemeyer, Boles and McMurrian37 was used to measure the participants’ work-family conflict levels. The scale, which includes 5 statements, is designed as a 5-point Likert type (ranging from 1 = Strongly disagree-5 = Strongly agree). The cut-off value of the scale was calculated as 2.30. In the study conducted by Efeoğlu and Özgen,Reference Efeoğlu and Özgen38 the validity and reliability of the research in Turkish was examined. Previous studies have shown that the scale shows strong internal consistency.Reference Efeoğlu and Özgen38, Reference Karabay39 Similarly, in this study, the internal consistency coefficient (Cronbach Alpha) was determined to be high (α = .82).
Data collection
Health care workers who were in the hospital between November 18 and 24, 2023 were included in this research. Verbal informed consent was obtained from all participants. Participants were informed that they had the option of refusing to participate in the study. They were assured that the results would only be used in an academic study and that the data would remain confidential. Anonymous surveys were distributed to health care professionals and the completed surveys were collected back.
This study was approved by the Social Sciences and Humanities Ethics Committee of Kahramanmaraş Sütçü Imam University (ref. no. 263962).
Data analysis
Data were analysed using SPSS v.26 and AMOS v.15. Descriptive statistics (frequency distribution and arithmetic mean) were used to determine participants’ socio-demographic characteristics, earthquake anxiety, perceived stress, and work-family conflict levels. In addition, the cut-off value was calculated for each scale. Pearson correlation analysis was applied to examine the relationship between earthquake anxiety, perceived stress, and work-family conflict. Regression analyses were used to examine the effect of earthquake anxiety on perceived stress and work-family conflict. P value < 0.05 was considered significant.
Results
Descriptive statistics for health care workers are given in Table 1. It was observed that there were more women (61.3%) and married (53.3%) employees in the study. The education level of nearly half of the employees, whose average age is 30.01 ± 6.83, is determined as undergraduate (48.0%). In addition, when the cut-off values calculated for the scales were considered, it was revealed that the earthquake anxiety (2.98 ± 0.94), perceived stress (1.98 ± 0.61), and work-family conflict (2.55 ± 0.97) levels of health care workers were at moderate levels. Finally, it was observed that a significant portion of the participants were nurses (50.7%). After the nurses, physicians (22.0%), health technicians (15.3%), and administrative personnel (12.0%) participated in the study.
Descriptive statistics
The relationships between earthquake anxiety, perceived stress, and work-family conflict levels are examined in Table 2. A positive significant relationship was found between earthquake anxiety and both perceived stress (r = 0.476; P < 0.01) and work-family conflict levels (r = 0.450; P < 0.01). Additionally, a significant positive relationship was found between perceived stress and work-family conflict level (r = 0.370; P < 0.01).
Pearson correlations of the variables
**P<0.01; *P<0.05.
When examined according to socio-demographic characteristics, it was observed that earthquake anxiety (r = 0.274; P < 0.01) and work-family conflict (r = 0.237; P < 0.01) increased slightly as the level of education increased (Table 2). Similarly, it was determined that perceived stress was slightly higher in women (r = -0.173; P < 0.05) and married people (r = 0.222; P < 0.01). Finally, it has been found that earthquake anxiety, although low, increases with age (r = 0.166; P < 0.05).
When Table 3 is examined, it is observed that the earthquake anxiety explains 22.6% of the total variance in the perceived stress of health workers (Model 1). Simple regression analysis revealed that earthquake anxiety has significant effect on perceived stress (β = 0.476, P < 0.05). Hypothesis 1 was accepted. Likewise, hierarchical regression analysis was used to examine the impact of earthquake anxiety and perceived stress on work-family conflict. In this context, firstly, the effect of earthquake anxiety on work-family conflict was examined in Model 2. It has been observed that earthquake anxiety has a significant effect on work-family conflict (β = 0.450, P < 0.05). Hypothesis 2 was accepted. When Model 2 was examined, it was determined that earthquake anxiety explained 20.2% of the total variance in work-family conflict, and the explanatory power of the model increased by 4.5% with the inclusion of perceived stress and education level in Model 3. Similarly, perceived stress was found to have a significant effect on work-family conflict (β = 0.200, P < 0.05). On the other hand, the effect of education level on work-family conflict was not found to be significant (β = 0.126, P > 0.05).
Regression analyses
Discussion
This is the first study to evaluate the anxiety levels of health care professionals after the earthquake and examine the effect of earthquake anxiety on perceived stress and work-family conflict. According to our findings, earthquake anxiety plays a critical role in the perceived stress and work-family conflict levels of health care professionals. It has been observed that health care workers with above-average anxiety levels may experience earthquake anxiety, as well as increase their stress and work-family conflict levels.
There are very limited studies examining the impact of the earthquake on health care professionals in Turkey. In a short report published in Lancet, a physician who experienced the earthquake shared his observations and underlined that health care workers were also earthquake victims.Reference Genc40 Another study conducted in Turkey revealed that health care workers experienced significant anxiety problems after the 2020 Elazığ earthquake.Reference Cansel and Ucuz41 Considering the effect of traumatic events experienced together with the earthquake, a similar effect was expected in our study group. Although a high level of anxiety was not detected, our research showed that the anxiety levels of health care professionals were above average. We think that the time passed after the earthquake and the psychological support programs received had an effect. Apart from these, Ikizer, et al.Reference Ikizer, Karanci and Doğulu42 emphasized in their study that the effects of the earthquake may last for a long time and stated that health care professionals can avoid traumas and concerns. Likewise, it was emphasized in the study that being in a society that does not want to talk about the disaster can also be effective.
We found that earthquake anxiety significantly affected the level of work-family conflict. Similarly, we have not come across any research in the literature that directly examines the impact of the earthquake on work-family conflict. In a study conducted only in the US, we saw that health care professionals focused on 2 basic factors during the earthquake. These factors are that health care workers do not work in another role and do not have children who need special care at home.Reference Charney, Rebmann and Flood43 With this finding, it can be said that health care professionals may experience work-family conflict if there are children who require special care. This important factor can be included in the research questions as a control variable in future studies. Apart from this, there is evidence that many unexpected events such as epidemics and fires negatively affect health care professionals. For example, Vaziri, et al.Reference Vaziri, Casper and Wayne44 revealed in their study that health care workers experienced high levels of work-family conflict during the COVID-19 epidemic. Likewise, it has been observed that health care workers are undecided between work and family during fire and hurricane periods.Reference Davidson, Sekayan and Agan26, Reference French, Sole and Byers27
There is limited evidence in the literature that the stress levels of health care workers are negatively affected by the earthquake.Reference Cansel and Ucuz41, Reference Guo, Li and Chan45–Reference Tahernejad, Ghaffari and Ariza-Montes47 A similar result was obtained in our research. It has been observed that as earthquake anxiety increases, the perceived stress levels of health care professionals also increase. Likewise, as a result of the hierarchical regression analysis, it was concluded that work-family conflict may increase further when perceived stress is added to earthquake anxiety. It has been observed that the explanatory effect of earthquake anxiety on work-family conflict increases with perceived stress.
In a study conducted on emergency health workers, the focus was on socio-demographic variables affecting the earthquake anxiety of the participants. In this study, women, those whose relatives died in the earthquake, and individuals who had material loss reported higher levels of anxiety.Reference Zortuk, Bedel and Selvi48 Similarly, in this study, we found that some socio-demographic factors were associated with earthquake anxiety. Although the relationships we obtained were not strong, we observed that earthquake anxiety increased as education and age increased.
Some practices can be considered to minimize the mental problems that may occur in health care workers after the earthquake. At the beginning of these practices, training can be given to health care workers to improve their ability to manage disasters. These trainings can be given both within the institution and at universities. For example, in the research conducted on volunteer health care workers after the great Nepal earthquake in 2016, the importance of training on disaster management was emphasized and it was stated that the negative effects of disasters could be reduced with these trainings.Reference Fredricks, Dinh and Kusi49 A similar result was reached in a study conducted as a result of the earthquake in Indonesia, and it was stated that earthquake preparedness levels were higher with regular training given to health care workers.Reference Lopo, Razak and Maidin50
Limitations
The small sample size was a limitation of the study. Many factors, such as the increase in demand for health services especially after the earthquake, busy working hours of health institutions, and the sensitivity of the earthquake issue, limited the sample size. Likewise, it should be underlined that the research is specific to the Kahramanmaraş context. Although the findings obtained are valuable and guiding, caution should be exercised in terms of generalizability.
When we considered the model of our research, we saw that studies examining the impact of the earthquake on health care workers were limited. For this reason, we used research conducted after other events/disasters when comparing our results. We are aware that this is also an important limitation and that each event/disaster has different causes and consequences. A good example of this is stated in a study conducted on health care workers in the US. In the study comparing the pandemic and the earthquake, it was revealed that health care workers were more willing to work during the earthquake rather than the pandemic.Reference Charney, Rebmann and Flood43
Conclusion
It has been revealed that perceived stress and work-family conflict may increase as earthquake anxiety increases. Additionally, it was observed that the earthquake anxiety levels of health care workers were above average. We think that the results are valuable in that they provide some evidence about how the earthquake affected the lives of health care professionals. On the other hand, it is not always possible to overcome the effects of natural disasters that cause great destruction, such as earthquakes, in a short time. At this point, it is of great importance to develop protective policies for health care workers, an important component of society.
In this study, only the anxiety levels of health care workers exposed to earthquakes were evaluated. Although not the same issue, a study conducted after the Wenchuan earthquake revealed that the endurance levels of health care workers who were and were not exposed to the earthquake were low.Reference Charney, Rebmann and Flood43 At this point, a different research design can be planned in subsequent studies, taking into account the opinions of health care professionals who were not exposed to the earthquake. On the other hand, the development levels of countries can also directly affect the results. Today, in countries such as Japan that experience similar earthquakes, there may be less loss of life. At this point, planning a comprehensive study that takes different sample groups into consideration can also make a significant contribution to the generalizability of the results.
Author contribution
FY: Conceptualization, Methodology, Analysis, Investigation, Writing—Original Draft; AT: Writing—review & editing; SDY; Conceptualization, Analysis, Writing—review & editing; ET: Writing— Investigation.
Funding statement
We received no financial support for the research, authorship, and/or publication of this article.
Competing interests
No potential conflict of interest was reported by the author(s).
