Qual Life Res (2013) 22:733–743
DOI 10.1007/s11136-012-0197-4
The association between post-traumatic stress disorder symptoms
and the quality of life among Wenchuan earthquake survivors:
the role of social support as a moderator
Changyi Zhao • Zhibin Wu • Jiuping Xu
Accepted: 3 May 2012 / Published online: 7 June 2012
Ó Springer Science+Business Media B.V. 2012
Abstract
Objective To examine the role of the three types of social
support as possible moderating factors between post-trau-
matic stress disorder (PTSD) and its relationship to two
domains of the quality of life (QOL).
Methods A cross-sectional survey was done in a local
area near the epicenter of the severe earthquake in
Wenchuan. The Diagnostic and Statistical Manual of
Mental Disorders, Fourth Edition (DSM-IV), the standard
Chinese 12-item Short Form (SF-12v2), and the Social
Support Rating Scale (SSRS) were used to interview a total
of 2,080 earthquake survivors in the one-year follow-up
period. Multiple regressions were performed to evaluate
the moderating role of social support on the relationship
between PTSD and QOL.
Results Among survivors one-year after the Wenchuan
earthquake, being a woman (p \ 0.01), having a lower level
of education (p \ 0.01), having a lower level of income
(p \ 0.01), having a worse housing status (p \ 0.05) and
having a higher level of exposure (p \ 0.05) were risk
factors for a poorer QOL (DR2 = 0.063). PTSD symptoms
negatively influenced the QOL (DR2 = 0.145), while social
support positively influenced the QOL (DR2 = 0.016).
However, the interaction between social support and PTSD
weakened the negative effect of PTSD on the QOL
(DR2 = 0.012). Subjective support and support availability
moderated the association between PTSD and the QOL
(DR2 = 0.010).
C. Zhao  Z. Wu  J. Xu (&)
Uncertainty Decision-making Laboratory, Sichuan University,
No. 24, South, Section 1 Yihuan Road, Chengdu 610065,
Sichuan, People’s Republic of China
e-mail: xujiuping@scu.edu.cn
Conclusion Subjective support and support availability
are more useful strategies to improve the QOL of the
earthquake survivors with PTSD symptoms.
Keywords Post-traumatic stress disorder 
Quality of life  Social support  Earthquake
Introduction
Earthquakes caused some of the most devastating natural
disasters of the twenty century [1]. Many studies have
shown evidence that earthquakes can impair the quality of
life (QOL) of survivors [2, 3]. To improve victims’ QOL, it
is necessary to understand how a catastrophic earthquake
and its consequences affect people [4]. Several follow-up
studies have attempted to identify the risk factors associ-
ated with the poor QOL, which is believed to be associated
with mental distress and behavioral change in the aftermath
of an earthquake [2–5]. Among these mental distresses,
post-traumatic stress disorder (PTSD) is the most com-
monly studied and probably the most frequent psychopa-
thology [6, 7]. The prevalence of PTSD was 10.0–34.3 %
in Taiwan after the 1999 earthquake [4], 25 % in Turkey
after the 1999 earthquake [8], 74 % in Armenia after the
1988 earthquake [9], and 21.5–40.1 % in Wenchuan after
the 2008 earthquake [10]. The connection between earth-
quake-induced PTSD and QOL has been studied by health
researchers in recent years [11–13], who insisted that QOL
was strongly and negatively associated with PTSD and
depression. Although there seems to be a clear relationship
between PTSD and diminished QOL after earthquakes,
previous research in this area is somewhat limited. For
example, many scholars pointed out the importance of
early intervention for survivors with high risk factors [14],
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but few researchers have examined the potential mecha-
nisms through which QOL is reduced in earthquake sur-
vivors with PTSD.
The current study was designed to examine the potential
factors that might moderate the association between PTSD
and QOL. Specifically, this study hypothesized that (1)
PTSD was negatively related to the survivors’ QOL post-
earthquake, and (2) social support had a major effect on
moderating the association between the PTSD and QOL of
survivors after the earthquake. Social support was selected
as it can mitigate the negative impact of earthquakes on
people’s wellbeing, as conducted in several studies with
cross-sectional surveys among post-earthquake survivors
[15, 16]. However, inadequate social support might bring no
or even a negative impact on people’s wellbeing because the
appropriateness of social support depends on cultural con-
texts, the life event, the characteristics of the individual and
the relationship between the provider and receiver [17, 18].
Though previous research has investigated how PTSD
influences the QOL, how social support relates to PTSD,
and how social support relates to QOL separately, few of
them have paid attention to the question of how the negative
association between PTSD and QOL may be avoided using
social support. This study is important for policy makers
and society in understanding the consequences of PTSD on
the earthquake victims’ QOL. In addition, there is evidence
that a large amount of resources, both domestic and inter-
national, were under-utilized in the efforts to assist the
earthquake victims [19]. Therefore, the knowledge of how
to develop suitable social support strategies to improve
survivors’ wellbeing after an earthquake might help in
developing more efficient and effective health programs.
In order to test our assumptions, a large-scale survey
(N = 2,080) was conducted in severely affected counties in
Sichuan and Shaanxi 1 year after the Wenchuan earth-
quake. The earthquake struck Wenchuan in Sichuan on
May 12, 2008, measuring 8.0 on the Richter scale.
According to the Ministry of Civil Affairs, more than
70,000 were confirmed dead and more than 400,000
injured, with 18,467 listed as missing and about 6.5 million
people left homeless. The survivors reported significantly
lower scores in the QOL assessment than the general
population in the region [15], which provided a suitable
context for the implementation of the study.
Methods
Sample and procedure
All participants were selected from earthquake-stricken
areas in two provinces-Sichuan and Shanxi. In Sichuan
Province, eighteen counties were chosen: Dujiangyan,
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Qual Life Res (2013) 22:733–743
Pengzhou, Chongzhou, Shifang, Mianzhu, Jiangyou, Anx-
ian, Pingwu, Beichuan, Jian’ge, Qingchuan, Hanyuan,
Wenchuan, Lixian, Maoxian, Songpan, Heishui, and
Xiaojin. In Shaanxi Province, Lueyang was selected. These
counties were selected because they had suffered more
extensive damage than other counties in China. The
inclusion criteria were as follows—having a high degree of
exposure to the earthquake and experiencing the complete
process of the earthquake—with a fair distribution of sex,
age, and place.
Survey teams were temporarily established, including
two graduate students from Sichuan University and one
staff from the local government. They participated in a
5-day training program that included lectures describing the
study protocol and instruments, role-play interviews, and
mutual discussion. The survey comprised all assessments
and was administered by senior staff psychiatrists and
psychologists from Sichuan University’s Medical School.
Before conducting the formal investigation, a pilot test
was carried out in May and June 2009, with a group of
randomly selected survivors participating. Minor modifi-
cations and adjustments were made according to the
feedback from the pilot test. The final version of the
questionnaire was used in the formal investigation. All
assessment forms were translated from English to Chinese
and back-translated by a bilingual team of professionals.
From July to September 2009, the trained groups were
assigned to the counties based on a schedule arranged in
advance. They visited households who lived in their original
houses and in temporary shelter. Houses and tents were
randomly selected on the basis of the total number of the
house and tents, and one respondent within each selected
house or tent was randomly selected. Nearly two-thirds of
the subjects whose houses had fully collapsed in the earth-
quake had moved into new houses constructed by the gov-
ernment. Group members explained the goals of the study to
the inhabitants and made clear that anonymity would be
ensured. Some of the inhabitants declined the interview
because they were wary of such earthquake surveys and
avoided talking about the event. If this was the case, the next
closest one was invited instead. Very few respondents had a
low education level or had literacy problems. The group
members helped those who had problems to note down
answers and accompanied them in the process of completing
the survey. To ensure privacy, interviewers and participants
were encouraged to complete the questionnaire in privately.
There was daily supervision throughout the survey.
The study and procedures described were approved by
the ethics committee of Sichuan University and written
informed consent was obtained from each subject after a
full explanation of the study procedures. The investigation
was conducted in accordance with the latest version of the
Declaration of Helsinki.
Qual Life Res (2013) 22:733–743
Instruments
The self-report questionnaire covered items on four sets of
data, relating to demographic characteristics and exposure
to the earthquake, PTSD, QOL and social support.
Demographic characteristics and exposure
to the earthquake
The demographic characteristics included age, gender, level
of education, monthly income, and housing status. Age was
divided into four groups: 18–30 (coded as 1), 31–40 (coded
as 2), 41–50 (coded as 3), older than 51 (coded as 4). Gender
was coded as 1 (male) and 2 (female). The level of education
was coded to 1 (no degree), 2 (Bachelor) and 3 (Graduate).
There were 4 monthly income levels, namely, 1 = \1,000
Yuan, 2 = from 1,000 to 2,000 Yuan, 3 = from 2,000 to
3,000 Yuan, 4 = more than 3,000 Yuan. Housing status was
coded as: 1 = original houses, 2 = public dormitory,
3 = rented house, 4 = temporary settlements.
Assessment of exposure was summed from multiple
choices to measure whether participants had encountered
the following situations as a result of the earthquake: per-
sonal injuries; deaths or injuries of family members, rela-
tives or friends; loss of or damage to personal or family
property; being a witness to other people seriously injured
or killed; changing jobs after the earthquake; and relocation
to temporary shelters. The higher scores represented greater
earthquake-related exposure. Exposure degrees were coded
as: low exposure (0–1 event), moderate exposure (2–3
events), and high exposure (more than 4 events) groups.
PTSD
A previous study validated the PTSD Check List-Civilian
Version (PCL-C) for collecting background information on
residents and determining PTSD symptoms that result from
disaster related psychiatric disorders [10], which consisted
of 17 items corresponding to each symptom in the Diag-
nostic and Statistical Manual of Mental Disorders, Fourth
Edition (DSM-IV) PTSD criteria B, C, and D [20].
With regard to the Wenchuan earthquake, each symptom
was measured on a scale of 1–5 (rated 1 = not at all,
2 = slightly, 3 = moderately, 4 = severely, 5 = extremely
severely). Criteria B was re-experience of the earthquake
(5 symptoms), criteria C was avoidance and emotional
numbing (7 symptoms), and criteria D was increased arousal
(5 symptoms). The self-report scores of every symptom in
each criterion from the respondents were added to measure
the scale for each criterion. A sum score derived from the
ratings on 17 individual symptoms allows for the quantifi-
cation of PTSD severity. The score in each PTSD domain
was simply added up, generating a total PTSD score ranging
735
from 17 to 85. The coefficient of Cronbach’s alphas for PTSD
was 0.88.
QOL
QOL has been defined as an individual’s perception of their
position in life in the context of the culture and value
systems in which they live and in relation to their goals,
expectations, standards and concerns [21]. It was measured
using the standard Chinese SF-12v2, which consists of 12
items measuring the eight QOL domains. The SF-12v2 was
chosen because it is a good measure for large group studies
(greater than n = 500) and has been validated in China
where a general population norm is available with inter-
national comparability [22, 23]. The SF-12v2 scales
included two dimensions, the physical component score
(PCS) and the mental component score (MCS). PCS
included physical functioning (PF, 2 items), role physical
(RP, 2 items), bodily pain (BP, 1 item) and general health
(GH, 1item), while MCS included vitality (VT, 1 item),
social functioning (SF, 1 item), role emotional (RE, 2
items), and mental health (MH, 2 items) [24].
The US norm based scoring algorithm for SF-12v2 was
used to score the QOL based on Ware’s paper in 1996 [25].
Each question was measured on a 5-point Likert scale
(rated 1 = not at all, 2 = slightly, 3 = moderately,
4 = severely, 5 = extremely). There were 12 questions in
the questionnaire according to the 12 items, which was
revised after the pilot test. The score in each domain of the
SF-12v2 was simply added up, generating a total QOL
score ranging from 12 to 60. A higher score reflected better
perceived health [24]. The coefficient of Cronbach’s alphas
for QOL was 0.83.
Social support
Social support has been defined as the ‘assistance and
protection given to others, especially to individuals’ [26]. It
was measured using the Social Support Rating Scale (SSRS,
which has been shown to have high reliability and validity
on a wide range of Chinese populations [27]. The 2 month
test–retest reliability of the SSRS exceeded 0.92 [28]. The
SSRS contains 10 items, measuring 3 types of social sup-
port: subjective support (SS, 4 items), objective support
(OS, 3 items), and support availability (SA, 3 items). Sub-
jective support reflects the perceived interpersonal network
that an individual can count on. Objective support reflects
the degree of actual support an individual received in the
past. Support availability refers to the pattern of behavior
that an individual utilizes when seeking social support [15].
In our study, 10 questions were designed according to
Xiao’s work in 1999 that was adjusted for the Wenchuan
earthquake. The item scores of the SSRS were simply
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added up, generating a total support score ranging from 12
to 66 [27], a subjective support score ranging from 8 to 32
(4 questions), an objective support score ranging from 1 to
22 (3 questions), and a support availability score ranging
from 3 to 12 (3 questions), respectively. Higher scores
indicate stronger social support. The Cronbach alpha
coefficient for social support was 0.91.
Data analysis
In the present study, descriptive statistics, variance analy-
sis, and correlation analysis were selected. Data were
expressed as a frequency for the nominal variables and as a
mean ± standard deviation (SD) for continuous variables.
Demographic characteristics and exposure to the earth-
quake were control variables in the analysis. Multiple
regression analysis was the principal data analysis tech-
nique used to examine the hypothesis. For missing data, list
wise deletion was used. All tests were 2-tailed, and sig-
nificance was set at 0.05. All statistical procedures were
completed using SPSS16.0 (SPSS, Chicago, IL, USA).
Results
Survey responses
Due to extensive destruction from the earthquake, some
families were unable to remain in their homes and
subsequently relocated. At the time of the survey one-year
after the earthquake, a total of 2,300 households were
interviewed, however, 220 households in the sample areas
were not interviewed, because of the inability to locate the
family (n = 139; 6.04 %), refusal to participate in the
survey (n = 38; 1.65 %), difficulties in understanding
Mandarin (n = 27; 1.17 %), or ineligibility of household
inhabitants (n = 16; 0.70 %). 2,080 subjects subsequently
consented to participate and completed the survey. The
results provided herein are based upon data from these
2,080 subjects.
The mean age of the 2,080 participants at the time of the
interview was 38.24 ± 8.82 years (ranging from 18 to
68 years). The majority (i.e., 59 %) of the subjects were
male. Overall, 52.6 % of the respondents had a relatively
low education level. Apart from the Han ethnic group, the
following ethnic groups participated: Tibetan, Qiang, Hui,
Tujia and Yi (Table 1).
Grouped by demographic variables and the variables to
assess exposure to the earthquake, the scores for physical
health, mental health and overall health status are shown in
Table 2. The gender group only had different evaluations
in mental health status. Male reported higher scores.
Except for the mental health status, subjects of different
ethnic groups reported different scores in physical health
and overall health status. The Hui ethnic group had the
highest score. For age, education, income, housing status,
exposure and PSTD subgroups, significant differences were
found in all three aspects. The 51–68 age group, the

Table 1 The characteristics of

N % N %
the study sample (N = 2,080)
Gender Ethnic group
Male 1,227 59.0 Han 1,674 80.5
Female 853 41.0 Tibetan 147 7.1
Qiang 211 10.1
Age groups (years) Hui 37 1.8
18–30 441 21.2 Other 11 0.5
31–40 849 40.8
41–50 609 29.3
51–68 181 8.7 Education level
Graduate 47 2.3
Income (RMB/month) Bachelor 938 45.1
\1,000 385 18.5 No degree 1,095 52.6
1,000–2,000 1,360 65.4
a
Exposure degrees were 2,000–3,000 264 12.7
categorized by the number of [3,000 71 3.4
the events as a result of the Housing status
earthquake that the participants
Exposurea Original house 758 36.4
have encountered, and were
coded as: low exposure (0–1 High 392 18.9 Public dormitory 295 14.2
event), moderate exposure (2–3 Moderate 766 36.8 Rented house 643 30.9
events), and high exposure Low 922 44.3 Temporary settlement 384 18.5
(more than 4 events)

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Table 2 Scores of physical and

Variables SF-12 physical health SF-12 mental health SF-12 health
mental health on each socio-
demographic variables Mean (SD) p value Mean (SD) p value Mean (SD) p value
(N = 2,080)
Gender *
Male 12.16 (2.23) 16.56 (1.72) 28.39 (2.79)
Female 11.91 (2.30) 16.26 (1.73) 28.01 (2.97)
Age (years) ** * *
18–30 11.91(2.43) 16.27 (1.64) 28.15 (2.95)
31–40 11.77 (2.11) 16.24 (1.70) 28.02 (2.95)
41–50 11.93 (2.16) 16.12 (1.77) 27.98 (2.89)
51–68 12.15 (2.39) 16.37 (1.76) 28.57 (2.87)
Ethnic group ** *
Han 11.78 (2.31) 16.30 (1.74) 28.09 (2.96)
Tibetan 12.17 (2.20) 16.21 (1.81) 28.33 (2.81)
Qiang 11.99 (1.96) 16.13 (1.60) 28.17 (2.39)
Hui 13.08 (1.70) 16.67 (2.04) 29.76 (2.96)
Education level *** *** ***
Graduate 13.41 (2.61) 16.76 (1.77) 29.90 (3.07)
Bachelor 12.02 (2.45) 16.31 (1.70) 28.42 (2.94)
No degree 11.71 (2.06) 16.41 (1.65) 28.46 (2.82)
Income (RMB/month) *** *** ***
\1,000 RMB 11.50 (2.39) 16.11 (1.82) 27.51 (3.12)
1,000–2,000 RMB 11.83 (2.24) 16.29 (1.74) 28.11 (2.81)
2,000–3,000 RMB 12.32 (2.16) 16.43 (1.67) 28.75 (2.66)
[3,000 RMB 13.61 (1.84) 16.62 (1.54) 30.34 (2.63)
Housing status * * *
Original house 12.09 (2.36) 16.47 (1.70) 28.54 (2.87)
Public dormitory 12.09 (2.37) 16.18 (1.79) 28.32 (2.89)
Rented house 11.39 (1.99) 16.47 (1.75) 27.68 (2.79)
The difference tests for ‘Age’ Temporary settlement 11.41 (2.00) 15.90 (1.65) 27.22 (2.79)
and ‘PTSD’ were computed by Exposure *** *** ***
t test, while the difference testes
High 11.72 (2.24) 16.15 (1.75) 27.92 (2.97)
among other subgroups were
performed by the analysis of Moderate 11.80 (2.27) 16.29 (1.70) 27.94 (2.81)
variance (ANOVA) Low 12.10 (2.31) 16.33 (1.78) 28.48 (2.92)
PTSD post-traumatic stress PTSD *** *** ***
disorder No PTSD 12.17 (2.26) 16.25 (1.64) 28.39 (2.88)
* p \ 0.05; ** p \ 0.01; PTSD 10.20 (1.66) 15.49 (1.74) 26.69 (2.47)
*** p \ 0.001

survivors with higher education level, the [3,000 RMB/
month income group, the group living in the original house,
the low exposure group, and the no PTSD group had the
highest score. Recall that in all the eight subgroups, a
higher score indicated a better level of quality of life.
Correlation analysis
The correlation coefficients among the study variables are
presented in Table 3. The PTSD symptoms and social
support were highly related to the two domains of QOL, as
was expected. From Table 3, PTSD symptoms were related
to the hypothesized consequences. For the correlation
between PTSD and the three dimensions of social support,
the highest correlation coefficient (r = -0.37) was between
PTSD and subjective support. The three dimensions of
social support are also significantly correlated with MCS
and PCS. The highest correlation coefficient was between
subjective support and MCS (r = -0.24). The three
dimensions of social support correlated significantly with
each other. The highest correlation coefficient (r = 0.47)
was between subjective support and support availability.
Regression analysis
Using the total QOL score as a dependent variable, the
results of the hierarchical regression analyses are presented
in Table 4. Survivors who were male and with a high level

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Table 3 Correlation coefficients among the study variables

1 2 3 4 5 6 7

1. Exposure 1.00
2. PTSD 0.15* 1.00
3. SS 0.08* -0.37** 1.00
4. OS 0.14* -0.08** 0.27** 1.00
5. SA 0.11* -0.22** 0.47** 0.38** 1.00
6. MCS -0.07** -0.12** 0.24** 0.17** 0.16** 1.00
7. PCS -0.12** -0.04** 0.08** 0.04** 0.27** 0.56** 1.00
PTSD post-traumatic stress disorder, SS subjective support, OS objective support, SA support availability, PCS physical health component score,
MCS mental health component score
* p \ 0.05, ** p \ 0.01

Table 4 Risk factors and

Variables QOL
interaction effect analysis for
total QOL score (N = 2,080) B SE Beta DR2 R2

Step 1 0.063** 0.063**

Gender -0.808 0.164 -0.136**
Age 0.134 0.098 0.041
Ethnic group -0.059 0.121 -0.013
Education 0.479 0.152 0.090**
Income 0.666 0.130 0.154**
Housing -0.156 0.067 -0.064*
Exposure -0.094 0.050 -0.051*
Step 2 0.145** 0.209**
PTSD -0.115 0.010 -0.351**
B unstandardized, beta Step 3 0.016** 0.225**
standardized coefficients, R2 Social support 0.072 0.014 0.145**
explanation rate, DR2 change in Step 4 0.012** 0.237**
explanation rate in each step
PTSD 9 social support -0.005 0.001 -0.101**
* p \ 0.05; ** p \ 0.01

of education, high level of income, better housing status,
and low exposure to the earthquake had a higher QOL
score. Demographic characteristics provided 6.3 % change
in the QOL (DR2 = 0.063, p \ 0.01). A lower QOL score
was explained by a higher level of PTSD, which accounted
for the 14.5 % change of the R2 of the model (DR2 =
0.145, p \ 0.01). In addition, the level of social support
positively contributed to the explanation (DR2 = 0.016,
p \ 0.01). The interaction term between PTSD and social
support made a significant contribution to the explained
variance (DR2 = 0.012, p \ 0.01). Thus, our hypotheses
were supported by the analysis. It was proved that PTSD
had a negative effect on the QOL, and, that social sup-
port was a moderator to the negative effects of PTSD on
QOL.
Similarly, when using MCS and PCS as the dependent
variables, results of the regression analyses are presented in
Tables 5 and Table 6, respectively.
MCS was best explained from survivors’ PTSD
symptoms (DR2 = 0.134, p \ 0.01). Subjective support
and support availability had positive effects on MCS
(DR2 = 0.028, p \ 0.01). As for interactions, a lower
level of PTSD with a higher level of subjective support
was related to a higher level of MCS. In addition, the
interaction between PTSD and support availability
made a significant contribution to the explained vari-
ance in MCS (DR2 = 0.012, p \ 0.01). Survivors who
received more subjective support and support avail-
ability were protected from the negative effects of
PTSD on MCS.
PCS was found to be better in survivors with a better
status of housing and a higher income level (DR2 = 0.007,
p \ 0.01). Better PCS was related to a lower level of PTSD
(DR2 = 0.005, p \ 0.01), and explained by a higher level
of objective support (DR2 = 0.029, p \ 0.01). No inter-
action term between PTSD and social support made a
significant contribution.
In all, it proved that not all the interactions between
types of social support and PTSD influenced each domain
of the QOL.

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Table 5 Risk factors and

Variables MCS
interaction effect analysis for
MCS score (N = 2,080) B SE Beta 4R2 R2

Step 1 0.068** 0.068**

Gender -0.806 0.163 -0.135**
Age 0.129 0.097 0.039
Ethnic group -0.075 0.120 -0.017
Education 0.468 0.151 0.088
Income 0.951 0.150 0.220**
Housing -0.151 0.067 -0.062*
Exposure -0.111 0.050 -0.060*
Step 2 0.134** 0.202**
PTSD -0.116 0.010 -0.356**
Step 3 0.028** 0.230**
SS 0.160 0.056 0.153**
OS 0.059 0.010 0.036
B unstandardized, beta
standardized coefficients, R2 SA 0.331 0.106 0.121**
explanation rate, DR2 change in Step 4 0.010** 0.240**
explanation rate in each step, SS PTSD 9 SS 0.004 0.003 0.052**
subjective support OS objective
PTSD 9 OS 0.013 0.006 0.088
support SA support availability
PTSD 9 SA 0.007 0.011 0.024**
* p \ 0.05; ** p \ 0.01

Discussion
The present study represents how social support mitigates
the negative effects of PTSD symptoms on the QOL among
earthquake survivors. It indicated that PTSD was strongly
and negatively related to the QOL, and social support was
strongly and positively related to the QOL, while social
support weakened the negative effect of the PTSD symp-
toms on the QOL among survivors 1 year after the
Wenchuan earthquake. Social support contributed to a
significant change in the PTSD-QOL model in general. It
was proved in our study that subjective support and support
availability moderated the relationship between PTSD and
MCS.
Some papers have studied the risk factors of survivors’
QOL post-earthquake [4, 5, 29]. In this study, it was
obvious that the PTSD was the main cause for poor QOL
among Wenchuan earthquake survivors. As can be
observed from Table 7, though there are differences in the
location and severity of the earthquake coupled with the
study subjects’ characteristics, the study methodology, and
assessments used to measure the severity of PTSD symp-
toms and the QOL, the present findings of the association
between PTSD and QOL is comparable to other studies
[4, 13, 14, 30, 31].
In our study social support was found to be associated
with QOL, which is consistent with the findings of other
studies [4, 32]. Objective support was positively related to
the PCS of QOL, while subjective support and support
availability were positively related to the MCS of QOL.
Social support not only improves QOL directly, but also
exerts an indirect positive influence on QOL through
facilitating post-disaster recovery among victims [5, 33].
In this study, it was found that PTSD was negatively
related to the PCS of QOL, but these negative effects were
not buffered by any type of social support, differs from
Kuwabara’s study of the 2004 Niigata-Chuetsu earthquake
in Japan [34]. They suggested social support could alleviate
both the psychological and physical effects of an earth-
quake. One possible explanation was that some PTSD
symptoms in our sample, such as re-experiencing the
earthquake, may decline over time [10, 35], so it was not
perceived by the respondents as a serious problem that
could be solved through social support. Another explana-
tion might be the difference in how social support and QOL
were measured.
It is worth noting that the QOL variables which were
significantly influenced by the interaction variables were
the MCS. This finding might be explained by the fact that
the independent variables among survivors with PTSD
symptoms were narrowed to those whose QOL was mainly
affected by their mental health. Among the interaction
variables, subjective support and support availability
turned out to be the most significant moderating factors for
MCS PTSD symptoms in the QOL.
Subjective support is a mediator variable which can
influence behavior [36]. It can mitigate the adverse effect
of PTSD symptoms on QOL in at least two ways. First,
it determines how individuals perceive the support they
have received. Second, it helps individuals comprehend

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Table 6 Risk factors and

Variables PCS
interaction effect analysis for
PCS score (N = 2,080) B SE Beta DR2 R2

Step 1 0.048** 0.048**

Gender 0.820 0.111 0.174
Age 0.100 0.066 0.038
Ethnic group 0.031 0.083 0.009
Education 0.257 0.103 0.061
Income 0.605 0.104 0.176**
Housing -0.062 0.046 -0.032*
Exposure -0.047 0.034 -0.032
Step 2 0.123** 0.171**
PTSD -0.142 0.007 -0.550**
Step 3 0.034** 0.206**
SS 0.039 0.016 0.069
OS 0.027 0.038 0.024**
B unstandardized, beta SA 0.260 0.072 0.121
standardized coefficients, R2
explanation rate, DR2 change in Step 4 0.008 0.214
explanation rate in each step, SS PTSD 9 SS 0.002 0.002 0.036
subjective support, OS objective PTSD 9 OS 0.011 0.004 0.097
support, SA support availability
PTSD 9 SA 0.003 0.005 0.020
* p \ 0.05; ** p \ 0.01

Table 7 The association between PTSD and QOL in different earthquakes

Study Sample PTSD measure QOL measure Findings

Wang The 1998 Zhangbei- The Chinese translation of the The Chinese version When compared with the non-affected comparison
[13] Shangyi symptoms checklist (SCL) of the WHOQOL- group, the victims suffered significantly. More
earthquake in BREF psychological distress in terms of depression,
northern China somatization and anxiety adversely affected the
victims’ quality of life.
Chou [4] The 1999 Chi-Chi The Taiwanese version of the The The quality of life in subjects who develop PTSD
earthquake in Mini-International MOS SF-36 and/or MDE would be worse than those in the
Taiwan Neuropsychiatric Interview Others or Healthy group.
(MINI)
Tsai [12] The 1999 Yu-Chi The Disaster-Related The Medical 3 years after the earthquake, the estimated rate of
earthquake in Psychological Screening Outcomes Study PTSS had declined, and the QOL of the survivors
Taiwan Test (DRPST) Short Form-36 varied according to how their PTSS had
(MOS SF-36) progressed. Survivors with delayed onset PTSS
exhibited a lower QOL when PTSS occurred.
Goenjian The 1999 Parnitha The UCLA PTSD Reaction Quality of Life The QOLQ domain scores were negatively
[30] earthquake in Index (PTSD-RI) Questionnaire correlated with PTSD and depression.
Greece (QOLQ)
The The 2008 Wenchuan The Diagnostic and Statistical The standard Chinese The PTSD was the main cause of the poor QOL
present earthquake Manual of Mental Disorders, 12-item Short Form among Wenchuan earthquake survivors
study Fourth Edition (DSM-IV) (SF-12v2) (DR2 = 0.145).

environmental situations more favorably and actually
reduce exposure to negative effects. Consequently, one
main explanation for why subjective support buffered the
detrimental effects of PTSD symptoms could be that
people with a high level of subjective support tend to use
more effective coping strategies (e.g. use of hostile reac-
tion, withdrawal and wishful thinking) than people with a
low level of subjective support. Thus, survivors with a
higher level of subjective support naturally prevented
themselves from avoidance, emotional numbing and
arousal, and as a result, were more active and efficient in
their social activity, had fewer difficulties in their daily
lives due to emotional problems, and had better feelings
about their QOL. It has been proved in other studies that
subjective support is positively associated with most
domains of the QOL measured by the SF-36 and subjective

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support is a more powerful predictor of subsequent
improvements in PTSD symptoms than objective support
[15, 37].
Several studies have also implied that support avail-
ability is an important factor influencing the psychological
environment of disaster victims [38, 39]. In this light, more
support availability is related to less arousal and encour-
ages survivors to get involved in more social activities
functioning as a moderator between PTSD and MCS,
which is consistent with Watanabe et al.’s [40] observation
among displaced older adults following the 1999 Taiwan
earthquake . Assessing the type of social support an indi-
vidual needs is context dependent and contingent on the
culture under consideration [41], so another explanation for
the moderator effect of support availability might be the
one-child policy in China. The Chinese family structure is
specialized because of the one-child policy, so finding
more ways to ask for help and maintaining more positive
interpersonal relations are viewed as very important and
useful methods to improve the QOL among survivors with
PTSD.
In Ke et al.’s paper, objective support was positively
associated with every domain of QOL among Wenchuan
earthquake survivors [14]. However, in our paper it was
proved to have nothing to do with the negative effects of
PTSD symptoms on QOL. The present study supported
conclusions from other papers that the different dimensions
of social support may play different roles in health, and
emotional support is more important than tangible support
[42]. Thus, it was speculated that, owing to their mental
impairment, survivors with PTSD symptoms after the
earthquake perceived the quantity and quality of objective
support differently from survivors without these symptoms,
and were more sensitive to the subjective support and
support availability than objective support.
In addition, the study found that QOL was closely
related with demographic characteristics. It identified
gender (being a woman), education (lower level), income
(lower level) and housing (worse status) as risk factors for
poorer QOL. These findings are consistent with other
studies [4, 5, 13, 29]. Apart from demographic character-
istics, exposure to the earthquake (higher level) appeared to
decrease QOL for many people in our study. This was also
proved in previous works [38, 42, 43].
Several limitations to this study should be noted. Firstly,
because of the lack of data from before the earthquake, it
cannot be assumed that all the PTSD symptoms reported
here are direct results of the earthquake. Secondly, a survey
in non-disaster areas was not conducted, thus a compara-
tive study based on regional differences is not available at
present. Another limitation of the study was that the vari-
ance explained by the social support examined remained
rather low in part of the regression models. This suggests
741
that it would be useful to broaden the domain of examined
variables, so other kinds of psychological impairments
could be taken into account in future studies or other
moderator factors could be incorporated in the models.
Fourthly, selection bias may exist in the data because of the
sample and recruitment method. Lastly, a self-report
instrument was used so the participants may have over or
under reported.
Despite these limitations, the results emphasize the
importance of developing suitable social support strategies
to improve QOL for earthquake survivors with PTSD
symptoms. Since different dimensions of social support
may play different roles in health and QOL [44], it is
highly recommended that further social support is needed
as part of long-term mental health care policies for earth-
quake survivors, especially for those who are female, have
a lower level of education, a lower level of income, live in
a worse status of housing and have a higher level of
exposure to the earthquake. Further, mental health services
which provide emotional support are needed to access
survivors with PTSD. In all, the social support provided by
the government and the society to survivors with PTSD
should not only focus on objective support, but should
consider a more comprehensive approach by helping
survivors establish and maintain supportive social rela-
tionships by providing more support networks and more
ways to participate socially, as well as to enhance self-
confidence and personal skills by encouraging more sub-
jective support, to cope with PTSD symptoms in order to
improve their QOL.
Acknowledgments We are grateful to the editors and anonymous
referees for their insightful comments and suggestions. We would like
to thank all of the interviewees who showed great patience in
answering the questionnaires. This research was supported by Major
Bidding Program of National Social Science Foundation of China
(Grant no. 08&ZD009) and also partially sponsored by the project of
Investigation Propaganda Department of China Association for Sci-
ence and Technology (Grant no. 2009DCYJ12) and by the ‘‘985’’
Program of Sichuan University ‘‘Innovative Research Base for Eco-
nomic Development and Management’’.
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