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The extent to which education provides protection in the face of a large-scale natural disaster is investigated. Using longitudinal population-representative survey data collected in two provinces on the island of Sumatra, Indonesia, before and after the 2004 Indian Ocean tsunami, we examine changes in a broad array of indicators of well-being of adults. Focusing on adults who were living, before the tsunami, in areas that were subsequently severely damaged by the tsunami, better educated males were more likely to survive the tsunami, but education is not predictive of survival among females. Education is not associated with levels of post-traumatic stress among survivors 1 year after the tsunami, or with the likelihood of being displaced. Where education does appear to play a role is with respect to coping with the disaster over the longer term. The better educated were far less likely than others to live in a camp or other temporary housing, moving, instead, to private homes, staying with family or friends, or renting a new home. The better educated were more able to minimize dips in spending levels following the tsunami, relative to the cuts made by those with little education. Five years after the tsunami, the better educated were in better psycho-social health than those with less education. In sum, education is associated with higher levels of resilience over the longer term.

 RESEARCH AND PRACTICE  Objectives. We assessed the levels and correlates of posttraumatic stress reactivity (PTSR) of more than 20 000 adult tsunami survivors by analyzing survey data from coastal Aceh and North Sumatra, Indonesia.Methods. A population-representative sample of individuals interviewed before the tsunami was traced in 2005 to 2006. We constructed 2 scales measuring PTSR by using 7 symptom items from the Post Traumatic Stress Disorder (PTSD) Checklist-Civilian Version. One scale measured PTSR at the time of interview, and the other measured PTSR at the point of maximum intensity since the disaster.Results. PTSR scores were highest for respondents from heavily damaged areas. In all areas, scores declined over time. Gender and age were significant predictors of PTSR; markers of socioeconomic status before the tsunami were not. Exposure to traumatic events, loss of kin, and property damage were significantly associated with higher PTSR scores.Conclusions. The tsunami produced posttraumatic stress reactions across a wide region of Aceh and North Sumatra. Public health will be enhanced by the provision of counseling services that reach not only people directly affected by the tsunami but also those living beyond the area of immediate impact. (Am J Public Health.

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R® is a registered trademark Limited Print and Electronic Distribution RightsThis document and trademark(s) contained herein are protected by law. This representation of RAND intellectual property is provided for noncommercial use only. Unauthorized posting of this publication online is prohibited. Permission is given to duplicate this document for personal use only, as long as it is unaltered and complete. Permission is required from RAND to reproduce, or reuse in another form, any of its research documents for commercial use. For information on reprint and linking permissions, please visit www.rand.org/pubs/permissions.html.The RAND Corporation is a research organization that develops solutions to public policy challenges to help make communities throughout the world safer and more secure, healthier and more prosperous. RAND is nonprofit, nonpartisan, and committed to the public interest.RAND's publications do not necessarily reflect the opinions of its research clients and sponsors.Support RAND Make a tax-deductible charitable contribution at

Data from the Indonesia Family Life Survey are used to investigate the impact of a major expansion in access to midwifery services on women's use of antenatal care and delivery assistance. Between 1991 and 1998, Indonesia trained some 50,000 midwives, placing them in poor communities that were distant from health-care centers. We analyze information from pregnancy histories to relate changes in the choices that individual women make across pregnancies to the arrival of a trained midwife in the village. We show that regardless of a woman's educational level, the placement of village midwives in communities is associated with significant increases in women's receipt of iron tablets and in their choices about care during delivery—changes that reflect their moving away from reliance on traditional birth attendants. For women with relatively low levels of education, the presence of village midwives has the additional benefit of increasing use of antenatal care during the first trimester of pregnancy. The results of the study suggest that bringing services closer to women can change their patterns of use.

Over 130,000 people died in the 2004 Indian Ocean tsunami. The correlates of survival are examined using data from the Study of the Tsunami Aftermath and Recovery (STAR), a population-representative survey collected in Aceh and North Sumatra, Indonesia, before and after the tsunami. Children, older adults and females were the least likely to survive. Whereas socio-economic factors mattered relatively little, the evidence is consistent with physical strength playing a role. Pre-tsunami household composition is predictive of survival and suggests that stronger members sought to help weaker members: men helped their wives, parents and children, while women helped their children.