Psychology, Health & Medicine
ISSN: 1354-8506 (Print) 1465-3966 (Online) Journal homepage: http://www.tandfonline.com/loi/cphm20
Predicting positive mental health in internally displaced persons in Indonesia: the roles of economic improvement and exposure to violent conflict Sherly Saragih Turnip, Dag Sörbom & Edvard Hauff To cite this article: Sherly Saragih Turnip, Dag Sörbom & Edvard Hauff (2015): Predicting positive mental health in internally displaced persons in Indonesia: the roles of economic improvement and exposure to violent conflict, Psychology, Health & Medicine, DOI: 10.1080/13548506.2015.1051554 To link to this article: http://dx.doi.org/10.1080/13548506.2015.1051554
Published online: 10 Jun 2015.
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Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=cphm20 Download by: [University of Otago]
Date: 12 November 2015, At: 23:23
Psychology, Health & Medicine, 2015 http://dx.doi.org/10.1080/13548506.2015.1051554
Predicting positive mental health in internally displaced persons in Indonesia: the roles of economic improvement and exposure to violent conflict Sherly Saragih Turnipa,b*, Dag Sörbomc and Edvard Hauff b,d
Downloaded by [University of Otago] at 23:23 12 November 2015
a
Faculty of Psychology, University of Indonesia, Depok, Indonesia; bInstitute of Clinical Medicine, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway; c Department of Information Science/Statistics, Uppsala University, Uppsala, Sweden; d Department of Psychiatry, Ullevål University Hospital, Oslo, Norway (Received 3 August 2014; accepted 11 May 2015) Positive mental health, rather than just the absence of mental illness, is rarely investigated among the internally displaced persons (IDPs) affected by violent conflict in low-income countries. The purpose of this study was to investigate a model that could explain the interrelationship between factors contributing to positive mental health in displaced populations. In a longitudinal study we examine poverty, exposure to traumatic events and the change of material well-being after one year. We collected data in two consecutive years (2005 and 2006) from a community-based sample of IDPs in Ambon, Indonesia, through face-to-face structured interviews with consenting adults. Participants of this study were IDPs lived in Ambon during the violent conflict period. We interviewed 471 IDPs in the first year and reinterviewed 399 (85%) of the same subjects in the second year. The IDPs possessed good sense of coherence and subjective well-being. Our final model, which was generated by the use of structural equation modeling, fits the data well (χ2 = 52.51, df = 45, p = .21, CFI = .99, RMSEA = .019). Exposure to violent conflict had a negative impact on IDPs’ mental health initially and better economic conditions improved it (r = −.30 and .29 respectively). Mental health status one year previously was a strong predictor of future mental health, followed by individual economic growth in the past year (r = .43 and .29 respectively). On a group level the IDPs were resilient and adaptive to survive in adverse living conditions after devastating violent conflict, and the economic improvement contributed to it. Keywords: developing country; longitudinal studies; mental health psychological symptoms; poverty
Introduction Some studies have found that positive mental health is independent of mental illness (Keyes & Westerhof, 2012; Tennant, Joseph, & Stewart-Brown, 2007). People with mental illness still have varying levels of positive mental health, and people who do not have mental illness may still lack positive mental health (Huppert & Whittington, 2003). These studies were consistent with our previous report which confirmed that despite high prevalence of mental distress among internally displaced persons (IDPs) in Ambon, they appeared to function in daily life and fulfilled their role expectations *Corresponding author. Email: [email protected] © 2015 Taylor & Francis
Downloaded by [University of Otago] at 23:23 12 November 2015
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(Turnip & Hauff, 2007). Therefore there is a need to study the positive mental health of the IDPs’ in an empirical way to assess the strength of the community and possible predictor. The term positive mental health is a complex construct that covers both experience and functioning (Ryan & Deci, 2001). In this study, we focus on the sense of coherence (SOC) and subjective well-being (SWB) as indicators of positive mental health that cover the experience and functioning aspects. Poverty and socioeconomic problems have frequently been stated to be one of the most important factors associated with mental disorders (Cashman et al., 2005; Patel & Kleinman, 2003). However, previous studies rarely focused on the change of material well-being as a predictor of mental health in a longitudinal perspective. We consider this to be a particularly important potential predictor of mental health in low and middle income country, considering that it may be influenced by systematic interventions in order to achieve an improvement (e.g. by microcredit schemes). The aim of this study is to examine the extent to which positive mental health status can be predicted by change in socioeconomic conditions and exposure to violent conflict surrounding the IDPs in Indonesia. We hypothesized a longitudinal model to examine two main hypotheses: (1) that earlier exposure to violent conflict and poverty would predict mental health in 2005 and 2006; and (2) the combination of improved economic conditions in the one-year interval and mental health in 2005 would predict mental health in 2006. Methods Sample We collected data in a longitudinal community-based study conducted on IDPs in Ambon Island for two consecutive years from same participants. T1 was in 2005 and T2 was in 2006. The refusal rate at T1 was 3% and the attrition rate at T2 was 15%. There were 471 and 399 participants at T1 and T2 respectively. The study’s ethical clearance was obtained from The Faculty of Psychology, Universitas Indonesia. Measures Exposure to violent conflict In the 2005 data collection process, participants were asked if they had ever witnessed murder, witnessed violence toward people or witnessed violence toward property during the course of the violent conflict. These observed variables indicated the latent variable exposure to violent conflict (violcon) in the structural equation modeling (SEM) analysis. Poverty During the 2005 data collection process, participants were asked to complete a socioeconomic questionnaire. The development of the questionnaire and detailed scoring process was explained in a previous paper (Turnip & Hauff, 2007). These variables indicated the latent variable poverty in the SEM analysis.
Psychology, Health & Medicine
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Changes in economic conditions In the 2006 data collection process, participants were asked to assess their economic conditions in 2006 compared to the previous year. There were two scores: satisfaction and income–purchasing power. These variables indicated the latent variable changes in economic conditions (changeeco) in the SEM analysis.
Downloaded by [University of Otago] at 23:23 12 November 2015
Positive mental health SOC and SWB constructed the latent variable positive mental health (pmh) in the SEM analysis. We conducted cultural adaptation of SOC 13 using the monitoring translation form and retained all 13 items of the original version (van Ommeren et al., 1999). In this study, the sum of all the items was then multiplied by 7/5 to make the total score comparable to other results (Hollifield et al., 2002). The SWB questionnaire used in this study was part of a larger set of instruments developed in Indonesia (Eggleston et al., 2001; Irwanto et al., 1997). Statistical analysis Student’s t-test and ANOVA were used for comparing mean scores of SOC and SWB at T1 and T2. For these purposes, data were analyzed using SPSS for Windows, version 14.0 (SPSS Inc, 2005). The main part of this study was analyzed using SEM. We tested the initial measurement model of predictors of positive mental health (see Figure 1). We modified the model using the same data, driven by modification indices and t values. The software used for the SEM was LISREL 8.8 (Scientific Software International Inc, 2004). Results IDPs who had traumatic experiences had increased both their SOC and their SWB during the one-year interval (Table 1). Participants with better income and purchasing power at T2 had a significant increase in both SOC and SWB scores (t-test = −2.4, p = .018, and t-test = −2.863, p = .005, respectively). Path analysis models The imputation process replaced all the missing values and analyses were conducted with a sample of 471 subjects (Table 2). Observed variables in the models were good indicators of their latent variables with high factor loadings, varying from .629 to .866. In the initial path analysis model, there were five latent variables; exposure to violent conflict (violcon), poverty and change in economic conditions (changeeco), and two variables measuring positive mental health in 2005 (pmh 05) and 2006 (pmh 06). The initial model did not have a good fit (χ2 = 85.62, df = 45, p = .00025). The CFI was .96 and RMSEA was .044. Using several steps we produced our last model (Figure 2), which has good fit and no further suggestion from modification indices and tvalues. This final model had good fit indicators with χ2 = 52.51 (df = 45, p = .21). The CFI for the final model was .99 and RMSEA was .019 (Table 3).
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Analysis of predictors of positive mental health
Downloaded by [University of Otago] at 23:23 12 November 2015
Both exposure to violent conflict and poverty significantly predicted positive mental health in 2005 (pmh 05), with factor loadings of −.30 and .29, respectively. Exposure to violent conflict showed that more traumatic experiences predicted less positive mental health. Since higher poverty measure score indicated better economic condition, higher poverty as a latent variable predicted better positive mental health.
Figure 1.
Basic model of variables.
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Table 1. Mean scores of SOC and SWB according to demographic characteristics, traumatic experiences and economic changes of IDP in Mollucas, Indonesia. N
Total sample Gender Female Male
Downloaded by [University of Otago] at 23:23 12 November 2015
Age at T2
ISSN: 1354-8506 (Print) 1465-3966 (Online) Journal homepage: http://www.tandfonline.com/loi/cphm20
Predicting positive mental health in internally displaced persons in Indonesia: the roles of economic improvement and exposure to violent conflict Sherly Saragih Turnip, Dag Sörbom & Edvard Hauff To cite this article: Sherly Saragih Turnip, Dag Sörbom & Edvard Hauff (2015): Predicting positive mental health in internally displaced persons in Indonesia: the roles of economic improvement and exposure to violent conflict, Psychology, Health & Medicine, DOI: 10.1080/13548506.2015.1051554 To link to this article: http://dx.doi.org/10.1080/13548506.2015.1051554
Published online: 10 Jun 2015.
Submit your article to this journal
Article views: 25
View related articles
View Crossmark data
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=cphm20 Download by: [University of Otago]
Date: 12 November 2015, At: 23:23
Psychology, Health & Medicine, 2015 http://dx.doi.org/10.1080/13548506.2015.1051554
Predicting positive mental health in internally displaced persons in Indonesia: the roles of economic improvement and exposure to violent conflict Sherly Saragih Turnipa,b*, Dag Sörbomc and Edvard Hauff b,d
Downloaded by [University of Otago] at 23:23 12 November 2015
a
Faculty of Psychology, University of Indonesia, Depok, Indonesia; bInstitute of Clinical Medicine, Division of Mental Health and Addiction, University of Oslo, Oslo, Norway; c Department of Information Science/Statistics, Uppsala University, Uppsala, Sweden; d Department of Psychiatry, Ullevål University Hospital, Oslo, Norway (Received 3 August 2014; accepted 11 May 2015) Positive mental health, rather than just the absence of mental illness, is rarely investigated among the internally displaced persons (IDPs) affected by violent conflict in low-income countries. The purpose of this study was to investigate a model that could explain the interrelationship between factors contributing to positive mental health in displaced populations. In a longitudinal study we examine poverty, exposure to traumatic events and the change of material well-being after one year. We collected data in two consecutive years (2005 and 2006) from a community-based sample of IDPs in Ambon, Indonesia, through face-to-face structured interviews with consenting adults. Participants of this study were IDPs lived in Ambon during the violent conflict period. We interviewed 471 IDPs in the first year and reinterviewed 399 (85%) of the same subjects in the second year. The IDPs possessed good sense of coherence and subjective well-being. Our final model, which was generated by the use of structural equation modeling, fits the data well (χ2 = 52.51, df = 45, p = .21, CFI = .99, RMSEA = .019). Exposure to violent conflict had a negative impact on IDPs’ mental health initially and better economic conditions improved it (r = −.30 and .29 respectively). Mental health status one year previously was a strong predictor of future mental health, followed by individual economic growth in the past year (r = .43 and .29 respectively). On a group level the IDPs were resilient and adaptive to survive in adverse living conditions after devastating violent conflict, and the economic improvement contributed to it. Keywords: developing country; longitudinal studies; mental health psychological symptoms; poverty
Introduction Some studies have found that positive mental health is independent of mental illness (Keyes & Westerhof, 2012; Tennant, Joseph, & Stewart-Brown, 2007). People with mental illness still have varying levels of positive mental health, and people who do not have mental illness may still lack positive mental health (Huppert & Whittington, 2003). These studies were consistent with our previous report which confirmed that despite high prevalence of mental distress among internally displaced persons (IDPs) in Ambon, they appeared to function in daily life and fulfilled their role expectations *Corresponding author. Email: [email protected] © 2015 Taylor & Francis
Downloaded by [University of Otago] at 23:23 12 November 2015
2
S. Saragih Turnip et al.
(Turnip & Hauff, 2007). Therefore there is a need to study the positive mental health of the IDPs’ in an empirical way to assess the strength of the community and possible predictor. The term positive mental health is a complex construct that covers both experience and functioning (Ryan & Deci, 2001). In this study, we focus on the sense of coherence (SOC) and subjective well-being (SWB) as indicators of positive mental health that cover the experience and functioning aspects. Poverty and socioeconomic problems have frequently been stated to be one of the most important factors associated with mental disorders (Cashman et al., 2005; Patel & Kleinman, 2003). However, previous studies rarely focused on the change of material well-being as a predictor of mental health in a longitudinal perspective. We consider this to be a particularly important potential predictor of mental health in low and middle income country, considering that it may be influenced by systematic interventions in order to achieve an improvement (e.g. by microcredit schemes). The aim of this study is to examine the extent to which positive mental health status can be predicted by change in socioeconomic conditions and exposure to violent conflict surrounding the IDPs in Indonesia. We hypothesized a longitudinal model to examine two main hypotheses: (1) that earlier exposure to violent conflict and poverty would predict mental health in 2005 and 2006; and (2) the combination of improved economic conditions in the one-year interval and mental health in 2005 would predict mental health in 2006. Methods Sample We collected data in a longitudinal community-based study conducted on IDPs in Ambon Island for two consecutive years from same participants. T1 was in 2005 and T2 was in 2006. The refusal rate at T1 was 3% and the attrition rate at T2 was 15%. There were 471 and 399 participants at T1 and T2 respectively. The study’s ethical clearance was obtained from The Faculty of Psychology, Universitas Indonesia. Measures Exposure to violent conflict In the 2005 data collection process, participants were asked if they had ever witnessed murder, witnessed violence toward people or witnessed violence toward property during the course of the violent conflict. These observed variables indicated the latent variable exposure to violent conflict (violcon) in the structural equation modeling (SEM) analysis. Poverty During the 2005 data collection process, participants were asked to complete a socioeconomic questionnaire. The development of the questionnaire and detailed scoring process was explained in a previous paper (Turnip & Hauff, 2007). These variables indicated the latent variable poverty in the SEM analysis.
Psychology, Health & Medicine
3
Changes in economic conditions In the 2006 data collection process, participants were asked to assess their economic conditions in 2006 compared to the previous year. There were two scores: satisfaction and income–purchasing power. These variables indicated the latent variable changes in economic conditions (changeeco) in the SEM analysis.
Downloaded by [University of Otago] at 23:23 12 November 2015
Positive mental health SOC and SWB constructed the latent variable positive mental health (pmh) in the SEM analysis. We conducted cultural adaptation of SOC 13 using the monitoring translation form and retained all 13 items of the original version (van Ommeren et al., 1999). In this study, the sum of all the items was then multiplied by 7/5 to make the total score comparable to other results (Hollifield et al., 2002). The SWB questionnaire used in this study was part of a larger set of instruments developed in Indonesia (Eggleston et al., 2001; Irwanto et al., 1997). Statistical analysis Student’s t-test and ANOVA were used for comparing mean scores of SOC and SWB at T1 and T2. For these purposes, data were analyzed using SPSS for Windows, version 14.0 (SPSS Inc, 2005). The main part of this study was analyzed using SEM. We tested the initial measurement model of predictors of positive mental health (see Figure 1). We modified the model using the same data, driven by modification indices and t values. The software used for the SEM was LISREL 8.8 (Scientific Software International Inc, 2004). Results IDPs who had traumatic experiences had increased both their SOC and their SWB during the one-year interval (Table 1). Participants with better income and purchasing power at T2 had a significant increase in both SOC and SWB scores (t-test = −2.4, p = .018, and t-test = −2.863, p = .005, respectively). Path analysis models The imputation process replaced all the missing values and analyses were conducted with a sample of 471 subjects (Table 2). Observed variables in the models were good indicators of their latent variables with high factor loadings, varying from .629 to .866. In the initial path analysis model, there were five latent variables; exposure to violent conflict (violcon), poverty and change in economic conditions (changeeco), and two variables measuring positive mental health in 2005 (pmh 05) and 2006 (pmh 06). The initial model did not have a good fit (χ2 = 85.62, df = 45, p = .00025). The CFI was .96 and RMSEA was .044. Using several steps we produced our last model (Figure 2), which has good fit and no further suggestion from modification indices and tvalues. This final model had good fit indicators with χ2 = 52.51 (df = 45, p = .21). The CFI for the final model was .99 and RMSEA was .019 (Table 3).
4
S. Saragih Turnip et al.
Analysis of predictors of positive mental health
Downloaded by [University of Otago] at 23:23 12 November 2015
Both exposure to violent conflict and poverty significantly predicted positive mental health in 2005 (pmh 05), with factor loadings of −.30 and .29, respectively. Exposure to violent conflict showed that more traumatic experiences predicted less positive mental health. Since higher poverty measure score indicated better economic condition, higher poverty as a latent variable predicted better positive mental health.
Figure 1.
Basic model of variables.
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Table 1. Mean scores of SOC and SWB according to demographic characteristics, traumatic experiences and economic changes of IDP in Mollucas, Indonesia. N
Total sample Gender Female Male
Downloaded by [University of Otago] at 23:23 12 November 2015
Age at T2
