UvA-DARE is a service provided by the library of the University of Amsterdam (http://dare.uva.nl) UvA-DARE (Digital Academic Repository) Positive psychology interventions in a multi-ethnic and cross-cultural context Hendriks, T. Link to publication Creative Commons License (see https://creativecommons.org/use-remix/cc-licenses): Other Citation for published version (APA): Hendriks, T. (2018). Positive psychology interventions in a multi-ethnic and cross-cultural context. General rights It is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s), other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons). Disclaimer/Complaints regulations If you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, stating your reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Ask the Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam, The Netherlands. You will be contacted as soon as possible. Download date: 27 Aug 2020
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UvA-DARE is a service provided by the library of the University of Amsterdam (http://dare.uva.nl)
UvA-DARE (Digital Academic Repository)
Positive psychology interventions in a multi-ethnic and cross-cultural context
Hendriks, T.
Link to publication
Creative Commons License (see https://creativecommons.org/use-remix/cc-licenses):Other
Citation for published version (APA):Hendriks, T. (2018). Positive psychology interventions in a multi-ethnic and cross-cultural context.
General rightsIt is not permitted to download or to forward/distribute the text or part of it without the consent of the author(s) and/or copyright holder(s),other than for strictly personal, individual use, unless the work is under an open content license (like Creative Commons).
Disclaimer/Complaints regulationsIf you believe that digital publication of certain material infringes any of your rights or (privacy) interests, please let the Library know, statingyour reasons. In case of a legitimate complaint, the Library will make the material inaccessible and/or remove it from the website. Please Askthe Library: https://uba.uva.nl/en/contact, or a letter to: Library of the University of Amsterdam, Secretariat, Singel 425, 1012 WP Amsterdam,The Netherlands. You will be contacted as soon as possible.
All rights reserved. No part of this thesis may be produced, stored in a
retrieval center of any nature, or transmitted, in any form or by any
means, electronic, mechanical, photocopying, recording or otherwise
without the permission of the author.
Design cover by Dulcy Oudsten & Consuela Esseboom
Printed by Gildeprint Drukkerijen, the Netherlands
POSITIVE PSYCHOLOGY INTERVENTIONS IN A MULTI-ETHNIC
AND CROSS-CULTURAL CONTEXT
ACADEMISCH PROEFSCHRIFT
ter verkrijging van de graad van doctor
aan de Universiteit van Amsterdam
op gezag van de Rector Magnificus
prof. dr. ir. K.I.J. Maex
ten overstaan van een door het College voor Promoties ingestelde commissie,
in het openbaar te verdedigen in de Agnietenkapel
op donderdag 1 november 2018, te 10:00 uur
door Tom Hendriks
geboren te Veldhoven
Promotor:
Prof. dr. J.T.V.M. de Jong Universiteit van Amsterdam
Copromotoren:
Prof. dr. T.L.G. Graafsma Anton de Kom Universiteit van Suriname
Dr. M. Schotanus-Dijkstra Universiteit Twente
Overige leden:
Prof. dr. A.H. Fisher Universiteit van Amsterdam
Prof. dr. A.C. Homan Universiteit van Amsterdam
Prof. dr. A.J. Pols Universiteit van Amsterdam
Prof. dr. M. Bartels Vrije Universiteit Amsterdam
Prof. dr. J.A. Walburg Universiteit Twente
Prof. dr. J.B. Rijsman Tilburg Universiteit
Faculteit der Maatschappij-- en Gedragswetenschappen
Content
7 Chapter 1 General introduction
Part I - Positive psychology interventions in cross-cultural perspective 33 Chapter 2 How WEIRD are positive psychology interventions? A
bibliometric analysis of randomized controlled trials on the science of well-being
61 Chapter 3 The efficacy of multi-component positive psychology
interventions: A meta-analysis and systematic review
97 Chapter 4 The efficacy of positive psychology interventions in non-
Western countries: A meta-analysis and systematic review Part II – Positive psychology in a multi-ethnic context: Resilience and mental well-being in Suriname 135 Chapter 5 Strengths and virtues and the development of resilience: A
qualitative study in Suriname during a time of economic crisis 155 Chapter 6 Psychological resilience and mental well-being in a multi-
ethnic context: Findings from a randomized controlled trial 185 Chapter 7 Mediators of a cultural adapted positive psychology
intervention aimed at increasing well-being and resilience. Part III - Yoga as a cultural sensitive positive intervention 215 Chapter 8
The effects of yoga on positive mental health among healthy adults: A systematic review and meta-analysis
243 Chapter 9 The effects of Sahaja Yoga meditation on mental health:
A systematic review 265 Chapter 10 General discussion 295 Samenvatting (Summary in Dutch) 301 Publications 305 Dankwoord (Acknowledgements in Dutch) 311 About the author
Even a happy life cannot be without a
measure of darkness, and the word
happy would lose its meaning if it were
not balanced by sadness. It is far better
take things as they come along with
patience and equanimity.
Carl Gustav Jung
7
Chapter 1
General introduction
8
General introduction
Since its independence from the Netherlands in 1975, the Republic of Suriname
has experienced a turbulent development. Periods of freedom and democracy
alternated with periods when freedom was limited and democracy was flawed.
Times of economic prosperity were followed by severe economic crises. Over the
past 40 years, the Surinamese population has ridden through many peaks and
troughs. In 2015, after nearly a decade of growth, the economy plunged into a
deep recession, devaluing the monetary value of the Surinamese dollar by over
100%. In addition, democracy in Suriname may currently also be in danger. Events
in the recent history of Suriname have probably put the resilience of the
Surinamese people to the test.
The main goal of this thesis is to explore if a so-called positive psychology
intervention (PPI) can contribute to increased resilience and mental well-being
among healthy adults in Suriname. I will also bring yoga meditation as a possible
additional positive intervention into the limelight of positive psychology.
The thesis is divided into three parts, each addressing distinct goals. The goals of
the first part of this thesis are to determine to what extent PPIs are Western-
centric and to explore the efficacy of PPIs both generally and in non-Western
countries in particular. In the second part, I aim to determine the efficacy of a
culturally adapted PPI that was conducted in Suriname and to report on possible
mediators of the PPI we tested. In addition, I will discuss what strengths and
virtues among the ethnic groups in Suriname contribute to increased resilience
and well-being. In the third part, the goal is to examine the feasibility of yoga
meditation as a culturally sensitive positive intervention in Suriname.
Resilience and well-being are multi-dimensional constructs that are influenced by
socio-economic, cultural, and even historic factors (Gunderson, 2010; Holling,
1973). To clarify the recent challenges that the Surinamese population has been
facing, general information on the Republic of Suriname and its history will firstly
be provided in this general introduction. Then, I will briefly discuss the two main
outcomes of the core study of this thesis, namely, resilience and well-being. Next,
a brief history of positive psychology is presented, including criticism of the
movement from cross-cultural researchers, followed by an overview of the
development of positive psychology in Suriname. I will then briefly discuss positive
psychology interventions and describe how I culturally adapted the intervention
9
that I developed and tested in Suriname. A plea for yoga as a positive (psychology)
intervention will then be made, before the general introduction is concluded with
the outline of the thesis.
Suriname: A multi-ethnic nation under stress
The quantitative and qualitative studies that are presented in this thesis were
conducted among participants in Paramaribo, the capital of Suriname. Suriname is
a country located in the north-east of South America, above Brazil and between
Guyana and French Guyana. Suriname is a multi-ethnic society that consists of
Afro-Surinamese (Creoles 31% and Maroons 10%), Hindustani (37%), Javanese
(15%), Amerindians (2%), Chinese (2%), and other ethnic groups (3%) (The World
Factbook, 2016). It is a plural society where people from many different origins
and religions peacefully coexist, perhaps because no single ethnic group has a
majority status (Chickrie, 2011; St-Hilaire, 2001). The multi-ethnic composition of
the population is the direct result of colonization that started in the 17th century
when the English colonized the territory. After the Anglo-Dutch Wars between
1665 and 1674, the sovereignty of Suriname was transferred to the Dutch, in
exchange for New Amsterdam (New York) (Allen, 2015). Between 1668 and 1823,
more than 300,000 African slaves were brought to Suriname to work at coffee,
cacao, cotton, and sugarcane plantations (Price & Price, 1980) . Thousands of
slaves escaped into the interior forests, where they established independent
communities. The descendants of these escaped slaves are known as Maroons,
whereas the descendants of the slaves that remained at the plantations are
referred to as Creoles (Cairo, 2007). After the abolishment of slavery in 1863, the
Dutch began to import contract laborers from Asia, mostly from India (known as
Hindustani or East Indians) and Java, Indonesia (called Javanese) (Chickrie, 2011).
Between 1873 to 1940 more than 34,000 East Indians and nearly 33,000 Javanese
contract workers arrived in Suriname (Hoefte, 1998). In 1975, the country gained
its independence from the Netherlands and the Republic of Suriname was formed.
Almost 40,000 Surinamese people migrated to the Netherlands in 1975 (Choenni &
Harmsen, 2007). Currently, the country has an estimated 585,000 residents, with
the majority living in the capital Paramaribo (The World Factbook, 2016). The three
main religions in Suriname are Christianity (48%, most prevalent among Afro-
Surinamese), Hinduism (27%, most prevalent among East Indians), and Islam (20%,
most prevalent among Javanese and 10% of the East Indians). Dutch is still the
official language, but most Surinamese also speak Sranang Tongo, a language that
was created by the slaves from Africa (Van den Berg & Aboh, 2013), that local
inhabitants refer to as Negro-English.
10
Troubled times in Suriname
In 2011, after years of strong economic growth that started in 2005, the
Surinamese economy entered a recession. In 2015, the gross national product
(GNP) was decreased by 7% (KNOEMA, 2016) and between September 2015 and
May 2016, the nominal currency of the Surinamese dollar depreciated by 99%
against the US dollar, and the Consumer Price Index (CPI) increased by 55%
(Economic Commission for Latin America, 2016). In June 2016, Suriname had the
world’s third highest inflation rate globally, preceded only by Sudan and Venezuela
(Trading Economics, 2016). The negative impact of economic crises on the well-
being of the population in general have been well reported: economic crises have
been associated with reduced well-being and self-esteem, and increased
symptoms of impaired well-being such as depression, anxiety, and stress
2012; Pepping, Donnovan, & Davis, 2013) and the admiration for certain Buddhist
teachers that many prominent positive psychologists openly express during
positive psychology conferences. There are now even hybrid programs that
combine mindfulness-based intervention techniques with PPIs (Ivtzan & Lomas,
2016; Ivtzan et al., 2016; Niemiec, Tayyeb, & Spinella, 2012). I do recognize the
importance of mindfulness meditation as a way to increase well-being, and the
contributions of Buddhist philosophy to Western psychology. However, I
personally have the impression that the positive psychology movement suffers
from tunnel vision, by focusing almost exclusively on the benefits of Buddhist
based meditation. Positive psychology, in general, is neglecting and overlooking
knowledge from other spiritual traditions that may offer similar or even other
paths to well-being, for example, the practice of yoga, which entails more than just
physical exercise. Yoga is aimed at achieving personal growth that may eventually
lead to an enlightened state of consciousness (DeMichelis, 2005). Surprisingly, in
my literature study during this thesis, I found only three articles (Butzer, Ahmed, &
Khalsa, 2016; Ivtzan, & Papantoniou, 2014; Kumar & Kumar, 2013) and one book
(Levine, 2011) from Western scholars, that view yoga from a positive psychology
perspective. While for Western populations, mindfulness may be a good cultural
fit, in view of its secular nature (Niemiec, 2013), mindfulness may not be a suitable
for non-Western populations with a non-Buddhist religious background. For
example, in Suriname, almost 40% of the population adheres to Hinduism. I
believe that yoga, rather than mindfulness meditation, made be a more effective,
21
efficacious, and feasible way to increase well-being. With this thesis, I hope to
contribute to change the tunnel vision in positive psychology, which may hamper
advances in scientific understanding of the process of meditation, as well as well-
being.
Outline of thesis
The thesis is divided into the following three parts:
Part I - Positive psychology interventions in cultural perspective
This part consists of three peer-reviewed articles. Chapter 2 addresses the
question as to what extent the science of positive psychology is Western-centric
and provides data from a bibliometric analysis. Chapter 3 focuses on the general
efficacy of multi-component positive psychology interventions, whereas chapter 4
focuses on the efficacy of positive psychology interventions from non-Western
countries in particular. Chapters 3 and 4 both present data from a meta-analysis
and a systematic review.
These studies were conducted in view of the paucity in the literature. The
previously published meta-analyses contained relatively few MPPIs, since this type
of intervention has only recently been conducted on a larger scale. Furthermore,
the previous analyses contained virtually no studies that were conducted from
non-Western countries. To date it is unknown if PPIs are also becoming more
applied in non-Western countries and if non-Western PPIs are as efficacious as
PPIs conducted in Western countries.
Part II - Positive mental health and resilience
This part features three additional peer-reviewed articles, each presenting results
from studies that were conducted among Surinamese populations. Chapter 5
covers the relationship between strength and virtues and the development of
resilience in Suriname, based on qualitative data obtained from in-depth
interviews. Chapters 6 and 7 present data from an RCT that was conducted among
healthy workers in Paramaribo, and focuses on the effects of an MPPI on positive
mental health, resilience, and other psychological outcomes and possible
mediators and moderators. These chapters form the core part of this thesis. First, I
wanted to know what factors contribute to resilience and well-being in the context
of Suriname. In view of the lack of literature, I conducted a series of in-depth
22
interviews with community representatives, health care professionals,
representatives from religious institutions, and academic scholars specialized in
social sciences. After qualitative data analyses, findings from this study were used
in the cultural adaptation process of a positive psychology intervention that was
originally developed in the Netherlands. With the assistance of a group of local
trainers, the intervention was conducted throughout a period of three months.
Finally, we conducted quantitative data analyses, the findings of which are
reported in this thesis.
Part III - Yoga as a culturally sensitive positive intervention
The third part of this thesis consists of two peer-reviewed articles on yoga.
Chapter 8 explores the efficacy of yoga on positive mental health in general, on
the basis of a meta-analysis and systematic review. Next, we focus on a specific
form of yoga meditation that is practiced in Suriname, namely Sahaja Yoga
meditation (SY). Chapter 9 discusses the overall psychological effects of this form
of yoga on the basis of data from a systematic review.
While mindfulness meditation is included in many MPPI interventions, the use of
meditation forms that are rooted in the philosophy of yoga are often overlooked.
Almost a third of the Surinamese population consists of people of East Indian
origin. In this light, yoga as a form of intervention to increase mental well-being
may be a better cultural fit than mindfulness meditation, which is based on
Buddhism. This part explores the use of yoga as a culturally sensitive positive
intervention in Suriname.
23
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Part I
Positive psychology interventions
in cross-cultural perspective
32
33
Chapter 2
How WEIRD are Positive Psychology
Interventions? A Bibliometric Analysis of
Randomized Controlled Trials on the
Science of Well-being
This chapter is published as:
Hendriks, T., Warren, M., Hassankhan, A., Schotanus-Dijkstra, M., Graafsma, T.,
Bohlmeijer, E. T, & de Jong, J. (2018). How WEIRD are positive psychology
interventions? A bibliometric analysis of randomized controlled trials on the
science of well-being.
The Journal of Positive Psychology, 1-13.
34
Abstract
The past two decades have witnessed a rapid rise in well-being research, and a
profusion of empirical studies on positive psychology interventions (PPIs). This
bibliometric analysis quantifies the extent to which rigorous research on PPIs that
employ randomized controlled trials (RCTs) reach beyond Western Educated
Industrialized Rich Democratic (WEIRD) populations. A search was conducted
through databases including PubMed, PsycINFO, and Scopus for studies from
1998 to 2017. In total, we found 187 full-text articles that included 188 RCTs from
24 countries. We found that RCTs on the efficacy of PPIs are still predominately
conducted in Western countries which accounted for 78.2% of the studies. All
these countries are highly industrialized and democratic, and study populations
are often highly educated and have a high income. However, there is a strong and
steady increase in publications from non-Western countries since 2012, indicating
a trend towards globalization of positive psychology research.
Introduction
Many scholars agree that until recently, research in psychology and other
disciplines in the social sciences has been Western-centric (Berry, 2013; Cole,
2006; Jahoda, 2016; Stewart, 2012; Sue, 1999). Psychology as a social science has
been criticized for being primarily a Western enterprise that uses findings from
studies of thought and behavior of people living in the Western hemisphere and
generalizes them to the entire human population. On the basis of an analysis of
six premier APA journals, Arnett (2008) concluded that American psychologists
focus on 5% to 7% of the human population. In particular, psychological research
is dominated by scholarship emerging from the United States (Eysenck, 2001).
Even within cross-cultural psychology, U.S. psychologists are responsible for 50%
to 75% of all published articles, and tend to be cited more often (Allik, 2013) than
psychologists from other countries. Additionally, a large majority of the samples
are drawn from undergraduate psychology students at North American
universities (Arnett, 2008), and these samples are very atypical and do not
represent characteristics of the majority of the world’s population. Henrich and
colleagues (2011a, 2010b) describe these samples as WEIRD – Western,
Educated, Industrialized, Rich and Democratic – to capture the demographic
characteristics as well as to allude to the idiosyncratic nature of the populations
35
represented in the majority of published research. The acronym highlights that
the larger part of the scientific knowledge about human psychology is based on
the findings of studies conducted within a specific research population, namely,
wealthy undergraduate students in the U.S.
In line with broader trends in psychological science, as identified by
Arnett (2008), a bibliometric analysis of positive psychology publications from the
inception of the field in 1998 to 2010, reported that 74.5% of the authors were
affiliated with institutions in North America, 17.6% in Europe, 3.2 % in Asia
(mostly China), 1.4% in Africa (mostly South Africa), and 0.9% in South and
Central America. Hence, approximately 94.5% of the research stems from
Western countries, and only 5.5% from non-Western countries (Schui & Krampen,
2010). Their analyses included quantitative and qualitative research papers,
edited books, book chapters, and dissertations. In this paper, we focus on
randomized controlled trials (RCTs) examining the effects of positive psychology
interventions (PPIs). PPIs are interventions aimed at increasing positive feelings,
behaviors, and cognitions, that use pathways or strategies to increase well-being
based on positive psychological theories and empirical research (Schueller,
Kashdan, & Parks, 2014; Schueller & Parks, 2014).
Mirroring the concerns in broader psychological science, cross-cultural
psychologists and anthropologists have expressed concern that such a strong
North American influence in positive psychology distorts the construction of
human happiness and flourishing; positive psychology is bound to North
American culture and neglects the cultural embeddedness of positive human
behavior (Christopher & Hickinbottom, 2008; Frawley, 2015). They argue that the
positive psychology movement is deeply entrenched in Northern American
ideology that emphasizes the pursuit of individual happiness as one of the most
important goals in life. The antecedents of human flourishing most frequently
studied tend to be those located within the individual. Flourishing is constructed
predominately as an individual process and achieved through the cultivation of
individual strengths and virtues while the importance of external factors on
macro-and micro-economic levels, as well as social, cultural and even historical
factors, are underestimated or simply neglected (Becker & Marecek, 2008). Thus,
the research emerging from North America seems to reflect the foci and cultural
values of the region. A more recent systematic review of 863 empirical articles
about positive psychology studies published between 1998 to 2014, reported that
41% of the studies were conducted in the U.S., 24% in Europe, 7% in Canada, 6%
36
in Australia. So, only about 78% of the articles were conducted in Western
countries indicating a trend towards greater global representation of research in
positive psychology (Kim, Doiron, Warren, & Donaldson, 2018). Kim and
colleagues’ (2018) review of the research emphases and foci found support for
the assertion that the contributions situated outside of North America reflected
the values, priorities, and cultural ideologies of the regions in which they
originated, and this enriched the science.
Positive psychology is a relative newcomer to the scientific community
and still draws some skepticism regarding its credibility (Coyne & Tennen, 2010;
Frawley, 2015; Vazquez, 2013). Since the RCT is considered the golden standard
in clinical research – the most rigorous method that can determine causal
relations between interventions and outcomes (Sibbald & Roland, 1998), positive
psychology studies that uphold this standard are more likely to be accepted by
the broader scientific community. Therefore, we have focused on RCTs of PPIs in
this bibliometric review. To summarize, we assess the state-of-the-art with
respect to the cultural and socio-demographic context of current RCTs on the
effects of PPIs.
Present study
In this study, we report on the general characteristics of RCTs and present the
types of positive activities that are included in the intervention. Further, to
address past concerns about positive psychology being too Western-centric
(Christopher & Hickinbottom, 2008; Cameron, 2016), the current study examines
whether positive psychology is truly a “WEIRD” science, by analyzing the country
of origins, educational level of the participants, the industrialization level of the
originating countries, the classification of the income levels of these countries,
and finally the classification of political regimes.
Method
Literature search methods
A systematic literature search was conducted in the following three databases:
PubMed, PsycINFO, and Scopus, from 1998 through 2016. The last run was
conducted on the 25th of July 2017. The search was conducted by the first and
third author. We searched the databases with the following terms: "positive
37
psycho*" OR wellbeing OR happiness OR happy OR flourishing OR "life
satisfaction" OR "satisfaction with life" OR optimism OR gratitude OR strengths
OR forgiveness OR compassion AND "random*”. The search strings were adapted
to each database. While Western journals that are devoted to the science of well-
being are included in the aforementioned mainstream databases (e.g. the Journal
of Positive Psychology and the Journal of Happiness Studies), these databases
may not include publications from non-Western positive psychology journals.
Therefore, we conducted a search in Google and found two such journals, namely
the Indian Journal of Positive Psychology and the Iranian Journal of Positive
Psychology. We conducted a hand search through their websites. Finally,
reference lists of four recent meta-analyses (Bolier et al., 2013; Chakhssi, Kraiss,
Sommers-Spijkerman, & Bohlmeijer, 2018; Dickens, 2017; Sin & Lyubomirsky,
2009) and seven recent review articles on PPIs (Casellas-Grau, Font, & Vives,
For this study, we focused on RCTs of PPIs. We included: (1) randomized
controlled trials and cluster-randomized trials on PPIs; (2) studies that were
published in peer-reviewed journals; (2) studies published from 1998, the
inaugural year of positive psychology, through 2016. We excluded: (1) non-
randomized controlled studies; (2) studies published in dissertations and grey
literature.
Data extraction and analysis
Bibliometric data (number of authors, publication year, origin, journal of
publication), data on participants (population, sample size, mean age, gender,
education) and intervention data (intervention components, control groups,
delivery mode, number of sessions/modules, session duration and type of
positive psychology activities) were extracted by the first author. Two authors
classified WEIRD indicators in the following ways. Data were analyzed
descriptively using SPSS® version 23 and Microsoft Excel®.
Western. Following Gosling et al. (2010), we classified North America,
Western Europe, Israel, Australia and New Zealand as Western-societies. We also
examined the number of participants explicitly identified as Caucasian or non-
Caucasian. Finally, we examined if the interventions in the studies were culturally
38
adapted, that is, if there was evidence of systematic modification of evidence-
based treatments (EBT) or intervention protocols so that they were made
compatible with the cultural patterns, meanings, and values of participants in the
intervention (Bernal & Domenech Rodriguez, 2012).
Educated. Education was assessed using two methods. At the macro-level,
the level of human development in a specific country was used as an indicator for
the education level. This was done on the basis of the data from the Human
Development Report (2015) that classified the general population of the country
as having a very high, high, medium, or low level of human development (United
Nations Development Programme, 2015). We also analyzed education on an
individual level and report the numbers and percentages of study participants
who received a higher education (attended college or university for at least one
year).
Industrialized. The term ‘industrialized’ is often associated with a high level of
economic and technological development of a country. We classified countries as
having an advanced economy or an emerging/developing economy on the basis
of data from the World Economic Outlook (International Monetary Fund, 2016).
Countries that are described as advanced economies are characterized by high
gross domestic product (GDP) and a high degree of industrialization (International
Monetary Fund, 2016). Countries classified as emerging/developing economies
are markets with high growth expectations, characterized by a high level of risk
and extremely volatility (Mody, 2004).
Rich. As few individual studies report demographics on the income
level of the participants, we primarily used country data from the Global Wealth
Databook (2013) that aims to provide the best available estimates of the wealth-
holding of households worldwide (Credit Suisse, 2013). In order to be exhaustive,
we also reviewed the income of study participants in studies in which this
information was reported.
Democratic. Classification of the state of democracy was based on the
Democracy Index as compiled by the Economist Intelligence Unit (Kekic, 2008).
39
Results
General bibliometrics We identified a total of 8,248 records. After removal of duplicates, 7,136 records remained. These records were screened by the first and third author, after which 301 records were found to be eligible. Of these records, 114 articles were excluded. We finally included 187 articles in our bibliometric analysis that consisted of 188 original studies. Figure 1 shows the results of the literature search.
Since 1998 was considered as the year of the conception of the positive
psychology movement, the earliest year of publication was 1998 with two
studies, followed by two years in which no RCTs were published. Between 2001
and 2009, the number of studies varied from two to four per year, except for a
peak of twelve studies in 2006. In 2009, there were eight published studies, in
2010 the number dropped to five. From 2011, there is a steady rise in the number
of studies, with peaks in 2014 (33 studies) and 2016 (49 studies). An overview is
depicted in Figure 2. In the period from 1998 to 2007 no publications from non-
Western countries were published on a yearly basis, with the exception in 2004
with one study from China. During the period 2008 - 2016 every year a minimum
of one RCT from a non-Western country was published.
The studies were published in 118 different journals, and the following journals
published three or more studies: The Journal of Positive Psychology (n = 24,
12.2%), Journal of Happiness Studies (n = 8, 4.3%), Journal of Clinical Psychology
(n = 7, 3.7%), Journal of Consulting and Clinical Psychology (n = 4, 2.1%), Journal
of Medical Internet Research (n = 4, 2.1%), Aging & Mental Health (n = 3, 1.6%),
American Psychologist (n = 3, 1.6%), Frontiers in Psychology (n = 3, 1.6%),
International Journal of Geriatric Psychiatry (n = 3, 1.6%), Journal of Personality
and Social Psychology (n = 3, 1.6%), and Social Indicators Research (n = 3, 1.6%).
40
Figure 1. Results of literature search
Scre
enin
g El
igib
ility
Id
enti
fica
tio
n
Additional records identified through
other sources
(n = 876)
Total records: (n =8,248)
Records after duplicates removed: (n = 7,136)
Full-text articles excluded (n = 114) Main reason for exclusion: Not a RCT (n = 40) Not a PPI (n = 38) Article not available (n = 13) Prior to 1998 and in 2017 (n = 18) Review/protocol/dissertation/ book chapter (n = 5)
No psychological outcomes (n=2) Non randomized controlled trial (n=1) Full text in English not available (n=1)
Articles included in bibliometric analysis (n = 187)
Studies included in bibliometric analysis (n = 188)
Records identified through
database searching
(n = 7,372)
PubMed: (n = 2,167)
PsycINFO: (n = 4,041)
Scopus (n = 1,164)
Pubmed n = 512
PsycInfo n = 1935
Scopus n = 2,194
Full-text articles assessed for eligibility
(n = 301)
Titles and abstracts screened
(n = 7,136)
Records excluded (n =6,835)
Incl
ud
ed
41
Figure 2. Randomized controlled trials on positive psychology interventions through time.
Studies from Western countries Studies from non-Western countries
Participants
A total of 43,582 individuals participated in 188 RCTs. Study sample sizes ranged
from 10 to 3,363 (median = 83.0). The mean age of the participants was 37.1 (29
studies did not report the mean age of the participants). There were 164 (87.2%)
studies that included adults, of which 10 (5.3%) were elderly (older than 62
years). Twenty-two studies (11.7%) included children or adolescents and 2 studies
(1.1%) included both adults and children. Sixty-six studies were conducted among
clinical populations (35.1%) and 122 studies among non-clinical populations
(64.9%). For the clinical population, the two most frequently studied conditions
were depression (n = 13, 19.7% of the clinical population) and cancer (n = 10,
1.6%), South Korea (n = 3, 1.6%), Taiwan (n = 3, 1.6%), Israel (n = 2, 1.1%), and
Norway (n = 2, 1.1%). Countries where one study (0.5%) per country was
conducted were Belgium, Finland, Malaysia. the Philippines, South Africa, and
Turkey. Table 3 also contains the overview of the country origins.
Sixty-two studies from Western origins reported the ethnicity of the participants:
from a total of 8,713 participants, 5,936 were Caucasian (68.1%) and 2,777 were
non-Caucasian (31.9%). Although not specifically reported in all studies from non-
Western origins, we believe it is fair to assume all participants from these 41
studies (n = 11,266) to be non-Caucasian, bringing the total (estimated) number
of non-Caucasian participants to 14,183 (32.2%) of the entire population. In
addition, we examined whether the interventions were culturally adapted or not.
We found 17 (41.5%) studies using intervention programs that were culturally
adapted, and 24 (58.5%) studies in which the programs were not culturally
adapted (including 4 studies in which there was no clear description).
Education. In total, 17 (70.8%) countries were characterized by very high
human development, two (8.3%) countries were characterized by high human
development and three (12.5%) countries were characterized by medium human
development (See Table 3). It should be noted that mainland China is indicated as
having high human development, whereas Hong Kong, China is indicated as
having very high human development (10 studies). Data from Taiwan were not
available. However, since Taiwan is known as one of the five so–called 'Asian
economic tigers' we believe it is reasonable to assume the level of education is
comparable to South Korea and Hong Kong. Thus, Taiwan is classified as having
very high human development. On an individual level, it was possible to partly
analyze the educational level of populations in the trials: 98 (52.1%) studies
provided sufficient information. We found that from the 17,627 participants in
these 98 studies, 12,771 participants (72.4%) had a relatively high educational
level, having attended at least one year of college.
46
Industrialized. The economies of 17 (70.8%) countries were classified as
advanced (See Table 3). These countries include all Western countries and three
non-Western countries (Japan, South Korea, and Taiwan). Six countries (25.0%)
were classified as emerging and developing economies (India, Iran, Malaysia, the
Philippines, South Africa, and Turkey). China (4.2%) is considered to have an
emerging economy, and Hong Kong, SAR to have an advanced economy. One
hundred sixty-six (88.3%) of the studies were conducted in countries with an
advanced economy (including 10 studies from Hong Kong, China) and twenty-two
studies (11.7%) were conducted in countries with an emerging economy
(including 5 studies from mainland China).
Rich. Seventeen (70.8%) countries were classified as high-income
countries (HIC) (See Table 3). These countries again include all Western countries,
Japan, South Korea, and Taiwan. Two non-Western countries (8.3%) were
classified as an upper middle-income country (South Africa, Malaysia), three
(1.5%) as lower middle-income countries (Iran, the Philippines, Turkey) and India
as a low-income country (4.2%). China was classified as a lower middle-income
country, while Hong Kong SAR was classified as a high-income country (Credit
Suisse, 2013). One hundred sixty-six (88.3%) of the studies were conducted in
high-income countries (HIC), including 10 studies from Hong Kong, China. Twenty-
two studies (11.7%) were conducted in low- and middle-income countries (LMIC).
On an individual level, income was reported in only 14 studies from Western
countries (7.4%) and three studies from non-Western countries (1.6%). In light of
this limited number of studies, particularly in non-Western countries, we are
unable to draw any meaningful conclusions.
47
Table 3. Number of studies per country and WEIRD descriptions
COUNTRY STUDIES REGION EDUCATED INDUSTRIALIZED
RICH DEMO CRATIC
USA 74 (39.4%)
W Very high human development
Advanced economy
High income Full democracy
Australia 18 (9.6%) NW Very high human development
Advanced economy
High income Full democracy
China 15 (8.0%) NW (Very) high human*
development
Advanced/ emerging
economy**
High/Lower middle income
Authoritarian
Iran 10 (5.3%) W High human development
Emerging economy
Lower middle income
Authoritarian
UK 10 (5.3%) W Very high human development
Advanced economy
High income Full democracy
Switzerland 9 (4.8%) W Very high human development
Advanced economy
High income Full democracy
The Netherlands
8 (4.3%) W Very high human development
Advanced economy
High income Full democracy
Canada 6 (3.2%) W Very high human development
Advanced economy
High income Full democracy
Spain 6 (3.2%) W Very high human development
Advanced economy
High income Full democracy
Germany 4 (2.1%) W Very high human development
Advanced economy
High income Full democracy
India 3 (1.6%) W Medium human development
Emerging economy
Low income Flawed democracy
Ireland 3 (1.6%) W Very high human development
Advanced economy
High income Full democracy
Italy 3 (1.6%) W Very high human development
Advanced economy
High income Full democracy
Japan 3 (1.6%) NW Very high human development
Advanced economy
High income Full democracy
South Korea 3 (1.6%) NW Very high human development
Advanced economy
High income Flawed democracy
Taiwan 3 (1.6%) NW Very high human development
Advanced economy
High income Flawed democracy
Israel 2 (1.1%) NW Very high human development
Advanced economy
High income Full democracy
Norway 2 (1.1%) NW Very high human development
Advanced economy
High income Full democracy
Belgium 1 (0.5%) W Very high human development
Advanced economy
High income Full democracy
Finland 1 (0.5%) W Very high human development
Advanced economy
High income Full democracy
Malaysia 1 (0.5%) NW High human development
Emerging economy
Upper middle income
Flawed democracy
The Philippines
1 (0.5%) NW Medium human development
Emerging economy
Lower middle income
Flawed democracy
South Africa 1 (0.5%) NW Medium human development
Emerging economy
Upper middle income
Flawed democracy
Turkey 1 (0.5%) NW High human development
Emerging economy
Lower middle income
Flawed democracy
48
Abbreviations: NW: non-Western; W:Western * Mainland China is indicated as having a high human development (5 studies), whereas Hong Kong, SAR is indicated as having very high human development (10 studies)** Mainland China is indicated as having an emerging economy, whereas Hong Kong is indicated as having an advanced economy
Democratic. Fifteen (62.5%) countries were classified as full democracies
and these include all Western countries (See Table 3). Six non-Western countries
were either classified as flawed democracies (India, Malaysia, the Philippines,
South Africa, South Korea, and Taiwan, in total 25.0%), two countries were
authoritarian (China and Iran, in sum 8.3%). In light of recent developments, we
have also classified Turkey as a flawed democracy (4.2%) (Kekic, 2008). One
hundred fifty (79.8%) of the studies were conducted in countries with a full
democracy, 13 (6.9%) in countries with flawed democracies, and 25 (13.3%)
studies were conducted in countries with authoritarian regimes.
Discussion
The purpose of this study was to examine trends in the publication of RCTs in
positive psychology and to determine to what extent positive psychology is
currently Western-centric. Findings reveal an incremental growth in the number
of RCTs on the effects of positive psychology, suggesting an increasing interest in
research on the efficacy of PPIs. These findings are in line with a previous
bibliometric analysis on the growth of positive psychology that included peer-
reviewed journal articles, authored books, edited books, book reviews, and
dissertations (Schui & Krampen, 2010). Our analysis also showed that until
recently positive psychology was indeed culturally biased since the large majority
of the RCTs originated from Western countries. However, since 2014, we witness
a sharp rise in publications from non-Western countries that now account for
over one-third of the studies. This suggests that there is a growing trend in PPIs
towards globalization. Analysis revealed that life review and spiritual activities
were the most frequently used activities in non-Western countries. Activities that
were used much less frequently compared to Western PPIs, were acts of
kindness, mindfulness, best possible selves, and physical activities. In addition, we
found that 24 interventions (58.5%) from non-Western studies were not
49
culturally adapted. Some exercises are already highly adaptive and perhaps
culture-free. Life review (positive reminiscence), for example, focuses on an
individual's personal memories (Lau & Cheng, 2011) which are usually tied to a
specific cultural and historical setting, and therefore, may be applied universally.
In other studies, the interventions were based on a specific protocol that was
developed in the West, for example, the Positive Psychotherapy (PPT) protocol. In
17 studies (41.5%) the interventions were culturally adapted, for example, by
shifting the focus of the intervention from the individual to their relationships
with family and community members. A study involving 2,070 participants in
Hong Kong aimed to increase subjective well-being and health-related quality of
life by fostering positive communication among families. This was done by
conducting regular positive psychology activities such as positive reminiscence
and expression of gratitude in cooking and dining with family members (Ho et al.,
2016). Emic meditation practices can also be integrated into PPIs to ensure a
better cultural fit. This was done in a study among 78 Hong Kong school teachers
in which regular counting-your-blessings exercises were supplemented by Naikan-
meditation-like questions, bringing the exercise in line with Confucian teachings
of daily self-reflection (Chan, 2013). Studies from Iran have examined the effects
of Islam-based PPIs where gratitude towards Allah is actively expressed, or
strengths and virtues that are prominently featured in the Qur’an are practiced
Ebrahimi, 2015) and the ‘Happy Kitchen Family project’ (Ho et al., 2016). The
process of cultural adaptation of interventions has been widely described by
leading authors in the field of cross-cultural psychology (Domenech- Rodriguez &
Bernal 2012, Hinton and Laroche 2012, Hinton and Jalal 2014, Kirmayer 2006).
Whereas cultural psychiatry focuses on the cultural idioms of distress (Hinton &
Lewis-Fernández, 2010), positive cross-cultural psychology could concentrate on
discovering culturally salient indicators of well-being. For example, a qualitative
study conducted in Suriname, South America found that the concept of rukun is
associated with resilience among the Javanese ethnic group (Hendriks, Graafsma,
Hassankhan, Bohlmeijer, & de Jong, 2017). Rukun can be described as living in
harmony with one surrounding, which includes the spiritual world. Another
example in the context of Suriname is Opo Yeye, a mental well-being model based
on traditional knowledge of the winti belief system among Afro-Surinamese
(Cairo, 2012). We recommend use of a mixed method approach (Teddlie &
Tashakkori, 2011) to discover emic models and expressions of well-being.
Secondly, we recommend that organizations that strive to promote the
dissemination of positive psychology should actively reach out to researchers in
non-Western countries, for example, by attending regional psychology
conferences in non-Western countries, or inviting leading cross-cultural
researchers as speakers at positive psychology conferences. Finally, we
recommend the examination of the efficacy of PPIs from non-Western countries,
including a moderator analysis including WEIRD and other factors (for example
the influence of gender, and if an intervention was culturally adapted or not).
54
Conclusion
Although, positive psychology is still a science dominated by WEIRD populations,
we see a strong trend towards a more global distribution of scientific productivity
over the past four years. The ratio of non-Western to Western RCTs has dropped
from 1:13 during the period from 1998 to 2012, to an average of 1:2.6 over the
past four years, with China and Iran now in the top five of countries that produce
the most RCT publications in the field of positive psychology. Although the
majority of the studies on positive psychology is still from Western countries,
there is much promise of positive psychology expanding globally.
Competing interests
The authors declare that they have no competing interests.
55
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Chapter 3
The Efficacy of Multi-component
Positive Psychology Interventions: A
Systematic Review and Meta-analysis
This chapter is submitted as:
Hendriks, T., Schotanus- Dijkstra, M., Hassankhan, A., Graafsma, T., de Jong, J.,
E. T. (2018). The efficacy of multi-component positive psychology interventions:
A systematic review and meta-analysis.
62
Abstract
A previous meta-analysis of randomized controlled trials examining the efficacy of
positive psychology interventions (PPIs) reported small effects on subjective and
psychological well-being and depression. The large majority of the studies in this
analysis consisted of interventions containing a single positive activity. Recently,
we see a sharp increase in the number of multi-component positive psychology
interventions (MPPIs). The aim of the current article is to examine the efficacy of
MPPIs, through a systematic review and meta-analysis. We included 37
randomized controlled trials (RCTs) that were published in 37 articles between
1998 and May 2017. We found standardized mean differences of Hedges’ g =
0.46 for subjective well-being, Hedges’ g = 0.37 for psychological well-being,
Hedges’ g = 0.32 for depression, and Hedges’ g = 0.30 for anxiety. However,
removing outliers or low-quality studies reduced the effect sizes considerably.
Moderator analyses were significant, showing larger effect sizes for studies from
non-Western countries, than studies from western countries. This systematic
review and meta-analysis found evidence for short term and long-term effects
MPPIs in improving mental health. MPPIs have a small to moderate effect on
subjective and psychological well-being, and a small effect on depression and
anxiety. Further well conducted research among diverse populations is necessary
to strengthen claims on the efficacy of MPPIs.
Introduction
Since its establishment, the positive psychology movement has set out to redirect
the course of psychological research: away from a focus on pathology, diseases
and deficits, and towards the study of human strengths, flourishing and the
optimal functioning of individuals, groups, and institutions (Gable & Haidt, 2005;
Seligman & Csikszentmihalyi, 2000; Sheldon, 2001). Since its inauguration in
1998, the movement has made a considerable impact on the scientific
community, with an exponential growth of publications (Donaldson et al., 2014;
Hart & Sasso, 2011; Rusk & Waters, 2013). Positive psychology builds on the ideas
of humanistic psychology, but employs state-of the art-research methods to
Sin & Lyubomirsky,, 2009) and six review articles on PPIs (Casellas-Grau et al.,
2014; Macaskill, 2016; Rashid, 2015; Sutipan et al., 2016; Walsh et al., 2016;
Woodworth et al., 2016).
Selection of studies
After removal of duplicates, titles and abstracts were screened by two reviewers
(first and third author). Full texts of potential relevant articles were assessed. We
included studies based on the following criteria: (1) studies were RCTs; (2) studies
were administered to healthy adults or adults in clinical populations in the age
range of 18-65 years; (3) interventions comprised at least three activities or
modules which were explicitly based on strategies aiming at positive emotions,
behavior, cognitions and mental well-being; (4) studies were published in peer
reviewed journals; (5) studies used outcome measures to examine the effects on
subjective and psychological well-being, depression, anxiety, stress. We excluded:
(1) cluster randomized controlled trials; (2) intervention that were primarily
based on mindfulness (including Acceptance and Commitment therapy, loving
kindness meditation) and forgiveness therapy programs; (3) studies that did not
provide sufficient data to calculate post-treatment effect sizes per condition and
the author was unable to provide the necessary data upon request; (4) studies
that were published in book chapters, in dissertations and studies in grey
literature; (5) articles that were not published in English.
Data extraction
One reviewer performed the data extraction, which was then verified by the
second reviewer. Any disagreements were resolved by consensus and through
consultation with the last author. The following data was gathered: authors, year
of publication, country of origin, condition of participants, program
name/intervention type, delivery form, description of control group, number of
sessions, duration of session period, follow-up assessment, number or
participants per condition at post-test level, mean age and standard deviation of
participants, percentage of female participants, retention rate at post-test level
66
per condition, type of outcome and used questionnaires. For the meta-analyses,
we extracted means and standard deviations at post-test. In case of insufficient
data or unclear reporting, we contacted the authors through e-mail. In total,
fifteen authors were contacted, of which eight provided sufficient additional data
to include the study in our analysis.
Quality assessment
Two reviewers (TH, MS) independently assessed the quality of each study using
the Cochrane Collaboration’s tool for assessing risk of bias in RCTs (Higgins et al.,
2011) with the following six criteria: (1) was there a description of sequence
generation?; (2) was allocation of the participants to the interventions
concealed?; (3) were outcome measures blinded, administered by an
independent person or via online assessment?; (4) was there a description of the
withdrawals/drop-outs?; (5) was a power analysis carried out or was the group
size per condition larger than 50?; (6) was an intention-to-treat analysis
conducted, or were there zero drop-outs? One point was appointed for each
criterion met. The quality of a study was assessed as ‘high’ when a minimum of
five criteria were met, ‘medium’ when three to four criteria were met, and ‘low’
when less than three criteria were met. Consensus between the two reviewers
was reached through discussion.
Statistical analyses
Data analyses was performed with the program Comprehensive Meta-Analysis
(CMA, version 3.3.070). We used the means, standard deviations and sample
sizes for each study, to calculate the effect size using dichotomous outcomes. For
each comparison between a PPI and a control group, Hedges’ g effect sizes were
calculated to assess the between-group differences at post-test. These effect
sizes were calculated by subtracting the average score of the PPI group from the
average score of the comparison group (both at post-test) and dividing the result
by the pooled standard deviations obtained from the two groups. We used
Hedges’ g because this effect size measure is more accurate than Cohen's d when
study sample sizes of the studies are small (Cuijpers, 2016), which is the case in
almost half of the studies we included. Similarly to Cohen’s d, Hedges’ g effect
sizes of 0 to 0.32 can be considered as small, effect sizes of 0.33 to 0.55 as
moderate, and effect sizes of 0.56 to 1.2 as large (Lipsey & Wilson, 1993). In the
calculation of effect sizes for depression, stress and anxiety we used the scores on
instruments that explicitly measured these outcomes. For subjective and
psychological well-being, we also used scores from instruments related to these
67
constructs of well-being. See Table 1 for detailed information on the used
instruments per outcome. If more than one measure was used for a particular
outcome in one study, the pooled effect size was calculated. Thus, each study
provided only one effect size for all outcomes. When available, we computed
between-group effect sizes (Hedges’ g) for follow-up differences. We made a
distinction between short-term follow-up effects (3 months or shorter after post-
test) and long-term follow-up effects (longer than 3 months after post-test).
Due to the diverse populations, we expected considerable heterogeneity.
Therefore, we performed the meta-analysis using a random effects model, with a
95% confidence interval and using a two-tailed test. Separate meta-analyses were
performed for subjective well-being, psychological well-being, depression, anxiety
and stress. Forest plots of post between-group effect sizes were produced for
each outcome variable, both with and without outliers. We considered a study as
an outlier when its 95% confidence interval (CI) was outside the 95% CI of the
overall mean effect size (on either side). We identified outliers through visual
inspection of the forest plots. We tested for statistical heterogeneity between
studies using the I2 statistics, a measure of how much variance between studies
can be attributed to differences between studies, beyond the expected chance
(Higgins & Green, 2011). We used the I2 statistic to estimate the percentage of
heterogeneity across the studies not attributable to random sample error alone.
A value of 0% indicated no heterogeneity. Values of 25%, 50% and 75% reflected
low, moderate and high degrees of heterogeneity, respectively (Higgins &
Thompson, 2002).Significant heterogeneity was indicated by a significant Q
statistic (p < 0.05), meaning that one or more variables were present that
moderated the observed effect size.
Exploratory subgroup analyses were conducted to examine the
moderating effects of the following variables: (1) population types: clinical and
non-clinical; (2) intervention: PPI and PPI plus other types of intervention; (3)
delivery mode: group intervention, individual and self-help; (4) control group:
active and non-active controls; (4) duration of trial: eight weeks or less, more
than eight weeks; (5) quality rating: low score (0, 1, 2), medium score (3, 4), high
score (5, 6) ; (6) region: Western or non-Western. Following Gosling et al. (2010),
we classified North America, Western Europe, Israel, Australia and New Zealand
as Western-countries, other countries were classified as non-Western. We also
assessed the moderating effects of quality ratings on a continuous scale using
68
meta-regression analyses.
We assessed publication bias in the following ways. First, we created a
funnel plot by plotting the overall mean effect size against study size. Absence of
publication bias is present when there is a symmetric distribution of studies
around the effect size, while a higher concentration of studies on one side of the
effect size than on the other indicates publication bias (Sterne et al., 2008).
Second, we calculated a fail-safe N, a formal test of funnel plot asymmetry, for
each analysis. This fail-safe N indicates the number of unpublished non-significant
studies that would be required to lower the overall effect size below significance
(Egger et al. 1997; Orwin 1983). Findings were considered robust if the fail-safe N
≥ 5k + 10, where k is the number of studies (Rosenberg, 2005). Third, we used the
Trim and Fill method (Duval & Tweedie, 2000). This procedure imputes the effect
sizes of missing studies and produces an adjusted effect size accounting for the
missing studies.
Results
Study selection
In total we found 7,632 records: 2167 from PubMed, 4041 from PsycINFO, 1164
from Scopus, and 260 from searching reference lists. After removal of duplicates,
6,437 records remained for screening. Of these, we discarded 6,134 articles
based on screening title and abstract that did not meet the inclusion criteria. We
then assessed 303 full text articles. Finally, 37 articles with a total of 37 studies
met the inclusion criteria and were included in the meta-analysis. Results from
one study was published in two articles (Asl et al., 2016, Asl et al., 2014), and two
studies were reported in one article (Seligman et al., 2006). Figure 1 displays the
selection process in a flow diagram.
Study characteristics
The studies included a total of 5,199 participants at post measurement level.
Sample sizes ranged from 18 to 1,288, with a median of 67. Nineteen studies
(51.4 %) were conducted among clinical populations and 18 among non-clinical
populations (48.6%). Delivery modes were group (n = 20, 54.0%; n = 11 clinical, n
= 9 non-clinical), self-help (n = 15, 40.5%; n = 6 clinical, n = 9 non-clinical) and
individual (n = 2, 5.4%; n = 2 clinical). Eighteen control conditions were active
69
control groups (cognitive behavioral therapy, n = 5, 27.8%; placebo, n = 5, 27.8%)
treatment as usual, n = 5, 27.8%, meditation/relaxation, n = 2, 5.6% and
dialectical behavioral therapy, n = 1, 2.8%). Nineteen control conditions were
non-active (waiting list, n = 10, 52.6%; no intervention, n = 9, 47.4%). The number
of sessions varied between 1 and 28, with an average of 9 sessions (SD = 5.73).
Eight studies did not report the number of sessions. The duration of the
intervention varied between 1 day and 20 weeks, with an average of 8.3 weeks
(SD = 3.70). One study did not report on the duration period. Seventeen studies
reported follow-up effects; seven studies reported short term follow-up effects
(1-3 months), seven studies reported long term follow-up effects (3-12 months)
and three studies reported short term and long-term follow-up effects. The mean
age of the participants was 40.0 years (SD = 11.85). Of the total, 3,399
participants were female (65.4%). This number is based on 33 studies since 4
studies did not report the distribution of male and female participants. The
average retention rate was 73.8% for the intervention groups, and 79.2% for the
control groups (n = 32). The main characteristics of the studies are presented in
Table 1.
Study measures
We reported on the following outcomes: subjective well-being, psychological
well-being, depression, anxiety and stress. Outcomes that were classified as
subjective well-being included happiness, emotional and subjective well-being,
satisfaction with life, positive affect, quality of life, cognitive well-being, and well-
being.
70
Figure 1. Results of literature search
Outcomes that were classified as psychological well-being included flourishing, authentic
living, personal growth, meaning, autonomy, (work) engagement, psychological capital,
environmental well-being, perspective, positive relations, purpose in life, and self-
acceptance. In four studies, more than one measure of psychological well-being was
present. In total, we found 28 studies that reported on subjective well-being, 25 studies on
depression, 17 studies on psychological well-being, 7 studies on anxiety and 7 studies on
stress.
Reference check
(n = 260)
Records identified through
database searching
(n = 7,372)
PubMed: (n = 2,167)
PsycINFO: (n = 4,041)
Scopus (n = 1,164)
Pubmed n = 512
PsycInfo n = 1935
Scopus n = 2,194
Scre
enin
g El
igib
ility
Id
enti
fica
tio
n
Total records: (n = 7,223)
Records after duplicates removed: (n = 6,437)
Full-text articles excluded (n = 266) Main reason for exclusion: Single component PPI (n = 120) Not a RCT (n = 40) Not a PPI (n = 39 Article not available (n = 15) Cluster RCT (n = 14) < 3 positive activities (n = 13) Review/protocol/dissertation/ book chapter (n = 8) Age < 18 or >65 (n = 5) Incomplete data/unclear reporting (n = 4) No relevant outcome (n = 4) Published before 1998 (n = 3)
No psychological outcomes (n=2) Non randomized controlled trial (n=1) Full text in English not available (n=1)
Articles included (n = 37)
Studies included (n = 37)
Full-text articles assessed for eligibility
(n = 303)
Titles and abstracts screened
(n = 6,437)
Records excluded (n = 6,134)
Incl
ud
ed
71
Table 1. Main study characteristics of included studies of the meta-analyses of multicomponent positive psychology interventions
First Author, Year, Country
Condition of participants
Inter- vention
Delivery Control group
Sessions, duration
T2 N-post Mean age/ SD
%F
%R
Outcome measures*
Asgharipoor, 2012, Iran Patients with major depression
Abbreviations: SG = Sequence generation; AC = Allocation concealment; BOA = Blinding of main outcome assessments; DW = Description of withdrawals/ drop-outs; PA = Power analysis or N>50; ITT = Intention-to-treat analysis/ 0 drop-outs
76
Quality assessment
The outcome of the quality assessment is shown in Table 2. The quality of the
studies was scored from 0 to 6 (M= 2.78, SD = 1.58). Six studies were rates as high
(16.2%), with one study meeting all the quality criteria. Seventeen (45.9%) studies
were rated as moderate and fourteen studies (37.8%) were rated as low-quality
studies. Nineteen studies (47.5%) reported adequately how randomization took
place, while in only seven studies (17.5%) allocation of the participants to the
intervention or control group was concealed. In twenty-one (52.5%) studies,
outcome assessment was blinded mainly because online assessment was used. In
thirty studies (75.0%), drop-outs were adequately described. Thirteen studies
(32.5%) had a population size larger than 50 per allocated arm. Thirteen studies
(32.5%) analyzed outcomes on the basis of an intention-to-treat analyses or had
zero drop-outs.
Post-treatment effects
Between – group effects
The main results are presented in Table 3.
Effects on subjective well-being
For subjective well-being (28 comparisons), a significant moderate effect was
observed (g = 0.46, 95% CI: 0.25 to 0.68, p = 0.000) at post treatment. The effect
sizes of the studies ranged from -0.86 to 3.06. Heterogeneity analysis revealed a
significant and high level of heterogeneity (I2 = 83.82, Q: 166.55, p = 0.000).
Removing seven outliers (Asgharipoor et al., 2012; Celano et al., 2016; Cerezo et
al., 2014; Dowlatabadi et al., 2016; Lü et al., 2013; Muller et al., 2016; Peters et
al., 2017) reduced both the effect size (g = 0.35, 95% CI: 0.22 to 0.48, p = 0.000)
and the heterogeneity, which was moderate (I2 = 47.55, Q = 38.13, p = 0.009).
* p < 0.05; ** p < 0.01; *** p < 0.001; ns: non-significant
Contrary to the funnel plots, Egger’s regression intercept was significant for
psychological well-being (2.08, t = 2.30, df = 15, p = 0.036), but not significant for
subjective well-being (1.35, t = 1.14, df = 26, p = 0.265) and depression (1.54, t =
1.86, df = 23, p = 0.075). Finally, when possible missing studies were imputed
using the Duval and Tweedie’s trim-and-fill method, the adjusted effect sizes
increased for subjective well-being (g = 0.61, 95% CI: 0.39 to 0.83) and depression
(g = 0.36, 95% CI: 0.17 to 0.55), but not for psychological well-being. In sum,
potential missing publications seem not to have influenced the results of the
meta-analyses, and if so, the presented results are conservative.
Follow-up effects
Follow-up periods ranged from one month (short term follow-up) to twelve
months (long term follow-up). Analysis showed a significant moderate effect (g =
0.36, 95% CI: 0.08 to 0.65, p = 0.013) for subjective well-being at follow-up
measurement (12 comparisons). After removal of two outliers the effect size
increased (g = 0.52, 95% CI: 0.28 to 0.76, p = 0.000). We also found a moderate to
large follow-up effect for depression (11 comparisons) follow-up measurement (g
= 0.54, 95% CI: 0.10 to 0.99, p = 0.017). After removal of one outlier the effect
size decreases, but was still moderate (g = 0.35, 95% CI: 0.00 to 0.70, p = 0.049).
We did not calculate follow- up effect sizes for psychological well-being, anxiety
and stress due to the small number of studies reporting follow-up effects (4, 4
and 3 respectively).
85
Discussion
Main findings
The aim of this study was to examine the efficacy of MPPIs across randomized
controlled trials. Following a systematic literature search, we included 37 articles
describing 37 studies on the effects of MPPIs in our meta-analysis. We found
moderate effect sizes for subjective well-being (g = 0.46) and psychological well-
being (g = 0.37), and small effect sizes for depression (g = 0.32) and anxiety (g =
0.30). After removing outliers, the effect sizes decreased for subjective well-being
(g = 0.35), psychological well-being (g = 0.30) and depression (g = 0.21), while the
effect size for anxiety remained unchanged. Removing low quality studies also
resulted in lower effect sizes for subjective well-being (g = 0.32), psychological
well-being (g = 0.23), depression (g = 0.13) and anxiety (g = 0.29). The findings for
stress were somewhat contradictory. We initially found no significant effect for
stress on the basis of seven comparisons. However, removing one study that was
both an outlier and a low-quality study, resulted in a significant moderate effect
size (g = 0.50). Follow-up results showed that moderate effects on subjective
well-being maintained (g = 0.37), and even increased (g = 0.53) when outliers
were excluded. For depression, we found a moderate to large long-term effect
size (g = 0.54). Omitting one outlier decreased the effect size, although this was
still moderate (g = 0.35). We did not calculate follow-up effects for psychological
well-being, anxiety and stress due to the limited amount of available studies.
If we compare our findings to a previous meta-analysis of RCT’s on the effect of
PPIs (Bolier et al., 2013), we can draw several conclusions. Firstly, over the past
five years, there has been a sharp increase in the number of RCTs involving
MPPIs: we found 37 studies in comparison to 7 studies in the study of Bolier et al.
(2013). Secondly, our findings suggest that MPPIs have larger effect on subjective
well-being, psychological well-being and depression than (mainly) single
component interventions. However, the difference is minimal. Due to the large
heterogeneity of the studies we were not able to determine the factors that
contribute to these findings, except for the moderating effects of non-Western
studies. Thirdly, we found that MPPIs have moderate follow-up effects for
subjective well-being and depression, whereas Bolier et al. (2013) found small
follow-up effects for subjective well-being and no significant effects for
depression. These findings are in line with the implications from the so-called
Synergistic Change Model (Rusk et al., 2017). This model explains that lasting
positive change as a result of a PPI, is most likely to occur when interventions are
86
targeted at multiple domains of positive functioning. In contrast to single
component interventions, MPPIs consist of different positive activities that target
several domains, which may decrease the risk of relapse and increase the
likelihood of spill-over effects and synergy between the various activities.
Fourthly, our meta-analysis is the first that found promising results of PPIs on
anxiety and stress. This is due to the fact that outcomes on anxiety and stress
were only reported in studies on that were published recently (since 2012). Still,
the total number of studies that reported on these outcomes, was limited,
namely seven for each outcome.
Explorative subgroup analyses revealed that MPPIs from non-Western
countries have a larger effect size for subjective well-being, psychological well-
being, and stress than studies from Western countries. This could partially be
explained by the fact that the included studies from non-Western countries had
much smaller sample sizes than the studies from Western countries (median of
34.0 compared to a median of 88.5). Prior studies have shown that trials with
small sample sizes tend to overestimate effect sizes (Slavin & Smith, 2009; Zhang
et al., 2013) . Also, non-Western studies scored lower on quality rating, namely a
mean rating score of 1.0, compared to a mean rating score of 3.43 for Western
countries. Results from our meta-regression analysis also suggest that the effect
sizes for subjective well-being, psychological well-being and depression were
lower for the studies with a higher quality rating. In our analysis, we see that
studies that report high effect size are more often the low-quality studies and
from non-Western countries. For example, for subjective well-being four studies
reported an effect size larger than g = 1.70 (Asgharipoor et al., 2012; Cerezo et al.,
2014; Dowlatabadi et al., 2016; Lü et al., 2013). Three of these studies were from
non-Western countries. Additionally, as expected subgroup analyses for
psychological well-being and stress showed that studies with non-active control
groups reported significantly larger effect sizes than studies with active control
groups. This finding is in line with conclusions drawn from other meta-analyses.
For example, a meta-analysis of 49 RCTs comparing cognitive-behaviour therapies
against various control conditions reported that interventions with a waiting list
condition had larger effects sizes, compared to active controls (Furukawa et al.,
2014). Hendriks et al. (2017) reported that increases in psychological well-being
following yoga interventions were only significant in interventions with no active
controls. Summarily stated, the more effective components that a comparison
group has, the greater the diminishment smaller the effect size will be (Karlsson &
Bergmark, 2014).
87
Study limitations
We believe there are two major limitations to the findings of this study. The first
one is the relatively small numbers of studies per outcome and subgroup.
Although the number of studies in the field of positive psychology is increasing,
also in comparison to other psychological sub-disciplines (Hart & Sasso, 2011;
Rusk & Waters, 2013), the output still remains low (Schui & Krampen, 2010). For
example, while for psychological well-being there were fourteen studies
conducted among non-clinical populations, we only found three studies among
clinical populations that measured the effects of the MPPIs. With such a small
sample of studies, definite conclusions on the effects of MPPI on any outcome
measures among the clinical population cannot be drawn. With a limited number
of studies and, on average, a high level of heterogeneity, the impact of excluding
a single study could also have a high impact. This was illustrated in our findings
for stress: based on seven studies we found no significant effects, however, after
removing one outlier we did find a significant and even a moderate effect for
stress. In fact, the effect size for stress was then the highest of all outcomes (g =
0.50).
The second limitation applies to the quality of the studies, or better said:
the lack thereof. Only 15% of the studies could be classified as high-quality
studies (n = 6), 43% of the studies (n = 17) were classified as moderate, and 35 %
of the studies were classified as low-quality studies (n = 14). The main reasons for
the lack of quality are the omission of randomization procedures (51% of the
studies), the failure to state whether or not allocation of the participants was
concealed (81%), and the failure to state whether or not the outcome assessment
was blinded (43%). Furthermore, 24 studies (64.9%) conducted completers-only
analyses, as opposed to intention-to-treat analyses, thereby increasing the risk of
selection bias (Yelland et al., 2015). Another limitation is that the majority of the
studies is weakly powered: 23 of the 37 studies (62.2%) had a population less
than 50 participants per condition. Seventeen studies (45.9%) even had less than
30 participants. Studies with low power have a weak predictive value, have a low
probability of finding an effect or exaggerate the magnitude of the effect when an
effect is discovered (Button et al., 2013, Slavin & Smith, 2009).
88
Conclusion and recommendations
Despite the limitations we conclude that MPPIs have small to moderate effects on
subjective and psychological well-being and small effects on depression, anxiety
and stress. However, some recommendations are in order. Firstly, there is a need
for a more rigorous methodological approach in studies in the field of positive
psychology, which should lead to higher quality studies. This recommendation is a
reoccurring one, having been stated several previous PPI meta-analyses (Bolier et
al., 2013; Weiss, Westerhof, & Bohlmeijer, 2016). We believe this to be
imperative for PPIs in particular, considering the explicit call for more rigorous
research methods to study well-being which is often heard in positive psychology
(Diener, 2009; Froh, 2004; Linley & Joseph, 2004; Linley et al., 2006). We
recommend that future studies are designed based on a power-analysis to avoid
the risk that clinical trials fail to detect meaningful differences (Adams-Huet &
Ahn, 2009), or at least include a minimum of 50 participants per condition. We
highly recommend that future studies pay more attention to methodological
reporting and follow protocols guidelines such as the CONSORT (Moher et al.,
2010) or the Standard Protocol Items: Recommendations for Interventional Trials
(SPIRIT) guidelines (Chan et al., 2013). In light of the growing number of RCTS
from non-Western countries, this recommendation particular applies to studies
from such countries, since all non-Western studies we included had a low study
quality rating. Secondly, although our findings contribute to a better
understanding of the effectiveness of MPPIs, due to the high heterogeneity of the
studies it was not possible to clearly determine the conditions for optimal
conditions. More future studies among diverse populations could enrich the field
of positive psychology and mental health and contribute to more insight into the
optimal conditions for positive psychology interventions. Finally, the effects of
MPPIs on stress are promising, but our findings were based on a limited amount
of studies. Again, further high-quality research is needed to make any definite
claims on the efficacy of MPPIs.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions The meta-analyses and data-analyses were conducted by TH, who also wrote the manuscript. The literature search was conducted by TH and AH, the risk of bias analysis was conducted by TH and MS. MS also cross-checked the data analyses. JdJ was an advisor in the project. EB was the editor of the article. All authors contributed to the writing of the manuscript and approved the final manuscript.
89
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Appendix 1. Strings of the search strategy
PUBMED: ((well-being[Title/Abstract] OR happiness[Title/Abstract] OR happy[Title/Abstract] OR flourishing[Title/Abstract] OR "life satisfaction"[Title/Abstract] OR "satisfaction with life"[Title/Abstract] OR optimism[Title/Abstract] OR gratitude[Title/Abstract] OR strengths[Title/Abstract] OR forgiveness[Title/Abstract] OR compassion[Title/Abstract] OR "positive psych*"[Title/Abstract])) AND "random"*[Title/Abstract] PSYCINFO: well-being or happiness or happy or flourishing or "life satisfaction" or "satisfaction with life" or optimism or gratitude or strengths or forgiveness or compassion or "positive psych*").ti. and ("well-being" or happiness or happy or flourishing or "life satisfaction" or "satisfaction with life" or optimism or gratitude or strengths or forgiveness or compassion or "positive psych*"). ab. and random*.af SCOPUS: #1 well-being or happiness or happy or flourishing or "life satisfaction" or "satisfaction with life" or optimism or gratitude or strengths or forgiveness or compassion or "positive psych*" #2 AND ABS(well-being or happiness or happy or flourishing or "life satisfaction" or "satisfaction with life" or optimism or gratitude or strengths or forgiveness or compassion or "positive psych*")AND TITLE-ABS-KEY(random*)) AND DOCTYPE(ar) AND PUBYEAR > 1997 AND ( LIMIT-TO ( SUBJAREA,"MEDI" ) OR LIMIT-TO ( SUBJAREA,"HEAL" ) OR LIMIT-TO ( SUBJAREA,"PSYC" ) OR LIMIT-TO ( SUBJAREA,"SOCI" ) OR LIMIT-TO ( SUBJAREA,"NURS" ) OR LIMIT-TO ( SUBJAREA,"BUSI" ) OR LIMIT-TO ( SUBJAREA,"MULT" ) ) AND ( LIMIT-TO ( LANGUAGE,"English" ) ) AND ( LIMIT-TO ( AFFILCOUNTRY,"United States" ) ) AND ( LIMIT-TO ( EXACTKEYWORD,"Human" ) OR LIMIT-TO ( EXACTKEYWORD,"Article" ) OR LIMIT-TO ( EXACTKEYWORD,"Humans" ) OR LIMIT-TO ( EXACTKEYWORD,"Controlled Study" ) OR LIMIT-TO ( EXACTKEYWORD,"Male" ) OR LIMIT-TO ( EXACTKEYWORD,"Female" ) OR LIMIT-TO ( EXACTKEYWORD,"Adult" ) OR LIMIT-TO ( EXACTKEYWORD,"Randomized Controlled Trial" ) OR LIMIT-TO ( EXACTKEYWORD,"Controlled Clinical Trial" ) OR LIMIT-TO ( EXACTKEYWORD,"Middle Aged" ) OR LIMIT-TO ( EXACTKEYWORD,"Aged" ) OR LIMIT-TO ( EXACTKEYWORD,"Clinical Trial" ) OR LIMIT-TO ( EXACTKEYWORD,"Physiology" ) OR LIMIT-TO ( EXACTKEYWORD,"Priority Journal" ) OR LIMIT-TO ( EXACTKEYWORD,"Major Clinical Study" ) OR LIMIT-TO ( EXACTKEYWORD,"Young Adult" ) OR LIMIT-TO ( EXACTKEYWORD,"Treatment Outcome" ) OR LIMIT-TO ( EXACTKEYWORD,"Methodology" ) OR LIMIT-TO ( EXACTKEYWORD,"Quality Of Life" ) OR LIMIT-TO ( EXACTKEYWORD,"Clinical Article" ) OR LIMIT-TO ( EXACTKEYWORD,"Procedures" ) OR LIMIT-TO ( EXACTKEYWORD,"Questionnaire" ) OR LIMIT-TO ( EXACTKEYWORD,"Human Experiment" ) OR LIMIT-TO ( EXACTKEYWORD,"Normal Human" ) OR LIMIT-TO ( EXACTKEYWORD,"Wellbeing" ) OR LIMIT-TO ( EXACTKEYWORD,"Double Blind Procedure" ) OR LIMIT-TO ( EXACTKEYWORD,"Randomization" ) OR LIMIT-TO ( EXACTKEYWORD,"Depression" ) OR LIMIT-TO ( EXACTKEYWORD,"Outcome Assessment" ) OR LIMIT-TO ( EXACTKEYWORD,"Random Allocation" ) OR LIMIT-TO ( EXACTKEYWORD,"Follow Up" ) OR LIMIT-TO ( EXACTKEYWORD,"Questionnaires" ) OR LIMIT-TO ( EXACTKEYWORD,"Exercise Therapy" ) OR LIMIT-TO ( EXACTKEYWORD,"Time" ) OR LIMIT-TO ( EXACTKEYWORD,"Animals" ) OR LIMIT-TO ( EXACTKEYWORD,"Double-Blind Method" ) OR LIMIT-TO ( EXACTKEYWORD,"Well-being" ) OR LIMIT-TO ( EXACTKEYWORD,"Psychology" ) OR LIMIT-TO ( EXACTKEYWORD,"Psychological Aspect" ) OR LIMIT-TO ( EXACTKEYWORD,"Stress, Mechanical" ) OR LIMIT-TO ( EXACTKEYWORD,"Training" ) OR LIMIT-TO ( EXACTKEYWORD,"Physical Activity" ) OR LIMIT-TO ( EXACTKEYWORD,"Strength" ) OR LIMIT-TO ( EXACTKEYWORD,"Mental Health" ) OR LIMIT-TO ( EXACTKEYWORD,"Placebo" ) OR LIMIT-TO ( EXACTKEYWORD,"Health Status" ) OR LIMIT-TO ( EXACTKEYWORD,"Happiness" ) OR LIMIT-TO ( EXACTKEYWORD,"Personal Satisfaction" ) OR LIMIT-TO ( EXACTKEYWORD,"Self Concept" ) OR LIMIT-TO ( EXACTKEYWORD,"Life Satisfaction" ) OR LIMIT-TO ( EXACTKEYWORD,"Follow-Up Studies" ) OR LIMIT-TO ( EXACTKEYWORD,"Anxiety" ) OR LIMIT-TO ( EXACTKEYWORD,"Satisfaction" ) OR LIMIT-TO ( EXACTKEYWORD,"Psychological Well Being" ) OR LIMIT-TO ( EXACTKEYWORD,"Self Report" ) OR LIMIT-TO ( EXACTKEYWORD,"Instrumentation" ) OR LIMIT-TO ( EXACTKEYWORD,"Emotion" ) OR LIMIT-TO ( EXACTKEYWORD,"Adaptation, Psychological" ) OR LIMIT-TO ( EXACTKEYWORD,"United States" ) OR LIMIT-TO ( EXACTKEYWORD,"Fatigue" ) OR LIMIT-TO ( EXACTKEYWORD,"Social Support" ) OR LIMIT-TO ( EXACTKEYWORD,"Affect" ) OR LIMIT-TO ( EXACTKEYWORD,"Pilot Study" )
96
Appendix 2. Abbreviations of questionnaires
Subjective well-being: AHI: Authentic Happiness Index; BMIS: Brief Mood Introspection Scale (BMIS); CES-D pa: Center for Epidemiological Studies Depression Scale, positive affect subscale; MHC-SF-ewb subscale: Mental Health Continuum –Short Form - emotional well-being subscale; OHI: Oxford Happiness Index; PANAS: Positive and Negative Affect Schedule; PHI: Pemberton Happiness Index; SHS: Subjective Happiness Scale; SlAs: Standardized linear analog scale; SPANE: Scale of Positive and Negative Experience; SWLS: Satisfaction With Life Scale; SWS: Subjective Well-being Scale; VAS: Visual Analog Scale-Happiness
Psychological well-being: APM: Appreciation inventory scale: present moment; COS: Compassion for Others scale; FS: Flourishing Scale; GSE: Generalised self-efficacy scale; HFS: Happiness Flourishing Scale; MHC-SF pwb: Mental Health Continuum Short Form - psychological well-being subscale; MLQP: Meaning in Life Questionnaire – presence subscale; OTH: Orientations to Happiness Questionnaire; PCQ: PsyCap Questionnaire; PPTI: Positive Psychotherapy Inventory; PIL: Purpose In Life Test; PWBS: Psychological Well-Being Scales; RAW: Resilience at Work; SWS: Subjective Well-being Scale pwb subscale
Depression: BDI: Beck Depression Index; CES-D: Center for Epidemiological Studies - Depression scale; DASS-21: Depression Anxiety Stress Scale; HADS-D: Hospital Anxiety and Depression Scale, depression; HRSD: Hamilton Rating Scale for Depression; QIDS-SR: 16-item Quick Inventory of Depressive Symptomatology; SCL-90R: Symptom Checklist-90 Revised
psychological well-being (PWB), 13 studies measured depression, and five studies
reported on anxiety. The study characteristics are presented in Table 1.
Additional records identified through
other sources
(n = 931)
Records identified through
database searching
(n = 7,241)
PubMed: (n = 1,966)
PsycINFO: (n = 3,804)
Scopus (n = 1,471)
Pubmed n = 512
PsycInfo n = 1935
Scopus n = 2,194
Scre
enin
g El
igib
ility
Id
enti
fica
tio
n
Total records: (n = 8,172)
Records after duplicates removed: (n = 7,516)
Full-text articles excluded (n = 344) Main reason for exclusion: From a Western country (n = 256) Not a RCT (n = 33) Not a PPI (n = 26) No relevant outcome (n = 7) Article not available (n = 15) Dissertation (n = 5) Incomplete data/unclear reporting (n = 4), Age < 18 (n = 5) Full text not in English (n = 2)
Similar control group (n =2)
RCTs included (n = 28)
Full-text articles assessed for eligibility
(n = 372)
Titles and abstracts screened
(n = 7,516)
Records excluded (n = 7,144)
Incl
ud
ed
10
7
09
99
99
99
99
99
99
99
99
99
99
99
99
pp
pp
p
Table 1. Study characteristics of RCTs on PPI from non-Western countries
Abbreviations: SG: Sequence generation; AC: Allocation concealment; BOA: Blinding of main outcome assessment; DDO: Description of drop-outs; N>50, PA: N>50 or power analysis; ITT: Intention-to-treat analysis or 0 drop-outs
112
Post-test treatment effects The random effects model showed that PPIs were significantly more effective for all outcome measures compared to the control conditions. The main results are presented in Table 3 and explained below. Effect sizes of the individual studies are plotted in Figures 2, 3, and 4. Table 3. Between-group effects
Pek, & Finkel, 2008). In addition, several studies from Iran were recently
published that examined the effects of Islamic-based PPIs (Al-Seheel & Noor,
2016; Rouholamini et al., 2016; Saeedi, Nasab, Zadeh, & Ebrahimi, 2015). Such
intervention may constitute a cultural fit with the backgrounds of the
participants. This, in turn, could result in greater enthusiasm, commitment and
participation among the study populations, and therefore contribute to higher
effect sizes.
121
Study limitations
Besides the low quality of the studies, there are four additional limitations to the
findings of this meta-analysis. First, our findings were based on a relatively small
number of studies per outcome and subgroup. For example, psychological well-
being was an outcome in only eight studies, depression in 11 studies, and anxiety
in five studies. Sample sizes were relatively small in the exploratory subgroup
analyses. This limits the interpretation of the differences between groups. Due to
the small number of studies, publication bias analysis was not performed for
psychological well-being, depression and anxiety. Follow-up effects could only be
calculated for subjective well-being and depression, and findings should be
treated with caution in light of the limited numbers. For these reasons, definite
conclusions on the effects of PPIs from non-Western countries cannot be drawn.
Second, due to the high heterogeneity of the studies, it was not possible to
clearly determine optimal conditions, for example, differences in efficacy
between clinical or healthy populations, or differences in duration of the
intervention. Third, only studies published in peer reviewed journals in the
English language were included. Studies that were published in book chapters,
dissertations, studies in grey literature and studies that were not in the English
language (for example, two studies from Iran, which were only available in
Arabic) were excluded. Fourthly, only RCTs were included in the analyses, and
non-randomized controlled trials were excluded. While RCTs are considered the
gold standard in clinical research (Rosen, Manor, Engelhard, & Zucker, 2006), they
are often cost intensive and complex (Korn & Freidlin, 2012). Sufficiently
powering an RCT with its concomitant costs may not always be feasible in low-
and middle-income countries, due to lack of financial resources. For example, 625
articles on positive psychology in the Indian Journal of Positive Psychology were
screened. These studies were conducted in India and other Asian countries. Only
two of these studies were RCTs. Including quasi-experimental studies, which are
perhaps more often conducted in non-Western countries than RCTs, could
increase the number of studies in the subgroups and thereby provide a more
complete overview of the efficacy of PPIs in non-Western countries.
122
Recommendations
The limited number of studies included contributed to the finding of no
significant moderators and unreliable results for the publication bias analyses.
Research in the field of positive psychology in non-Western countries is still in its
infancy. A bibliometric analysis revealed that in the time period 1998 - 2013, only
nine RCTs from non-Western countries were published, and that number has now
(2018) almost quadrupled (Hendriks et al., 2018a). With this strong trend towards
globalization of positive psychology, the study quality of non-Western country
RCTs could benefit from protocol guidelines such as the Consolidated Standards
of Reporting Trials (CONSORT) (Schulz, Altman, & Moher, 2010) or the Standard
Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines
(Chan et al., 2013). Further, we urge researchers from non-Western countries to
publish in peer-reviewed journals, even when there is a null finding of no effect,
as this is likely to reduce the publication bias in positive psychology research.
123
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Appendix 1. Strings of the search strategy
PUBMED: ((well-being[Title/Abstract] OR happiness[Title/Abstract] OR happy[Title/Abstract] OR flourishing[Title/Abstract] OR "life satisfaction"[Title/Abstract] OR "satisfaction with life"[Title/Abstract] OR optimism[Title/Abstract] OR gratitude[Title/Abstract] OR strengths[Title/Abstract] OR forgiveness[Title/Abstract] OR compassion[Title/Abstract] OR "positive psych*"[Title/Abstract])) AND "random"*[Title/Abstract] PSYCINFO: well-being or happiness or happy or flourishing or "life satisfaction" or "satisfaction with life" or optimism or gratitude or strengths or forgiveness or compassion or "positive psych*").ti. and ("well-being" or happiness or happy or flourishing or "life satisfaction" or "satisfaction with life" or optimism or gratitude or strengths or forgiveness or compassion or "positive psych*"). ab. and random*.af SCOPUS: #1 well-being or happiness or happy or flourishing or "life satisfaction" or "satisfaction with life" or optimism or gratitude or strengths or forgiveness or compassion or "positive psych*" #2 AND ABS(well-being or happiness or happy or flourishing or "life satisfaction" or "satisfaction with life" or optimism or gratitude or strengths or forgiveness or compassion or "positive psych*")AND TITLE-ABS-KEY(random*)) AND DOCTYPE(ar) AND PUBYEAR > 1997 AND ( LIMIT-TO ( SUBJAREA,"MEDI" ) OR LIMIT-TO ( SUBJAREA,"HEAL" ) OR LIMIT-TO ( SUBJAREA,"PSYC" ) OR LIMIT-TO ( SUBJAREA,"SOCI" ) OR LIMIT-TO ( SUBJAREA,"NURS" ) OR LIMIT-TO ( SUBJAREA,"BUSI" ) OR LIMIT-TO ( SUBJAREA,"MULT" ) ) AND ( LIMIT-TO ( LANGUAGE,"English" ) ) AND ( LIMIT-TO ( AFFILCOUNTRY,"United States" ) ) AND ( LIMIT-TO ( EXACTKEYWORD,"Human" ) OR LIMIT-TO ( EXACTKEYWORD,"Article" ) OR LIMIT-TO ( EXACTKEYWORD,"Humans" ) OR LIMIT-TO ( EXACTKEYWORD,"Controlled Study" ) OR LIMIT-TO ( EXACTKEYWORD,"Male" ) OR LIMIT-TO ( EXACTKEYWORD,"Female" ) OR LIMIT-TO ( EXACTKEYWORD,"Adult" ) OR LIMIT-TO ( EXACTKEYWORD,"Randomized Controlled Trial" ) OR LIMIT-TO ( EXACTKEYWORD,"Controlled Clinical Trial" ) OR LIMIT-TO ( EXACTKEYWORD,"Middle Aged" ) OR LIMIT-TO ( EXACTKEYWORD,"Aged" ) OR LIMIT-TO ( EXACTKEYWORD,"Clinical Trial" ) OR LIMIT-TO ( EXACTKEYWORD,"Physiology" ) OR LIMIT-TO ( EXACTKEYWORD,"Priority Journal" ) OR LIMIT-TO ( EXACTKEYWORD,"Major Clinical Study" ) OR LIMIT-TO ( EXACTKEYWORD,"Young Adult" ) OR LIMIT-TO ( EXACTKEYWORD,"Treatment Outcome" ) OR LIMIT-TO ( EXACTKEYWORD,"Methodology" ) OR LIMIT-TO ( EXACTKEYWORD,"Quality Of Life" ) OR LIMIT-TO ( EXACTKEYWORD,"Clinical Article" ) OR LIMIT-TO ( EXACTKEYWORD,"Procedures" ) OR LIMIT-TO ( EXACTKEYWORD,"Questionnaire" ) OR LIMIT-TO ( EXACTKEYWORD,"Human Experiment" ) OR LIMIT-TO ( EXACTKEYWORD,"Normal Human" ) OR LIMIT-TO ( EXACTKEYWORD,"Wellbeing" ) OR LIMIT-TO ( EXACTKEYWORD,"Double Blind Procedure" ) OR LIMIT-TO ( EXACTKEYWORD,"Randomization" ) OR LIMIT-TO ( EXACTKEYWORD,"Depression" ) OR LIMIT-TO ( EXACTKEYWORD,"Outcome Assessment" ) OR LIMIT-TO ( EXACTKEYWORD,"Random Allocation" ) OR LIMIT-TO ( EXACTKEYWORD,"Follow Up" ) OR LIMIT-TO ( EXACTKEYWORD,"Questionnaires" ) OR LIMIT-TO ( EXACTKEYWORD,"Exercise Therapy" ) OR LIMIT-TO ( EXACTKEYWORD,"Time" ) OR LIMIT-TO ( EXACTKEYWORD,"Animals" ) OR LIMIT-TO ( EXACTKEYWORD,"Double-Blind Method" ) OR LIMIT-TO ( EXACTKEYWORD,"Well-being" ) OR LIMIT-TO ( EXACTKEYWORD,"Psychology" ) OR LIMIT-TO ( EXACTKEYWORD,"Psychological Aspect" ) OR LIMIT-TO ( EXACTKEYWORD,"Stress, Mechanical" ) OR LIMIT-TO ( EXACTKEYWORD,"Training" ) OR LIMIT-TO ( EXACTKEYWORD,"Physical Activity" ) OR LIMIT-TO ( EXACTKEYWORD,"Strength" ) OR LIMIT-TO ( EXACTKEYWORD,"Mental Health" ) OR LIMIT-TO ( EXACTKEYWORD,"Placebo" ) OR LIMIT-TO ( EXACTKEYWORD,"Health Status" ) OR LIMIT-TO ( EXACTKEYWORD,"Happiness" ) OR LIMIT-TO ( EXACTKEYWORD,"Personal Satisfaction" ) OR LIMIT-TO ( EXACTKEYWORD,"Self Concept" ) OR LIMIT-TO ( EXACTKEYWORD,"Life Satisfaction" ) OR LIMIT-TO ( EXACTKEYWORD,"Follow-Up Studies" ) OR LIMIT-TO ( EXACTKEYWORD,"Anxiety" ) OR LIMIT-TO ( EXACTKEYWORD,"Satisfaction" ) OR LIMIT-TO ( EXACTKEYWORD,"Psychological Well Being" ) OR LIMIT-TO ( EXACTKEYWORD,"Self Report" ) OR LIMIT-TO ( EXACTKEYWORD,"Instrumentation" ) OR LIMIT-TO ( EXACTKEYWORD,"Emotion" ) OR LIMIT-TO ( EXACTKEYWORD,"Adaptation, Psychological" ) OR LIMIT-TO ( EXACTKEYWORD,"United States" ) OR LIMIT-TO ( EXACTKEYWORD,"Fatigue" ) OR LIMIT-TO ( EXACTKEYWORD,"Social Support" ) OR LIMIT-TO ( EXACTKEYWORD,"Affect" ) OR LIMIT-TO ( EXACTKEYWORD,"Pilot Study" )
132
133
Part II
Positive psychology in a Multi-Ethnic Context:
Resilience and Mental Well-being in Suriname
134
135
Chapter 5
Strengths and Virtues and the
Development of Resilience: A Qualitative
Study in Suriname during a Time of
Economic Crisis
This chapter is published as:
Hendriks, T., Graafsma, T., Hassankhan, A., Bohlmeijer, E., & de Jong, J. (2018).
Strengths and virtues and the development of resilience: A qualitative study in
Suriname during a time of economic crisis. International Journal of Social
Psychiatry, 64(2), 180-188.
136
Abstract
Resilience can be described as the capacity to deal with adversity and traumatic
events. The current economic situation in Suriname and its social economic
consequences may demand a great amount of resilience for people living in
Suriname. In this explorative study we examined the relation between strengths
and resilience among the three major ethnic groups in Suriname. Semi-structured
interviews were conducted with twenty-five participants. We sought to gather
viewpoints from community representatives, health care professionals, and
academic scholars about the personal resources used by people in Suriname to
help them deal with the consequences of the current socio-economic crisis. We
identified major five strengths that were associated with resilience: religiousness,
hope, harmony, acceptance and perseverance. While these strengths contribute to
the development of resilience, they can under certain circumstances have an
ambiguous influence. Our findings suggest that religiousness is the bedrock
strength for the development of resilience in Suriname. We recommend that
future positive psychological interventions in non-Western countries integrate
positive activities with religious elements into program interventions, to achieve a
better cultural fit.
Introduction
The Republic of Suriname is a country located in the northeast of South America.
Suriname has an estimated population of 585.000, with almost half of its
residents living in the capital Paramaribo. Suriname is a multi-ethnic society that
consists of Afro-Surinamese (Creoles-16% and Maroons-22%), Hindustani (27%),
Javanese (14%), mixed ethnicity (13%), Amerindians (4%), Chinese (1%), and
other (3%) (Menke, 2016). The three main religions in Suriname are Christianity
(48.4%), Hinduism (22.3%), and Islam (13.9%) (Algoe & Schalkwijk, 2016).
Suriname is currently classified by the World Bank as an upper middle-income
country, this classification was based on data prior to the crisis. After nearly a
decade of strong economic growth, the economy entered a recession in 2015,
which is expected to decrease the GNP in 2016 with 7% (KNOEMA, 2016).
Between September 2015 and May 2016 the Consumer Price Index (CPI)
137
increased with 55% and the nominal currency of the Surinamese dollar
depreciated with 98.8% against the US dollar (ECLAC, 2016). In June 2016
Suriname had the world’s third highest inflation rate globally, just after Sudan and
Venezuela (TradingEconomics, 2016).
The consequences of economic crises can affect well-being of the
population in a negative way; decrease and/or loss of income due to
unemployment are two of the main risk factors affecting people’s well-being.
Symptoms of impaired well-being such as depression, anxiety, and reduced
subjective well-being and self-esteem have often been reported (Fernández &
López-Calva, 2010; Glonti et al., 2015; Karanikolos et al., 2013; Ng, Agius, &
Zaman, 2013; Paul & Moser, 2009; Zivin, Paczkowski, & Galea, 2011). Increases in
mortality rates are associated with economic crises, both in Western and
developing countries, as well as deaths caused by homicide (Falagas,
Vouloumanou, Mavros, & Karageorgopoulos, 2009) and suicide (Piovani &
Aydiner-Avsar, 2015; Uutela, 2010; Van Hal, 2015; Veenhoven & Hagenaars,
1989). The latter may be of great relevance, considering the high rates of suicide
in Suriname in general, and among the Hindustani population in the district of
Nickerie in particular, where suicide is linked to poverty and unemployment
(Graafsma, Kerkhof, Gibson, Badloe, & Van de Beek, 2006; Graafsma, Westra, &
Kerkhof, 2016; van Spijker, Graafsma, Dullaart, & Kerkhof, 2009).
Resilience is commonly understood as the capacity to deal effectively
with stress and adversity, to adapt successfully to setbacks (Burton, Pakenham, &
Smit, & Westerhof, 2010). Due to these findings, we suggest that using
the VIA in the context of a collectivistic country such as Suriname, and
possibly other
Programmatic implications
In terms of implications for PPIS non-Western countries, we firstly
recommend that PPIs include strength and virtues activities that are
culturally adapted. This can be done, for example by organizing focus
groups with community representatives to identify the most prevalent
strengths among the target group. Also, prevalent religious practises can
be integrated into PPIs, for example by integrating tales from the various
Holy Scriptures and prayer and meditation exercises into the program
modules. An example of such an approach is a study by Saeedi et al.
(2015) who conducted a positive psychology intervention with an Islamic
approach that included Islamic comments on the program. We suggest
that when integrating religious elements into a program, this should be
done in combination with making participants aware of active strengths
such as perseverance, leadership and teamwork. In addition, we suggest
incorporating goal setting activities, to avoid that the PPI will stimulate
passivity. Secondly we advise using different or additional instruments
than the VIA list when inventorying strengths in non-Western
communities such as the strength based approach by Linley that identifies
60 strength profiles that may be a better fit with non-Western cultural
values such as 'connector', ' rapport builder' or 'service' (Linley, Willars,
Biswas-Deiner, Garcea, & Stairs, 2010).
Limitations
This study provided data from a small group of respondents with
particular fields of expertise. Since the sample does not reflect the entire
Suriname population, it is not possible to extrapolate the findings to the
general Suriname population. One limitation of the study is that people
from lower socio-economic strata that have been hit hardest by the
149
economic crisis have not been interviewed. Another limitation of the
study was that all respondents we interviewed lived and worked in
Suriname's capital Paramaribo. We did not interview people who lived
outside of Paramaribo, for example in the districts Nickerie or Marowijne.
Caution is warranted when making causal inferences on the basis of the
data from this study. Simply because participants report that some factors
are important for resilience, it does not mean that factors actually
generate resilience. Furthermore, we recommend further quantitative
research on the prevalence of strengths among the various ethic cultural
groups in Suriname.
Conclusion
In conclusion, this qualitative study illustrates how religious may be considered
the bedrock factor for resilience in Suriname. It is interconnected with other
strength, including hope and perseverance. Religiousness, however, can also
inhibit the development of resilience, when it is focused on a passive attitude. For
non-Western countries, we recommend that future positive psychology programs
take into account the pivotal role of religiousness as a potential resilience
enhancing factor. This could be done by integrating religious rituals into program
exercises, and by choosing program modules that are in line with religious and
cultural values in a particular study population. Such programs should also
promote active agency.
Competing interest
The authors declare that they have no competing interests.
Funding
This research received no specific grant form any funding agency in the public, commercial,
or non-profit sectors.
150
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155
Chapter 6
Psychological Resilience and Mental
Well-being in a Multi-ethnic context:
Findings from a Randomized Controlled
Trial
This chapter is submitted as:
Hendriks, T., Schotanus-Dijkstra, M., Hassankhan, A., Sardjo, W., Graafsma, T.,
Bohlmeijer, E., & de Jong, J. (2018). Psychological resilience and mental well-being
in a multi-ethnic context: Findings from a randomized controlled trial.
156
Abstract
The objective of this study is to evaluate the efficacy of a culturally adapted multi-
component positive psychology intervention (MPPI) on resilience and well-being.
We conducted a randomized controlled trial among 158 eight employees of
multi-ethnic origin, in Paramaribo, Suriname. The participants were assigned to a
seven-session intervention program, or a waiting list control group. Data were
collected at baseline, seven weeks after intervention onset, and at 3-month
follow-up. The intervention was culturally adapted and strict guidelines were
followed to minimize risk of bias. Repeated measure analyses revealed large
significant improvements on resilience, and mental well-being. Moderate to large
significant improvements were also found for depression, anxiety, and positive
and negative affect. In conclusion, a culturally adapted MPPI may be a promising
intervention to increase resilience and positive mental health among healthy
adults with a multi-ethnic background.
Introduction
Resilience can be described as the capacity to deal effectively with stress and
adversity, to adapt successfully to setbacks (Burton, Pakenham, & Brown, 2010;
Luthar, Cicchetti, & Becker, 2000; Zautra, Hall, & Murray, 2008), and to bounce
back after negative emotional experiences (Tugade & Fredrickson, 2004).
Resilience refers to positive outcomes in spite of threats to adaptation or
development (Masten, 2001) and factors and mechanisms that play a role in
dealing functionally with, and contribute to successful adaptation to problems
(Friborg, Hjemdal, Martinussen, & Rosenvinge, 2009). Some have argued that
resilience can refer to (1) people who—after a traumatic event—have not
developed symptoms of pathology, or do so to a lesser extent (Bonanno, 2004),
or (2) to people who remain engaged and energetic under stressful experiences
Abbrevations: SMS = Strong Minds Suriname intervention group; WL = Wait-list control group Note: there were no significant group differences, except gender and ethnicity, with an overrepresentation of male participants from Javanese descent in the intervention group.
171
Interaction effects
The means and standard deviations, results of the independent t-test and
the effect sizes are presented in Table 3. Assumptions for performing
parametric analysis of (co)variance were all met.
Primary outcome
We found a significant time × group interaction effect for resilience (F (1) =
22.77, p < 0.001) indicating that participants in the intervention group
reported a stronger increase in resilience immediately after the
intervention. We found a large effect size at post-treatment (d = 0.76, 95%
CI = 0.43 - 1.09).
Secondary outcomes
The ANCOVA analysis after the intervention also revealed significant
differences between the intervention and waiting list group, as measured by
the MHS-SF. Overall, we found a large effect (d = 0.62, 95%CI = 0.30-0.94).
Concerning the subscales of the MHS-SF, the effect sizes were as follows:
moderate for emotional well-being (d = 0.38, 95%CI = 0.06-0.70) and large
for social well-being (d = 0.59, 95%CI = 0.27-0.91) and psychological well-
being (d = 0.55, 95%CI = 0.23-0.87). Compared to the waiting list control
group, the participants in the intervention group reported significantly lower
levels of depression and anxiety. The effect size on depression was
moderate (d = 0.50, 95%CI = 0.18-0.82), and for anxiety the effect size was
small (d = 0.32, 95%CI = 0.00-0.64). Furthermore, we found that the
intervention significantly increased positive affect and decreased negative
affect. The effect size was moderate for positive affect (d = 0.38, 95%CI =
0.06-0.70) and large for negative affect (d = 0.70, 95%CI = 0.37-1.01). Finally,
the results showed that there were no significant differences for stress (p =
Table 3. Means and standard deviations for outcome measures and results of analysis of covariance for intervention effects and Cohen’s d, modified ITT analysis
intervention group; SWB = Social Well-being, measured with MHC-SF.
Follow-up effects
Three months after the intervention was completed, the follow-up
assessment was conducted among the intervention group. Paired t-test
results demonstrated significant within-group improvements on the
following outcomes: resilience [ t(79) = 3.23, p = 0.002], mental health
[ t(79) = 3.94, p < 0.001], emotional well-being [ t(79) = 3.33, p = 0.001],
social well-being [ t(79) = 3.77, p < 0.001], psychological well-being [ t(79) =
2.96, p = 0.004], depression [ t(79) = 4.51, p < 0.001], anxiety [ t(79) = 4.08, p
< 0.001], stress [ t(79) = 4.54, p < 0.001], positive affect [ t(79) = 4.47, p <
0.001], negative affect [ t(79) = 2.08, p = 0.041)], and financial distress [ t(79)
= 1.15, p = 0.002)]. No significant within group difference for psychological
flexibility was found.
Adherence and participant satisfaction
We defined attendance rate as high when participants attended seven or six
sessions, as moderate when five or four sessions were attended, and as low when
three or fewer sessions were attended. The mean number of attended sessions
was 5.41 (SD=1.85), indicating that the attendance rate was moderate. Among
members of the intervention group (80 participants) thirty (37.5%) attended all
seven sessions, twenty (25.0%) attended six sessions, twelve (15.0%) attended
five sessions, four (5.0%) attended four sessions, three (3.8%) attended three
sessions, seven (8.8%) attended two sessions, and four (5%) attended only one
session. The mean score for the overall client satisfaction of the program was
2.95 (SD=0.634), indicating a high client satisfaction, and 93.8% of the
participants indicated that they were satisfied with the program. When asked to
what extent the program lived up to their expectations, 13.8% of the participants
indicated that the program did not. Regarding the question of whether the
174
program met their needs or not, 48.8% of the participants reported that the
program inadequately met their specific needs. However, 95% of the participants
would recommend the program to others.
Discussion
The aim of this study was to study the efficacy of a culturally adapted
multicomponent positive psychology intervention (MPPI) among healthy
employees in Suriname. We demonstrated that a seven-week MPPI was superior
to a waiting list condition in increasing resilience and mental well-being. In
addition, we found significant increases for positive affect, as well as a decrease
in the levels of depression, anxiety, and negative affect. The intervention did not
significantly decrease stress and financial distress, nor did it increase
psychological flexibility. The effect sizes on resilience, mental well-being, and
negative affect were large and thus greater than the moderate effect sizes we
expected on these outcomes. Our study also showed that improvements in the
intervention group were maintained for up to three months, as indicated by
results at follow-up. Results at follow-up even showed significant improvements
on stress and financial distress.
Research on resilience often focuses on understanding the processes
explaining how some people can flourish in the midst of adversity (Yates, Tyrell, &
Masten, 2015). Scholars in the field of resilience research share common ground
with scholars in the field of positive psychology, who explore human conditions
for flourishing (Ryff & Singer, 2003). However, to date, few studies have
examined the effects of MPPIs on the resilience of those on the work floor. These
studies do report findings that are in line with results from our study. For
example, an Australian study on the effects of a five week resilience program
among 28 healthy employees (Rogerson, Meir, Crowley-McHattan, McEwen, &
Pastoors, 2016) measured resilience by improvements on items such as living
authentically, maintaining a positive perspective, managing stress, and building
social networks. These outcomes are comparable to the dimensions of the Ryff’s
Scales of Psychological Well-being (Ryff, 2014). The study reported significant
increases in psychological well-being. A large effect size (g = 0.70) was found,
which is comparable to our outcome on resilience (g = 0.76), and slightly higher
175
than our outcome on psychological well-being (g = 0.55). Another study among
healthy employees that examined the effects of a training to increase
psychological capital reported a significant increase on psychological well-being
(Luthans, 2010). Psychological capital was defined as a state characterized by self-
efficacy, optimism, hope and resilience. The study tested an intervention among
242 healthy employees. While the study consisted of a series of exercises that
were designed to increase the participants' levels of self-efficacy, hope, resilience,
and optimism, the intervention itself only consisted of a single two-hour training.
The reported effect size in that particular study was considerably lower (g = 0.36)
than the outcome for psychological well-being in our study. The short duration of
the training could have contributed to the difference in effect sizes between that
study and the study we conducted. Our findings on mental well-being are
comparable to the results of a recently published study on the effects of a MPPI
among 275 adults with low or moderate well-being (Schotanus-Dijkstra et al.,
2017). While the delivery of this program differed (applying self-help instead of
group-based delivery), the content of the program was comparable, with eight
modules covering topics including positive emotions, identifying and using
strengths, optimistic thinking, resilience, and positive relations. Moreover, the
effect sizes we found in the current study were considerably larger than those
reported in a recent meta-analysis on the efficacy of MPPIs (Hendriks, 2018b).
This analysis identified the type of control group as a significant moderator; on
average, studies that used a non-active control group reported significantly larger
effects on psychological well-being and stress than studies using an active control
group. Since the control condition in our study was a waiting list group, the high
effect sizes in our study may partly be due the use of non-active control group. In
addition, it should be noted that – in contrast with our study - work-related
training programs in Suriname are usually only made accessible to higher staff
members. Therefore, the likelihood exists that participation in the SMS program
was considered a privilege and a novelty by those in attendance. In general,
novelty effects may lead to greater enthusiasm for and attention paid to a
particular intervention by its participants (Ammenwerth & Rigby, 2016; Turner-
McGrievy, Kalyanaraman, & Campbell, 2013). This could thus have contributed to
the higher overall effect sizes.
176
Strengths and limitations
One strength of this study was its methodological rigor. Often, the quality of PPI
studies from non-Western countries is low (Hendriks, 2018a), and low study
quality is often associated with larger effect sizes (Cuijpers, van Straten,
Bohlmeijer, Hollon, & Andersson, 2010). By strictly following the SPIRIT guidelines
for RCTs (Chan & Laupacis, 2013), we aimed to minimize the risk of bias. For
example, to minimize selection biased we randomly allocated the participants
and concealed their allocation to the conditions. The study was also partially
blinded to minimize performance and detection bias. Finally, all statistical
analyses were based on a modified intention-to-treat (mITT) basis, minimizing
attrition bias. Another strength was the fact that we culturally adapted the
program and that it was conducted by local trainers, who spoke both Dutch and
Sranang Tongo (a local Surinamese language). Cultural adaptation contextualizes
the content of an intervention, increasing the fit with the needs of the
participants (Lau, 2006), which can contribute to an increase of the efficacy of
and intervention (La Roche & Lustig, 2010; Tharp, 1991). It may also enhance
participants engagement (Barrera Jr, Castro, Strycker, & Toobert, 2013), and
reduce preliminary drop-out (Hwang, 2006).
This RCT also has several limitations, the first of which pertains to the
use of the questionnaires. Although we mostly used questionnaires that were
validated among Dutch speaking populations in The Netherlands and Belgium, the
questionnaires were not validated among Dutch speaking Surinamese
populations. Unvalidated questionnaires, being less reliable and valid, may yield
inconsistent results (Boynton & Greenhalgh, 2004). To all appearances, we doubt
whether the Psychological Flexibility Questionnaire (PFQ) was a reliable
instrument to measure flexibility in our target population, especially considering
that only 8.8% of our participants had a high education level. We already omitted
seven questions from the original questionnaire because of feedback given during
a focus group meeting (the omissions being due to the complexity of the
questions). Some of the remaining questions were perhaps too complicated still
for participants possessing a limited comprehension of the Dutch language. The
second limitation is the possible influence of two biases, namely social desirability
and fatigue/boredom. Social desirability is the tendency to answer questions in a
way to make oneself look good (He, Bartram, Inceoglu, & Van de Vijver, 2014)
and research suggests that social desirability may be larger in collectivistic
countries (Johnson & Van de Vijver, 2003; Kim & Kim, 2016; Lalwani, Shavitt, &
Johnson, 2006). This bias may have influenced the way people filled out
177
questionnaires, in particular the DASS-21. This questionnaire measures symptoms
of depression, anxiety, and stress, and participants with such symptoms may have
wanted to avoid reporting the true extent of their symptoms for fear of
stigmatization or negative consequences. Although the questionnaires were
anonymous and our reassurance that participants’ privacy would be ensured, we
still encountered strong concerns and distrust about privacy issues among the HR
representatives of the participating companies during the focus group meetings.
In addition, at post-assessment and follow-up, we observed respondent fatigue
and boredom, which could lead to an increase of variance of error because more
mistakes are made (Hess, Hensher, & Daly, 2012). For example, there were
several participants whom we knew had a low literacy level, but who finished the
questionnaires in a relative short time. This could have resulted in a the tendency
to overuse the end points of a scale, which is commonly known as extreme
response style bias (He, Bartram, Inceoglu, & Van de Vijver, 2014). The third
limitation concerns the generalization of the findings to the Surinamese working
population. In this study, we used a self-selected sample of companies, which is
not representative for all companies in Suriname. Participation in the training
required companies to commit substantial fractions of their workforce to the
intervention. This reduced the scope of companies that were able to participate
in the intervention. Company fitness may have been a significant bottleneck due
to the recession during which recruitment and the intervention itself took place.
Even if one omits smaller, ineligible and struggling companies, the fact remains
that convenience sampling was used during the recruitment of companies. This
means that the approached and ultimately participating companies cannot be
considered to be representative for companies in their respective size bracket or
sector. Another factor limiting generalizability is participants’ educational level. In
our study sample, employees possessed a higher level of educational attainment
than the national norm, as reported in the 2012 national census (Algemeen
Bureau Statistiek, 2012). A final limitation is related to the presence of external
factors during the trial, which were not under our control, and that could have
influenced the assessment outcomes. The economic situation during the period
leading up to the intervention period was quite unstable. At the time of the trial
protest marches against the government were organized, a rare phenomenon in
Suriname. We observed that tensions were rising daily. These events may have
influenced our outcomes and could be regarded as potential confounders. The
extent to which they had an influence, however, remains unknown.
178
Recommendations for future research
While this study was conducted in the context of a work environment, many
findings may also be relevant for public mental healthcare. We recommend the
further development, implementation and assessment of culturally adapted
MPPIs that are analogous to the SMS program. In light of the problem of
suicidality among the Hindustani in the Surinamese district of Nickerie and parts
of Guyana (Graafsma, 2016), we would recommend integrating specific
Hindustani cultural and religious activities and rituals into a MPPI. For example,
by illustrating strengths and virtues on the basis of the Hindustani cosmological
model, or by integrating Hindustani prayers or yoga meditation exercises into a
program. Thus, different versions of MPPIs could be developed, each targeting a
specific cultural/ethnic/religious group (e.g. Christian Afro-Surinamese and
Javanese Muslims). Given the fact that our study was conducted by local
facilitators, the SMS program (or a similar MPPI) could be also be implemented
on a larger scale among adolescents in schools if their teachers were to be trained
as facilitators. For future research in general, we further recommend exploring
the possibilities of integrating messaging services such as WhatsApp (WhatsApp
Inc., Mountain View, CA) into the intervention to increase engagement and
adherence. During the trial, the coaches of the program formed their own
WhatsApp group. They shared positive experiences, positive media news, shared
inspiring quotes and encouraged each other. This led to greater enthusiasm and
engagement on their part, which had a positive influence on their interactions
with the participants. A group app accessible for participants could be an
additional strategy to increase exposure and engagement. A group app that
continues after the intervention may hypothetically even prolong the effects of
an intervention because it entails an element of a sustained self-help group.
Regarding the assessment procedure, we recommend limiting the number of
questionnaires and items when conducting questionnaires among participants
with a low education level. In this way, bias due to boredom or fatigue could be
limited. In addition, we recommend the development of measure instruments
that are validated among the Surinamese population. A final limitation pertains to
the target population of the SMS program. Our drop-out analyses suggest that
participants with higher scores on resilience or lower scores on depression at
baseline were more likely to drop-out. This finding suggests that perhaps the SMS
program may be less beneficial for these participants, or at the very least be
perceived as less beneficial.
179
To our knowledge, this is the first RCT in the field of positive psychology
that was conducted on the continent of South America. Our study demonstrated
that a culturally adapted MPPI could be effective in increasing resilience and
mental well-being. It also showed that large effects sizes could be achieved, while
adhering to strict norms that ensure a high study quality. This makes this MPPI a
promising intervention in the context of Suriname and the Caribbean.
Ethical approval and consent to participate
The research was conducted in accordance with the regulations of the Surinamese Wet
Medisch-wetenschappelijk Onderzoek met mensen (WMO) and the principles of the
Declaration of Helsinki (59th, 2008). The trial was approved by the Ethics Committee of the
University of Twente in The Netherlands (BCE16487) and registered at The Netherlands
National Trial Register (NTR6157) on February 7, 2017 (Netherlands National Trial Register
2017). Written informed consent for participation in the study was obtained from all
participants prior to the baseline assessment.
Competing Interest
The authors declare that they have no competing interests.
Funding
The study was funded by the University of Amsterdam and through sponsoring by
following participating Surinamese companies: Multi Electronic System N.V., Surinaamse
Postspaarbank N.V. and the InterMed Group. Except for Wantley Sardjo, the CEO of Multi
Electrical System N.V., and co-author in this study, funders had no role in, or control over
the collection, management, analysis, interpretation and publication of the data.
Availability of data and materials
Data and materials are available at Open Science Framework (Hendriks, 2017a). Data is
coded to ensure anonymity of the participants.
Acknowledgements
We would like to thank em. prof. Jan Walburg and Rijkwessel de Valk, formerly at Royal
Dutch Shell for the use of the original Shell Resilience Program. We would also like to thank
the following Surinamese psychologists for participating in the focus groups: dr. Glenn
Leckie, drs. Maja Heijmans-Goedschalk, and drs. Mavis Hoost.
180
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Mediators of a Cultural Adapted Positive Psychology Intervention aimed at
increasing Well-being and Resilience
This chapter is submitted as:
Hendriks, T., Schotanus-Dijkstra, M., Graafsma, T., Bohlmeijer, E., & de Jong, J. (2018). Mediators of a cultural adapted positive psychology intervention aimed
at increasing well-being and resilience.
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Abstract
We examined mediators of a multi-component positive psychology intervention
for healthy employees. The intervention aimed to increase resilience and positive
mental health. We analyzed data from a randomized controlled trial involving 158
participants who were assigned to a seven-session intervention program or a
waiting list control group. In total, 144 participants completed baseline and
posttest assessment. The mediating effects positive emotions and psychological
flexibility on treatment outcomes resilience and positive mental health at post-
test assessment were examined. Mediator analyses showed that these
improvements possibly and partially work through increasing positive emotions.
Psychological flexibility could not be considered a mediator. However, due to the
absence of a timeline during measurement, definite conclusions on the mediating
effect of positive emotions cannot be draw.
Introduction
Since the advent of the positive psychology movement, there has been a growing
number of studies investigating the effectiveness of positive psychology
interventions (PPIs) on mental well-being and mental disorders (Rusk & Waters,
2013). PPIs are interventions aimed at increasing positive feelings, behaviors, and
cognitions, using evidence-based pathways or strategies to increase well-being
(Schueller, Kashdan, & Parks, 2014; Schueller & Parks, 2014). To date, several
meta-analyses have examined the efficacy of PPIs. The reported effect sizes on
mental well-being varied considerably, from small to large (Bolier et al., 2013;
Chakhssi, Kraiß, Sommers-Spijkerman, & Bohlmeijer, 2018; Hendriks et al., 2018a,
Hendriks et al., 2018b; Sin & Lyubormirsky, 2009). This discrepancy can be
attributed to the differences in included studies, for example randomized versus
non-randomized controlled studies, studies on single versus multi-component
interventions, studies including clinical populations versus entire populations, and
studies from Western versus non-Western countries. While many studies now
have established the efficacy of PPIs, it is less clear what the working mechanisms
of PPIs are. Several studies have explored the presence of mediators, i.e. variables
that represent mechanisms or pathways through which an independent variable
is able to influence a dependent variable (Baron & Kenny, 1986). Studies that
focused on the relationship between PPIs and mental well-being have identified
the following factors as possible mediators: positive emotions (Li, Jiang, & Ren,
were performed according to the procedures as described by Preacher and Hayes
(2008), using the PROCESS tool, version 3.0 (Hayes, 2012). Multiple mediator
analyses were performed, by entering the core processes (positive emotions and
psychological flexibility) simultaneously in the regression models, using model 4.
In the analyses, X is the intervention condition (coded 1 for the intervention
group and 0 for the waiting list control group). Y is the change in outcomes
(increase in well-being and resilience), from T1-T0, and M is the possible
mechanism of change from T1-T0 (increase in positive emotions and flexibility).
For each path, unstandardized regression coefficients were calculated. Path a
represents the effect of the intervention (X) on the mediator (M), and path b
represents the effect of the mediators (M) on the outcomes (Y). Path c represents
the total effect of the intervention (X) on the outcome (Y) and path c’ is the direct
effect of the intervention (X) on the outcome (Y), while partialling out the effect
of the mediator (M). The indirect effect of X on Y through M is calculated as the
product of a and b (ab), of which the bias corrected (BC) 95% were based on
5,000 bootstrap samples. Estimates are statistically significant at p < 0.05, or if
the 95% CI did not contain zero (Preacher & Hayes, 2008).
Results
Demographics
Table 1 shows the baseline characteristics of the participants in the intervention
and the waiting list control group. The mean age of the participants was 36.3
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years (SD= 9.6 years) and 60% of the participants was female. The largest ethnic
group was the Javanese (42%), followed by the Hindustani (25%), and the Afro-
Surinamese group (15%). Participants of mixed origins accounted for 17% of the
population. The main religious backgrounds were Christianity (42%), Islam (30%),
and Hinduism (18%). The majority of participants had a lower (46%) or
intermediate educational level (42%). The Intermed group (private healthcare
company) provided 44% of the participants, the Surinaamse Postspaarbank
(savings bank) 29%, and Multi Electrical Systems (construction company) 27%.
Almost all participants reported a moderate (44%) or high (50%) level of financial
distress, only 6% reported a low level.
Drop out and adherence
Initially, 173 participants were randomized. However, two days before the start of
program participation of fifteen employees from one company was cancelled,
due to unexpected changes in the working schedule. We defined drop-outs as
participants who completed the baseline assessment but who did not complete
post-test and/or follow-up assessments. In total, 158 participants completed the
baseline assessment (T0), 144 (91%) completed the post-test assessment (T1) at
seven weeks, and 120 (76%) the three-month follow-up assessment (T2). There
were 14 drop-outs (9%) between pre-test and post-test. Between post-test and
follow-up assessment 24 participants dropped out (14%). The attendance rates
were as follows: 59% attended six or seven sessions (n = 47), 20% (n = 16)
attended three, four or five sessions, and 21% (n = 17) attended one or two
sessions. The difference between drop-outs in the intervention group and waiting
list group was not significant. At the post-test assessment (T1), there was a
significant difference in age between drop-outs and completers (M = 46.1 vs 35.4,
F(1-156) = 1.15, p <0.001). In addition, we found that the average education level
and income of drop-outs was significantly lower. This indicates that employees
with a low educational level and low income were more likely to drop-out. At
follow-up, we found no significant differences between drop-outs and completers
on any measured demographics. Further analysis showed that drop-outs
significantly scored higher on resilience and lower on depression at pre-test than
completer. This indicates that people with a higher level of resilience or a lower
level of depression were more inclined to drop-out.
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Table 1. Baseline characteristics of participants
SMS (n = 80) WL (n=78) Total (n = 158) Age, M (SD) 36.2 (9.4) 36.5 (9.9) 36.3 (9.6) Gender, n (%)
Male 38 (48.8) 25 (32.1) 63 (39.9)
Female 42 (51.2) 53 (67.9) 95 (60.1)
Companies, n (%)
InterMed 35 (44.9) 35 (43.8) 70 (44.3)
SPSB 28 (35.9) 17 (21.3) 45 (28.5)
MES 15 (19.2) 28 (35.0) 43 (27.2) Education, n (%)
Lower 44 (55.0) 31 (39.7) 75 (47.5)
Middle 29 (36.3) 36 (46.2) 65 (41.1)
Higher 7 (8.8) 11 (14.1) 18 (11.4)
Ethnicity, n (%)
Javanese 39 (48.8) 27 (34.6) 66 (41.8)
Hindustani 18 (22.5) 22 (28.2) 40 (25.3)
Afro-Surinamese 6 (7.5) 18 (23.1) 24 (15.2)
Mixed 17 (21.3) 10 (12.8) 27 (17.1)
Amerindian 0 (0.0) 1 (1.3) 1 (0.6)
Religion, n (%)
Christian 30 (37.5) 36 (46.2) 66 (41.8)
Islam 24 (30.0) 23 (29.5) 47 (29.7)
Hinduism 15 (18.8) 14 (17.9) 29 (18.4)
Javanism 3 (3.8) 0 (0.0) 3 (1.9)
None 8 (10.0) 5 (6.4) 13 (8.2)
Level of financial stress
Low 3 (3.8) 6 (7.7) 9 (5.7)
Moderate 36 (45.0) 34 (43.6) 70 (44.3)
High 41 (51.2) 38 (48.2) 79 (50.0)
Abbreviations: SMS = Strong Minds Suriname intervention group; WL= Waiting list control group InterMed = Intermed Caribe N.V.; SPSB = Surinaamse Postspaarbank; MES = Multi-Electrical Systems N.V.
Note: there were no significant group differences, except gender and ethnicity, with an overrepresentation of male participants from Javanese descent in the intervention group.
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Bivariate correlations
Table 2 displays the bivariate correlations between resilience, mental well-being
(that include the subscales of the MHC-SF), and the potential mediators. We
found that all correlations were significant and ranged from .29 to .89. Most
correlations were moderate to strong. High correlations were found between all
different outcomes of mental well-being. The correlations between the scales
measuring resilience and the potential mediators, were higher than the
correlations between the correlations between the subscales of mental well-
being and the potential mediators. A low score was found between positive affect
and emotional well-being. This is remarkable, since both emotional well-being
and positive affect both aim to measure positive emotions.
Table 2. Bivariate correlations between potential mediators and outcome measures at baseline.
We performed multiple mediation analyses. Figures 2 and 3 show the
unstandardized regression coefficients on changes in mental well-being and
resilience, respectively. Coefficients of the a-paths on mental well-being and
resilience were significant for positive emotions (p < .01) but not for psychological
flexibility (p = .13). This implies that the intervention led to increased levels of
positive emotions, but not to an increase in psychological flexibility. All b-paths
were significant and show that positive emotions predicted mental well-being
(moderate effect) and resilience (small effect), and psychological flexibility
predicted mental well-being (large effect) and resilience (small effect). The
intervention was effective in increasing mental well-being and resilience, and this
was still the case when including the mediators (c’). The effect of including
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positive emotions and psychological flexibility as mediators for mental well-being
was larger, whereas the effect of these mediators on resilience was small. The BC
95%CI of the specific indirect effect for positive emotions for well-being did not
contain zero (ab = .08, BC 95% CI = .01 to .17), while it did contain zero for
psychological flexibility (ab = .10, BC 95% CI = -.01 to .23) Regarding resilience, the
BC 95% CI of the specific indirect effect for positive emotions also did not contain
zero (ab = .04, BC 95% CI = .01 to .09), while it did contain zero for psychological
flexibility (ab = .02, BC 95% CI = -.01 to .06). This suggests that positive emotions
are a mediator for well-being and resilience, whereas psychological flexibility is
not a mediator. The total model explained 12% of the variance in well-being and
26% of the variance in resilience.
Figure 2. Multiple mediation positive emotions and psychological flexibility as mediators of the intervention group versus waiting list group (T0-T1) on mental well-being.
Figure 3. Multiple mediation positive emotions and psychological flexibility as mediators of the intervention group versus waiting list group (T0-T1) on resilience.
Our study also demonstrated that the intervention did not increase psychological
flexibility. This could be explained by the following. First, we used the PFQ
questionnaire to measure psychological flexibility, and this instrument was not
validated among the Surinamese population. During the cultural adaptation
process of the intervention, seven questions were omitted from the original
questionnaire, based on feedback of a focus group of Surinamese psychologists.
This was due to the complexity of the questions, in view of our participants who
for a large part had a low educational level. Perhaps the remaining were still
complex, which could have led to extreme response style bias (He, Bartram,
Inceoglu, & Van de Vijver, 2014). Second, perhaps increases in flexibility were not
possible due to a ceiling effect. During the period prior to our study, participants
had to deal with high inflation rates, 55% in 2016 and 22% in 2017 (KNOEMA,
2018). The majority of the participants (65%) indicated that they earned less than
270 US dollars per month. It is very likely that in order to adapt to the financial
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changes, flexibility was already at a high level. In addition, it is possible the
cultural background of the participants is responsible for already high levels of
flexibility. A qualitative study we conducted prior to the intervention, showed
that acceptance is one of the major strengths among the Surinamese people
(Hendriks, Graafsma, Hassankhan, Bohlmeijer, & de Jong, 2017), and acceptance
is one of the core processes to develop psychological flexibility (Hayes, 2006). In
addition, the majority of the participants in our study also had an East-Asian
ethnic background (67%). People from East-Asian cultures tend to value low
arousal emotions (e.g. calmness, acceptance) more than people from the West
(Tsai, Knutson, & Fung, 2006) and emphasize adjusting one’s needs to those of
their social environment (Shin & Lyubomirsky, 2017), which requires
psychological flexibility.
Strengths and limitations
To our knowledge, this is the first study that examined the mediating role of
positive emotions and psychological flexibility of a multi-component PPI among
participants with a multi-ethnic background, in a non-Western country. In
addition, the intervention was culturally adapted, which may have contributed to
a better cultural fit with the participants. For example, to maximize positive
emotions, participants practiced how to integrate the ‘three good things’ exercise
(Seligman, Steen, Park, & Peterson, 2005) into their daily prayer, since
religiousness is a major source for resilience in Suriname (Hendriks, Graafsma,
Hassankhan, Bohlmeijer, & de Jong, 2017). During the forgiveness exercise,
participants asked forgiveness from God, Allah, Brahma, or the Universe,
depending on their religious/spiritual convictions. Through self-affirmations we
aimed to increase psychological flexibility through surrendering a higher power.
This underlines the innovative character of the study. Another strength of the
study as a whole, is its scientific rigor. The study was conducted according to
Standard Protocol Items: Recommendations for Interventional Trials (SPIRIT)
guideline for RCTs (Chan & Laupacis, 2013)(Chan et al., 2013), the cultural
adaptation process was conducted according to guidelines as described by
Domenech-Rodriguez and Wieling (2004), and the statistical procedures of the
mediation analyses was based on latest developments in the field (Hayes, 2012;
Preacher & Hayes, 2008).
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This study also has several limitations. First, we did not establish a
timeline for the mediator and the outcomes, meaning that we did not measure
positive emotions before resilience and mental well-being. According to Kazdin
(2007, 2009), this is an essential requirement for demonstrating the effect of a
mediator. Therefore, we cannot ensure that the level of positive emotions
changed before resilience and mental well-being changed, so a definite causal
relationship between the mediator and the outcome cannot be established. It is
possible that resilience and mental well-being changed prior to the change in
positive emotions. Second, we have limited our study to two possible mediators.
There are other processes that could play a mediating role in the development of
resilience and well-being in Suriname. For example, strengths and virtues that are
related to resilience, according to a previously conducted quantitative study in
Suriname, namely religiousness, hope, harmony, acceptance and perseverance
(Hendriks et al., 2017). Focus groups meetings with HRM representatives of the
participating companies and psychologists brought forth the advice to limit the
number of questionnaires/items, in light of the low educational level of the
participants and possible fatigue. Therefore, we were limited in the number of
constructs we could measure. Third, we used self-report questionnaires in Dutch,
and these questionnaires were not validated within the local context. Although
Dutch is the official language in Suriname, the spoken language during the
intervention was mostly Sranang Tongo, an English-based creole language. Some
questions in the instruments of measure may have been too complicated for
participants with a limited Dutch language comprehension, and this may have
biased the outcomes. This could, for example, lead to extreme or midpoint
response style bias (He & van de Vijver, 2012), or acquiescence bias which is more
likely to occur among people with low socioeconomic status in collectivistic
cultures (Harzing, 2006). In order to limit possible bias, the questionnaires were
checked for content, semantic, and conceptual equivalence, and were tested
among a small group of employees prior to the intervention. During the
assessment, participants could ask for assistance from local coaches, if they had
difficulties understanding questions. Despite these measures, bias still may have
played a role.
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Recommendations for future research
We recommend the following. First, as Kazdin (2007, 2009) pointed out, a
timeline problem is present in the vast majority of literature examine mediator of
psychotherapy. We found this also to be the case in positive psychology
literature. Therefore, we recommend that studies that attempt to discover causal
effects for mediators in PPIs establish a clear timeline, i.e. the measurement of
the potential mediators should be conducted prior to the outcomes. Second,
several theoretical frameworks and models have suggested possible mechanisms
for positive change. We recommend that future mediator studies focus on
examining and operationalizing the mechanism for change that are presented in
specific/such models. In particular, the Synergetic Change Model (SCM) (Rusk,
Vella-Brodrick, & Waters, 2017) is the most elaborate model today. The five
domains of the SCM may correspond to specific mediators. Emotions is one of the
major domains, and as described in this article, several studies have indeed
identified positive emotions as mediators. Other mechanisms may correspond to
the different domains of the SCM. For example, change in character strengths and
virtues, as conceptualized by Values-In-Action (VIA) strengths classification
system (Proctor, Carmel, Maltby, & Linley, 2011), could be a possible mechanism,
and is related to the domain ‘virtues and relationships’ of the SCM. Third,
measuring outcomes in non-Western countries should preferable be done using
questionnaires that are validated in the corresponding country. If this is not
possible due to financial or other limitations, questionnaires should be at least
checked for content, semantic and conceptual equivalence.
Conclusion
We conclude that a cultural adapted multi-component PPI was effective in
increasing resilience and mental well-being among employees in Suriname.
Mediator analyses showed that these improvements possibly and partially work
through increasing positive emotions. However, due to the absence of a timeline
during measurement definite conclusions on the mediating effect of positive
emotions cannot be draw. Future studies should investigate other possible
mechanisms for lasting positive change, in order to develop the most efficacious
combinations of components within multi-component PPIs that take into account
the cultural background of the participants in the intervention.
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Ethical approval and consent to participate
The research was conducted in accordance with the regulations of the Surinamese Wet
Medisch-wetenschappelijk Onderzoek met mensen (WMO) and the principles of the
Declaration of Helsinki (59th, 2008). The trial was approved by the Ethics Committee of the
University of Twente in The Netherlands (BCE16487) and registered at The Netherlands
National Trial Register (NTR6157) on February 7, 2017 (Netherlands National Trial Register
2017). Written informed consent for participation in the study was obtained from all
participants prior to the baseline assessment.
Author contributions
The first author was the principal investigator of the randomized controlled trial and
responsible for the concept, design and drafting of the manuscript. The second author was
responsible for co-editing. The remaining authors are additional supervisors. All authors
read and approved the final manuscript.
205
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• PWB (PWS): Significant effects for yoga (4w and 12w), physical exercise (12 w) and yoga + physical exercise (4w,12 w)
Bonura et al., 2007, USA
1. Yoga 2. Physical Exercises 3. Wait list control
33 33 32
77 A+P+D
Y+PE: 6, 6w, 45 min.
• PWB (STAI/STAXI/GDS/GSES/CDSES/LGMS) Significant effects for yoga (p<.001)
• General Self Efficacy (GSEC) and Self Efficacy daily living (CDSECS): Significant effect for yoga (p<.001)
Bowden et al., 2012, England
1. Brain Wave Vibration 2. Yoga 3. Mindfulness
12 9 12
A+P
BWV+Y+M: 10, 5w, 75 min. + 10 min. daily practice
• Mindfulness (MAAS): No significant effects for BWV (p=.062), significant effects for Iyengar yoga (p= .028) and Mindfulness (p=.028)
Bowden et al., 2014, England
1. Brain Wave Vibration 2. Yoga
17 14
18-32 A
BWV+Y: 8-12, 8-12w, 75 min. + 10 min. daily practice
• PWB: (WEMWBS): Significant effects for BWV (p=.014), no significant effects for yoga (p=.32)
• Mindfulness (MAAS): Significant effects for BWV (p=.005) and yoga (p=.012)
Cusumano et al., 1992, Japan
1. Yoga 2. Progressive Relaxation
45 45
A+P 9, 3w, 80 min. • Self-esteem (RSS): No significant effects
Elavsky & McAuley, 2007, USA
1. Yoga 2. Walking 3. Non-active control
51 60 39
49.9 A+P
Y: 12, 4m, 60 min. + 15-45 min. daily practice
• Self-esteem (RSS, PSPP): No significant effects
225
Ghoncheh et al. , 2003, USA
1. Yoga 2. Progressive Muscle Relaxation
20 20
34 A
5, 5w, 30 min.
• Disengagement, Joy, Mental quiet (SRSI): Significant effects for PMR disengagement (p<.005) and joy (p<.01) at week 5, mental quiet (p<.04) at week 5. No significant effects for yoga.
Godse et al., 2015, India
1. Yoga 2. Non active control
40 40
A+P
2 weeks, 14 days, 20 min.
• Mental quiet, Ease/Peace, Rested/Refreshed, Strength and Awareness, Joy ((SRDI) Significant effects for yoga (p < .01)
Sahdra, Shaver, & Brown, 2010). We suggest that future research in the field of
yoga should not only focus more on positive outcomes, but on positive
psychological constructs that are linked to those that are rooted in yoga
philosophy and Hinduism such as moksha (meaning), ananda (bliss, happiness),
buddhi (wisdom), or kaivalya (detachment). Using the theoretical frame work of
the yoga philosophy could also shed a new light on the psychological mechanisms
behind yoga interventions and meditation in general.
Conclusions
Positive mental health consists of three dimensions: psychological well-being,
emotional well- being and social well-being. This meta-analysis is the first address
the efficacy of yoga in the development of positive mental health in a non-clinical,
adult population. The current body of research suggests that yoga is only
associated with an increase in psychological well-being, in comparison to no
treatment. This finding may be counterintuitive; people who practice yoga expect
that it will contribute to an increase in their mental health. In this study we
addressed several possible explanations for our findings including the small
number of studies, the heterogeneity of the interventions and the way mental
234
health is being measured. More rigorous research is needed to draw definite
conclusions on the effects of yoga on positive mental health.
Competing Interest
The authors declare that they have no competing interests.
Author’s contributions
This article is part of a PhD thesis from the first author Tom Hendriks (TH); he wrote the
manuscript, including background, results and discussion. The second author Joop de Jong
(JJ) is the main PhD promoter and provided supervision throughout the writing process.
The third author Holger Cramer (HC) conducted the meta-analysis and was responsible for
all statistical data and the final editing of the manuscript.
Funding
This research received no specific grant form any funding agency in the public, commercial,
or non-profit sectors.
235
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Chapter 9
The Effects of Sahaja Yoga Meditation on
Mental Health: A Systematic Review
This chapter is published as:
Hendriks, T. (2018). The effects of Sahaja Yoga meditation on mental health: a
systematic review. Journal of Complementary and Integrative Medicine, 15 (3).
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Abstract
The objective was to determine the efficacy of Sahaja Yoga (SY) meditation on mental
health among clinical and healthy populations A systematic review was performed. All
publications on SY were eligible. Databases were searched up to November 2017,
namely PubMed, MEDLINE (NLM), PsycINFO, and Scopus. An internet search (Google
Scholar) was also conducted. The quality of the randomized controlled trials was
assessed using the Cochrane Risk Assessment for Bias. The quality of cross-sectional
studies, a non-randomized controlled trial and a cohort study was assessed with the
Newcastle-Ottawa Quality Assessment Scale We included a total of eleven studies;
four randomized controlled trials, one non-randomized controlled trial, five cross-
sectional studies, and one prospective cohort study. The studies included a total of
910 participants. Significant findings were reported in relation to the following
outcomes: anxiety, depression, stress, subjective well-being, and psychological well-
being. Two randomized studies were rated as high quality studies, two randomized
studies as low quality studies. The quality of the non-randomized trial, the cross-
sectional studies and the cohort study was high. Effect sizes could not be calculated in
five studies due to unclear or incomplete reporting. After reviewing the articles and
taking the quality of the studies into account, it appears that SY may reduce
depression and possibly anxiety. In addition, the practice of SY is also associated with
increased subjective well-being and psychological well-being. However, due to the
limited number of publications, definite conclusions on the effects of SY cannot be
made and more high quality randomized studies are needed to justify any firm
conclusions on the beneficial effects of SY on mental health.
Introduction
Meditation as a useful form of intervention to increase mental health is becoming a
focus of scientific attention. Although meditation is a practice that is also part of
monotheistic religions such as Christianity, Islam, and Judaism, it is often associated
with Eastern traditions, religions, and philosophies such as Yoga, Buddhism, Taoism,
and Jainism. There is no clear definition of meditation; meditation is an umbrella term
for a range of techniques aimed at calming the mind. Furthermore, what is understood
by the term meditation is subjected to trends and hypes. With the coming of the
flower power age in the late sixties, Eastern philosophies and meditation became
known to the general public, in particular Transcendental Meditation (TM) and
Herbert Benson’s TM derivative Relaxation Response (Benson & Klipper, 1992).
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Hundreds of studies on the effects of TM were published in the 1970s and 1980s,
although there has been much debate on the methodological quality of these studies
(Manocha, 2008). The 1980s saw the consolidation of the popularity of yoga. Yoga is
comprised of different techniques of which physical postures (asanas), breathing
exercises (pranayama), and meditation (dhyana) are the three main ones (Barnett &
Shale, 2012; Forfylow, 2011). It was mostly the practice of postural yoga in
combination with breathing exercises, and not meditational yoga, that became
popular through forms such as Hatha yoga, Iyengar yoga, Kundalini yoga, Bikram yoga,
Kriya yoga, and countless others (Austin, 2002; Mehta, 2010). What is referred to as
‘modern postural yoga’ (Ahrens & Forbes, 2014) has become a synonym for yoga: in
the West yoga is now mostly perceived as the practice of physical exercises to improve
health and fitness, rather than a meditation form that is aimed at achieving an
enlightened state of consciousness, as it was originally intended.
The past decade saw the breakthrough of mindfulness and a growing interest
in Buddhist psychology/philosophy. The acceptance of mindfulness meditation in the
scientific and therapeutic community can partially be attributed to a large number of
research studies, with a growing amount of randomized controlled trials. This may
have had a positive effect on the quality of studies in the field of meditation in general.
Several systematic reviews and meta-analyses on the effects of meditation were
recently published, but in a number of them meditation forms such as Yoga, Tai Chi,
and Qi Gong were excluded (Fjorback, 2011; Goyal et al., 2014; Sedlmeijer et al.,
2012). In these studies, it appears meditation is divided into two categories:
meditation focused on mental processes and meditation focused on bodily processes.
And while these publications claim to report on the (psychological) effects of
meditation in general, they in fact only reported on two forms of meditation:
transcendental meditation and mindfulness. Other forms of meditation were
excluded.
One form of meditation overlooked by prior reviews is Sahaja Yoga (SY). SY is
a form of meditation, developed in the 1970’s by Nirmala Srivastava. SY offers a simple
way to awaken the Kundalini, an inner energy believed to reside in the sacrum bone.
By awakening the Kundalini, it is believed a yogi can enter into a state of thoughtless
awareness, or mental silence (Hernandez, Suero, Rubia, & Gonzalez-Mora, 2015;
Manocha, Black, Spiro, Ryan, & Stough, 2010). In this state the attention is in the
present moment, with full awareness of the surroundings but with elimination of
unnecessary thought activity (Rubia, 2009). In Hindu philosophy, this state of
thoughtless awareness is also known as thuriya-avastha (Ramamurthi, 1995) and is
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akin to the awareness state that is being described in open monitoring meditation
(Lutz, Jha, Dunne, & Saron, 2015). Perhaps due to the typical categorization of yoga as
a program of physical relaxation, SY has been excluded from most prior reviews of
meditation research. This article adds to the conversation by presenting a systematic
review of research on the effects of SY on mental health.
Method
The PRISMA guidelines for systematic reviews and meta-analyses (Moher, Liberati,
Teztlaff, & Altman, 2009) and the recommendations of the Cochrane Back Review group
(Higgins & Green, 2011) were followed in the planning and the implementation of the
review.
Identification and selection of studies
All publications on SY were eligible. The following databases were searched up through
November 2017: PubMed, Medline, Scopus, and PsycINFO. The final data extraction date
was November 30, 2017. Since the expected number of publication was low, all fields in
the databases were searched using the term "sahaja yoga". Furthermore, the references
of the relevant publications were checked for additional eligible papers and an internet
search (Google scholar, Researchgate.net, Academia.edu) was executed using the
keyword mentioned above. Three authors of publications on SY were also contacted by e-
mail. After removal of duplicates, a title-abstract review was done, after which all papers
that were identified as publications on the effects of SY were screened. Studies that met
the following criteria were fully analyzed: (1) full text available; (2) randomized controlled
trial studies, non-randomized controlled trial studies, cross-sectional studies and
controlled cohort studies; (3) outcomes were related to mental health; (4) participants
were healthy adults or adults belonging to a clinical population. For each eligible
publication, the following information was gathered: name of the main author(s), year of
publication; location; study design; participants description; conditions; sample size per
condition; mean age; percentage of female participants; program information; outcome
measures; instruments.
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Quality assessment
Two reviewers independently rated each randomized controlled trial using five items for
quality assessment from the Cochrane Risk Of Bias Assessment Tool: (1) Selection bias -
RCT Healthy adults 1. SY 2. Relaxation 3. Waitlist
42 40 39
42.5 41.4 42.3
- - -
Both: 8 week: 2 x a week 60 min session, 2 x daily 10-20 min at home
PSQ STAI-t
Stress - (p =.026) Depression - (p =.019)
Manocha et al., 2012, Australia [30]
Cross-sectional survey
Healthy adults 1. Long-term SY meditators 2. General population
343 44 (13.4) 61.4 No program, survey
SF-36 MLS
Bodily pain - (p = 0.002) General health + (p = 0.001) Vitality + (p = 0.001) Social functioning + (p = 0.001) Role limitation emotional - (p =0.001) Mental health (p = 0.001)
Morgan, 2001, England [29]
NRCT Adults with symptoms of anxiety, depression
1. SY 2. CBT 3. Waitlist
8 6 10
37.1 39.2 37.0
58.3% (total)
Both: 6 week program, once a week 2 hour sessions.
HADs GHQ-12
Anxiety – (p =.006) Depression – (p =.001)
25
1
Schneider et al, 2010, Europe [24]
NRCT Healthy adults 1. SY 2. Waiting list 1. SY 2. Waiting list 1. SY 2. Hatha Yoga 3. Waiting list 1. SY 2. Waiting list
10 - 8 - 44 - - 31 -
-
-
6 week program, two 45 minute sessions per week + daily meditation at home (recommended).
PANAS WVS STAI
Positive Affect +
• Happiness + (p = .008)
• Fearlessness + (p = .016)
• Inspired + (p =.10) ns Negative Affect -
• Sadness - (p =.001)
• Fatigue – (p =.001)
• Upset - (p =.003)
• Anger - (p =.003)
• Nervous - (p =.009)
• Lack of authenticity - (p =.09)
• Dissatisfaction - (p=.10) ns
Sharma et al., 2005, India [23]
RCT Adults with major depression
1. SY + medication 2. Non active control group + medication
15 15
-
42.3% (total)
8 week program: 3 times a week a 30 minute session.
HAM-D HAM-A
Depression - (p <.001) Anxiety - (p <.001)
Abbreviations; AQLQ: Asthma Quality of Life Scale; CAS: Clinical Anxiety Scale; EPQ: Eysenck Personality Questionnaire; GHQ-12: General Health Questionnaire; HADs: Hospital Anxiety and Depression scale; HAM-A: Hamilton Rating Scale for Anxiety; HAM-D: Hamilton Rating Scale for Depression; MES: Multidimensional ethics scale; MLS: Meditation Lifestyle Survey; NS: not significant PANAS: Positive and Negative Affect Scale; POMS: Profile of Mood States; PSQ: Psychological Strain Questionnaire; SF-36: Medical Outcomes Study Short Form 36 Questionnaire; STAI-t: State Trait Anxiety Inventory; TAS-20: Toronto Alexithymia Scale; WHOQOL-BREF: World Health Organization Quality of Life-BREF; WHOQOL-SRPB -Organization Quality of Life Spirituality, Religiousness and Personal Beliefs; WVS: World Values Survey * EEG studies conducted with 62 channel EEG, Scan 4.1.1. software, 128 channel ESI system, 64-channel QuickCap with imbedded AG/AgC1 electrodes Self-developed questionnaires
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Table 2. Outcome Cochrane Risk Assessment for Bias
meta-analysis on the effects of yoga on patients with depressive disorders and
individuals with elevated levels of depression reported moderate short-term
improvements on depression and anxiety (Cramer, Lauche, Langhorst, & Dobos,
2013), and another meta-analysis on the effects of yoga for prenatal depression
also reported significant decreases in depression (Gong, Ni, Shen, Wu, & Jiang,
2015). Improvements on subjective and psychological well-being in yoga research
are less often reported. Some meta-analyses report increases in indicators of
well-being, such as quality of life, and positive effect (Buffart et al., 2012; Cramer,
Lange, Klose, Paul, & Dobos, 2012; Cramer et al., 2013) while other studies found
no significant improvements in well-being (Cramer, Lauche, Haller, & Dobos,
2013; Cramer, Lauche, Klose, Langhorst, & Dobos, 2013), or only improvements
when yoga is compared to no intervention (Hendriks, de Jong, & Cramer, 2017).
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In regard to the study quality, we found that half of the RCTs in SY had a low risk
of bias, and therefore can be classified as studies of high quality. For the non-
randomized controlled trial, the cross-sectional study and the cohort study the
quality was also high. These findings are not in line with previous studies that
examined the study quality in meditation and yoga research. Our findings suggest
that the overall quality of studies on SY is higher than in studies on other forms of
meditation and yoga. In general, the majority of randomized trials in the field of
meditation suffer from a lack of methodological rigor (Ospina et al., 2007). A
meta-analytic study reported that from the more than 3,000 articles on
meditation that were published between 1973 and 2007, only four percent could
be classified as randomized controlled trials. Although this study identified 133
randomized studies, after excluding studies that lacked methodological rigor (e.g.
trials without an active control group, too few participants, no blinding
procedures and not using appropriate methods of statistical analyses) only five
high quality studies remained (Manocha, 2008). Although it appears that the
growing interest in meditation, in particular mindfulness, has led to the
publication of more randomized controlled studies since 2007, the quality of
these studies is still not optimal. For example, a meta-analysis on meditation
programs for psychological stress and well-being (Goyal et al., 2014) included 47
randomized studies, of which 36 studies were published from 2007 up to 2013. Of
these studies only eight were assessed having a good quality, eighteen having a
fair quality and nine having a poor quality. In summary, we can conclude that
although there are the limited number of studies on the effects of Sahaja Yoga
meditation, the large majority of the studies are of high quality, which is an
exception to the rule in yoga research.
Strengths and Limitations
In addition to the relative high quality of SY meditation studies, another strength
was the inclusion of four cross-sectional studies that provided evidence for
positive effects of SY meditation on the basis of objective outcome measures (e.g.
EEG, MRI scans), rather than subjective outcome measures (self-report
questionnaires). The disadvantage of cross-sectional studies is that only
association, and not causation can be inferred (Levin, 2006; Sedgwick, 2014). A
further limitation in our review was the small number of studies on the effects of
SY, in particular the number of randomized controlled trials. In order to present
an overview of the potential benefits of SY, we therefore included a non-
randomized controlled trial and a prospective cohort study. With regard to non-
randomized and cross-sectional trials, although these may offer weaker evidence
for the efficacy of an intervention, it would be unwise to simply discard their
259
findings. The validity of findings of such studies may depend on the quality of the
trial. A non-randomized study that has a low risk of bias is comparable to a well-
performed randomized trial, whereas trials that have a moderate or high risk of
bias cannot be considered comparable (Sterne, Higgins, & Reeves, 2014).
Recommendations
In relation to SY research there are the following recommendations: First, more
studies among different populations on the effects of SY are needed to make any
firm conclusions on the effects of SY. These studies should maintain a high study
quality. In case of controlled studies, we strongly advice that researchers report
sufficient statistical data (e.g. means and standard deviations at post-test
assessment), so effect sizes can be calculated. Second, the effects of SY on stress
and anxiety should be explored further since the current evidence is weak. Third,
although several studies reported increases in feelings of happiness, fearlessness,
bliss and integrity, more research on the effect of SY in the development of
positive qualities is needed to justify any such claims in this matter. In addition,
more studies on the development of positive aspects such as resilience,
subjective well-being, and personal values such as forgiveness, courage or
transcendence are recommended. Finally, the psychological mechanisms that are
applicable to SY should be investigated, to offer a rationale how the reported
specific effects could be explained. These recommendations also stretch out to all
forms of meditation research.
Conclusion
This research summarizes the effects of SY meditation on mental health. Our
findings suggest that SY can reduce depression, anxiety, and increase subjective
well-being. In addition, long-term practice of SY is associated with increased
subjective and psychological well-being. However, due to the small number of
publications definite conclusions on the effects of SY cannot be made.
260
Acknowledgments
The author would like to thank prof. dr. J. de Jong at the University of Amsterdam, prof. dr.
P. Cuijpers and dr. E. Karyotaki at the VU University Amsterdam, prof. dr. T. Graafsma at
the Anton de Kom University of Suriname for their corrections and support. Etienne
Joemai at ADEKUS is thanked for co-assessing the quality of the studies. Finally, dr. C.
Danyluck at the University of Colorado is thanked for his suggestions for improvements.
Author disclosure statement
The author is a practitioner of Sahaja Yoga, but is not financially affiliated with the
organization. This article is part of a PhD program in which the author is supervised by
academics that are not in any way linked to Sahaja Yoga. This research received no specific
grant from any funding agency in the public, commercial or not-for-profit sectors.
261
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Chapter 10
General discussion
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General discussion
Recently, there has been a strong increase of the number of studies that examine
the efficacy of positive psychology interventions (PPIs). We defined PPIs as
interventions aimed at increasing positive feelings, behaviors, and cognitions, and
using evidence-based pathways or strategies to increase well-being (Schueller,
Kashdan, & Parks, 2014). Moreover, interventions that contain multiple positive
By many of its practitioners yoga is regarded as a spiritual activity to enhance
well-being (Quilty, Saper, & Goldstein, 2013), and it was originally intended to
reduce mental activity, in order to enter into an enlightened state of awareness
(Rubia, 2009). However, in our meta-analysis on yoga that was presented in
Chapter 8, we found that only 5% of the current research on yoga is focused on
well-being, most yoga studies focus on the effects on ill-being and disorders. In
addition, most yoga research is based on studies on the effects of the practice of
physical postures and/or breathing exercising, which we found only had a
significant effect on psychological al well-being when compared a non-active
control group. I therefore recommend a shift in the field of yoga research
towards (1) positive outcomes, and (2) the effects of yoga intervention based on
the practice of meditation. In regard to the first recommendation, I advise that
the research should not only focus on positive psychological constructs that are
commonly studied in Western societies, such as happiness, flourishing, and even
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mindfulness. I would recommend to focus more on constructs that are rooted in
yoga philosophy and Hinduism such as moksha (meaning), ananda (bliss,
happiness), buddhi (wisdom), kaivalya (detachment), and thuriya avastha
(thoughtless awareness, or mind-emptiness). In regard to the research on Sahaja
Yoga meditation (SY), a form of meditational yoga as the name implies, I
recommend further studies that examine the effects of Sahaja Yoga meditation
on character strengths and virtues. A RCT that was included in the systematic
review, reported that short-term practice of meditation could significantly change
personal values, which included strengths and constructs akin to character
strengths and virtues (e.g. forgiveness, world of beauty, unity with nature, and
reduced pre-occupation with preserving public image). This suggests that Sahaja
Yoga is an evidence-based strengths-based intervention. It should be noted that
the aforementioned study is the one of the first RCTs that suggest that character
strengths can be developed through short-term practice of meditation.
VI. Further development, implementation and testing of PPIs among
specific ethnic groups in Suriname
In Chapter 6 we demonstrated that a culturally adapted MPPI can be effective in
increasing resilience and mental well-being among employees with multi-ethnic
backgrounds in Paramaribo. Our trial was the first PPI that was conducted in
Suriname. I recommend further research on the effects of PPI among other
populations in Suriname, extending the research to clinical populations and
adolescents and children. I advise the development of MPPIs of which the
theoretical framework and the content of the positive activities are adapted to
specific populations and their cultural background. For example, in light of the
problem of suicidality among the Hindustani in the Surinamese district of Nickerie
and parts of Guyana (Graafsma, Westra, & Kerkhof, 2016; van Spijker, Graafsma,
Dullaart, & Kerkhof, 2009), I would recommend integrating specific Hindu cultural
and religious activities and rituals into MPPIs.
For example, by illustrating strengths and virtues on the basis of the Hindu
cosmological model, or by integrating Hindu prayers. A s described earlier,
religious activities can increase well-being. Rituals, on their part, can have a
transformative function and contribute to a change towards a more positive self-
image and to the development of a more adaptative mental state (Hinton &
Kirmayer, 2016). Rituals intensify (positive) emotions, and may strengthen
existing (positive) emotions and produce other (positive) emotions (Collins, 2004).
285
I would strongly recommend to integrate yoga meditation into MPPIs, or even to
develop hybrid programs similar to recently developed programs that combine
positive psychotherapy with mindfulness-based interventions (Ivtzan, Niemiec, &
Briscoe, 2016; Ivtzan, Young, et al., 2016). In addition, indigenous people and
Maroons living in the urban and rural areas in Suriname are also facing specific
challenges, including poverty (Kambel, 2006), increased suicidality (Graafsma,
Westra, & Kerkhof, 2016) , and child maltreatment (Graafsma, 2015; van der
Kooij et al., 2015). Such challenges may have contributed to a high prevalence of
psychological distress among such groups (Gunther, Smits, & Krishnadath, 2017).
In light of our findings presented in this thesis, MPPIs designed to increase
resilience and well-being could be beneficial for the mental well-being of such
groups, under the condition that interventions are cultural sensitive.
VII. Development of validated questionnaires and conducting studies on
the effects of biases
As described in the limitations, we mainly used questionnaires that were
validated among Dutch speaking populations in The Netherlands and Belgium. I
therefore recommend future researchers in Suriname to either develop their own
validated questionnaires or to adapt existing questionnaires and validate them
among the Surinamese population. Questionnaires in Dutch could be developed,
or in the local Sranang Tongo language, which is more often spoken among lower
educated population in Suriname and by a growing number of Chinese migrants.
Development and validation may at first sight be problematic since this process
requires knowledge and expertise that is currently not available in Suriname.
However, with the advent of the bachelor program in psychology at the Anton de
Kom University of Suriname in 2010, and the master program in psychology in
2017, it is expected that the number of psychologists in Suriname will sharply
grow in the near future. Possibly knowledge exchange projects between Dutch
universities and the Anton de Kom University of Suriname could be set up in the
near future, where Dutch experts in the field of cross-cultural development of
questionnaires can train the new generation of Surinamese psychologists.
Connected to this theme, I would also recommend future researchers to study
the influence of possible biases in Suriname. For example, extreme or midpoint
response style bias (He & van de Vijver, 2012), or acquiescence bias which is more
likely to occur among people with low socioeconomic status in collectivistic
286
cultures (Harzing, 2006).
VIII. Strength and Virtues studies among the main ethnic groups in
Suriname
In Chapter 5 findings of a qualitative study that examined strengths and virtues
among the Surinamese populations were presented. In addition to five major
strengths that were associated with the Surinamese people in general, we found
that particular strength and virtues were associated with the different ethnic
groups in Suriname. For example, frugality was a strength that was associated
with Hindustani. According to several Hindustani respondents, saving money for
future purposes is part of the culture, especially in the older generations of
Hindustani. Furthermore, joyfulness was associated with the Creoles, sense of
pride with the Maroons, and humility with the Javanese. In Chapter 5 I did not
report these findings, since they were only mentioned by a few respondents. To
gain insight into the strengths and virtues that are present among the four main
ethnic groups, I would recommend further quantitative studies on the prevalence
of strength and virtues among the main ethnic groups in Suriname. It is
imperative that researchers avoid the use of questionnaires based on VIA
Classification of Strengths and Virtues (McGrath & Walker, 2016). Although, the
VIA theoretical model is the most widely applied theoretical framework studying
character strengths and virtues, it only includes strength and virtues that are
culturally ubiquitous or regarded as universal (Peterson, Ruch, Beermann, Park, &
Seligman, 2007) and excludes strength and virtues specific to cultural
(sub)groups. An alternative would be to use the strengths listed in the Strengths
Book (Linley, Willars, Biswas-Deiner, Garcea, & Stairs, 2010), or to develop a
strength questionnaire that includes strengths that are present in interdependent
cultures. But to delve deeper into this question one would like to use mixed
methods as the preferred road to obtain insight.
287
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Samenvatting
(Summary in Dutch)
Dit proefschrift is verdeeld in drie gedeelten, ieder met specifieke doelen. Het doel
van het eerste gedeelte was om te onderzoeken in hoeverre positieve psychologie
interventies (PPI’s) Westers georiënteerd zijn en hoe doeltreffend ze zijn. In het
tweede gedeelte werd gekeken naar de effecten van een PPI die is uitgevoerd in
Paramaribo, Suriname. Daarnaast werd er onderzocht welke psychologische
factoren in Suriname bijdragen aan veerkracht. Het doel van het derde gedeelte
was om te exploreren wat de effecten van yoga zijn op mentaal welzijn.
Het proefschrift bestaat uit tien hoofdstukken. In hoofdstuk 1 werd in de
algemene inleiding allereerst achtergrondinformatie over Suriname gegeven. De
thema’s veerkracht en mentaal welzijn werden vervolgens vanuit de literatuur
belicht. Daarna volgde een korte ontstaansgeschiedenis van de positieve
psychologie, gevolgd door de ontwikkeling van de positieve psychologie in
Suriname. Verder werd uitgelegd wat er precies verstaan wordt onder PPI’s, welke
theoretische modellen de werking van PPIs mogelijk verklaren, en wat het belang
is van het cultureel aanpassen van PPI’s wanneer ze in niet-Westerse landen
worden uitgevoerd. Het eerste hoofdstuk werd afgesloten met mijn kijk op de
onderbelichte mogelijkheden van yoga als interventie binnen de positieve
psychologie stroming.
Na de generale inleiding volgde het eerste deel van het proefschrift dat in
ging op positieve psychologie interventies vanuit een cross-cultureel perspectief.
In hoofdstuk 2 gingen we dieper in op de vraag in hoeverre de positieve
psychologie een Westers georiënteerde wetenschap is. Dit deden we op basis van
de resultaten van een bibliometrische analyse van artikelen met
onderzoeksresultaten van gerandomiseerde, gecontroleerde studies. We vonden
dat het merendeel van het onderzoek naar de effecten van PPI’s nog steeds
afkomstig was uit Westerse landen; namelijk zo’n 78%. We constateerden echter
ook een sterke groei van het aantal studies afkomstig uit niet-Westerse landen
sinds 2012. Verder bespraken we de meerwaarde die PPI’s bieden in niet-Westerse
landen, bijvoorbeeld dat ze kunnen bijdragen aan het verkleinen van de ‘treatment
gap’, oftewel het gegeven dat er een gat is tussen vraag en aanbod binnen de
geestelijke gezondheidszorg in niet-Westerse landen, een tekort dat mede
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veroorzaakt door een tekort aan hoogopgeleid personeel. PPI’s sluiten mogelijk
beter aan bij niet-Westerse bevolkingsgroepen omdat sommige positieve
activiteiten gebaseerd zijn op spirituele of religieuze uitgangspunten.
Hoe effectief zijn PPI’s nu eigenlijk? In hoofdstuk 3 beschreven we de
uitkomsten van een meta-analyse van randomized controlled trials (RCTs). We
richtte ons op multi-componenten PPI’s (MPPI’s). Analyse wees uit dat de
effectgrootte van MPPI’s op subjectief en psychologisch welbevinden ‘gematigd’ is,
en ‘klein’ op depressie en angst. Hierbij valt de kanttekening te plaatsen dat de
effectgroottes daalden wanneer uitschieters uit de analyse werden weggelaten.
Een moderatoren analyse onthulde verder dat de effectgroottes in studies uit niet-
Westerse landen op het subjectief welzijn, het psychologisch welzijn en op
depressie wel drie tot vier keer groter zijn dan bij studies uit Westerse landen. Dit
hield in dat als we de studies uit niet-Westerse landen zouden weglaten uit de
meta-analyse, de effecten op subjectief welzijn, psychologisch welzijn en depressie
sterk zouden dalen en alle effecten ‘klein’ zouden zijn. De hogere effectgroottes
houden vermoedelijk verband met de lagere kwaliteit van studies en verschillende
soorten bias in niet-Westerse studies. Een tweede beperking van de meta-analyse
was het relatief lage aantal studies uit niet-Westerse landen, namelijk zeven. De
bevindingen van deze meta-analyse waren voor ons dan ook aanleiding voor een
tweede meta-analyse, waarbij we de effectiviteit van alle PPI’s uit niet-Westerse
landen wilden onderzoeken, dus zowel enkelvoudige als multi-componenten PPI’s.
De resultaten van deze analyse werden gerapporteerd in hoofdstuk 4. De
meta-analyse bevatte 28 studies uit verschillende niet-Westerse landen, waarvan
de meeste afkomstig waren uit China (12 studies) en Iran (6 studies). Voor
subjectief welzijn en psychologisch welzijn waren de effectgroottes wederom
‘gematigd’, maar voor depressie en angst waren de effectgroottes ‘groot’.
Wanneer uitschieters werden weggelaten, daalde de effectgrootte voor subjectief
welzijn, hoewel deze nog steeds ‘gematigd’ was. De effectgrootte voor
psychologisch welzijn daalde naar ‘klein’ en ook de effectgrootte voor angst
daalde, hoewel het effect nog wel als ‘groot’ beschouwd kon worden. Wederom
werd een kwaliteitsmeting gedaan. De resultaten lieten zien dat de gemiddelde
studiekwaliteit heel laag was en dit kan hebben bijgedragen aan een overschatting
van effectgroottes. Naast methodologische vertekening of bias spelen mogelijk
andere factoren een rol die bijdragen aan de hogere doeltreffendheid van studies
uit niet-Westerse landen. Bijvoorbeeld de collectivistische cultuur, die wellicht kan
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leiden tot een grotere invloed van sociale wenselijkheid bij het proces van meting.
Omdat de toegang tot geestelijke gezondheidzorg in niet-Westerse landen vaak
beperkt is, kan de deelname aan een psychologische interventie als een nouveauté
beschouwd worden, en dit kan het verwachtingspatroon van deelnemers
beïnvloeden. Als laatste hebben we een andere mogelijkheid geëxploreerd:
namelijk dat PPI’s in niet-Westerse landen doeltreffender zijn omdat ze cultureel
goed passen. Veel oefeningen waaruit PPI’s bestaan zijn weliswaar gericht op het
vergroten van het individuele welzijn, maar doen dit door oefeningen die vaak een
collectivistisch karakter hebben, bijvoorbeeld het uitdrukken van dankbaarheid
naar anderen toe. Daarnaast zijn enkele activiteiten in PPI’s ontwikkeld die
gebaseerd zijn op een niet-Westerse levensfilosofie, namelijk het Boeddhisme.
Ook zien we binnen PPI’s integratie van religieuze en spirituele activiteiten. De
holistische benadering van veel PPI’s kunnen mogelijk leiden tot een verhoogd
enthousiasme en toewijding bij deelnemers in niet-Westerse landen en hierdoor
bijdragen tot hogere effectgroottes.
Het tweede deel van het proefschrift richtte zich op de ontwikkeling van
veerkracht en mentaal welzijn in Suriname. Hoofdstuk 5 beschreef de uitkomsten
van een kwalitatief onderzoek. Centraal in deze studie stond de vraag welke
karaktersterkten geassocieerd werden met veerkracht binnen de drie grootste
etnische bevolkingsgroepen in Suriname. Dit tegen het licht van de gevolgen van
de recente economische crisis in Suriname. Er zijn 25 diepte-interviews met
vertegenwoordigers van de verschillende etnische gemeenschappen, professionals
binnen de gezondheidszorg en academische onderzoek afgenomen. We