Discussion: Ethics in Cross-Cultural Research

 Please read instructions carefully

Ethics are a critical and essential element of psychology. Psychologists must follow all appropriate laws and policies of their organization, locality, state, nation, and professional group. Additional ethical issues are often posed when conducting research cross-culturally, such as new or different issues regarding power and privilege, and factors involving different ideas and beliefs about gender, age, status, religion, and so on. Great skill and a delicate touch are often required to be certain each person appropriately follow all ethical considerations to the satisfaction of all involved, yet achieving this goal is essential to ensure a high standard of research as well as a high standard of behavior.

For this week, you will examine ethical issues related to cross-cultural research and the necessary course of action. You also will examine ethical dilemmas that you might encounter related to your own personal culture and point-of-view. In addition, you will finalize your Module 4 Assessment for final submission.

While many psychologists may be familiar with ethical considerations in their own culture, such as the use of Institutional Review Boards (IRBs) to review research, or the existence of professional documents such as American Psychological Association’s (APA) code of ethics, when conducting research outside of their majority home culture, they may be at a loss. For instance, the psychologist may not be aware of different rules and regulations for research in different nations, or about various spoken and unspoken cultural beliefs about morals and ethics and the role and purpose of research, such as differing understandings and beliefs about what merits co-authorship or what constitutes privacy and confidentiality. Familiarizing yourself with such ethical considerations will be important for you to understand in your future professional practice. 

Examine ethical issues related to cross-cultural research and the necessary course of action.

 Consider the following:

 Professor Plum wants to investigate cross-cultural differences in attitudes towards different foods. He is very interested in nation “X”. However, he has never been there nor does he know the language or culture or the political situation. He also does not know if there are any psychologists living in that nation. Understanding attitudes about foods in this nation may help with people with eating disorders in Professor Plum’s country and eventually may help people with eating disorders in many nations.

As you consider Professor Plum’s research, think about the impact of his plans on human subject protection. Also, consider the ethical implications of the aims of his research purposes and his ability to gain information that will accurately represent those from whom he collects data.

Before Professor Plum begins his research, post and explain some of the potential ethical issues he will need to consider (i.e., impact on human subject protection) and why this is an important consideration.  Further explain two ethical issues and suggest what courses of action might be appropriate. 

 Note: Be sure to support your postings and responses with specific references to the Learning Resources and identify current relevant literature to support your work. 

II
Oh, the Perlllission,
Perlllits, and Approvals
You Will Need

Research Permissions

A week later we were in Kampala getting more permits. In addit ion to
bri nging t he Land Rover into t he country, and the permit to keep it in t he
country (renewable every two weeks – we’d have to drive eight hours
each way to keep it current), and t he permit to bring dollars into t he
country, and the permit to change money, and the permit to buy rationed
” necessities” (kerosene, petrol, sugar, soap, beer), and the permit to enter,
and the permit to work, and the perm it to bring in scientific equipment, and
the perm it to ca rry an extra five gallons of petrol in a jerry can-in addit ion
to all these- Marc needed the National Research Counci l to approve his
prog ram and the forest ry department to grant him a forest permit.

– Halko and Hauser 1996, 92

Field research typically requires formal permissions, often at many levels.

Sometimes a dozen or more kinds of permissions, seals of approval, official let­

ters, and verbal agreements are necessary prior to commencing a field project.

Permission to be in the foreign country, permission to be in the physical space
constituting “the field area,” permission to conduct research that involves in ­

teracting with and/ or measuring other people, permission to capture, tag, and/

or measure wild animals, permission to bring field equipment in and out of the

study area, permission to collect objects in archaeological or paleontological

surveys, permission to collect plant samples, rock samples, tissue samples, or

whatever, and finally permission to export those samples out of the country

9

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10

•

CHAPTER 2

of origin and import them into the country where further analyses will be
conducted. Permissions must often be negotiated in person, sometimes by
personally walking paperwork through from office to office and waiting for an
appropriate official to sign off on the project. In some cases, paperwork must
be submitted far in advance for review by a research-permitting committee.

Some researchers tend to think they have the right to do “research” where
and how they wish because of implications for advances in scientific knowl­

edge or public policy decisions. The lack of a formal research review process
is taken by some as liberty to conduct research without permission. But safe­
guards have been put in place to ensure adequate review of research projects
that affect the welfare/preservation of human and animal subjects, environ­
ments, and objects. This chapter describes some of the common research
permissions that field researchers regularly obtain for their work. Giiven that
permitting systems are seemingly ever evolving and can vary remarkably
across research topics and field locales, we offer just a few examples here and
emphasize the importance of consulting other experienced researchers who
have conducted fieldwork on similar topics in a given field locale.

PERMISSIONS TO STUDY THE LIVING

For research on living human and animal subjects, researchers generally first
obtain permission to conduct field research from the home institution. In the
United States, human subjects’ research requires approval by a federally regu­
lated Institutional Review Board (IRB), and research involving live animals
requires approval by a federally regulated Institutional Animal Care and Use
Committee (IACUC). These permissions are required by U.S. institutions
even when data collection is conducted off-site in a different country. Many
other countries have similar procedures for obtaining research approval at
the home institutional level, but here we will focus on the U.S. institutions.

Institutional Review Boards

Institutions in the United States use IRBs to evaluate the ethical aspects of
research projects involving human subjects. For more information on U.S.
policies, visit: http://www.hhs.gov/ohrp/assurances/irb/. IRBs operate under
U.S. federal guidelines that have developed in recent decades in response to
documented abuse and ethical violations by past investigators. The Tuskegee
Syphilis Study is a well-known example of such transgressions within the

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RESEARC H PERM I SS I ONS • 11

United States but similar ethical violations have occurred when U.S. research­
ers have gone abroad. Just recently, the United States issued a formal apology
for unethically experimenting on prisoners and army personnel in Guatemala
to learn more about the natural history of sexually transmitted infections
in the 1940s (Presidential Commission for the Study of Bioethics 2011).
Although often seen as a hurdle by the research community, IRBs share
important common goals with investigators to ensure research is conducted
ethically, with solid scientific methods, and in ways that maximize benefits
and minimize risks to study subjects (Burke 2005). They are essentially peer/
community review mechanisms analogous to the peer review system of
journals and the review panels of federal funding organizations like National
Institutes of Health (NIH) and National Science Foundation (NSF).

A plan to obtain informed consent is central to IRB approval for human
subjects research. The term “informed consent” is used to indicate that per­
sons participating as research subjects have a clear understanding of what
their participation involves, and based on that understanding, have agreed
to participate. Informed consent is based on the principle of respect for per­
sons, one of the three ethical principles governing human subjects research
(U.S. Department of Health and Human Services n.d.). It is the cornerstone
of the protection of human subjects that the IRB process seeks to ensure. In
the United States, informed consent is typically obtained using a written de­
scription of the research protocol and potential risks and benefits (including
compensation), which must be signed by each research subject. Understand­
ably, the default procedure outlined above is not necessarily appropriate in
all cultural contexts, hence the process of obtaining IRB approval for field
research may, on occasion, present a significant challenge. For investigators
working in countries with different cultural norms than those in the home
country, obtaining IRB approval is often contingent upon clear explanations
of the project that help the committee understand the unique context of the
field research experience. It is important to keep in mind that the human
subjects research experiences of committee members may have been largely
restricted to the controlled laboratory or clinical setting in the United States,
and without the proper context and explanations, a field research project can
appear to violate some of the rules that the committee is there to ensure are
followed. Important differences encountered during field studies may include
recruiting nonliterate human subjects, and conducting research in a cultural

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12 • C H APTER 2

context whereby informed consent must be provided by a community leader,
or head of family, rather than the individual participant.

Institutional Animal Care and Use Committees

IACUCs operate to ensure ethical, humane care and use of animals in re­
search. For field projects on live animals, IACUC permissions are contingent
upon researchers providing detailed documentation of research methods,
with strong justification provided for any protocols that involve potential for
pain or distress to the study subjects. Any invasive darting, blood- or tissue­
collection protocols. together with all methods for animal handling, receive
detailed scrutiny to ensure ethical treatment of all study subjects that mini­
mizes stress and suffering, justifies the choice of study subject, and ensures
the minimum appropriate number of study individuals to adequately address
the research question. Some field researchers are surprised at the range of is­
sues contained in IA CUC forms that may not be even remote considerations
for their field studies (such as surgery, euthanasia), but federal regulations
require that all contingencies be addressed prior to granting permissions for
research. Field research involving noninvasive animal observation or film­

ing procedures may be eligible for IACUC exemption, using special forms
available from the IACUC committee at the relevant U.S. institution. IACUC
committees may also provide follow-up questions on any field projects that
place researchers in close proximity to potentially dangerous animals during
data collection (including the study animals, or other animals occupying the
same habitat) . Similar to IRBs discussed above, it is helpful to remember that
the committee reviewing an IA CUC proposal for a field project may not have
experience in research outside the laboratory setting, so it is worth taking the
extra time to explain the field context of the research in a clear and detailed
fashion in order to justify the study subjects chosen, number of individuals
needed, and methodologies for data collection.

Gaining approvals

Institutional committees may have a limited review schedule, and must
reach a decision and provide approval documentation to a researcher prior to
commencement of study. It is important to be aware of the review dates, and
to submit proposals in a timely fashion in order to ensure that home institu­
tional permission documentation is in place well in advance of the project, as

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RESEARC H PERM I SS I ONS • 13

this is often a prerequisite for obtaining permissions from the host country
where fieldwork is to be conducted, and is increasingly being required at the
time of submission of grant proposals to support field research. Additional
local permissions may also be required; hence failure to obtain institutional
research permissions can result in significant delay or disruption of a field
study. Keeping home institution permissions up to date is also important at
the publication stage, as many journals require that documentation in the
methods section of papers that publish field research results. Although many
bemoan the lengthy forms and explanations required by institutional review
panels, it is important to recognize that this first step may in fact be far less of
a challenge than the myriad of hurdles that follow in obtaining permissions
to conduct field research in the international setting.

In our experience, IRB or IACUC approval is often now contingent upon
approval from a similar institution in the host country. This can present quite
a hurdle when an investigator is without collaborators or affiliated institu­
tions in the host country, or in cases where approval from the host country
must be obtained by making a request in person. Seemingly endless loops can
arise when the host country ethical committee will not grant approval until
the home institution grants approval, but the home institution will not grant
approval until the host country ethical committee grants approval. In box 2.1
Todd Foster describes failed attempts to contact the host country IRBs in the
Marshall Islands from his home institution, and the tangled web of contin­
gent approvals that faced him once he arrived.

Todd’s predicament is not a unique one. When more than one approving
body is involved, it can be a challenge to get contingent approvals, even when
home. It can at times appear that there is no end to the circle. Often the home
institution can be educated about the challenges of working abroad and can
provide conditional approval until final approval is obtained from the foreign
institution. It can be helpful to describe the challenges to your home IRB in
person with the chair of the committee or, if available, during the committee
meeting. Once conditional approval is in place, you can more easily amend
approvals at home based on the foreign institution’s requirements. Having
an advocate in the foreign institution is also invaluable to making the process
run more smoothly.

Given the myriad of challenges of conducting research in an international
setting, the best approach is to consider the IRB or IACUC process as a peer

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14 • CHAPTER 2

MARSHALLESE CHILDREN

Todd Foster

My project involves examining the growth and development

of Marshallese children. I came to the Republic of the Marshall

Islands (RMI) on August 1st of this year. I attempted to get hu­

man subjects clearance before I left, but contacts in the RMI

would not respond to my e-mails or phone calls before I left for

the field. What I learned is that it is rude to conduct “business”

over the Internet in Marshallese culture. Face-to-face meetings

are preferred. So, I couldn’t get a response. Furthermore, a pilot

study I had completed with another Marshallese researcher in

2006 complicated things. That researcher was from a differ­

ent family lineage, one that was having problems with family

lineages of people I needed to get clearance from in the RMI.

Having cleared that up with my contacts and submitting my ap­

plication to my host university, something else went wrong. My

host university got into some trouble regarding human subjects

over the summer and had to revamp their entire p rocess. T h is

resulted in a backlog of five hundred applications. After waiting

six weeks, my advisor was able to get some strings pulled and

I got a caseworker assigned. Now, I am doing anthropometrics,

so I need a research assistant. This research assistant is going to

be appointed by the Republic of the Marshall Islands Ministry of

Health. They will not appoint this research assistant until I get hu­

man subjects approval from the Marshall Islands Human Subject

Council. The Marshall Islands Human Subject Council will not

give me approval until I get approval from my host university’s

human subject council. My host university’s human subject

council will not give me approval until I get a research assistant.

Hopefully, you were able to follow the circulation of that as well

as have a good laugh. Anyway, I am almost at the end of the tun­

nel and I think (god, I hope!) I will finally begin collecting data in

January after being in the field for six months.

•

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RESEARCH PERMISS I ONS • 15

review essential to and benefiting field research. The process takes time, so it

is important to be cognizant of deadlines, and to allow sufficient time for ad­

dressing relevant issues raised by the review committee. Similarly, one must be

aware of and allow sufficient time for the ethical review process in the field area.

PERMISSION TO DO RESEARCH IN HOST COUNTRY: VISAS

In addition to the general travel visas discussed in chapter 3, some countries

require specific research visas in order to conduct a study, and obtaining a
research visa may require research clearance from an in-country institution or

ethics committee. Brazil is an example, as Barbara Piperata explains in box 2.2 .

• ,1.1:•••
A RESEARCH VISA I N BRAZIL

Barbara Piperata

There is a very specific type of visa for research in Brazil. It costs

about $200 and can only be obtained if you can demonstrate that

you have (1) a local counterpart; (2) have received approval for
your research; and (3) can demonstrate you have the funds to

pay for the research . You also have to submit the full research

proposal for review. When I went to Brazil for my dissertation

research in 2001, you needed federal government approva l!, and

since my research was on health it had to be approved by CONEP

(Comissao Nacional de Etica em Pesquisa, the National Commis­

sion on Ethics in Research ), which was a long, drawn out process.

My understanding now is that you still need to do this unless you

are affiliated with an organization (a university, for example) that

has a recognized internal ethics review board. Now when I work

in Brazil I go through the IRB at Universidade de Sao Paulo and

a colleague acts as the lead and ushers the proposal through. I

have not had any recent problems and the process has gone from

taking six to twelve months to about three months.

•

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16 • CHAPTER 2

The process may not always be clear to an outsider, and as experienced
by Barbara, countries and institutions within them may change policies and
procedures on a regular basis. It is helpful to have a colleague in a local insti­
tution who can shepherd the protocol through the process; however, that is
no guarantee that the process will be any faster or smoother. Ice was recently
delayed due to the seemingly ever-changing research permissions process in
Kenya. A relatively simple project, deemed to be expedited by her university
IRB, took nine months for approval, even with the assistance of a very help­
ful colleague and the government research institution. As a result, she spent
six weeks training local staff rather than collecting data. Luckily, she had an
excellent collaborator and enough infrastructure and assistance locally to
complete the data collection in her absence when she needed to return to her
other academic duties.

It is also important to keep in mind that embassies can withhold and re­
voke visas at any time depending on poli tical conditions. For example, Den­
tan (1970) described that while he was in Indonesia undertaking an intensive
language course in preparation for field research, official relations between
Indonesia and the United States deteriorated to the point that the Indonesian
embassy refused to issue him a visa for more than three months’ residence,
leaving him insufficient time to conduct the research he had planned.

PERMISSIONS FROM HOST COUNTRY INSTITUTIONS

Even with an appropriate visa, research clearance, and a formal affiliation
with a local university or research institute, there may be a plethora of na­
tional, district, and/or local institutions in the host country with interests in
regulating research by outsiders. Sandra Gray describes the impressive “maze
of officialdom” she navigated in Uganda at both the national and district
levels in order to conduct human subjects research in Karimojong (agropas­
toralist) communities (box 2.3). Regulating parties included a ministry and an
affiliated hospital at the national level, and a parliament, ministry, a.nd eight
other offices/organizations at the district level. Each of these political entities
was external to, and did not necessarily operate in concert with, the political
structures in the Karimojong communities she wanted to study.

The complexity of internal political structures that Gray describes is not
always evident to an incoming researcher. Dufour commenced fieldwork
in Colombia in the 1970s with an appropriate visa, permission from the

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RESEARCH PERMISSIONS • 17

KARIMOJONG POLITICS, REVISITED

Sandra Gray

Since 1998 I have been conducting fieldwork among Karimojong

agropastoralists in northeast Uganda. The Karimojong were

the subjects of Neville Dyson-Hudson’s seminal 1966 mono­

graph Karimojong Politics. Navigation of the political aspects of

fieldwork in sub-Saharan Africa is always challenging. Initially

research permission was procured from the Ugandan Ministry

of Science and Technology and a Ugandan affiliation with the

Child Health and Development Center at Mulago Hospita l . Ad­

ditionally, permission was required and obtained from multiple

hierarchical political structures in Karamoja: (1) the parliamentary

structure, represented by elected members of parliament and

by the minister of state for Karamoja Affairs, the district ad­

ministrative officer, and the district medical officer, all of whom

are appointed administrators; (2) a system of local councils; (3)

the National Resistance Movement, the revolutionary body that

brought Yoweri Museveni to power at the end of the Ugandan

civil war. While much time and personal effort was expended in

receiving the “seal of approval” from this maze of officialdom, in

reality the success of the research depended on the goodwill of

the Karimojong communities in which I worked, which derived

entirely from the acceptance and support of the indigenous gov­

erning structure.

Indigenous governance among the Karimojong is based on

the consensus of local elders. In fact, although a plethora of rules

and regulations are imposed by officialdom, in reality these can­

not be effectively executed unless they are sanctioned by the

elders. Thus, Ugandan politics is external to and often in opposi­

tion to Karimojong politics. Very early in the research, I found

myself in the crossroads of these two political trajectories.

(continued)

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18 • CHAPTER 2

i:J.fi¥¥ii·Uiilt1Jiiif ·I

Each homestead is identified with a senior male elder, and in

each of the four clusters of homesteads in which I worked, one

elder carried particular authority as a consequence of his senior­

ity, his skill as a herder, and his wisdom. I met with the elders

in each cluster and collectively, and they agreed to allow me to

work there. I then appealed to the female elders-women were

after all the subjects of the study- and they likewise agreed. For

the most part, I had little interaction with males thereafter.

In the cluster of one of the most senior elders (Apangoleyiara),

however, the research took a somewhat different shape. Early on,

Apangoleyiara began to visit the place where I was interviewing

the women. Each day he sat quietly at a discreet distance from

the enclosure and observed the work. He never interrupted its

progress; he simply sat, listened, and observed. Eventually, other

elders joined him, but they followed his lead and sat quietly. On

one morning as we began our interviews, a young man – in his

late thirties perhaps-strode angrily into the enclosure where the

women and I were seated. He accosted me loudly in Ngakari­

mojong-and with some menace, inasmuch as he was armed
with an AK-47, the diplomatic tool of choice among the younger

political set. My interpreter translated quickly- he, Mudong, was

the local council chair; I had not obtained his permission; he had

been away for the past week or so and what right did I have to

work in this place without consulting him? I should leave unless

I planned adequate remuneration (to him). I instructed my team

to pack up the equipment and, through my interpreter, told him

we assumed we had gained permission but since we had not, we

would leave. He continued to rail at us as we prepared to depart

and to scold the women who had dared to participate (and who

grumbled as he shooed us off).

At the start of the altercation, I saw Apangoleyiara rise from

the circle of elders and walk back to the homestead. When my

crew and I had finished packing up our equipment and were

heading back to the vehicle, Apangoleyiara reappeared with an

object in his hand. He came directly to me and, without a word,

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RESEARCH PERMISSIONS • 19

extended the object, which was a live chicken. I took it, dumb­

founded, and he returned to the homestead. Suddenly, the noise

in the enclosure-Mudong’s vituperation, the grumbling of the

women, the low hum from the elders-quieted, and everyone

sat in silence, looking first at me, then at Mudong. He lowered

his gun, shifted nervously, then appealed to me to wait. I should

stay, he said (somewhat flustered). It was a misunderstanding.

People seemed to like working with me. Certainly we could work

something out. He would allow me to stay. He shook my hand.

Continue your work, he said, and walked away. The women

chuckled. The elders looked solemn. My interpreter’s eyes met

mine, and we looked at the chicken. We smiled.

•
Ministry of the Interior and the Ministry of Health (it was a health-related
project), permission from the regional Catholic bishop (this was the highest
regional authority), and permission from the local community. But it turned
out that these were not sufficient, and she was threatened with deportation
by the Ministry of Culture for not obtaining their permission as well. This
underscores the importance of identifying all legitimate host country stake­
holders and obtaining permissions prior to commencing research-a task
made much easier as more and more countries make their scientific research
policies explicit on the web, often with downloadable permit forms and on­
line submission procedures. As we have noted many times already, talking
with experienced researchers in the field area is often the best head start to
smoothing the process for a successful field project. If you work ahead and
still have problems, it is best to keep a level head and do what you can to work
within the system you find yourself. Gray was probably able to move forward
because she had established strong ties and trust with the local

community.

Importantly, permission for a specific project does not last forever. As Lee
(1995) notes, “Access to a research setting is never a given. What is open at
one juncture can be closed at another time or in different circumstances.”
He gives the example of Brewer (1993), who was studying routine policing

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20 • C H A P T E R 2

activities in Northern Ireland. Brewer was originally granted permission be­
cause his research was of interest to the chief constable but when that person
retired, the new chief discontinued his research permission.

Nor are the conditions attached to research permissions always clear.
In box 2.4 Jeremy Koster recounts the tale of almost losing the permission
from local authorities in Nicaragua due to a misunderstanding related to
whether or not his wife would provide weekly English classes to the local
community. Often a collaborator from the host country is useful in navigat­
ing these types of issues.

Jeremy’s story demonstrates not only the challenges of getting research
permissions but the importance of giving something back to the communities
within which we work. He was able to resolve the misunderstanding and result­
ing difficulty by listening to his community and providing a reasonable solu­
tion. When demands are asked of you that you cannot honor, consider finding
something that is within your ability that also will satisfy the community.

PERMISSION FROM THE LOCAL COMMUNITY

Institutional, national, and regional permissions may or may not be relevant
at the local level where the research will actually take place. Generally, it is
necessary to obtain the consent of the community, and not just individuals
within the community. Anthropologists have long navigated this issue, but it
is worth pointing out here, as even recently, local permission has presented an
unexpected hurdle to medical researchers in the field {Diallo et al. 2005). The
need for local community buy-in may also be important to convey to IRBs
unfamiliar with the culture of field areas outside North America. Research
may pose risks to local communities that are separate from the risks to indi­
viduals (Khan 2005). For example, indigenous nations in the United States
and Canada typically have established protocols governing research (Kawul­
ich 2011). As Teufel explains in box 2.5, Native American groups have taken
active steps to protect the community as well as the individuals within. They
are aware of the impact of research on their communities, and hence prefer
to be the last approving body for all research proposals that concern them.
Community requirements for approval can go beyond what is typica[ of IRBs
and may include approval of all presentations and publications resulting from
the work. As Teufel points out, this additional permitting layer ensures that
researchers think about the impact of their results on the “researched” them­
selves, an important consideration for all field projects.

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RESEARCH PERMISSIONS • 21

•:1.t•••
REQUEST TO TEACH ENGLISH

Jeremy Koster

Researchers who want to work in the indigenous territories of Ni­

caragua’s Bosawas Reserve must first secure permission from the

territorial leadership. When I arrived to begin my fieldwork, I there­

fore arranged to have a meeting with the territorial president, vice

president, and secretary, along with various community leaders.

Everyone at the meeting recognized that, because I was still

a graduate student, the scope of my project would be smaller

than other projects. Nevertheless, the leadership seemed im­

pressed when I indicated that I could provide a few dollars per

month for every household that participated in my study. We

drafted an agreement (convenio) that documented the com­

pensation, the length of the project, and my plans to weigh all

harvested fish and game.

At that point, the indigenous president, Felipe, observed that,

while there were clear benefits to the community where I would

be working, it would also be appropriate to provide something for

the people of the territory more generally. He patiently explained

that many people in the reserve earnestly wanted to learn English,

and then turned to my wife, Stefanie, and wondered if she could

travel to provide English lessons every week in Raiti, the terrijtorial

capital. Stefanie was caught off guard by Felipe’s request, but she

promised to consider the possibility. Content with this answer,

Felipe ended the meeting by wishing us well and assuring us that

he would have a typed version of the convenio soon.

It was about three months later when Felipe returned from

Managua with a typed version of the convenio. He sent a mes­

sage by radio. asking that I travel to Raiti to sign the document.

Stefanie arranged for a couple of local men to ferry us two hours

downstream to another community, from which it was another

two-hour walk to Raiti. Covered in mud and tired from the trip,

we were stunned to arrive in Raiti and see that Felipe had inserted

(continued)

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22 • C H A P T E R 2

i:J.f:W#ii·Uiilt1Jiiif ·I

a clause in the convenio about weekly English lessons to be taught

by Stefanie. By that point, Stefanie was engrossed in her conser­

vation work, and we had realized that it would not be feasible to

travel to Raiti on a weekly basis. I therefore explained to Felipe

that I could not sign the document until that clause was removed.

Felipe was disappointed, but he acquiesced.

Another two months passed, and the date for the territorial

assembly was approaching. It was an election year, and Felipe

was hoping to be reelected as president. He was also receiving

considerable pressure to solicit donations from organizations to

fund the assembly, specifically to purchase the supplies needed

to feed approximately one hundred participants for three days.

Felipe had already received sizable donations, but not enough.

He contacted me by radio to say that, because I had not fulfilled

my end of the convenio, he was requesting approximately $400

to pay for the assembly. If I did not provide the money, I risked

being denied permission to continue my research.

I was scheduled to provide an update on my research at the

assembly, and I brought along a fair amount of money just in
case. I had underestimated the ire that the situation had aroused

among the leaders in Raiti. During my presentation, one man

stood up and loudly interrupted, accusing me of being just like

Christopher Columbus, always taking and taking and giving

“trinkets” in return. Another spoke up in my defense, insisting

that my thesis research would not make me wealthy. I added

that the people in my study community seemed content with the

compensation, which provided higher pay per hour than virtually

any other job in the reserve.

These explanations did not mollify the crowd, and I left the

meeting worried that someone might be angry enough to at­

tack me on my way home. In the end, though, tempers on both

sides cooled fairly quickly. Stefanie and I arranged for some col­

leagues at the U.S. embassy to donate some English language

materials to the people of Raiti. Felipe was not reelected, and

his successor made no additional demands during the remain­

der of my research.

•

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R ES EA R C H P E R M I S S I 0 N S • 23

WORKING IN A TRIBAL COMMUNITY

Nicky Teufel

Native Americans have endured more than a century of research

they have not consented to involving observation, interviews, and

measurement. Data have been collected, analyzed, interpreted,

and disseminated most often by non-natives. Over the last two

decades in an emerging era of indigenous self-determination,

tribes have developed formal and informal systems of approving

research. These systems tend to have greater jurisdiction than a

standard Institutional Review Board (IRB) and are designed not

only to protect the rights of individual human subjects but also

to prevent the collective harm that has occurred when sacred

cultural beliefs, practices, and instruments, and even distinctive

biological characteristics (e.g., metabolic rates, body composi­

tion, genetic markers, etc.) have been described and interpreted

outside the larger sociocultural context and without consultation

from native experts.

For projects that involve tribal members, tribal review com­

mittees, boards, or councils require that investigators request

approval and, in some cases, a tribal resolution for development

of grant applications, research plans, and protocols, as well as

all lay and scientific presentations and publications. These com­

mittees often prefer to be last approving body. Subsequently

investigators are asked to gain approval from their institution’s

IRB and then the tribe, so the tribe is assured no additional

changes will be made after its approval. This order of approval

can create a dilemma for an investigator as many academic and

research institutions prior to review may request some evidence

that the tribal community has approved the proposed research.

Investigators should consult with their institutional IRB to resolve

this predicament.

(continued)

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24 • C H A P T E R 2

i:J.fi¥4Ji·Uiilt1Jiiif ·I

Publication review by nonresearchers and actually the re­

searched requires that investigators think about the local im­

pact of their work and fit their outcomes to the sociocultural

context. The following example comes from a tribal community

that had given consent for a project to implement and evalu­

ate the impact of in-school physical activity sessions led by

trained community members to build capacity in a setting with

few or no certified physical education teachers. The joint team

of native and non-native researchers developed a publication

sharing pre- and post-intervention outcomes reporting changes

in youth’s anthropometric measures and level of fitness. The

draft manuscript was submitted to the tribal committee for

permission to publish. The manuscript used the term obese to

describe a proportion of the youth. The tribal committee was

concerned about the derogatory overtones of the word obese.

In addition, the committee asked about the validity of applying

Centers for Disease Control and Prevention (CDC) standards

developed from non-native populations to native youth. The

researchers and committee collaborated to revise the wording
to state that these youth fell above CDC’s recommended weight

for height. The revision may seem small but the collaborative

process yielded a document acceptable to both the researched

and researchers. A trusted relationship built on mutual respect

was initiated and paved the way for another decade of approved

collaborative research in this community.

•
In the 1970s some benefits of Dufour’s fieldwork in the Amazon were

evident to the community. For example, she and her spouse provided basic
health-care supplies, including general antibiotics, TB treatments, wound­
care supplies, and rehydration IV fluids, under the supervision of a nurse
at the nearest mission. A second benefit was an agreement to provide peri­
odic “gifts” to the village in lieu of payments to individuals. The risks were

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R E S EA RC H P E R M I S S I 0 N S • 25

less obvious at first, but included the possibility of introducing infectious
diseases, particularly colds, as the researchers traveled between the village
and other sites.

Diallo et al. (2005) outlined the steps to obtaining community permission
in rural Mali for a malaria vaccine study. The first step was to study the com­
munity to understand local customs and to identify legitimate community
representatives. These included a district-level administrator, an elected

mayor, and traditional community leaders (neighborhood chiefs and school
directors). This step was followed by a series of meetings: (1) an introductory
meeting with the leaders to explain the proposed research and to solicit guid­
ance on how best to obtain community permission; (2) formal meetings with
leaders to explain the goals of the project as well as risks and benefits in detail;
(3) personal visits with leaders to further explain the project and answer ques­
tions; ( 4) meetings with traditional health providers to explain the project
and solicit collaboration as it was a health-related project. Information about
the project was communicated to heads of households by the neighborhood
chiefs. Only after all of those steps had been completed did researchers ap­
proach individual subjects for participation.

The politics of local authority are not always so clear cut.

Trudy Turner

describes a situation in box 2.6 in which she thought she had obtained per­
mission at all levels of authority, but found that she missed the lowest level.

AND .. . CONSENT FROM THE SUBJECTS THEMSELVES

The fundamental level of approval needed for research projects involving
human subjects is usually the informed consent of individual participants.
Informed consent is a requirement of IRB approval for most types of research
involving human subjects, and is often required by other ethics committees. It
can be a challenge to implement subject consent in field situations for at least
two reasons. First, the concept of an individual providing informed consent
may fly in the face of cultural practices that allocate that responsibility to a
community or clan leader, or a head of family. Second, the format of informed

consent typically required by IRBs is a written document that the subject must
sign, and in our experience, signing such a document can be seen as a very
strange custom, and one to which little significance is attached. Furthermore,
when working with nonliterate populations, ethical concerns arise when asking
people to sign a document that they cannot read, or fully understand even when

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26 • C H A P T E R 2

A NEW FIELD SITE

Trudy Turner

I have been doing fieldwork in Africa for more than thirty-five

years. Over the course of numerous field projects, many things

have gone wrong. There has been a smash-and-grab while I was

in a car at a red light; there has been a car accident; there has

been illness; there have been endless bureaucratic hassles and

hassles with landlords; and there has been loneliness. There

has also been the privilege of meeting wonderful people and

having lots of adventures. But one incident sticks in my mind

as something that exemplified for me some of the difficulty in

doing field research.

My team and I had been in Kenya for nearly a year. We had

set up three field sites and had spent over a month at each site

trapping and sampling vervet monkeys for a population genetics

survey. We wanted to complete one final site, but were having

trouble locating one that met all our requirements. We found a

place and packed up all our gear, our equipment, and moved out

with two trucks to set up field camp for us and for our workers.

When we got to the site we could not reach the campsite because

we could not cross a river that had swollen during the rains. We

turned back with no real plan B.

We searched for another site for a few weeks and finally

settled on one somewhere between Amboseli and the Maasai

Mara in the south. Once again we packed up everything and

moved to set up camp. It was with great relief that we were

spending our first night in our new camp in a lovely site by a

small pond not too far from the base of Kilimanjaro . It was a

moment of great relief.

Suddenly a car pulled up and three extremely large men got

out. The leader of the men said that he represented the local

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R ES EA R C H P E R M I S S I 0 N S • 27

Maasai council and asked us who told us we could camp on this

land. We certainly had all the national and local permissions

to be where we were. We had confirmed our presence on this

piece of land with the official authorities. But apparently the local

permission had not included a discussion with the local Maasai.

Things escalated. There was yelling and the head man and my

assistant were facing off against each other. My assistant was 6

feet 4 inches tall and the other man was taller and bigger. Things

looked bad and looked like there was going to be a real fight. I

was exhausted from the weeks of looking and preparing and was

incredibly dismayed at the turn of events. When things looked

really perilous, I could think of nothing but to actually place my­

self between these two men and stop this (I am 5 feet 3 inches).

Throwing myself between them forced them to move away from

each other. I asked the Maasai what we could do to make things

right. He said that if we paid 400 shillings to the local Maasai

council we could stay. I agreed, but said I did not have the money

on me. I did not want to give him the money right then. I did not

mind paying the local council, but I did not want the money to
just go to this man, because then we were vulnerable to another

visit another night. I agreed to meet him at the local council

house the next day.

We arrived the next day at the local council house and pre­

sented the money in clear sight of several other people. Now

everyone knew we had paid to be able to camp on the land and

we were left alone for the rest of our stay in the area.

What I learned was that there are many levels of authority.

Even though I had done everything we had done in other places,

in this one place, we needed to do something more. But I did

not want to pay a bribe to a single person. If I was going to give

something to a community, I wanted to be sure it went to the

community.
•

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28 • C H A P T E R 2

it is read to them. Rather, what is most important is a meaningful discussion of
the intent of the project, and what participation really means in terms of time,
costs, and benefits. This kind of a discussion is part of a process of establishing
trust between researchers and subjects, something that should be fundamental
to research on human subjects. Issues of recruitment/retention of study sub­
jects will be discussed in greater detail in chapter 5.

EVEN RESEARCH ON INANIMATE OBJECTS REQUIRES PERMITS

Field research projects that do not involve living subjects, such as archaeolog­
ical or paleontological studies, can also require a complex and lengthy set of
permissions, with requirements that vary by host country. These may include
permission, for example, by Ministries of Science, Culture, or the Environ­
ment, as well as affiliations with and permissions from local academic insti­
tutions. In most cases, researchers conducting projects on nonliving subjects
do so in partnership with local or governmental agencies that act to facilitate
the research and interface with local communities to improve protection
and preservation of localities containing antiquities, and improve positive
outcomes and impacts of the research. In these types of studies, separate
permissions are often required for excavation and export (where applicable)
of study samples, requiring due diligence by researchers to avoid transgres­
sions that could result in misunderstandings and/or prosecution by local and
international authorities. For these and all field projects, it is best to research
well in advance the laws governing research practices for the country in which
fieldwork is to be conducted, and engage in detailed consultations with in­
stitutions and/or individuals experienced in working in the host country to
establish a plan for obtaining appropriate permissions for the research topic.

PERMITS, PERMITS, AND MORE PERMITS

The topic of equipment and sample transport is addressed in greater depth in
chapter 3 with examples of the different challenges that field researchers en­
countered. But in short, field researchers must obtain all necessary permissions
for and be aware of regulations that govern: the import and export of equip­
ment required for field research; the import and export of fossils and other an­
tiquities; and the transport of biological materials that could contain etiological
agents, hosts, and vectors of human disease. These include regulation of human
and animal tissues into the United States by the United States Department of

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R E S EA RC H P E R M I S S I 0 N S • 29

Health and Human Services, and regulation of plant and soil samples from for­
eign countries by the United States Department of Agriculture. Even shipping
materials themselves can prove problematic (for example, shipping crates made
from local wood may require additional permissions/inspections so it is often
better to go with plastic or metal containers). In general, it is important to look
into the ins and outs of import/export for research equipment and materials
ahead of time to avoid unnecessary delays and difficulties.

And finally, even transporting oneself across borders during field research
can require unanticipated permissions. Sheets Payson (2006) claims that
Dante’s The Inferno omitted border crossings in Central America, describ­
ing his ordeal of crossing from El Salvador to Guatemala and the “fees” and
stamps demanded, the ever-present threat of being sent back to the capital city
for some kind of document that could take days to obtain, and the elaborate
complexities of a process that seemed designed to keep him from his work.

SUGGESTIONS AND STRATEGIES

A successful field research project in a foreign country generally requires a
variety of permissions, permits, and approvals. Some concern the research
itself, and others are simply required in order for a researcher to legally stay
in the field area. Some are easy to anticipate from the outside, others are not.

In short, the best strategy is to adopt the attitude that nothing should be
taken for granted when it comes to getting a new field project up and run­
ning, and unanticipated wrinkles can occur with research permissions even in
long-term projects. In our experience, it is most useful for researchers new to
a field area to identify mentors who are familiar with the local setting and/or
type of research project to obtain important pointers about the permissions
specific to their study, to allow plenty of time to obtain permissions at all
levels, and as ever, prepare to encounter and address unexpected challenges!
Specifically we recommend the following prior to beginning a field project:

• Seek research clearance and permits well in advance of planned travel. It is
often best to start with your home institution. Plan minimally six months
in advance and ideally a full year in some locations.

• Determine if you need a research visa to enter the country or if you can en­
ter on a tourist visa and seek the necessary host country permissions while
you are in country.

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Chapter 2

The Concept of Posttraumatic Growth in an Adult Sample
from Port-au-Prince, Haiti

A Mixed-Methods Study |
Grant J. Rich, Skultip (Jill) Sirikantraporn, and Wismick Jean-Charles

In recent years, resilience has been examined more frequently in cross-cultural contexts in order to better capture the
nuances of the recovery/thriving process after trauma as it varies around the globe. This chapter focuses upon
posttraumatic growth (PTG) in a sample of adult Haitians from Port-au-Prince, Haiti’s largest city and capital, and
the site of its devastating 2010 earthquake.

A BRIEF HISTORY OF TRAUMA IN HAITI

Haiti is a Caribbean nation that is located in the Greater Antilles archipelago, where it occupies the western quarter
of the island of Hispaniola (the eastern portion of the island is the Dominican Republic). It population is estimated
at between 10 and 11 million, and thus it is the second most populous nation in the Caribbean (Dash, 2010). Today,
French is spoken, though Haitian Kreyòl predominates, and the population is 95 percent white and 5 percent white
or mixed (Haiti, 2017). Its Gini index indicates extremely high economic inequality between the wealthy and the
poor, and it ranks very low on the UN Human Development Index, a composite measure of life expectancy,
education, and per capita income, ranking 163rd out of 188 nations in 2016 (list of countries by Human
Development Index, 2017).

Haiti has a diverse history. The region was originally inhabited by the indigenous people, the Taínos. Christopher
Columbus landed there on his first voyage in 1492, near the present-day cities of Limonade and Cap Haitian. The
Spanish brought infectious diseases, creating small pox epidemics, and maltreatment of the natives included the
forced labor encomienda system and forced conversions to Catholicism. The native population was decimated over
time and piracy flourished. After Spanish rule from 1492 to 1625, French rule dominated, and the western part of
the island was renamed Saint Domingue (the 1697 Treat of Ryswick formally ended the French-Spanish hostilities).
The French imported and enslaved thousands of Africans, transporting them to Saint Domingue to work in the
sugarcane and coffee plantations. The colonial whites became vastly outnumbered by the enslaved Africans, and
other additional social groups emerged, such as free blacks and free coloreds (Dubois, 2004; Geggus, 2014; Girard,
2010; James, 1963).

Eventually, free coloreds, as well as enslaved and free blacks, agitated for rights and freedom. In the 1790s,
revolts such as that led by Ogé and Chavannes paved the way for the Haitian Revolution, which was led by
Toussaint L’Ouverture, a former slave (and notably slave owner himself), and was in part inspired by the 1789
French Revolution. The Haitian Revolution resulted in the end of slavery and the defeat of Napolean Bonaparte’s
army. Thus, in 1804 Haiti became not solely the only nation in the world that was created as a result of a successful
slave revolt (in 1804), it also became the first independent country in Latin America and the Caribbean, and the
second republic in the Americas (Dubois, 2004; Geggus, 2014; Girard, 2010; James, 1963).

Unfortunately, the ensuing decades were tumultuous ones politically, socially, and economically for Haiti, with
many leadership transitions, including an almost 20-year-long occupation by the United States and its forces from

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1915 to 1934. Soon after arrival, the US Marines took control of Port-au-Prince and the banks, declared martial law,
and censored journalists (Dash, 2010; Dubois, 2004, 2013; Farmer, 2005; Girard, 2010). During the Duvalier
dynasty (1957–1986), severe abuses and corruption continued under both Papa and Baby Doc Duvalier, as
evidenced by the rulers’ use of the Tontons Macoutes group, which kept order by terrorizing the general public,
especially political opponents. Political instability continued, with coups d’etat in 1991 and 2004 especially notable.
The most significant event of the past decade was the magnitude 7.0 earthquake that struck Haiti on January 10,
2010. Estimates of the death toll ranged from 100,000 to over 200,000. Over 1.6 million were left homeless, and
infrastructure was decimated, especially in Port-au-Prince, the national capital and largest city. The aftermath of the
earthquake included a large cholera outbreak, adding to and prolonging the devastation. Haiti was the poorest nation
in the Western hemisphere before the earthquake, and its institutions and recovery were further destroyed by the
earthquake. Humanitarian aid from foreign governmental and nongovernmental groups was not always received,
was not received in timely fashion, or was distributed in corrupt fashion, causing further problems for Haitians
(Dubois, 2013; Farmer, 2011; Katz, 2013). Indeed, Haiti often ranks among the most corrupt countries in the world
on the Corruption Perceptions Index, and crime, especially in Port-au-Prince, is a continuing concern, especially in
areas such as Cité Soleil (e.g., Schwartz, 2010). Poverty is often associated with social problems, and indeed in
Haiti, there is a notable challenge of modern-day slavery (known as restavec), in which poor, vulnerable children
are sent to live and work with an adult, sometimes a distant relative, in what amounts in many cases to brutal
servitude (Cadet, 1998; Haiti, 2017).

In October 2016, Hurricane Matthew struck Haiti as a Category 4 storm. Death toll estimates ranged from the
official figure of 546 to over 1,000 and damage estimates approached US$2 billion, with approximately 175,1000
left homeless (Hurricane Matthew, 2017). Much of the worst of the hurricane was in southern Haiti, though gusts of
60 MPH reached Port-au-Prince. Data collection for the present chapter was conducted in Port-au-Prince, Haiti,
approximately one month later in November 2016.

METHOD

Participants

For the quantitative portion of this study, there were 113 participants. They were sampled from Port-au-Prince,
Haiti’s largest city, and the site of the 2010 earthquake. Table 2.1 revealed the descriptive results of the
demographic variables. The demographic questionnaire revealed that the mean age of the participants was 26.56
(SD= 5.60, min-max= 19–48). The sex ratio of the participants was relatively equal with 46.9 percent female and
52.2 percent male. For marital status, 83.8 percent identified as single and 6.3 percent reported being married.
About 55.1 percent reported having a four-year college education and 17.8 percent a master’s degree; 40.4 percent
reported moderate income and 50.5 percent low to very low income; and 80.9 percent self-identified as Christian.
One Hundred percent of the sample reported having experienced at least 3 types (out of 17) of traumatic events with
50.8 percent reporting at least 11 traumatic events.

Table 2.1 Descriptive Characteristics of the Sample (N=113)

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Variables Number (%) Mean Range

Age 26.56 19- 48
Gender

Female 53 (46.9)
Male 59 (52.2)

Marital Status
Single 93 (83.8)
Married 7 (6.3)
Divorced 1 (.9)
Decline to answer 9 (8.1)

Income
Very high 2 (1.8)
High 8 (7.3)
Moderate 44 (40.4)
Low 38 (34.9)
Very low 1 7 (‘I 5.6)

Education
High school 3 (2.8)
Two-year college 21 (18 .6)
Four-year college 59 (55.1)
Master’s 19 (17.8)
Advanced degree 2 (‘I. 9)
Dec line to answer 3 (2.8)

Employment
Employed for wages 14 (12.7)
Self-employed 2 (1.8)
Out of work for more than one year 5 (4.5)
O ut of work for less than one year 4 (3.6)
Student 84 (76.4)

Religion
Christianity 89 (80.9)
O ther (but did not specify) 14 (‘12.7)
Decline to answer 7 9 (6.40)

Life Event Total 11 3-1 7
Frequency

3- 5 events 3 (6.1)
6-10 events 28 (43.2)
11-13 events 20 (30.8)
14-1 7 events 13 (20)

Type of event
Natural Disaster 81 (95.3)
Fire or Explosion 61 (65.6)
Transportation Accident 67 (71.3)
Serious accident at work, home 51 (54.3)
Exposure to toxic substance 40 (43.5)
Physical assaul t 62 (64.6)
Assault w ith a weapon 54 (58.8)
Sexual assault 42 (44.2)

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In part 2 of the study, that is, the in-depth interview, 11 out of 113 total participants participated. All participants
were female.

Measures

A total of 113 participants were administered a survey consisting of six questionnaires: a demographic form, the life
events checklist (LEC), the PTG inventory (PTGI) scale, the Adult Resilience Measure (ARM), the Meaning in Life
Questionnaire (MLQ), and the Satisfaction with Life Scale (SWLS).

Life Events Checklist
The LEC scale is a self-report measure of participants’ lifelong exposure to traumatic events according to the
posttraumatic stress disorder (PTSD) criterion A diagnosis in the Diagnostic and Statistical Manual of Mental
Disorders (DSM)-5. Subjects are given a list of 17 traumatic stressors to choose whether the trauma happened to
them, they witnessed it, they learned about it, or it was part of their job, or else they indicate they are not sure, or
that the question doesn’t apply (Gray, Litz, Sue, & Lombardo, 2004).

Posttraumatic Growth Inventory Scale
The PTGI scale is a 21-item Likert scale measuring participants’ degree of PTG according to Tedeschi and Calhoun
(1996) in the following five subscales: relating to others, new possibilities, personal strength, spiritual change, and
appreciation of life. Each subscale consists of possible responses from a Likert scale of 1–6 (1= I did not experience
this change as a result of my crisis; 6= I experienced this change to a very great degree as a result of my crisis).

The PTGI scale has been shown to have satisfactory internal consistency among the total and subscales scores
and test-retest reliability (Taku, Cann, Calhoun, & Tedeschi, 2008). Studies have examined the cross-cultural
validity of the PTGI scale and whether the items are more influenced by personality or culture. A study by Taku and
Oshio (2015) assessed whether the items in the subscale truly measured PTG variables, using a Japanese sample.
The results showed that PTG measured by the scale is more likely to occur when core beliefs are challenged, and
few occur without cognitive effort. Thus, the significant personality factor in PTG measured by the PTGI scale
shows that it is likely a largely universal phenomenon, or at least one present in multiple cultures. Additional cross-
cultural studies have suggested that differences in the degree of PTG dimensions are culturally influenced (Cormio,
Romitto, Giotta, & Mattioli, 2015; Ho, Law, Wang, Shih, Hsu, & Hou, 2013).

Adult Resilience Measure-28
The ARM is a 28-item Likert scale that was adapted from the Child and Youth Resilience Measure-28 (CYRM-28;
Ungar & Liebenberg, 2011), one of the most culturally sensitive resilience measures (Windle, Bennett, & Noyes,
2011). The measure was derived from data collected in 12 different countries over 3 different continents. The ARM­

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28 has three subscales (individual, relational, and contextual resilience). Reliability analyses were conducted, which
demonstrated that the CYRM-28 and its subscales were internally consistent (Leibenberg, Ungar, & Van de Vijver,
2012).

Meaning in Life Questionnaire
The MLQ is a ten-item scale rated on a seven-point scale from “Absolutely True” to “Absolutely Untrue” on the
person’s perception of meaning in life. There are two subscales: the presence of meaning subscale, measuring how
full individuals feel their lives are of meaning (Steger, Frazier, Oishi, & Kaler, 2006), and the search for meaning
subscale, measuring how motivated individuals are in finding meaning in their lives. The MLQ has good reliability
(presence: α= .82, and search: α= .87), test-retest stability, and good fit factor structure (Steger, Frazier, Oishi, &
Kaler, 2006).

Satisfaction with Life Scale
The SWLS is a five-item scale measuring cognitive judgments of one’s life satisfaction (Diener, Emmons, Larsen,
& Griffin, 1985). Respondents answer how much they agree or disagree with each of the five items, using a seven-
point scale that ranges from 7 = strongly agree to 1 = strongly disagree. A meta-analysis study found that 62 articles
that investigated the reliability of the SWLS in different populations found an average of .76 reliability coefficients
(Vassar, 2007).

Semi-structured Interview Guide
An interview guide included 20 open-ended questions in French and aimed to explore in-depth experiences and
understanding of the concept of PTG. The questions were based on recent research and clinical literature on PTG
and on cultural literature on the Haitian culture and society (Cadet, 1998; Dash, 2010; Dubois, 2013; Girard, 2010).
Participants could answer the interview questions in French or in Haitian Kreyòl.

DATA ANALYSES

Quantitative Data

Descriptive statistics were used for frequency findings on the demographic variables, LEC, PTGI, ARM, MLQ, and
SWLS. Reliability analyses were utilized to test each measure’s internal reliability (Cronbach alpha’s; see Table 2.2
for the reliability results). T-test analyses were used to examine whether there were any mean differences of LEC,
PTGI, ARM, MLQ, and SWLS among different demographic groups. Pearson correlation analyses were used to
analyze correlations between the study main variables. A multiple linear regression model was used to examine the
effects of independent variables (demographic variables, PTGI, MLQ, SWLS) on the dependent variable (ARM
subscales). All significant results were set at p value < .05.

Table 2.2 Reliability Analyses Results

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Qualitative Data

The Grounded Theory was used to generate an emergent theory through the discovery of themes (Glaser & Strauss,
1967) from a purposively recruited group of people who have experienced the same phenomenon, which is the 2010
Earthquake. Maximum variable sampling (Maykut & Morehouse, 1994) was attempted by recruiting from all adult
age groups and socioeconomic status. The sample size was determined by the concurrent process of data collection
and coding procedures until the saturation point was met, the point at which no new themes were forthcoming
(Maykyt & Mayhouse, 1994). Constant comparative analysis through three stages of coding (open coding, axial
coding, and selective coding) was used to discover emerging themes and an overarching theory (see Glaser &
Strauss, 1967). There were several strategies utilized to increase trustworthiness of the study findings. First, peer
scrutiny of the research project was used where three coders independently coded the data and compared emerging
categories and themes until the final version of categories and themes were agreed upon. Second, an audit trail and
journaling among researchers was utilized to increase researchers’ reflexivity and progressive subjectivity (Lincoln
& Guba, 1985) to minimize the intrusive influence of the researchers’ own biases on the research procedures and
findings.

RESULTS AND DISCUSSION

Quantitative Results

Reliability Analysis Results
A total of 113 Haitians participated in the study by completing six questionnaires. The reliability analysis
(Cronbach’s alpha) was utilized to examine internal reliability of PTGI, ARM, MLQ, and SWLS with p value < .05. The results showed acceptable to great reliability for PTGI subscales (except for spiritual change) as follows: relating to others (α = .81), new possibilities (α = .72), appreciation of life (α = .74), personal strength (α = .72), total PTG (α = .93), and spiritual change (α = .49). The results showed good reliability for ARM subscales as follows: individual (α = .74), relational (α = .76), contextual (α = .70), and total resilience (α = .85). The results

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showed acceptable reliability for MLQ subscales as follows: presence of meaning in life (α = .70) and search for
meaning (α = .76). Lastly, the results showed acceptable reliability for SWLS (α = .77).

Table 2.3 revealed the descriptive results of each main variable of the study and correlation matrix of the main
variables.

Table 2.3 Intercorrelation Matrix of PTGI, MLQ, ARM, and SWLS (N=113)

Bivariate Correlation Results
As shown in Table 2.3, Pearson correlation analyses showed the relationship between PTGI and other main
variables as follows: (1) PTGI-relating to others was significantly related in the positive direction to all subscales of
ARM, the presence of meaning subscale of MLQ, and SWLS; (2) PTGI-new possibilities was significantly related
in the positive direction to all subscales of ARM (except for relational resilience), the presence of meaning subscale
of MLQ, and SWLS; (3) PTGI-personal strengths was significantly related in the positive direction to individual
resilience and contextual resilience, the presence of meaning subscale of MLQ, and SWLS; (4) PTGI-appreciation
of life was significantly related in the positive direction to the presence of meaning subscale of MLQ and SWLS;
and (5) PTGI-total was significantly related in the positive direction to all subscales of ARM (except for relational
resilience), the presence of meaning subscale of MLQ, and SWLS. Lastly, PTGI-spiritual change was found to be
significantly related in the positive direction to SWLS only.

Pearson correlation analyses showed the relationship between MLQ and other main variables as follows: (1) the
presence of meaning subscale was significantly related in the positive direction to all subscales of ARM, all
subscales of PTGI, and SWLS; (2) the search for meaning subscale was found to not be significantly related to any
other variables.

Pearson correlation analyses showed the relationship between SWLS and other main variables as follows: (1)
total life satisfaction was significantly related in the positive direction to all subscales of ARM; (2) total life
satisfaction was significantly related in the positive direction to all subscales of PTGI; (3) total life satisfaction was
significantly related in the positive direction to the presence of meaning subscale of MLQ but not the search for
meaning subscale of MLQ.

Multiple Linear Regression Results
To clarify the relationship between PTG construct and resilience construct, a multiple linear regression was
calculated to predict the effects of PTGI subscales and other main variables (MLQ and SWLS) on resilience (ARM)

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subscales. A significant regression equation was found for individual resilience (F(8,56) = 7.226, p < .000), with R2

of .508. Participants’ predicted individual resilience is equal to 28.40 (B) + 1.004 (PTGI-total) + 1.239 (PTGI­
relating to others) + 1.811 (PTGI-new possibilities) +1.224 (PTGI-personal strength) + .264 (presence of meaning).

A significant regression equation was found for relational resilience (F(8,52) = 2.484, p < .023), with R2 of .276. Participants’ predicted relational resilience is equal to 23.304 (B) + 1.194 (PTGI-new possibilities) + 2.75 (presence of meaning).

Qualitative Results

Eleven (all female) participants who completed the quantitative part volunteered to participate in the in-depth
interview for qualitative analysis. There are five emergent categories (appreciation of life, personal strength, change
in interpersonal relations, the role of religion in trauma recovery, perceived happiness) and eight themes.

This section presents exemplary quotations that capture the major categories found, together with their major
themes (at least 60 percent of participant endorsement); discusses the themes of PTG that emerged from the data by
the Grounded Theory method; and compares these themes with previous literature on Tedeschi and Calhoun’s
model of PTG. Five categories and ten themes emerged from the data (see Figure 2.1).

Figure 2.1 Grounded Theory for Posttraumatic Growth Model in the Haitian Sample (N=11).

Category 1: Appreciation of Life

This category depicted themes that are related to the participants’ endorsement of the sense of appreciation of life.
This category is closely aligned with appreciation of life, one of the main domains in the original PTG model by
Tedeschi and Calhoun (1996). There are two prominent themes in this category.

Theme 1: “Do not Take Life for Granted”
Ten of 11 participants (90 percent) mentioned statements that they learned to not take life for granted after having
experienced life trauma. Quotes from participants to illustrate this theme include:

What gives you hope: Because I was alive, and there were other people who did not have that chance. (P#3)

The fact that I’m living and I’m not sick. I wake up everyday, I come here and I can see my friends. (P#6)

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I see that life is short so we have to make our mark during our time here because like fire, it goes by fast. (P#7)

I always hear other says life is short, and it can be gone in one instant (very quickly). (P#9)

Theme 2: Living Life in the Moment to the Fullest
Nine of 11 participants (81 percent) also stated that they learned to live life in the moment and accept all the good
and the bad that it presents. Quotes from participants to illustrate this theme include:

To take advantage of the present moment because we do not know when we’re going to die, or when we will perish
somewhere in the world or at least when life will end on earth, we do not know, so we must take advantage of the
experience, the present moment to enjoy life fully. (P#1)

You come to realize that everything is temporary, just live the present moment….It’s like enjoying every moment
whether it was good or bad because it’s all of the little things together which makes life. (P#9)

We should…as long as we’re living, we should live life to the fullest and realize that we’re alive and after this trauma
that we have experienced. Try to live as much as we can. (P#4)

It is to celebrate the present moment. (P#10)

Category 2: The Role of Religion in Trauma Recovery

This category is closely related to spiritual change domain in the Tedeschi and Calhoun’s model (1996). This
category captures themes that participants mentioned how religion has helped them cope with trauma and crisis in
life. There are two themes in this category.

Theme 1: Recovery through God and Prayers
Eleven of 11 participants (100 percent) endorsed that they have recovered from life crisis through God, their
connection with God, or prayers. Quotes from participants to illustrate this theme include:

Sometimes I don’t even want to live, I even thought of killing myself sometimes, but my God helps me stay hopeful.
(P#4)

Religion…yes, it’s true after a traumatic event I lean more toward prayer. (P#5)

I always referred to the Bible, I’m always…the people who often support me are the priests, so I can say religion
influenced [my recovery]. (P#6)

Spirituality because I truly believe in God. When I know that I am really traumatized and I pray often. (P#7)

Theme 2: Knowing that “I am not alone” with Support from Church
Seven out of 11 participants (63 percent) mentioned that the reason that regularly going to church helped them cope
with life problems is because they got to learn about other people’s struggles, which helped them know that they
were not alone in their struggles and life hardship. Quotes from participants to illustrate this theme include:

I’m also a choir member. Although there are difficulties in life that does not mean that you are the only one who’s going
through it. (P#4)

I pray often, I go to church, I sing and because I sing and pray so I forget what has just happened, and get out of myself.
And I see that I’m not the only one who is in this situation and that there are other people who has been through it as
well. (P#7)

Category 3: Perceived Happiness

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As part of trauma recovery, the concept of happiness was tapped into, and two different themes with regards to
perceived happiness were identified.

Theme 1: Peace and Freedom to Enjoy Life
Ten out of 11 participants (90 percent) stated that happiness to them means “being free,” “being at peace with
oneself,” and/or “having the freedom to enjoy life.” Quotes from participants to illustrate this theme include:

I believe that happiness is being free to take life as it is without resigning oneself of the bad thing of life or at least, the
traumatic experience, to learn to be guided by the good thing of life without worrying about the problems that happen to
us every day. (P#1)

You’re free with your choices, your actions, and to be the person that you want to be, to have good friends and family.
(P#3)

Happiness is when I am at peace with myself. (P#4)

You are happy when you’re feeling good and at peace in your place. (P#11)

Theme 2: Money is Necessary for People when they do not have Enough
While none of the participants endorsed money as their own source of happiness, 10 out 11 participants (90 percent)
believed that money is a source of happiness for other Haitians. Quotes from participants to illustrate this theme
include:

¾ of Haitians would say they want to have money because we do not have enough. (P#3)

Money is more important for Haitians because we live in a society that is poor I can say that money will always be more
important to them. (P#8)

I will not speak in general; I will speak about my friends who are Haitians. They think that having a lot of money is what
can make them happy. (P#10)

Category 4: Personal Strength

This category depicts the themes in relation to the recognition of their personal assets in overcoming trauma in life.

Theme 1: Self-acceptance and the Ability to Move Forward
Eight out of 11 participants (72 percent) endorsed the idea that accepting one’s self and one’s ability to move
forward helped them cope with the tragic incident. Quotes from participants to illustrate this theme include:

It is to overcome…I mean to surpass what has happened and use it as a lesson, yes that’s it. (P11)

Then you learn to accept yourself for who you are after these things, I think. (P3)

It’s accepting that you have been through what happened. Try to live with it day by day until the pain is completely
gone. (P#4)

Accept that it when something bad happened to you then you learn from the traumatic experience, it helped you to
blossom personally. (P#8)

Theme 2: Strength to Overcome
Nine out of 11 participants (81 percent) reported that they saw their own inner strength as a way to get through
trauma. Quotes from participants to illustrate this theme include:

I learned that that I was stronger than I thought. (P#3)

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I think I was a child also whom could not face a series of traumatic events but after I become stronger when going
through traumatic events. (P#5)

I always believe in my strength….I learned that I am someone who is strong of character after I’m traumatized (P#6)

I simply told myself I have been through this already so I can overcome other obstacles and there is no need to be afraid.
(P#7)

Category 5: Change in Interpersonal Relations

This category captured the ways in which the participants’ relationships with others have changed after trauma. Two
themes emerged in this category.

Theme 1: Increased Desire to Help People who are in Need
Eight out of 11 participants (72 percent) stated that they have an increased desire to help people in need. Quotes
from participants to illustrate this theme include:

I take time to help others who are weaker than me. (P#7)

I now concentrate more in my studies and said to myself that I will be a future psychologist, I would like to be more
present for the people who surround me and need my help. (P#4)

I now dedicate my life to help others. It helps and comforts me. (P#11)

Theme 2: Be Kinder to People in Life
Eight out of 11 participants (72 percent) mentioned the change in their approach when it comes to their existing and
new relationships. More specifically, the participants want to be kinder to their family and close friends and “treat
them right,” but when it comes to new relationships, many of them responded that they are being less open and
more discriminative about who they can trust. Quotes from participants to illustrate this theme include:

I have learned to respect people, to love people, and to treat people as they should be treated. One must also learn to
honor people, learn how to tell people how wonderful they, how important they are in our lives since we do not know
exactly when that person may leave the world. (P#1)

I think that this person if I approached him/her, I would speak to him/her more gently, and not rush him because the
earthquake really marked the Haitian people. They (my family) did their best to be there for me as much as possible also.
(P#4)

It is to spend time with my family and the people I love. They mean a lot to me. (P#11)

CONCLUSION

Haiti has suffered much trauma in its history. In addition to the legacy of colonialism and slavery, occupation by
foreign powers, and, in recent decades, frequent political turmoil and corruption, Haiti has suffered tragic natural
disasters. Most significantly, the 2010 earthquake led to deaths estimated between 100,000 to over 200,000 persons,
leaving 1.6 million homeless and decimating much infrastructure. In 2016, shortly before data collection for the
present study, Hurricane Matthew struck Haiti, leading to deaths estimated from over 500 to over 1,000, leaving
approximately 175,000 homeless, with damages estimated at nearly US$2 billion.

Studies from several disciplines have shown that the trauma exposure has taken a societal and psychological toll
on Haitians (Cadet, 1998; Dubois; 2013; Farmer 2013; Girard, 2010; Katz, 2013; Nicolas, 2013; Schwartz, 2010).
Internationally, outside of Haiti, the PTG literature has revealed promising results related to the positive changes
that may result from the struggle to cope with trauma, enhancing scholars’ and practitioners’ understanding of the
effects of trauma on individuals (Calhoun & Tedeschi, 2006, 2013; Joseph & Linley, 2008; Theron, Liebenberg, &

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Ungar, 2015; Weiss & Berger, 2010). This study was one of the first attempts aiming to understand the concept of
PTG from local Haitians in Port-au-Prince, all of whom were affected by the 2010 earthquake. Quantitative results
indicate correlations between various PTGI subscales and various subscales of the ARM and the MLQ.
Additionally, total life satisfaction (SWLS) was significantly correlated with all subscales of both the PTGI and the
ARM. The study found that PTGI (except for the spiritual change subscale) may be a culturally appropriate measure
to assess PTG. The Grounded Theory analysis of the qualitative data revealed five prominent categories and ten
themes that are essential for the experience of PTG in the Haitian sample. Qualitative results suggest growth
components including gratitude and appreciation for life, increased role of religion, a changed sense of perceived
happiness and role of money, increased personal growth and personal strength, and enriched connections with
others. In sum, these results carry significance for clinical application development.

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Chapter 3

The Concept of Posttraumatic Growth in a Cambodian Sample
A Grounded Theory Study

Skultip (Jill) Sirikantraporn, Grant J. Rich, and Nashaw Jafari

Studies have documented that people do report growth or positive outcomes as a result of their struggle to cope with trauma or stressful life events (Bonanno, 2005; Calhoun & Tedeschi, 2006;
McMillen, 1999). The term “posttraumatic growth” (PTG) was developed to conceptualize the phenomenon. Most Western studies have suggested that the core elements of PTG include improved
relating to others, seeing new possibilities in life, spiritual change, and increases in personal strength and appreciation of life (Tedeschi & Calhoun, 1996). More recently, the concept of PTG has
begun to be investigated across cultures in both quantitative and qualitative studies. For instance, relevant research includes samples from Australia (Shakespeare-Finch & Copping, 2006), Japan
(Taku, Calhoun, Tedeschi, Gil-Rivas, Kilmer, & Cann, 2007), Bosnia (Powell et al., 2003), and China (Ho et al., 2013), and from cancer survivors across cultures (Diaz, Cordova, & Spiegel,
2012). The cross-cultural findings suggest that the five dimensions of PTG (personal strength, appreciation of life, relating to others, spiritual change, and new possibilities; Tedeschi & Calhoun,
1996) may or may not vary across cultures, especially for cultures in which the self is defined as individualistically oriented, compared to collectivistically oriented (Helgeson, Reynolds, &
Tomich, 2006; Yang, 2003). This indicates that more in-depth examinations for different cultures are warranted.

Since the end of the horrific and tragic era of the Khmer Rouge, which peaked between 1975 and 1979, and which killed approximately two million people, a quarter of the whole Cambodian
population at that time, from execution, disease, starvation, and overwork (Chandler, 2007; Hinton, 2004; Kierman, 2008), Cambodia continues to be plagued by the trauma and cycles of violence
and victimization due to ongoing political and social instability, high rates of poverty, and limited access to resources (Jarl, Cantor-Graae, Chak, Sunbaunat, & Larsson, 2015). A recent survey of
nearly 3,000 adults from 9 of the 25 provinces in Cambodia found that an estimated 31 percent of women and 18.4 percent of men suffer from probable anxiety disorders and 19.7 percent of
women and 10.2 percent of men suffer from probable depressive disorders. This survey also found that of those who experienced the civil war, 92.3 percent experienced at least one traumatic
event, with a mean of seven events, and that among younger participants who did not experience the civil war, 70.2 percent experienced at least one traumatic event (RUPP, 2012).

Living in the posttraumatic era after the experience of the atrocity of the genocide, Cambodians have had to find ways to cope with the psychological impact. Throughout the past decades of
research, many cultural studies, including work in medical anthropology, have examined the cultural meanings of trauma and trauma responses among Cambodians as a result of the Khmer Rouge
(Becker, Gay, Beyene, & Ken, 2000; Hinton et al., 2009; Hinton, Howes, & Kirmayer, 2008; Ratliff, 1997; Van Schaack, Reicherter, & Chhang, 2011). However, to understand the complete
picture of trauma study in cultural context, it is also important to explore cultural meanings of growth and positive changes after trauma. This study, therefore, aimed to investigate the concept of
PTG among a Cambodian sample from both etic and emic perspectives of cultural psychology.

Trauma studies in Cambodia have evolved in their attempts to understand the effects of trauma on Cambodians’ psychological and cultural health. A trauma-based cultural syndrome was
defined as the set of salient culturally specific trauma-related symptoms of survivors of the Khmer Rouge, and include kyol goeu (wind overload), which causes one to become unconscious, fall to
the ground, turn pale, and sweat (Hauff, 2001), sleep paralysis (“the ghost pushes you down”), nightmares, and panic attacks (Hinton, Pich, Chhean, & Pollack, 2005). Another important
Cambodian trauma phenomenon is “broken courage” or “baksbat,” which overlaps to some degree with posttraumatic stress disorder (PTSD) (Chhim, 2013). Baksbat is the idiom of distress
experienced by Khmer persons as a lack of trust in others, submissiveness, feeling fearful, and being “mute and deaf” (Chhim, 2013). The interpersonal nature of many of the above symptoms,
such as sleep paralysis and baksbat, may partially explain why healing practices found to be important for Cambodian trauma survivors are interpersonal by nature. Some of these identified
practices among Cambodian trauma survivors are making merits to the deceased, holding a festival for loved ones, and healing the wider community (Agger, 2015).

The struggle of Cambodians over the past few decades has been further complicated by the intergenerational effects of trauma (intergenerational transmission of trauma) to the younger
generation Cambodians. Often the adverse effects of intergenerational transmission of trauma are referred to as “unspoken trauma.” Although the young Cambodians experienced their own
suffering acquired from post-genocide effects, coupled with the direct damage done to the country’s current human and socioeconomic development, these effects and impacts on the country’s
youth have been under-acknowledged (Rich, 2015). One proposed path of transmission is through family interactions. Such a pathway suggests that the enduring effects of violence experienced by
the survivors of the genocide have significantly impacted the ability of their children and young adults to form a stable sense of security and attachments. A study of Cambodian mothers, who
experienced the Khmer Rouge, and their daughters confirmed and expanded this path by revealing that the mother’s PTSD was predictive of her daughter’s anxiety (Field, Muong, &
Sochanvimean, 2013). In addition, the mother’s role-reversing parental style mediated the relationship (Field, Muong, & Sochanvimean, 2013).

Another path of transmission of effects is through lingering effects of socioeconomic issues stemming from the Khmer Rouge, which have kept Cambodia in severe poverty decades after the
genocide. Corruption and abuse of power in the government and military present during the Khmer Rouge era have continued to affect the post-genocide country’s poor research infrastructure and
accessibility as well as have led to mistrust in the government among young-generation Cambodians (Hinton, 2002). These effects of intergenerational trauma have caused many young
Cambodians to continue to suffer from trauma stemming from the Khmer Rouge era despite the fact that they were not even there themselves.

The focus of the above studies in Cambodia has been on the negative outcomes of trauma, which is understandable, because it enables researchers and practitioners to establish culturally
appropriate diagnosis and treatment. However, a more complete, culturally appropriate understanding of recovery from trauma, and of growth after trauma, is also necessary to cultivate ways of
coping and thriving after any type of trauma. The purpose of the present study is to fill a gap in the existing Cambodia trauma studies by exploring the concept of PTG to conceptualize this term
from within the culture. Thus, a primary goal of the current study was to identify specific factors associated with PTG in the Cambodian context, examining whether more universalist and Western
assumptions in the preexisting PTG literature apply to the present sample.

METHODS

Participants

Twelve participants participated in the in-depth interview. These participants were drawn from a larger mixed-methods study of 70 participants (mean age = 20.86) conducted in Phnom Penh,
Cambodia’s largest city (Rich, 2015). There were six female and six male participants in the qualitative portion of the study. Most identified as single (83 percent), and as from mid-level
socioeconomic status (SES; 75 percent). Most reported they had completed high school (66 percent) and were currently students (75 percent) and self-identified as Buddhist (91 percent). All of
them reported having experienced at least one traumatic experience.

Data using the life events checklist (Gray, Litz, Hsu, & Lombardo, 2004) from the larger quantitative sample found that 97 percent endorsed at least one type of trauma, and 84 percent endorsed
5+ types of traumas (Sirikantraporn, Rich, Jafari, & Chandhok, 2016). The most frequent number of traumas endorsed by the quantitative sample was 9 (17 percent of the sample). The most
frequently endorsed types of traumas were: (1) transportation accident, 90 percent; (2) natural disaster, 86 percent; and (3) severe human suffering, 73 percent. To protect participant
confidentiality, researchers are not able to link specific qualitative interviewees to specific quantitative measure responses.

Measures

Semi-structured Interview Guide

An interview guide included 20 open-ended questions in the Khmer language and aimed to explore in-depth experiences and understanding of the concept of PTG. The questions were based on
recent research and clinical literature on PTG and on cultural literature on the Khmer culture and society (e.g., Chandler, 2007; Ratliff, 1997).

Data Analysis

Grounded theory was suitable for this study because the study proposed to examine the phenomenon of PTG from the point of view and insight of the local people, a topic and approach which has
not yet been explored in-depth within the Cambodian context. Grounded theory was used to generate an emergent theory through the discovery of themes (Glaser & Strauss, 1967). Theoretical
sampling was used to increase the maximum variable sampling (Maykut & Morehouse, 1994). The sample size was determined by the concurrent process of data collection and coding procedures
until the saturation point was met, the point at which no new categories were forthcoming (Maykyt & Mayhouse, 1994). Constant comparative analysis through three stages of coding (open

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coding, axial coding, and selective coding) was used to discover emerging themes and an overarching theory (see Glaser & Strauss, 1967). There were several strategies utilized to increase
trustworthiness of the study findings. First, peer scrutiny of the research project was used, where three coders independently coded the data and compared emerging categories and themes until the
final version of categories and themes were agreed upon. Second, an audit trail and journaling among researchers was utilized to increase researchers’ reflexivity and progressive subjectivity
(Lincoln & Guba, 1985) to minimize the intrusive influence of the researchers’ own biases on the research procedures and findings.

Procedure

This research was a collaborative project between Alliant International University and the American University of Phnom Penh (AUPP). This chapter focuses on the qualitative portion of a mixed-
methods study; the quantitative portion of the study includes data utilizing such measures as the life events checklist (LEC), PTG inventory (PTGI) scale, and the Adult Resiliency Measure (ARM)
(Sirikantraporn, Rich, Jafari, & Chandhok, 2016). The Institutional Review Board (IRB) approval was obtained from both institutions. This was the first research project conducted at AUPP, a
new university founded in 2014. AUPP created an IRB specifically to facilitate our work, and this IRB included faculty as well as student board members. Thus, the timeframe for approval was
somewhat extended and the IRB approval process began in early Autumn 2014, and approval was received in Winter/Spring 2015. The voluntary nature of student participation was emphasized.
Planning for data collection was involved, especially as summer student schedules were only finalized around time of the researcher’s arrival to Cambodia from the United States. Because student
schedules were very full, extra credit for research participation was not permitted, and since several field trips for summer classes conflicted with previously arranged data collection schedules,
multiple data collection sessions were conducted. Two bilingual Khmer English student teaching assistants (TAs) arranged and conducted the interviews. At the end of the data collection period, a
debriefing session was held by one of the faculty coauthors with the student TAs also present, and all students were invited; the session was well attended and students demonstrated an interest
both in social science research methods and in the work’s relevance and potential value for Cambodia.

RESULTS AND DISCUSSION

Overall, the model of PTG proposed by Tedeschi and Calhoun was supported in this Cambodian qualitative sample (N = 12. 50 percent female). This section presents exemplary quotations (F
means the quotation was from a female participant and M means the quotation was from a male participant) that capture the major categories found, together with their major themes; discusses the
themes of PTG that emerged from the data by the Grounded Theory method; and compares these themes with previous literature on Tedeschi and Calhoun’s model of PTG. Four categories and ten
themes emerged from the data (see Figure 3.1).

Figure 3.1 Construction of PTG in the Present Cambodian Sample.

Category 1: Personal Growth

Personal growth is defined as personal strengths and positive personal aspects of growing as a result of one’s struggle to cope with trauma. This category was made up of three themes (i.e., self-
efficacy, acceptance, and self-actualization).

First Theme: Self-efficacy

Reported by 66 percent of the participants (8 out of 12), self-efficacy, which refers to one’s belief in one’s ability to successfully execute behaviors necessary to produce specific performance
attainments (Bandura, 1986), is reflected in the selective code by the catch phrase, “I now know I can overcome future stressful events.” The experience is seen as a turning point at which the
person feels a sense of independence for having been able to cope with and survive the event because they have done so with the last trauma. This theme has also been found in an Australian
sample (Shakespeare-Finch & Copping, 2006), and it can be considered in line with the increased personal strength dimension of the five-factor Tedeschi and Calhoun model that found that
individuals have a strong belief in one’s ability to face life problems after enduring a stressful life event. Some of the responses to illustrate this theme are:

At the end it makes me stronger, but before it [the trauma] makes me stronger it…it kind of destroys me a little bit until I knew that I shouldn’t be there because it’s not going too good for me, then I got
stronger. But I always got stronger after everything that happened. (F)

Like I’m the most important person who can makes me a better person and also the one who can keep myself going so… I have a feeling that everything is possible if I want it to happen. (M)

I am able to pick myself up and start over, like not dwelling on some uh, bad experience in the past that hinders me from achieving other things that I want in life. (M)

Second Theme: Acceptance
The second theme refers to personal growth that stems from the ability to accept the situation and to accept the good and not-so-good qualities of life, of self, and of others, and to recognize that
“no one and no family is perfect.” This theme was mentioned by 66 percent of the participants (8 out of 12), and is exemplified by the quote, “so it changed about my life—[xxx] no one is perfect
and people have their own flaws” (M). More responses to illustrate this theme include:

Learned to accept that you are not perfect and you still have something to improve. (F)

For anything or about anything it’s just kind of whatever happens, happens, whatever doesn’t, doesn’t … sometimes things happen for a reason. (F)

I feel like open to that be more accepting. And I’m more willing to try to accept other peoples’ flaws but I also at the same time am more close and accepting about my own feelings. (M)

While this theme was not explored and measured in the original five-factor model of Tedeschi and Calhoun’s PTGI (1996), it was viewed later by the authors as a precursor (and not an
outcome) of growth (Tedeschi & Calhoun, 2004).

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This theme was also found to be a salient PTG theme in the Australian sample (Shakespeare-Finch & Copping, 2006). While Acceptance is viewed as a precursor and not an outcome of growth
when Tedeschi and Calhoun explained that valuing the event itself can be a catalyst for growth (Tedeschi & Calhoun, 2004), in this study’s sample, acceptance implied not only accepting what
happened but also accepting different qualities (positive and negative) in oneself and others, which suggests that acceptance may function as both a precursor and an outcome of PTG. After
trauma, a less extreme and more balanced way of viewing the world has also been found in a longitudinal PTG study of tsunami survivors to be serving as a coping resource after the disaster, in
which both positive and negative experiences are integrated (Siqveland, Nygaard, Hussain, Tedeschi, & Heir, 2015).

Third Theme: Self-actualization

Self-actualization is defined in this study as increased self-knowledge and self-realization of one’s life priorities and one’s capabilities (Heylighen, 1992). This theme, found in 75 percent of the
participants (9 out of 12), appears to be more related to inner satisfaction of self and self-awareness, rather than outward satisfaction in career or intellectual achievements. The self-actualizing
process has been believed to potentially be interrupted and “forfeited” in trauma sufferers (George & Sar, 2006). As the person learns to confront and grow from trauma, this process may resume
and become available to survivors again (Dass-Brailsford, 2007). This supports the notion in the PTG literature that self-actualization is an outcome of one’s acceptance and confrontations of the
trauma (Joseph & Linley, 2005). Exemplary quotes of this theme include:

I don’t think it has affected, like I said earlier, what I wanted in life is still what I want in life, just I improve on that goal, improve on the, on the process of how I want to achieve it. Instead of just wanting
it, I know I have a better idea, a clearer idea in order to reach that goal. (M)

I know that I’m strong and I can focus on what is important to me and my goals. (M)

Self-efficacy, acceptance, and self-actualization emerged as three salient and interconnected themes that appear important for the participants’ sense of increased personal strength.

Category 2: Interpersonal Growth

The second category, interpersonal growth, is defined as the growth-promoting factors that are related to one’s interpersonal relationships as a result of trauma. Two major themes were identified
as supporting interpersonal growth: (1) increased appreciation for social support and (2) increased empathy and altruism.

First Theme: Increased Appreciation for Social Support

Eighty-three percent of the participants (10 out of 12) reported the importance of support from family, friends, and community. This support can be in the form of having at least one person to
think of when they experienced high stress. One participant captured this dimension by stating, “without such support, I wouldn’t have been where I am today.” Social support has been identified
as one of the essential dimensions of growth after trauma (Tedeschi & Calhoun, 2004), and further studies suggested that the relationship between social support and growth may be the perceived
availability of emotional support (Schroevers, Helgeson, Sanderman, & Ranchor, 2010), which allows successful cognitive coping and recovery after trauma (Tedeschi & McNally, 2011).

In addition, this theme illustrates the closer and warmer interpersonal relationships that often exist post-trauma in comparison to prior to the trauma. These findings strongly support the
literature of PTG, which highlights the warmer, more intimate relations with others after a stressful life event. One important quality of closer interpersonal relationship among this sample is good
listening, which was reported by 58 percent of the participants, such as is reflected in this quote: “My friends and family help me a lot because they are good listeners” (M). This finding potentially
expands the PTG literature by clarifying that good listening from one’s social support person(s) is one of the important qualities of a good relationship, and such supportive listening may help one
feel better as one struggles to cope with stressful life events. While this dimension of good listening has not be directly explored in relation to PTG, Woodward and Joseph (2003) indicated that
having relationships where the traumatic individuals can feel nurtured and validated and experience genuine acceptance from others through “active, attentive, and compassionate listening” may
not only help them recover, but also foster PTG. As the finding from this study suggested, this person may be anyone, including a close friend, family member, spiritual leader, and/or mentor.
Some of the exemplary quotes for this theme are:

I, first of all, I didn’t realize that he was that sick. I just don’t know what, and then, after his recovery, I realized how much he meant to me and I really appreciate it. Every single day I tell him I love him
and take care of him more and we’ve become much closer. (F)

Friends and family help me a lot. They keep encouraging me to go on and live happily. (M)

I learned, like, people in the fear factor, people are like, frightened. So, we all know that most, mostly when we are frightened, we are frightened and feeling down. So, I learned that we should encourage
each other to stand up. (M)

Second Theme: Empathy and Altruism

After the stressful life experience, 66 percent of the participants (8 out of 12) reported that they have become more considerate and aware of the impact of their actions on other people and how
other people feel when facing difficult situations. Half of these participants also reported their desire to help others who are facing life challenges. Based on the PTG study on Asian communities,
Yang (2003) found that the way to actualize in collectivist cultures, such as in some Asian cultures, may be via self-correction and self-examination to develop such qualities as altruism, kindness,
and conscientiousness, to uphold the ultimate goal, personal-social harmony. The findings of this study support the notion that factors related to growth among this Cambodian sample may be
related to the collectivistic aspect of self and relationships with others.

Quotes from participants to illustrate this theme include:

I mean, sometimes because actually I room with others, and sometimes they know about my problems and I am not the only one—[xxx] people are having harder lives than me and they can still do it, and
then some people will just come out and talk about their difficulties too, and it makes me feel better—people have difficult things in life. (M)

I think I learn I learn how to know what the other people are thinking when I’m with them. Instead of just doing what I want and not really taking into consideration how the other people may felt by it.
Yeah. (M)

You don’t want other people to feel the same thing [hopeless and fearful]. I learned to give people advice and help, so they don’t have to feel the same thing that I went through. (F)

Category 3: Transitions that Facilitate Growth

Transactions that facilitate growth refer to factors that are significant in helping them grow from trauma. There are three emerging themes in this category (i.e., moving from fear to courage,
modifying priorities, and opening to new experiences).

First Theme: Moving from Fear to Courage

Sixty-six percent of participants (8 out of 12) reported this change. Fear is a prime emotion involved in trauma and traumatic experience, and it plays a role in PTSD by triggering mind and body
to avoid certain feared situations/persons that are a reminder of the trauma (Morey et al., 2015). This theme suggests that the increased personal strength in one’s ability to overcome future
adversity may stem from the conscious shift from fear to courage among this sample. This shift appears to be highly relevant to the Cambodian population and the PTSD-idiom of broken courage
(baksbat; Chhim, 2013). Some relevant quotes from the qualitative sample include:

It made me more brave after the loss. (F)

I learned that even I’m look stronger, but once in a fear events or frightened events, I’m a bit of a coward. But, with the encouragement of my friends and family, I’ll evolve to stand up, to be strong. (M)

Actually when I first encountered that event, I felt very frightened, covered, and just, scared (laughs). I didn’t move anything, but after that it taught me a lot about being courageous. (F)

I am not fearful now, but I’m just more cautious with what I do. (F)

I became more courageous. I mean, it didn’t really impact my goal, it just made me more conscious about something that happened. (F)

Second Theme: Modifying Priorities

Fifty-eight percent of the participants (7 out of 12) stated that the way they value things in life has been different from before the stressful event. This shifting in priorities has been documented as
an important change after trauma among those who experience growth. Changed philosophy of life, however small, is a highlighted element in Calhoun and Tedeschi’s (1996) model. Shifts in
priorities are often considered the outcome of trauma that facilitates growth in PTG among cancer patients (Cordova, Cunningham, Carlson, & Andrykowski, 2001; Sears, Stanton, & Danoff-

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Burg, 2003; Widows, Jacobsen, Booth-Jones, & Fields, 2005). This seems to be congruent with this present study’s participants, who reported that after the stressful life experience, they realized
what is more important and meaningful in life that they had before taken for granted. With regards to the modifying priorities theme, some illustrative quotes from the qualitative sample include:

at first I wanted to go as far as possible, but right now when I learned about problems with my parents I don’t want to go that far, I want to be with them more, and before, all it means to me to be successful
in life was to be successful academically and with my career, but right now it comes to both- family and career. (M)

Before, I focused on other people and what they think, but now I’m focusing on my goals and on what I want to accomplish. (F)

Third Theme: Opening to New Experiences

Ninety-nine percent of the participants (11 out of 12) reported that they became more open to new experiences in life. A study of the Big Five personality traits and PTG found that people who are
more open to new experiences appear to be more likely to benefit from PTG (Almedon, 2005; Tedeschi & Calhoun, 2004). These studies suggest that the openness to new experiences may enable
people to be more likely to seek social support, search for necessary and adaptive information, and cognitively process the information in helping them cope, find meaning, and thrive after trauma.

This speculation was supported by a more recent study on PTG and coping, which found that the appreciation of life and the new possibilities of PTGI subscales showed positive associations
with six adaptive coping strategies (active coping, planning, positive reframing, turning to religion, using emotional and instrumental support) (Alexander & Oesterreich, 2013). Quotes that relate
to the opening to new experience theme include the following examples from the qualitative sample:

Because I see things differently, before…I used to be really closed minded about things, but after that, I actually see things more wide and clear. (F)

More cautious to new experiences with new people but more open to new experiences in general. Yeah. (F)

It helped me be more open to people and new things. (F)

In sum, three emerging themes that support the category of transitions that facilitate growth after trauma in terms of Tedeschi and Calhoun’s (1996, 2004) model were: (1) moving from fear to
courage, (2) modifying priorities, and (3) opening to new experiences.

Category 4: The Role of Religion/Spirituality

This category entails responses that detail the role of religion and spirituality on positive changes as a result of trauma. Two themes emerged to support this category: (1) a shift in
religious/spiritual understanding and (2) a change in the role of karma.

First Theme: Shift in Religious and Spiritual Understanding
Seventy-five percent of participants (9 out of 12) reported that their religious beliefs decreased after trauma and/or played no role in their trauma and recovery to begin with. Sixty-six percent of
participants’ responses (8 out of 12) may potentially be understood within the realm of increased spirituality through feeling more connected with others and increasing personal faith in accepting
and overcoming life stress.

Religion and spirituality have played a significant role since the conception of the term “PTG” (Shaw, Joseph, & Linley, 2005). Research, however, has shown different results when it comes to
its negative or positive role on PTG. While religious coping may help explain increased PTG after trauma (Schultz, Tallman, & Altmaier, 2010), there are also studies suggesting poor mental
health outcomes associated with negative religious coping and with religious rigidity (Chan & Rhodes, 2013; Harrison et al., 2001; Pargament, Smith, Koenig, & Perez, 1998). These findings
suggest that it may not be religion itself, but rather it is the positive use of religion and openness to changes in a person’s religious belief and spirituality that matter more in terms of PTG
(Calhoun, Cann, Tedeschi, & McMillan, 2000). One study described spiritual growth as stronger spiritual orientation related to worldview, goals, relationships with others, and sense of self,
dimensions which are positively related to PTG (Cole et al., 2008). Exemplary quotes for this theme include:

Having good friends and family of course, and yeah being able to spend time with them, you know, especially after a long and tiring day at school you know, go grab something to eat. (M)

Just that you know sometimes things do happen for a reason and maybe in the long run things will play out the you know the way they are meant to play out so. You don’t always get what you want but
that’s for a reason. (F)

But my faith in religion has been decreasing ever, ever…the older I get the lesser faith I have in religion,” “I learned that myself is pretty strong. Like that I’m gonna face in life, that’s a way for me. After
that event, when I also experience like harsh things in life after that I’m not as devastated as the first time cause I know it’s just something that I can overcome. (M)

Second Theme: Change in the Role of Karma
The majority of the participants (75 percent) reported that they did not believe that karma played a role in their suffering and/or their recovery. A few of the participants (33 percent or 3 out of 12)
shared that they now see karma as a guide for their future actions by believing that their future is determined by their own actions. When discussing karma, one participant stated, “If I want to
succeed or do something, I can do it myself.” Others also expressed complex views of karma:

I try my best to do good, but I mean, like, it doesn’t necessarily mean you get any good. So … yeah. But I keep on doing it anyway; maybe there’s a part of me that believes it. (F)

I don’t know if it will or not, but if I have a choice, I wouldn’t want it to because I want to make my own choices in life. I don’t want something that has already been set up by, uh super natural something
like that, that will gonna happen even if I don’t want it to happen; I don’t believe in that. I believe I always have a choice. (M)

I don’t really believe in karma. No, I mean I believe in karma, but when I’m in my hard times, I don’t really think about karma or anything because I am thinking about ways to solve it. (F)

The concept of karma is an essential one to explore, as it is a central component in Khmer Buddhism, referring to the cause-effect of one’s actions, and that one deserves things that happen to
them because of one’s past actions, including in past lives (Smith-Hefner, 1999). After the atrocities of the Khmer Rouge, many studies have attempted to understand the role of karma in
individuals’ healing and explanations for life events (e.g., Coggan, 2015; Harris, 2008; Ratliff, 1997). Some found that Khmer people stray from using the traditional way of understanding karma
in their healing journey (Ledgerwood, Ebihara, & Mortland, 1994). The finding of this theme may suggest that an example of these shifts is a shift of the focus of Khmer Karma from past actions
to present actions to determine future results.

CONCLUSION

In conclusion, data reveal that participants developed a maturing perspective, including a sense of increased personal strength, and a shifting from a powerless to an empowered sense of identity.
In addition, data indicate increased and enriched connections with others, and an activated desire to help others. Finally, connection to an ability to find meaning in suffering in a future-oriented
manner aided PTG after life hardships. Such data help evaluate assumptions from the existing cross-cultural literature on PTG—such as the assumption that PTG is universally experienced—that
have been difficult to evaluate, given the preexisting state of information, notably the lack of data on this issue with a Cambodian sample. In particular, the Cambodian data show that many
features of the PTG model described with Western samples are confirmed by the Cambodian data. These data are also important as help-seeking behaviors and options for most Cambodians differ
from behaviors and options of many needing similar help in the United States and other Western nations. For instance, when seeking help for mental health issues, 50 percent of a national
Cambodian sample approached family, 28 percent monks, 24 percent a medium, and 21 percent traditional healers, but only 3.9 percent approached doctors and 24 percent a pharmacy (RUPP,
2012). In addition, psychiatric medications, even when and where available, are very expensive, a year’s supply often costing more than the annual salary of the average Cambodian (Rich, 2015).
Understanding coping styles and PTG experiences in this sample thus may suggest interventions that are effective and feasible, given current local financial and service provider realities, and may
serve as a caution to well-intentioned international groups who plan to simply attempt to apply Western models to the current situation in Cambodia.

The Cambodia data do largely support the model of PTG proposed by Tedeschi and Calhoun (1996; 2004) and which was examined in a number of studies with Western samples. The model
and results carry potential significance for development of clinical interventions and applications. The findings help to enrich understanding of these issues by revealing more in-depth points of
view than offered through use of only numeric questionnaires developed originally for use in Western nations. Such results provide particularly valuable information, given the extensive
prevalence of exposure to traumatic events both in those who experienced the civil war in Cambodia and in younger participants in the contemporary Cambodia of today (RUPP, 2012).
Unfortunately, the RUPP study (2012) did not examine PTG, but it did examine PTSD and trauma, finding similar scores between urban and rural populations.

One specifically local issue that merits detailed future study is the role of religion and spirituality (including karma) with respect to PTG in the Cambodian context. Given the tragic history of
Buddhism during the Khmer Rouge era, when most of the monks were killed or driven out of the country, and many temples and libraries destroyed, it is likely that there are many unique features
to the experience of religion and spirituality today in Cambodia, especially as religious and educational institutions reemerge. Since the present research utilized an urban sample, future research
also should explore how PTG may manifest itself in rural Cambodian samples as well as nonstudent samples, as social support systems, financial and intellectual resources, and worldviews may

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differ in such groups. The present data may serve both current and future researchers well in terms of providing data on various contemporary subgroups in Cambodia (college students, employed,
urban) that may be utilized to help evaluate why subgroups may vary or not vary with respect to traumatic experiences. Additionally, the present study is particularly valuable as it examines a
subgroup of Cambodians that were born after the end of the Pol Pot era, yet who experienced traumatic events at similar rates as those who directly experienced the civil war in the 1970s (97
percent in the current sample of students, 92.3 percent for the RUPP (2012) sample that personally experienced the civil war). Future researchers may find it valuable to examine what is universal,
or at least held in common by several groups, in the trauma experiences of these subgroups, and what may be more specific to a certain cohort and historical context.

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