Discussion

In this study, mental trauma and coping with trauma situations in emergency service workers, who gave medical intervention to earthquake victims in the 2020 İzmir earthquake, were evaluated. In the study, the participant was determined to be intermediate traumatic and anxiety levels of the participants were above the average. ^{Reference Tanhan and Kayri17,Reference Öner and Le Compte19} Studies have shown that emergency room personnel are at high risk for mental health problems, including anxiety, depression, and psychological distress. ^{Reference Taylor, Cocks and Ashe22,Reference Lu, Mueser and Yanos23} In particular, it has been determined that post-traumatic stress disorder is approximately 2 to 3 times more common among various groups of emergency service personnel (eg, ambulance specialists, rescue workers) than in the general population. ^{Reference Taylor, Cocks and Ashe22} We defined as traumatic according to the results of the scale, as a clinical this may not be sufficient to meet the symptoms of PTSD, more often it may be considered sub-PTSD. This study has implications for the nosology and symptoms of PTSD. We believe that the part of health-care workers in our study can be evaluated as subsyndromal PTSD. ^{Reference Lu, Mueser and Yanos23} Identification of subsyndromal PTSD provides the opportunity for early treatment and better prognosis. As McFarlane and colleagues argue, subsyndromal PTSD should not be viewed merely as a normal response to an abnormal event. ^{Reference McFarlane, Lawrence-Wood and Van Hooff24} Post-traumatic stress symptoms, even at the subsyndromal level, have been found to be associated with increased anxiety symptoms with significant social and occupational impairment, as is full PTSD. Administrative steps may be necessary to ensure that health-care personnel identified as having subsyndromal PTSD receive trauma-focused treatment and long-term follow-up. ^{Reference Lawrence-Wood, Baur and Lawrence25,Reference McLaughlin, Demyttenaere, Koenen, Bromet, Karam and Koenen26}

When exposed to more stress, they should be considered as “symptoms that are a harbinger of later mental disorders.” We found that the younger participants and those with the highest education level (doctoral) were more affected by the earthquake, which may make them more at risk in terms of trauma. We found that men, the youngest group (20-25 y old), those with a master’s degree, use “positive reappraisal” as a coping mechanism. The subsyndromal group is not defined as completely non-pathological, because clinically significant impairments are significant. According to Mylle and Maes (2004), taxonomy is important because the diagnosis also defines the medico-legal positions of the subjects and the position of individuals with subthreshold PTSD is uncertain. ^{Reference Mylle and Maes27} However, in the literature, PTSD symptoms are higher in the subsyndromal group compared with the healthy ones. Although not a clear diagnostic category, subthreshold PTSD may not be part of a normative response to trauma but should be considered because it can cause significant impairment and be chronic. It was researched to determine the stress level left on the health workers who experienced and responded to the 30 October Izmir earthquake. Because Turkey is in an earthquake zone, it faces damages resulting from disasters. It is necessary to take preventive measures to minimize the losses and damages that may occur after the earthquake and to prevent mental health problems that may arise after the quake. ^{Reference Akalın, Şakiroğlu and Eren28}

A relationship was found between postearthquake trauma and negative perceptions of the individual and the world, self-blame. According to the theoretical premise of cognitive models of psychopathology, dysfunctional cognitive processing in the form of distorted evaluations is very important in the emergence of psychological disorders. Negative post-traumatic cognitions are important in the development, persistence, and treatment of PTSD. It has been determined that these cognitions contribute to the individual’s sense of “present threat,” thereby increasing vulnerability to develop PTSD. ^{Reference Hyland, Murphy and Shevlin29–Reference van Heemstra, Scholte and Ehring31} Levels of postearthquake trauma were found to be linked to state and trait anxiety, as well as religious coping. Religious coping was found to be more prevalent, especially when the individual’s negative self-perceptions increased. When people are confronted with trauma, crisis, or stressful events, they often use a variety of coping strategies. Coping can be defined as the thoughts and behaviors that individuals use to manage the internal and external demands of situations that are considered stressful. Spirituality may be quite beneficial in the aftermath of a terrible event. When faced with distress or trauma, most people turn to religion or spirituality as a coping mechanism, and they often find it to be effective. ^{Reference Mesidor and Sly32,Reference Park, Sacco and Mills33} It appears to be the primary mechanism through which spirituality and religion influence psychological outcomes. ^{Reference Mesidor and Sly32} When it comes to dealing with stress and major life events, religion’s ability to provide meaning in life is especially apparent. Religious coping can be defined as “the degree to which religion is a part of the process of understanding and coping with critical life events”. ^{Reference Pargament, Ano, Wachholtz, Paloutzian and Park34}

Social assistance has been shown in studies to help people recover after a disaster. One of the most commonly reported coping mechanisms among survivors is seeking help. Individuals’ perceptions about their family, friends, and society are referred to as perceived social. Understanding and satisfying the needs of disaster-affected people requires a familial context. Social support is a resource that changes the negative perception of self and affects psychological and physical well-being, psychosocial adaptation, and personal gains. ^{Reference Mesidor and Sly32,Reference Samuel and Burger35} It has been observed that increased social support improves mental well-being, particularly in cases of increased anxiety. It was observed that there was an increase in state and trait anxiety levels, negative cognitions about oneself, negative cognitions about the world, and self-blame increased the behavior of seeking social support after the earthquake in the study participants.

Evaluating the scores obtained from the age scale showed that there was a significant difference between the groups in the positive reassessment subscales of SCESS, with the 26- to 30-y-old group receiving the highest score. According to Ericsson’s Psychosocial Theory, people of different ages encounter different life events, go through a series of life stages of psychosocial development, and the major social emotions at each life stage. It solves the conflict well. ^{Reference Erikson36} Folkman and Lazarus (1980) have a contextual theory of aging. ^{Reference Folkman and Lazarus37} They argue that different types of stressors appear with age, and that these differences in stressors affect coping strategies and health outcomes. Adults’ stress exposure differs depending on their life context, according to the contextual theory of Folkman and Lazarus (1980). ^{Reference Folkman and Lazarus37} As a result, it exhibits a variety of stress levels. According to 1 study, as people get older, they are less affected by stress and anger. ^{Reference Stone, Schwartz and Broderick38} According to Socioemotional Selectivity Theory, which explains the change in emotional functioning with advancing age, it has been found that, as perceptions of time alive decrease (a natural consequence of aging), people prioritize achieving emotion-focused goals over knowledge-based goals. ^{Reference Sliwinski, Freed and Scott39} In another study investigating the level of stress during the COVID-19 (coronavirus disease 2019) period, it is found that the stress level decreases with increasing age; the adolescent population perceives the highest amount of stress, while middle-aged adults perceive the least amount of stress. ^{Reference Singh, Mani Pandey and Datta40} According to another study, post-traumatic growth and post-traumatic stress have a low-level significant positive relationship. This demonstrates that those who have growth because of a traumatic event also have stress symptoms. ^{Reference Kardaş and Tanhan41}

According to the gender of the participants, it was determined that men got higher scores in the positive PR subscale of SCESS. In addition to the effects of the COVID-19 pandemic on physical health, it can also have several adverse effects on people’s mental health. However, these adverse effects may differ according to gender. In a previous study, coping with negative situations in life was evaluated in young adults, and it was found that young male adults exhibit faster-coping strategies. ^{Reference Salas-Rodríguez, Gómez-Jacinto and Hombrados-Mendieta42} It has been determined that men can make decisions faster than women and have more tendency to take risks. It has been determined that women have difficulty coping with negative situations, experience more anxiety, and show depressive symptoms. ^{Reference Yang, Luo and Zhou43} At the same time, studies in the literature have found a significant relationship between young age and the female gender with the probability of developing these problems. ^{Reference Serrano-Ripoll, Meneses-Echavez and Ricci-Cabello44} The sample formed with the majority of the middle age group may have affected the result. Again, in this context, the fact that the male group was significant even though the female group in the sample group was high revealed results incompatible with the literature.

It was determined that postgraduate graduates received high scores in the positive re-evaluation sub-dimension of the SCESS according to their education level. In the literature, Baysak et al. (2019) also found that positive re-evaluation increased as the level of education increased; In this context, the result supports the literature. ^{Reference Baysak, Eroğlu and Utku45} After disasters with devastating effects such as earthquakes, people’s trauma response levels and coping levels may differ. ^{Reference Erdener46} According to Erdener (2019), it was concluded that those who graduated from university and graduate school experienced more secondary trauma. ^{Reference Erdener46}

At the end of the study, there was no significant difference between the occupational groups of physicians and nurses in terms of coping with stress. Many factors cause occupational stress. Occupational stress has become a growing problem in health-care workers in recent years. ^{Reference Trifunovic, Jatic and Kulenovic47} The reason why there was no difference between occupational groups in the study may be because the sample mainly consisted of nurses and that both occupational groups had the same intense working conditions. In addition, both occupational groups act with high professional responsibility when intervening with the patient. There may be similar increases in work intensities, especially during disasters, which may give similar reactions to being affected by the disaster. Different results were also found in the studies. According to a study on mental health, nurses with occupational group-specific differences were found to have the highest mental health disorders and burnout. ^{Reference Diekmann, Böckelmann and Karlsen48} According to another study, it was found that, while the state anxiety scores of doctors and nurses are very close to each other, the trait anxiety scores of nurses are higher than doctors. Still, this difference was not statistically significant. ^{Reference Sakaoğlu, Orbatu and Emiroglu49} A disaster is a natural event that has irreversible consequences. The psychological dimension of health workers affected by all the damage and who are involved in the response is among the issues that need to be addressed in detail. Implementation of recovery programs for health workers after disasters have been seen among the methods that can be effective. According to a published study, it was emphasized that health systems should support the health and well-being of doctors and nurses with evidence-based interventions to improve community health and increase the quality and safety of care must be provided. ^{Reference Melnyk, Kelly and Stephens50}

In the study, no significant difference was found in the SCESS in terms of past mental health problems and having a family member with a psychiatric illness. In fact, those with a history of mental illness are often expected to have high postdisaster stress levels. Understanding the traumatic response within a psychopathological framework is vital. It is rarely possible for PTSD to occur in isolation following a traumatic event. The perception of isolation or lack of social connection with others is associated with loneliness. May evoke psychological responses that often occur in situations such as depression, anxiety, or substance use. ^{Reference Hyland, Murphy and Shevlin29} In the literature, it was determined that people with a previous history of mental illness showed depressive symptoms after the earthquake. It is seen that those who have a history of mental illness in the past have high levels of help expectations and postearthquake stress. ^{Reference Kılıç51,Reference Uğur, Kartal and Mete52} In another study, it was reported that there might be differences in the level of the psychological impact of individuals in coping with trauma after an earthquake. It has been determined that, after disasters such as earthquakes that occur suddenly and whose consequences are unpredictable, there may be psychological problems that improve in a few weeks. ^{Reference Kılıç51} According to Baysak et al. (2019), it was seen that mental health problems experienced in the past were effective in coping with postearthquake stress. ^{Reference Baysak, Eroğlu and Utku45} The low rate of participants with a history of mental illness and a family history of mental illness in the study may have affected the result.