Académique Documents
Professionnel Documents
Culture Documents
Research report
Mount Sinai School of Medicine, 1 Gustave L. Levy Place, NY 10029, United States
New York University, 50 West 4th Street, NY 10012, United States
c
University of New Mexico, 1 University Boulevard Northeast, Albuquerque, NM 87131, United States
d
Yale University School of Medicine, 153 College Street, New Haven, CT 06510, United States
b
a r t i c l e i n f o
a b s t r a c t
Article history:
Received 2 October 2012
Accepted 23 October 2012
Available online 27 November 2012
Background: High rates of posttraumatic stress disorder (PTSD) and depressive symptoms have been
observed in earthquake survivors from less developed areas of the world. This study, conducted three
years after the 2005 Pakistan earthquake, aimed to identify potentially protective psychosocial factors
associated with lower PTSD and depressive symptom levels.
Methods: Adult earthquake survivors (N 200) were recruited from affected areas in Northwestern
Pakistan and completed self-report questionnaires measuring PTSD and depressive symptoms, positive
and negative affect, and four psychosocial variables (purpose in life, positive and negative religious
coping, and social support).
Results: Sixty ve percent of participants met criteria for probable PTSD. Purpose in life was associated
with lower symptom levels and higher positive emotions. A form of negative religious coping (feeling
punished by God for ones sins or lack of spirituality) was associated with higher symptom levels and
negative emotions. Higher perceived social support was associated with higher positive emotions.
Other signicant relationships were also identied.
Limitations: Limitations include the recruitment of a sample of convenience, a modest sample size, and
the cross-sectional nature of the study.
Conclusions: Findings suggest that some psychosocial factors may be protective across cultures, and
that the use of negative religious coping is associated with poorer mental health outcomes in
earthquake survivors. This study can inform preventive and treatment interventions for earthquake
survivors in Pakistan and other less industrialized countries as they develop mental health care
services.
& 2013 Elsevier B.V. All rights reserved.
Keywords:
Posttraumatic stress disorder
Earthquake
Pakistan
Purpose in life
Religious coping
Social support
1. Introduction
Earthquakes plagued mankind long before their emotional,
social and economic impact was ever studied. Over the last
decade, research has documented the heavy toll of mental illness,
in particular posttraumatic stress disorder (PTSD), in survivors of
this most devastating of natural disasters. A growing number of
studies have documented high rates of PTSD and depressive
symptoms in earthquake survivors from Pakistan and other less
developed areas of the world (Ahmad et al., 2010; Ehring et al.,
2011; Hashmi et al., 2011; Irmansyah et al., 2010; Lommen et al.,
Corresponding author. Tel.: 1 212 659 9145; fax: 1 212 659 9291.
E-mail address: adriana.feder@mssm.edu (A. Feder).
1
Both authors contributed equally.
0165-0327/$ - see front matter & 2013 Elsevier B.V. All rights reserved.
http://dx.doi.org/10.1016/j.jad.2012.10.027
factors associated with resilience to trauma exposure has accumulated in the last decade, including the potentially protective
role of positive emotions and healthy social supports (Alim et al.,
2008; Feder et al., 2009; Fredrickson, 2004; Hoge et al., 2007). Of
longstanding theoretical interest but less well-studied empirically
in trauma survivors is an individuals sense of purpose in life
(Alim et al., 2008; Feder et al., 2009; Pietrzak et al., 2010; Pietrzak
et al., 2011). The role of religious coping is also of interest in the
face of trauma, especially in the developing world where religion
is of central cultural signicance (Ali et al., 2012).
On October 8th 2005, at 8:50 am, an earthquake measuring
7.6 on the Richter scale struck the Northwestern Frontier Province in
Pakistan. The most devastating earthquake to strike the region in the
last century, according to some estimates there were more than
250,000 casualties and over 3.5 million people became homeless,
with no relief in sight and nowhere to go. The present cross-sectional
study, carried out in 2008, aimed to document the prevalence of
posttraumatic stress symptoms three years after the disaster, and to
identify psychosocial factors associated with lower PTSD and depressive symptom levels in earthquake survivors.
Based on our prior ndings (Ahmad et al., 2010) and those of
others (Ali et al., 2012; Basoglu et al., 2001; Galea et al., 2005), we
hypothesized that female gender, lower education, loss of loved
ones, and closer proximity to the epicenter would be signicantly
associated with higher symptom levels. We additionally predicted
that higher purpose in life (Alim et al., 2008; Hoge et al., 2007)
and higher perceived social supports (Ali et al., 2012; Ehring et al.,
2011; Naeem et al., 2011; Zhao et al., 2009) would be signicantly
associated with lower symptom levels. While neither positive nor
negative religious coping showed any signicant associations
with symptom levels in our previous study, we re-examined the
factor in this study due to the larger and more demographically
diverse sample collected for the present study. Finally, we sought
to identify psychosocial factors associated with reported levels of
positive and negative emotions.
2. Method
2.1. Participants
Survivors of the earthquake (161 men and 39 women, mean
age37.7 years) were recruited by the principal investigator, S.A.
Participants were primarily recruited from the vicinity of Muzaffarabad and Balakot in Pakistan. S.A. traveled to several schools
and other institutions to recruit adult subjects who volunteered
to participate without any form of compensation. Participants
included anyone with exposure to the earthquake who consented
to participate.
2.2. Procedure
The study was approved by the Institutional Review Board of
the New York University. Informed consent was obtained from all
subjects before the self-report questionnaires were administered.
The consent forms were translated into Urdu and were read aloud
and explained to any illiterate participants before consent was
obtained. All questionnaires were also translated into Urdu and
reviewed by a consensus team before they were administered.
2.3. Materials
All constructs of interest were measured by a self-report questionnaire. The questionnaire contained demographic and trauma
exposure information as well as self-report scales to determine the
level of PTSD and depressive symptoms, positive and negative affect,
157
158
(n 182200)a
37.7 (11.7)
161 (80.5%)
157 (78.5%)
11
14
17
37
83
38
29.2
183
163
(5.5%)
(7.0%)
(8.5%)
(18.5%)
(41.5%)
(19.0%)
(25.6)
(91.5%)
(81.5%)
87 (43.5%)
46 (23.0%)
40 (20.0%)
27 (13.5%)
3. Results
Table 1 summarizes demographic characteristics and earthquake exposure. Over half of the participants had some level of
college education. A large majority of participants sustained home
damage and became homeless as a result of the earthquake.
A third of the sample lost at least one close family member.
Table 2 lists mean symptom scale and psychosocial scale scores.
Almost 65% of the participants met criteria for probable PTSD
(60% of male and over 80% of female participants). Table 3 shows
the percentage of responses for each item of the RCOPE. Notably,
the majority of the population demonstrated high levels of
positive religious coping. Over half of the sample agreed strongly
with only the last item of the RCOPE-N subscale, mentioned above
(I feel God is punishing me for my sins or lack of spirituality).
Table 4 shows the correlation matrix for all variables. Female
gender and loss of close family members were positively correlated with total TSSC score, while higher education showed a
negative correlation with total TSSC score. Further, loss of close
family members was also positively correlated with negative
emotions, and higher education was positively correlated with
positive emotions and negatively correlated with negative emotions. Purpose in life was negatively correlated with total TSSC
score and negative emotions, and positively correlated with
positive emotions. Two items of the negative religious coping
subscale were each signicantly positively correlated with total
TSSC scores: I express my anger at God and I feel God is
punishing me for my sins or lack of faith. Both statements were
also signicantly negatively correlated with purpose in life.
Higher perceived social support was positively correlated with
female gender, higher education and positive emotions, and
negatively correlated with negative emotions.
Table 2
Psychometric properties for TSSC scores and psychosocial variables.
n192198a
Variables, mean (SD)
Possible range
M or %
SD
TSSC-total score
TSSC-PTSD subscale score
Probable PTSDb
Male
Female
TSSC-depression subscale score
PANAS-positive subscale score
PANAS-negative subscale score
Social support
Purpose in life
Positive religious coping
Negative religious coping
I wonder whether God has abandoned me
I express my anger at God
I feel God is punishing me for my sins or lack of spirituality
069
051
018
1050
1050
0100
848
09
38.4
29.61
64.6%
60.4%
82.1%
8.70
32.25
26.76
61.14
31.33
8.04
15.91
11.60
5.11
6.54
8.43
30.29
6.51
1.75
03
03
03
.89
.64
1.88
1.28
1.13
1.29
a
n varies due to missing data. TSSC Traumatic Stress Symptom Checklist; PTSD posttraumatic stress disorder; PANAS Positive and negative
affect schedule.
b
Probable PTSD was assigned to any participant whose mean TSSC-PTSD subscale score was at least 25.
159
Table 3
Percentage of Responses on Items of the RCOPE (n193197)a.
Items
I
I
I
I
I
I
Moderately (%)
6.6
63.7
5.1
71.9
17.0
25.9
0
6.7
0.5
8.9
1.0
11.7
1.5
6.2
3.6
3.1
8.2
10.7
91.8
23.3
90.8
16.1
73.7
51.8
Table 4
Correlation matrix between all variables.
Variables
10
11
12
13
14
15
16
17
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
.28nnn
.17n
.12
.04
.07
.02
.15n
.003
.01
.004
.15n
.25nnn
.28nnn
.14
.10
.05
.50nnn
.12
.08
.13
.12
.01
.07
.03
.12
.10
.08
.08
.07
.02
.05
.07
.24nn
.10
.04
.02
.06
.001
.07
.04
.05
.06
.05
.13
.12
.02
.30nnn
.06
.11
.10
.24nn
.17n
.30nnn
.26nnn
.24nn
.23nn
.18n
.40nnn
.02
.02
.06
.04
.06
.07
.05
.04
.07
.06
.01
.10
.11
.06
.06
.13
.13
.13
.26nnn
.25nnn
.26nnn
.02
.19nn
.003
.08
.17n
.10
.02
.08
.05
.13
.02
.01
.04
.13
.13
.16n
.06
.06
.08
.04
.07
.25nn
.27nnn
.05
.15n
.15n
.11
.04
.16n
.18n
.08
.22nn
.21nn
.23nn
.17n
.33nnn
.13
.32nnn
. .28nnn
.36nnn
.29nnn
.35nnn
.07
.06
.11
.30nnn
.23nn
.98nnn
.88nnn
.24nn
.64nnn
.77nnn
.23nn
.61nnn
.24nn
.61nnn
.24nn
Note. 1. Gender; 2. Age; 3. Marital Status; 4.Education; 5. Distance from epicenter; 6. Loss of close relatives; 7. RCOPE-P (positive religious coping); 8. RCOPE item 2
(I wonder whether God has abandoned me); 9. RCOPE item 4 (I express my anger at God);10. RCOPE item 6 (I feel God is punishing me for my sins or lack of spirituality); 11.
Purpose in life; 12. Medical Outcomes Study Social Support Survey; 13. Traumatic Stress Symptom Checklist (TSSC)-total; 14. TSSC-PTSD (posttraumatic stress disorder)
subscale; 15. TSSC-Depression subscale; 16. positive and negative affect schedule (PANAS)-positive; 17. PANAS-negative.
p o .05.
p o.01.
nnn
p o.001.
n
nn
4. Discussion
Over half of the participants (64.6%) met criteria for probable
PTSD three years after the event, a nding which lies on the higher
end within the range of 10% to 87% of reported PTSD prevalence
from other earthquakes (Goenjian et al., 1994; Goenjian et al., 2000;
Kessler et al., 1995; Kuo et al., 2007; McMillen et al., 2000). Findings
that female gender, lower education and loss of close family
members were associated with higher posttraumatic symptom
levels in earthquake survivors replicate previous ndings from our
work and several others (Ahmad et al., 2010; Ali et al., 2012;
Basoglu et al., 2001; Galea et al., 2005).
160
Table 5
Hierarchical regression analysis for variables associated with total TSSC scores, and TSSC-PTSD and TSSC-depression subscale scores
(n 175179)a.
TSSC-total
TSSC-PTSD
TSSC-Depression
Modela
Variable
R2 for model
R2 for model
R2 for model
Gender
Age
Marital status
Education
Gender
Age
Marital status
Education
Epicenter
Death score
Gender
Age
Marital status
Education
Epicenter
Death score
R-COPE 6
Gender
Age
Marital status
Education
Epicenter
Death score
R-COPE item 6
Purpose in life
MOS-SSS
R-COPE Positive
.248nn
.014
.038
.311nn
.228nn
.001
.057
.257nn
.031
.172n
.230nn
.016
.067
.214nn
.038
.167n
.163n
.220nn
.039
.020
.179n
.045
.143n
.129y
.240nn
.008
.023
.126
.280nnn
.043
.055
.291nnn
.258nnn
.034
.085
.239nn
.067
.162n
.260nnn
.051
.094
.196n
.074
.156n
.163n
.251nn
.003
.056
.169n
.079
.139y
.138y
.195nn
.003
.002
.130
.131y
.033
.019
.293nnn
.119
.060
.006
.246nn
.066
.169n
.120
.036
.021
.198n
.062
.162n
.169n
.114
.103
.039
.155y
.054
.131y
.122y
.305nnn
.019
.062
.074
.144
.164
.205
.148
.169
.190
.094
.115
.193
a
n varies due to missing data; TSSC Traumatic Stress Symptom Checklist; PTSD posttraumatic stress disorder; RCOPE item 6 I feel
God is punishing me for my sins or lack of spirituality; MOS-SSS Medical Outcomes Study Social Support Survey, emotional/information
subscale; R-COPE positive positive religious coping.
y
p o.10.
n
po .05.
nn
p o .01.
nnn
p o .001.
Table 6
Linear regression analysis for variables associated with PANAS positive and
negative scales (n 178) a.
PANAS-P
PANAS-N
Modela
Variable
R2 for model
R2 for model
Age
Gender
Marital status
Education
Age
Gender
Marital status
Education
Epicenter
Death score
Age
Gender
Marital status
Education
Epicenter
Death score
R COPE 6
Age
Gender
Marital status
Education
Epicenter
Death score
R-COPE 6
Purpose in life
MOS-TOT
R-COPE P
.109
.116
.152y
.198nn
.122
.123
.156y
.221nn
.024
.083
.132
.125
.162y
.192n
.029
.087
.124
.074
.137y
.125
.084
.058
.126y
.083
.249nn
.260nn
.049
.044
.029
.064
.145y
.438nnn
.009
.061
.119
.421nnn
.090
.071
.030
.064
.131
.360nnn
.080
.062
.253nnn
.026
.060
.092
.305nnn
.064
.038
.223nn
.209nn
.101
.072
.186
.040
.049
.159
.189
.246
.288
a
n varies due to missing data; PANAS-P positive and negative affect
schedule-positive affect subscale; PANAS-N positive and negative affect schedule-negative affect subscale; R-COPE item 6 I feel God is punishing me for my
sins or lack of spirituality; MOS-SSS Medical Outcomes Study Social Support
Survey, emotional/information subscale; R-COPE Positive positive religious
coping.
y
p o .10.
n
p o .05.
nn
p o.01.
nnn
p o.001.
Further, in our sample a higher sense of purpose was signicantly associated with higher self-reported positive emotions,
even in the presence of posttraumatic symptoms. A study of
earthquake survivors in El Salvador found positive emotions to be
as prevalent as negative emotions (Vazquez et al., 2005). Positive
emotions are known to be associated with better physical and
mental health, and promote more adaptive and effective coping
(Cohn et al., 2009; Folkman, 2008; Ong et al., 2006). In empirical
studies, positive emotions were found to foster efcient emotion
regulation and faster physiological recovery from stress (Tugade
and Fredrickson, 2004). In stressful situations, the ability to
experience positive alongside negative emotions is thus thought
to serve a protective function. Further, Fredrickson (2001) postulated a relationship between positive emotions and nding
positive meaning after life events. In a study of veterans living
with spinal cord injury, purpose in life was not only signicantly
associated with but also accounted for a large portion of the
variance in psychological wellbeing (deRoon-Cassini et al., 2009).
4.2. Religious coping
Of the three aspects of negative religious coping measured in
this sample, feeling abandoned by God, expressing anger at God,
and a feeling of being punished by God for ones sins or lack of
spirituality, the third item was endorsed by over half of the
respondents. After adjusting for demographic characteristics and
trauma severity, it was only this particular form of negative
161
162
Conict of interest
The authors have no conicts of interest to report.
Acknowledgements
The authors wish to thank the following individuals in Pakistan whose
contributions helped us with data collection and recruitment logistics: ShahidGhafoor, MBBS, Khalid Hussain, and Nisar Ahmad. Special thanks to RiffatAra
Ahmad, MBBS, AamirSajjadHaider, and SahidGhafoor, MBBS, for assistance with
translation services. We also thank William Taboas, MA, and Gerardo Acosta for
assisting with data entry and verication.
References
Ahmad, S., Feder, A., Lee, E.J., Wang, Y., Southwick, S.M., Schlackman, E., Buchholz,
K., Alonso, A., Charney, D.S., 2010. Earthquake impact in a remote South Asian
population: psychosocial factors and posttraumatic symptoms. Journal of
Traumatic Stress 23, 408412.
Ali, M., Farooq, N., Bhatti, M.A., Kuroiwa, C., 2012. Assessment of prevalence and
determinants of posttraumatic stress disorder in survivors of earthquake in
Pakistan using Davidson Trauma Scale. Journal of Affective Disorders 136,
238243.
Alim, T.N., Feder, A., Graves, R.E., Wang, Y., Weaver, J., Westphal, M., Alonso, A.,
Aigbogun, N.U., Smith, B.W., Doucette, J.T., Mellman, T.A., Lawson, W.B.,
Charney, D.S., 2008. Trauma, resilience, and recovery in a high-risk African
American population. American Journal of Psychiatry 165, 15661575.
Altindag, A., Ozen, S., Sir, A., 2005. One-year follow-up study of posttraumatic
stress disorder among earthquake survivors in Turkey. Comprehensive Psychiatry 46, 328333.
Ano, G.G., Vasconcelles, E.B., 2005. Religious coping and psychological adjustment
to stress: a meta-analysis. Journal of Clinical Psychology 61, 461480.
Basoglu, M., Salcioglu, E., Livanou, M., Ozeren, M., Aker, T., Kilic, C., Mestcioglu, O.,
2001. A study of the validity of a screening instrument for traumatic stress in
earthquake survivors in Turkey. Journal of Traumatic Stress 14, 491509.
Benight, C.C., Swift, E., Sanger, J., Smith, A., Zeppelin, D., 1999. Coping self-efcacy
as a mediator of distress following a natural disaster. Journal of Applied Social
Psychology 29, 24432464.
Charuvastra, A., Cloitre, M., 2008. Social bonds and posttraumatic stress disorder.
Annual Review of Psychology 59, 301328.
Cohn, M.A., Fredrickson, B.L., Brown, S.L., Mikels, J.A., Conway, A.M., 2009.
Happiness unpacked: positive emotions increase life satisfaction by building
resilience. Emotion 9, 361368.
deRoon-Cassini, T.A., de, S., Valvano, A., Hastings, J., Horn, P., 2009. Psychological
well-being after spinal cord injury: perception of loss and meaning making.
Rehabilitation Psychology 54, 306314.
Ehring, T., Razik, S., Emmelkamp, P.M., 2011. Prevalence and predictors of
posttraumatic stress disorder, anxiety, depression, and burnout in Pakistani
earthquake recovery workers. Psychiatry Research 185, 161166.
Feder, A., Nestler, E.J., Charney, D.S., 2009. Psychobiology and molecular genetics of
resilience. Nature Reviews Neuroscience 10, 446457.
Folkman, S., 2008. The case for positive emotions in the stress process. Anxiety,
Stress & Coping 21, 314.
Frankl, V.E., 1959. Mans Search for Meaning. Beacon Press, Boston, MA.
Fredrickson, B.L., 2001. The role of positive emotions in positive psychology: the
broaden-and-build theory of positive emotions. American Psychologist 56,
218226.
Fredrickson, B.L., 2004. The broaden-and-build theory of positive emotions.
Philosophical Transactions of the Royal Society B: Biological Sciences 359,
13671377.
Galea, S., Nandi, A., Vlahov, D., 2005. The epidemiology of post-traumatic stress
disorder after disasters. Epidemiologic Reviews 27, 7891.
Goenjian, A.K., Najarian, L.M., Pynoos, R.S., Steinberg, A.M., et al., 1994. Posttraumatic stress disorder in elderly and younger adults after the 1988 earthquake
in Armenia. American Journal of Psychiatry 151, 895901.
Goenjian, A.K., Steinberg, A.M., Najarian, L.M., Fairbanks, L.A., Tashjian, M., Pynoos,
R.S., 2000. Prospective study of posttraumatic stress, anxiety, and depressive
reactions after earthquake and political violence. American Journal of Psychiatry 157, 911916.
Hashmi, S., Petraro, P., Rizzo, T., Nawaz, H., Choudhary, R., Tessier-Sherman, B.,
Kasl, S., Nawaz, H., 2011. Symptoms of anxiety, depression, and posttraumatic
stress among survivors of the 2005 Pakistani earthquake. Disaster Medicine
and Public Health Preparedness 5, 293299.
Hoge, E.A., Austin, E.D., Pollack, M.H., 2007. Resilience: research evidence and
conceptual considerations for posttraumatic stress disorder. Depression and
Anxiety 24, 139152.
Irmansyah, I., Dharmono, S., Maramis, A., Minas, H., 2010. Determinants of
psychological morbidity in survivors of the earthquake and tsunami in Aceh
and Nias. International Journal of Mental Health Systems 4, 110.
Janoff-Bulman, R., 1992. Shattered Assumptions: Towards a New Psychology of
Trauma. Free Press, New York.
Karanci, A.N., Rustemli, A., 1995. Psychological consequences of the 1992 Erzincan
(Turkey) earthquake. Disasters 19, 818.
Ke, X., Liu, C., Li, N., 2010. Social support and quality of life: a cross-sectional study
on survivors eight months after the 2008 Wenchuan earthquake. BMC Public
Health 10 573-573.
Kessler, R.C., Sonnega, A., Bromet, E., Hughes, M., et al., 1995. Posttraumatic stress
disorder in the National Comorbidity Survey. Archives of General Psychiatry
52, 10481060.
zc- ur
zel, S.,
umez,
Niaz, U., 2006. Role of faith and resilience in recovery from psychotrauma.
Pakistan Journal of Medical 22, 204207.
Niaz, U., Hassan, S., Hassan, M., 2007. Post-traumatic stress disorder (PTSD),
depression, fear and avoidance in destitute women, earthquake survivors of
NWFP, Pakistan. Journal of Pakistan Psychiatric Society 4, 4449.
Ong, A.D., Bergeman, C., Bisconti, T.L., Wallace, K.A., 2006. Psychological resilience,
positive emotions, and successful adaptation to stress in later life. Journal of
Personality and Social Psychology 91, 730749.
Pargament, K.I., Koenig, H.G., Perez, L.M., 2000. The many methods of religious
coping: development and initial validation of the RCOPE. Journal of Clinical
Psychology 56, 519543.
Pietrzak, R.H., Goldstein, M.B., Malley, J.C., Rivers, A.J., Johnson, D.C., Morgan III,
C.A., Southwick, S.M., 2010. Posttraumatic growth in veterans of Operations
Enduring Freedom and Iraqi Freedom. Journal of Affective Disorders 126,
230235.
Pietrzak, R.H., Russo, A.R., Ling, Q., Southwick, S.M., 2011. Suicidal ideation in
treatment-seeking Veterans of Operations Enduring Freedom and Iraqi Freedom: the role of coping strategies, resilience, and social support. Journal of
Psychiatric Research 45, 720726.
Priebe, S., Grappasonni, I., Mari, M., Dewey, M., Petrelli, F., Costa, A., 2009.
Posttraumatic stress disorder six months after an earthquake: ndings from
a community sample in a rural region in Italy. Social Psychiatry and
Psychiatric Epidemiology 44, 393397.
Ryff, C.D., Keyes, C.L.M., 1995. The structure of psychological well-being revisited.
Journal of Personality and Social Psychology 69, 719727.
Sherbourne, C.D., Stewart, A.L., 1991. The MOS social support survey. Social
Science & Medicine 32, 705714.
Smith, T.B., McCullough, M.E., Poll, J., 2003. Religiousness and depression:
evidence for a main effect and the moderating inuence of stressful life
events. Psychological Bulletin 129, 614636.
Southwick, S.M., Vythilingam, M., Charney, D.S., 2005. The psychobiology of
depression and resilience to stress: implications for prevention and treatment.
Annual Review of Clinical Psychology 1, 255291.
Stratta, P., Capanna, C., Riccardi, I., Carmassi, C., Piccinni, A., DellOsso, L., Rossi, A.,
2012. Suicidal intention and negative spiritual coping one year after the
earthquake of LAquila (Italy). Journal of Affective Disorders 136, 12271231.
163