The main findings of this study can be summarised as follows: paramedic trainees had high rates of PTSD, depression and trauma exposure (based on self-reported symptoms). Participants meeting criteria for PTSD had significantly higher rates of depression, perceived stress and physical health symptoms and significantly lower rates of resilience and social support. Higher rates of trauma exposure and depression and lower rates of social support and resilience were significant predictors of PTSD. Depression had a mediating effect on the relationship between trauma exposure and PTSD. These finding mirrors prior research
Paramedic trainees had high rates of trauma exposure, both related (e.g. witnessing a transport accident) and unrelated (e.g. being a victim of physical assault) to work. Trauma exposure that is unrelated to work, including childhood exposure to violence, abuse and neglect, may influence career choice among paramedics. A high rate (38.4%) of physical, sexual and emotional abuse was found in a sample of Canadian veteran paramedics
. An association between childhood abuse and neglect and higher mental and physical health symptom scores was also reported in that sample
. Together with the findings of our study, it suggests that exposure to early adversity may impact on the career choice of paramedics.
16% of paramedic trainees met symptom criteria for PTSD. The rate of current PTSD is considerably higher than the 12 month prevalence rate of 0.6% among South Africans (based on lay administered structural interview)
. The rate of PTSD is consistent with that documented by a group of Dutch researchers (2003) who found that 12% of emergency workers displayed PTSD symptoms
. Two other studies found much higher rates of PTSD symptomatology among ambulance service workers at 21% and 22%, respectively
The current study also found high rates of depression among paramedic trainees (28%). Depression was a significant predictor of PTSD and had a mediating effect between trauma exposure and PTSD status. In a study of disaster workers 16% of workers developed depression seven months after work-related trauma exposure
. The rate of depression among emergency ambulance workers in the UK has been found to approximate 10%
. Differences in the rate of depression may, in part, be due to ascertainment differences or secondary to the high rates of exposure to trauma in South Africa.
Rates of alcohol abuse were similarly high with 24% of paramedic trainees meeting criteria for abuse. Twelve month prevalence rates of alcohol abuse in the South African general population have been estimated at 4.5% and 11.1 for life-time prevalence in the age group 18–34 (based on a lay administered structured interview)
. A study conducted in the South African higher education sector found that 11% of students in the age group 15–49 consumed alcohol on a weekly or daily basis
. This suggests a disturbing pattern of alcohol abuse within at-risk vocations. Males had higher rates of alcohol abuse than females. These findings are in line with the South African Stress and Health study where substance use disorders were found to be significantly associated with male gender. Alcohol abuse in emergency medical care occupations should be investigated further, given the high prevalence of alcohol abuse in the Western Cape Province of South Africa
In a Brazilian study it was found that ambulance workers with PTSD had significantly poorer physical and mental health than workers without PTSD
. This, too, was the case in the current study, with the PTSD group endorsing more physical health ailments than the non-PTSD group. Paramedic trainees with PTSD had a higher mean number of varied traumatic exposures, higher levels of depression and stress, poorer physical health and lower levels of social support and resilience than those without PTSD. Previous studies have also shown that higher trauma exposure, stress and depression levels, low resilience and low social support are associated with PTSD
[18, 36, 37].
Overall, resilience and social support were predictors of PTSD status. We measured social support with regards to three areas of personal contact – family, friends and a significant other. Social support may be conceptualised on three tiers, namely support by family and friends (tier one), support by community and religious organisations (tier two) and support by formal services such as the police (tier three)
. Social support is considered to improve coping, decrease stress levels and has a positive effect on health and well-being
. In a Dutch study, social support in the workplace was found to positively predict PTSD in emergency care personnel
. It has been proposed that the most common type of social support associated with PTSD is emotional support: the more emotional support received (from loved ones or supervisors and colleagues) after a traumatic event, the lower the risk of developing PTSD
. Many studies have focused on support provided in the workplace or by emergency service staff rather than on personal social support, which could explain some of the discrepancy across studies on the effects of social support on PTSD
[14, 16, 39].
Strengths and limitations
Some limitations deserve mention. Since the measures employed were self-report questionnaires, the responses reflect the participants’ perceptions and not clinician or trained lay interviewer diagnoses. The use of self-report measures may have inflated the frequency of psychiatric disorders found in this sample. Participants reported experiencing traumas unrelated to their occupation which may have contributed to PTSD symptomatology. The large number of questionnaires administered in one sitting could have caused participant fatigue and this may have influenced the accuracy of the results. The study was also cross-sectional in design which precludes causal inferences and measurement of symptom change over time. The cross-sectional design also limits the interpretation of the mediation analysis. We cannot determine if the mediating effect is due to comorbidity (e.g. depression and PTSD) or if there is a temporal sequence of events (e.g. trauma leads to depression and depression leads to PTSD).
Several aspects of the sample distinguish this study from previous research. While studies have investigated PTSD among paramedic staff in South Africa, none, to our knowledge, have investigated predictors of PTSD among paramedic trainees. Trauma exposure is common among paramedic staff and trainees are particularly vulnerable to the adverse effects associated with trauma exposure, due to a lack of experience. Early identification and treatment of PTSD is important to prevent chronic PTSD and the debilitating effects thereof. The homogeneity of the sample is an added strength as there have been few studies on risk factors for PTSD that focus on specific trauma types and at-risk populations. Future studies could compare the effects of trauma frequency and repeated same-trauma exposures on mental and physical health outcomes in paramedic trainees and practising, experienced paramedics, as well as include other occupation groups, such as police officers and fire fighters.