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Positive psychology interventions in a multi-ethnic and cross-cultural context

Hendriks, T.

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Download date: 27 Aug 2020

POSITIVE PSYCHOLOGY INTERVENTIONS

IN A MULTI-ETHNIC AND

CROSS-CULTURAL CONTEXT

Tom Hendriks

This thesis was prepared at the Department of Psychology, Faculty of

Social Sciences, Anton de Kom University of Suriname, in a

cooperation with the Amsterdam Institute for Social Science,

University of Amsterdam.

Please cite as:

Hendriks, T. (2018). Positive psychology interventions in a multi-

ethnic and cross-cultural context. (Dissertation). Amsterdam,

University of Amsterdam.

ISBN: 978-94-632-3374-3

© 2018 by T. Hendriks

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

(Fernández & López-Calva, 2010; Gili, Roca, Basu, McKee, & Stuckler, 2012; Glonti

et al., 2015; Karanikolos et al., 2013; Paul, 2009; Zivin, Paczkowski, & Galea, 2011).

Economic crises are also associated with increased suicide rates (Ng, Agius, &

Zaman, 2013; Piovani & Aydiner-Avsar, 2015; Uutela, 2010; Van Hal, 2015;

Veenhoven & Hagenaars, 1989). This may be of great relevance to the context of

Suriname, considering the high rate of suicide in Suriname in general, and in the

district of Nickerie in particular, where suicide is linked to poverty and

unemployment (Graafsma, Kerkhof, Gibson, Badloe, & van de Beek, 2006; van

Spijker, Graafsma, Dullaart, & Kerkhof, 2009). According to one study (Sobhie, de

Abreu-Kisoengingh, & Dekkers, 2016; Sobhie, Deboosere, & Dekkers, 2015), 16% of

the population in Suriname were already living below the poverty line in 2012,

while 53% of the population was at risk of falling into poverty. Currently, Suriname

is classified as an upper middle-income country (The World Bank, 2016). However,

in my opinion, this classification is outdated. Firstly, this was the classification prior

to the economic crisis in Suriname. Secondly, the lower limit for this category is a

monthly salary of USD330. Our study was conducted among three companies in

the private sector, and over 65% of the participants indicated that they earned less

than USD270 per month. It should be noted that wages of people working in the

commercial sector are usually higher than the public sector, where more than 61%

of the people in Suriname work. For reasons mentioned above, I think since 2017

Suriname can be considered a lower middle-income country.

11

Adding to the economic situation is an ongoing political crisis. In 2017, the

prosecutor of the Surinamese Court Martial recommended a 20-year prison

sentence for the current president of Suriname, Desi Bouterse, for his role in the

so-called “December killings.’’ This term refers to events that took place in

December 1982, when 15 opponents of the military regime led by Bouterse were

arrested and executed (Dew, 1994). The trial is ongoing and Suriname appears to

be divided between those who want to forget about the past and offer forgiveness

to offenders for their past crimes, and those who persevere in their quest for

justice.

With the suboptimal economic situation before the advent of the crisis

and the ongoing socio-political tensions in mind, I expect that the recent

developments in Suriname have had, and/or will have a strong negative impact on

the well-being of the general population. The situation may require high levels of

resilience, in order for the Surinamese people to recover from the recent

adversities.

Resilience and mental well-being

The main topic of this thesis is the relationship between PPIs and two outcomes:

resilience and mental well-being. Resilience is a phenomenon that is studied by

various scientific disciplines, including traumatology, developmental

psychopathology, neuro-biological psychology (Graber, Pichon, & Carabine, 2015),

and even in (social) ecology and engineering (Baggio, Brown, & Hellebrandt, 2015).

There are various definitions of the term “resilience.” Some have described

resilience 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 the capacity to bounce back after

negative emotional experiences (Tugade & Fredrickson, 2004). Others refer to

resilience as showing 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 contributing to successful adaptation to problems

(Friborg, Hjemdal, Martinussen, & Rosenvinge, 2009). In a review on the wide

variety of definitions, concepts and theories of resilience, Fletcher and Sarkar

(2013) concluded that the definitions of resilience are centered around two

concepts, namely, adversity and positive adaption.

12

In positive psychology literature, an often-used synonym for mental well-being is

positive mental health. Although it has been acknowledged since the 1940's that

mental health is more than the absence of mental illness (Jahoda, 1959; Sigerist,

1941; World Health Organization, 1948), until recently, the dominant view on

mental health was based on the assumption that mental health can be measured

along a single dimension, with the presence or absence of mental illness on each

end of the bipolar continuum (Greenspoon & Saklofske, 2001). However, there is

accumulating evidence that this may not be the case (Huppert & So, 2013; Keyes,

2005; Lamers, Westerhof, Bohlmeijer, ten Klooster, & Keyes, 2011; Lamers,

Westerhof, Glas, & Bohlmeijer, 2015). Two similar models were developed within

the theoretical framework of positive psychology that describe psychopathology

(mental illness) and well-being (mental health) as two independent dimensions,

namely, the Dual-Factor Model of Mental Health (Antamarian, Scott Huebner, Hills,

& Valois, 2010; Greenspoon & Saklofske, 2001; Lyons, Scott Huebner, Hills, &

Shinkareva, 2012) and the Two Continua Model (Keyes, 2013; Keyes, 2007;

Westerhof & Keyes, 2010). These models imply that individuals with many

symptoms of pathology can experience high or low levels of well-being, and the

same applies to individuals with no pathological symptoms. In this thesis, the Two

Continua Model forms the basis for understanding the concept of well-being. This

model was mainly developed by American psychologist Corey Keyes (2002, 2005,

2007). Keyes (2007) argues that positive mental health consists of three

dimensions of mental well-being: (1) emotional well-being, (2) psychological well-

being, and (3) social well-being. Emotional well-being (EWB) consists of positive

affect and quality of life and reflects the level of positive emotions people

experience. Psychological well-being (PWB) consists of six dimensions: self-

acceptance, personal growth, purpose in life, environmental mastery, autonomy,

and positive relations with others. PWB determines our (positive) psychological

functioning. Social well-being (SWB) entails five aspects of social functioning,

namely, social acceptance, social actualization, social contribution, social

coherence, and social integration (Keyes, 2007). The Mental Health Continuum-

Short Form (MHC-SF) is a self-report questionnaire that was developed by Keyes

(Keyes et al., 2008), which is widely used in well-being research. This instrument is

also used in the randomized controlled trial (RCT) in this thesis to measure mental

well-being. The study of mental well-being is one of the main focal points of study

by scholars in the field of positive psychology (Henry, 2007).

13

Positive psychology: A brief history

Positive psychology can be defined as the scientific study of the conditions and

processes that contribute to the flourishing or optimal functioning of people,

groups, and institutions (Gable & Haidt, 2005). Martin Seligman’s presidential

address to the American Psychological Association in 1998 (Seligman, 1999) is

often regarded as the starting point of the movement. In their seminal paper

Positive Psychology: An Introduction, Seligman and Csikszentmihalyi

(2000) argue that “Psychologists have scant knowledge of what makes life worth

living” (p. 5). The aim of positive psychology was to change the direction of

psychology: away from the focus of what is “wrong” with people, towards an

understanding of what is “right,” thereby restoring the balance between the two

(Gable & Haidt, 2005). This goal, however, was not a new one. Historically, positive

psychology is strongly rooted in humanistic psychology, and it was, in fact,

Abraham Maslow who first coined the term “positive psychology” in his book

Motivation and Personality. In the chapter “Towards a positive psychology,” he

noted that the focus in psychology was mainly on the negative aspects of human

behavior, and he strongly advocated a change in direction (Maslow, 1954).

Humanistic psychology only partially managed to change the course of psychology;

its influence was restricted to the field of psychotherapy. Researchers in

humanistic psychology mainly took a qualitative approach, instead of quantitative,

and this led to a lack of empirical bases for many of the theories that were put

forth by the movement (Schui & Krampen, 2010). Aside from the work of a handful

of pioneers studying themes such as subjective well-being (Diener, 1984; Diener,

Sandvik, Seidlitz, & Diener, 1993; Veenhoven, 1991), psychological well-being (Ryff

& Keyes, 1995; Ryff & Singer, 1998) and goal setting (Sheldon & Elliot, 1998), prior

to 1998, knowledge of what could make people happier and under what

conditions happiness could flourish was mostly found in pseudo-scientific

psychology books (Salerno, 2005). Since the advent of positive psychology,

however, there has been an incremental growth in the number of scientific

publications on positive aspects of human behavior, cognition, and emotion. A

study that quantitatively assessed the size, reach, impact, and topic breadth of

positive psychology publications found over 18,000 documents in PsycINFO that

were identified as belonging to positive psychology (Rusk & Waters, 2013). This

study reported that the percentage of citable positive psychology related

documents in PsycINFO increased from 1.5% in 1998 to 4.4% in 2011. Another

recent study identified 1,336 peer-reviewed scientific papers that were published

14

between 1999 and 2013, of which 771 (58%) were empirical studies. This study

also reports a sharp incremental growth in the number of published studies: an

average of 14.2 studies per year in the period 1999 - 2003, 74.5 studies per year in

the period 2004 - 2007, and 161.2 studies per year in the period 2008 - 2013

(Donaldson, Dollwet, & Rao, 2014). However, the overall efficacy of PPIs has been

reported in only two studies (Sin & Lyubomirsky, 2009; Bolier et al., 2013).

Therefore, the current thesis addresses this paucity in the literature by including

several systematic reviews and meta-analyses on positive psychology.

Over the past three decades, the positive psychology movement has also

brought forth numerous books that stretch beyond the realm of pop-psychology,

handbooks and college textbooks. There are several positive psychology

associations, including the International Association of Positive Psychology (IPPA)

and the European Network of Positive Psychology (ENPP), and two dedicated

positive psychology journals (i.e. The Journal of Positive Psychology and the Journal

of Happiness Studies), that both have a current impact factor of 2.37. Positive

psychology conferences are organized all over the world (Linley, Joseph,

Harrington, & Wood, 2006), and courses in positive psychology are now conducted

at numerous universities, including Ivy League universities such as Harvard

University (Russo-Netzer & Ben Shar, 2011), the University of Pennsylvania

(Seligman, Ernst, Gillham, Reivich, & Linkins, 2009), and, most recently, Yale

University, where a course in happiness has become the most favored class among

students of psychology, as well as of students from other academic disciplines

(Shimer, 2018).

Since its inception, the movement has met its fair share of criticism, in

particular during its first decade. Critics have put forward the argument that

positive psychology fails to recognize the reality of the negative aspects in life

(Gable & Haidt, 2005). Some even disdainfully label the movement as

“happiology,” since research in the years prior to the start of the movement and

during its early years was mainly focused on happiness (Akhtar, 2012). By pairing

the term “positive” with “psychology,” the movement suggests that there is a

relationship between personal life and the ideal of happiness, and it creates an

association between the ideal of happiness and psychology as a scientific discipline

(Becker & Marecek, 2008). Positive psychology, perhaps rightfully, has also been

accused of ignoring the work of past researchers (Lazarus, 2003; Taylor, 2001) and

to neglect classical knowledge. Some even go as far as to state that the movement

does not offer anything new (Fernandez-Rios & Cornes, 2009). Others assert that

15

the movement has a tendency to make over-exaggerated claims about the efficacy

of positive psychology interventions (Coyne & Tennen, 2010). Through

developments in the field, much of the early criticism can now be refuted

(Vazquez, 2013). The criticism that is most relevant in relation to this thesis stems

from cross-cultural psychologists and anthropologists. In general, they argue that

positive psychology tends to neglect the cultural embeddedness of human

behavior and is ethnocentric (Christopher & Hickinbottom, 2008; Frawley, 2015).

Positive psychology is mainly concerned with self-development and self-

enhancement and is based on dominant Western ideologies of individualism

(Christopher & Hickinbottom, 2008). In defense of positive psychology, Vázques

(2012) points out that positive psychology is one of the areas that has given much

thought to cultural differences and has published many transcultural studies. An

extensive literature study by Donaldson et al. (2014) reported that 23% of all

publications in the field of positive psychology stems from non-English speaking

countries, and a recent study also reports that 22% of articles on positive

psychology were conducted in non-Western countries (Kim, Doiron, Warren, &

Donaldson, 2018).

Positive psychology in Suriname

Psychology in Suriname as a discipline is still in its infancy. The Surinamese

Association for Psychologists (SVPO) currently has 32 members. Most of them

received their formal education in the Netherlands. Suriname has one university,

the Anton de Kom University of Suriname (AdeKUS). In 2011, AdeKUS started a

bachelor program in psychology, which was set up under the guidance of the

Erasmus University Rotterdam (EUR). The program follows the EUR curriculum and

the problem-based learning didactic method (Wood, 2008). Each year, 25 students

are admitted to the program. In 2017, a master program in psychology was

launched, so it is expected that in the near future the number of psychologists in

Suriname will grow. Positive psychology was introduced to the academic

community in Suriname in 2013, during a suicide prevention symposium at the

Institute of Graduate Studies and Research (Hendriks, 2013). The Caribbean

Regional Conference of Psychology in Paramaribo in November 2014 featured a

table discussion on the integration of meditation in psychotherapy in the

Surinamese context. The Dutch Magazine of Positive Psychology published an

article on the relevance of positive psychology in Suriname in April 2016

16

(Hendriks, Sanches, & Graafsma, 2016). In May 2016, the Department of

Psychology at AdeKUS launched the course “The Upward Spiral: An Introduction to

Positive Psychology” as part of the bachelor program in psychology. This program

was endorsed by Tal Ben Shahar, former Harvard professor and pioneer in the field

of positive psychology education (Russo-Netzer & Ben Shahar, 2011). In June 2016,

a delegation of nine AdeKUS students visited the Fourth World Congress on

Positive Psychology at Lake Buena Vista, Florida, USA. In 2017, as part of this

thesis, a large- scale RCT that studied the effects of a multi-component positive

psychology intervention (MPPI) among 178 workers in Paramaribo, Suriname was

conducted. Bachelor students in psychology contributed to the implementation of

the intervention and to the scientific research of the study. Positive psychology

was also introduced into the neighboring country, Guyana, in October, 2017, when

two lectures on PPIs were featured at two Public Symposia on Suicide, Youth

Violence, and Professional Psychology in Georgetown and New Amsterdam,

Guyana. The most recent development was the start of the course “Positive

Mental Health” in January, 2018, as part of the master program in psychology.

Both positive psychology programs at AdeKUS were developed by the author. I

have also set up a research line in positive psychology at the university, and several

psychology students have chosen positive psychological themes for their bachelor

and/or master thesis, such as mental well-being, work engagement, mindfulness,

and character strengths and virtues. So, it is expected that the future will bring

more publications from Suriname in the field of positive psychology.

Positive psychology interventions

A substantial part of the publications in the field of positive psychology consists of

empirical studies that test positive psychology theories and positive psychology

interventions (PPIs) (Donaldson, Dollwet, & Rao, 2014). PPIs can be defined as

interventions that use evidence-based pathways or strategies to increase well-

being, positive feelings, behaviors, and cognitions (Schueller, Kashdan, & Parks,

2014; Schueller & Parks, 2014). A distinction can be made between single

component intervention studies and multi-component intervention studies. Single

component intervention studies usually consist of one positive psychology activity,

for example, studies on the effects of “gratitude journaling” (DeSteno, Lim,

Dickens, & Lerner, 2015; Digdon & Koble, 2011; Isik & Erguner-Tekinalp, 2017; Lau

& Cheng, 2011), “acts of kindness” (Alden & Trew, 2013; Buchanan & Bardi, 2010;

17

O'Connell, O'Shea, & Gallagher, 2016) and “character strengths” (Gander, Proyer,

Ruch, & Wyss, 2013; Park, Peterson & Seligman, Rashid, & Parks, 2006; Peterson &

Seligman, 2004). There are a few studies that include an intervention consisting of

two positive activities, for example, a study by Pietrowsky & Mikutta (2012) that

included “best possible selves” exercises and “three good things” exercises. MPPIs

can be considered as interventions that are composed of a minimum of three

positive psychology activities (Hendriks et al., 2018). It should be noted that some

interventions were specifically developed by scholars who consider themselves

explicitly as positive psychologists, and there have also been evidence-based

interventions that were developed outside, or prior to, the positive psychology

movement and that were embraced by positive psychology. Examples of PPIs that

were developed within the framework of positive psychology are the activities in

positive psychotherapy, a protocolized form of psychotherapy (e.g. “Using Your

Strengths,” ” “Three Good Things,” “Obituary/Biography,” “Gratitude Visit,”

“Active-Constructive Responding,” and “Savoring”) (Seligman, Rashid, & Parks,

2006) . Examples of interventions that were embraced by the positive psychology

movement include forgiveness (Coyle & Enright, 1997; McCullough, 2000;

McCullough, Worthington Jr, & Rachal, 1997), reminiscence (Cook, 1998; Wong &

Watt, 1991), and mindfulness (Kabat-Zinn, 2003; Langer, 1992). The overall effects

of PPIs have been reported in two studies. A meta-analysis by Sin and Lyubomirsky

(2009) that included 51 randomized and non-randomized controlled studies

reported a large effect for enhanced well-being (r = .29, d ≅ 0.60) and reduced

depressive symptoms (r = 0.31, d ≅ 0.65). Another meta-analysis that included 39

randomized controlled studies (Bolier et al., 2013) reported moderate effect sizes

(d = 0.34) for subjective well-being, and small effects sizes for psychological well-

being (d = 0.20) and depression (d = 0.20).

Several models and theories have recently been introduced that attempt

to explain how PPIs can contribute to increased positive mental health. The

Hedonic Adaptation Model holds that a particular positive change in life will result

in an initial boost in well-being, and through the occurrence of a number of

positive events during a given (intervention) period, well-being can be maintained

(Sheldon, Boehm, & Lyubomirsky, 2012). The model also suggests that changes are

influenced by intrinsic motivation, greater variety of activities, and greater

appreciation of the intervention. The Positive Activity Model was introduced by

Lyobomirsky and Layous (2013) and suggests that four particular elements of

positive activities can increase well-being, namely, emotions, thoughts, behaviors,

and need satisfaction. The effects of a PPI are moderated by attributes of the

18

intervention (e.g. dosage, variety, sequence, built-in social support) and attributes

of the participant (e.g. motivation, efficacy beliefs, baseline affective state,

personality, social support, and demographics) (Lyubomirsky & Layous, 2013).

Quoidbach, Mikolajczak, and Gross (2015) argue that positive change can be

understood through the framework of the emotion regulation theory. This theory

suggests five emotion regulation strategies that can increase positive emotions

(e.g. situation selection, situation modification, attentional deployment, cognitive

change, and response modulation) (Quoidbach, Mikolajczak, & Gross, 2015).

Another explanation for the effects of PPIs can be found in the flexibility

hypothesis of healing (Hinton & Kirmayer, 2016). This theory holds that flexibility is

a positive psychological state that may explain why psychotherapy and other forms

of healing achieve their effects. Lastly, The Synergetic Change model posits a

dynamic system approach that explains how PPIS can contribute to positive mental

health (Rusk, Vella-Brodrick, & Waters, 2017). The model covers five major

domains of psycho-social functioning, namely, (1) Attention and Awareness, (2)

Comprehension and Coping, (3) Emotions, (4) Goals and Habits, and (5)

Relationships and Virtues. In addition, the importance of biological, physiological,

and environmental factors is recognized. The model suggests there is a synergetic

interaction between the various domains, which in turn can lead to relapse, spill-

over effects, or synergy. It is argued that PPIs can create synergetic changes in

psycho-social function, since positive activities can be targeted at single or multiple

domains. For example, writing a gratitude letter is targeted at increasing one’s

positive emotions (domain 4), but may also lead to positive changes in the

relationship with the person to whom the letter is addressed (domain 5).

The Synergetic Change Model is the most inclusive model that addresses

mechanisms of change in PPIs to date, and therefore, to me, it is the most

compelling theoretical framework. The positive activities that are included in the

intervention program that is tested in this thesis, target the five different domains,

as identified by Rusk and colleagues (2017). Module 1 of this intervention program

raises awareness on resilience, thus targeting the domain “awareness and

attention.” By focusing on expressing gratitude, module 2 targets the domain

“emotions.” In module 3, activities including discovering positive emotions and

engaging in acts of kindness, thus targeting the domains “emotions” and “virtues

and relationships.” In module 4, participants discover their own strengths and

virtues, thus mainly targeting the domain “virtues and relationships.” Module 5

aims at setting positive goals; this is related to the domain “Goals and habits.”

Module 6 focuses on positive reframing, thus targeting “comprehension and

19

coping.” Letting go of negative emotions through forgiveness and expressing

gratitude through daily prayer is practiced in module 7, thereby targeting the

domains ‘emotions,” and “goals and habits.” “Attention and Awareness” is

targeted throughout the entire intervention through short meditation and

breathing exercises that were conducted in each module.

Cultural adaptation of a Western intervention

The intervention that was tested in this thesis is called the Strong Minds Suriname

(SMS) Program. It was based on the Shell Resilience Program (SRP), which, in turn,

was adapted by the Department of Health Psychology and Technology of Twente

University. The SRP was originally developed by the health department of

multinational Royal Dutch Shell in 2011 (Hildering van Lith, 2015) and for this

study, the program was culturally adapted to the Surinamese context. Cultural

adaptation can be described as the systematic modification of an evidence-based

treatment (EBT) or intervention protocol so it becomes more compatible with the

cultural patterns, meanings, and values of participants in the intervention (Bernal

& Domenech-Rodriguez, 2012). Cultural adaptation was conducted according to a

three-phased process, following guidelines for cultural adaptation as described by

Domenech-Rodriguez and Wieling (2004) and guidelines for the implementation of

cultural sensitive cognitive behavioral therapies (Hinton & Jalal, 2014; Hinton, Pich,

Hofmann, & Otto, 2013; Hinton, Rivera, Hofmann, Barlow, & Otto, 2012). During

the first phase, we conducted focus group meetings with human resource

management representatives of the participating companies. The original SRP

contained 10 modules, and finally six topics were selected that were deemed

highly relevant to the Surinamese context. During the second phase, I adapted the

content of the original SRP training. While keeping the structure and practical set-

up of the SRP intact (for example, training employees from the participating

companies to deliver the exercises in small groups, the structure of the training

manual, duration of the sessions), I replaced the original activities. Originally, the

intervention activities were derived from the framework of neuro-linguistic

programming (NLP) (Bandler, Grinder, & Andreas, 1982), but NLP is often viewed

as pseudo-scientific, because there is insufficient empirical evidence supporting

the claim that NLP improves mental health (Murray, 2013; Sturt et al., 2012;

Witkowski, 2010). Therefore, I integrated positive psychology activities into the

program, activities for which there is ample scientific evidence in support of their

efficacy (Bolier et al., 2013; Rashid, 2015; Sin & Lyubomirsky, 2009). During

additional focus group meetings, the content, semantic, conceptual, and technical

equivalence of the program and the instruments to measure possible changes

20

were reviewed by a group of local psychologists. During the third stage of the

adaptation process, we tested the intervention on a group of eight employees

from the three participating companies. These employees were also trained as

coaches for the intervention. On the basis of their feedback, I adjusted the training

manual and exercises and developed the final version of the training.

Yoga and positive psychology

Positive psychology appears to have embraced Buddhist philosophy and

mindfulness meditation, judging by the fact that many PPIs include mindfulness

exercises (Cerezo, Ortiz-Tallo, Cardenal, & De La Torre-Luque, 2014; Cohn,

Pietrucha, Saslow, Hult, & Moskowitz, 2014; Drozd, Skeie, Kraft, & Kvale, 2014),

the amount of studies on mindfulness that have been published in leading positive

psychology journals (Coo & Salanova, 2017; Jislin-Goldberg, Tanay, & Bernstein,

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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31

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,

2014; Ghosh & Deb, 2016; Macaskill, 2016; Rashid, 2015; Sutipan, Intarakamhang,

& Macaskill, 2016; Walsh, Cassidy, & Priebe, 2017; Woodworth, O-Brien-Malone,

Diamond, & Schuz, 2016) were checked.

Eligibility criteria

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,

20 1 2 2 2 3 3

12

31

85

10 1012

27

14

30

00

00 0 0

1 0

0

01

1

2

1 2

3

6

7

19

1 9 9 8 1 9 9 9 2 0 0 0 2 0 0 1 2 0 0 2 2 0 0 3 2 0 0 4 2 0 0 5 2 0 0 6 2 0 0 7 2 0 0 8 2 0 0 9 2 0 1 0 2 0 1 1 2 0 1 2 2 0 1 3 2 0 1 4 2 0 1 5 2 0 1 6

42

15.2%). Other categories were patients with addiction problems (n = 5, 7.6%),

patients with affective disorders (n = 5, 7.6%), patients with cardiac problems (n =

4, 6.1%), patients with chronic pain (n = 3, 4.5%), HIV/AIDS patients (n = 3, 4.5%),

patients with traumatic brain injury (n = 3, 4.5%), patients with diabetes (n = 2,

3.0%), patients with PTSD (n = 1, 1.5%), and women with fertility problems (n = 1,

1.5%). Twelve studies did not specify the nature of the physical or psychological

problems (18.3%). The non-clinical population consisted of healthy adults (n = 59,

48.4%), university/college students (n = 39, 32.0%), school children/adolescents

(n = 15, 12.3%), and elderly (n = 9, 7.4%). The proportion of female participants at

baseline assessment ranged from 0% (5 RCTs, 2.7%) to 100% (30 RCTs, 16.0%),

with a median of 72.0% (IQR=29.4). Seven RCTs (3.7%) did not report the

proportion of female participants at baseline assessment. The total number of

women participating in the 180 remaining studies is 29,889, which is 73.7% of the

population in the 180 studies.

Interventions

We made the distinction between single component intervention studies and

multi-component intervention studies. Single component intervention studies

usually consist of one or two single positive psychology activities. Multi-

component positive psychology interventions (MPPIs) are interventions that are

composed of a minimum of three positive psychology activities that follow one or

more of the following pathways: (1) savoring (intensifying and prolonging

momentary pleasurable experiences); (2) expressing gratitude

(through reflection and activities of expression); (3) engaging in acts of kindness;

(4) promoting positive relationships; (5) promoting meaning and purpose

(Hendriks et al., 2017; Schueller & Parks, 2012; Schueller et al., 2014). Our

analysis contained 118 single component interventions (62.8 %) and 70 multi-

component interventions (37.2%). Interventions were delivered in the following

ways: group based (n = 98, 52.0%), individual (n = 11, 5.9%), and self-help (n = 79,

42.1%). Thirty-two self-help studies were delivered online (17.1%). It should be

noted that one group-based interventions provided additional individual sessions,

two individual interventions provided an online supplement, and thirty-two self-

help studies were delivered completely online.

Positive psychology activities

In our analysis, we included 169 studies (89.9%) that specified the positive

psychology activities; we excluded 19 studies (10.1%) that provided only

information on the themes or the domains of the modules, or an incomplete

43

overview of the activities. Similar activities were often presented under different

names. Finally, we categorized the activities into 15 types of positive psychology

activities (See Table I). We found that activities that focus on the recollection of

positive feelings were the most frequently used activities. Other popular positive

psychology activities include positive psycho-education, identifying and using

strengths and virtues, the expression of gratitude, acts of kindness, and positive

thinking. A complete overview is shown in table 1.

When comparing the activities used in non-Western versus Western

studies (and considering the overall ratio of 1:3.6), we can conclude that life

review (positive reminiscence) and spiritual activities are used considerably more

often, whereas acts of kindness, mindfulness, best possible selves and physical

activities are used considerably less often in non-Western countries.

Table 1. Overview positive psychology activities

Positive activity Total non-Western Western

# % # % # %

Positive recollection 85 50.3% 18 10.7% 67 39.6%

Positive psycho-education 46 27.2% 13 7.7% 33 19.5%

Strengths and Virtues 40 23.7% 11 6.5% 29 17.2%

Gratitude expression 37 21.9% 11 6.5% 26 15.4%

Acts of kindness 36 21.3% 6 3.6% 30 17.8%

Positive thinking 35 20.7% 9 5.3% 26 15.4%

Goal setting 31 18.3% 10 5.9% 21 12.4%

Mindfulness 31 18.3% 6 3.6% 25 14.8% Life review 30 17.8% 14 8.3% 16 9.5%

Forgiveness 26 15.4% 6 3.6% 20 11.8%

Meaningful activities 23 13.6% 4 2.4% 19 11.2%

Best possible self 21 12.4% 2 1.2% 19 11.2%

Spiritual activities 14 8.3% 6 3.6% 8 4.7%

Healthy life style 11 6.5% 0 0.0% 11 6.5%

Self-compassion 11 6.5% 3 1.8% 8 4.7%

44

WEIRD bibliometrics

Western. We found that 147 studies (78.2%) originated from Western

countries compared to 41 studies (21.8%) from non-Western countries. The

studies were conducted in 24 different countries; the 14 Western countries were

Australia, Belgium, Canada, Finland, Germany, Ireland, Israel, Italy, Norway, The

Netherlands, Spain, Switzerland, United Kingdom and the United States. The ten

non-Western countries were China, India, Iran, Japan, Malaysia, the Philippines,

South Africa, South Korea, Taiwan, and Turkey. We witnessed a sharp increase in

the number of studies from non-Western origins through time (See Figure 2). In

the period from 1998 through 2007, we only found 1 published study of non-

Western origin, which was published in 2004. From 2008 to 2011, an average of

0.75 studies per year was published. Since 2012, the number has been rising

sharply. In 2012, there were two published studies (16.7%): one from Iran and

one from Japan. In 2013, three studies (20%) from non-Western countries were

published: two from China and one from South Korea. In 2014, there were six

studies (18.2%): two from China, one each from India, Iran, Japan, and South

Africa. In 2015, seven studies (33.3 %): three from China, two from Iran, one from

India and one from Turkey. Finally, in 2016 there were 19 published studies

(38.8%): seven from China, five from Iran, two from South Korea, and one each

from India, Japan, Malaysia, the Philippines, and Taiwan. Over the past 20 years,

the ratio of non-Western vs. Western RCTs has increased from 1:13.3 in the

period 1998 - 2011, to an average of 1:2.6 in the period 2012 - 2016. This is

shown in Table 2.

Table 2. Ratio non-Western versus Western publications

Year # non-Western RCTs

# Western RCTs Ratio

1998-2011 4 53 1:13.3 2012 2 11 1:5.5 2013 3 12 1:4.0 2014 6 27 1:4.5 2015 7 14 1:2.0 2016 19 30 1:1.6

1:3.6

Most studies were conducted in the United States (n = 74, 39.4 %), followed by

Australia (n = 18, 9.6%), China (n = 15, 8.0%; n = 10, 5.3% in Hong Kong and n = 5,

2.7% in the mainland of China), Iran (n = 10, 5.3%), and the United Kingdom (n =

45

10, 5.3%). Countries where five to nine studies were conducted were: Switzerland

(n = 9, 4.8%), The Netherlands (n = 8, 4.3%), Canada (n = 6, 3.2%), and Spain (n =

6, 3.2%). Countries where two to five studies were conducted were Germany (n =

4, 2.1%), India (n = 3, 1.6%), Ireland (n = 3, 1.6%), Italy (n = 3, 1.6%), Japan (n = 3,

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

(Al-Seheel & Noor, 2016; Rouholamini, Kalantarkousheh, & Sharifi, 2016).

So why is it important to know how much research actually stems from

non-Western countries? A frequently voiced concern by cross-cultural

psychologists and the international research community is that science is an

enterprise that predominantly consists of researchers from Western countries,

and that findings from studies among Western populations are frequently

generalized to populations in non-Western countries (Sue, 1999; Berry, 2013).

Traditional psychology is a science that was developed in the West and positive

psychology is a movement that was initiated by American psychologists (Seligman

& Csikszentmihalyi, 2000). At first glance, the roots of positive psychology seem

to lie in the typical American tradition of 'positive' individualism (Díaz & González,

2012), propagating the idea that with enough effort and determination ‘every

underdog can become a millionaire.’ However, our analysis tells a more complex

story. In practice, many PPIs integrate knowledge and activities that are rooted in

Eastern philosophies, in particular, Buddhism (Levine, 2011; Cassaniti, 2014;

Walsh, 2015). We found that PPIs often include exercises in mindfulness and

cultivate self-compassion and compassion for others. Although the aim of

50

activities involving gratitude, practicing forgiveness and acts of kindness are

targeted at improving individual well-being, many do so via establishing better

relationships with others. While their goal may be individualistic, these activities

work through collectivistic pathways. For example, writing a gratitude letter is an

individual activity, but it is the interaction of an individual with the social

environment during the accompanying gratitude visit that may contribute to the

positive changes (Seligman, Steen, Park, & Peterson, 2005). Gratitude expression

can also be practiced in the context of the family, as the previously mentioned

cluster RCT among 2,070 participants in Hong Kong demonstrated (Ho et al.,

2016). Other examples of community-based PPIs that focus on improving social

relationships can be found in studies from South Africa (Eloff et al., 2014), China

(Ho et al., 2016), and India (Leventhal et al., 2015; Leventhal et al., 2016). By

unjustly discarding positive psychology as a Western-ethnocentric science, the

legitimacy of the movement and its interventions are undermined. This may

hamper the search for new and evidence-based methods to increase well-being

among the global population.

With a growing focus on diversity in health care, we believe that it is

important for positive psychologists to be aware of cultural differences. Cross-

cultural studies have shown that Western-derived interventions combating

mental health threats such as depression, posttraumatic stress disorders or

suicidal behavior can conflict with local ideas of appropriate social interaction,

norms regarding privacy, dignity, and family solidarity (Wickramage, 2006). While

such interventions may be effective in Western countries, they may not be so in

different cultural settings, or they may even be harmful (Ganasan, 2006). For

example, emotional disclosure may increase anxiety and stress, lead to family

conflict, or stigmatization (Christopher, Wendt, Marecek, & Goodman, 2014).

While the concept of happiness across cultures has been studied widely (Diener &

Suh, 2010; Joshanloo, 2014; Selin & Davey, 2012; Veenhoven, 2012) and there are

several studies on cultural differences on expression of positive emotions (Leu,

Wang, & Koo, 2006; Ong, Bergeman, Bisconti, & Wallace, 2006; Tugade &

Frederickson, 2012), a cross-cultural approach to positive psychology in general is

still in its infancy.

The trend towards a growing number of studies evaluating the impact of

PPIs in non-Western countries has an important implication. PPIs have the

potential to partially overcome one of the largest obstacles that mental health

care faces in low- and middle-income countries (LMICs), namely the so-called

51

‘treatment gap’. Up to 75% of people in need of mental health care in LMICs do

not receive any treatment because traditional psychological interventions are

often costly and cannot be implemented on a large scale due to scarcity of mental

health professionals (Kohn, Saxena, Levav, & Saraceno, 2004; Saraceno et al.

2007). PPIs, however, consist of activities that are relatively simple which allow

PPIs to be conducted by local lay counselors who have a less formal education. In

this way, PPIs can contribute to scaling-up of services for mental health care. The

WHO describes scaling-up as planned efforts to increase the impact of health

service innovations that are successfully tested in pilot or experimental projects

to benefit more people and to foster policy and program development on a

lasting basis (Simmons, Fajans, & Ghiron, 2007). Scaling-up is a primary concern in

Global Mental Health (Eaton et al., 2011; Meffert, Neylan, Chambers, & Verdeli,

2016). We do, however, emphasize that for the treatment of severe mental

disorders highly skilled mental healthcare professionals are irreplaceable.

In addition to overcoming the treatment gap, the field of positive

psychology has opened up ways to study constructs that are important in various

religious and spiritual traditions (Falb & Pargament, 2014). Many PPIs have

already integrated activities in the domain of spirituality and religion (Rye, Wade,

Fleri, & Kidwell, 2013). In this way PPIs are suitable for non-Western populations,

considering that these populations often subscribe to a two-tiered vision of the

world (Taylor, 1985). In a two-tiered system a belief in a particular cosmological

framework is the foundation for understanding life and giving meaning to one’s

everyday experiences, whereas in a one-tiered system the process of meaning

giving is a personal, cognitive one (Christopher & Hickinbottom, 2008). Because of

the inclusion of spiritual themes, PPIs can easily be adapted to different cultural

settings, as demonstrated by Islamic based PPIs that were conducted in Iran (Al-

Seheel & Moor, 2016; Rouholamini, Kalantarkousheh, & Sharifi, 2016; Saeedi,

Naseb, Zadeh, & Ebrahimi, 2015).

PPIs may also counter another reason why people with mental health

problems in developing countries do not seek help, namely, the fear for

stigmatization, either self-stigma or affiliated stigma (Abdullah & Brown, 2011;

Hinton & Laroche, 2012; Mascayano, Armijo, & Yang, 2015). PPIs may bypass this

problem because they are focused on enhancing positive thoughts, feelings, and

behaviors (Sin & Lyubomirsky, 2009), and through the practice of gratitude,

optimism, acts of kindness, meditation, and other activities that are not

stigmatizing (Layous, Chancellor, Lyubomirsky, Wang, & Murali Dorais, 2011). The

52

development of character strengths, such as social intelligence and kindness, may

even contribute to reducing the stigmatization of those who seek help for mental

health problems (Vertiloa & Gibson, 2014). Finally, many positive psychology

activities rely on the intuition and feelings of the participants, rather than

analytical thinking. Perhaps PPIs are even more suitable and effective in non-

Western countries than traditional psychological interventions such as psycho-

therapy and cognitive behavioral therapy since non-Western populations have a

more holistic view on life and an intuitive approach to thinking (Talhelm et al.,

2015).

Limitations

The contributions of this paper should be viewed in light of certain limitations.

Firstly, we only included randomized controlled trials in this bibliometric analysis.

RCTs are often cost intensive and complex (Korn & Freidlin, 2012), and therefore

may be a lesser used research design in non-Western countries. For example, an

article on the progress of positive psychology in India reported eight recent

studies on the effects of PPIs in India (Ghosh & Deb, 2016), but none of the

studies were RCTs. In our analyses we identified 265 articles published in the

Indian Journal of Positive Psychology, but only two of the studies (0.3%) were

RCTs. It is very likely that if we were to include other study designs, such as quasi-

experimental and observational studies, the percentage of non-Western studies

would increase. Secondly, our findings suggest that the so-called “10/90 gap” in

positive psychology is improving. This term refers to the claim that only ten

percent of global health research is spent on improving the conditions of people

in low-income countries that account for 90 percent of the global population

(Vidyasagar, 2006; Luchetti, 2014). Perhaps there is an overall trend towards

global health equity, and the aforementioned gap in mental health research is

closing in general. However, due to a paucity of recent research, we cannot

compare our findings to data from bibliometric analyses or reviews outside the

field of positive psychology. There might also be regional differences within the

same country that are not captured (Talhelm et al., 2015), but we believe our

study still offers insights that are more nuanced than otherwise available in the

field. A third limitation pertains to the term WEIRD itself. While this may be a

catchy acronym, and it is clear what it intends to describe, the individual factors

that form the acronym may not be equally informative. Furthermore, it can be

argued that the distinction between Western and non-Western is incorrect,

because what is considered ‘Western’, depends on the geographical location of

the observer. The distinction between high-income countries (HICs) and low- and

53

middle-income countries (LMICs) may be more suitable. Another option is the

distinction between countries with independent versus interdependent cultures

(Shin & Lyubomirsky, 2017). Also, there is another factor that may lead to a

generalization bias and which is not included in the acronym, namely gender. Our

study found that 71.2% of the total study population is female. As mirrored in

other reviews (e.g. Rao & Donaldson, 2015), this suggests a strong gender bias in

terms of study participation.

Recommendations

Firstly, we recommend research in the field of positive psychology from non-

Western countries to continue to develop culturally sensitive PPIs. This can be

done, for example, by matching the characteristics of the intervention and its

intended population (Laroche & Lustig, 2010). Good examples of such an

approach are the aforementioned Islam-based PPIs from Iran (Al-Seheel & Moor,

2016; Rouholamini, Kalantarkousheh, & Sharifi, 2016; Saeedi, Naseb, Zadeh, &

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

ensure scientific rigor (Froh, 2004; Sheldon & Kasser 2001). Studies that

investigate the efficacy of so-called positive psychology interventions (PPIs), are a

cornerstone of psychological inquiry.

63

There has been much discussion on the definition of PPIs. A broad

definition was introduced by Sin and Lyubomirsky (2009), who defined PPIs as all

interventions that aim at increasing positive feelings, behaviors and cognitions.

Narrower definitions were suggested by Bolier et al. (2013), who added that

these interventions ‘should have been explicitly developed in line with the

theoretical tradition of positive psychology’ (Bolier et al., 2013) and Parks and

Biswas-Diener (2013), who suggested that an intervention can only be regarded

as a PPI if sufficient empirical evidence exists suggesting significant effects for the

intervention (Parks & Biswas-Diener, 2013). Schueller and Parks (2014) argued

that in addition to the (positive) aim of an intervention, the pathways through

which the interventions operate is a second essential component when deciding

if an intervention can be considered as a PPI. They identified five pathways: (1)

savoring (intensifying and prolonging momentary pleasurable experiences); (2)

expressing gratitude (through reflection and activities of expression); (2) engaging

in acts of kindness; (4) promoting positive relationships; (5) promoting meaning

and purpose (Schueller & Parks, 2012; Schueller et al., 2014).

Building on these suggestions, we define positive psychology

interventions (PPIs) as interventions aiming at increasing positive feelings,

behaviors and cognitions, while also using theoretically and empirically based

pathways or strategies to increase well-being. To date, two meta-analyses have

been published that examined the overall effects of PPIs. The first meta-analysis

included 51 controlled studies and found large effects for enhanced well-being (r

= 0.29, d ≅ 0.60) and depressive symptoms (r = 0.31, d ≅ 0.65) (Sin &

Lyubomirsky, 2009). The second meta-analysis included 39 RCTs (Bolier et al.,

2013) and reported small effect sizes (d = 0.34) for subjective well-being,

psychological well-being (d = 0.20) and depression (d = 0.20). Bolier et al. (20103)

argued that the effect sizes in the meta-analysis by Sin and Lyubomirsky might be

overestimated.

Multi-component positive psychology interventions (MPPIs)

A differentiation can be made between single component intervention studies

and multi-component intervention studies. Single component intervention

studies usually consist of one or two positive psychology activities. For example,

studies on the effects of gratitude journaling (DeSteno et al., 2015; Digdon &

Koble, 2011; Isik & Erguner-Tekinalp, 2017; Lau & Cheng, 2011), engaging in acts

of kindness (Alden & Trew, 2013; Buchanan & Bardi, 2010; O'Connell et al., 2016)

and identifying and using character strengths (Proyer et al., 2015; Toback et al.,

64

2016). MPPIs may be considered as interventions that are composed of a

minimum of three positive psychology activities. Some MPPIs only contain

activities that were developed within the framework of positive psychology, for

example positive psychotherapy (PPT), a therapeutic approach that is based on

the principles of positive psychology (Rashid, 2015). Other MPPIs combine PPIs

with cognitive behavioural therapy (CBT) (Luthans et al., 2008; Luthans et al.,

2010; Rogerson et al., 2016), and mindfulness-based interventions which to a

large extent overlaps with principles of positive psychology (Arimitsu, 2016,

Ivtzan et al., 2016).

Present study

Over the years, there is a growing body of research on the efficacy of MPPIs. The

aim of this meta-analysis is to examine the efficacy of MPPIs on well-being, and

distress in both the general public and in clinical populations. MPPIs contain a

wide variety of positive activities that target different domains of mental well-

being. Consequently, we expect that MPPIs have a larger effect than has been

found in prior meta-analyses of mainly single component interventions, both at

post treatment and at follow-up measurements. We also conducted exploratory

subgroup analyses to examine the moderating effects of population types,

intervention types, delivery modes, control group types, trial duration, quality

rating, and regions. Finally, we performed a risk of bias analysis to determine the

quality of the studies and examined potential publication bias.

Method

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses

(PRISMA) guidelines for systematic reviews and meta-analyses (Moher et al.,

2010) and the recommendations of the Cochrane Back Review group (Higgins et

al., 2011) were followed in the planning and the implementation of the meta-

analysis.

Search strategy

A systematic literature search was conducted in the following three databases:

PubMed, PsycINFO and Scopus, from 1998 to August 2017. 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

65

psychology, well-being, happiness, happy, flourishing, life satisfaction, satisfaction

with, optimism, gratitude, strengths, forgiveness, compassion and random. The

search strings were adapted to the according database (see the Appendix 1).

Additionally, we checked the reference lists of four meta-analyses (Bolier et al.,

2013; Chakhssi, Kraiss, Sommers-Spijkerman, & Bohlmeijer, 2018; Dickens, 2017;

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

PPT Group CBT 6, 12w - Ne=9 Nc=9

26.4 (5.9)

72% 100% 100%

SWB: OHI; PWB: SWS pwb subscale; Dep: BDI; Stress: SUDS

Asl, 2014, 2016, Iran Infertile women PPT Group Waitlist 6, 6w - Ne=18 Nc=18

30.5 (5.7)

100% 84% 89%

SWB: OHI Dep: BDI

Carr, 2016, Ireland Patients with major depression

PPT Group TAU 20, 20w 3m Ne=28 Nc=29

41.0 66% 70% 73%

Dep: BDI

Celano, 2016, USA Patients with major depression

PPI Self-help CBT 6, 6w 6w Ne=29 Nc=29

44.0 (10.0)

69% 97% 94%

SWB: PANAS Dep: QIDS-SR

Cerezo, 2015, Spain Women with breast cancer

PPI Group Waitlist 14, 14w - Ne=87 Nc=88

50.0 (9.6)

100% 86% 83%

SWB: SWLS

Chaves, 2016, Spain

Women with major depression

PPI Group CBT 10, 10w - Ne=34 Nc=39

51.6 (10.4)

100% 72% 79%

SWB: SWL; PWB: PWBS; Dep: BDI; Anx: BAI

Cohn, 2014, USA Adults with type 2 diabetes

PPI Self-help: online

Placebo 8, 9w - Ne=25 Nc=17

- 51% 79% SWB: PANAS; Dep: CES-D; Stress: PSS

Cullen, 2015, UK Adults with acquired brain injury (ABI)

PPT Group TAU

8, 8w 11w Ne=10 Nc=10

- 37% 71% 71%

SWB: AHI; Dep, Anx, Stress: DASS-21

72

Dowlatabadi, 2016, Iran Women with breast cancer

PPT Group NI 10, 10 - Ne=17 Nc=17

36.6 (5.5)

100% 76% 81%

SWB: OHI Dep: BDI

Drodz, 2014-a, Norway Healthy Adults PPI Self-help: online

Waitlist 13, 4w 5m Ne=108 Nc=88

30.6 (8.4)

75% 97% 94%

SWB: PANAS

Drodz, 2014-b, Norway HIV patients with depressive symptoms

PPI Self-help: online

Waitlist 14, 5w - Ne=36 Nc=31

48.2 (9.3)

8% 72% 94%

SWB: SWS Dep: CES-D

Dyrbye, 2016, USA Healthy adults

PPI Self-help: online

NI 10, 10w Ne=145 Nc=145

- 32% 94%

98%

SWB: Slas; PWB: EWS, PJSC, WES

Feicht, 2013, Germany Healthy adults

PPI Self-help: online

Waitlist 21, 7w 4w Ne=72 Nc=57

37.2 (9.0)

69% 94% 100%

SWB: VAS; PWB: FS; Stress: SWSS

Guo, 2016, China Undergraduate students

PPT Group NI 8, 8 3m Ne=34 Nc=42

20.4 (1.2)

95% 81% 98%

PWB: GSE Dep: BDI

Huffman, 2011, USA Patients with Acute Cardiovascular disease

PPI Group NI 8, 8w - Ne=9 Nc1=7 Nc2=7

- - 90% 70% 70%

SWB: SHS Dep: CES-D Anx: HADS-A

Hwang, 2016, China Student with depression

PPT Group NI 12,6w 4m Ne=8 Nc1=8 Nc2=8

22.7 (2.3)

67% 73% 73% 80%

SWB: SPANE PWB: FS

Ivtzan, 2016, UK Healthy adults PPI +

MM Self-help: online

Waitlist 8, 8w 1m Ne=53 Nc=115

40.7 (11.3)

78.% 24%

52%

SWB: PHI; PWB: GSE, PWBS, MLQP, COS, APM; Dep: BDI; Stress: PSS

73

Joutsenniemi, 2014, Finland

Healthy adults PPI Self-help: e-mail based

Placebo 28, 13w - Ne=417 Nc1=438 Nc2=433

42.0 83.% 40% 37% 42%

PWB: HFS Dep: BDI

Kahler, 2015, USA Healthy adults, smoker

PPT Group TAU 6, 8w 26w Ne=35 Nc=31

46.0 (13.4)

50% 94% 87%

SWB: CES D-pa Dep: CES-D

Khayatan, 2014, Iran Women with

Multiple Sclerosis PPT Group NI 6,6w - Ne=15

Nc=15 31.1 (6.4)

100% 100% 100%

Dep: BDI

Koydemir, 2015, Turkey University students

PPI Self-help: online

Waitlist 5, 8w - Ne=44 Nc=36

18.7 (1.0)

48% - SWB: SHS PWB: PHS

Lü, 2013, China Adults, low trait positive affect

PPT Group NI 8, 8w - Ne=16 Nc=18

20.0 (4.3)

- 100% 100%

SWB: PANAS

Luthans, 2008, USA Healthy Adults PPI + CBT Self-help Placebo 2, 2w - Ne=187 Nc=177

32.2 - -

-

PWB: PCQ

Luthans, 2010, USA Healthy Adults PPI + CBT Group CBT 1,1d - Ne=153 Nc=89

21.1 42% -

-

PWB: PCQ

Müller, 2016, USA Patients, various (muscular) diseases

PPI Self-help Placebo 4, 4-8w 2.5 m

Ne=39 Nc=38

59.4 (11.8)

70% 77% 85%

SWB: PANAS Dep: HADS-D

Nikrahan, 2016, Iran Cardiac patients PPI Group Waitlist 6, 6 w 8w Ne=32 Nc=12

56.6 (8.7)

43% 78% 87%

SWB: OHI Dep: BDI

Page, 2013, Australia Healthy Adults PPI Group NI 6,6w 6m Ne=18 Nc=13

39.7 (10.0)

73% 58% 43%

SWB: SWLS, PANAS PWB: SPWB

Peters, 2017, Netherlands

Patients with chronic pain

PPI Self-help: online

CBT Waitlist

8, 8w 6m Ne=85 Nc1=80 Nc2 = 41

48.5 (12.0)

85% 73% 69% 80%

SWB: BMIS; Dep: HADS-D; Anx: HADS-A

74

Proyer, 2016, Switzerland

Healthy Adults PPI Group Waitlist 5, 12 1m Ne=50 Nc=50

45.7 (12.8)

69% 33%

SWB: AHI PWB: OTH

Roepke, 2015, USA Adults with depression symptoms

PPT + CBT

Self-help phone based

CBT/PPI Waitlist

1m 6w Ne=93 Nc1=97 Nc2=93

40.1 (12.4)

70% 22% 19% 42%

SWB: SWLS Dep: CES-D Anx: GAD-7

Rogerson, 2016, USA Healthy Adults PPI + CBT Group Waitlist 5, 5w - Ne=14 Nc=14

- - 93% 100%

PWB: RAW

Sanjuan, 2016, Spain Cardiac patients PPI Group TAU 24, 8w - Ne=57 Nc=51

54.4 (9.1)

17% 88% 84%

SWB: PANAS Dep: SCL-90-R

Schotanus-Dijkstra, 2016, Netherlands

Adults with low or moderate well-being

PPI Self-help (e-mail support)

Waitlist 8, 9w, 9m Ne=137 Nc=138

47.8 (10.9)

86% 89% 95%

SWB/PWB: MHC-SF Dep: HADS-D Anx: HADS-A

Seligman, 2006, USA, study 1

Students, mild depressive symptoms

PPT Group NI 6, 6w 3m Ne=19 Nc=21

- 43% - SWB: SWLS Dep: BDI

Seligman, 2006, USA, study 2

Adults with major depressive disorder

PPT Indivi-dual

TAU 14, 12w - Ne=11 Nc1=9 Nc2=12

- 69% 87% 60% 71%

SWB: SWLS PWB: PPTI Dep: HRSD

Schueller, 2, USA, 2012 Self-help–seeking adults

PPI Self-help: online

NI 6, 6w - Ne=151 Nc=204

- - 47% 57%

Dep: CES-D

Uliaszek, 2016, Canada University students

PPT + DBT

Group DBT 12, 12w - Ne=15 Nc=22

22.2 (5.0),

78% 56% 85%

PWB: PPTI; Dep/Anx: SCL-90-R D/A; Stress: DTS

Abbreviations: % F = percentage of female participants; % R = retention percentage; Anx = anxiety; CBT = Cognitive Behavioral Therapy; DBT = Dialectical Behavior

Therapy; Dep = depression; MM = Mindfulness meditation; PPI = Positive psychology intervention; PPT = positive psychotherapy; PWB = Psychological well-being; SWB=

Subjective well-being. T2 = follow up measure ; * See Appendix 2 for the abbreviations of the questionnaires.

75

Table 2. Quality assessment of RCTs

Studies SG AC BOA DW PA ITT Total

Asgharipoor, 2012 0 0 0 0 0 0 0 Asl, 2014 0 0 0 1 0 0 1

Carr, 2016 0 0 1 1 0 1 3 Celano, 2016 1 1 1 1 0 1 5 Cerezo, 2014 1 0 0 1 1 0 3

Chaves, 2016 0 1 1 1 0 1 4

Cohn, 2014 1 0 1 1 0 0 3 Cullen, 2015 1 1 1 1 0 0 4

Dowlatabadi, 2016 0 0 0 0 0 0 0

Drozd, 2014a 1 0 1 1 1 1 5 Drozd, 2014b 0 0 0 1 0 1 2

Dyrbye, 2016 1 0 1 1 1 0 4

Feicht, 2013 1 0 1 1 1 0 4 Guo, 2016 0 0 0 1 0 0 1

Huffman, 2011 0 1 0 0 0 0 1 Hwang, 2016 1 0 0 1 0 0 2 Ivtzan, 2016 1 0 1 1 1 0 4

Joutsenniemi,2014 1 1 1 1 1 1 6 Kahler, 2015 1 1 1 1 0 1 5

Khayatan, 2014 0 0 0 0 0 0 1 Koydemir, 2015 0 0 1 0 0 0 1

Lü, 2013 0 0 0 1 0 0 1

Luthans, 2008 1 1 1 0 1 0 4

Luthans, 2010 0 0 0 0 1 0 1

Mülller, 2016 1 0 1 1 0 0 3

Nikrahan, 2016 0 0 0 1 0 1 2

Page, 2013 1 0 1 1 0 0 3 Peters, 2017 0 0 0 1 1 1 3 Proyer, 2016 1 0 1 1 1 0 4

Roepke, 2015 1 0 1 1 1 1 5

Rogerson, 2016 1 0 1 1 0 0 3

Sanjuan, 2016 1 0 1 1 0 0 3

Schotanus-Dijkstra, 2016 1 0 1 1 1 1 5

Schueller 2012 0 0 1 1 1 0 3

Seligman, 2006 study 1 0 0 0 0 0 0 0

Seligman, 2006 study 2 0 0 1 1 0 0 2

Uliaszek, 2016 0 0 1 1 0 1 3

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).

77

Table 3. Between – group effects

Outcome measures N

Hedges’ g

95%CI Z Heterogeneity Q value I2

Fail-safe N

All studies post-treatment

Subjective well-being 28 0.46 (0.25-0.67) 4.30*** 166.55*** 83.79 667

Psychological well-being 17 0.37 (0.19-0.56) 3.98*** 72.47*** 77.92 222

Depression 25 0.32 (0.13-0.51) 3.25** 123.40*** 80.55 218

Anxiety 7 0.30 (0.10-0.49) 3.00** 9.52ns 36.99 19

Stress 7 0.30 (-0.11- 0.71) 1.44ns 20.83** 71.20 12

Studies post-treatment, excl. outliers

Subjective well-being 21 0.35 (0.22- 0.48) 5.18*** 38.13** 47.55 -

Psychological well-being 14 0.30 (0.15-0.45) 3.85*** 27.87** 53.35 -

Depression 24 0.21 (0.07- 0.36) 2.84** 66.01*** 41.92 -

Anxiety (no outliers) 7 0.30 (0.10-0.49) 3.00*** 9.52** 65.16 -

Stress 6 0.50 (0.23-0.78) 3.60*** 7.90ns 36.73

Studies post-treatment, excl. low quality studies

Subjective well-being 17 0.32 (0.07-0.56) 2.56* 120.48*** 86.72 -

Psychological well-being 11 0.23 (0.06-0.41) 2.57* 37.01*** 72.98 -

Depression 15 0.13 (-0.01-0.27) 1.76ns 34.97** 59.97 -

Anxiety 6 0.29 (0.07-0.50) 2.63* 9.43ns 46.95 -

Stress 6 0.50 (0.23-0.78) 3.60*** 7.90ns 36.73 -

Follow-up effects, all studies

Subjective well-being 12 0.36 (0.08-0.64) 2.50* 48.98*** 77.54 -

Depression 11 0.54 (0.10-0.99) 2.40* 79.18*** 87.37 -

Follow-up effects ,excl. outliers Subjective well-being 10 0.52 (0.28 –

0.76) 4.30*** 25.94*** 65.31 -

Depression 10 0.35 (0.00 – 0.70)

1.97* 39.62*** 77.28 -

* p < 0.05; ** p < 0.01; *** p < 0.001; ns: non-significant

78

When low quality studies were excluded the effect size remained small (g =0.32,

95% CI: 0.07 – 0.56, p = 0.011), with a high level of heterogeneity (I2 = 86.72, Q =

120.48, p = 0.000). The forest plots, in Figure 2 and 3, displays the post treatment

effects, including ad excluding outliers respectively.

Figure 2. Post-test effects of MPPIs on subjective well-being, including outliers

Effects on psychological well-being

For psychological well-being (17 comparisons), a similar significant moderate

effect was observed (g = 0.37, 95% CI: 0.19 to 0.59, p = 0.000) at post treatment.

Effect sizes ranged from -0.78 to 1.76. Heterogeneity was significant and high (I2 =

77.92, Q = 72.47, p = 0.000). Removing three outliers (Guo et al., 2016;

Joutsenniemi et al., 2014; Koydemir & Sun-Selisik, 2016) reduced the effect size (g

= 0.30, 95% CI: 0.15 to 0.45, p = 0.000). After omitting outliers, heterogeneity was

reduced to moderate (I2 = 53.35, Q = 27.87, p = 0.009). When studies with a low

quality were excluded, the effect size was lower (g = 0.23, 95% CI: 0.06 to 0.41, p

= 0.01), with a significant moderate to high level of heterogeneity (I2 = 72.98, Q =

37.01, p = 0.000). The forest plot, in Figure 3, displays the post treatment effects.

Study name Statistics for each study Hedges's g and 95% CI

Hedges's Lower Upper g limit limit Z-Value p-Value

Asgharipoor, 2012 1.77 0.72 2.83 3.30 0.00

Asl, 2014 0.89 0.22 1.56 2.60 0.01

Celano, 2016 -0.37 -0.86 0.11 -1.51 0.13

Cerezo, 2014 1.74 1.40 2.09 9.84 0.00

Chaves, 2017 0.19 -0.21 0.59 0.93 0.35

Cohn, 2014 0.07 -0.53 0.68 0.24 0.81

Cullen, 2015 0.33 -0.52 1.17 0.76 0.45

Dowlatabadi, 2016 1.80 1.01 2.60 4.44 0.00

Drodz, 2014, study 1 0.09 -0.19 0.37 0.63 0.53

Drodz, 2014, study 2 0.01 -0.46 0.49 0.05 0.96

Dyrbyre, 2016 0.05 -0.18 0.28 0.43 0.67

Feicht , 2013 0.92 0.56 1.29 4.98 0.00

Huffman, 2011 0.16 -0.77 1.10 0.34 0.73

Hwang, 2016 0.61 -0.34 1.56 1.26 0.21

Ivtzan, 2016 0.65 0.32 0.99 3.87 0.00

Kahler, 2015 0.18 -0.32 0.69 0.71 0.48

Koydemir, 2015 0.62 0.17 1.06 2.70 0.01

Lü, 2013 2.22 1.37 3.06 5.16 0.00

Mülller, 2016 -0.21 -0.65 0.24 -0.91 0.36

Nikrahan, 2016 0.42 -0.18 1.02 1.37 0.17

Page, 2013 0.33 -0.32 0.98 0.99 0.32

Peters, 2017 -0.23 -0.53 0.08 -1.45 0.15

Proyer, 2016 0.42 0.07 0.77 2.34 0.02

Roepke, 2015 0.21 -0.08 0.49 1.42 0.15

Sanjuan, 2016 0.25 -0.15 0.66 1.22 0.22

Schotanus-Dijkstra, 2017 0.61 0.37 0.85 4.98 0.00

Seligman, 2006, study 1 -0.02 -0.62 0.59 -0.05 0.96

Seligman, 2006, study 2 0.45 -0.41 1.30 1.02 0.31

0.46 0.25 0.67 4.30 0.00

-2.00 -1.00 0.00 1.00 2.00

Favours control Favours MPPI

Meta Analysis

79

Figure 3. Post-test effects of MPPIs on psychological well-being, including outliers

Effects on depression

For depression (25 comparisons), a significant small effect was observed (g =

0.32, 95% CI: 0.13 to 0.51, p = 0.001) at post treatment. Effect sizes of studies

ranged from -1.50 to 3.05. Heterogeneity was significant and high (I2 = 80.55, Q =

123.40, p = 0.000). Removing one outlier (Guo et al., 2016) reduced the effect size

(g = 0.21, 95% CI: 0.07 to 0.36, p = 0.004) and heterogeneity was moderate (I2 =

65.16, Q = 66.01, p = 0.000). When studies with a low quality were excluded, the

effect size was no longer significant.

Study name Statistics for each study Hedges's g and 95% CI

Hedges's Lower Upper g limit limit Z-Value p-Value

Asgharipoor, 2012 0.11 -0.78 0.99 0.23 0.81

Chaves, 2016 0.16 -0.24 0.56 0.78 0.43

Dyrbyre, 2016 -0.01 -0.24 0.21 -0.13 0.90

Feicht, 2013 0.41 0.06 0.76 2.31 0.02

Guo, 2016 1.27 0.78 1.76 5.08 0.00

Hwang, 2016 0.58 -0.37 1.53 1.20 0.23

Ivtzan, 2016 0.55 0.22 0.88 3.28 0.00

Joutsenniemi, 2014 -0.03 -0.17 0.10 -0.47 0.64

Koydemir, 2016 1.03 0.57 1.50 4.36 0.00

Luthans, 2008 0.10 -0.11 0.30 0.91 0.36

Luthans, 2010 0.36 0.10 0.62 2.68 0.01

Page, 2013 0.21 -0.44 0.87 0.64 0.52

Proyer, 2016 0.28 -0.07 0.63 1.59 0.11

Rogerson, 2013 0.70 -0.04 1.44 1.85 0.06

Schotanus-Dijkstra, 2017 0.63 0.39 0.87 5.10 0.00

Seligman, 2016, study 2 0.83 -0.05 1.71 1.84 0.07

Uliaszek, 2016 -0.34 -1.02 0.33 -1.00 0.32

0.37 0.19 0.56 3.98 0.00

-2.00 -1.00 0.00 1.00 2.00

Favours control Favours MPPI

Meta Analysis

80

Figure 4. Post-test effects of MPPIs on depression, including outliers

Effects on anxiety

For anxiety (5 comparisons), a significant small effect was observed (g = 0.30, 95%

CI: 0.10 to 0.49, p = 0.003) at post treatment. Effect sizes of studies ranged from -

0.70 to 1.44, and there were no outliers. The level of heterogeneity was not

significant. When one low quality study was excluded, the effect size was slightly

lower (g = 0.29, 95% CI: 0.07 to 0.50, p = 0.009), and the heterogeneity remained

insignificant.

Effects on stress

No significant effects were found for stress (7 comparisons) at post treatment.

Removing one outlier (Asgharipoor, 2012) resulted in finding a strong moderate

effect size (g = 0.50, 95% CI: 0.23 to 0.78, p = 0.000), and there was no significant

heterogeneity. The outlier belongs to the group of low qualities study.

Study name Statistics for each study Hedges's g and 95% CI

Hedges's Lower Upper g limit limit Z-Value p-Value

Asgharipoor, 2012 -0.60 -1.50 0.30 -1.30 0.19

Asl, 2014 0.90 0.23 1.57 2.62 0.01

Carr, 2017 0.40 -0.18 0.97 1.35 0.18

Celano, 2016 0.06 -0.42 0.54 0.25 0.80

Chaves, 2017 -0.08 -0.47 0.32 -0.37 0.71

Cohn, 2014 0.34 -0.27 0.95 1.10 0.27

Cullen, 2015 0.48 -0.42 1.38 1.04 0.30

Dowlatabadi, 2016 1.10 0.38 1.81 3.00 0.00

Drodz, 2014, study 2 0.03 -0.44 0.51 0.13 0.90

Guo, 2016 2.45 1.86 3.05 8.10 0.00

Huffman, 2011 0.06 -0.87 1.00 0.13 0.89

Ivtzan, 2016 0.74 0.40 1.07 4.34 0.00

Joutsenniemi, 2014 -0.01 -0.14 0.13 -0.12 0.90

Kahler, 2015 -0.17 -0.67 0.34 -0.65 0.52

Khayatan, 2014 1.20 0.44 1.96 3.10 0.00

Mülller, 2016 -0.04 -0.48 0.41 -0.16 0.87

Nikrahan, 2016 -0.05 -0.65 0.55 -0.17 0.86

Peters, 2017 -0.08 -0.38 0.23 -0.50 0.62

Roepke, 2015 0.31 0.02 0.59 2.12 0.03

Sanjuan, 2016 -0.21 -0.62 0.19 -1.02 0.31

Schueller, 2012 0.04 -0.17 0.25 0.36 0.72

Schotanus-Dijkstra, 2017 0.42 0.19 0.66 3.48 0.00

Seligman, 2006, study 1 0.47 -0.15 1.08 1.48 0.14

Seligman, 2006, study 2 1.40 0.45 2.35 2.89 0.00

Uliaszek, 2016 -0.22 -0.90 0.45 -0.66 0.51

0.32 0.13 0.51 3.25 0.00

-2.00 -1.00 0.00 1.00 2.00

Favours control Favours MPPI

Meta Analysis

81

Subgroup analyses

For subjective well-being, psychological well-being and stress, significant higher

effect sizes were found for studies from non-Western countries compared to

studies from Western countries. For psychological well-being and stress,

significant higher effect sizes were found for studies with a non-active control

group compared to studies with an active control group. For stress, effects sizes

were significantly higher for studies of medium quality than for studies of low

quality. All outcomes of the subgroup analyses are shown in Table 4.

Meta-regression analyses

We performed meta-regression analyses only for those outcome measures with

at least 10 comparisons (subjective well-being, psychological well-being and

depression). Results demonstrated that the effect sizes were moderated by study

quality. The slope was significant for subjective well-being (-0.16, Z = -2.34, p = -

0.020), psychological well-being (-0.12, Z = -2.20, p = 0.028) and depression (-

0.13, Z = -2.20, p = 0.028), indicating that the effect sizes were lower for the

studies with a higher quality rating.

Publication bias

The possibility of publication bias was also solely determined for subjective well-

being, psychological well-being and depression because of the small number of

studies included for anxiety and stress. We found some indications of publication

bias, but the results were not conclusive. The funnel plots for subjective well-

being and depression were somewhat asymmetrical, with a few more smaller

studies showing a negative outcome. However, the fail-safe numbers were higher

for subjective well-being (667), psychological well-being (222) and depression

(218) than required (150, 95 and 135 respectively).

82

Table 4. Subgroup analyses, including outliers

Outcome Criteria Value N Hedges’ g

(95% CI) I2 Z

Subjective Population Clinical 17 0.41 0.08 –0.74 86.39 2.45 *

Well-being Non-clinical 11 0.52 0.28 – 0.68 78.89 4.00***

Intervention PPI 26 0.46 0.23 – 0.69 84.61 3.96

*** PPI + other 2 0.42 -0.02 – 0.86 75.34 1.88 ns

Delivery Group 14 0.75 0.36 – 1.13 84.68 3.79

*** Individual 2 0.39 -0.22 – 0.99 0.00 1.26 ns

Self-help 12 0.22 -0.01 – 0.44 80.18 1.90 ns

Control Active 11 0.27 -0.06 – 0.60 74.23 1.61 ns

Non-active 17 0.56 0.30 - 0.81 85.36 4.30

*** Duration ≤ 8 weeks 19 0.32 0.11 – 0.54 74.19 2.97 **

> 8 weeks 9 0.73 0.29 – 0.59 76.09 3.24**

Quality High 5 0.18 -0.12 – 0.48 75.62 1.16 ns

Medium 12 0.38 0.04 – 0.73 89.28 2.21 *

Low 11 0.76 0.35 – 1.18 74.69 3.58

*** Region Western 21 0.29 0.07 – 0.51 83.81 2.62 *

Non-Western 7 1.13 0.62 – 1.64 71.47 4.34

***

Psychological Population Clinical 3 0.35 0.10 – 0.59 0.00 2.73 **

Well-being Non-clinical 14 0.38 0.14 – 0.62 81.55 3.05 **

Intervention PPI 13 0.42 0.18 – 0.67 80.71 3.44 **

PPI + other 4 0.35 0.10 – 0.60 59.05 2.72 **

Delivery Group 9 0.38 0.10 – 0.65 60.25 2.70 **

Individual 1 0.83 -0.05 – 1.71 0.00 1.84 ns

Self-help 7 0.34 0.09 – 0.60 86.89 2.63 **

Control Active 7 0.12 -0.05 – 0.29 47.50 1.35 ns

Non-active 10 0.54 0.29 – 0.80 75.66 4.16

*** Duration ≤ 8 weeks 9 0.55 0.29 – 0.81 73.04 4.13

*** > 8 weeks 8 0.18 -0.06 – 0.42 75.42 1.50 ns

Quality High 2 0.29 -0.36 – 0.94 95.45 0.88 ns

Medium 9 0.21 0.05 – 0.38 44.87 2.55 *

Low 6 0.73 0.32 – 1.13 67.00 3.54

*** Region Western 13 0.26 0.10 – 0.43 70.92 3.13**

Non-Western 4 0.88 0.42 – 1.33 49.12 3.79***

83

Depression Population Clinical 18 0.21 0.01 – 0.40 57.96 2.10 *

Non-clinical 7 0.52 0.11 – 0.93 92.72 2.49 *

Intervention PPI 22 0.32 0.11 – 0.53 80.83 2.96

*** PPI + other 3 0.35 -0.10 – 0.79 73.75 1.53 ns

Delivery Group 14 0.40 0.04 – 0.77 84.76 2.15 *

Individual 2 0.93 0.02 – 1.83 47.75 2.01 *

Self-help 9 0.14 -0.03 – 0.31 62.35 1.65 ns

Control Active 15 0.30 0.00 – 0.60 84.04 1.97 *

Non-active 9 0.34 0.12 – 0.57 68.07 3.02

***

Duration ≤ 8 weeks 16 0.39 0.11 – 0.66 83.01 2.74 **

> 8 weeks 9 0.16 -0.07 – 0.40 63.67 1.37 ns

Quality High 5 0.05 -0.07 – 0.16 12.10 0.78 ns

Medium 10 0.17 -0.06 – 0.40 65.40 1.47 ns

Low 10 0.70 0.13 – 1.28 85.67 2.40*

Region Western 19 0.16 0.02 – 0.30 58.56 2.22 *

Non-Western 6 0.85 -0.02 – 1.72 89.45 1.92 ns

Anxiety Population Clinical 5 0.21 0.03 – 0.39 0.00 2.34 *

Non-clinical 2 0.38 -0.24 – 0.99 68.60 1.20 ns

Intervention PPI 6 0.29 0.03 – 0.54 46.63 2.20 *

PPI + other 1 0.29 0.00 – 0.57 0.00 1.99 *

Delivery Group 3 0.10 -0.22 – 0.43 0.00 0.63 ns

Individual 1 0.16 -0.70 – 1.02 0.00 0.36 ns

Self-help 3 0.38 0.10 – 0.65 66.17 2.69 **

Control Active 5 0.14 -0.07 – 0.36 0.00 1.31 ns

Non-active 2 0.47 0.14 – 0.79 67.39 2.79 **

Duration ≤ 8 weeks 4 0.24 0.05 – 0.44 0.00 2.42 *

> 8 weeks 3 0.29 -0.16 – 0.73 72.13 1.25 ns

Quality High 2 0.47 0.14 – 0.79 67.39 2.79 **

Medium 4 0.13 -0.09 – 0.34 0.00 1.11 ns

Low 1 0.49 -0.46 – 1.44 0.00 1.01 ns

Stress Population Clinical 3 - 0.24 -1.14 – 0.66 73.26 -0.53 ns

Non-clinical 4 0.59 0.25 – 0.92 48.50 3.43 **

Intervention PPI 5 0.03 -0.53 – 0.59 73.46 0.10 ns

PPI + other 2 0.75 0.39 – 1.11 12.85 4.08

***

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Stress Delivery Group 3 -0.05 -1.30 – 1.19 85.26 -0.08 ns

Individual 1 -0.07 -0.79 – 0.93 0.00 0.16 ns

Self-help 3 0.60 0.37 – 0.82 0.00 5.23

*** Control Active 4 -0.17 -0.77 – 0.43 59.89 -0.57 ns

Non-active 3 0.69 0.46 – 0.92 0 5.84***

Duration ≤ 8 weeks 4 0.65 0.41 – 0.88 4.61 5.45

*** > 8 weeks 3 -0.27 -1.09 – 0.54 72.72 -0.66 ns

Quality Medium 6 0.50 0.23 – 0.78 0.00 3.60

*** Low 1 -1.28 -2.25 – -0.31 36.74 -2.57 *

Region Western 6 0.50 0.23 – 0.78 0.00 3.60

*** Non-Western 1 -1.28 -2.25 – -0.31 36.74 -2.57 *

* 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" )

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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

Anxiety: BAI: Beck Anxiety Inventory; DASS-21: Depression Anxiety Stress Scales; HADS-A: Hospital Anxiety and Depression Scale, anxiety; SCL-90R: Symptom Checklist-90 Revised; STAI: State-Trait Anxiety Inventory

Stress: DASS-21: Depression Anxiety Stress Scale; DTS: Distress Tolerance Scale; PSS- Perceived Stress Scale; SUDS: Subjective Units of Distress scale; SWSS: Stress Warning Signals Scale

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Chapter 4

The Efficacy of Positive Psychology

Interventions from non-Western

countries: A Systematic Review and

Meta-analysis

This chapter is published as:

Hendriks, T., Hassankhan, A., Schotanus-Dijkstra, M., Graafsma, T., Bohlmeijer,

E.T., & de Jong, J. (2018). The efficacy of non-Western positive psychology

interventions: A systematic review and meta-analysis. International Journal of

Wellbeing, 8(1), 71-98.

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Abstract

Recently, there has been a sharp increase in the number of studies of positive

psychology interventions (PPIs) from non-Western countries. The aim of this

study is to review and evaluate the efficacy of these PPIs. Databases, including

PubMed, PsycINFO, and Scopus, were searched up to December 2017. In

addition, we performed hand searches and reference checks. After removal of

duplicates, 7,516 studies were screened and finally 28 randomized controlled

trials (RCTs) were included in the meta-analysis. A random effects model was

used to compare group effect-sizes at post-test. Results showed that PPIs from

non-Western countries have a moderate effect on subjective well-being (g = 0.48)

and psychological well-being (g = 0.40), and a large effect on depression (g = 0.62)

and anxiety (g = 0.95). However, caution is warranted for the interpretation of

the effect sizes in light of the study quality, which was assessed as low. This

indicates the possibility of biases, which may explain why PPIs from non-Western

countries report larger effect sizes than PPIs from Western countries.

Introduction

In the past decade, there has been a rapidly growing number of studies

investigating the effects of positive psychology interventions (PPIs) (Rusk &

Waters, 2013). To date, it appears that consensus on the definition of PPIs has

not yet been reached. Sin and Lyubomirsky (2009) introduced a broad definition,

defining PPIs as all interventions that are aimed at increasing positive feelings,

behaviors, and cognitions. Narrower definitions were suggested by Bolier et al.

(2013), who added that these interventions should have been explicitly

developed in line with the theoretical tradition of positive psychology, and Parks

and Biswas-Diener, who suggested that an intervention can only be regarded as a

PPI if sufficient empirical evidence exists suggesting significant effects for the

intervention (Parks & Biswas-Diener, 2013). Schueller and Parks (2014) argued

that in addition to the (positive) aim of an intervention, the pathways through

which the interventions operate is a second essential component in deciding if an

intervention can be considered as a PPI. They identified the following five

pathways: (1) savoring (intensifying and prolonging momentary pleasurable

experiences), (2) expressing gratitude (through reflection and activities of

expression), (3) engaging in acts of kindness, (4) promoting positive relationships,

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and (5) promoting meaning and purpose. More recently, Shin and Lyobomirsky

(2017) used the term “positive activity interventions” instead of PPIs, and the

term “positive interventions” is also used (Gander, Proyer, Ruch & Wyss, 2013;

Rashid, 2009). We define positive psychology interventions (PPIs) as interventions

aiming at increasing positive feelings, behaviors and cognitions and using

pathways or strategies to increase well-being based on theories and empirical

research, following Schueller and Parks (Schueller & Parks, 2014; Schueller,

Kashdan, & Parks, 2014).

The growth of the scientific output from scholars in the field of positive

psychology is not only limited to publications from Western countries; since 2012,

there has also been a strong increase in the number of studies originating from

non-Western countries (Hendriks et al., 2018b). Previously published meta-

analyses of randomized controlled trials have examined the overall effects of

PPIs. A meta-analysis by Bolier et al. (2013) that included 39 trials reported small

effect sizes for subjective well-being, psychological well-being, and depression.

More recently, the authors of the current meta-analysis also examined the effects

of 37 multi-component PPI (MPPIs) programs containing at least three positive

psychology activities (Hendriks et al., 2018b). This meta-analysis found a

moderate effect size for subjective well-being, a small to moderate effect size for

psychological well-being, and a small effect for depression and anxiety. In

addition, this study showed that the region of origin of the studies was a strong

and significant moderator. More precisely, PPIs from non-Western countries had

substantially larger effects than PPIs from Western countries. For example, the

effect size for subjective well-being was large (g = 1.13) for non-Western studies,

compared to small (g = 0.29) for studies from Western countries. Effect sizes for

psychological well-being and depression also showed substantial differences.

Effect sizes for non-Western studies were three to five times larger than the

effect sizes for studies from Western countries. The difference was mainly

attributed to the overall lower quality of non-Western studies. It should be noted

that, following Gosling, Sandy, John, and Potter (2010), North America, Western

Europe, Australia, Israel, and New Zealand were classified as Western countries. A

risk of bias analysis was conducted to assess the quality of the studies. Findings

from this analysis demonstrated that the average quality of studies from Western

countries was moderate, whereas the average quality of studies from non-

Western countries was low (Hendriks et al., 2018b). For example, from the eight

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non-Western studies, only one used an intention-to-treat analysis for the

statistical data, in only one study assessment was blinded, none described the

process of randomization (sequence generation) or the allocation of participants,

and all studies had fewer than 50 participants per condition.

Present study

Since only multi-component PPIs were include in the aforementioned meta-

analysis (Hendriks et al., 2018b), findings on the efficacy of studies from non-

Western countries were based on a relatively small number of studies (nine out

of 37 RCTs). In this meta-analysis, RCTs of single component, as well as multi-

component PPIs from non-Western countries will be compared to interventions

performed in Western countries. The characteristics of the studies, including

study quality, will also be examined, to attempt to explain differences in effect

sizes.

Method

The Preferred Reporting Items for Systematic Reviews and Meta-Analyses

(PRISMA) guidelines (Moher et al., 2010; Moher, Liberati, Teztlaff, & Altman,

2009) and the recommendations of the Cochrane Back Review group (Higgins et

al., 2011) were followed in the planning and the implementation of the meta-

analysis. No protocol was registered.

Search strategy

A systematic literature search was conducted by the first author (TH) and second

author (MS) in the following databases: PubMed, PsycINFO, and Scopus, from

1998 through 2017. PubMed and PsycINFO are recommended as databases to be

used in meta-analyses in mental health research (Cuijpers, 2016). We did not

include the Cochrane Central Register of Controlled Trials, since that database

does not allow export of citations, which complicates the screening process.

Instead, we selected Scopus, another often used database for systematic reviews

and meta-analyses (Davis, Mengersen, Bennett, & Mazerolle, 2014). The search

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was conducted by the first and third author (TH, AH), and the last run was

conducted on December, 8, 2017. Databases were searched with the following

terms: "positive 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*”. Search strings were

adapted according to the database (see Appendix 1). The reference lists of three

meta-analyses (Bolier et al., 2013; Chakhssi, Kraiss, Sommers-Spijkerman, &

Bohlmeijer, 2018; Dickens, 2017) and seven review articles on PPIs (Casellas-Grau,

Font, & Vives, 2014; Ghosh & Deb, 2016; Macaskill, 2016; Rashid, 2015; Sutipan,

Intarakamhang, & Macaskill, 2016; Walsh, Cassidy, & Priebe, 2016; Woodworth,

O-Brien-Malone, Diamond, & Schuz, 2016) were also checked. In addition, a hand

search through the websites of three known non-Western journals in the field of

positive psychology was conducted, namely, the websites of the Indian Journal of

Positive Psychology, the Iranian Journal of Positive Psychology, and the Middle

East Journal of Positive Psychology. Preliminary findings of a study that was

recently conducted by the authors of this meta-analysis (Hendriks et al., 2017)

were also included.

Selection of studies

After removal of duplicates, we screened titles and abstracts. Full texts of

potentially relevant articles were fully assessed. This was done by the first (TH)

and third (AH) author independently. Studies were included based on the

following criteria: (1) randomized controlled trials; (2) conducted in non-Western

countries; (3) administered to healthy adults or adults in clinical populations; (4)

published in peer reviewed journals, in the English language; (5) validated

outcome measures were used to examine the effects on subjective and

psychological well-being, depression, or anxiety. We excluded studies that: (1) did

not provide sufficient data to calculate post-test effect sizes per condition; (2)

were published in book chapters, dissertations, and studies in grey literature; (3)

reported effects of mindfulness-based therapies, Acceptance and Commitment

Therapy, and Compassion Focused Therapy, considering the vast number of

meta-analyses on these interventions that have been published in the past

decade.

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Data extraction

The following data was gathered: author(s), year of publication, country of origin,

study design, sample description, intervention type, delivery mode, 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, and the questionnaires that measured subjective

well-being, psychological well-being, depression or anxiety. Means and standard

deviations at post-test were extracted. In the case of insufficient data or unclear

reporting in the studies, we contacted the authors through e-mail.

Quality assessment

The quality of the studies was independently assessed by the first (TH) and third

(AH) author, using the Cochrane Collaboration’s tool for assessing risk of bias in

randomized trials (Higgins et al., 2011). The following six criteria were assessed:

random sequence generation, allocation concealment, blinding of participants

and personnel, description of drop-outs, power analysis, and intention-to-treat

analysis or no drop-outs. One point was appointed for each criterion that was

met, as described in the studies. According to this assessment tool, the quality of

a study was assessed as “high” when five or six criteria were met, “moderate”

when three or four criteria were met, and “low” when fewer than three criteria

were met. Disagreements between the first (TH) and third (AH) author were

discussed until consensus was reached. If any disagreement persisted, the second

author (MS) or fifth author (EB) were consulted.

Data analysis

Data analysis was conducted with the program Comprehensive Meta-Analysis

(CMA, version 3.3.070, Biostat, Inc.). Means, standard deviations, and sample

sizes for each study were used to calculate the effect sizes. For each comparison

between a PPI and a control group, we calculated the Hedges' adjusted g because

Hedges' g is more accurate than Cohen's d when sample sizes of the studies are

small (Cuijpers, 2016). Effect sizes indicate the difference between the two

groups at post-test and 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 of the two groups. Effect

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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). If more

than one measure was used for a similar outcome, we pooled the means and the

standard deviations, so that each study outcome had one effect size (Thalheimer

& Cook, 2002). If more than one experimental group was compared to another

active control group and a non-active control condition in a particular study, we

used data from the active control group. Standardized mean differences (SMD)

with 95% confidence intervals (CI) were calculated as the differences in means

between groups divided by the pooled standard deviation using Hedges’ g. A

positive SMD was defined as an indicator of beneficial effects for the PPI

compared with the control condition. Intention-to-treat samples were used if

possible. For the calculation of effect sizes for subjective well-being, we used

instruments that explicitly indicated that they measured emotional well-being, as

defined by Keyes (2007). These were the Mental Health Short Form - subjective

well-being subscale (Keyes, 2005), the Oxford Happiness Inventory (Hills & Argyle,

2002), the WHOQOL-BREF Psychological Health Scale (WhoqolGroup, 1998), the

Subjective Happiness Scale (Lyubomirsky & Lepper, 1999), the Subjective Well-

being Questionnaire (Molavi, Torkan, Soltani, & Palahang, 2010), the Life

Satisfaction Index/Scale (Adams, 1969), the Satisfaction with Life Scale (Diener,

Emmons, Larsen, & Griffin, 1985), the Enright Forgiveness Inventory - positive

affect subscale (Enright & Rique, 2004), the Index of Well-Being & Index of

General Affect (Campbell, Converse, & Rodgers, 1976), the Multiple Mood Scale -

positive emotions (Terasaki, Kishimoto, & Koga, 1992), the Positive and Negative

Affect Schedule, and the Scale of Positive and Negative Experience (Watson,

Clark, & Tellegen, 1988). For psychological well-being, we used instruments that

explicitly measured psychological well-being, as defined by Keyes (2007). These

were the Flourishing Scale (Diener et al., 2010), the Mental Health Short Form -

psychological well-being subscale (Keyes, 2005), Well-being/Ill-being Scale

(Kitwood & Bredin, 1997), the Ego Resilience Scale (Block & Kremen, 1996), the

Self Compassion Scale (Neff, 2003), the Symptom Checklist-90 Revised - inverted

score (Derogatis & Unger, 2010), and two unnamed scales measuring

empowerment and organizational commitment (Im, Cho, Kim & Heo, 2016)). For

depression and anxiety, we used instruments that explicitly measured depression

and anxiety. These were the Beck Depression Index (Beck, Steer, & Brown, 1996),

the Center for Epidemiological Studies - Depression Scale (Andresen, Malmgren,

Carter, & Patrick, 1994), the Depression Anxiety Stress Scale (Lovibond &

Lovibond, 1995), the Geriatric Depression Scale (Lee, Chiu, & Kwong, 1994), the

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Beck Anxiety Inventory (Beck & Steer, 1990), Death Anxiety Scale (Templer,

1970), and the State-Trait Anxiety Inventory (Spielberger, 2010). If more than one

measure for a specific outcome was reported, a variance-weighted average of

effect sizes from the scales within each study was used to calculate one effect size

(Marín-Martínez & Sánchez-Meca, 1999). When follow-up data was available,

between-group effect sizes (Hedges’ g) at these time points were calculated.

Heterogeneity

Statistical heterogeneity between studies was tested using the I2 statistic. This is

a measure that indicates study-to-study dispersion due to real differences, over

and above random sampling error (Higgins & Thompson, 2002). A randomized

effects model with a 95% confidence interval and a two-tailed test were

performed for the heterogeneity analyses. The I2 statistic was used to estimate

the percentage of heterogeneity across the studies not attributable to random

sampling error alone. A value of 0% indicated no heterogeneity. Values of 75%,

50% and 25% reflected high, moderate, and low 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. All studies were included,

outliers were not removed.

Subgroup analyses

Explanatory subgroup analyses were conducted to examine moderating effects of

seven possible moderators. These moderators were: (1) study population: clinical

or non-clinical; (2) mode of delivery of the PPI: group or self-help; (3) intervention

type: single component or multi-component; (4) type of control group:

active/placebo or non-active/waitlist; (5) duration of the intervention: ≤ 8 weeks

or > 8 weeks; (6) cultural adaptation of the PPI: yes or no; (7) quality rating of the

study: low, moderate, or high.

Publication bias

Publication bias was assessed in the following ways. First, a funnel plot was

created by plotting the overall mean effect size against study size. Absence of

publication bias is present when there is a symmetrical distribution of studies

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around the effect size (Sterne, Egger, & Moher, 2008). Second, a fail-safe N was

calculated for each analysis to test the asymmetry of each funnel plot. The fail-

safe N indicates the number of unpublished non-significant studies that would be

required to lower the overall effect size below significance (Egger, Smith,

Schneider, & Minder, 1997; Orwin, 1983). Findings were considered robust if the

fail-safe N ≥ 5k + 10, where k is the number of studies (Rosenberg, 2005). Third,

the Trim and Fill method (Duval & Tweedie, 2000) was used. This procedure

imputes the effect sizes of missing studies and produces an adjusted effect size

accounting for the missing studies.

Results

Study selection

We identified a total of 8,172 records. After removal of duplicates, 7,516 records

remained. These records were screened, after which 372 records remained.

These articles were assessed for eligibility, and finally 28 studies were included in

the meta-analysis, which were published in 29 articles. The complete selection

process is shown in Figure 1.

Study characteristics

The RCTs were published between 2012 and December 2017. Seven studies (25%)

were conducted among clinical populations and 21 studies (75%) among non-

clinical populations. Delivery modes were group based (n = 21, 75%) and self-help

(n = 7, 25%). Eleven studies (39%) had an active control group and 17 studies

(61%) had a non-active control group (waiting-list, n = 1; no intervention, n = 16).

The studies included a total of 3,009 participants. Sample sizes from the

intervention groups ranged from nine to 828, with a mean of 25.7 participants

(excluding the cluster randomized controlled trial). Fourteen studies (50%) had

fewer than 20 participants in the intervention group, ten (36%) had between 20-

40 participants in the intervention group, three (11%) had between 40-60

106

Figure 1. Results of literature search

participants in the intervention group, and there was one (4%) cluster

randomized controlled trial with 828 participants in the intervention group.

Twelve (43%) studies were from China (five from mainland China, seven from

Hong Kong), six (21%) from Iran, three (11%) from Taiwan, two (7%) from Japan,

two (7%) from South Korea, and Malaysia, Suriname, and Turkey each accounted

for one study. One of the self-help-based interventions was an online

intervention. Twenty-five studies reported the percentage of female participants,

which was 67% (n = 2,010). Excluding one cluster randomized controlled trial

lowered the percentage of female participants to 61% (n = 1,817). Twenty-one

studies measured subjective well-being (SWB), eight studies measured

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

First author/ year/country

Sample Intervention Delivery Control group

Sessions, duration

FU

N (post)

Mean age /SD

% fem.

RR (post)

Outcome measures

Al-Seheel, 2016, Iran

Students Gratitude, Islamic-based

Self-help PPI + Placebo

2w - Ne=19 Nc1=20 Nc2=21

21.9 (1.2)

85% Nt=95% SWB: SPANE, SWLS

Arimitsu, 2016, Japan

Healthy adults Self- compassion

Group WL 7, 7w 3m Ne=16 Nc=12

23.3 85% Ne=80% Nc=60%

SWB: MMS, PWB: SCS; Dep: BDI, Anx: STAI

Asgharipoor, 2012, Iran

Patients with depression

PPT Group CBT 6, 12w - Ne=9 Nc=9

26.4 (5.9)

72% Ne=100% Nc=100%

SWB: OHI; PWB: SWS-PWB sub Dep: BDI

Asl, 2014, 2016, Iran

Infertile women

PPT Group WL 6, 6w - Ne=15 Nc=16

30.5 (5.7)

100% Ne=83% Nc=89%

SWB: OHI Dep: BDI

Chan, 2013, China, HK

Students Counting blessings

Self-help Placebo 1, 8w - Ne=40 Nc=41

33.7 (7.2)

81% Nt=97% SWB: SWLS

Cheng, 2015, China, HK

Healthy adults Gratitude Self-help Placebo 4w 3m Ne=34 Nc1=34

- 55% Dep: CES-D

Chiang, 2008, Taiwan

Elderly Life review Group WL 8, 8w - Ne=36 Nc=39

78.1 (3.7)

100% Nt=71% SWB: LISA

Chiang, 2010, Taiwan

Elderly Reminiscence Group WL

8, 8w 3m Ne=45 Nc=47

77.2 (4.0)

100% Nt=75% PWB: SCL-90R Dep: BDI

10

8

09

99

99

99

99

99

99

99

99

99

99

99

99

pp

pp

p

Choy, 2016, China, HK

Elderly Reminiscence Group WL 6, 6w 6w Ne=39 Nc=42

78.0 (7.1)

67% Ne=85% Nc=62%

SWB: LSS Dep: GDS

Deng, 2016, China

Healthy adults Gratitude Group NI 5w - Ne=36 Nc=29

35.7 (9.4)

0% _ SWB: SWBQ

Dowlatabadi, 2016, Iran

Women with breast cancer

PPT Group NI 10, 10w - Ne=17 Nt=17

36.6 (5.5)

100% Ne=76% Nc=81%

SWB: OHI Dep: BDI

Guo, 2016, China, HK

Students PPT Group NI 8, 8w 3m

Ne=34 Nc=42

20.4 (1.2)

95% Ne=81% Nc=98%

Dep: BDI

Hendriks, 2017, Suriname

Healthy adults MPPI Group WL 7,7w - Ne=80 Nc=78

36.3 (9.6)

60% Ne=91% Nc=91%

SWB, PWB: MHSF Dep, Anx, Stress: DASS-21 Ho, 2016,

China, HK* Healthy families MPPI Group +

Self-help Placebo 2, 4w 12w Ne1=828

Ne2=433

- 75% Ne=71% Nc=83%

SWB: SHS

Hwang, 2016, China

Student PPT Group NI 10, 5w 4m Ne=8 Nc1=8 Nc2=8

22.7 (2.3)

67% Ne=72% Nc1/2 = 80.0%

SWB: SPANE PWB: FS

Im, 2016, Korea

Nurses MPPI Group NI 4, 9w - Ne=25 Nc=24

25.6 (2.7)

82% Ne=100% Nc=96%

PWB: ERS

Ji, 2016, China

Students Forgiveness Group WL 10, 10w Ne=16 Nc=12

20.2 (1.4)

89% Nt=78% SWB: EFI Anx: STAI

Khayatan, 2014, Iran

Women with MS

PPT Group NI

6, 6w Ne=15 Nc=15

31.1 (6.5)

100% Ne=100% Nc=100%

Dep: BDI

10

9

09

99

99

99

99

99

99

99

99

99

99

99

99

pp

pp

p

Koydemir, 2015, Turkey

Students Strength-based intervention

Self-help (online)

WL 5, 8w Ne=44 Nc=36

18.7 (1.0)

48% - SWB: SHS, SWLS, PHS

Lai, 2004, China Elderly Reminiscence Group Active control

6, 6w 6w Ne=36 Nc1=30

85.6 (7.0)

68% Nt=85% PWB: WIB

Lau, 2011, China Elderly Gratitude Group Active control + NI

1 Ne=29 Nc1=25 Nc2=29

62.5 (7.1)

60% - ANX: Das

Lü, 2013, China Students MPPI Group NI 8, 8w Ne=16 Nc=18

20.0 (4.3)

57% Ne=84% Nc=100%

SWB: PANAS

Nikrahan, 2016, Iran

Healthy adults MPPI Group 3 x PPI, WL 6, 6w 15w Ne1=13 Ne2=13 Ne3=15 Nc = 14

56.6 (8.7)

24% Nt=100% SWB: OHI Dep: BDI

Otsuka, 2012, Japan

Healthy adults Gratitude Self-help Placebo 4w 1m Ne=19 Nc=19

48.5 (5.1)

28% Nt=50% SWB: SHS

Wong, 2016, China

Students Self-compassion writing

Self-help Placebo 3d, -, 3m

Ne=33 Nc=32

20.5 (1.4)

54% Nt=100% Dep: CES-D

Wu, 2016, Taiwan

Patients with dementia

Spiritual reminiscence

Group NI 6,6 w Ne=50 Nc=53

73.6 (7.4)

69% Ne=100% Nc=94%

SWB: LISA

Yousefi, 2015, Iran

Elderly women Reminiscence Group Active control

6, 3w 1m Ne=14 Nc=14

65.2 (6.4)

100% Ne=93% Nc=88%

SWB: OHQ

Zhang, 2014, China

Students Forgiveness Group NL

1 4w Ne=10 Nc1=11

22.1 (1.0)

100% Nt=100% SWB: IWB/IGA Dep: BDI; Anx: BAI

* CRCT: cluster randomized controlled trial;

110

Abbreviations:

% fem: percentage of females; FU: Follow- up

HK: Hong Kong; NI: No intervention; RCT: randomized controlled trial; RR (post): Retention rate at post-test;

MPPI: multicomponent positive psychology intervention; PPT: positive psychotherapy; WL: Wait-list control

group

Subjective well-being - EFI: Enright Forgiveness Inventory - positive affect subscale; IWB/IGA: Index of Well-

Being & Index of General Affect; LSS: Life Satisfaction Scale; LISA: Life Satisfaction Index; MHC-SF: Mental

Health Continuum Short Form - subjective well-being subscale; MMS: Multiple Mood Scale; OHI: Oxford

Happiness Index; OHQ: Oxford Happiness Questionnaire; PANAS: Positive and Negative Affect Schedule;

PHS: WHOQOL-BREF Psychological Health Scale; SHS: Subjective Happiness Scale; SPANE: Scale of Positive

and Negative Experience; SWBQ: Subjective Well-being Questionnaire; SWLS: Satisfaction With Life Scale;

SWS: Subjective Well-being Scale

Psychological well-being - ERS: Ego Resilience Scale FS; Flourishing Scale; MHC-SF: Mental Health

Continuum Short Form - psychological well-being subscale; SCL-90R: Symptom Checklist-90 Revised

(inverted score); SCS: Self Compassion Scale; SWS: Subjective Well-being Scale; pwb subscale; WIB: Well-

being/Ill-being Scale

Depression - BDI: Beck Depression Index; CES-D: Center for Epidemiological Studies - Depression Scale;

DASS-21: Depression Anxiety Stress Scale; GDS-15: Geriatric Depression Scale

Anxiety - BAI: Beck Anxiety Inventory; DAS: Death Anxiety Scale; DASS-21: Depression Anxiety Stress

Scales; STAI: State- Trait Anxiety Inventory

Quality assessment

In total, the six quality criteria were assessed for 28 studies. The lowest score was

0 (five studies), the highest score was 6 (two studies). The overall study quality

was low, with a mean score of 1.79 (SD = 1.67). Three studies (11%) were rated

with a high quality, two (7%) with a moderate quality, and 23 (82%) with a low

quality. The description of the method that was used to generate the allocation

sequence (sequence generation) was reported in 10 studies (36%). Description of

the method used to conceal the allocation sequence (allocation concealment)

was reported in only five studies (18%). Blinding of main outcome assessment

was described in only three studies (11%). In 19 studies (68%) it was clearly

described how many drop-outs there were during the intervention period. A

power-analysis was conducted in seven studies (25%). Five studies (18%) used an

intention-to-treat analysis, and one study (4%) reported zero drop-outs. The

outcome of the quality assessment is shown in Table 2.

111

Table 2. Quality assessment of RCTs on PPIs in non-Western countries

Studies SG AC BOA DDO PA ITT Total Score

Quality Rating

Al-Seheel, 2016 0 0 0 1 0 1 2 Low Arimitsu, 2016 0 0 0 1 0 0 1 Low Asgharipoor, 2012 0 0 0 0 0 0 0 Low Asl, 2014, 2016 0 0 0 1 0 0 1 Low Chan, 2013 0 0 1 1 0 0 2 Low Cheng, 2015 1 1 1 1 1 1 6 High Chiang, 2008 1 0 0 0 0 0 1 Low Chiang, 2010 1 0 0 1 0 0 2 Low Choy, 2015 0 0 0 0 0 1 1 Low Deng, 2016 0 0 0 0 0 0 0 Low Dowlatabadi, 2016 0 0 0 1 0 0 1 Low Guo, 2016 0 0 0 1 1 0 2 Low Hendriks, 2017 1 1 1 1 1 1 6 High

Ho, 2016 1 1 0 1 1 1 5 High

Hwang, 2016 1 0 0 1 0 0 2 Low

Im, 2016 1 0 0 1 1 0 3 Moderate

Ji, 2016 0 0 0 1 0 0 1 Low

Khayatan, 2014 0 0 0 0 0 0 0 Low

Koydemir, 2015 0 0 0 0 0 0 0 Low

Lai, 2004 0 0 0 1 0 1 2 Low Lau, 2011 0 0 0 0 1 0 1 Low Lü, 2013 0 0 0 1 0 0 1 Low

Nikrahan, 2016 1 1 0 1 0 1 4 Moderate

Otsuka, 2006 0 0 0 1 0 0 1 Low

Wong, 2016 0 1 0 1 0 0 2 Low

Wu, 2016 1 0 0 0 0 0 1 Low

Yousefi, 2015 1 0 0 1 0 0 2 Low Zhang, 2014 0 0 0 0 0 0 0 Low

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

Outcome measures N Hedges ' g

95%CI Z Heterogeneity Q value I2

Fail-safe N

All studies post-treatment

SWB 21 0.48 (0.24 - 0.72) 3.97*** 103.60*** 80.69

272

PWB 8 0.40 (-0.03 - 0.83) 1.81** 35.26*** 80.15

29

Depression 13 0.62 (0.19 - 1.05) 2.81** 94.87*** 87.35

202

Anxiety 5 0.95 (0.28 - 1.61) 2.77** 22.95*** 82.57

41

Studies post-treatment, excl. outliers

SWB 17 0.36 (0.18 - 0.53) 4.01*** 28.69*** 44.22

-

PWB 7 0.22 (-0.05 - 0.49) 1.61ns 9.74ns 38.37

-

Depression 10 0.69 (0.38 - 0.99) 4.44*** 26.55*** 66.11

-

Follow-up effects, excl. outliers

SWB 8 0.43 (0.08 - 0.77) 2.45* 21.61** 67.60

-

Depression 7 0.77 (0.23 - 1.30) 2.82*** 38.55** 84.43

-

* p < 0.05; ** p < 0.01; *** p < 0.001; ns: non-significant Abbreviations: SWB: Subjective well-being; PWB: Psychological well-being

113

Effects on subjective well-being

For subjective well-being, a significant moderate to large effect was observed

from 21 comparisons at post-test (g = 0.48, 95% CI: 0.24 to 0.72, p < 0.001). The

effect sizes of the studies ranged from 0.34 to 2.22. Heterogeneity analysis

revealed a significant and high level of heterogeneity (I2 = 80.69, Q: 103.60, p <

0.001). Removing four outliers reduced the effect size to g = 0.36 (95% CI: 0.18 to

0.53, p < 0.001). The heterogeneity was moderate after outliers were removed

(I2= 44.22, Q = 28.69, p < 0.001), which means that there may be methodological

issues which could lead to a high risk of bias. The forest plot in Figure 2 displays

the post-treatment effects, including outliers.

Figure 2. Effects of PPIs on subjective well-being, including outliers

Effects on psychological well-being

For psychological well-being (eight comparisons), a significant moderate effect

was observed (g = 0.40, 95% CI: -0.05 to 0.83, p = 0.070) at post-treatment. Effect

sizes ranged from -0.42 to 1.50. Heterogeneity was significant and high (I2 =

80.15, Q = 35.26, p < 0.001). After excluding one outlier, significant effects were

no longer found. Figure 3 displays the post-treatment effects in a forest plot.

Study name Statistics for each study Hedges's g and 95% CI

Hedges's Standard Lower Upper g error Variance limit limit Z-Value p-Value

Al-Saheel, 2016 0.19 0.31 0.10 -0.42 0.81 0.61 0.54

Arimitsu, 2016 0.08 0.33 0.11 -0.57 0.73 0.24 0.81

Asgharipoor, 2012 1.77 0.54 0.29 0.72 2.83 3.30 0.00

Asl, 2014 0.89 0.34 0.12 0.22 1.56 2.60 0.01

Chan, 2013 0.38 0.23 0.05 -0.06 0.83 1.69 0.09

Chiang, 2008 0.81 0.24 0.06 0.34 1.27 3.38 0.00

Choy, 2015 0.15 0.22 0.05 -0.28 0.59 0.70 0.48

Deng, 2016 0.79 0.26 0.07 0.29 1.29 3.08 0.00

Dowlatabadi, 2016 1.80 0.41 0.16 1.01 2.60 4.44 0.00

Hendriks, 2017 0.37 0.16 0.03 0.06 0.69 2.35 0.02

Ho, 2016 -0.08 0.06 0.00 -0.19 0.04 -1.30 0.19

Hwang, 2016 -0.44 0.48 0.23 -1.38 0.50 -0.92 0.36

Ji, 2016 0.95 0.39 0.15 0.18 1.72 2.43 0.02

Koydemir, 2015 0.75 0.23 0.05 0.30 1.20 3.25 0.00

Lü, 2013 2.22 0.43 0.18 1.37 3.06 5.16 0.00

Nikrahan, 2013 0.31 0.31 0.09 -0.29 0.91 1.01 0.31

Otsuka, 2012 0.00 0.28 0.08 -0.56 0.56 0.01 1.00

Wong, 2016 -0.22 0.25 0.06 -0.71 0.26 -0.91 0.36

Wu, 2016 0.43 0.20 0.04 0.04 0.81 2.16 0.03

Yousefi, 2015 0.36 0.36 0.13 -0.36 1.07 0.98 0.33

Zhang, 2014 -0.37 0.43 0.19 -1.22 0.48 -0.86 0.39

0.48 0.12 0.01 0.24 0.72 3.97 0.00

-2.00 -1.00 0.00 1.00 2.00

Favours control Favours PPI

Meta Analysis

114

Figure 3. Effects of PPIs on psychological well-being, including outliers

Effects on depression

A significant large effect for depression (13 comparisons) was observed (g = 0.62,

95% CI: 0.19 to 1.05, p < 0.001) at post-treatment. Effect sizes of studies ranged

from -0.89 to 2.45. Heterogeneity was significant and high (I2 = 87.35, Q = 94.87, p

= 0.000). Removing three outliers increased the effect size (g = 0.68, 95% CI: 0.38

to 0.99, p < 0.001) and heterogeneity was significant and high (I2 = 66.11, Q =

26.55, p < 0.01). The forest plot in Figure 4 displays the post-treatment effects.

Figure 4. Effects of PPIs on depression, including outliers

Study name Statistics for each study Hedges's g and 95% CI

Hedges's Standard Lower Upper g error Variance limit limit Z-Value p-Value

Arimitsu, 2016 0.99 0.35 0.12 0.30 1.68 2.80 0.01

Asgharipoor, 2012 0.11 0.45 0.20 -0.78 0.99 0.23 0.81

Chiang, 2009 1.50 0.23 0.05 1.04 1.96 6.39 0.00

Hendriks, 2017 0.20 0.16 0.03 -0.11 0.51 1.27 0.21

Hwang, 2016 -0.42 0.48 0.23 -1.36 0.52 -0.88 0.38

Im, 2016 0.57 0.29 0.08 0.01 1.13 1.99 0.05

Lai, 2003 -0.04 0.25 0.06 -0.54 0.46 -0.15 0.88

Wong, 2016 0.03 0.25 0.06 -0.45 0.51 0.12 0.91

0.40 0.22 0.05 -0.03 0.83 1.81 0.07

-2.00 -1.00 0.00 1.00 2.00

Favours control Favours PPI

Meta Analysis

Study name Statistics for each study Hedges's g and 95% CI

Hedges's Standard Lower Upper g error Variance limit limit Z-Value p-Value

Arimitsu, 2016 0.78 0.34 0.12 0.11 1.46 2.27 0.02

Asgharipoor, 2012 -0.60 0.46 0.21 -1.50 0.30 -1.30 0.19

Asl, 2014 0.90 0.34 0.12 0.23 1.57 2.62 0.01

Cheng, 2015 0.86 0.25 0.06 0.36 1.35 3.41 0.00

Chiang, 2009 1.05 0.22 0.05 0.62 1.49 4.76 0.00

Choy, 2015 0.99 0.23 0.05 0.53 1.45 4.25 0.00

Dowlatabadi, 2016 1.10 0.37 0.13 0.38 1.81 3.00 0.00

Guo, 2016 2.45 0.30 0.09 1.86 3.05 8.10 0.00

Hendriks, 2017 0.37 0.16 0.03 0.06 0.69 2.35 0.02

Khayatan, 2014 1.20 0.39 0.15 0.44 1.96 3.10 0.00

Nikrahan, 2013 -0.05 0.31 0.09 -0.65 0.55 -0.17 0.86

Wong, 2016 -0.39 0.22 0.05 -0.83 0.05 -1.72 0.09

Zhang, 2014 -0.89 0.45 0.20 -1.77 -0.01 -1.97 0.05

0.62 0.22 0.05 0.19 1.05 2.83 0.00

-2.00 -1.00 0.00 1.00 2.00

Favours control Favours PPI

Meta Analysis

115

Effects on anxiety

Effects on anxiety were reported in five studies. A significant large effect was

observed (g = 0.93, 95% CI: 0.28 to 1.59, p = 0.006) at post-treatment. Effect sizes of

studies ranged from 0.15 to 2.54. Heterogeneity was significant and moderate (I2 =

44.22, Q = 22.95, p < 0.001). There were no outliers. The forest plot in Figure 5

displays the post-treatment effects.

Figure 5. Effects of PPIs on anxiety, including outliers

Subgroup analyses

A moderator analysis was conducted for subjective well-being and depression,

but not for psychological well-being, due to a limited amount of studies for this

outcome. Also, due to a limited amount of studies from moderate (n = 3) and high

quality (n = 2), the moderating effects of study quality were not reported. Our

analysis showed that none of the variables had a moderating effect. All outcomes

of the subgroup analyses are shown in Table 4.

Study name Statistics for each study Hedges's g and 95% CI

Hedges's Standard Lower Upper g error Variance limit limit Z-Value p-Value

Arimitsu, 2016 0.15 0.37 0.14 -0.58 0.87 0.40 0.69

Hendriks, 2017 0.33 0.16 0.03 0.02 0.65 2.10 0.04

Ji, 2016 1.79 0.44 0.19 0.93 2.66 4.06 0.00

Lau, 2011 0.58 0.26 0.07 0.06 1.09 2.18 0.03

Zhang, 2014 2.54 0.57 0.33 1.42 3.67 4.43 0.00

0.95 0.34 0.12 0.28 1.61 2.77 0.01

-2.00 -1.00 0.00 1.00 2.00

Favours control Favours PPI

Meta Analysis

116

Table 4. Results of moderator analysis

Outcome Criteria Value N Hedges’ G (95% CI) Z-Value (p-Value)

Subjective Population Clinical 6 0.88 (0.45 - 1.31) 3.99 (0.00) ***

well-being Non-clinical 15 0.32 (0.07 - 0.58) 2.50 (0.01) *

Delivery Group 16 0.64 (0.37 - 0.91) 4.65 (0.00) ***

Self-help 5 -0.01 (-0.18 - 0.16) -0.10 (0.92) ns

Intervention Single component

11 0.33 (0.10 - 0.56) 2.84 (0.00) ***

Multi component

10 0.70 (0.26 - 1.14) 3.13 (0.00) ***

Control Active 8 0.16 (-0.20 - 0.51) 0.87 (0.38) ns

Non-active 13 0.66 (0.34 - 0.97) 4.06 (0.00) ***

Duration ≤ 8 weeks 16 0.32 (0.12 - 0.52) 3.08 (0.00) **

> 8 weeks 5 1.27 (0.24 - 2.30) 2.41 (0.02) **

Adaptation Adapted 10 0.30 (-0.01 - 0.60) 1.92 (0.06) **

Not adapted 11 0.64 (0.35 - 0.94) 4.25 (0.00) ***

Depression Population Clinical 6 0.63 (0.10 - 1.16) 2.34 (0.02) *

Non-clinical 7 0.62 (-0.05 - .28) 1.82 (0.07) **

Delivery Group 11 0.70 (0.23 - 1.16) 2.93 (0.00) ***

Self-help 2 0.23 (-0.99 - 1.45) 0.37 (0.71) ns

Intervention Single component

5 0.37 (-0.32 - 1.07) 1.06 (0.29) ns

Multi component

8 0.78 (0.18 - 1.38) 2.52 (0.01) *

Control Active 4 -0.21 (-1.02 - 0.61) -0.49 (0.62) ns

Non-active 9 0.96 (0.52 - 1.41) 4.23 (0.00) ***

Depression Duration ≤ 8 weeks 10 0.79 (0.34 - 1.24) 3.43 (0.00) ***

> 8 weeks 3 0.04 (-0.97 - 1.05) 0.08 (0.94) ns

Adaptation Adapted 3 0.15 (-0.59 - 0.89) 0.41 (0.67) ns

Not adapted 10 0.76 (0.23 - 1.29) 2.81 (0.00) **

* p < 0.05; ** p < 0.01; *** p < 0.001; ns: non-significant.

117

Publication bias

For subjective well-being, the funnel plot was asymmetrically distributed in such a

way that it was skewed in favour of studies with moderate to large effect sizes.

This indicates the presence of publication bias. Egger’s regression intercept also

suggests that publication bias existed (intercept = 2.40, t = 3.72, df = 19, p =

.0001). The mean effect sizes were calculated by imputing missing studies using

the Trim and Fill method. One study was imputed and the effect size was adjusted

to g = 0.52 (95% CI: 0.28 - 0.75), meaning the effect size actually increased. Our

findings are in line with other meta-analyses on the efficacy of well-being

interventions (Bolier et al., 2013; Chakhssi et al., 2018; Weiss, Westerhof, &

Bohlmeijer, 2016), which consistently report more bias towards the publication of

positive outcomes. Publication bias findings were not reported for psychological

well-being, depression, and anxiety, due to the low numbers of studies (eight, 13,

and five respectively). Such low numbers could lead to an unreliable publication

bias analysis (Cuijpers, 2016; Lau, Ioannidis, Terrin, Schmid, & Olkin, 2006).

Follow-up effects

The follow-up effects of the PPIs were examined from four weeks after

baseline/post-test up to three months after baseline/post-test (see Table 3).

Follow-up effects for psychological well-being and anxiety could not be calculated

due to the limited amount of studies, namely four and two respectively. For

subjective well-being (eight comparisons) the effect size slightly decreased (g =

0.43, 95% CI: 0.08 - 0.77, p = 0.01). For depression (seven comparisons, after

removal of one outlier), an increased effect size (g = 0.77, 95% CI: 0.23 - 1.30, p =

0.005) was found. These findings suggest that PPI’s in non-Western countries are

also effective up to three months follow-up.

118

Discussion

This study aimed to examine the efficacy of PPIs from non-Western countries

across randomized controlled trials. Following a systematic literature search, 28

RCTs were included in the meta-analysis. A moderate effect size was found for

subjective well-being (g = 0.48) and psychological well-being (g = 0.40), and large

effect sizes for depression (g = 0.62) and anxiety (g = 0.95). After removing

outliers, the effect sizes decreased for subjective well-being (g = 0.36) and for

psychological well-being (g = 0.22), but slightly increased for depression (g =

0.69). Follow-up results showed slightly decreased effect sizes for subjective well-

being (g = 0.43) and an increased effect size for depression (g = 0.77). The overall

study quality was low. Three studies were rated with a high quality, two with a

moderate quality, and 23 with a low quality. There were also indications of

publication bias, with a bias towards the publication of studies with positive

results and with large effect sizes. Our findings on the larger effect sizes of studies

from non-Western countries are in line with a previous meta-analysis on MPPIs

(Hendriks et al., 2018b), that reported substantially larger effect sizes of PPIs from

non-Western countries on subjective well-being, psychological well-being, and

depression. The effects of PPIs on anxiety have not been reported in previous

meta-analyses, most likely because of the low number of studies reporting this

outcome. Since our meta-analysis was based on only five studies reporting on

anxiety, caution is warranted when interpreting findings on anxiety in this study.

The moderate to large effect sizes found in the current meta-analysis are also

larger than those reported in a meta-analysis on PPIs by Bolier et al. (2013), which

did not include non-Western studies. Hence, our findings indicate that the effect

size of PPIs that are conducted in non-Western countries have larger effects than

PPIs that are conducted in Western countries.

A possible explanation for the larger differences in effect sizes is the low

quality of the studies from non-Western countries. The mean score of the study

quality in this analysis was 1.79, indicating that there is a high risk of bias in the

studies and the overall study quality is rated as low. In comparison, a previous

meta-analysis of MPPIs where study quality was determined using the same

criteria revealed a mean score of 3.43 for quality of studies from Western

countries (Hendriks et al, 2018b). A high risk of bias, or low study quality, is often

associated with larger effect sizes, or vice versa. For example, a meta-analysis on

the efficacy of psychotherapy (Cuijpers, van Straten, Bohlmeijer, Hollon, &

Andersson, 2010) reported relatively smaller effect sizes in studies of higher

119

quality, compared with low-quality studies. A meta-analysis on the efficacy of

PPIs (Bolier et al., 2013) suggested that the association between high effect sizes

and lower study quality might also be applicable to PPIs . Our quality analysis

showed that RCTs of PPIs from non-Western countries often do not adequately

describe the sequence generation of randomization, or how allocation to the

intervention was concealed. Inadequate random sequence and allocation

concealment can overestimate treatment effects significantly (Armijo-Olivo et al.,

2015; Dettori, 2010). Blinding of assessors was also not described in the large

majority of the studies, which can lead to overestimation of treatment effects

(Schulz & Grimes, 2002). The found sample sizes were also small: 14 studies (50%)

had fewer than 20 participants in the intervention group, and 10 studies (36%)

had between 20 and 40 participants in the intervention group. The large majority

of the studies in this meta-analysis was underpowered, which can lead to inflated

estimates of the effect sizes (La Caze & Duffull, 2011). Only five studies used

intention-to-treat analysis (ITT), which is a statistical method where data from all

randomized participants is analyzed, regardless of their adherence. Intention-to-

treat analysis avoids an overestimation of the effects of an intervention (Gupta,

2011; Hollis & Campbell, 1999).

In addition to the methodological biases, other biases may contribute to

higher effect sizes in non-Western countries. A well-known phenomenon in

psychology is the Hawthorne effect. The awareness of being observed leads to

conformity and social desirability, which in turn leads to positive behavior

outcomes (McCambridge, Witton, & Elbourne, 2014). Research suggests that in

collectivistic societies people tend to respond in more socially desirable ways, to

maintain good relationships with others (Johnson & Van de Vijver, 2003; Lalwani,

Shavitt, & Johnson, 2006). Another aspect of the Hawthorne effect is the novelty

effect of an intervention. In studies on the effects of mobile health interventions

in Western countries, it is noted that new technologies are perceived as more

novel and having more value than traditional interventions. This novelty effect

may lead to greater enthusiasm among participants and a greater attention to a

particular intervention (Ammenwerth & Rigby, 2016; Turner-McGrievy,

Kalyanaraman, & Campbell, 2013). In non-Western countries, this effect could

also be applicable to regular psychological interventions, since access to mental

health interventions is limited (de Jong et al., 2015; Rathod et al., 2017).

120

Despite the lower study quality and the influence of possible biases that may

have contributed to overestimation of the effect sizes, the possibility that PPIs in

non-Western countries have larger effect sizes than PPIs from Western countries

simply because they are more effective cannot be excluded. We suggest that PPIs

constitute a good cultural fit with non-Western populations. Western European

and North American cultures (“Western”) are often described as independent,

whereas Asian and South American cultures (“Eastern”) are characterized as

interdependent (Markus & Kitayama, 1991; Morris & Peng, 1994; Park, Uchida, &

Kitayama, 2016). While the goal of positive psychology interventions is to

increase the well-being of the individual, many positive interventions operate

through collective pathways that aim to improve interdependent relationships.

The self, in interdependent cultures, is often perceived as a group-self with strong

connections and feelings towards family members and the close environment. In

such a setting, a group intervention may elicit more social support and well-being

than in an individualized, independent and egocentric cultural setting. Examples

are positive psychology activities such as the gratitude visit (Davis et al., 2016;

Emmons & Stern, 2013), acts of kindness (Buchanan & Bardi, 2010), and

forgiveness (Derakhtkar & Ahangarkani, 2016). In addition, many positive

psychology activities aim to stimulate low arousal emotions such as kindness

(Otake, Shimai, Tanaka-Matsumi, Otsui, & Fredrickson, 2006; O'Connell, O'Shea,

& Gallagher, 2016), and compassion (Arimitsu, 2016; Yang, Liu, Shao, Ma, & Tian,

2015), and integrate prayer and other spiritual activities (Rouholamini,

Kalantarkousheh, & Sharifi, 2016; Wu & Koo, 2016) into interventions. Studies

show people from Eastern cultures prefer such low arousal emotions (Lim, 2016;

Tugade & Fredrickson, 2004), and there is evidence suggesting cultural fit of

emotions is associated with better health (Yoo & Miyamoto, 2018). PPIs often

include activities that aim to increase awareness, based on Buddhist philosophy,

for example, mindfulness-based activities (Hamilton, Kitzman, & Guyotte, 2006;

Ivtzan & Lomas, 2016), and loving kindness meditation (Fredrickson, Cohn, Coffey,

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" )

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Part II

Positive psychology in a Multi-Ethnic Context:

Resilience and Mental Well-being in Suriname

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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.

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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)

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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, &

Brown, 2010; Luthar, Cicchetti, & Becker, 2000; Zautra, Hall, & Murray, 2008) and

to bounce back after negative emotional experiences (Tugade & Fredrickson,

2004). Resilience is an active and multi-dimensional process, with three

overarching characteristics, namely individual, positive, dispositional attributions,

family cohesion and support, and availability of external support systems

(Garmezy, 1993; Masten & Garmezy, 1985; Rutter, 1987; Werner, 1993). Socio-

economic, cultural and historical factors also can influence resilience, both at

individual as well as collective levels (Gunderson, 2010; Holling, 1973). Most

research on resilience in low and middle income countries focuses on resilience

following distress caused by severe adverse events such as war (Hall, Tol, Jordans,

Bass, & de Jong, 2014; Song, Tol, & de Jong, 2014; Tol, Song, & Jordans, 2013),

political violence (Hobfoll, Mancini, Hall, Canetti, & Bonanno, 2011; Johnson et

al., 2009; Lavi & Slone, 2011; Tol et al., 2013) or natural disasters (Adger, Hughes,

Folke, Carpenter, & Rockström, 2005; Binder, Baker, Mayer, & O'Donnell, 2014;

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Fu, Leoutsakos, & Underwood, 2013). Much less is known about the effects of

economic crises on mental health, especially in countries where large segments of

the population are already living below, near or just above the poverty line, such

as Suriname (Sobhie, Deboosere, & Dekkers, 2015; van der Kooij et al., 2015). We

argue that the current socio-economic crisis will demand a great amount of

resilience of the Surinamese population in order to cope with the problems in

their daily lives.

Present study

Findings of this study were used in the cultural adaptation process of a positive

psychology intervention (PPI) that aims to increase resilience among healthy

employees in Paramaribo, Suriname. In this study we will focus on the specific

positive and dispositional attributions of resilience, namely strengths. One of the

most often used activities in PPIs is identifying and using character strengths

(Andrewes, Walker, & O’Neill, 2014; Gander, Proyer & Ruch, 2016; Mitchell,

Stanimirovoc, Klein, & Vella-Brodrick, 2009; Proyer, Gander, Wellenzohn, & Ruch,

2015). We will classify strengths according to the Virtues In Action Classification

(VIA) (Peterson & Seligman, 2004). According to the VIA, virtues are considered

core characteristics that have been valued by religious thinkers and philosophers

throughout history, whereas character strengths are pathways to these virtues

(Niemiec, 2012). The VIA mentions twenty four universal character strengths.

(Duan et al., 2012; Park, Peterson, & Seligman, 2004). Studies suggest that the

development of character strengths is associated with increased resilience (Boe,

2016; Martínez-Martí & Ruch, 2017; Shoshani & Slone, 2016) and post-traumatic

growth (Duan & Guo, 2015; Peterson, Park, Pole, D'Andrea, & Seligman, 2008).

The main research question in this qualitative study is ‘what strengths are

associated with resilience are present in Suriname?

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Method

The consolidated criteria for reporting qualitative research (COREQ) were

followed in the reporting of the findings (Tong, Sainsbury, & Craig, 2007).

Data collection

Data was collected through semi-structured in-depth interviews that were

conducted in the capital Paramaribo. The following aspects were explored: (1)

participants’ understanding of the concept of resilience; (2) the prevalence of

strengths associated with resilience; (3) the prevalence of specific strengths

within the three main ethnic groups in Suriname. Table 1 shows an overview of

the main questions that were asked during the interviews.

Table 1. Overview of the main interview questions

Opening question: “What is your background and working experience?”

Introductory question: “What is your view on the economic situation of the past year?”

Transition question: “What does resilience mean to you?”

Key questions: • “What strengths can stimulate resilience in Suriname?”

• “What are typical strengths among the Creole/Maroon/Hindustani/Javanese population in Suriname?”

Closing question: “How resilient are the Surinamese people?”

Participants

Candidates were recruited through purposive sampling (Palys, 2008) and

snowball sampling (Atkinson & Flint, 2001). We focused on community

representatives, health care professionals, representatives from religious

institutions and academic scholars specialized in social sciences. We sought to

gather viewpoints about the resources used by different communities to help

them deal with the consequences of the current socio-economic crisis. In total,

thirty-nine people were approached via e-mail or telephone; five candidates did

not react, five candidates refused participation for various reasons and two

interviews were cancelled. In total twenty-seven participants were interviewed in

twenty-five interview sessions. The first author interviewed all subjects in person

at a location they preferred. During the interview no other persons besides the

participant and the researcher were present, except for two interviews that were

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conducted with two participants present, who answered the questions

alternately. All interviews were audio recorded and no field notes were made.

Interviews were conducted in the Dutch language and lasted between forty-five

and sixty minutes. Two interviews were removed from the study due to technical

reasons. In our analysis we finally included twenty-three interviews with twenty-

five participants. Table 2 shows the demographic characteristics of the

participants.

Table 2. Demographics.

Male 17

Female 8

Total 25

Mean age 57

Age range 24-71

% college education 68%

Focus of expertise

General 8

Afro-Surinamese* 7

Hindustani 7

Javanese 3

Occupation

Community representative 2

Entrepreneur 3

Health care professional 7

Representative religious institution 5

Scholar 6

* Creoles and Maroons

Interviews

All interviews were conducted by the first author who received a formal academic

training in conducting qualitative research. The interviewer was superficially

acquainted through work with eight respondents prior to the interviews.

Participants were informed of the general goal of the study (e.g. ‘resilience in the

light of the current economic crisis in Suriname’) and its context (e.g. ‘part of a

dissertation on resilience and positive psychology in Suriname’). None of the

participants received any financial compensation. Written informed consent was

obtained from all participants.

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Data analysis

All interviews were transcribed in Dutch and coded in English. All quotes were also

translated to English. Data analysis was carried out with the use of ATLASti7.5.7.

Coding went through a three-stage procedure. In the first stage the first author

performed an open coding analysis for all interviews. No coding tree was provided.

In the second stage axial coding was performed. In the third stage selective coding

was performed by the first and third author separately. Transcripts were not

returned to the participants. After publication, all participants will receive a copy

of the article.

Results

Most of our respondents had an individualistic understanding of the

concept of resilience and referred to resilience as ‘the capacity to deal with

adversity‘ or ‘bouncing back after blows’ and underline the importance of

persistence and flexibility:

“Resilience for me is the capacity to get up on your feet again. No matter

what the outlook is, being able to continue and to make something or

your life”. [Respondent 20]

During the interviews many different strengths were mentioned by the respondents, but

we found five major strengths that may contribute to the development of resilience that

are applicable to all major ethnic groups. Religiousness, or spirituality, is the main

strength, and could be regarded as a bedrock for resilience. Hope, harmony, acceptance

and perseverance are four strengths that are strongly associated with resilience. These

four strengths all are perceived as related to religiousness, independent from religious

denomination.

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Religiousness

According to our respondents, religiousness – independent from the world religion and

philosophies they adhere to- provides meaning, stability, a sense of security and offers

comfort and solace. It can “bring you to a peaceful state of mind”. Religiousness also

strengthens social ties. In fact, it is regarded as the prime social network of many people

in Suriname. Religiousness is also described as a source of empowerment, giving people

the strength to both accept and improve their situation. The way religiousness is

expressed may vary per denomination. Church attendance, daily prayer and bible study

are mentioned as religious activities practiced by most Afro-Surinamese Christians. Most

church service focus on perfervid prayer. Some representatives of the congregations also

underline the importance of carrying out Christian virtues such as kindness and charity.

One respondent, a high representative of the Roman Catholic Church, underlines the

importance of daily prayer and meditation:

“Meditation is an individual process, we have few group meditations, people are

encouraged to start the day with silence, in prayer. Not to start the day with all the

noise, but rather seeking silence”. [Respondent 4]

Attendance at mandirs (Hindu temple) and mosques, and daily prayer are also important

for Hindus and Muslim respectively. For some Hindus meditation is a fundamental part of

their religious practices. Yoga is also suggested as a way of increasing resilience, although

two Hindustani respondents clearly point out that yoga consists of many steps including

dnyana (meditation) and that the popular ‘Western’ yoga styles that solely focus on

asanas (physical postures) may not be very helpful in developing resilience. Orthodox

Javanese Muslims practice salah (congregational prayer), which is seen as a form of

meditation. One respondent explained that most Muslims in Suriname usually do not

uphold to five daily moments of prayer for practical reasons, although many try to attend

the salāt al-jum ’ah, the congregational prayer on Friday after noon. A practice of

orthodox Surinamese Muslims that was also mentioned by several respondents was

ramadan (fasting), while unorthodox Muslims and Javanists practice a variety of rituals to

appease the gods and spirits, for example slametan (ritual meal offerings). One

respondent explained how he believes religiousness can provide people with guidelines

how to deal with uncertainty. The various Holy Scriptures give illustrations how this was

done in ancient times, by religious figures who act as positive role models. Respondents

also associate religiousness with strengths such as love, kindness, and gratitude. The

display of these strengths can contribute to the development of resilience: While

religiousness is considered a factor that generally increases resilience, several

respondents also point out that religiousness may have an inhibiting influence on

resilience. This will be discussed in the section on acceptance.

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Hope

Despite the difficult economic situation, all respondents mentioned that

they remain hopeful. They report a general positive future outlook

among the people in Suriname. An example of hope and optimistic

thinking is the often-heard belief that Suriname is a country that has

been blessed by God, because Suriname has a fertile soil. Plants grow

very quickly and people never have had to worry about starvation. None

of the respondents has a negative long-term outlook on the economic

situation, everyone believes that eventually better times in Suriname will

come, since the country still has many untouched natural resources.

Religious faith is a main source of hope. Respondents have the

impression that most Surinamese have a strong faith in God and the

belief that He will take care of his people keeps the people in Suriname

going. This was voiced by a representative of the Catholic Church in the

following way:

“We want to live and have to bear the things that are missing now,

because there is a deep-rooted faith within us, which we call hope and

which keeps people on their feet”. [Respondent 4]

Harmony

In general, there appears to be a strong sense of belongingness and

connectedness in Suriname. All respondents underline the importance of unity

and living in harmony with each other. Harmony is also strongly related to

religiousness. Social relations that are forged during religious activities

(attendance of church, temple or mosque services) are an important source for

resilience according to our respondents. Although striving for harmony was found

to be present in all ethnic groups, it appears to be a pivotal aspect of the Javanese

community. Among the Javanese there is a strong sense of solidarity and unity.

Living in harmony is a central way of life, in Javanese language known as rukun.

One expression of rukun is the gotong royong, a system of mutual cooperation

where people save money collectively. For example, in this system houses are

built and paid for collectively. This striving for harmony also has a spiritual

dimension:

“Javanese believe that they have to live in harmony with their environment,

to live harmony with the people around them. This is expressed through their

kindness, humility, their acceptance and that fact that they do not want to

cause any problems among each other (…) the Javanese believe that they

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always have to live in harmony, not only with their surroundings but also with

the spiritual world”. [Respondent 15]

The view that well-being is related to a harmonious relation with God and other

deities or ancestral and nature spirits is present throughout all ethnic and

religious groups in Suriname.

Acceptance

Another often reported strength that may contribute to resilience in Suriname is

acceptance. Acceptance is closely related to harmony: if one is to avoid conflict

with others, an accepting attitude may work effectively. Acceptance is also

related to religiousness. In order to cope with daily stress, people simply accept

the situation as it is, and surrender themselves to the situation, which is

considered the will of God. Acceptance and religiousness can increase resilience

according to our respondents. On the other hand, these factors can also decrease

or inhibit the development of resilience. Acceptance and religiousness can lead to

passivity, when people simply accept their situation as immutable or predestined:

“Within the Evangelic Brotherhood Church, it is called “saka fasi” (literally a

fixed matter). A sort of humility: as a human you are nothing. Whatever

happens to you, you have to take it”. [Respondent 2]

“In the Surinamese language we have a saying "Libi yu srefi gi gron tapu"

which literally means to surrender yourself to the world. That means having

no resilience”. [Respondent 1]

In some cases, religious beliefs can lead to magical ways of thinking, which

is even stimulated in some religious congregations. One respondent, an

Afro-Surinamese anthropologist, referred to the term ‘cargo cult’ which he

believes is particularly strong among the Creoles and Maroons:

“This is the point of view that people believe that everything will be better at

some point, that better times will come. The ancestors and spirits will return

and bring you wealth and prosperity. As a way of speaking, one day you wake

up and there is a bag of one million SRD on your table or beside your bed”.

[Respondent 17]

The view that religion may hinder the development of resilience was mainly

voiced by respondents who had a neutral or skeptical attitude towards religion.

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The representatives of the religious communities we have spoken to clearly

advocate a pro-active interpretation of the teachings of the scriptures.

Perseverance

As a people, the Surinamese see themselves as persevering. Many respondents

place the current crisis in a historical perspective as many people have gone

through times that were much harsher than the current situation:

“After all the misery we have gone through, we remain optimistic, we know

that every cloud has a silver lining. We have had slavery, we have had

contract work. We have had colonial structures. We have had authoritarian

education. We have had 'revolutions. We have had economic downfalls. But

you will not get us down”. [Respondent 1]

Perseverance is also related to religiousness; faith in God is what keeps many

people going, as previously was indicated in the section on hope. Among the

Hindustani population, perseverance is reflected in their workings ethics, which

are said to be strong. This can be associated with the Hindu concept of

swadharma: the personal duties. Their sense of duty is what may lie behind

perseverance, according to one respondent.

“The drive why people actually do things is the sense of duty. You have to

do your swadharma; your own duties. That is a strong concept in

Hinduism”. [Respondent 14]

Discussion

Most of our respondents had an individualistic understanding of the term

resilience. Resilience is mostly viewed as the capacity to deal with adversity. In

our study we focused on resilience in the light of the current economic crisis.

Resilience pertains mostly to the capacity of dealing with financial adversities that

have a profound impact on the emotional, social, spiritual well-being of people in

Suriname. We noted that physical, mental, occupational, and

environmental/political aspects of resilience were not addressed by most of our

respondents.

146

In our study we identified five major strengths that are associated with

resilience: religiousness, hope, harmony, acceptance, and perseverance.

Religiousness is the bedrock component, with hope, harmony, acceptance, and

perseverance as components that are interconnected with religiousness.

Religiousness offers solace and a sense of security. It also provides a source of

empowerment and meaning. Religious practises differ per creed. Daily prayer and

devotional service at home, reading religious scriptures and meditation are

activities that seem to contribute to emotional and psychological well-being in all

religious. Attendance services in churches, mandirs, and mosques also strengthen

social ties and contribute to social well-being of people in Suriname.

Our findings about the role of religion in relation to mental health are

consistent with findings from previous studies, suggesting that religious and

spiritual activities serve as protective factors for mental health, as they can be

powerful sources of happiness, meaning, hope, and harmony (AbdAleati,

Zaharim, & Mydin, 2014; Brewer-Smyth & Koenig, 2014; Ivtzan, Chan, Gardner, &

Prashar, 2013; Koenig, 2012; Lun & Bond, 2013; Park et al., 2013; Rizvi & Hossain,

2016). Religiousness can also contribute to a decrease of indicators of negative

mental health including depression, anxiety, stress, substance abuse, mortality

rate, and suicidality (Gonçalves, Lucchetti, Menezes, & Vallada, 2015; Koenig,

2012; Lucchetti, Lucchetti, & Koenig, 2011; Wu, Wang, & Jia, 2015). Morton et al.

(2016) identified three mechanisms that may explain the relationship between

religiousness and mental health: religions institutions often promote healthier

lifestyles; attendance to religious service increases social support and the

participation in religious rituals lead to the experience of more positive emotions.

Although in our study the first mechanism was not brought to light, the other two

mechanisms did appear prominently. First, our findings suggest that religiousness

has a strong social support function in Suriname. According to our respondents,

being with family members and friends is very important and religious institutions

play a central role in maintaining and expanding the social network of people.

This is applicable to all ethnic groups. All throughout Paramaribo there are

churches, temples, and mosques that function as places of social gatherings. The

different religions in Suriname appear to live in harmony with each other, and

people of different creeds coexist peacefully and interacted in daily life. Literature

discussing the positive relation between religiousness and social support dates

back to Durkheim's work in the beginning of the twentieth century. Durkheim

underlined the social function of religion and argued that religion is a source of

solidary and social cohesion (Durkheim & Bellah, 1973; Moñivas, 2007). More

147

recent studies suggest that a strong sense of belonging to a religious

congregation is associated with better health (Krause & Wulff, 2005), increases

meaning in life (Lambert et al., 2013), and acts as a protective factor against

loneliness and depression (Baskin, Wampold, Quintana, & Enright, 2010).

Thwarted belongingness, however, may increase the risk for suicide (Silva,

Ribeiro, & Joiner, 2015).

However, religiousness also has an ambivalent role, meaning

that it can actually inhibit the development the resilience in Suriname.

Particularly, when it is combined with two others strength. Religiousness

in combination with acceptance and hope can result in a passive attitude.

People will simply accept their disadvantaged situation as something that

is the will of God. The hope that things will someday simply change for

the better, can reinforce this passivity. Church attendance and other

religious rituals then become a form of escapism. While this may be an

effective short-term coping strategy for stress, it can inhibit the

development of resilience in the long run. Two respondents underlined

the importance of active agency, in relation to religiousness and

spirituality. They argue that religiousness is a strong stimulant for the

development or resilience, when people act to improve their situation.

In our analysis we set out to classify strengths according to

the VIA list. Almost all character strengths of the VIA list were mentioned

by the respondents somewhere during the interviews, but religiousness,

hope, and perseverance were mentioned most frequently. In addition to

these three major strengths, we found strengths (or possibly virtues) that

are not acknowledged in the VIA categorization, namely harmony and

acceptance. We define harmony (unity) as a virtue that entails striving to

live harmoniously with the social, natural and/or spiritual environment.

Kim et al. (2010) argued that harmony is a virtue comprised of a number

of strengths including modesty/humility, prudence, forgiveness, love,

kindness, gratitude, and hope. Acceptance refers to the ability to accept

changing situation quickly and the flexibility to be able to adapt quickly to

different situations. We find it remarkable that acceptance is not (yet)

included in the VIA list, since it is a core virtue in all eastern religions and

philosophies. Acceptance even plays an essential part of psychological

therapies that have been accepted in Western countries such as

148

mindfulness based therapies (Bohlmeijer, Prenger, Taal, & Cuijpers, 2010;

Demarzo, Montero-Marn, Cuijpers, & Garcia-Campayo, 2015; Hayes,

Follette, & Linehan, 2004) and Acceptance and Commitment therapy

(Fledderus, Bohlmeijer, Pieterse, & Schreurs, 2012; Fledderus, Bohlmeijer,

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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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

(Hobfoll et al., 2012; Hobfoll, Mancini, Hall, Canetti, & Bonanno, 2011). Resilience

is an active process and can be conceptualized as multi-dimensional, having three

overarching characteristics: (1) individual, positive and dispositional attributions;

(2) family cohesion and support; (3) availability of external support systems

(Garmezy, 1993; Masten, 1985; Rutter, 1987; Werner, 1993). Various factors

influence resilience at individual as well as collective levels, where socio-

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economic, cultural and historical factors also can be of influence. The mechanisms

of resilience are therefore not only applicable to the mental ability of people to

adapt, but also apply to socio-environmental and socio-economic systems

(Gunderson, 2010; Hobfoll & de Jong, 2013; Holling, 1973).

Resilience researchers focus on discovering vulnerability (risk) factors

that may hinder the development of resilience. In addition, they investigate the

protective factors that are present (Rutter, 1987). Earlier studies identified

resilience as a set of personal characteristics, that include hardiness, self-efficacy,

self-esteem, optimism, faith, and humor, while later studies viewed resilience as a

motivating life force within the individual (Grafton, Gillespie, & Henderson, 2010).

Researchers in the field of resilience and positive psychology have in common

that both focus on the benefits of salutogenic constructs (Luthar, Lyman, &

Crossman, 2014) and resource factors for the development of mental health

(Miller-Lewis, Searle, Sawyer, Baghurst, & Hedley, 2013).

Much like resilience, mental health is an umbrella term with various

definitions attempting to capture its essence. Until recently, the dominant view

on mental health was based on the assumption that mental health can be

measured along a single dimension, with the presence or absence of mental

illness based on a predetermined cut-off point (Keyes, 2007). However, there is

growing evidence that this may not be the case (Huppert & So, 2013; Lamers,

Westerhof, Bohlmeijer, ten Klooster, & Keyes, 2011; Lamers, Westerhof, Glas, ,

2015). Several models have been developed that suggest that there is multi-

dimensionality in mental health and disorders. According to the network

approach, mental disorders are considered networks that consist of interacting

symptoms (Borsboom, 2008; Cramer, Waldorp, Maas, & Borsboom, 2010).

Mental health depends on the interaction between the connectivity of the

symptoms in the network (either weak or strong) and external stressors

connectivity (also either weak or strong). When weak network connectivity and

stressors are present, there is mental health with high resilience (Borsboom,

2017). The Dual-Factor Model of Mental Health (Antamarian, Scott Huebner, Hills,

& Valois, 2010; Greenspoon & Saklofske, 2001; Lyons, Scott Huebner, Hills, &

Shinkareva, 2012) and the Two Continua Model (Keyes, 2013; Keyes, 2007;

Westerhof & Keyes, 2010) are two models that were developed within the

theoretical framework of positive psychology. Both describe psychopathology

(mental illness) and well-being (mental health) as two independent dimensions.

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Individuals with many symptoms of pathology can experience low as well as high

of well-being, and the same applies to individuals with no pathological symptoms.

According to Keyes (2002), mental well-being consists of three dimensions of

mental well-being: (1) emotional well-being, (2) psychological well-being, and (3)

social well-being.

To date, there have only been a few studies that have examined the

direct relationship between resilience and mental well-being in general and the

efficacy of resilience interventions in the workplace in particular. A systematic

review on resilience training among healthy employees identified 11 studies

(Robertson, Cooper, Sarkar, & Curran, 2015). Only three studies examined the

effect of a program that was specifically designed to increase resilience through a

randomized controlled trial (RCT). These studies reported outcome measures that

fall at least under one of the three dimensions of mental well-being. The first

study was a cluster RCT in a government agency in the United States. Seventy-five

employees participated in a five-day resilience-training program. Significantly

higher levels of self-esteem, higher internal locus of control, higher sense of

purpose in life, and enhanced interpersonal relationships were reported,

compared to a control group that did not receive an intervention (Waite, 2004). A

second study among 20 U.S. physicians showed that resilience training consisting

of a single 90-minute session increased resilience, quality of life, and reduced

stress and anxiety compared to a waiting list control group (Sood, Prasad,

Schroeder, & Varkey, 2011). The third study was an online resilience training

among 26 Australian sales managers who were trained in seven aspects of

resilience. The study aimed to measure the effects of the training on well-being,

quality of life, work performance, depression, and anxiety. No significant effects

were found in comparison to the waiting list control group. This was attributed to

the high drop-out rate, as only seven of the 26 managers actually completed the

program (Abbott, Klein, Hamilton, & Rosenthal, 2009). In addition to the small

number of studies, they were all conducted in either the United States or

Australia. It is thus still questionable whether the results can be generalized to

employees in a non-Western, collectivistic country such as Suriname, where most

people may have a interdependent self-construct (Markus & Kitayama, 1991).

Multi-ethnic context

The RCT was conducted in Paramaribo, the capital city of Suriname, which is

situated in northeastern South America. Suriname is a multi-ethnic society that

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consists of Afro-Surinamese (41%; a group that can be subdivided into Creoles -

31% and Maroons -10%), Hindustani (37%), Javanese (15%), Amerindians (2%),

Chinese (2%) and other ethnic groups (3%) (TWFB). The three most predominant

religions are Christianity (48%, most prevalent among Afro-Surinamese),

Hinduism (27%, most prevalent among Hindustani) and Islam (20%, most

prevalent among Javanese and 10% of the Hindustani people). Currently, the

estimated population is 585,000 residents, with the majority living in the capital

Paramaribo (The World Factbook, 2016).

Present study

The intervention used in this study is a multicomponent positive psychology

intervention (MPPI). Recently, we have witnessed a sharp increase of the number

of MPPIs. A meta-analysis reported that effect sizes from RCT studies from non-

Western countries were substantially larger for subjective well-being,

psychological well-being, and stress, than effect sizes from MPPIs from Western

countries (Hendriks et al., 2018a). The differences were largely attributed to the

poorer methodological quality of RCTs from non-Western countries. However,

there were also indications that MPPIs may be more effective in non-Western

countries, due to a better cultural fit (Hendriks, 2018a). We sought to perform a

study addressing the following question, to what extent can a culturally adapted

MPPI increase resilience and mental well-being among healthy workers in

Suriname? We hypothesized that a MPPI can significantly increase resilience and

mental well-being, and on the basis of previous meta-analyses (Bolier et al., 2013;

Hendriks et al., 2017b) we expect moderate effect sizes.

Method

Study design

The study was a single-blinded parallel RCT, with an active intervention group and

a waiting list control group. The trial was designed according to the Standard

Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines

(Chan & Laupacis, 2013).

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Participants and procedure

We recruited employees from three companies in Paramaribo, Suriname.

Potential participants were screened by the respective human resource managers

of said companies and included on the basis of the following criteria: (1)

participants had to be aged between 18 and 60 years; (2) participants had to be

sufficiently fluent in the Dutch language to capably fill out questionnaires, read a

training manual, and participate in written exercises; (3) participants had to be

willing to participate in a weekly 2-hour program for seven consecutive weeks.

Employees who did not meet these inclusion criteria were excluded. Participation

was voluntary and occurred on an opt-out basis. Several measures were taken to

promote participant retention. For example, the execution of the program

modules took place during working hours, at one of Paramaribo’s best available

training facilities, and participants were provided with snacks and beverages

during the training. We randomized 173 employees; 158 participants completed

the baseline assessment (T0) and started the intervention, 144 participants

completed the post-test assessment, seven weeks after the baseline assessment

(T1), and 120 participants completed the follow-up assessment, three months

after the post-test assessment (T2). Figure 1 provides an overview of the flow of

participants. Participants were randomly assigned to either the intervention

group or the waiting list control group using the online program research

randomizer (https://www.randomizer.org). This was done by an independent

administrator from the Anton de Kom University of Suriname. During the initial

session, each participant received a sealed opaque envelope containing their

given group number which corresponded to one of the conditions. This procedure

was done by a different independent party to maximize allocation concealment.

The study was single-blinded. The human resource managers of the participating

companies created a personal code for each participant. The assessors who

entered and analyzed the data could only identify participants by this code and

not by their names. All participants received an information letter and an

invitation to attend the initial session. During this session with all participants, the

questionnaires were administered (T0), after which all participants engaged in

psycho-educational training and received the envelopes with the allocation

details. One week after the initial session, the official training program started for

the intervention group. In total, seven sessions were conducted over a period of

seven consecutive weeks. After seven sessions, the posttest assessment was

conducted for the intervention group and the waiting list group (T1). In the week

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following the posttest measurement, the participants in the waiting list group

started the program. Follow-up measures (T2) were conducted at three months

after the end of the training sessions. The assessment of the primary and

secondary outcomes was done through the analysis of self-report measures.

The intervention

The intervention program was titled Strong Minds Suriname (SMS) and was based

on the Shell Resilience Program (SRP), which was originally developed by the

health department of multinational Royal Dutch Shell in 2011. Table 1 shows an

overview of all seven sessions and the types of activities that were included. The

duration per module was two to three hours (including a break) and consisted of

a general theoretical introduction (psycho-education) followed by three or four

group exercises. Participants also received voluntary homework assignments (e.g.

keeping a gratitude journal). The modules were conducted by two senior trainers

(the first and fourth author) who were responsible for the psycho-education, and

a group of eight coaches (employees from the participating companies) who led

the positive activities. Several strategies were implemented to ensure fidelity

(Horner, Rew, & Torres, 2006). The coaches received a formal two-day ‘train the

coach training’ prior to the program. A training manual was developed to

standardize the training by the coaches, this in addition to a manual for the

participants. Due to financial reasons and time restrictions, only a basic fidelity

check was conducted. The main author observed the interaction between the

local coaches and the participants, and after each intervention session, a

debriefing session with the coaches was held.

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Figure 1. Flow-chart of participants in the Strong Minds Suriname program

Assessed for

eligibility

( n = 546)

Met eligibility

criteria

(n = 173)

Did not meet eligibility

criteria

( n = 373)

Randomized

(n = 173)

Allocated to intervention

Strong Minds Suriname

(n = 87)

Allocated to wait list

control group

(n = 86)

Completed base line

assessment

(n = 80)

Completed base line

assessment

(n = 78)

Completed post-test

assessment

(n = 73)

Completed post-test

assessment

(n = 71)

Completed 3 months

assessment

(n = 66)

Completed 3 months

assessment

(n = 54)

Allocation

Follow-up

Analyzed (n = 80)

Analyzed (n = 78)

Analysis

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Measures

Primary outcome

The primary outcome was (psychological) resilience. This was assessed with the

Dutch Resilience Scale (RS-nl) (Portzky, Wagnild, De Bacquer, & Audenaert, 2010),

the Dutch adaptation of the Wagnild and Young Resilience Scale (Wagnild &

Young, 1993). The RS-nl uses a four-point Likert scale with two anchoring

statements ranging from “strongly disagree” (1) to “strongly agree” (4). The

neutral value from the original version of the RS-NL was omitted, forcing

participants to respond either negatively or positively to each item. Its

corresponding Cronbach’s alpha in the present study was .90 at pre-test, .92 at

post-test and .93 at follow-up assessments.

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Table 1. Content Strong Minds Suriname program

# Theme Positive activities

1 Resilience - Veerkracht • Introduction: psycho-education on resilience (all groups)

2 Be grateful Gran Tangi: wees dankbaar

• Psycho-education on gratitude

• Relaxation, breathing exercise (i)

• Writing down a gratitude statement (i)

• Verbally expressing gratitude (g)

• Writing a gratitude letter (i)

• Closing moment: verbal expression of positive emotions (g)

• Home work (optional): gratitude visit (i), three good things (i)

3 Positivity starts with you Positiviteit begint bij jezelf

• Psycho-education on positive and negative emotions (i)

• Relaxation, breathing exercise (i)

• Reflection on homework assignments (g)

• Discovering and discussing positive and negative emotions (g)

• Outdoor random acts of kindness and presentation (g)

• Closing moment: verbal expression of positive emotions (g)

• Home work (optional): gratitude visit (i), three good things (i), random acts of kindness at home or work (i)

4 Developing your own strengths Bouw aan je sterke kanten

• Psycho-education on strengths

• Relaxation, breathing exercise (i)

• Reflection on homework assignments (g)

• Discovering strengths (g)

• Creating a strength symbol/strength word cloud (g)

• Closing moment: verbal expression of positive emotions (g)

• Home work (optional): gratitude visit (i), three good things (i), random acts of kindness at home or work, using strengths at work or at home (i)

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5 Your goals are attainable Jouw doelen zijn haalbaar

• Psycho-education on goal setting (SMART goals)

• Physical exercise (i)

• Reflection on homework assignments (g)

• Discussion on goal setting, Checking and developing a SMART goal

• Closing moment: verbal expression of positive emotions (g)

6 Over coming your problems Je problemen overwinnen

• Psycho-education on Adversity/Belief and Consequences

• Written exercises in changing negative to positive beliefs

• Closing moment: verbal expression of positive emotions (g)

7 Let it go Laat het los

• Psycho-education on forgiveness and spirituality

• Moment of silence: exercise in thoughtless awareness (i)

• Forgiveness exercise (writing and verbal expression) (g/i)

• Expressing gratitude through prayer and surrendering (i)

• Closing moment: verbal expression of positive emotions (g)

Abbreviations: (g) group exercise; (i) individual exercise

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Secondary outcomes

Mental well-being

Mental well-being was measured by Mental Health Continuum-Short Form (MHC-

SF), a 14-item questionnaire that measures emotional well-being, social well-

being, and psychological well-being (Keyes, 2002) We used the validated Dutch

version (Lamers et al., 2011; Westerhof & Keyes, 2010). Participants were asked

to indicate their emotions over the past four weeks. Item scores ranged from

"never" (0) to "(almost) always" (5), with a higher score indicating a higher level

of well-being. Its Cronbach’s alpha in the present study was .89 at pre-test, .92 at

post-test, and .94 at follow-up assessments.

Depression, Anxiety, Stress

These outcomes were measured using the Dutch version of the Depression

Anxiety Stress Scale (DASS-21), a 21-item questionnaire that measures

depression, anxiety and stress (de Beurs, van Zweden, & Hamming, 2010). Item

scores range from "did not apply to me at all - never" (0) to "applied to me very

much, or most of the time – almost always" (3), with a higher score indicating a

higher level of depression, anxiety or stress. Cronbach's alpha for depression in

the present study was .75 at pretest, .77 at post-test, and .85 at follow-up

assessments. For anxiety, Cronbach’s alpha was .69 at pretest, .78 at post-test,

and .85 at follow-up assessments. Its Cronbach's alpha for stress was .77 at

pretest, .78 at post-test, and .83 at follow-up assessments.

Psychological flexibility

This outcome was measured with the Psychological Flexibility Questionnaire

(PFQ). The PFQ originally is a 20-item questionnaire that measures five factors

related to psychological flexibility (Ben-Itzhak, Bluvstein, & Maor, 2014).

However, we selected 13 questions of the first three factors, which are positive

perception of change, characterization of the self as flexible, and self-

characterization as open and innovative. During a focus group meeting with

psychologists and HR representatives who rated the questionnaires, it was

decided not to include the seven questions pertaining to the last two factors

because these questions on reality perception were considered to be too complex

for the target population (i.e. mostly employees with a low or intermediate

educational level. Items were rated on a six-point Likert-type scale ranging from

"not at all" (1) to "very much" (6), with a high score indicating greater

psychological flexibility. Its Cronbach's alpha in the present study was .87 at

pretest, .92 at post-test, and .95 at follow-up assessments.

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Financial distress

Financial distress was measured with the InCharge Financial

Distress/FinancialWell-Being Scale (IFDFW), an eight item scale that measures

levels of financial distress or financial well-being (Prawitz et al., 2006). Items on

the IFDFW are rated on a ten-point scale ranging from "overwhelming stress" (0)

to "no stress at all" (10), with a higher score indicating a higher level of financial

well-being. Its Cronbach's alpha in the present study was .81 at pretest, .86 at

post-test, and .95 at follow-up assessments.

Positive and negative affect

Positive and negative affect were measured with the Positive and Negative Affect

Schedule (PANAS), a 20-item scale that measures two opposites of mood

(Watson, 1988). Items on the PANAS are rated on a five-point scale from "little, or

not very much" (0) to "very much" (10), with a higher score indicating a higher

level of positive of negative feelings or thoughts. We used the Dutch version of

the scale (Engelen, De Peuter, Victoir, Van Diest, & Van den Bergh, 2006). The

Cronbach's alpha for positive affect in the present study was .86 at pretest, .86 at

post-test, and .90 at follow-up assessments. The Cronbach's alpha for negative

affect was .84 at pretest, .86 at post-test, and .88 at follow-up assessments.

Client satisfaction and adherence

Client satisfaction was measured with the Client Satisfaction Questionnaire (CSQ-

8). The CSQ-8 is an 8-item questionnaire that is designed to measure client

satisfaction with services (Larsen, Attkisson, Hargreaves, & Nguyen, 1979). Items

on the CSQ are rated on a 4-point Likert Scale. Its Cronbach's alpha in the present

study was .86 at post-test. Based on attendance lists that were filled out by the

facilitators during the trial period, we calculated the adherence rate.

Sample size

The required sample size was calculated a priori. Based on the preliminary results

of a meta-analysis of the effects of MPPIs (Hendriks et al., 2018b), an effect size

of d = 0.51 for resilience was expected. Assuming this effect size, a two-sided

significance level of 5% on an independent t-test with a statistical power of 80%,

128 participants were needed. Accounting for a loss of power resulting from a

dropout rate of no more than 17.5 %, it was planned to include a minimum of 150

participants, distributed equally over both conditions, in this trial.

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Statistical analyses

Analysis of all randomized participants was impractical. Therefore, a modified

intention-to-treat (mITT) analyses (Gupta, 2011) was used instead of a regular

intention-to-treat analysis (Heritier, Gebski, & Keech, 2003). Of the 173

randomized participants, 15 did not attend the baseline assessment due to work-

related scheduling conflicts. Crucially, these absences were unrelated to the

randomization itself and unlikely to introduce bias as they were the result of

extraneous workflow processes and not individual volition (Hollis & Campbell,

1999). All other participants were included, regardless of adherence over the

course of the intervention and extraneous factors. All cases of item or unit level

missing data from the included participants were imputed using the estimation

maximization (EM) algorithm (Dempster, Laird, & Rubin, 1977). Outcomes at

post-test were analyzed using univariate analysis of covariance (ANCOVA), which

models the outcome as a function of intervention group (classified factor) and the

respective baseline value (linear covariate). We examined the interaction of

condition by time (2 x 2) on each outcome. Results were computed using 5,000

bootstrap samples. Effect sizes were calculated using the relevant t-statistic, using

the following formula to calculate the effect sizes (Nakagawa & Cuthill, 2007):

d = t(n1+n2)

√(n1n2) √ (df’)

We examined whether the effects in the intervention condition were maintained

at follow-up by conducting paired-sample t-tests, comparing the scores on the

follow-up with those at baseline. All data analyses were conducted with IBM®

SPSS® Statistics (version 23). In addition, we used the software tool R (version

3.4.1) to calculate the confidence intervals (CIs).

Results

Baseline characteristics

Table 2 summarizes the baseline characteristics of the sample. The mean age of the

participants was 36.3 years (SD= 9.6). Just over half of the participants were female

(59.5%). The majority of participants had a low (46.2%) or intermediate level of

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educational attainment (41.8%). The largest ethnic group was Javanese (41.8%),

followed by the Hindustani ethnicity (25.3%), and the Afro-Surinamese group

(15.2%). Participants of mixed origins accounted for 17.1% of the population. The

most frequently noted religious backgrounds were Christianity (41.8%), Islam (29.7%)

and Hinduism (18.4%). Furthermore, 8.2% of the population indicated that they were

non-religious. Table 2 also contains information on the civil status, number of

children in the household, and monthly net income of the participants. There were

no significant differences at baseline for age, education, religion civil status, number

of children in the household, and income. Despite randomization, there were

significant differences for gender and ethnicity, with an overrepresentation of male

participants from Javanese descent in the intervention group.

Drop-outs

Initially, we randomized 173 participants. Two days before the start of the training

one company cancelled the participation of fifteen of their employees due to

unexpected scheduling changes. We therefore 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 completed the baseline assessment and started

the intervention, 144 (91.1%) participants completed the post-test at seven weeks,

and 120 (75.9%) the three-month follow-up assessment. Between the pre-test and

post-test, there were 14 drop-outs (8.9%), split evenly between both groups.

Between post-test and follow-up assessment 24 participants dropped out (13.8%).

Although there were more drop-outs in the waiting list group, this difference was not

significant. At the post-test assessment (T1), we found 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, the average education level and income of drop-outs was significantly

lower, indicating that employees with a low educational level and low income were

more likely to drop-out. At follow-up, there were no significant differences between

drop-outs and completers on any measured demographics. Further analysis showed

that drop-outs had a significantly higher score on resilience and a lower score on

depression at pre-test than completers, indicating 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 2. Baseline characteristics of participants in intervention, control group and total sample

SMS (n = 80)

WL (n =78)

Total (n = 158)

SMS (n = 80)

WL (n =78)

Total (n = 158)

Age, M (SD) 36.2 (9.4) 36.5 (9.9) 36.3 (9.6) Education, n (%)

Gender, n (%) Low 44 (55.0) 31 (39.7) 75 (47.5)

Male 38 (48.8) 25 (32.1) 63 (39.9) Intermediate 29 (36.3) 36 (46.2) 65 (41.1)

Female 42 (51.2) 53 (67.9) 95 (60.1) High 7 (8.8) 11 (14.1) 18 (11.4)

Ethnicity, n (%) Religion, n (%)

Javanese 39 (48.8) 27 (34.6) 66 (41.8) Christian 30 (37.5) 36 (46.2) 66 (41.8)

Hindustani 18 (22.5) 22 (28.2) 40 (25.3) Islam 24 (30.0) 23 (29.5) 47 (29.7)

Afro-Surinamese

6 (7.5) 18 (23.1) 24 (15.2) Hinduism 15 (18.8) 14 (17.9) 29 (18.4)

Mixed 17 (21.3) 10 (12.8) 27 (17.1) Javanism 3 (3.8) 0 (0.0) 3 (1.9)

Amerindian 0 (0.0) 1 (1.3) 1 (0.6) None 8 (10.0) 5 (6.4) 13 (8.2)

Civil status, n (%) Children, n (%)

Single 34 (42.5) 35 (44.9) 69 (43.7) 0 32 (40.0) 25 (32.1) 57 (36.1)

Married 39 (48.8) 30 (38.5) 69 (43.7) 1 19 (23.8) 23 (29.5) 42 (26.6)

Concubinage 5 (6.3) 10 (12.8) 15 (9.5) 2 19 (23.8) 22 (28.2) 41 (25.9)

Windowed 1 (1.3) 2 (2.6) 3 (1.9) 3 8 (10.0) 6 (7.7) 14 (8.9)

Divorced 1 (1.3) 1 (1.3) 2 (1.3) 4 > 2 (2.6) 2 (2.6) 4 (2.5)

Monthly net salary in US dollars

< $ 135 18 (22.5) 13 (16.7) 31 (19.6)

$ 135 - $ 270 37 (46.3) 35 (44.9) 72 (45.6) $ 400 – $ 530 9 (11.3) 10 (12.8) 19 (12.0)

$ 270 - $400 11 (13.8) 13 (16.7) 24 (15.2) > 530 5 (6.3) 7 (9.0) 12 (7.6)

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.

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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 =

0.08), financial well-being (p = 0.31) and psychological flexibility (p = 0.20).

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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

Measures SMS Waiting list

Ma SDa Ma SDa F(df) P ᶯ2 Effect sizes d* [95%CI]

RS-NL baseline 3.07 0.40 3.13 0.30 RS-NL post-test 3.22 0.32 3.05 0.34 22.77 (1) .000 .128 0.76 (0.43-1.09)

RS-NL follow-up 3.19 0.33 3.08 0.32

MHS-SF Total baseline 3.23 1.13 3.57 0.82

MHS-SF Total post-test 3.78 0.96 3.49 0.94 14.92 (1) .000 .088 0.62 (0.30-0.94)

MHS-SF Total follow-up 3.68 0.93 3.56 0.84

MHS-SF EWB baseline 3.49 1.36 3.81 0.96

MHS-SF EWB post-test 3.96 1.11 3.80 0.99 5.53 (1) .020 .034 0.38 (0.06-0.70)

MHS-SF EWB follow-up 3.92 0.95 3.76 0.91

MHS-SF-SWB baseline 2.71 1.39 3.06 1.17

MHS-SF-SWB post-test 3.39 1.19 2.94 1.20 13.43 (1) .000 .080 0.59 (0.27-0.91)

MHS-SF-SWB follow-up 3.27 0.95 3.18 1.04

MHS-SF-PWB baseline 3.52 1.17 3.87 0.88

MHS-SF-PWB post-test 4.00 0.92 3.81 0.96 11.98 (1) .001 .072 0.55 (0.23–0.87)

MHS-SF-PWB follow-up 3.90 0.98 3.76 0.91

DASS-21 dep. baseline 1.78 0.51 1.71 0.39

DASS-21 dep. post-test 1.50 0.33 1.64 0.41 9.86 (1) .002 .060 0.50 (0.18-0.82)

DASS-21 dep. follow-up 1.52 0.40 1.63 0.35

DASS-21 anx. baseline 1.64 0.41 1.69 0.42

DASS-21 anx. post-test 1.49 0.37 1.63 0.46 4.01 (1) .047 .025 0.32 (0.00-0.64)

DASS-21 anx. follow-up 1.44 0.41 1.50 0.35

DASS-21 stress baseline 1.84 0.45 1.91 0.44

DASS-21 stress post-test 1.69 0.42 1.83 0.43 3.13 (1) .079 Not significant

DASS-21 stress follow-

up

1.62 0.38 1.73 0.34

IFDFW baseline 6.56 1.62 6.36 1.79

IFDFW post-test 6.00 1.72 6.26 1.69 1.04 (1) .31 Not significant

IFDFW follow-up 5.86 1.68 6.38 1.61

PFQ baseline 3.92 0.47 4.03 0.47

PFQ post-test 3.94 0.54 3.92 0.47 1.69 (1) .195 Not significant

PFQ follow-up 3.98 0.52 3.90 0.53

PANAS pa baseline 3.69 0.56 3.82 0.57

PANAS pa post-test 3.82 0.53 3.74 0.54 5.67 (1) .018 .035 0.38 (0.06-0.70)

PANAS pa follow-up 3.97 0.58 3.80 0.46

PANAS na baseline 2.12 0.58 2.04 0.50

PANAS na post-test 2.04 0.57 2.32 0.59 18.81 (1) 0.00

0

0.11 0.69 (0.37 – 1.01)

PANAS na follow-up 1.99 0.61 2.29 0.51

173

a = Unadjusted condition means and standard deviations (SD)

Abbreviations: DASS-21 = Depression, Anxiety and Stress Scale; EWB = Emotional Well-being,

measured with MHC-SF; IFDFW = InCharge Financial Distress/Financial Well-Being Scale; ITT =

intention-to-treat; MHC-SF = Mental Health Continuum-Short Form; NA = Negative Affect, measured

with PANAS; PA = Positive Affect, measured with PANAS; PANAS = Positive and Negative Affect

Schedule; PEQ: Partial eta-squared; PFQ = Psychological Flexibility Questionnaire; PWB = Psychological

Well-being, measured with MHC-SF; RS-NL = Dutch Resilience Scale; SMS = Strong Minds Suriname

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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Chapter 7

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,

187

2017; Schiffrin, 2013; Schotanus-Dijkstra, Pieterse, Drossaert, Walburg, , 2017;

Tugade& Fredrickson, 2004; Vulpe & Dafinoiu, 2012), empathy (Sandage &

Worthington, 2010), gratitude (Emmons & McCullough, 2003), goal setting (Otto,

Szczesny, Soriano, Laurenceau, & Siegel, 2016), positive thinking (Yu, Lam, Liu, &

Stewart, 2015), self-efficacy (Toussaint, Barry, Bornfriend, & Markman, 2014),

and psychological flexibility (Kashdan, Barrios, Forsyth, & Steger, 2006). In

contrast to studies on well-being, to date, there have only been a few studies that

examined the causal relationship between well-being interventions and resilience

(Abbott, Klein, Hamilton, & Rosenthal, 2009; Robertson, Cooper, Sarkar, &

Curran, 2015; Sood, Prasad, Schroeder, & Varkey, 2011). These studies were

conducted in Western countries, and did not examine the role of mediators.

In this article, we will focus on two possible mediators in the

development of well-being, namely positive emotions and psychological

flexibility. The literature has identified both variables as factors that mediate the

relationship between PPIs and well-being. Both potential mediators are linked to

theoretical frameworks that attempt to explain how and why PPIs can increase

mental well-being. One theory was developed within the framework of positive

psychology, namely the broaden-and build theory of positive emotions

(Fredrickson, 2001). The other theory was developed from the viewpoint of

cultural psychiatry, namely the flexibility hypothesis of healing (Hinton &

Kirmayer, 2016), which may be relevant in light of the multi-ethnic background of

the participants of the intervention on which our study is based.

Positive emotions

Building on the work of Isen and colleagues (1984, 1985, 1987), Fredrickson’s

broaden-and-build theory of positive emotions (2001) argued that positive

emotions expand people’s attention and cognition, which enables creative

problem solving and flexible thinking. Hence, positive emotions broaden a

person's thought and action repertoire, which in their turn build durable,

personal, physical, and psychological resources (Fredrickson, 2004, 2005). Other

theoretical models have also identified positive emotions as a central element for

positive change. For instance, the Hedonic Adaptation Model (Sheldon &

Lyubomirsky, 2012), holds that a particular change in life, that is accompanied by

the experience of positive emotions, will result in an initial boost in well-being.

Through the occurrence of a number of positive events during a giving period

(such as an intervention) well-being can be maintained. The Positive Activity

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Model suggests that four particular elements of positive activities can increase

well-being, namely (positive) emotions, thoughts, behaviours, and need

satisfaction (Lyubomirsky & Layous, 2013). Positive change can also be

understood through the framework of the emotion regulation theory. This theory

suggests different emotion regulation strategies that can increase positive

emotion (Quoidbach, Mikolajczak, & Gross, 2015). Lastly, the Synergetic Change

Model suggests that lasting changes in mental well-being depends on a complex,

dynamic interaction between various domains of psycho-social functions (Rusk,

Vella-Brodrick, & Waters, 2017). The model covers five major domains, including

positive emotions. In this article we focus on positive emotions as a possible

mediator, since the broaden-and-build theory of positive emotions (Fredrickson,

2001) is one of the most influential theories emerging from positive psychology,

and in later models positive emotions are also the core element for

understanding positive changes.

Psychological flexibility

Another theory that may explain the mechanism behind positive change during

an intervention is the flexibility hypothesis of healing (Hinton & Kirmayer, 2016).

According to this theory flexibility is “the ability to consider different actions,

adopt multiple cognitive frames, or “mindsets”, explore possibilities, and

experience diverse modes of being-in-world”. Drawing on their work in the field

of anthropology and cultural psychiatry, Hinton & Kirmayer (2016) argue that all

healing practices (Western psychotherapy and indigenous practices alike), induce

positive psychological states marked by cognitive and emotional flexibility or an

increased ability to shift cognitive sets. Thus, (psychological) flexibility is a general

mechanism that may also explain the working of PPIs. The concept of

psychological flexibility has been studied for over 50 years, under a numerous

different names including ego-resilience (Block, 1961; Block & Block, 2006), self-

regulation (Carver & Scheier, 2001), and response modulation (Patterson &

Newman, 1993). Kashdan & Rottenberg (2010) describe psychological flexibility as

a dynamic process involving: (1) adaptation to changing situational demands, (2)

reconfiguring of mental resources, (3) shifting perspective, and (4) balancing

competing desires, needs, and life domains. They argued that psychological

flexibility is a key ingredient to psychological health, but that it has largely been

neglected by (positive) psychologists as a cornerstone for daily well-being

(Kashdan & Rottenberg, 2010). Achieving psychological flexibility, however, is the

primary aim in Acceptance and Commitment Therapy (ACT) (Arch et al., 2012;

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Ciarrocchi, Kashdan, & Harris, 2013), which has been recognized as an evidence

based therapy in the treatment of various mental health disorders (Bohlmeijer,

Fledderus, Rokx, & Pieterse, 2011; Bramwell & Richardson, 2018; Vowles &

McCracken, 2008) and increasing well-being (Fledderus, Bohlmeijer, Smit, &

Westerhof, 2010). Lack of psychological flexibility has been associated with

increased psychopathology (Hayes, Luoma, Bond, Masuda, & Lillis, 2006), for

example rumination (Nolen-Hoeksema, Wisco, & Lyubomirsky, 2008), social and

emotional disfunctioning in depression (Ellgring, 2007; Rottenberg, Salomon,

Gross, & Gotlib, 2005), and anxiety (Borkovec, 1994).

It has been suggested that positive emotions may build psychological

flexibility, and that psychological flexibility in its turn generates positive emotions

(Cohn, 2008; Ong, Bergeman, Bisconti, & Wallace, 2006; Tugade & Fredrickson,

2004; Vulpe & Dafinoiu, 2012). For example, a study among US college students

following the September 11th terrorist attacks, demonstrated that students

people with high levels of ego resilience (i.e. psychological flexibility) were better

to rebound from adversity, and the relation was mediated by positive emotions

(Fredrickson, Tugade, Waugh, & Larkin, 2003). In view of the relationship

between positive emotions and psychogical flexibility, we chose psychological

flexibility as a second major mediator.

Present study

Recently, we conducted a randomized controlled trial that examined the effects

of a PPI on mental well-being and resilience among healthy employees with a

multi-ethic background in Paramaribo, Suriname. In this study, we will examine

the mediating effects of positive emotions and psychological flexibility on mental

well-being and resilience. We hypothesize that both positive emotions and

psychological flexibility mediate the relation between the intervention and the

outcomes.

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Methods

Participants and procedure

Employees from three companies in Paramaribo, Suriname were recruited.

Potential participants were screened by the human resource managers of the

companies. The inclusion criteria were as follows: (1) age between 18 and 60

years; (2) participants had sufficient knowledge of the Dutch language to fill out

questionnaires, read the training manual, and participate in written exercises; (3)

willing to participate in a weekly two-hour program for seven consecutive weeks.

The study was a single-blinded parallel randomized controlled trial with an active

intervention group and a waiting list control group. After screening, participants

were randomly assigned to either the intervention or the control condition, using

the online program research randomizer (https://www.randomizer.org). The

assessment of the outcomes was done through self-report measures (paper-and-

pencil tests). Baseline assessment was administered during an initial

informational session with all participants (T0), after which the participants

received the envelopes with the allocation details. One week after the initial

session, the official training program started for the intervention group. In total,

seven sessions were conducted in seven consecutive weeks. After seven sessions,

post-test assessment was conducted for the intervention group and the waiting

list group (T1). After the intervention group finished in the program, the

participants in the waiting list condition started the intervention. Follow-up

measures (T2) were conducted at three months after the end of the training

sessions. Figure 1 provides an overview of the flow of participants.

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Figure 1. Flow-chart of participants in the Strong Minds Suriname program

Assessed for

eligibility

( n = 546)

Met eligibility

criteria

(n = 173)

Did not meet eligibility

criteria

( n = 373)

Randomized

(n = 173)

Allocated to intervention

Strong Minds Suriname

(n = 87)

Allocated to wait list

control group

(n = 86)

Completed base line

assessment

(n = 80)

Completed base line

assessment

(n = 78)

Completed post-test

assessment

(n = 73)

Completed post-test

assessment

(n = 71)

Completed 3 months

assessment

(n = 66)

Completed 3 months

assessment

(n = 54)

Allocation

Follow-up

Analyzed (n = 80)

Analyzed (n = 78)

Analysis

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The intervention

The intervention program was titled Strong Minds Suriname (SMS) and consisted

of a series of activities that involved exploring one's positive emotions, engaging

in new activities, reframing negative thoughts and adopting a positive and

adaptive mind-set. Seven weekly sessions were conducted and each session had a

specific theme, namely (1) resilience; (2) gratitude; (3) positive emotions; (4)

discovering strengths; (5) goal setting; (6) positive thinking; (7) letting go:

forgiveness, surrendering and prayer. Except for the first informational sessions,

each session started with psycho-education, followed by three or four positive

activities. The exercises were conducted by local coaches who prior to the

intervention received training. Exercises included a variety of prototypical positive

psychology activities, including writing a gratitude letter (Seligman, Rashid, &

Parks, 2006), performing acts of kindness (Buchanan & Bardi, 2010), identifying

and using strengths (Proyer, Gander, Wellenzohn, & Ruch, 2015), positive goal

setting (Bolier, Haverman, & Walburg, 2010), and practicing forgiveness (Akhtar &

Barlow, 2016). Breathing exercises, expressing gratitude through prayer, and

silence meditation were also practiced. Voluntary homework assignments

included keeping a gratitude journal and paying a gratitude visit. The duration per

module was two to three hours, including a break. Cultural adaptation was

conducted according to a three phased process, following guidelines for cultural

adaptation as described by Domenech-Rodriguez and Wieling (2004) and

guidelines for the implementation of cultural sensitive cognitive behavioral

therapies (Hinton & Jalal, 2014; Hinton, Pich, Hofmann, & Otto, 2013; Hinton,

Rivera, Hofmann, Barlow, & Otto, 2012). During the first phase, focus group

meetings with human resource management representatives of the participating

companies were conducted, to select topics on well-being and resilience that

seemed relevant to the Surinamese context. During the second phase the content

of the original SRP training was adapted and new content was added. Additional

focus group meetings focused on reviewing the content, semantic, conceptual,

and technical equivalence of the program and the measure instruments. During

the third stage of the adaptation process, the intervention was tested on a group

of eight employees from the participating companies. These employees were also

trained as coaches for the intervention. On the basis of their feedback, the

training manual and exercises were adjusted and the final version of the training

was developed. For a detailed description of the content of the intervention, see

Appendix I.

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Outcome measures

Mental well-being was measured with the Mental Health Continuum-Short Form

(MHC-SF) (Keyes, 2005), a 14-item questionnaire that measures emotional well-

being, social well-being, and psychological well-being. We used the validated

Dutch version (Lamers, Westerhof, Bohlmeijer, ten Klooster, & Keyes, 2011).

Participants had to indicate the frequency of a range of experienced emotions

over the past four weeks. Item scores range from "never" (0) to "(almost) always"

(5), with a higher mean score indicating a higher level of well-being. Its

Cronbach’s alpha in the present study was .89 at pre-test, .92 at post-test, and .94

at follow-up assessment. Resilience was measured with the Dutch Resilience

Scale (RS-nl) (Portzky, Wagnild, De Bacquer, & Audenaert, 2010). This scale is a

Dutch adaptation of the Wagnild and Young Resilience Scale (Wagnild & Young,

1993). The scale consists of 25 items that measures two dimensions of resilience:

personal competence and acceptance of self and life. It uses a 4-point Likert scale

with two anchoring statements from ‘strongly disagree’ (1) to ‘strongly agree’ (4),

with a higher mean score indicating a higher level of resilience. Its Cronbach’s

alpha in the present study was .90 at pre-test, .92 at post-test, and .93 at follow-

up assessment.

Mediator measures

Positive emotions were measured with the Positive Affect subscale of the Positive

and Negative Affect Schedule (PANAS), a 20-item scale that measures two

opposites of mood (Watson, Clark, & Tellegen, 1988). We used the Dutch version

of the PANAS (Engelen, De Peuter, Victoir, Van Diest, & Van den Bergh, 2006).

Items on the PANAS are rated on a five-point scale ranging from "little, or not

very much" (0) to "very much" (10), with a higher score indicating a higher level of

positive or negative feelings and thoughts. Cronbach's alpha for positive affect in

the present study was .86 at pretest, .86 at post-test, and .90 at follow-up

assessment. Cronbach's alpha for negative affect was .84 at pretest, .86 at post-

test, and .88 at follow-up assessment. Psychological flexibility was measured with

the Psychological Flexibility Questionnaire (PFQ). The PFQ originally is a 20-item

questionnaire that measures five factors related to psychological flexibility: (1)

positive perception of change; (2) characterization of the self as flexible; (3) self-

characterization as open and innovative; (4) a perception of reality as dynamic

and changing; (5) a perception of reality as multifaceted (Ben-Itzhak, Bluvstein, &

Maor, 2014). We translated the question to Dutch and selected all 13 questions

of the first three factors. We did not include questions pertaining to the last two

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factors. This was done on the basis of feedback from a focus group meeting of

psychologists in the context of the cultural adaptation process. The questions

from the PFQ on reality perception were considered too complex and abstract for

our target population (lower educated employees). Items of the PFQ are rated on

a 6-point Likert-type scale from "not at all" (1) to "very much" (6), with a higher

score indicating greater psychological flexibility. Its Cronbach's alpha in the

present study was .87 at pre-test, .92 at post-test, and .95 at follow-up

assessments. These findings are comparable to the reliability of the original scale,

that reported a Cronbach’s alpha coefficient of .85.

Statistical analyses

Missing data at baseline and post-test were imputed, using the estimation

maximization (EM) algorithm (Dempster, Laird, & Rubin, 1977). Mediator analyses

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

195

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.

197

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.

(1) (2) (3) (4) (5) (6) (7)

(1) MHC-SF Mental well-being 1

(2) MHC-SF EMO Emotional well-being .78* 1

(3) MHC-SF SOC Social well-being .88* .56* 1

(4) MHC-SF PSY Psychological well-being .89* .60* .62* 1

(5) RS-nl Resilience .48* .40* .29* .54* 1

(6) PANAS-PA Positive affect .48* .33* .36* .52* .64*

1

(7) PFQ Psychological flexibility .52* .30* .40* .57* .65*

.68*

1

* p < .001

Multiple mediation models

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

198

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.

R2 = 0.11

Total effect (c-path) is given in parentheses.

*p < .05, **p < .01, ***p < .001, ns = not significant.

Intervention Mental well-being

Positive emotions 0.37* 0.21**

.45***(0.62***)

Psychological flexibility 0.13 ns 0.76***

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Figure 3. Multiple mediation positive emotions and psychological flexibility as mediators of the intervention group versus waiting list group (T0-T1) on resilience.

R2 = 0.26

Total effect (c-path) is given in parentheses.

*p < .05, **p < .01, ***p < .001, ns = not significant.

Discussion

The aim of this study was to investigate possible mechanisms of change of a

culturally adapted multi-component positive psychology intervention. We

hypothesized that positive emotions and psychological flexibility mediate the

relationship between the intervention program and mental well-being and

resilience. The intervention used in this study has previously shown to increasing

well-being and resilience with large effect sizes for mental well-being (d = 0.62,

95% CI = 0.30 - 0.94) and resilience (d = .76, 95% CI = .43-1.09) (Hendriks et al.,

2018c). These results were in line with earlier studies that reported

improvements on mental well-being for MPPIs (Carr, Finnegan, Griffin, Cotter, &

Hyland, 2016; Cullen et al., 2015; Feicht et al., 2013; Nikrahan et al., 2016; Proyer,

Gander, Wellenzohn, & Ruch, 2016). Multiple meditation analyses in the current

study demonstrated that the intervention led to increased levels of mental well-

being and resilience at post-test, through its effect on positive emotions. Thus,

our hypothesis that positive emotions mediated the relationship between the

intervention and well-being and resilience was confirmed. However, in the multi

meditation models, the percentages of the variance in the outcomes were small,

Intervention Resilience

Positive emotions 0.18* 0.21**

.18***(0.23***)

Psychological flexibility 0.13 ns 0.13***

200

11% in mental well-being and 26 % for resilience, respectively. Therefore, we

conclude that the mediating role of positive emotions is small.

While several correlational studies have reported the meditating role of positive

emotions on well-being and resilience (Schiffrin, 2014; Tugade & Fredrickson,

2004; Vulpe & Dafinoiu, 2012), there is a lack of causal studies examining possible

mediators in PPIs. Recently, a RCT among 275 adults with suboptimal mental

health demonstrated that positive emotions, along with the use of strengths,

optimism, self-compassion, resilience and positive relations mediated the

development of mental well-being, during an 8-week multi-component PPI

(Schotanus-Dijkstra, Pieterse, Drossaert, & Walburg, 2017). However, positive

relations, self-compassion and optimism were the strongest predictors of the

efficacy of the intervention on mental well-being, anxiety and depression, and the

mediating effect of positive emotions were small. This finding is in line with the

results from our mediator analysis, suggesting a limited role for positive emotions

as a possible mechanism for change through a multi-component PPI.

Our study did not find support for the hypothesis that psychological

flexibility played a mediating role between the intervention and well-being and

resilience. This outcome contrasts with findings from other studies that identified

the mediating role of psychological flexibility on mental well-being (Fledderus,

Bohlmeijer, Fox, Schreurs, & Spinhoven, 2013; Kashdan, Barrios, Forsyth, &

Steger, 2006; Wicksell, Olsson, & Hayes, 2010). and resilience (Ong, Bergeman,

Bisconti, & Wallace, 2006; Tugade & Fredrickson, 2004; Vulpe & Dafinoiu, 2012).

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

201

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).

202

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.

203

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.

204

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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Appendix I. Content Strong Minds Suriname program

# Theme Positive activities

1 Resilience - Veerkracht • Introduction: psycho-education on resilience (all groups)

2 Be grateful Gran Tangi: wees dankbaar

• Psycho-education on gratitude

• Relaxation, breathing exercise (i)

• Writing down a gratitude statement (i)

• Verbally expressing gratitude (g)

• Writing a gratitude letter (i)

• Closing moment: verbal expression of positive emotions (g)

• Home work (optional): gratitude visit (i), three good things (i)

3 Positivity starts with you Positiviteit begint bij jezelf

• Psycho-education on positive and negative emotions (i)

• Relaxation, breathing exercise (i)

• Reflection on homework assignments (g)

• Discovering and discussing positive and negative emotions (g)

• Outdoor random acts of kindness and presentation (g)

• Closing moment: verbal expression of positive emotions (g)

• Home work (optional): gratitude visit (i), three good things (i), random acts of kindness at home or work (i)

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4 Developing your own strengths Bouw aan je sterke kanten

• Psycho-education on strengths

• Relaxation, breathing exercise (i)

• Reflection on homework assignments (g)

• Discovering strengths (g)

• Creating a strength symbol/strength word cloud (g)

• Closing moment: verbal expression of positive emotions (g)

• Home work (optional): gratitude visit (i), three good things (i), random acts of kindness at home or work, using strengths at work or at home (i)

5 Your goals are attainable Jouw doelen zijn haalbaar

• Psycho-education on goal setting (SMART goals)

• Physical exercise (i)

• Reflection on homework assignments (g)

• Discussion on goal setting, Checking and developing a SMART goal

• Closing moment: verbal expression of positive emotions (g)

6 Over coming your problems Je problemen overwinnen

• Psycho-education on Adversity/Belief and Consequences

• Written exercises in changing negative to positive beliefs

• Closing moment: verbal expression of positive emotions (g)

7 Let it go Laat het los

• Psycho-education on forgiveness and spirituality

• Moment of silence: exercise in thoughtless awareness (i)

• Forgiveness exercise (writing and verbal expression) (g/i)

• Expressing gratitude through prayer and surrendering (i)

• Closing moment: verbal expression of positive emotions (g)

Abbreviations: (g) group exercise; (i) individual exercise

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Part III

Yoga as a cultural sensitive positive intervention

214

215

Chapter 8

The Effects of Yoga on Positive Mental

Health among Healthy Adults:

A Systematic Review and Meta-analysis

This chapter is published as:

Hendriks, T., de Jong, J., & Cramer, H. (2017). The effects of yoga on positive

mental health among healthy adults: a systematic review and meta-analysis.

Journal of Alternative and Complementary Medicine, 23(7), 505-517.

216

Introduction

The rising popularity of yoga has been a worldwide trend in the new millennium.

During the period from 2002 to 2012 the use of yoga in the United States alone

increased from 5.1% to 9.5% (Clarke, Black, & Stussman, 2015) Yoga has become

a focal point of scientific attention, with a sharply increasing number of

publications on its beneficial effects (Cramer, Lauche, & Dobos, 2014; Jeter, Singh,

& Slutsky, 2015). That the growing interest in yoga is more than a fleeing trend

was underlined when the United Nations in December 2014 declared the 21st of

June as 'International Day of Yoga', which aims at raising awareness worldwide of

the benefits of yoga (Abraham, 2015). Yoga is originally a spiritual practice rooted

in Indian philosophy. In modern practice its main techniques consist of postural

exercises (asanas), breathing exercises (pranayama), and meditation (dnyana)

(Boehm, Lyubomirsky, & Sheldon, 2012; Cramer, Krucoff, & Dobos, 2013). People

practice yoga for a variety of reasons. They expect relief from pain, stress,

depression and other physical health issues. In addition to that, people practice

yoga for spiritual reasons and to increase feelings of happiness (Park, Riley,

Bedesin, & Stewart, 2014; Quilty, Saper, Goldstein, & Khalsa, 2013). Some have

pointed out that in the West the focus is on the physical benefits of yoga (such as

relaxation, stress relief) while in the East the focus is on the integration of body

and the mind (de Michelis, 2004). Although the primary reasons for people in

Western countries to start practicing yoga may be physical ones, with continued

practice there seems to be a shift towards spiritual reasons, suggesting a holistic

mind-body-spirit experience (Park, Riley, Bedesin, & Stewart, 2014).

Positive mental health

Positive psychology is a movement that focuses on the scientific study of the

conditions and processes contributing to the flourishing or optimal functioning of

people, groups, and institutions (Gable & Haidt, 2005; Sheldon & King, 2001).

With the emergence of the positive psychology movement, there has been a shift

of the view on the concept of mental health. The traditional approach of mental

health regards mental illness and mental well-being as two opposite poles of a

continuum (Greenspoon & Saklofske, 2001). The notion that mental health does

not equal the absence of mental illness is gaining territory. Positive Mental Health

(PMH) is defined as a health state characterized by the presence of psychological

well-being (positive individual functioning, self-realization), emotional well-being

(feelings of happiness and satisfaction), and social well-being (positive social

functioning) (Keyes, 2002; Westerhof & Keyes, 2010). The Dual Factor Model of

217

Mental Health (Antamarian, Scott Huebner, Hills, & Valois, 2010; Doll, 2008;

Wang, Zhang, & Wang, 2011) and the Two Continua Model (Keyes, 2002, 2005,

2007; Lamers, Westerhof, Glas, , 2015; Westerhof & Keyes, 2010) are two similar

models that suggest mental illness and mental well-being are two separate

dimensions that correlate.

Positive psychology and yoga

In order to understand and treat mental illnesses clinical psychology historically

has focused on classifying psychological dysfunctions (Lyons, Scott Huebner, Hill,

& Shinkareva, 2012; Sheldon & King, 2001). Positive psychology aims at changing

this approach and has developed various interventions the past two decades

various interventions. These positive psychology interventions consist of

techniques and exercises aimed at developing personal strengths, and enhancing

positive emotions, life satisfaction, personal growth and meaning (Casellas-Grau,

2014). Examples of evidence based positive psychology exercises are

‘remembering three good things’ (Gander, Proyer, & Ruch, 2016; Odou & Vella-

Brodrick, 2013; Pietrowsky & Mikutta, 2012) , ‘identifying and using character

strengths’ (Andrewes, Walker, & O'Neill, 2014; Mitchell, Stanimirovic, Klein, &

Vella-Brodrick, 2009; Proyer, Gander, Wellenzohn, & Ruch, 2015), ‘performing

acts of kindness’ (Buchanan & Bardi, 2010), ‘counting one's blessings’(Emmons,

2003), ‘gratitude exercises’ (Boehm, Lyubomirsky, & Sheldon, 2011; Chan, 2013;

Ghandeharioun, Azaria, Taylor, & Picard. 2016; Ouweneel, LeBlanc, & Schaufeli,

2014), ‘appreciation of beauty exercises’ (Proyer, Gander, Wellenzohn, & Ruck,

2016) and ‘savoring the moment exercises’ (Hurley & Kwon, 2012). Positive

psychology has contributed to a shift from a focus on the negative indicators of

mental health towards more research on positive indicators of mental health. A

wide variety of recently published meta-analyses report on indicators of positive

mental health such as compassion (MacBeth, & Gumley, 2012; Zessin, Dickhäuser,

& Garbade, 2015), forgiveness (Davis et al, 2015; Wade, Hoyt, Kidwell, &

Worthington, 2014), gratitude (Davis etal ., 2015) , goal setting (Kleingeld, van

Mierlo, & Arends, 2010), hope (Alarcon, Bowling, & Khazon. 2013), resilience (Hu,

Zhang, & Wang, 2015; Lee et al., 2013) . Many positive psychology interventions

have also integrated mindfulness meditation (Bolier et al., 2013; Burckhardt,

Manisavasagar, Batterham, Hadzi-Pavlovic, 2016; Cohn, Pietrucha, Saslow, Hult, &

Moskowitz, 2014; Feicht et al., 2013; Nikrahan et al., 2016). Positive psychology in

general promotes mind-body interventions but its focus appears to be limited to

interventions based on Buddhist principles such as mindfulness based

interventions (Bohlmeijer, Prenge, Taal, & Cuijpers, 2010; Hamilton, Kitzman, &

Guyotte, 2006; Ivtzan et al., 2016; Niemiec, 2012) and Acceptance and

218

Commitment therapy (Bohlmeijer, Lamers, & Fledderus, 2015; Fledderus,

Bohlmeijer, Pieterse, & Schreurs, 2012). Besides ongoing research of the effect of

mindfulness based meditation on negative indicators of mental health, such as

anxiety, depression, stress, there is a growing number on studies that investigate

the link between mindfulness and specific positive constructs, such as

compassion (Blunt & Blanton, 2014; Roeser & Eccles, 2014), forgiveness (Webb,

Dustin Phillips, Bumgarner, & Conway-Williams, 2013), gratitude (Loo, Tsai, Raylu,

& Oei, 2014), happiness (Hollis-Walker & Colosimo, 2010), optimism (Malinowski

& Lim, 2015), self-awareness/self-control (Vago & Silbersweig, 2012) and

character strengths and virtues (Niemiec, Tayyab, & Spinella, 2012). However,

while the positive psychology movement seems to have fully embraced

mindfulness and the Buddhist philosophy, it appears that it is neglecting the

benefits of yoga and ignores the psychological and philosophical knowledge that

can be found in yoga philosophy and Hinduism. During the systematic database

search we performed, we only encountered a handful of publications discussing

the relation between yoga and positive psychology (Ivtzan, & Papantoniou, 2014;

Kumar & Kumar, 2013; Levine, 2011) or indicators of positive mental health, for

example passion (Carbonneau & Vallerand, 2010). This is odd when you realize

that positive psychology and yoga share much common ground when it comes to

their specific goals; both focus on achieving well-being, increasing meaning in life

and personal growth.

Aim of the study

Although most people believe and expect that yoga will increase their well-being,

to our best knowledge there have not been any studies that examine the

relationship between yoga and (positive) mental well-being among healthy

adults. The aim of this meta-analysis is to investigate the effects of yoga on

positive mental health among adults from non-clinical populations, to establish if

there is a possible causal relation. A national survey on the mental and physical

benefits of yoga among 4307 practitioners reported that only 1.1% of the

practitioners of yoga indicated that they were languishing, that is experiencing

severe mental and/or physical problems (Ross, Friedman, Bevans, & Thomas

2013), while a bibliometric analyses reported that 73.9% of published randomized

controlled trials on yoga focus on non-healthy participants (Cramer et al., 2014).

In this study are interested in whether yoga can improve positive mental health in

healthy individuals rather than serving as a therapeutic intervention. Physical

conditions clearly influence positive mental health indicators, mental conditions

even more so. In order to reduce heterogeneity, only trials on healthy individuals

(or those from the general population) were included. We only included

219

outcomes of randomized controlled trials (RCT’s) because the RCT is widely taken

as the gold standard for doing scientific research in the field of medicine and

psychology (Cuijpers, 2016; Kaptchuk, 2001; West et al., 2008).

Methods

The PRISMA guidelines for systematic reviews and meta-analyses (Moher,

Liberati, Teztlaff, & Altman, 2009) and the recommendations of the Cochrane

Back Review group (Higgins et al., 2011) were followed in the planning and the

implementation of the review.

Inclusion criteria

The inclusion and criteria for this review were: (1) adults belonging to a non-

clinical population; (2) studies with outcomes that could be identified as positive

indicators of mental health; (3) all structured forms of yoga that offer a postural

based (asanas), breathing based (pranayama) or meditation based (dnyana)

program or a combination of these three elements; (4) randomized controlled

trials. Research indicates that the various yoga styles do not differ in their odds of

reaching positive conclusions (Cramer, Lauche, Langhorst, & Dobos, 2016) so

there will be no differentiation of the effects per style.

Literature search

Data was gathered in the following ways: (1) for studies prior to 2014 we first

included all randomized controlled trials that were found in a bibliometric

analysis that was conducted in 2014 by one of the authors (Cramer et al., 2014).

In this analysis electronic data bases Medline/PubMed, Scopus, the Cochrane

Library, IndMED were searched, and the tables of content of yoga specialty

journals not listed in medical databases were checked. Search terms around the

key word “yoga” were used for the literature search; the complete search

strategy for PubMed/Medline is shown in table 1 and the search strategy was

adapted for the other databases; (2) for studies from 2014 through 2015

databases PubMed/Medline, Scopus, IndMED and the Cochrane Library were also

searched, using the aforementioned strategy. In addition, references of several

meta-analysis, reviews and trials were checked. We only included studies that

were published in articles in peer reviewed journals, and did not include research

from grey literature, dissertations or conference proceedings.

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Table 1. Search strategy

PubMed/Medline

# 1 Yoga [MeSH Terms]

# 2 Yoga* [Title/Abstract] OR Yogic [Title/Abstract] OR Pranayam*

[Title/Abstract] OR Asana* [Title/Abstract] #3 #1 OR #2

#4 Randomized Controlled Trial [Publication Type] OR controlled

clinical trial [Publication Type] OR randomized [Title/Abstract]

OR placebo [Title/Abstract] OR random [Title/Abstract] OR randomly

[Title/Abstract] OR trial [Title/Abstract] OR group [Title/Abstract]

#5 #3 AND #4

Asterisks (*) represent truncations (PubMed finds all terms that begin with a given text string).

Data extraction

The data extraction was performed by one reviewer (TH) and independently

checked by a second reviewer (HC). The following data was extracted: authors,

year of publication, country origin, population, intervention, number of

participants who completed the trial, primary and secondary outcomes, post

measurements of mean and standard deviation. Consensus was achieved by

discussion.

Risk of bias assessment

Two authors (TH, HC) independently assessed the risk of bias using the Cochrane

risk of bias tool (Higgins et al., 2011) on the following domains: selection bias

(random sequence generation, allocation concealment), performance bias

(blinding of participants and personnel), detection bias (adequate outcome

assessor blinding), attrition bias (incomplete outcome data), reporting bias

(selective outcome reporting) and free of other bias (such as extreme baseline

imbalance, author alliance, population bias) (Jadad & Enkin, 2007). Consensus

was achieved by discussion.

Data analysis

Assessment of overall effect size

Separate meta-analyses were conducted for comparisons of yoga to different

control interventions using Review Manager 5 software (Version 5.1, The Nordic

Cochrane Centre, Copenhagen). Meta-analyses were conducted by random

effects models if at least two studies assessing this specific outcome were

available. Standardized mean differences (SMD) with 95% confidence intervals

(CI) were calculated as the difference in means between groups divided by the

pooled standard deviation using Hodges’s correction for small study samples. (55)

221

Where no standard deviations were available, they were calculated from

standard errors, confidence intervals or t-values (Higgins & Green, 2008), or

attempts were made to obtain the missing data from the trial authors by email. A

positive SMD (i.e. higher values in the yoga group) was defined to indicate

beneficial effects of yoga compared to the control intervention. If necessary,

values were inverted (Higgins et al., 2011) Cohen's categories were used to

evaluate the magnitude of the overall effect size with (1) SMD=0.2-0.5: small; (2)

SMD=0.5-0.8: medium; and (3) SMD>0.8: large effect sizes (Cohen, 1988).

Assessment of heterogeneity

Statistical heterogeneity between studies was analyzed using the I2 statistics, a

measure of how much variance between studies can be attributed to differences

between studies rather than chance. The magnitude of heterogeneity was

categorized as (1) I2=0–24%: low heterogeneity; (2) I2=25–49%: moderate; (3)

I2=50–74%; and (4) I2=75–100%: considerable (Higgins & Green, 2008; Higgins,

Thompson, Deeks, & Altman, 2003). The Chi2 test was used to assess whether

differences in results are compatible with chance alone. Given the low power of

this test when only few studies or studies with low sample size are included in a

meta-analysis, a p-value ≤ 0.10 was regarded to indicate significant

heterogeneity.

Sensitivity analyses

To test the robustness of significant results, sensitivity analyses were conducted

for studies with high versus low risk of selection bias (adequate random sequence

generation and allocation concealment). If heterogeneity was present in the

respective meta-analysis, sensitivity analyses were also used to explore possible

reasons for statistical heterogeneity.

Publication bias across studies

Assessment of publication bias was originally planned by using funnel plots

generated using Review Manager software (Higgins & Green, 2013). As less than

10 studies were included in each meta-analysis, funnel plots could not be

analyzed.

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Results

Study selection

We identified a total of 1901 records. The flowchart is presented in Figure 1.

After the removal of duplicates 495 records remained for screening. Of these, 297

articles were excluded because they were related to the clinical population,

leaving 202 of full-text articles to be assessed for eligibility. Of these 182 were

excluded: 170 studies did not have any outcome that could be classified as a

positive outcome, eight studies did have a positive outcome but the population

was under 18 years of age, one was not a yoga intervention, four used a program

where yoga was combined with other invention types, and from one study the

results had been published in an earlier study which was included.

Figure 1. Results of literature search

312 RCTs from

original search

2014

2014-2015 search

1583 of records identified

through database searching

422 PubMed

864 Scopus

239 Cochrane Library

58 IndMED

Scre

enin

g El

igib

ility

Id

enti

fica

tio

n

495 of records after duplicates removed

182 articles excluded - 170 no positive outcome - 8 Age < 18 - 3 mixed method or no yoga intervention - 1 study re-published

17 of studies included in quantitative analyses

(meta-analyses)

20 of studies included in qualitative analyses

202 of full-text articles assessed for eligibility

293 full text articles excluded; clinical population

Incl

ud

ed

6 RCTs from hand

search 2014

3 articles excluded;

insufficient raw data

223

In total 20 studies were included in the systematic review: 17 studies were

included in the quantitative meta-analysis; three studies were included in the

qualitative analysis due to insufficient raw data (incomplete means and/or

standard deviation).

Study characteristics

Table 2 show the characteristics of the 20 included RCT’s. Seven studies

originated from India, six studies from the United States, four studies from the

United Kingdom, one study from Australia, one study from Japan, and one study

from Turkey. The studies were published between 1983 and 2015. The total

number of participants was 1901 of which 769 participants received an exclusive

yoga intervention. In eight studies the yoga intervention consisted of combination

of physical postures (asanas), breathing exercises (pranayama) and meditation

(dnyana), in eight studies a combination of physical postures and breathing

exercises, one study consisted of physical postures and meditation, and three

studies consisted of only physical postures. The average intervention period was

nine weeks, with an average of 12sessions that lasted around 53 minutes on

average. In ten of the twenty studies daily practice between 10 and 60 minutes

was advised, with an average of 30 minutes. The control conditions used were

yoga plus physical exercises (100), physical exercises (319), mindfulness (94),

progressive muscle relaxation (65), brain wave vibration (29),) and non-active

control groups (536 participants). The age of the participants ranged from 18 to

77 years, with some studies not reporting (mean) age. The female ratio in total

was 61%. (The study by Haber et al., 1983 reported the female ratio of two

groups at baseline which was 66% and 60% but did not report the number of

females who completed the trial).

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Table 2. Characteristics of included studies

Author, Year, Country

Intervention N Age Yoga type

Sessions, weeks, duration

Results/Instrument

Bhat et al., 2012, India

1. Yoga 2. Physical Exercises 3. Y+PE 4. Non-active control

100 100 100 100

25-30 A+P Y: 60, 12w, 45 min. PE: 60, 12w Y&PE: 60, 12w

• 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)

• Love, Thankfulness, Prayerfulness, Childlike innocence, Awe, Mystery, Timeless/boundless (SRDI)s: No significant effects

Haber, 1983, India

1. Yoga 2. Physical exercise

43 43

69.4 A+P

Y+PE: 10, 10w + daily practice

• PWB (BS): Significant effects for yoga and physical exercise (p<.05)

Harinath et al., 2004, India

1. Yoga (Y) 2. Physical Exercises

15 15

29.6 A+P+D Y+PE: 3m + 60 min. daily practice

• PWB: Significant effects yoga group (p < .001)

Hartfiel et al., 2011, United Kingdom

1. Yoga 2. Wait list control

20 20

39.3 A+P+D

Yoga: 6-18, 6w, 60 min. + 35 min. daily practice

• Life purpose and satisfaction (IPPA): Significant effects in yoga group (p < .009).

• Self-confidence (IPPA): Significant effects in yoga group (p < .001)

• Agreeableness (IPPA): small but no significant increase.

Hartfiel et al., 2012, United Kingdom

1. Yoga 2. Wait list control

33 26

44.8 A+P+D

Yoga: 8, 8w, 60 min, 20 min. daily practice

• PWB (PANAS X): Significant effects for yoga (p<.001): Serenity (p < .001), Self-assured (p < .01) and Attentiveness (p < .01), Joviality: No significant effect for yoga

226

Jayabharathi, 2014, India

1. Yoga 2. Non active control

128 126

49.1 A+P+D Yoga: 41, 18, 35-40 min. daily practice

• PWB, Social relations and Environment (WHOQoL-BREF): Significant effects (p<.001) for yoga

Kanojia et al., 2013, India

1. Yoga 2. Non active control

25 25

18.3 A+P+D 78, 13w, 40 min.

• PWB: Significant effects at postmenstrual phase (p<.01) and premenstrual phase (p<.001)

Rakhshani et al., 2010, India

1. Yoga 2. Physical Exercises

51 51

28.5 A+P+D 48-54, 16 -18 w + daily practice

• PWB (WHOQOL-100):: Significant effects for yoga: (p <.001)

• Social Relationships (WHOQOL-100): Significant effects for yoga: (p <.001)

• Independence, Spirituality, Environment (WHOQOL-100): Non-significant effects

Shelov et al., 2009, USA.

1. Yoga 2. Non-active control

23 23

34.4 A+P 8, 8w, 60 min. + daily practice

• Mindfulness (FMI): Significant effects for yoga (p<.05) and control group (p<.01)

Taspinar et al., 2014, Turkey

1. Yoga 2. Resistance Exercise 3. Non-active control

17 17 17

25.6 A+P 21, 7w, 50 min. • Self-esteem (RSS): Significant effects for yoga and resistance exercise

Varambally et al., 2012, India

1. Yoga 2. Wait list

7 11

28.6 A+D 12, 4w + 2m daily practice

• PWB (WHOQOL – BREF): Significant effects for yoga: (p<.05)

• Social relationships, Environment (WHOQOL – BREF): Non-significant effects

Vogler et al., 2011, Australia

1. Yoga 2. Non-active control

19 19

73.2 A 16, 8w weeks, 90 min, + 3x w 15-20 min daily practice

• Emotional well-being (MCS/LOQ): Small but non-significant effects in emotional well-being (p=.04)

• Self-care (MCS/LOQ): Small but non-significant improvement in the yoga group (p=.04) and self-care (p=.001)

• Social connectedness, purpose and meaning (MCS/LOQ): No significant effects

227

Wolever et al., 2012, USA

1. Yoga 2. Mindfulness 3. Non-active control

76 82 47

A+P+D

12, 12w, 60 min • Mindfulness (CAMS-R): Significant effect on mindfulness (p<.01)

Abbreviations: PWB: psychological well-being; Yoga types: A: Asanas; P: Pranayama; D: Dnyana Instruments: BS: Bradburn Scale, CAMS-R: Cognitive and Affective Mindfulness Scale-Revised CDSES: Chronic Disease Self-Efficacy Scales, FMI: Freiburg Mindfulness Inventory, GDS: Geriatric Depression Scale, GSES: General Self-Efficacy Scale, IPPA: Inventory of Positive Psychological Attitudes, LGMS: Lawton’s PGC Morale Scale, LOQ: Life's Odyssey Questionnaire, MAAS: Mindfulness Attention Awareness Scale, MCS: Mental Component Summary, PANAS-X: Positive and Negative Affect Scale, PSPP: Physical Self Perception Profile, PWS: Psychological Well-being Scale, RSS: Rosenberg Self-esteem Scale, SRDI: Smith Relaxation Disposition Inventory, SRSI: Smith Relaxation States Inventory, STAI: State-Trait Anxiety Inventory, STAXI: State-Trait Anger Expression Inventory, WEMWBS: Warwick-Edinburgh Mental Well-being Scale, WHOQOL-100:World Health Organization Quality of Life , WHOQoL-BREF: World Health Organization Quality of Life Scale

Study measures

In total we found 32 types of measures that could be indicated as indicators of

positive mental health (at ease/peacefulness, attentiveness, aware, awe and

wonder, childlike innocence, disengagement, independence, joviality, joy,

emotional well-being, environment, life and health attitude, life purpose

satisfaction, love and thankfulness, mental quiet, mindfulness, mystery,

peacefulness, prayerfulness, quality of life, rested/refreshed, positive affect,

psychological well-being, purpose and meaning, self-assured/self-confidence,

self-efficacy, self-esteem, serenity, spiritual, social relationships, strengths and

awareness, timeless/boundless). However, a meta-analysis requires a comparison

of a similar outcome in minimum of two studies with a comparable control group

(either active or non-active control group). In total only sufficient data on four

indicators of positive mental health was available to do the meta-analysis. These

four indicators are psychological well-being, life satisfaction, social relationships

and mindfulness. The first indicator corresponds with the construct of

psychological well-being in the framework of PMH. The second indicator

corresponds with emotional well-being, and the third indicator corresponds with

social well-being. Mindfulness is a state of focused non- judgmental attention,

with the awareness being in the present moment (Kabat-Zinn, 2003; Keng,

Smoski, & Robins, 2011) and is associated with increased well-being (Brown &

Ryan, 2003; Harrington, Loffredo, & Perz, 2014; Weinstein, Brown, & Ryan, 2009).

It could be regarded as a proxy measure of positive mental health in general.

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Risk of bias in individual studies

The risk of bias assessment for each study is shown in Table 3. Selection bias was

low in eight of the twenty studies, in the other studies the risk could not be

determined because the randomization process was not described. Allocation

concealment was only described properly in three studies and therefor classified

as having a low risk of bias. Blinding of participants and personnel was described

in three studies, leading to the classification of a high risk of bias. Only one study

properly described outcome assessor blinding, scoring a low risk of bias; the other

studies did not report any information. Risk of attribution bias was low in three

studies, high in four studies and unclear on 13 studies. In eighteen studies all

analyzed outcomes were reported, so these studies appear to be free from

selective reporting.

Table 3. Risk of bias assessment of the included studies using the Cochrane risk of bias tool

Author, Year SB PB DB AB RB OB

Bhat et al., 2012 Unclear Unclear Unclear Unclear Unclear Low risk Unclear

Bonura et al., 2014 Unclear Unclear Unclear Unclear Unclear Unclear Low risk

Bowden et al., 2012 Low risk Low risk Unclear Unclear Unclear Low risk High risk

Bowden et al., 2014 Low risk Unclear Unclear Unclear Unclear Low risk High risk

Cusumano et al.,

1992

Unclear Unclear Unclear Unclear Unclear Low risk Unclear

Elavsky et al., 2007

Unclear Unclear Unclear Low risk Low risk Low risk Low risk

Ghoncheh et al.,

2003

Unclear Unclear Unclear Unclear Unclear Low risk Unclear

Godse et al., 2015 Low risk Unclear Unclear Unclear High risk Low risk Unclear

Haber, 1983 Unclear Unclear Unclear Unclear Unclear Unclear Unclear

Harinath et al., 2004 Low risk Unclear Unclear Unclear Unclear Low risk Unclear

Hartfiel et al., 2011 Low risk Unclear High risk Unclear Unclear Low risk High risk

Hartfiel et al., 2012 Unclear Unclear Unclear Unclear High risk Low risk Low risk

Jayabharathi, 2014

eeee201422014201

4India

Low risk Unclear Unclear Unclear Low risk Low risk Low risk

Kanojia et al., 2012 Unclear Unclear High risk Unclear Unclear Low risk Low risk

Rakhshani et al.,

2010

Low risk Unclear High risk Unclear Unclear Low risk Low risk

Shelov et al., 2009 Unclear Unclear Unclear Unclear Unclear Low risk Unclear

Taspinar et al., 2015 Unclear Low risk Unclear Unclear High risk Low risk Low risk

Varambally et al.,

2012

Low risk Low risk Unclear Unclear High risk Low risk Low risk

Vogler et al., 2011 Unclear Unclear Unclear Unclear Low risk Low risk Unclear

Wolever et al., 2012 Unclear Unclear Unclear Unclear Unclear Low risk Unclear

Abbreviations: SB = Selection bias: 1) random sequence generation; 2) allocation concealment; PB = Performance bias- blinding of participants, personnel; DB = Detection bias - adequate outcome assessor blinding; AB = Attribution bias – incomplete outcome data; RB = Reporting bias - Selective outcome reporting; OB = Other bias

229

Finally, three studies were classified as having a general high risk of bias due to

author affiliation, not specifying funding or having high unaccounted drop-outs

rates. Eight studies that clearly addressed funding and absence of conflict of

interest were rated having low risk of bias. In conclusion, the overall risk of bias

could not be determined, due to unclear reporting.

Data analysis

Meta-analyses of psychological well-being revealed significant group differences

favoring yoga over no intervention (n = 768; SMD 0.69, 95% CI 0.16, 1.22; p =

0.01; I2 90%). No such group differences occurred compared to physical activity (n

= 552; SMD 0.00, 95% CI -0.34, 0.35; p = 0.99; I2 72%; Figure 2). No effects of yoga

compared to no intervention occurred for life satisfaction (n = 140; SMD 0.39,

95% CI -0.47, 1.25; p = 0.38; I2 80%; Figure 3); and social relationships (n = 310;

SMD 0.30, 95% CI -1.21, 1.81; p =0.69; I2 95%; Figure 4). Further meta-analyses on

mindfulness revealed no group differences between yoga and no intervention (n

= 169; SMD -0.09, 95% CI -0.47, 0.29; p = 0.65; I2 27%); and yoga and physical

activity (n = 52; SMD -0.17, 95% CI -0.72, 0.38; p = 0.54; I2 0%); while group

differences favoring mental activity over yoga were found (n = 179; SMD -0.30,

95% CI -0.60, -0.01; p=0.05; I2 0%; Figure 5).

Figure 2. Effects of yoga on psychological well-being

230

Figure 3. Effects of yoga on mindfulness

Figure 4. Effects of yoga on life satisfaction

Figure 5. Effects of yoga on social relationships

231

Sensitivity analyses

When only studies with low risk of selection bias were included, only the effects

of yoga compared to no intervention on psychological well-being remained

significant, only one RCT could be included in this analysis (n=18; SMD=1.02; 95%

CI 0.00, 2.04; p = 0.05). The effect on mindfulness favoring mental activity over

yoga no longer was significant, only one RCT could be included in this analysis (n =

18; SMD=-0.60; 95% CI -1.48, 0.29; p= 0.19).

Discussion

Following a systematic literature search we included 17 studies in the meta-

analysis. Although we found 32 different indicators of positive mental health, only

four of these indicators were present in two or more studies, namely

psychological well-being, social relationships, life satisfaction and mindfulness.

For psychological well-being we found that yoga had favorable effects over no

intervention but did not have a favorable effect over mental activity and physical

activity. In relation to life satisfaction and social relationships we found no

significant effects for yoga versus no intervention. For mindfulness we found that

yoga interventions had no significant effects on mindfulness in comparison to no

intervention, and no significant effect compared to control groups that featured

mental and psychical activity. It appears that yoga is not effective in the

development of positive mental health in general, except maybe for the

dimension psychological well-being.

Limitations

There are several limitations in this meta-analysis. Firstly, there are a very limited

number of studies that focus on positive outcomes in healthy adults. From almost

500 RCT’s, only 20 studies (4%) reported positive outcomes for yoga among

healthy adults, a very disproportionate ratio. We identified 32 different indicators

of positive mental health but could only include measures for four indicators:

psychological well-being, life satisfaction, social relationships and mindfulness.

For psychological well-being we found 8 studies that measured the effect of yoga

versus no intervention and 6 studies for yoga versus physical activity. For life

satisfaction and mindfulness, we only found two studies that measured the effect

of yoga versus an active and/or no intervention, for social relationships only three

studies. Based on only two or three studies we believe definite claims on the

232

presence or absence of certain effects cannot be made. In sum, we can only draw

a firm conclusion on the effects of yoga on psychological well-being, being that

yoga only improves psychological well-being compared to no intervention. It

could be argued that with so such a small number of studies a meta-analysis is

not warranted. However, Davey et al. 2011 performed an analysis of 22,453

meta-analyses and found the median number of included studies was three,

under three quarters contained five or fewer studies(Davey, Turner, Clarke, &

Higgins, 2011). Thus, we do not regard the limited amount of studies in our meta-

analysis is an exception. Secondly, findings of this study must be interpreted with

caution due to the clinical heterogeneity of the intervention in regard to the

various yoga traditions, the differences in duration and frequency of the

intervention. In addition to the heterogeneity, most studies display a poor

methodological reporting making a clear risk of bias assessment practically

impossible. Thirdly, we believe there are limitations to the way psychological

well-being is being measured. The majority of the study psychological well-being

is measured using quality of life questionnaires and reflect the traditional view of

mental health, that mental health is the absence of mental illness. We believe

that the presence of positive outcomes are more likely to be found, when

measured by instrument that reflects the dual factor/ two continua model

approach to mental health, by using questionnaires such as the Mental Health

Short Form (Lamers, Westerhof, Bohlmeijer, ten Klooster, & Keyes, 2011), the

Positive Mental Health instrument (Seow et al., 2016) or even the Positive and

Negative Affect Scale (Watson, Clark & Tellegen, 1988).

Suggestions for future research

Firstly, as we have seen that only 5% of the current research is focused on

positive outcomes we suggest that future research in the field of yoga makes a

shift from the focus on negative outcomes towards positive outcomes, so there is

more of a balance between the two outcomes. Secondly positive constructs

should not be measured by scales that define positive mental health merely as

the absence of mental illness. We also suggest positive mental health is not only

measured in a general sense (psychological well-being, quality of life) but more

specifically just like mindfulness research focuses the relation with specific

positive constructs. Thirdly, studies on the effects of yoga intervention that

primarily focus on physical postures (asanas). Whereas the relationship between

positive mental health and meditation have been found, there is simply no study

that focus on the sole effects of yoga meditation (dnyana). We recommend that

future studies focus more on the effects of yogic meditation. Fourthly, since the

overall risk of bias could not be assessed due to unclear reporting, we

233

recommend that future researchers pay more attention to the quality of

methodological reporting, for example by following the CONSORT guidelines for

reporting parallel group randomized trials (Schulz, Altman, & Moher, 2010).

Fifthly, we question if modern researchers in the field of psychology and yoga are

actually measuring what practitioners intend to achieve through yoga. In our

meta-analysis we only found one study that measured spirituality. A survey

among 604 US students reported that 73% considered yoga to be a spiritual

activity (Quilty, Saper, Goldstein, & Khalsa, 2013), and many practitioner’s expect

that yoga will lead to an increased sense of spirituality (Park, Riley, Bedesin, &

Stewart, 2016). However in research the spiritual aspects of yoga are rarely

addressed (Büssing, Michalsen, Khalsa, Telles, & Sherman, 2012). In this light we

would like to remind the field that the original goal of yoga, as described in the

Yoga Sutras (Patañjali, 2003), was the removal of fluctuations of the mind. What

Patañjali addresses as ‘fluctuations of the mind’ could be associated with modern

psychological constructs such as worrying, rumination, or mental activity.

However, we have not found a single study that measure mental activity in yoga

studies. Many studies in the field of mindfulness that focus on outcomes that play

an important role in Buddhism such as compassion (Dahm et al., 2015; Lo, Ng, &

Chan, 2015; Williams, Dalgleish, Kuyken, & Cecil, 2014) and non-attachment

(Brown & Ryan, 2003; Sahdra, Ciarrochi, Parker, Marshall, & Heaven, 2015;

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).

245

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

246

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 -

random sequence allocation; (2) Selection bias - allocation concealment; (3) Performance

bias - blinding of outcome assessment; (4) Attrition bias - completeness of outcome data;

(5) Reporting bias - selective findings. Random sequence generation refers to the

description of the method that was used to generate the allocation sequence. Allocation

concealment refers the description of the method used to conceal the allocation

sequence. Performance bias refers to the measures used to blind participants and

researchers from any knowledge of which intervention participants received. Attrition bias

refers to the completeness of the reporting of outcome data for the main outcomes,

including attrition and exclusions of participants from the analysis. Reporting bias refers to

bias due to selective outcome reporting (Higgins et al., 2011). One point was appointed for

each criterion met. The quality of a study was assessed as ‘high’ when a minimum of four

criteria were met, ‘medium’ when two or three criteria were met, and ‘low’ when less

than two criteria were met. Consensus between the two reviewers was reached through

discussion. The quality of the non-randomized controlled trial, the cross-sectional studies,

and the cohort study was assessed using the Newcastle-Ottawa Quality Assessment Scale

(NOS). The NOS employs three main study assessment criteria: (1) selection; (2)

comparability; (3) exposure. In total, there are nine items and a maximum of 9 points can

be awarded (Wells et al., 2013). The use of the NOS is endorsed by the Cochrane

Collaboration to assess the quality of observational studies (Higgins & Green, 2011).

Effect size calculation

Where possible, effect sizes (Cohen’s d) were calculated by subtracting the average

score of the experimental group from the average score of the control group, and

dividing the outcome by the pooled standard deviations of both groups. This was done

using outcome data at post-test level. 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 1.20 as large

(Lipsey & Wilson, 1993).

Results

Study selection

Eleven studies met the selection criteria, Figure 1 outlines the selection process.

Study characteristics

The studies included a total of 910 participants. Four studies (36.4%) were randomized

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controlled trials, four (36.4%) were cross-sectional studies. Other study designs were a

non-randomized controlled trial (9.1%, n = 1), a cross-sectional survey (9.1%, n = 1),

and a prospective cohort study (9.1%, n = 1). Seven studies (63.6%) included healthy

adults, four studies (35.4%) included adults with health problems (general health

problems, asthma, anxiety/depressive symptoms, and major depression). Eight studies

(72.7%) had an active control group, three studies (27.3%) had a non-active control

group. Five studies (45.5%) examined the effects of a SY intervention compared to

another form of intervention. Two studies (18.8%) compared effects between long-

term and short-term practitioners of SY. Four studies (36.4%) compared long-term

practitioners of SY to a control group of non-meditators. The mean age of the

participants was 42.3 (SD= 4.1), and the percentage of female participants was 57.6%

(excluding three studies that did not report the gender of the participants). The

characteristics of the studies can be found in Table 1.

Figure 1. Results of literature search

17 of additional records identified

through hand searching

115 records retrieved from

electronic databases search:

26 PubMed

32 Medline

16 PsycINFO

41 Scopus

Pubmed n = 512

PsycInfo n = 1935

Scopus n = 2,194

Scre

enin

g El

igib

ility

Id

enti

fica

tio

n

29 records excluded at article

review level*

17: No psychological outcome

7: Chapter, Review/analysis or

letter to the editor

2: Article not available

1: No control group

1: Study with children

1: Survey * records could be excluded

for multiple reasons

No psychological outcomes (n=2) Non randomized controlled trial (n=1) Full text in English not

11 included articles in systematic review

40 full-text articles reviewed

Total records: 133

Records after duplicates removed: 71

31 records excluded at title-

abstract review level*

20: not related to SY

9: reviews/analyses

2: dissertation/thesis

Incl

ud

ed

24

9

Table 1. Study characteristics

Authors, Year , Country

Design Participants Conditions N Mean age/SD

Female %

Program Instruments* Outcome

Aftanas and Golocheikine, 2001, Soviet Union [25]

Cross-sectional study

Healthy adults 1. Short-term SY meditators 2. Long-term SY meditators

11 16

35. 54.5%

No program, EEG study

Feelings of bliss + (p <.014) Mental activity - (p <.025)

Aftanas and Golocheikine, 2003, Soviet Union [26]

Cross-sectional study

Healthy adults 1. Short-term SY meditators 2. Long-term SY meditators

11 16

35.2

54.5%

No program, EEG study

STAI-t, TAS-20, EPQ, Self-developed questionnaires

Trait anxiety - (p <.022) Neuroticism - (p <.028) Difficulties in identification of feelings - (p <.002) Mental activity - (p <.025) Happiness + (p <.014)

Aftanas and Golocheikine, 2005, Soviet Union [27]

Cross-sectional study

Healthy adults 1. Long-term SY meditators 2. Control group non-meditators

25 25

- -

50% No program, EEG study

Self-developed questionnaires

Emotional arousal - (p <.01)

Chung et al. , 2012, India [28]

Pros. cohort study

Adults with general health problems

1. SY 2. Conventional therapy

67 62

40.53 42.0

49.6%

1. 1-week treatment at SY health center 2. TAU at hospital

WHOQOL-BREF, WHOQOL-SRPB CAS

Quality of Life + (p <.001) Anxiety - (p <.001)

Hernandez et al., 2016, Spain [31]

Cross-sectional study

Healthy adults 1. Long-term SY meditators 2. Control group non-meditators

23 23

46.7 (11.2)

73.9% No program, FMRI scan

Voxel-based morphometry (VBM) with DARTEL

Increased Grey Matter Volume

25

0

Manocha et al. 2002, Australia [21]

RCT Adults with asthma 1. SY 2. Relaxation/ CBT exercises

21 26

37.0 55.3%

Both: 4 month, 2 h per week + 2 x daily 10-20 min. exercises at home

AQLQ POMS

Mood + (p =.007) Tension + (p =.005) Fatigue - (p =.005)

Manocha et al., 2011, Australia [22]

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

SB PB AB RB Tally rsg ac

Manocha, 2002 1 1 1 1 1 5/5 Manocha, 2011 1 1 1 1 1 5/5 Schneider, 2010 0 0 0 0 0 0/5 Sharma, 2005 0 0 0 0 0 0/5

Abbreviations: SB = Selection bias: rsg) random sequence generation; ac) allocation concealment; PB = Performance bias- blinding of participants, personnel; DB = Detection bias - adequate outcome assessor blinding; AB = Attribution bias – incomplete outcome data; RB = Reporting bias - Selective outcome reporting

Other study designs

The overall study quality was high. For the cross-sectional studies, the non-

randomized controlled trial, and the prospective cohort study, we found that in

all seven studies case definition was adequate. The selected cases seemed to be

representative and the control groups were comparable to the intervention

groups. Comparability and definition of controls was adequate in at least five

studies. In all studies the cases and controls were comparable on the age factor

but in only two studies additional factors were reported. There was

ascertainment of exposure as well as a complete report of non-response rates in

all studies. Six studies also used the same method of ascertainment. Results are

shown in Table 3.

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Table 3. Outcome Newcastle-Ottawa Quality Assessment Scale

Selection Comparability Exposure Tally S1 S2 S3a C1a C2 C3 E1 E2a E3

Aftanas, 2001 1 1 1 0 1 0 1 1 1 7/9

Aftanas, 2003 1 1 1 1 1 0 1 1 1 8/9

Aftanas, 2005 1 1 1 1 1 0 1 1 1 8/9

Hernandez, 2015 1 1 1 1 1 1 1 1 1 9/9

Manocha, 2012 1 1 0 1 1 0 1 1 1 7/9

Morgan, 2011 1 1 1 1 1 0 1 1 0 7/9

S1 S2 S3b C1b C2 C3 E1 E2b E3

Chung, 2012 1 1 1 0 1 1 1 0* 1 7/9

Abbreviations: S1 = Case definition, S2 = Representativeness, S3a = Selection of controls, S3b = exposed cohort; C1a = Definition of control, C1b = Outcome not present, C2 = Age comparability, C3 = Other controlled factors; E1 = Ascertainment of exposure, E2a = Same method of ascertainment, E2b = Adequate follow-up time, E3 = Non- response rate

Effect size calculation

Effect sizes are shown in Table 4. Effect size calculation was possible in three out of

four randomized studies, and in one non-randomized study. The three cross-

sectional interventions studies did not provide sufficient statistical information

(means and standard deviation at post-test level) to calculate effect sizes. These

studies set out to investigate the differences in brain activity in long-term

meditators of Sahaja Yoga versus short-term meditators (Aftanas & Golocheikine,

2003; Aftanas & Golocheikine, 2001) and long-term meditators versus non-

meditators (Aftanas & Golosheykine, 2005) and not to measure the effects of a SY

intervention. Extended information on the primary outcomes (EEG measures) was

reported in all studies, but information on the secondary outcomes (psychological

effects) was less clearly presented. For example, two studies by Aftanas &

Golocheikine (2001, 2003) only reported the mean outcomes at post-test level, but

not the standard deviations, making effect size calculations impossible. One study

did report pre-post measures, and though the results were listed in a figure, the

exact values were not reported, making it impossible to calculate the effect sizes

(Aftanas & Golosheykine, 2005). This was also the case in the study by Chung and

colleagues (2012). Finally, in one randomized study (Schneider, Zollo, & Manocha,

2010) that consisted of four different trials, the exact number of the participants in

the control groups was not reported. Moreover, the study did not report means,

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standard deviations of other outcome data that is necessary to calculate effect

sizes. Authors were contacted but did not provide the information after a second

reminder.

Table 4. Effect sizes of included RCTs and NRCT

Main author Design Effect size

Manocha, 2002 RCT • SY vs. Relaxation/CBT on AQLQ Mood: Cohen’s d= 0.48 (95%CI -0.04 to 0.10), p < 0.05

Manocha, 2011 RCT • SY vs. no treatment on PSQ (stress): Cohen's d = 0.30 (95%CI -0.19 to 0.70), p < 0.05

• Relaxation vs. no treatment on PSQ (stress): Cohen's d = -0.09 (95%CI -0.53 to -0.40), p < 0.001

• SY vs. no treatment on DD (depression): Cohen's d= 0.90 (95%CI 0.46 to 1.33), p < 0.001

• Relaxation vs. no treatment on DD (depression): Cohen's d= 0.60 (95%CI 0.13 to 1.01), p = 0.01

Morgan, 2001 NRCT • SY vs. non-active control on HADS anxiety: Cohen's d = 0.36 (95%CI -0.57 to 1.30), p < 0.001

• SY vs. non-active control on HADS depression: Cohen's d = 0.24 (95%CI -0.67 to 1.17), p < 0.001

Sharma, 2005 RCT • SY vs. active control group on HAM-D (depression): Cohen's d=0.75 (95%CI 0.01 to 1.50), p < 0.05

• SY vs. active control group on HAM-A (anxiety): Cohen's d=1.16 (95%CI 0.35 to 1.88), p < 0.001

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The effects of Sahaja Yoga on mental health

We found results on the following outcomes: anxiety (four studies), depression

(three studies), psychological well-being (three studies), stress (one study), and

subjective well-being (five studies). The effects of SY on mental health are

presented in Table 1 and 2.

Depression

The available research suggests that SY may have beneficial effects on depressive

symptoms in healthy adults. One high quality randomized study (Manocha et al.,

2002) showed a significant reduction on depressive feelings. The effect size of SY

vs. no treatment was high (d = 0.90, 95%CI 0.46 to 1.33). There is also an indication

that SY may reduce depression in patients with a depressive order. A randomized

study (Sharma, 2005) reported a decrease of depression compared to the active

control group, with an effect size of d = 0.75 (95%CI 0.01 to 1.50). This study,

however, was of lower quality. Finally, a significant reduction of depression was

found in a non-randomized study of high quality, which reported a small (d = 0.24,

95%CI -0.67 to 1.17) but significant improvement on depression with patients

assessed to be primarily suffering from recognized symptoms of ‘anxiety’, with or

without symptoms of depression (Morgan, 2000).

Stress

There is evidence that SY reduces stress in healthy adults (Manocha et al., 2011).

A high quality RCT reported a small effect size for SY vs. no treatment (d = 0.30,

95%CI -0.19 to 0.70), and there also was a small negative effect size for the

relaxation control group vs. no treatment

(d = -0.09, 95%CI -0.53 to -0.40).

Anxiety

There are indications that SY may decrease anxiety. One randomized study

reported significant reductions in anxiety in patients suffering from depression,

with a large effect size (d = 1.16, 95%CI 0.35 to 1.88) for SY vs. active control

group (Sharma, Das, Mondal, Goswami, & Ghandi, 2005) . A high quality non-

randomized study also reported a significant decrease in anxiety, with an effect

size of d = 0.36 (95%CI -0.57 to 1.30) (Morgan, 2000). Anxiety reducing effects of

SY were also found in a cross-sectional EEG study among healthy adults. In

addition to self-reported decreases in anxiety, EEG recordings also showed

increased activation of alpha activity, which is associated with reduced levels of

anxiety (Aftanas & Golocheikine, 2003). These findings are not conclusive,

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however. A randomized study did report a mean difference on state anxiety, but

this difference failed to be significant (Manocha et al., 2002).

Subjective well-being

A randomized controlled trial (Schneider, Zollo, & Manocha, 2010) among healthy

adults reported a significant increase of positive affect (happiness, fearlessness,

feeling inspired, integrity, feelings of bliss) and a decrease in negative affect

(sadness, feeling upset, angry, nervous, emotional instability). A cross-sectional

EEG study (Aftanas & Golocheikine, 2003; Aftanas & Golocheikine, 2001) that

compared the effects of SY meditation among long-term versus short-term

meditators reported significantly more positive emotions in the group of long-

term meditators and elevated scores of uneasiness and restlessness among the

short-term meditators. These subjective findings correlate positively with

measures of increased theta power in anterior frontal and frontal midline brain

regions. Another cross-sectional EEG study compared long-term meditators to

non-meditators that were exposed to an emotionally disturbing event. Long-term

meditators reported less negative emotions (anger, anxiety, disgust, and

contempt), and feelings of happiness did also not decrease in this group. The

findings in this study also suggests that long-term practicing of SY contributes to

lower emotional reactivity after stressful events (Aftanas & Golosheykine, 2005).

Furthermore, SY may increase mood and reduce tension and fatigue (Manocha et

al., 2002). A RCT among adults with asthma reported a significant increase in

mood compared to a relaxation/cognitive behavior therapy group with a strong

moderate effect size of (d=0.48, 95%CI -0.04 to 0.10). Improvements on mood

subscales of tension and fatigue were also reported. It should be noted that the

effects appear to be short-term; the follow-up two months after the intervention

showed no significant differences (Manocha et al., 2002). Higher levels of quality

of life (general health) were also found in a non-randomized controlled trial

(Morgan, 2000), a prospective cohort study (Chung, Brooks, Raid, Balk, & Rai,

2012), and a cross-sectional survey (Manocha, Black, & Wilson, 2012).

Psychological well-being

A randomized controlled trial (Schneider, Zollo, & Manocha, 2010) among 93

healthy adults reported significant increases of personal values (forgiveness,

world of beauty, unity with nature, and preserving public image). A cross-

sectional survey that compared 343 long-term SY meditators in Australia to the

general population reported significant higher scores on general health, mental

health, emotional and social functioning, and vitality (Manocha et al., 2012).

Finally, a study that investigated regional differences in grey matter volume

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(GMV) using Voxel-Based Morphometry compared 23 experienced practitioners

of Sahaja Yoga meditation to 23 non-meditators. Larger GMV was found in the

meditator group. Larger GMV is associated with more emotional control, feelings

of compassion, and introceptive perception (Hernández, Suero, Barros, González-

Mora, & Rubia, 2016). These findings suggest that long-term SY meditation

practice may enhance the aforementioned cognitive-emotional functions and

thereby may contribute to enhanced psychological well-being.

Discussion

At first glance, SY meditation seems to have positive and significant effects on

mental health. After reviewing the articles and taking the methodology and

quality of the studies into account, it appears that SY is associated with reduced

depression in both healthy adults, and in adults with a depressive disorder. SY is

also associated with decreased anxiety and increased subjective and psychology

well-being among healthy adults. Only one study found a small effect of SY on

stress. Our findings on the effects of SY on depression, anxiety, and stress are in

line with previous studies on the effects of yoga on these outcomes. For example,

several meta-analyses on the effects of yoga among patients with cancer

reported large reductions in distress, anxiety, and depression (Buffart et al., 2012;

Cramer, Lange, Klose, Paul, & Dobos, 2012; Lin, Hu, Chang, Lin, & Tsauo, 2011). A

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

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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.

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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.

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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

activities, so-called multi-component positive psychology interventions (MPPIs),

have become a focal point of attention in the field of (positive) psychology. The

main goal in this thesis was to explore if a culturally adapted MPPI can increase

resilience and mental well-being among employees with a multi-ethnic

background. In addition, the extent to which PPIs are Western-centric was

explored, what their efficacy is, and if studies from non-Western countries differ

from Western studies in their efficacy. Finally, the feasibility of yoga meditation

as a cultural sensitive positive activity targeting populations of East-Indian origin

in Suriname and the Caribbean was examined. In this general discussion, I will

first present the main findings of the studies. Second, I will discuss the strengths

and limitation of the studies in this thesis. Third, future research directions for

positive psychology studies are suggested.

Summary of main findings

❖ How Western-centric are positive psychology interventions?

While PPIs are still predominantly conducted in Western countries. However, there

is a strong and steady increase in publications of randomized controlled trials

from non-Western countries since 2012, indicating a trend towards globalization

of positive psychology research.

One of the major point of critics on the research in the field of positive

psychology is that it is too Western-centric (Christopher & Hickinbottom, 2008).

The acronym WEIRD is sometimes used to capture the demographic

characteristics, as well as to allude to the idiosyncratic nature of the populations

represented in the majority of published research in the academic field in general

(Henrich, Heine, & Norenzayan, 2010). The acronym stands for Western,

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Educated, Industrialized, Rich, and Democratic and underlines 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. (Arnett, 2008). Critics have expressed concern

that such a strong North American influence in all fields of psychology, could

distort the salience and the construction of human happiness and flourishing;

positive psychology is North American culture-bound and neglects the cultural

embeddedness of positive human behavior (Christopher & Hickinbottom, 2008;

Frawley, 2015). In Chapter 2, we presented a bibliometric analysis that examined

to what extent positive psychology is Western-centric. This analysis included 187

randomized controlled trials on PPIs that were conducted in the time period 1998

- 2016. We found that RCTs on the efficacy of PPIs are still predominantly

conducted in Western countries, which accounted for 78% of the studies.

However, we also found a strong and steady increase in publications of RCTs non-

Western countries since 2012. For example, in the period between 1998 and

2012, there were only four publications from non-Western countries, while there

were 53 publications from Western countries. The ratio of non-Western to

Western studies was 1:13.3 during that period. In the period between 2012 and

2017, 37 studies from non-Western countries were published, compared to 94

studies from Western. This is a ratio of 1:2.5. Hence, we concluded that there is a

strong trend towards a more global distribution of scientific productivity in the

field of positive psychology over the past five years and positive psychology is

becoming less Western-centric.

We suggested that the trend towards a growing number of non-Western

studies evaluating the impact of PPIs has important implications. PPIs may have

the potential to partially overcome the fact that in low and middle income

countries a majority of people in need of mental health care do not receive

treatment, due to scarcity of mental health care professionals (Kohn, Saxena,

Levav, & Saraceno, 2004; Saraceno et al., 2007). PPIs can contribute to scaling up

of services for mental health care, because they are relatively less complex, and

therefore can be applied by professionals who have received less formal

education. In addition, many PPIs allow for the integration of religious and

spiritual exercises from different traditions. The beneficial effects of religious and

spiritual practices have been widely reported, as they serve as protective factors

for mental health (AbdAleati, Zaharim, & Mydin, 2014; Brewer-Smyth & Koenig,

2014; Ivtzan, Chan, Gardner, & Prashar, 2013; Koenig, 2012; Lun & Bond, 2013;

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Park et al., 2013; Rizvi & Hossain, 2016). Studies also show that religiousness can

contribute to a decrease of depression, anxiety, stress, substance abuse,

mortality rate, and suicidality (Gonçalves, Lucchetti, Menezes, & Vallada, 2015;

Koenig, 2012; Lucchetti, Lucchetti, & Koenig, 2011; Wu, Wang, & Jia, 2015). Our

qualitative study that was presented in Chapter 5, also identified religiousness as

a possible bedrock strength in the development of resilience for people in

Suriname. Therefore, I think that PPIs are more suitable and effective in non-

Western countries than traditional psychological interventions such as psycho-

therapy and cognitive behavioral therapy since non-Western populations have a

more holistic view on life (Talhelm et al., 2015).

❖ What is the efficacy of multi-component positive psychology

interventions?

Evidence suggests that multi-component positive psychology interventions

(MPPIs) have beneficial short term and long-term effects in improving mental

health. The effects are small to moderate for subjective and psychological well-

being, and small for depression and anxiety.

To date, two meta-analyses have been published that examined the overall

effects of PPIs. Sin and Lyubomirsky (2009) conducted a meta-analysis that

included 51 controlled studies. They reported large effects for enhanced well-

being (r = 0.29, d ≅ 0.60) and depressive symptoms (r = 0.31, d ≅ 0.65) (Sin &

Lyubomirsky, 2009) . Another meta-analysis that included 39 RCTs (Bolier et al.,

2013) found small effect sizes for subjective well-being (d = 0.34), psychological

well-being (d = 0.20) and depression (d = 0.20). Discrepancies between the two

findings can be attributed to the differences in included studies. The study by Sin

and Lyubomirsky (2009) included non-randomized controlled studies, which may

have led to an overestimation of the effect sizes. Non-randomized studies tend to

report larger effect sizes than RCTs (Kunz & Oxman, 1998; Sacks, Chalmers, &

Smith Jr, 1982) and such studies are prone to a higher risk of bias (Cuijpers, 2016).

Furthermore, the two meta-analyses mainly contained single component PPI

studies, i.e. studies that examined the effects of a single positive activity, or in

some cases two combined positive activities. Recently, however, there has been a

growing number of studies on the effect of multi-component positive psychology

interventions (MPPIs), which we defined as PPIs consisting of a minimum of three

positive activities. We expected that MPPIs have a larger effect than single

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component interventions, since they target different domains of mental well-

being. In order to examine the efficacy of MPPIs, we conducted a meta-analysis

that was presented in Chapter 3. After a database search, we finally included 37

RCTs that were published between January 1998 and May 2017. Analyses showed

that MPPIs significantly increased subjective and psychological well-being, and

decreased depression and anxiety. We found standardized mean differences of d

= 0.46 for subjective well-being, d = 0.38 for psychological well-being, d= 0.32 for

depression and d = 0.29 for anxiety. However, removing outliers or low quality

studies reduced the effect sizes considerably. We concluded that MPPIs have a

small to moderate effect on subjective and psychological well-being, and a small

effect on depression and anxiety. The effect sizes we found were slightly higher

than effect sizes found in a previous meta-analysis that mostly contained single

component interventions (Bolier et al., 2013). This was partially explained by the

fact that MPPIs contain a wide variety of positive activities that target different

domains of mental well-being. Interestingly, subgroup analyses also showed that

studies from non-Western countries had larger effect sizes than studies from

Western countries, even up to four times as high. This finding led us to further

explore the efficacy of all types of PPIs in non-Western countries.

❖ What is the efficacy of positive psychology interventions from non-

Western countries and how can differences in effects sizes between

RCTs from Western and non-Western countries be explained?

Positive psychology interventions from non-Western countries have larger effect

sizes on well-being and mental disorders than PPIs from Western countries. This

can partially be explained by the overall lower study quality and possible

occurrence of biases. However, we hypothesize that larger effect sizes can possibly

be explained by a better cultural fit between PPIs and people from non-Western,

compared to people from Western countries.

While the previous meta-analysis focused on the efficacy of MPPIs in both

Western and non-Western countries, in the meta-analysis that was presented in

Chapter 4 we focused on studies that were conducted in non-Western countries,

and also included studies that examined the effects of single component PPIs and

MPPIs . We finally included 28 RCTs, 18 single component PPIs and 10 MPPIs.

Most studies were conducted in China (k = 12) and Iran (k = 6).

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Results showed that PPIs from non-Western countries have a moderate effect on

subjective well-being (g= 0.49) and psychological well-being (g = 0.41), and a large

effect on depression (g = 0.63) and anxiety (g = 0.97). No significant differences

were found between single or multicomponent PPIs. These findings clearly

demonstrated that PPIs have a higher effect in non-Western countries, than in

Western countries. The large differences were mostly attributed to the overall

lower study quality. Study quality was determined by assessing six criteria:

random sequence generation, allocation concealment, blinding of participants

and personnel, description of drop-outs, power analysis, intention-to-treat

analysis or no drop-outs (Cuijpers, 2016). One point was allocated for each

criterion that was met, as described in the studies.The quality of a study was

assessed as ‘high’ when five or six criteria were met, ‘moderate’ when three or

four criteria were met, and ‘low’ when less than three criteria were met. The

overall study quality was low, with a mean score of 1.79 (SD = 1.67). Three studies

(11%) had a high quality, two (7%) had a moderate quality, and twenty-three

(82%) had a low quality. However, there has been some debate about the relation

between effect sizes and study quality. We suggested that in addition to study

quality, other biases that are more likely to appear in non-Western countries may

have influenced the higher outcomes. For example, social desirablity could have

led to response bias (McCambridge, Witton, & Elbourne, 2014) . This bias may be

of particular influence in non-Western countries (Johnson & Van de Vijver, 2003),

where most people have an interdepent view of the self (Markus & Kitayama,

1991). Another effect that may have contributed to large effect sizes, is the

novelty effect of interventions, while other psychological interventions are often

scare or not available. This effect may lead to greater enthusiasm among

participants and a greater attention to a particular intervention (Ammenwerth &

Rigby, 2016; Turner-McGrievy, Kalyanaraman, & Campbell, 2013). In non-Western

countries, this effect could also be applicable to regular psychological

interventions, since access to mental health interventions is limited (de Jong et

al., 2015; Rathod et al., 2017).

Finally, we argued that PPIs in non-Western countries may have larger effect

sizes, simply because they are more effective. PPIs may constitute a better

cultural fit for interventions among non-Western populations. Although the goal

of PPIs is to increase the well-being of the individual, many activities (for example

expressing gratitude, acts of kindness, forgiveness) operate through collective

pathways that aim to improve interdependent relationships. The self, in

interdependent cultures, is often perceived as a group-self with strong

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connections and feelings towards family members and the close environment

(Park, Uchida, & Kitayama, 2016). In such a setting, a group intervention may

elicit more social support and well-being than in an individualized, independent

and ego-centric cultural setting. In addition, many positive psychology activities

aim to stimulate low arousal emotions such as kindness (Buchanan & Bardi, 2010;

O'Connell, O'Shea, & Gallagher, 2016), compassion (Arimitsu, 2016; Yang, Liu,

Shao, Ma, & Tian, 2015), and even integrate mindfulness meditation (Nikrahan et

al., 2016; Ramachandra, Booth, Pieters, Vrotsou, & Huppert, 2009), prayer and

other spiritual activities (Rouholamini, Kalantarkousheh, & Sharifi, 2016; Wu &

Koo, 2016) into interventions. Studies show people from Eastern cultures prefer

such low arousal emotions (Lim, 2016; Tugade & Fredrickson, 2004), and there is

evidence suggesting cultural fit of emotions is associated with better health (Yoo

& Miyamoto, 2018). Therefore, it is important that activities in PPIs are in

accordance with the prevalent patterns of emotions within the specific cultural

context of the intervention.

❖ What strengths and virtues are associated with resilience of people in

Suriname?

Five major strengths and virtues appeared to be associated with resilience in

Suriname: religiousness, hope, harmony, acceptance, and perseverance.

Religiousness appears to be the bedrock strength for the development of

resilience in Suriname. While these strengths contribute to the development of

resilience, they can under certain circumstances have an ambiguous effect.

In Chapter 5, we presented data from a qualitative study that represented

viewpoints from a group of 25 community representatives, health care

professionals, and academic scholars. During semi-structured interviews, the

sources for resilience used by people in Suriname, in the context of the current

socio-economic crisis in Suriname were discussed. First, we found that most

respondents had an individualistic understanding of the concept of resilience and

referred to resilience as ‘the capacity to deal with adversity ‘ or ‘bouncing back

after blows’ and underline the importance of persistence and flexibility. This view

is in line with the most common definition of psychological resilience that

describes resilience as the capacity to deal effectively with stress and adversity,

and to adapt successfully to setbacks (Burton, Pakenham, & Brown, 2010; Luthar,

Cicchetti, & Becker, 2000; Tugade & Fredrickson, 2004; Zautra, Hall, & Murray,

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2008). Second , we identified major five strengths that were associated with

resilience: religiousness, hope, harmony, acceptance, and perseverance. Our

findings suggested that religiousness is the bedrock strength for the development

of resilience in Suriname. While these strengths contributed to the development of

resilience, they can under certain circumstances have an ambiguous influence. For

example, Religiousness in combination with acceptance and hope can result in a

passive attitude, or when church attendance and other religious rituals become a

form of escapism. We recommended that future positive psychological

interventions in non-Western countries integrate positive activities with religious

elements into program interventions to achieve a better cultural fit. On the basis

of the findings of this study, we developed and integrated a module in the

intervention program, that incorporated exercises that had a religious/spiritual

character. These exercises were asking forgiveness from a Supreme Being,

expressing gratitude to a Supreme Being, and letting go of negative emotions

through surrendering them to a Supreme Being.

❖ Can a culturally adapted multi-component positive psychology

interventions increase resilience and mental well-being of healthy adults

in Suriname?

The Strong Minds Suriname program is a multi-component positive psychology

intervention that was culturally adapted. The program significantly increased

resilience and mental well-being of employees in Paramaribo, Suriname,

compared to employees in a wait-list group and large effects sizes were

measured.

The meta-analysis of non-Western RCTs on PPIs, described in Chapter 4, revealed

that a minority of the studies was culturally adapted (ten out of twenty). Many

scholars have acknowledged that almost every aspect of the diagnostic and

treatment process are influenced by culture and context (Bernal, Jiménez-Chafey,

& Domenech Rodríguez, 2009) and the need for cultural adaptation has long been

recognized by the American Psychological Association (American Psychological

Association, 2003, 2006, 2008). In Chapter 5, we reported on the development,

cultural adaptation, implementation, and testing of a MPPI we developed. The

program, titled Strong Minds Suriname, was adapted to the Surinamese cultural

context, following guidelines for cultural adaptation as described by Domenech-

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Rodriguez and Wieling (2004). The trial was designed according to the Standard

Protocol Items: Recommendations for Interventional Trials (SPIRIT) guidelines

(Chan & Laupacis, 2013) and various measures were taken to minimize risk of

bias. A randomized controlled trial among 158 eight employees of multi-ethnic

origin was conducted. Participants were assigned to a seven session intervention

program or a wait-list control group. The intervention included a variety of

evidence based positive activities including exercises in expressing gratitude, acts

of kindness, using and identifying character strengths, positive goal setting,

positive reframing, and letting go of negative emotions through forgiveness and

prayer. These exercises were conducted by a group of local coaches, employees

of the participating companies, who received a training prior to the intervention.

We found large improvements for resilience and mental well-being. Moderate to

large significant improvements were found for depression, anxiety, and positive

and negative affect. The intervention did not increase psychological flexibility or

decrease financial stress. The effect sizes we found in the current study were

considerably larger than expected. A possible explanation for this lies in the

novelty of the intervention, since novelty effects may contribute to greater

enthusiasm among participants and greater attention paid to a particular

intervention (Ammenwerth & Rigby, 2016; Turner-McGrievy, Kalyanaramam, &

Campbell, 2013). We concluded that a culturally adapted multi-component PPI is

a promising intervention to increase resilience and positive mental health among

healthy adults with a multi-ethnic background in Suriname, and perhaps other

multi-etnic settings in low and middle income countries in the Caribbean.

❖ Are positive emotions and psychological flexibility possible mechanisms

that can explain of effects of the SMS program on resilience and mental

well-being

Evidence from our study suggests that positive emotions may act as a possible

mechanism for positive change. We did not find a mediating effect for

psychological flexibility.

To date, few studies have examined possible mechanism of change in PPIs

(Schotanus-Dijkstra, Pieterse, Drossaert, & Walburg, 2017). Chapter 6 presented

findings from a mediator analysis. In this chapter, we focused on two possible

mediators in the development of well-being, namely positive emotions and

psychological flexibility. Studies have identified both factors as mediators in the

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relation between PPIs and well-being (Kashdan & Rottenberg, 2010; Li, Jiang, &

Ren, 2017; Schiffrin, 2014; Schotanus-Dijkstra et al., 2017; Tugade & Fredrickson,

2004; Vulpe & Dafinoiu, 2012). The two potential mediators are also linked to two

different theoretical frameworks that attempt to explain the mechanism behind

positive change, namely the broaden-and build theory of positive emotions

(Fredrickson, 2001) and the flexibility hypothesis of healing (Hinton & Kirmayer,

2016). Analyses showed that positive emotions were a significant mediator

between the intervention and resilience and well-being, but only had a small

effect. Furthermore, definite conclusions on the mediating effect of positive

emotions cannot be drawn, due to the absence of a timeline during measurement

of the study outcomes (Kazdin, 2009). We failed to find a significant mediating

effect for psychological flexibility. The latter was firstly attributed to the scale we

used to measure flexibility, the Psychological Flexibility Questionnaire (Ben-

Itzhak, Bluvstein, & Maor, 2014). We argued that several questions in this

instrument may have been too complex for our participants, of whom almost half

had a lower educational level. Secondly, increases in flexibility may have been

limited due to a ceiling limit. The study presented in Chapter 5 suggested 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). We

also suggested that the East-Asian ethnic background of the majority of our

participants could be associated with a relative high level of flexibility during our

baseline assessment. Studies show that people from East-Asian cultures

emphasize adjusting one’s needs to those of their social environment (Shin &

Lyubomirsky, 2017), which requires psychological flexibility.

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❖ Can yoga contribute to the mental well-being of healthy adults

The current body of research offers weak evidence that the practice of yoga

contributes to an increase in mental well-being among adults from non-clinical

populations. It should be noted that most studies in this field focus on postural

yoga, and not meditational yoga.

In previous chapters, we focused on MPPIs. These interventions often include

mindfulness meditation (Cerezo, Ortiz-Tallo, Cardenal, & de la Torre-Luque, 2014;

Chaves, Lopez-Gomez, Hervas, & Vazquez, 2017; Drozd, Mork, Nielsen, & Bjørkli,

2014). Although these meditation exercises have been adapted from Buddhist

traditions (Bohlmeijer, Prenger, Taal, & Cuijpers, 2010; de Jong, 2012), most

mindfulness-based meditation interventions are secular in nature (Brown & Ryan,

2003), which may account for the popularity of mindfulness in Western societies

(Niemiec, 2013). However, integrating secularized meditation into MPPIs may not

lead to an optimal fit for other populations, for example East-Indians in Suriname,

whom mostly adhere to Hinduism. We argue that for them yoga meditation may

be a better cultural fit. Although most people practice yoga for spiritual reasons

or to increase well-being (Park, Riley, Bedesin, & Stewart, 2016; Quilty, Saper,

Goldstein, & Khalsa, 2013), there have not been many studies that have

examined the effects of yoga on mental well-being as a primary outcome. In

Chapter 7 we presented an overview of the research on the effects of yoga on

well-being among non-clinical adult populations. We conducted a meta-analysis

that included 17 RCT’s. We reported on four indicators of well-being:

psychological well-being, life satisfaction, social relationships and mindfulness.

Results, surprisingly, showed that the practice of yoga only contributed to a

significant increase in psychological well-being when compared to no

intervention, but not compared to an active intervention (physical activity). No

significant effects were found for life satisfaction (emotional well-being), social

relationships (social well-being) and mindfulness (as a mental state). In this study

we questioned if modern researchers in the field of psychology and yoga are

actually measuring what practitioners intend to achieve through yoga. The

original goal of yoga, as described in the Yoga Sutras (Patañjali, 2003), was the

removal of fluctuations of the mind, which corresponds to modern psychological

constructs such as worrying, rumination, or mental activity. However, we have

not found a single study that measures mental activity in yoga studies.

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❖ What is the feasibility of Sahaja Yoga as method to increase well-

being?

Evidence suggests short-term practice of Sahaja Yoga reduces depression and

anxiety, increases subjective well-being, and character strengths and virtues.

Long-term practice is associated with enhanced cognitive-emotional functions.

Although the number of publications is too limited to draw any definite

conclusions on the beneficial effects of SY, we conclude that it can be a feasible

intervention to increase well-being. In particular among the East-Indian

(Hindustani) population, in light of the cultural fit.

Sahaja Yoga (SY) is a meditational form of yoga, and currently one of the most

practiced forms of yoga by East-Indians (Hindustani) in Suriname. In Western

countries SY is also known as a mental silence meditation (Manocha, Black, Sarris,

& Stough, 2011), which is basically a secularized version. In Suriname, a version is

practiced that is deeply rooted in yoga philosophy and incorporates many Hindu

rituals, including recitation of the names of Hindu deities, havan (sacrificial fire)

and puja (ceremonial worship). We conducted a systematic review to examine

the effects of SY on mental health. This review is presented in Chapter 8. In total,

eleven studies were included; four RCTs, one non-RCT, five cross-sectional

studies, and one prospective cohort study. Significant findings were reported on

anxiety, depression, stress, subjective well-being, and psychological well-being.

An EEG study among long-term practitioners demonstrated that SY contributes to

lower emotional reactivity after stressful events. One study investigated regional

differences in grey matter volume and reported larger GMV, which in its turn is

associated with more emotional control, feelings of compassion, and introceptive

perception (Hernández, Suero, Barros, González-Mora, & Rubia, 2016). The large

majority of the studies (k=9, 81.8%) were rated as having a high study quality.

This is an exception to the rule in yoga research, previous analyses have reported

percentages of high quality yoga studies from 4% (Manocha, 2008) to 17% (Goyal

et al., 2014). Definite conclusions on the beneficial effects of SY can, however, not

be draw due to the limited number of studies. Despite the paucity in the

literature, we concluded that SY can be a feasible intervention to increase well-

being. In particular among the East-Indian (Hindustani) population in Suriname

(and Guyana), in light of the cultural fit.

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Strenghths and limitations

The strengths and limitations of each individual study are described in each

chapter. In this section we first discuss three major overall strengths:

First, the intervention that was tested in this thesis was culturally

adapted, following guidelines for cultural adaptation as described by Domenech-

Rodriguez and Wieling (2004) and guidelines for the implementation of cultural

sensitive cognitive behavioral therapies (Hinton & Jalal, 2014; Hinton, Pich,

Hofmann, & Otto, 2013; Hinton, Rivera, Hofmann, Barlow, & Otto, 2012). Data

obtained from the qualitative study described in Chapter 5 were used to develop

an additional module for the original resilience program we adapted. This module

contained exercises that had a religious/spiritual character.

Second, the RCT, the qualitative study and the meta-analyses were

conducted according to rigorous scientific standards. For the RCT, we strictly

followed the Standard Protocol Items: Recommendations for Interventional Trials

(SPIRIT) guidelines for RCTs (Chan & Laupacis, 2013), thereby minimizing the risk

of bias. All statistical analyses were based on a modified intention-to-treat (mITT)

basis (Gupta, 2011), thus minimizing further bias. The study also had sufficient

statistical power, since the drop-out percentage was lower than the maximum

drop-out percentage that was calculated prior to the study. We followed the

Consolidated Criteria for Reporting Qualitative Research (COREQ) (Tong,

Sainsbury, & Craig, 2007) in the reporting of the findings of the qualitative study.

The meta-analyses were conducted according to The Preferred Reporting Items

for Systematic Reviews and Meta-Analyses (PRISMA) guidelines for systematic

reviews and meta-analyses (Moher et al., 2010, Moher, Liberati, Teztlaff, &

Altman, 2009) and the recommendations of the Cochrane Back Review group

(Higgins et al., 2011) . The statistical procedures of the mediation analyses were

based on latest developments in the field (Hayes, 2012; Preacher & Hayes, 2008).

Third, several studies have an innovative character. In the first part of

the thesis, we uncovered that there is a trend towards globalization in positive

psychology research. Furthermore, we demonstrated that over the past five

years, there has been a strong growth of intervention programs based on positive

psychology, and that these multi-component programs can achieve small to

moderate effects on well-being. We also devoted one article to the efficacy of

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RCT from non-Western countries, which adds to the knowledge of cross-cultural

positive psychology. In the second part of the thesis we demonstrated that a

MPPI that was conducted according to rigorous quality standards, can have large

effect sizes in a non-Western country. This study was the first large scale

intervention that was conducted in the field of psychology in Suriname. In

addition, it is also the first RCT in the field of positive psychology in South

America. And in the third part we examined the feasibility of yoga as a positive

intervention. While yoga is one of the most popular ways to increase well-being

(Park, Riley, Bedesin, & Stewart, 2016), the role that yoga has as a positive

intervention is under exposed, with only a handful of studies in positive

psychology focusing on the relation between yoga and mental well-being. In

particular, the potential benefits of meditational yoga forms of well-being such as

Sahaja Yoga, were presented. This is an innovative study as well, considering that

in positive psychology most researchers focus on mindfulness meditation.

We also identified three major limitations to the finding of this thesis. The first

pertains to all studies, the second and third limitation pertains to the findings of

the intervention we tested.

First, the limitations pertain to the samples used in the studies. In regard

to the qualitative study, data was only provided by a small group of respondents,

with particular fields of expertise. This sample represented three subgroups of

the population, which does not reflect the entire Suriname population. Since the

data provided was qualitative in nature, causal inferences or generalizations to

the entire research population cannot be made on the basis of the data from

qualitative studies (Thomson, 2011). The issue of the limited generalization of the

general population of Suriname also pertains to the findings of the RCT. We

recruited participants from a self-selected sample of companies, which is not

representative for all companies in Suriname. In regard to the systematic reviews

and meta-analyses, the limited amount of available studies on PPIs, and yoga

studies that focus on well-being, forms a limitation to the findings in these

studies.

Second, most questionnaires we used to measure the outcome of the

intervention were validated among Dutch speaking populations in The

Netherlands and Belgium. In addition, semantic, conceptual and technical

equivalence of the questionnaires were reviewed by a focus group of

psychologists and human resource professionals. Although adjustments were

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made to the questionnaires, they were not validated among Dutch speaking

Surinamese populations. Unvalidated questionnaires, being less reliable and valid,

may yield inconsistent results (Boynton & Greenhalgh, 2004).

Third, in this study we could not control for the influence of external

factors. During the trial, protest marches against the government were organized,

which is quite a unique phenomenon in Suriname. In the midst of the

intervention period of the intervention group, protesters were intimidated, which

led to growing tensions among the general public in Suriname, and among the

participants in our trial. These tensions lasted several weeks. During the

intervention period of the waiting-list group, there were no disturbing events.

The occurrence or absence of disturbing events may have influenced the

outcomes of the intervention, either in a positive way (higher positive outcomes),

or a negative way (lower positive outcomes). If, and to what extent, confounders

as described above had an influence, remains unknown.

Recommendations for future research

This thesis has provided answers to a number of research questions. Despite the

limitations of the studies, their outcomes offer starting points for future research

in the field of PPI within multi-ethnic societies. In this section I will suggest seven

recommendations for future research. The first five relate to research of PPIs in

general, the final three relate to the research in Suriname and the Caribbean. The

suggestions are as follows:

I. More RCTs should be conducted according to guidelines and protocols

A high risk of bias and a subsequent low study quality for most RCTs from non-

Western countries, is a reoccurring theme in this thesis. This applies for RCTS in

the field of positive psychology, as is described in Chapters 3 and 4, as well as

studies in the field of yoga, as is described in Chapters 8 and 9. Many positive

psychology scholars have repeatedly pleaded for a more rigorous methodological

approach for studies in the field of positive psychology (Diener, 2009; Froh, 2004;

Linley & Joseph, 2004; Linley, Joseph, Harrington, & Wood, 2006). I underline that

this applies in particular for studies conducted in non-Western countries

considering the aforementioned low study quality of RCTs in non-Western

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studies. By following guidelines and protocols possible risk of bias can be

reduced. As was demonstrated in Chapters 6 and 7, adequate measures to reduce

risk of bias can be taken if researchers prioritize this aspect. I do realize that in

practice, some risk of bias reducing measures are quite hard to realize in non-

Western countries, due to limited financial resources. For example, sufficiently

powering a RCT with its concomitant costs may not always be feasible. However,

most measures such as sequence generation, allocation concealment, or a

complete description of drop-outs can be conducted regardless the available

financial means. For RCTs, I advise following Consolidated Standards of Reporting

Trials (CONSORT) statement (Moher et al., 2010; Schulz, Altman, & Moher, 2010),

or the SPIRIT guidelines for RCTs (Chan & Laupacis, 2013). When conducting

qualitative studies, from which data can be used in the cultural adaptation

process as we demonstrated in Chapter 5, I recommend in-depth preparatory

qualitative research, and following the Consolidated Criteria for Reporting

Qualitative Research (COREQ) (Tong, Sainsbury, & Craig, 2007) or the Standards

for Reporting Qualitative Research (SRQR) (O’Brien, Harris, Beckman, Reed, &

Cook, 2014). I acknowledge the fact that research in the field of positive

psychology in non-Western countries is still in its infancy, as described in Chapters

2 and 4, and therefore it is understandable that the study quality of RCTs on PPIs

from non-Western countries is not yet on equal footing with the research quality

of positive psychology research from Western-countries.

II. RCTs of PPIs from non-Western countries should describe cultural

adaptation more detailed

There is considerable evidence that almost every aspect of the assessment and

intervention process in evidence-based treatments is influenced by culture and

context (Bernal et al., 2009). The content of an intervention is contextualized

through cultural adaptation. Studies show that this process increases the fit with

the needs and concerns of the participants (Lau, 2006), which can contribute to

an increase of the efficacy of and intervention (La Roche & Lustig, 2010; Tharp,

1991). Cultural adaptation may also enhance participants’ engagement (Barrera

Jr, Castro, Strycker, & Toobert, 2013) and reduce drop-out (Hwang, 2006). In

Chapter 4, a meta-analysis of PPIs in non-Western countries was presented. We

sought to find out if culturally adapted interventions had higher effect sizes than

interventions that were not adapted. We conducted a moderator analysis but

failed to find a significant moderating effect for cultural adaptation. Only 10 out

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of the 28 included studies indicated that cultural adaption took place. A further

analysis was not possible since only four studies provided an elaborate

explanation of the cultural adaptation process. For future studies in the field of

cross-cultural positive psychology, I therefore would like to suggest that (1) PPI

studies clearly indicate if cultural adaptation took place and if not, provide a

rationale why this was not done; (2) PPI studies that were culturally adapted

adequately describe the process of cultural adaptation. In this way future analysis

will be possible, for example evaluating the difference in efficacy of between

adapted versus non-adapted PPIs. Or facilitating analyses that focus on the

relationship between cultural adaptation and participant engagement, drop-out

rate, and client/participant satisfaction. In addition, I propose to develop

guidelines for the cultural adaptation of positive psychology interventions. To

date, several guidelines for the cultural adaptation of psycho-therapy and

cognitive behavioral therapy are available (Bernal, Bonilla, & Bellido, 1995;

Domenech-Rodriguez & Wieling, 2004; Hinton & Jalal, 2014; Hwang, 2006, 2009).

Such guidelines could contribute to a better integration of etic (the outsider

perspective) and emic (the perspective from within the culture) aspects in PPIs.

III. Further studies examining the mechanisms of PPIs should be conducted

Understanding the causal mechanisms that may explain how PPIs work is crucial

for gaining more knowledge how to optimize well-being interventions. As

described in Chapter 7, there are only a few studies that examine possible

mechanisms of PPIs. Therefore, I think it would be wise to include mediator

analyses in future studies on PPIs. However, Kazdin (2009), argued that the

effects found in mediator studies are correlational and indirect, because a third

variable may explain the change. A direct way of discovering possible mechanisms

is through component studies. In a dismantling component study, at least one

element of the intervention is removed and in an additive component study, an

additional component is added to an existing intervention. The dismantled or

additive interventions are then compared to the original interventions (Bell,

Marcus, & Goodlad, 2013). Dismantling or additive component studies may be a

way of separating active from non-active ingredients in PPIs, since they allow a

study of individual components in isolation or in combination with other

components of the intervention (Papa & Follette, 2015).

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Current mediator studies focus on psychological mechanisms that effect

positive changes. Future research should also look for other possible

explanations. As outlined in the Synergetic Change Model (Rusk, Vella-Brodrick &

Waters, 2017) environmental factors also influence positive changes. The

influence of contextual factors is often highly complex in non-Western countries.

Moreover, in non-Western countries social economic disparity or human rights

conditions may affect subgroups of the population. In such circumstances a PPI

may either have a pronounced effect or the opposite may take place, i.e. that dire

or grim living conditions overrule the effect of PPI.

In positive psychology, positive emotions are usually seen as brief and

temporary subjective feelings of an individual (Fredrickson, 2001, Hefferon,

2011), that may build social resources. Emotions are primarily regarded as a

reaction to external events and guided by personal characteristics. However,

people do not merely react to the emotions of people surrounding them, the

emotions are also interpreted and molded within the cultural setting. This implies

that emotions do not only have individual functions but also have social

functions, they influence social relations in a positive or negative way (Fisher, van

der Schalk, & Hawk, 2009). This is acknowledged in Fredrickson's broaden-and-

build theory of positive emotions (Fredrickson, 2004). Yet, little is known about

the effect of group interaction on the development of positive emotions (van

Kleef & Fisher, 2016). The social role of emotions is perhaps even stronger in

collectivistic societies with an interdependent self-view (Shin & Lyubomirsky,

2017). Considering the apparent crucial role of positive emotions in PPIs, we

advise in-depth research into the role of positive emotions in socio-cultural

context.

IV. Further integration of knowledge from other cultural traditions into

PPIs.

The VIA Classification of Character Strengths and Virtues (Peterson & Seligman,

2004), is often regarded as one of the cornerstones of positive psychology (Jose &

Padmakumari, 2016; O'Hanlon & Bertolino, 2012). This classification was

composed through extensive review of classic texts on the nature of virtue from

eight cultural traditions (i.e. Buddhism, Hinduism, Confucianism, Taoism, Judaism,

Christianity, Islam, and Athenian philosophy) (McGrath, 2015). The large majority

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of scholars in the field of positive psychology are based in Western countries, that

have a Judeo-Christian religious tradition. As we described in the general

introduction, positive psychologists appear to have embraced Buddhist

philosophy. However, the integration of knowledge from cultural traditions other

than Buddhism to date is limited. We recommend that positive psychologist

broaden their horizon by integrating knowledge, or to develop positive activities

that include elements from other cultural traditions than Buddhism. This may be

of importance in particular for mental health care in Europe, in light of the

growing number of migrants and refugees whose mental well-being might be

afflicted as a result of traumatic experiences (Fazel, Reed, Panter-Brick, & Stein,

2012; Kamperman, Komproe, & de Jong, 2007; Slobodin & de Jong, 2015).

Recently, several studies from Iran were published that examined the effects of

Islamic based PPIs (Al-Seheel & Noor, 2016; Rouholamini et al., 2016; Saeedi,

Nasab, Zadeh, & Ebrahimi, 2015). We recommend further development of

cultural fitting PPIs that focus on increasing resilience and well-being for people

with an Islamic background. This could be done, for example, through the

integration of Sufism-Islamic mindfulness (Irfan et al., 2017) into PPIs, or to

integrate Sufi themes such as patience (sabr), trust in God (tawwakul), or

contentment (rida) into PPIs, which was already done in the Sufi-based spiritually

augmented cognitive behavior therapy (Nizamie, Katshu, & Uvais, 2013).

V. Shift of focus in yoga research

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

284

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

identificeerden uiteindelijk vijf belangrijke karaktersterkten: religiositeit, hoop,

harmonie, acceptatie en doorzettingsvermogen. Religiositeit kon beschouwd

worden als de karaktersterkte die ten grondslag lag aan alle andere sterkten. De

studie schetste daarnaast het beeld dat religie, harmonie en acceptatie een

ambivalente rol kunnen hebben: ze kunnen ook resulteren in een passieve houding

die de ontwikkeling van veerkracht juist remt. Niettemin, de belangrijkste

conclusie die we uit de studie haalden betreft de cruciale rol die religie speelt bij

de ontwikkeling van veerkracht en het mentaal welzijn van mensen in Suriname.

Dit gegeven is meegenomen in het proces van culturele adaptatie van het

interventie programma Strong Minds Suriname (SMS), dat in het kader van dit

proefschrift ontwikkeld, geïmplementeerd en onderzocht werd. De effecten van

dit programma werden beschreven in hoofdstuk 6. De basis van de training was

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een bestaande veerkrachttraining die in het Westen is ontwikkeld. Deze training

werd aangevuld met evidence based oefeningen afkomstig uit de positieve

psychologie. Op basis van de resultaten van de eerder vermelde kwalitatieve

studie en op basis van de uitkomsten van diverse focusgroep bijeenkomsten met

vertegenwoordigers van de deelnemende bedrijven en een groep Surinaamse

psychologen werd de interventie aangepast aan de Surinaamse cultuur. In de

periode van 30 maart tot en met 7 juli 2017 is het programma uitgevoerd. In deze

periode hebben 158 werknemers van drie bedrijven in Paramaribo aan de

interventie deelgenomen. We vonden de volgende effecten: in vergelijking met

een wachtgroep leidde deelname aan het SMS programma tot een significante

toename van veerkracht, mentaal welzijn en positief affect. Daarnaast werden

niveaus van depressie, angst en negatief effect significant verlaagd. We

constateerden geen afname van stress, in het bijzonder van financiële stress, en

geen toename van psychologische flexibiliteit. De effectgroottes op veerkracht,

mentaal welzijn en negatief affect waren ‘groot’. De effecten bleven behouden bij

een vervolgmeting na drie maanden. Verder hebben we het risico op bias

geminimaliseerd door het strikt volgen van geprotocolleerde richtlijnen voor

uitvoering van RCTs.

In hoofdstuk 7 werden de resultaten gepresenteerd van een mediatoren

analyse. We onderzochten of twee variabelen, positieve emoties en

psychologische flexibiliteit de werking van het SMS programma op de uitkomsten

veerkracht en mentaal welzijn mogelijke gedeeltelijk konden verklaren. Multipele

mediatoren analyse wees uit dat positieve emoties een mogelijke mediator

vormen en voor een gedeelte de toename van veerkracht en mentaal welzijn

kunnen verklaren. We konden slechts een correlatie vaststellen wat betreft de

relatie tussen positieve emoties en de gemeten effecten, maar geen definitief

causaal verband. Dit kwam doordat we de mate van positieve emoties

tegelijkertijd met de mate van veerkracht en mentaal welzijn hebben gemeten, en

niet daarvoor. Dat er geen relatie is vastgesteld met betrekking tot psychologische

flexibiliteit heeft mogelijk te maken met de complexiteit van de vragenlijst die

beoogde het construct te meten.

In het derde en laatste deel van dit proefschrift stond de relatie tussen

yoga en mentaal welzijn centraal. De twee hoofdstukken in dit gedeelte kunnen

gezien worden als exploratief van aard: we keken enkel en alleen of yoga effectief

is bij het versterken van het mentaal welzijn.

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Hoofdstuk acht geeft de resultaten weer van een systematische review en

meta-analyse naar de effecten van verschillende soorten yoga interventies op

positieve mentale gezondheid (mentaal welzijn) onder gezonde populaties. De

meta-analyse bevatte 17 RCTs die de effecten van yoga op een reeks positieve

uitkomsten rapporteerden. We analyseerden het effect van yoga op de drie

domeinen van positieve mentale gezondheid: subjectief welzijn, psychologisch

welzijn en sociaal welzijn. Daarnaast keken we naar het effect van yoga op de staat

van mindfulness. We vonden enkel significante positieve effecten op

psychologisch welzijn wanneer yoga condities werd vergeleken met ‘geen

interventie’ condities. Dit is een opmerkelijke bevinding, omdat yoga vaak in

verband wordt gebracht met gezond leven, spiritualiteit en groter geluksgevoel.

In hoofdstuk 9 onderzochten we een vorm van yoga die in Suriname veel

wordt beoefend: Sahaja Yoga meditatie (SY). Deze vorm van yoga bestaat alleen

uit meditatie. Fysieke houdingen en ademhalingsoefeningen worden niet gedaan.

Het doel van SY is het bereiken van een staat van gedachteloosheid, die men

‘mind-emptiness’ zou kunnen noemen. De systematische review liet zien dat

Sahaja Yoga mogelijk depressie en angst kan verminderen. Ook werd Sahaja Yoga

in verband gebracht met toename van subjectief en psychologisch welzijn. We

onderwierpen de beschikbare studies aan een kwaliteitsmeting. De studiekwaliteit

was in zeven van de negen studies hoog. Dit is vrij uniek in onderzoek op het

gebied van yoga, de studiekwaliteit is over het algemeen laag. Hoewel er geen

definitieve conclusies over SY getrokken kunnen worden door het kleine aantal

studies, kan op basis van deze review SY wel als een potentieel effectieve positieve

interventie gezien worden. Meer onderzoek is echter noodzakelijk.

Ter afsluiting van het proefschrift werd in hoofdstuk 10 de algemene

discussie weergegeven. De belangrijkste bevindingen van de studies werden

beschreven, als ook de algemene sterke kanten en zwakheden van de studies. Zo

was een sterk punt dat alle studies uitgevoerd zijn volgens strikte

wetenschappelijke standaarden. Verschillende gestandaardiseerde protocollen en

richtlijnen voor het uitvoeren van meta-analyses, rapportage over kwalitatief

onderzoek, en de opzet en implementatie van een kwantitatief onderzoek naar de

effecten van een RCT zijn toegepast. Een ander sterk punt betrof het feit dat de

interventie die ontwikkeld en getest werd, cultureel is geadapteerd. De zwakke

punten hadden betrekking op het gebruik van vragenlijsten die niet voor de

Surinaamse bevolking gevalideerd waren. Daarnaast zijn de uitkomsten van de

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interventie beperkt generaliseerbaar naar andere bevolkingsgroepen in Suriname

en daarbuiten.

De algemene discussie sloot het proefschrift af met een reeks

aanbevelingen voor toekomstig onderzoek op het gebied van de cross-culturele

positieve psychologie in het algemeen, en in Suriname in het bijzonder. We

onderstreepten hoe belangrijk het is dat onderzoeken in niet-Westerse landen

worden uitgevoerd volgens gestandaardiseerde richtlijnen en protocollen, om de

kans op bias te reduceren. We adviseerden dat experimentele interventie studies

beter zouden moeten beschrijven of en hoe culturele adaptatie werd uitgevoerd.

Omdat er nog weinig bekend is over de mechanismen die de werking van PPI’s

kunnen verklaren, is meer onderzoek hiernaar ook wenselijk. Een andere

aanbeveling had betrekking op de integratie van kennis uit andere culturele

tradities binnen PPI’s, omdat de positieve psychologie tot op heden vooral kennis

van het Boeddhisme lijkt te integreren, en kennis uit andere tradities -

bijvoorbeeld kennis vanuit de yoga filosofie - over het hoofd lijkt te zien. Wat

betreft onderzoek op het gebied van yoga is een koersverandering wenselijk,

omdat dat onderzoek tot op heden vooral kijkt naar de relatie tussen yoga en

pathologie en lichamelijk klachten, terwijl yoga van origine een methode is om

zelfrealisatie te kunnen bereiken. Tot slot brachten we enkele aanbevelingen voor

toekomstig onderzoek in Suriname en andere landen met vergelijkbare etnische

bevolkingsgroepen naar voren. Het zou bijvoorbeeld ook interessant zijn om op

maat gemaakte PPI’s te ontwikkelen die zich met name richten op het vergroten

van mentaal welzijn binnen specifieke etnische groepen. Zoals bijvoorbeeld een

PPI gericht op het vergroten van mentaal welzijn binnen de Hindoestaanse

gemeenschap in gebieden als Nickerie of over de grens in Guyana, met het oog op

de problematiek rondom suïcidaliteit. Hierin zou yoga meditatie geïntegreerd

kunnen worden. Voor PPI’s in niet-Westerse landen in het algemeen adviseren we

verdere implementatie van religieuze en culturele rituelen, gezien de

transformatieve functie die ze kunnen leveren bij het versterken van positieve

emoties, het individuele en collectieve zelfbeeld, en het ontwikkelen van een

adaptieve attitude. Hierdoor kunnen PPI’s, naar onze mening, bijdragen aan het

vergroten van positieve veranderingen, zoals toename van veerkracht en mentaal

welzijn binnen multi-etnische en cross-culturele contexten.

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Publications

Publications published within the PHD project:

❖ 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. The Journal of

Positive Psychology, 1-13.

❖ Hendriks, T., Hassankhan, A., Schotanus-Dijkstra, M., Graafsma, T.,

Bohlmeijer, E.T., & de Jong, J. (2018). The efficacy of non-Western

positive psychology interventions: A systematic review and meta-

analysis. International Journal of Wellbeing, 8(1), 71-98.

❖ 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.

❖ Hendriks, T., de Jong, J., & Cramer, H. (2017). The effects of yoga on

positive mental health among healthy adults: a systematic review and

meta-analysis. Journal of Alternative and Complementary Medicine,

23(7), 505-517.

❖ Hendriks, T. (2018). The effects of Sahaja Yoga meditation on mental

health: a systematic review. Journal of Complementary and Integrative

Medicine, 15 (3).

302

Publications submitted to peer reviewed journals within the PHD project:

❖ Hendriks, T., Schotanus- Dijkstra, M., Hassankhan, A., Graafsma, T., de

Jong, J., E. T. (2018). The efficacy of multicomponent positive psychology

interventions: A systematic review and meta-analysis.

❖ 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.

❖ 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.

Work in progress, based on research within the PHD project:

❖ Hendriks, T., Schotanus-Dijkstra, M, Bohlmeijer, E.T, Graafsma, T. & de

Jong. (2019). Guidelines for the cultural adaptation of positive psychology

interventions. In: Llewelyn van Zyl (ed). Positive psychological

interventions: Theories, methodologies and applications within multi-

cultural context. Sage Publications.

❖ Hendriks, T., & Hassankhan, A. (2019). Work engagement in Suriname:

findings from a randomized controlled trial on the effects of a multi-

component positive psychology intervention.

❖ Hendriks, T., Pritikin, J., Choudhary, R., Hernandez, L., Amaral, F., &

Danyluck, C. (2019). Character strengths and virtues of long-term

practitioners of Sahaja Yoga meditation.

Publications in magazines

❖ Hendriks, T. (2018). De kunst van het loslaten. Tijdschrift voor Positieve

Psychologie, 1 17-21

❖ Hendriks, T., Sanches, M. & Graafsma, T. (2016). Positieve Psychologie in

Suriname. Tijdschrift voor Positieve Psychologie, 2, 16-22.

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Professional presentations

❖ Hendriks, T. (9 March, 2018). The Art of Letting go. Workshop at National

Congress of Positive Psychology, Ede, The Netherlands.

❖ Hendriks, T. (9 + 10 November, 2017). Positive Psychology Interventions

in the Prevention of Suicidal Behavior and Youth Violence. Invited

speaker at Public Symposium on Suicide, Youth Violence, and

Professional Psychology, Georgetown and New Amsterdam, Guyana

❖ Hendriks, T. (14 July, 2017). The Efficacy of Multi-component Positive

Psychology Interventions. Symposium presentation at Fourth World

Congress International Positive Psychology Association (IPPA), Montreal,

Canada.

❖ Hendriks, T. (8 April, 2017). Positive Emotions and Aggression

Management, National Psychology Congress. Invited speaker at

Paramaribo, Suriname.

❖ Hendriks, T (4 January, 2017). Positive Psychology in Suriname. Panorama,

Apintie TV Suriname.

https://www.youtube.com/watch?v=KG_a4C8f3xw&t=328s

❖ Hendriks, T. (2 June, 2015). Sahaja Yoga: A mind-emptiness approach of

meditation for developing character strengths. Poster presentation at

Third World Congress International Positive Psychology Association

(IPPA), Florida, USA.

❖ Hendriks, T. (14 November, 2014). What is the True Goal of Meditation?

Round table discussion at CANPA Caribbean Regional Conference of

Psychology. Paramaribo, Suriname.

❖ Hendriks, T. (13 November, 2014). The Psychological Effects of Sahaja

Yoga Meditation: a systematic review. Poster presentation at CANPA

Caribbean Regional Conference of Psychology. Paramaribo, Suriname.

304

305

Dankwoord

(Acknowledgements in Dutch)

De totstandkoming van dit proefschrift is voor mij een lange reis geweest. In dit

afsluitende stuk wil ik alle mensen bedanken die mij tijdens deze reis begeleid,

gesteund en/of geïnspireerd hebben.

Allereerst voel ik mij zeer vereerd dat prof. John Rijsman (Tilburg University), door

wiens bemiddeling ik in 1997 aan de Universidad Nacional Autónoma de México

mijn eerste academische werkervaring heb mogen opdoen, bereid is lid te zijn van

de leescommissie voor dit proefschrift. Deze ervaring ontwaakte in mij een sterk

verlangen om op een dag in Zuid-Amerika als psycholoog te werken. Dit verlangen

werd in 2010 vervuld in Paramaribo, Suriname. John, bedankt voor je bemiddeling!

In Suriname was het prof. dr. Tobi Graafsma die me vanaf het begin van mijn

academische carrière aanspoorde om onderzoek in Suriname te doen. Op zijn

uitnodiging gaf ik op 23 mei 2013 mijn eerste wetenschappelijke lezing bij het

Institute of Graduate Studies and Research, Anton de Kom Universiteit van

Suriname (AdeKUS). In deze lezing besprak ik onderzoek op het gebied van de

positieve psychologie en ging in op de effecten van mindfulness interventies op

risicofactoren voor suïcidaliteit. Hierbij plaatste ik wel één kanttekening:

mindfulness is mogelijk minder toepasbaar bij de suïcide preventie in Suriname en

Guyana. Suïcidaliteit is namelijk een probleem dat zich vooral afspeelt binnen de

Hindoestaanse gemeenschap. In mijn optiek zou je deze doelgroep beter kunnen

behandelen met een meditatievorm die gebaseerd is op de yoga filosofie en

waarbij men gebruikt maakt van rituelen en symbolen uit het Hindoeïsme. Deze

opvatting komt voort uit mijn andere interesse: de werking van Sahaja Yoga, een

meditatieve vorm van yoga die ik sinds 2008 beoefen. Na de lezing was ik eruit: ik

wilde onderzoek doen naar de effecten van meditatieve yoga binnen de context

van de positieve psychologie en bovendien hierop promoveren. Tobi wilde wel

eerste copromotor zijn. Als nuchtere wetenschapper griezelde hij wanneer ik sprak

over zaken als mantra’s en chakra’s, maar hij is altijd wel heel geïnteresseerd

geweest in de vernieuwende aanpak van de positieve psychologie. Ik wil hem

hierbij bedanken omdat hij mij aanspoorde om onderzoek te doen en voor zijn

steun tijdens het hele traject.

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In september 2013 stuurde Tobi mij een artikel van een Nederlandse hoogleraar

waar hij in Nederland en Suriname mee heeft samengewerkt: prof. dr. Joop de

Jong. In het artikel “Mindfulness, mist of mirakel?” (2012) beschrijft Joop de

bedenkingen die hij heeft bij de willekeur waarmee mindfulness technieken, die

gebaseerd zijn op het boeddhisme, klakkeloos overgeplant worden in de westerse

GGZ behandelpraktijk. Geïntrigeerd door zijn schrijf -en denkstijl, nam ik contact

met hem op. Toen ik hem vroeg of hij naar een geschreven stuk van mij wilde

kijken, reageerde hij enthousiast. Nadat ik zijn positieve feedback gelezen gehad,

kwam de hamvraag: “Joop, wil jij mijn hoofdpromotor worden?”. Joop stemde

direct in. In januari 2014 werd het allemaal administratief afgehandeld en werd ik

buiten-promovendus aan het Amsterdam Institute for Social Science Research van

de Universiteit van Amsterdam. Joop heeft mij gedurende de afgelopen jaren op

sublieme wijze begeleid en als wetenschapper gevormd. We hebben honderden

mailtjes uitgewisseld en Joop heeft tientallen versies van mijn artikelen onder de

loep genomen. Joop weet bij mij op een of andere manier altijd de juiste knoppen

in te drukken. Bij het lezen van kritiek op je werk, bijvoorbeeld door peer

reviewers, gaat aanvankelijk je bloed soms koken, raak je gedemotiveerd of klap je

gewoon tijdelijk dicht. Bij Joop is dit nooit gebeurd. De feedback die hij gaf was

altijd positief en constructief en zette mij aan om de lat nog hoger te leggen. Vaak

gaf hij mij suggesties die aansloten op ideeën die ik al in mijn hoofd had en die

eruit kwamen door Joop’s feedback. Andere keren corrigeerde Joop mij wanneer ik

te kort door de bocht vloog, of als het wetenschappelijke gehalte van wat ik

schreef discutabel werd. Voor mij is hij de perfecte promotor geweest. Woorden

schieten mij te kort om de impact te beschrijven die hij op mijn denken, werken en

leven heeft gehad. Joop, mille grazie!

De vierde persoon die ik wil bedanken is dr. Holger Cramer van de Universiteit

Duisburg- Essen. Tijdens mijn yoga literatuurstudie, kwam ik de naam Holger

Cramer steeds tegen. Ik stuurde hem ergens eind 2014 een e-mail en we konden

het direct met elkaar vinden. Holger, die ik een paar jaar jonger schat dan ik zelf

ben, heeft het afgelopen decennium meer dan 225 peer reviewed artikelen

gepubliceerd, waarvan velen als hoofdauteur. Holger mag zich dan met recht de

Europese specialist noemen op het gebied van onderzoek naar Complementary

and Alternative Medicine. Met Holger heb ik de eerste meta-analyse gedaan naar

het effect van yoga op positieve aspecten van de mentale gezondheid en ik heb

veel van hem geleerd. Holger, ich bewundere deine Begeisterung und es war eine

Ehre und Freude, mit dir zu arbeiten.

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De persoon van wie ik ook geleerd in het traject, is mij tweede co-promotor dr.

Marijke Schotanus-Dijkstra (Twente Universiteit). Marijke, je feedback op mijn

artikelen was altijd behoorlijk pittig, maar je wees me juist op die dingen waar ik

aanvankelijk minder aandacht aan besteedde. Je nauwgezetheid en

vastberadenheid heeft mijn werk naar een hoger niveau gebracht. Jouw

meticuleuze werkwijze breng ik nu ook weer over op mijn studenten die ik met

hun thesis begeleid. Marijke, bedankt voor de inzet! Dan wil hierbij ook prof. dr.

Ernst Bohlmeijer (Twente Universiteit) bedanken, die mij aan Marijke heeft

gekoppeld. Ernst, als toonaangevende schrijver en onderzoeker binnen de

positieve psychologie ben je vakinhoudelijk een ware bron van inspiratie voor mij.

Vanaf het moment dat jij aan boord bent gekomen, medio 2016, is alles in een

sneltreinvaart gegaan. Bedankt voor de fijne samenwerking!

Bij de AdeKUS wil ik dr. Manon Sanches bedanken, de richtingscoördinator van de

psychologie opleiding. Manon, bedankt dat je mij in 2014 vroeg om fulltime in

dienst te treden, waardoor ik mij voor 100% kon richten op mijn proefschrift. Door

jouw vertrouwen in mij, heb ik de vakken ‘Introductie in de Positieve Psychologie’

en ‘Positieve Mentale Gezondheid’ kunnen ontwikkelen. Hierdoor kan ik het

onderzoek dat ik doe, direct delen met een nieuwe generatie aankomende

psychologen in Suriname. Ook bedank ik andere collega’s voor hun steun: decaan

Loes Monsels, mijn kamergenoot Judith Martins en dr. Glenn Leckie die ook zijn

bijdrage leverde aan het culturele adaptatieproces van de interventie. Mijn dank

gaat ook uit naar aantal studenten die ik de afgelopen jaren heb begeleid.

Allereerst Wantley Sardjo. Wantley is naast student psychologie ook een

succesvolle ondernemer en directeur/eigenaar van een bedrijf in de

elektrotechniek. Samen met hem heb ik een randomized controlled trial (RCT)

opgezet, bedrijven bereid gevonden voor deelname en financiering en meer dan

30 trainingsdagen verzorgd aan zo’n 158 werknemers en een groep van 8 coaches

van drie Surinaamse bedrijven. Wantley, mijn Gran Tangi gaat dan ook naar jou

uit. Jouw betrokkenheid, toewijding en professionalisme zijn de belangrijkste

externe succesfactoren geweest voor het slagen van de RCT. Speciale dank gaat

verder uit naar een zeer getalenteerde student: Aabidien Hassankhan. Aabidien

heeft een passie voor statistische analyses en met zijn hulp heb ik mij door de

statistiek heen kunnen worstelen. Aabidien, ik hoop dat je in de toekomst je

academische carrière voorzet. Ook mijn andere thesis studenten die onderzoek

deden op het gebied van veerkracht, yoga en karaktersterkten, Sheetal Charan,

Shifana Binda en Alta Gracia Hildago, bedank ik voor hun toewijding en geduld.

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Bij het Amsterdam Institute of Social Science Research (AISSR) van de Universiteit

van Amsterdam bedank ik drs. Jose Komen, Janus Oomen en Muriel Kiesel voor

alle financiële en logistieke ondersteuning tijdens het traject. Jullie hebben me

echt fantastisch gefaciliteerd! Ik besef me hoeveel geluk ik heb gehad dat ik bij het

AISSR heb kunnen promoveren.

Gedurende het dissertatie traject heb ik verder met een aantal andere

onderzoekers samengewerkt en vele internationale contacten gelegd. Bij de Vrije

Universiteit Amsterdam wil ik prof. dr. Pim Cuijpers bedanken, die aanvankelijk

copromotor zou zijn. Door de verschuiving van yoga naar positieve psychologie

gedurende het traject ben ik overgestapt naar Twente Universiteit, maar ik wil

hem toch bedanken voor zijn bijdrage aan het begin mijn reis. Ook heb ik met

plezier samengewerkt met enkele Amerikaanse onderzoekers. Bijvoorbeeld met

Meg Warren van de Washington University. Haar wil ik bedanken voor haar

bijdrage aan het artikel dat in hoofdstuk 2 in deze dissertatie is opgenomen.

Verder heb ik de afgelopen jaren ook een internationaal cross-sectioneel

onderzoek gedaan naar de relatie tussen karaktersterkten en Sahaja Yoga

meditatie. Hiervoor wil ik de volgende onderzoekers bedanken: dr. Chad Danyluck

(University of Colorado, USA), dr. Joshua Pritikin (University of Virginia, USA), dr.

Rajeev Choudhary (University of Raipur, India), dr Lili Hernándes (University of

Nottingham Ningbo, China) en dr. Flávia Aparecida Amaral (Universidade Federal

dos Vales do Jequitinhonha e Mucuri, Brazil). Op dit moment werken we aan een

publicatie die volgend jaar uitkomt en die de basis gaat vormen voor een deel van

mijn postdoctoraal onderzoek. Ook dr. Sergio Hernández (Universidad de La

Laguna, Tenerife, Spain) en prof. dr. Katya Rubia (King's College University London,

UK) wil ik in het kader van het onderzoek naar de effecten van Sahaja Yoga

bedanken. Als laatste dank ik de man door wie ik in 2007 kennis maakte met de

positieve psychologie en me adviseerde over de opzet van het vak “Introductie in

de Positieve Psychologie’, prof. dr. Tal Ben-Shahar.

Mijn dank gaat ook uit naar de mensen die betrokken zijn geweest bij de

ontwikkeling en uitvoering van de RCT, dat het hart van deze dissertatie vormt.

Voor hun feedback tijdens de focusgroepen wil ik Irene Spangenthal en Stan

Franker van HEM Suriname N.V. bedanken. Zij zijn ook degenen geweest die mijn

vrouw op het juiste moment naar Suriname hebben gehaald.

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Ook de psychologen drs. Maja Goedschalk-Heijmans en drs. Mavis Hoost wil ik

bedanken voor hun feedback tijdens het culturele adaptatie proces. Samen met

hen heb ik een aantal jaren in Suriname een employee assistance programma

verzorgd bij o.a. Rosebel Goldmines en van de opbrengsten is ook een deel van het

dissertatie traject bekostigd.

Ook wil ik alle coaches bedanken die de oefeningen van het Strong Minds

Suriname programma hebben verzorgd en de HR-medewerkers van de bedrijven

die hun bijdrage leverden aan de culturele adaptatie en toezicht hielden op de

deelname van de werknemers. Ik bedank hierbij Charly Nassar, Patricia Najatirta-

Nasir, Farielle Soemodihardjo, Nuyen Djojosoematro (Multi-Electrical Systems),

Sharon Neral, Camille Essed, Gloria Sordam-White, Lenea Talea-Vlijter

(Surinaamse Postspaarbank), Farida Amatodja, Querida Neslo-Lie Kwie Sjoe,

Danielle Debipersad-Ralim en Ruth Ackson (InterMed). Mijn bijzondere dank gaat

uit naar de directeuren van de Surinaamse Postspaarbank en de InterMed Groep,

Ginmardo Kromosoeto en drs. Jim Rasam, voor het vertrouwen dat ze in mij en

Wantley hebben gesteld, het beschikbaar stellen van hun medewerkers en voor

het op hun rekening nemen van een groot deel van de kosten van de interventie.

Ook alle deelnemers van de bedrijven dank ik voor hun inzet, als ook alle

respondenten die ik heb geïnterviewd in het kader van mijn kwalitatief onderzoek

dat voorafging aan de interventie.

Mijn dank gaat ook uit naar al degenen die mij de afgelopen vijf jaar indirect

hebben gesteund in mijn werk. Met name mijn ouders Charles en Loes Hendriks.

Ze hebben altijd interesse getoond in mijn leven en werk in Suriname en ik voel me

bij hen altijd welkom wanneer ik in Nederland ben. Speciale dank gaat uit naar

mijn zwager en buurman Roy Tseng. Het afgelopen jaar heeft hij van ons huis en

onze tuin een omgeving gemaakt waar we heel prettig in kunnen wonen en

werken. Ook zijn vrouw Ingrid Oudsten dank ik, omdat ze altijd onze katten en

hond verzorgde als mijn vrouw en ik weer eens naar het buitenland gingen voor

een wetenschappelijk congres of yoga seminar. In de categorie ‘overige familie,

vrienden en bekenden’ bedank ik mijn zus Inge Hendriks en mijn zwager George

van Venrooij, Frans van Gennip en Annelien Veerman, Eric en Desy Block, Marco

en Linda Verhoeven, Frank van Galen, Leonidas Pakos en Wim Peeters. Ook wil ik

Monica en Jorrit in Amsterdam bedanken voor het verblijf bij hen tijdens een

werkbezoek begin dit jaar. Verder ook alle yogi’s van het Surinaamse collectief en

de collectieven van de landen die ik gedurende mijn onderzoek heb mogen

bezoeken: Nederland, België, Frankrijk, Zweden, Italië, de Verenigde Staten,

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Canada, Frans-Guyana, Brazilië, Paraguay, Argentinië en Chili. Ook wil ik alle yogi’s

wereldwijd bedanken die de karaktersterkten vragenlijst hebben ingevuld of mij

hebben geholpen bij het vinden van respondenten.

Dank ook aan de leescommissie leden: prof. dr. Agneta Fisher (Universiteit van

Amsterdam), prof. dr. Astrid Homan (Universiteit van Amsterdam), prof. dr.

Jeanette Pols (Universiteit van Amsterdam), prof. dr. Meike Bartels (Vrije

Universiteit Amsterdam), (wederom) prof. dr. John Rijsman (Tilburg University) en

prof. dr. Jan Walburg (Twente Universiteit) voor het lezen en beoordelen van mijn

proefschrift. Jan wil ik ook nog bedanken voor het beschikbaar stellen van het Shell

Resilience Program, dat de basis is geweest voor het Strong Minds Suriname

programma dat ik heb ontwikkeld. In dat kader bedank ik ook Rijkwessel de Valk

die toen bij Royal Dutch Shell werkte.

Tot slot wil ik twee hele bijzondere vrouwen bedanken. Ten eerste mijn shakti,

mijn vrouw Dulcy Oudsten. Bij deze spreek ik mijn diepste waardering uit voor

haar steun. Ze heeft me in 2010 meegenomen naar Suriname, waar ik alle kansen

heb gehad om datgene wat voor mij was voorbestemd ook daadwerkelijk te

verwezenlijken. Alle weekend -en avonduren achter de laptop gingen soms ten

koste van onze quality time, maar samen weten we toch een balans te vinden

tussen mijn toewijding aan het wetenschappelijke onderzoek en onze

gezamenlijke passie voor Sahaja Yoga meditatie. En daarover gesproken, als laatste

gaat mijn dank uit naar onze guru mata, H.H. Shri Mataji Nirmala Devi, die voor

ons een dagelijkse bron van kracht en energie is, waardoor ik mijn reis succesvol

heb kunnen afronden. Zij heeft mij uiteindelijk het antwoord gegeven op de vraag

hoe een mens volledig tot bloei kan komen, de vraag waarom ik in eerste instantie

psychologie ben gaan studeren.

Tom Hendriks,

Paramaribo, 30 september 2018

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About the author

Tom Hendriks was born in Veldhoven on the 9th of July 1971 and raised in

Eindhoven. He finished his study in Child and Youth Psychology at Tilburg

University in 1997, specializing in youth culture and recreational drug use. After

graduation he worked with alcoholics and drug users in Mexico City, as a trainee of

the Universidad Nacional Autónoma de México. This was a life changing

experience, after which he shifted his attention to sales and coaching. He then

worked in the Netherlands, Spain, and Germany, eventually starting an internet

company in 2000. In 2007, he became an IT recruiter at an international staffing

provider. Meanwhile he studied psychology vocationally, focusing on personal

excellence and flourishing, and started up his own consultancy practice.

Through his work, he met his wife, who was an IT cluster manager at a supply

chain multi-national. In 2010, they moved to Paramaribo, Suriname. There he

joined a group of psychologists and formed CARE providers, a company proving an

employee assistance program to multi-national companies such as Rosebel

Goldmines and DP World, and Suriname’s top company Staatsolie. In 2011, he

started to work as a part-time tutor in psychology, at the Department of

Psychology of the Anton de Kom University of Suriname (AdeKUS). This

department was set up in 2010 as a twinning project with the Erasmus University

Rotterdam, following their curriculum. He was offered a fulltime position at the

AdeKUS in 2014 and the same year he started as an external PhD candidate at the

Amsterdam Institute of Social Science Research of the University of Amsterdam.

His specialization is the cross –and intercultural applications of well-being

interventions. He has developed the bachelor course ‘Introduction in Positive

Psychology’ and the master course ‘Positive Mental Health’ at the AdeKUS,

developed and implemented an evidence-based cultural adapted multi-

component positive psychology intervention and published several papers in

international peer reviewed journals. He was a (invited) guest speaker, and

conducted workshops, during scientific conferences in Suriname, Guyana, Canada,

and the Netherlands.

Tom is married to Dulcy Oudsten, has nine cats and one dog, is a dedicated

practitioner of yoga meditation, and likes to play shred guitar.