p u b l i c h e a l t h 1 4 4 ( 2 0 1 7 ) 9 6 e1 0 2

Available online at www.sciencedirect.com

Public Health

journal homepage: www.elsevier.com/puhe

Original Research

Incidence and risk factors for post-traumatic stress

disorder in a population affected by a severe flood

A. Fontalba-Navas a,*, M.E. Lucas-Borja b, V. Gil-Aguilar c, J.P. Arrebola d,e,

J.M. Pena-Andreu f,i, J. Perez g,h,i
a
Mental Health Clinical Management Unit, Northern Almeria Health Area, Andalusian Health Service, Spain
b
Department of Agroforestry Technology and Science and Genetics, University of Castilla La Mancha, Albacete,
Spain
c
Primary Care Practice Cuevas del Almanzora, Northern Almeria Health Area, Andalusian Health Service, Spain
d
Radiation Oncology Department, Virgen de las Nieves University Hospital, Instituto de Investigaci
on Biosanitaria,
ibs. GRANADA, Granada, Spain
e
CIBER de Epidemiologa y Salud Publica (CIBERESP), Spain
f

laga, Spain
Department of Public Health and Psychiatry, University of Ma
g
CAMEO Early Intervention in Psychosis Services, Cambridgeshire and Peterborough NHS Foundation Trust,
Cambridge, UK
h
Department of Psychiatry, University of Cambridge, Cambridge, UK

article info abstract

Article history: Objectives: We aimed to study the risk of developing post-traumatic stress disorder (PTSD)
Received 26 July 2016 symptoms in people who resided in an affected area by an extremely severe flood, and
Received in revised form sociodemographic risk factors associated with this condition.
7 December 2016 Study design: A geographic information system (GIS) was used to distribute the rainfall data.
Accepted 13 December 2016 A case-control study was developed to study the relationship between PTSD and socio-
Available online 12 January 2017 demographic risk factors.
Methods: To delineate the areas affected by the flood and the intensity of this rainfall in
Keywords: comparison with historical hydrological data, we employed geographical information
Flood systems (GIS). Then, we recruited a representative sample of the affected population and
Flooding another population sample that lived at the time of this disaster in adjacent geographical
Natural disaster areas that were not affected. Both groups were randomly selected in primary care prac-
Post-traumatic stress disorder tices, from December 1st 2012 to January 31st 2013. All participants, 70 from the affected
Public health areas and 91 from the non-affected, filled a sociodemographic questionnaire and the
trauma questionnaire (TQ) to identify and rate PTSD symptoms.
Results: Our GIS analysis confirmed that the amount of precipitation in 2012 in the areas
affected by the flood was exceptionally high compared with historical average rainfall data
(461l per square metre vs 265). Individuals who resided in the affected areas at the time of the
flood were at much higher risk of developing PTSD symptoms (OR: 8.18; 95% CI: 3.99e17.59)

Abbreviations: DTM, digital terrain model; GIS, geographical information systems; IDW, inverse distance weighed; PTSD, post-trau-
matic stress disorder; TQ, trauma questionnaire.
* Corresponding author. Area Gestion Sanitaria Norte Almeria, Avda. Dra Ana Parra SN, Huercal-Overa, Almeria, 04618, Spain. Fax: 34
950451591.
E-mail address: andresfontalba@gmail.com (A. Fontalba-Navas).
i
Joint senior authors.
http://dx.doi.org/10.1016/j.puhe.2016.12.015
0033-3506/ 2016 The Author(s). Published by Elsevier Ltd on behalf of The Royal Society for Public Health. This is an open access article
under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
 p u b l i c h e a l t h 1 4 4 ( 2 0 1 7 ) 9 6 e1 0 2 97

than those living in adjacent, non-affected localities. Among the sociodemographic variables
included in this study, only material and financial losses were strongly associated with the
onset of PTSD (P < 0.001). Physical risk during this life-threatening catastrophe also indicated
a positive correlation with later development of PTSD symptoms; however, it did not reach
statistical significance (P 0.06).
Conclusions: Populations affected by severe floods may suffer an increase of PTSD symp-
toms in the following months. This finding, along with the importance of material losses as
a predictor for such disorder, may help develop effective plans to minimize the negative
impact of these natural disasters on public health.
2016 The Author(s). Published by Elsevier Ltd on behalf of The Royal Society for Public
Health. This is an open access article under the CC BY-NC-ND license
(http://creativecommons.org/licenses/by-nc-nd/4.0/).

stimuli that evoke a memory related to the traumatic situation

Introduction
International research on the consequences of natural di-
sasters has increased significantly in recent years due to
numerous material and human losses caused by these phe-
nomena. The majority of studies on the impact of natural di-
sasters focus on financial costs and tend to ignore their long-
term effects on public health.1
People who have experienced, or have been affected by,
natural disasters are able to recover with the support of their
families, friends or colleagues. However, a significant pro-
portion of them may still suffer from long-term health prob-
lems and disabilities that deeply affect their well-being. Such
events can cause grief, substance misuse, exacerbation of
domestic violence and other aggressive behaviours.2
Climate change is increasing the risk of flooding worldwide.
In Europe, 1.6 million people are at risk of experiencing a flood
each year.3 Indeed, the World Health Organisation (WHO) es-
timates that floods in Europe have affected 3.4 million people
over the last 10 years.4 Floods are amongst the most severe,
life-threatening natural disasters. They usually require long
recovery periods, mainly due to significant material damages.
In fact, works associated with cleaning, rebuilding and/or
refurbishing properties may be costly; affected areas may also
suffer from decline of both tourism and house prices.5 Thus,
people who have been affected by a severe flood may experi-
ence long-term stressors and strong fears of similar disasters
happening again.1 Recovery following a flood involves adap-
tation to new social circumstances. This often carries common
anxiety that may eventually evolve to more complex mental
health problems. Hence, the incidence of severe mental dis-
orders might increase significantly.6
Post-traumatic stress disorder (PTSD) is a condition that
arises as a delayed reaction to extremely threatening or
catastrophic, brief or long-lasting, situations. These events
(natural or man-made disasters, fights, serious accidents,
being witness of a violent death, being a victim of torture, rape
or other crimes) would, in themselves, cause distress to
almost everybody.7 PTSD is characterized by repeated epi-
sodes where the traumatic event is re-lived in the form of
dreams, flashbacks or intrusive memories often accompanied
by emotional numbness and dissociation. It may involve
detachment from others, anhedonia and avoidance of activ-
ities that remind the victim of the event. On some occasions,
may trigger extreme fear, panic or even aggressive behav-
iours. PTSD usually manifests with neuro-vegetative hyper-
activity, hypervigilance and insomnia. Anxiety and
depression may also be present, and substance misuse and
suicidal thoughts are relatively common. The onset occurs
after the traumatic event, following a latent period that may
last from a few weeks to several months.8
The main aim of this study was to compare the incidence
of PTSD symptoms between a population affected by a flood
and another living in adjacent geographical areas that were
not affected by this natural disaster. We also aimed to identify
sociodemographic risk factors associated with the develop-
ment of PTSD symptoms after suffering the flood.
Methods
Study area
On September 28th 2012, Almeria, a province in Southern
Spain, was affected by a severe storm with strong winds and
hail that lasted forty-five minutes. The heavy rainfall was
between 70 and 210l per square metre in some areas. Material
damages included 4300 properties and around 2000 vehicles
and garages which were filled with water and rendered use-
less. Three viaducts were damaged, mud and uprooted vege-
tation amassed in the municipal road network. Ten people
died as a consequence of this intense rainfall. This event and
its consequences were covered by national and international
news media. The total financial losses caused by this natural
disaster are still being calculated; the impact on mental health
has not yet been studied.
Study design
A geographic information system (GIS) was used to distribute the
rainfall data. A case-control study was developed to study the
relationship between PTSD and sociodemographic risk factors.
Study of the extreme precipitation
We studied precipitations recorded by weather stations
managed by the Spanish Meteorology National Agency
(AEMET; http://www.aemet.es). We employed a rainfall
98 p u b l i c h e a l t h 1 4 4 ( 2 0 1 7 ) 9 6 e1 0 2
database, including information from 35 weather stations
distributed across the study area. We collected data for a
period of 78 years (1935e2012). We completed missing infor-
mation by carrying out correlation analyses with nearby
stations.
The rainfall data analysis allowed us to create a spatial
map of precipitations in the study area. A geographic infor-
mation system (GIS) was used to distribute the rainfall data.
With the data obtained from each weather station, we applied
the following stepped methodology:
1. Interpolation method of the rainfall data. The Inverse
Distance Weighted (IDW) method was used to interpolate
annual tendencies of the climatic variables analyzed at
each station. This deterministic interpolation technique is
one of the most frequently used for the creation of spatial
interpolation maps.9
2. Verification of basic statistics for the data.
3. Procurement of a digital terrain model (DTM) using rainfall
as spot height.
4. Contour lines (isolines) were made at certain equidistance.
5. Data interpretation using the isolines obtained with the
GIS.10
Study population and data collection
We selected a representative sample of the directly (and
severely) affected population in the municipalities of Vera,
Cuevas del Almanzora and Pulpi in Almeria, which covered a
population of 37,154 in 2012 (Spanish National Institute of
Statistic; http://www.ine.es). Another population sample that
lived at the time of this disaster in adjacent (less than 30 kms
from the affected areas) municipalities (Zurgena, Macael and
Albox) that were not affected by the flood was also included in
this study. These municipalities covered a total population of
20,835 in 2012.
All participants were recruited by four General Practitioners
(GPs), two of them working in primary care practices covering
the municipalities affected by the flood and the other two in the
non-affected. In Spain, primary care usually is the first point of
contact for people with mental health problems. Everybody is
entitled to receive public health care; thus primary care prac-
tices are ideal places to detect people with emerging psychiatric
disorders, such as PTSD.11 We employed a simple systematic,
pragmatic sampling methodology, where GPs offered partici-
pation in the study, one to every five consecutive patients, aged
18 or over, seen in their clinics for any reason, at least 2 months
after the disaster; between December 1st 2012 and January 31st
2013. We checked, with GIS, whether those patients who
expressed an interest to take part resided in areas affected by
the flood on September 28th 2012.
After obtaining written consent, each participant filled a
basic sociodemographic questionnaire, including sex, age,
educational level and occupational status, and a validated
Spanish version of a trauma questionnaire (TQ)12,13 to identify
and rate PTSD symptoms.
The TQ is a self-report questionnaire that comprised three
sections. It begins with a screening that determines whether
the patient suffered any of the 17 different types of traumatic
events, including natural disasters. It also collects information
regarding the age at which the individual was exposed to any
of these events and the length of exposure. The second section
explores the specific traumatic events that the patient de-
scribes as most severe/worrying and confirms whether he/she
meets DSM-IV criterion A for PTSD.13 Physical risk and asso-
ciated stressors are identified in this section. The final section
contains 18 items, a list of symptoms, with dichotomic re-
sponses (YES/NO), to explore the presence of DSM-IV diag-
nostic criteria BeD for PTSD. It also provides a score that rates
the severity of the current presentation.
Material damages and losses caused by the flood were also
recorded, but only if the estimated costs associated with res-
torations or replacements had been fixed by a judiciary au-
thority and a damage evaluation expert opinion.
This study was approved by the Ethical Committee of
Clinical Investigation Almeria Centro (Spain).
Sample size
To detect differences in the incidence of PTSD symptoms be-
tween the population affected by the flood and those non-
affected living in adjacent municipalities, for a power of 90%
with a significance level of 5%, using a bilateral Chi-squared
test for two independent variables and assuming a propor-
tion of PTSD in the affected group of 22% and 1.95% in the non-
affected, we needed to include 53 participants in each group.
Statistical analysis
We compared the sociodemographic characteristics between
the population affected by the flood and the non-affected. We
employed t-test to compare the age of both groups and Chi-
square test for the sex distribution. For educational levels
and occupational status, we used ANOVA. To determine the
difference in the risk of developing PTSD symptoms between
both groups (odds ratio; OR), we employed logistic regression
adjusted for sex, age, educational level and occupational
status.
We used multivariable linear regression to evaluate factors
associated with the onset of PTSD symptoms, according to the
TQ. We created a single model with the following independent
variables: sex, age, educational level, occupation and
measurable impacts (physical risk and financial/material
looses). The linear regression model was adjusted for sex and
age regardless of their statistical significance, since PTSD is
more common in women14 and the elderly.15
P-values 0.05 were considered as statistically significant.
All analyses were performed using version 3.2.0 of R.16
Results
In 2012, the yearly amount of precipitation registered in the
affected area significantly exceeded the average yearly pre-
cipitation for the previous 78 years (1935e2012). For example,
the average yearly precipitation registered at the municipality
of Huercal Overa in 2012 was 461l per square metre and the
historical average was 312l. In Vera, the local weather station
registered 454l, whilst the historical average was 295. Thus, for
 p u b l i c h e a l t h 1 4 4 ( 2 0 1 7 ) 9 6 e1 0 2
these areas, the amount of precipitation in 2012 was excep-
tionally high. This difference is clearly shown in Figs. 1 and 2,
which display a digital terrain model (DTM) with the average
yearly precipitation in each map.
A total of 70 individuals affected by the flood and 91 from
the adjacent areas participated in this study. Using the sam-
pling methodology outlined above, GPs only had to approach
approximately 100 individuals in the affected areas and 150 in
the non-affected to recruit these samples between December
1st 2012 and January 31st 2013. The characteristics of both
groups are summarized in Table 1. There were no statistical
differences between the two samples with regard to sex, age,
educational level or occupational status.
The likelihood to suffer PTSD symptoms (OR) was 8.18
times higher (95% CI: 3.99e17.59) in the population affected by
the flood.
Among the variables included in this study, only material
losses were strongly associated with the onset of PTSD (see
Table 2). Interestingly, physical risk was also positively asso-
ciated with the later development of PTSD symptoms,
although the association was only borderline-significant.
Discussion
Extraordinary torrential rain that results in a severe flood may
cause severe distress in individuals affected, not only during
the event, but also in the aftermath.17 Our study shows that
people affected by floods may subsequently suffer symptoms
of PTSD. Since PTSD may be a prevalent disorder in the gen-
eral population, our comparison of a population affected by a
severe flood in Southern Spain with another, non-affected,
living in adjacent areas reinforced the association between
Fig. 1 e Raster image representing average yearly precipitation in the study area from 1935 to 2012.
99
the onset of PTSD symptoms and the flood, which was rigor-
ously analyzed with hydrological and statistical methods.
A previous meta-analysis suggested that trauma severity,
lack of social support and additional life stressors were strong
predictors of PTSD. However, these results were limited by the
variety of measures used to determine trauma severity, both
between and within different types of traumas.18 Focusing on
traumatic events, such as natural disasters, that allow the use
of more accurate and objective measures of severity can
reduce this limitation. For example, GIS accurately pinpointed
the geographical radius affected by this catastrophe and its
intensity.
Climate change is affecting the spatio-temporal variations
of extreme precipitation. It is expected that variations in fre-
quency and intensity of 24-h extreme precipitation will favour
the increase of torrential rain processes and dynamic
geomorphic hazards which may increase human and material
losses. Therefore, the consequences of a catastrophic flood on
a population are mainly related to the intensity and impact of
the disaster. However, sociodemographic factors may also
play an important part. Notably, the main sociodemographic
variable that predicted the onset of PTSD symptoms in our
study was the material and financial losses associated with
the disaster. Interestingly, this association was stronger than
the perception of serious physical risk at the time of this life-
threatening event. Our finding is in line with previous studies
that identified financial difficulties after domestic floods as a
risk factor to develop severe mental disorders.19,20
One of the limitations of the study is its cross-sectional
nature. We recruited participants and collected data be-
tween 2 and 4 months after the catastrophe. We did not follow
them up and could have missed some cases that developed
PTSD symptoms after a longer latent period. This would have
100 p u b l i c h e a l t h 1 4 4 ( 2 0 1 7 ) 9 6 e1 0 2

Fig. 2 e Raster image representing average yearly precipitation in the study area for 2012.

increased the incidence of this condition rather than sample during the study period. Most of them were recruited
decreasing it. Also, the study only included people recruited in consecutively, following the sampling methodology outlined
primary care practices, and not all the patients invited finally above. Furthermore, everybody in Spain has access to the
agreed to take part in the study, which might affect the gen- National Health System, which provides public healthcare for
eralisability of our results. However, as stated before, GPs did Spanish citizens, nationals of European Union (EU) Member
not have to invite a large number of people to recruit our final States and non-EU Member States, and other foreign na-
tionals, including undocumented immigrants within the
Spanish national territory.21 Thus, 100% of the population is
entitled to be treated in primary care practices.22 Accordingly,
Table 1 e Sociodemographic characteristics of the groups
we believe that our sample was representative of the people
affected and not affected by the flood.
Variable Affected Non- P-value
affected
N 70 91 Table 2 e Multivariable linear regression analysis to
Age (mean, SD) 51.58 (15,42) 51.74 (17,45) 0.95a determine predictors of PTSD symptoms according to the
Sex (% female) 64.03 62.60 0.82b TQ.
Education level (%) 0.87c
Variable Beta Standard P-
No education 1.4 1.1
error value
Primary school 24.3 22.0
High school 45.7 47.3 Intercept 0.28 2.38 0.90
University 28.6 29.7 Age 0.02 0.04 0.62
Occupational status (%) 0.64c Sex (female) 0.70 0.76 0.36
Employed 35.7 29.7 Occupation (housewife)a 0.14 1.32 0.91
Self-employed 8.6 11.0 Occupation (unemployed)a 0.11 1.14 0.92
Housewife 14.3 9.9 Occupation (retired)a 1.51 1.39 0.27
Unemployed 21.4 20.9 Occupation (self- 1.55 1.30 0.23
Retired 20.0 28.6 employment)a
TQ score (mean, SD) 5.39 (6.02) 1.59 (4.13) <0.01a Education (school)b 0.73 1.10 0.12
Physical risk during 12.90 2.20 <0.01b Education (high school)b 2.13 1.87 0.25
flood (%) Education (university)b 0.09 0.95 0.33
Material losses during 47.10 3.30 <0.01b Physical risk (yes) 2.85 1.47 0.06
flood (%) Financial losses (yes) 6.90 0.95 <0.01
a
t-test. Multiple R-squared: 0.3919; adjusted R-squared: 0.3457.
b a
Chi-square test. Reference: employed.
c b
ANOVA. Reference: no studies.
 p u b l i c h e a l t h 1 4 4 ( 2 0 1 7 ) 9 6 e1 0 2
living in the study area. Despite previous evidences suggesting
that PTSD is more common in women14 and the elderly,15 in
our study population age and sex were not found to be sig-
nificant predictors of PTSD symptoms. This might be due to
adjustment for other variables that were more strongly asso-
ciated with that outcome. Future studies in similar contexts
should consider other psychosocial factors that might also
contribute to predict the development of PTSD symptoms in
any of those two groups.
Our results indicate that the severe flood suffered by peo-
ple living in Almeria, Southern Spain, in September 2012
increased the incidence of PTSD symptoms in the following
weeks/months, and emphasize the importance of material
and financial losses as a strong predictor for the development
of this condition.23 These findings may help plan and develop
effective public health solutions to minimize the impact of
such disasters on the mental health of people whose posses-
sions and lives are destroyed by forces of nature. In addition to
better provision of trauma-focused mental health care and
appropriate financial support, other practical measures may
also prevent such disasters in certain regions prone to severe
flooding. For instance, GIS can help develop and plan many
land management tools, such as reforestation programs.
Planting trees or shrubs have been one of the most widely
used methods to prevent floods and sediment delivery from
hydrological catchment; plants greatly favour water infiltra-
tion and interception avoiding runoff processes.24 Check
dams, reforestations and silvicultural treatments should help
reduce the risk of floods and subsequent impact on pop-
ulations living in semi-arid areas, such as Almeria.
Author statements
Acknowledgements
AFN was the principal investigator, designed the study and
supervised data collection. MELB contributed to the study
design and was responsible for the GIS analysis. VGA coordi-
nated the recruitment of participants in primary care. JPA led
the statistical analysis. JMPA contributed to the design and
supervised the study team. AFN and JP drafted the manu-
script. All the authors read, edited and approved the final
manuscript.
Ethical approval
All procedures performed in studies involving human partic-
ipants were in accordance with the ethical standards of the
institutional and/or national research committee and with the
1964 Helsinki Declaration and its later amendments or com-
parable ethical standards.
This study was approved by the Ethical Committee of
Clinical Investigation Almeria Centro (Spain).
Informed consent
Informed consent was obtained from all individual partici-
pants included in the study.
101
Funding
JPA is under contract from the Instituto de Salud Carlos III,
Spain (Miguel Servet Program CP15/00193).
JP was supported by the NIHR programme grant RP-PG-
0606-1335 Understanding Causes of and Developing Effective
Interventions for Schizophrenia and Other Psychoses.
Competing interests
None declared.
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