Changes in religious beliefs and the relation of religiosity to posttraumatic stress and life satisfaction after a natural disaster.

OBJECTIVE: To study changes in religious beliefs and predictors of such changes in a community sample exposed to a natural disaster, and to investigate whether religiosity was linked to post-disaster mental distress or life satisfaction.
METHODS: An adult population of 1,180 Norwegian tourists who experienced the 2004 tsunami was surveyed by a postal questionnaire 2 years after the disaster. Data included religiosity, disaster exposure, general psychopathology, posttraumatic stress and life satisfaction.
RESULTS: Among the respondents, 8% reported strengthening and 5% reported weakening of their religious beliefs. Strengthening was associated with pre-tsunami mental health problems (OR: 1.82, 95% CI: 1.12-2.95) and posttraumatic stress (OR: 1.62, 95% CI: 1.22-2.16). Weakening was associated with younger age (OR: 0.98, 95% CI: 0.96-1.00) and posttraumatic stress (OR: 1.72, 95% CI: 1.23-2.41). Two years after the tsunami, 11% of the sample considered themselves to be positively religious. There were no significant differences in posttraumatic stress, general psychopathology or life satisfaction between religious and non-religious groups.
CONCLUSIONS: Religion did not play an important role in the lives of Norwegian tsunami survivors in general. Respondents who had the greatest disaster exposure were more likely to report changes in religious beliefs in both directions. Religious beliefs did not prevent post-disaster long-term mental distress, and religiosity was not related to higher levels of life satisfaction.

Introduction

Traumatic events affect not only the psychological dimension of the self, but also the faith system that gives meaning to life [40]. Religious beliefs can develop through the experience of traumatic events, and religion and spiritual beliefs can be helpful in psychological recovery [37]. Traumatic experiences sometimes enhance religious beliefs [7] or lead to an increase in religious activity [35]; alternatively, such experiences can result in a weakening of religious commitment [36] or even abandonment of religious faith [11].

Religion has often been perceived as a source of comfort, meaning and purpose for individuals who experience traumatizing life events [8, 34]. For many people, religion can make suffering understandable and bearable [32], and provides a means of coping in times of extreme stress [30, 31]. There have been many studies of religious coping [20] and of the relationship between religiosity and mental health [16, 18, 27]. The findings are somewhat inconclusive, although most report that religious commitment is related to better mental health [29]. Most of the studies are from the USA where religion seems to play an important role both at the community level [12, 26] and in the lives of many victims [34]. Also, the literature on the religion–health connection has focused almost exclusively on religion as predictor of health resulting in few studies where religiosity is used as an outcome measure [24].

In many European countries, religion plays a secondary role in daily life activities [19]. According to an international Gallup survey [15], the Norwegians are among the least religious people in Europe. Although the majority of Norwegians are members of the state church, religiosity does not impact on the daily lives of most individuals. Yet, attendance to religious ceremonies and participation in memorial services were striking among Norwegians in the aftermath of the 2004 tsunami. Such collective ritual response has also been described in the acute phase after major accidents in Norway [9]. However, it is unclear what role religion plays in the lives of Norwegian trauma victims in the long run and whether major disasters can induce enduring changes in religious beliefs.

In the present study, we explored the association of characteristics of survivors of a natural disaster and their religious beliefs. We specifically address four questions. First, what is the prevalence of changes in the strength of religious faith following the 2004 tsunami in Norwegian tourists? Second, what factors predict these changes? Third, does religion play an important role in the lives of the tsunami survivors 2 years after the disaster? And finally, are there any differences regarding posttraumatic stress, general psychopathology and life satisfaction between those who report that religion is a source of strength and those who do not?

Methods

Study sample and design

The 2004 southeast Asia tsunami was one of the largest tragedies in recent history with a death toll of 226,408 (Centre for Research on the Epidemiology of Disasters, de Louvain, Belgium, e-mail of 25 June 2008). In the days following the disaster, all Norwegian tourists were repatriated from disaster-affected countries and registered by the police upon their arrival in Norway. To investigate the long-term mental health aspects, 2 years after the tsunami a questionnaire was mailed to all registered individuals over the age of 18 years at the time of the disaster (N = 2,468). The questionnaire was returned by 1,180 survivors (49.3% response rate, 76 persons not located). The average current age of respondents was 45.0 years (SD = 12.9); 49.2% were men, 58.2% had ≥13 years of education, 68.5% were currently married or cohabitating and 73% were employed. The reported lifetime prevalence of contact with a general practitioner, psychologist or psychiatrist for mental health concerns was 23.3% prior to the tsunami.

Most respondents had been exposed to the tsunami as threat to their lives and/or horrific witness experiences [22].

We investigated lack of participation with follow-up telephone interviews in a random sample of non-participants (n = 171) [25]. Non-participants did not differ significantly from participants in terms of age and gender, but they reported lower levels of disaster exposure and lower levels of posttraumatic stress symptoms. The most frequently reported reasons for not participating in the study were lack of interest or time (39.2%) and not being directly affected by the disaster (32.2%).

The study was approved by the regional committee for medical research ethics and by the Norwegian Social Science Data Services.

Measures

Religiosity

Changes in religious beliefs were measured by a question from the ‘Religious Outcome Scale’ [33]: do you feel that you have become more religious after the tsunami? Subjects were asked to answer this question using a five-point scale: 1 = much more religious; 2 = somewhat more religious; 3 = no change; 4 = somewhat less religious; 5 = much less religious. Responses 1 and 2 were considered as strengthening of religious beliefs, while responses 4 and 5 were considered as weakening of religious beliefs.

Religiosity at the time of the study (“current religiosity”) was measured by a question from Zuckerman’s three-item Index of Religiousness [41]: how much is religion a source of strength and comfort to you? Responses were coded on a four-point scale ranging from 1 (= “none”) to 4 (= “a great deal”). Responses 1 and 2 were considered to indicate that the respondent was less religious (labeled non-religious), while responses 3 and 4 were considered to indicate that the respondent was positively religious (labeled religious).

Both questions concerning religion addressed personal feelings of religiosity rather than attachment to a religious community or participation in religious activities. Thus, the questions were applicable to all the respondents regardless of their specific belief system.

Disaster exposure

Respondents were asked about the degree to which they perceived that their life had been threatened by the tsunami, whether a close relative or friend died in the tsunami, and whether they sustained physical injuries from the tsunami. In a previous study of Norwegian tsunami survivors, the life threat intensity was the best predictor of health complaints [23].

Posttraumatic stressors and symptoms

The “List of Threatening Experiences, questionnaire version (LTE-Q)” [4] was used to assess additional stress experienced after the tsunami. This instrument measures 12 adverse life events during the previous year that carry significant long-term threat.

Current posttraumatic stress symptoms were measured using the Impact of Event Scale-Revised (IES-R) [39]. The IES-R is a 22-item self-report measure of subjective distress following exposure to traumatic events. Symptom severity was measured according to the original IES-R by five response anchors (0 = not at all, 1 = a little bit, 2 = moderately, 3 = quite a bit and 4 = extremely), as experienced in the previous 7 days.

The General Health Questionnaire (GHQ-28) [17], scored on a four-point Likert scale (0,1,2,3), was used as a measure of general psychopathology.

Life satisfaction was measured with Cantril’s Ladder of Life (LOL) [6] which consists of ten steps. The top rung of the ladder (10) represents the best possible life imaginable and the bottom rung (1) represents the worst possible life. Respondents were instructed to write the number of the step on which they felt they currently stood.

Statistics

Bivariate logistic regression analyses were used to determine associations between demographic and background variables, disaster exposure, current posttraumatic stress symptoms and dependent variables such as strengthening of religious beliefs (versus not) or weakening of religious beliefs (versus not). Odds ratio was used as measure of the strength of an association. Multivariate logistic regression analysis was used to determine the adjusted effects of predictors of changes in religious beliefs, controlled for age and gender. All variables that were significant in bivariate analyses were entered in the multivariate regression model. Bivariate analyses were performed using t tests (continuous variables) and Chi-square tests (categorical variables) to compare the religious and the non-religious respondent groups according to demographic and exposure variables. Multiple linear regression analyses were performed to assess the relationship between religiosity and measures of posttraumatic stress (IES-R), general psychopathology (GHQ-28) and life satisfaction (LOL), while adjusting for other significant variables.

All analyses were conducted using the software Statistical Package for the Social Sciences (SPSS, version 16.0). P values <0.05 were considered to be significant.

Results

The majority of responding Norwegian tourists, 86.5% (n = 1,005) reported no change in their religious beliefs following the tsunami, 97 (8.3%) reported strengthening of religious beliefs and 60 (5.2%) reported weakening. Strengthening of religious beliefs was bivariately associated with pre-tsunami mental health problems, life threat intensity as experienced during the tsunami, loss of a family member or close friend, inflicted injuries, posttraumatic stress and post-tsunami adverse life events (Table 1).

Table 1

Overview of bivariate logistic regression analyses conducted to determine general associations between becoming more religious and demographic variables, exposure variables and current posttraumatic stress

	Total N	More religious n (%) or mean	Odds ratio
Gender
Male	568	41 (7.2)
Female	594	56 (9.4)	1.34
Missing	17
Age (years)a	1,162	41.9 vs. 41.7	1.00
Missing	17
Education
<13 years	466	36 (7.7)
≥13 years	676	60 (8.9)	1.16
Missing	37
Married or cohabitinga
Yes	816	62 (7.6)
No	327	32 (9.8)	1.32
Missing	36
Employeda
Yes	922	74 (8.0)
No	240	23 (9.6)	0.82
Missing	17
Pre-tsunami mental health problems
No	870	60 (6.9)
Yes	275	35 (12.7)	1.97*
Missing	34
Life threat intensity
None	335	14 (4.2)
Small/moderate	415	28 (6.7)	1.66
Great/overwhelming	311	47 (15.1)	4.08**
Missing	118
Loss of family members or close friends
No	1,079	81 (7.5)
Yes	79	15 (19.0)	2.89**
Missing	21
Physical injury
No	1,002	71 (7.1)
Yes	141	25 (17.7)	2.83**
Missing	36
Post-tsunami adverse life events
No	436	24 (5.5)
Yes	714	73 (10.2)	1.96**
Missing	29
IES-Rb (mean item score)	1,158	0.90 vs. 1.55	2.21**
Missing	21

* P < 0.01

** P < 0.001

aAt the time of the disaster

bImpact of event scale-revised

A multivariate logistic regression model revealed that strengthening of religious beliefs remained significantly associated with pre-tsunami mental health problems (OR: 1.82, 95% CI: 1.12–2.95, P = 0.015) and with posttraumatic stress (OR: 1.62, 95% CI: 1.22–2.16, P = 0.001).

Weakening of religious beliefs was bivariately associated with younger age, life threat intensity, posttraumatic stress and post-tsunami adverse life events (Table 2).

Table 2

Overview of bivariate logistic regression analyses conducted to determine general associations between becoming less religious and demographic variables, exposure variables and current posttraumatic stress

	Total N	Less religious n (%) or mean	Odds ratio
Gender
Male	568	35 (6.2)
Female	594	25 (4.2)	0.67
Missing	17
Age (years)a	1,162	42.1 vs. 38.6	0.98*
Missing	17
Education
<13 years	466	28 (6.0)
≥13 years	676	30 (4.4)	0.73
Missing	37
Married or cohabitinga
Yes	816	38 (4.7)
No	327	21 (6.4)	1.41
Missing	36
Employeda
Yes	922	47 (5.1)
No	240	13 (5.4)	0.94
Missing	17
Pre-tsunami mental health problems
No	870	44 (5.1)
Yes	275	15 (5.5)	1.08
Missing	34
Life threat intensity
None	335	10 (3.0)
Small/moderate	415	23 (5.5)	1.91
Great/overwhelming	311	22 (7.1)	2.47*
Missing	118
Loss of family members or close friends
No	1,079	54 (5.0)
Yes	79	5 (6.3)	1.28
Missing	21
Physical injury
No	1,002	48 (4.8)
Yes	141	10 (7.1)	1.52
Missing	36
Post-tsunami adverse life events
No	436	14 (3.2)
Yes	714	46 (6.4)	2.01*
Missing	29
IES-Rb (mean item score)	1,158	0.93 vs. 1.41	1.81**
Missing	21

* P < 0.05

** P < 0.001

aAt the time of the disaster

bImpact of event scale-revised

A multivariate logistic regression model showed that weakening of religious beliefs remained significantly associated with younger age (OR: 0.98, 95% CI: 0.96–1.00, P = 0.047) and posttraumatic stress (OR: 1.72, 95% CI: 1.23–2.41, P = 0.002).

A minority of the study population (10.8%) reported that religion was an important source of personal strength and comfort (positively religious). Religiosity was associated with female sex, older age, unemployment, and pre-tsunami mental health problems, but not with exposure (analyses not shown). There were no significant differences between the religious and the non-religious groups regarding posttraumatic stress, general psychopathology and life satisfaction (Table 3).

Table 3

Comparing religious and non-religious respondent groups (t test) according to life satisfaction (LOL), general psychopathology (GHQ-28) and posttraumatic stress (IES-R)

	Religious group n = 128	Non-religious group n = 1,133	P values
LOLa
Mean score	7.38 (SD = 1.92)	7.28 (SD = 1.85)	0.58
GHQ-28b
Mean total score	26.2 (SD = 14.3)	24.3 (SD = 13.4)	0.22
IES-Rc
Mean total score	24.0 (SD = 19.2)	20.7 (SD = 18.2)	0.06

aLadder of life

bGeneral health questionnaire

cImpact of event scale-revised

Also when controlling for potential confounders such as gender, age, unemployment, and pre-tsunami mental health problems, no significant association between religiosity and posttraumatic stress, general psychopathology or life satisfaction were found.

Discussion

Our results showed bidirectional changes in religious beliefs in Norwegian disaster survivors 2 years after the 2004 southeast Asian tsunami. To the authors’ knowledge, no other study has examined changes in religious beliefs after a natural disaster. However, similar changes have been reported in studies after other types of traumas [11, 13, 14, 38]. In the present study, there was less change in religious beliefs compared to populations of potentially traumatized individuals with prolonged exposure, such as US war veterans [11, 14] and cancer patients with ongoing threat of life [38]. There was also less change in our study population than in a mixture of US community and mental health treatment samples that had experienced various potentially traumatizing events [13]. The respondents in the present study experienced the tsunami as a distinct and time-limited stressful event. Due to repatriation to safe and stable communities in Norway, they escaped the typical burden of secondary disaster stressors. Thus, the lower prevalence of change in religious belief may be due to the particular type, magnitude and duration of exposure [34].

Posttraumatic stress was the main predictor of both strengthening and weakening of religious beliefs. This is in agreement with some previous studies [13], but not with others [14]. Post-disaster stress may be a confounder for severe disaster exposure, which could be the real cause of religious changes or it may have triggered changes in religious beliefs by itself [1, 13]. It has been suggested that greater spirituality may develop as a coping mechanism in response to personal suffering [10]. Also, personal growth in general may follow trauma and subsequent struggle with adversity [5, 28].

Respondents with pre-tsunami mental health problems were more likely to report strengthening of religious beliefs. It is possible that previous mental health problems evoked spiritual or existential interests at an earlier stage of life [2, 3]. When coping with the tsunami, a strengthening of religious belief may have been more likely among those who had previously used religion as part of a coping strategy [32].

No differences were found in life satisfaction or general psychological distress between the religious and non-religious survivors. This does not support the general idea that religiosity prevents long-term mental stress [18, 24, 37] or leads to higher life satisfaction [18, 20, 27].

Limitations

The cross-sectional study design did not allow us to draw conclusions about cause–effect relationships. Use of single item measures limits an in-depth understanding of the findings given the complex construct of religiosity [24]. Also, caution should be exercised in generalizing our findings, which may be limited to populations who experience traumatic events with a sudden impact and relatively brief exposure.

The representativeness of the population in terms of religion may be questioned as participants had chosen to celebrate their Christmas holiday abroad in a non-Christian country. However, more than 90% of the Norwegian tsunami survivors were in Thailand, where Christmas is celebrated in tourist resorts and also by the Norwegian Church Abroad. Further, the participants were similar to the age- and gender-adjusted Norwegian population with regard to employment and marital status [21].

Conclusion

We found a bidirectional change in religious beliefs among a minority of the tourists who experienced the 2004 tsunami; changes in religious beliefs were more common among respondents who had the greatest disaster exposure. Our findings did not support the hypothesis that religious beliefs prevent long-term posttraumatic stress, and religiosity was not associated with higher levels of life satisfaction. Future studies should focus on repeated measures of religiosity, posttraumatic stress and life quality to examine religious stability, changes in religious beliefs and cause–effect relationships.