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Available online at www.sciencedirect.com

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Psychosocial and environmental distressresulting from a volcanic eruption: Studyprotocol

Sri Warsini, RN, MNSa,1, Kim Usher, RMRN, MNSt, PhDa,∗,Petra Buettner, MSc, PhDb,2, Jane Mills, RN, MN, PhDa,3,Caryn West, RN, GDip Res Methods, PhDa,4

a School of Nursing, Midwifery and Nutrition, James Cook University, PO Box 6811, Cairns, Queensland4870, Australiab School of Public Health, Tropical Medicine and Rehabilitation Sciences, James Cook University,Townsville, Queensland 4811, Australia

Received 20 September 2013; received in revised form 7 March 2014; accepted 18 March 2014

KEYWORDSVolcanic eruption;Psychosocial distress;Environmentaldistress;Natural disaster;Mixed methods

SummaryAim: To examine the psychosocial and environmental distress resulting from the 2010 eruptionof the Merapi volcano and explore the experience of living in an environment damaged by avolcanic eruption.Background: Natural disasters cause psychosocial responses in survivors. While volcanic erup-tions are an example of a natural disaster, little is currently known about the psychosocialimpact on survivors. Volcanic eruptions also cause degradation of the environment, which is

linked to environmental distress. However, little is currently known of this phenomenon.Design: An explanatory mixed method study.Methods: The research will be divided into three phases. The first phase will involve instrumentmodification, translation and testing. The second phase will involve a survey to a larger sampleusing the modified and tested questionnaire. The third phase will involve the collection of

Please cite this article in press as: Warsini, S., et al. Psychosocial and environmental distress resulting from a volcaniceruption: Study protocol. Collegian (2014), http://dx.doi.org/10.1016/j.colegn.2014.03.004

interviews from a sub set of the same participants as the second phase.

∗ Corresponding author. Tel.: +61 7 404 21391; fax: +61 7 404 21590.E-mail addresses: sri.warsini@my.jcu.edu.au (S. Warsini), kim.usher@jcu.edu.au, kim.usher@une.edu.au (K. Usher),

petra.buttner@jcu.edu.au (P. Buettner), jane.mills@jcu.edu.au (J. Mills), caryn.west@jcu.edu.au (C. West).1 Tel.: +61 7 404 21391; fax: +61 7 404 21590.2 Tel.: +61 7 443 31750; fax: +61 7 404 31767.3 Tel.: +61 7 404 21548; fax: +61 7 404 21590.4 Tel.: +61 7 404 21825; fax: +61 7 404 21590.

http://dx.doi.org/10.1016/j.colegn.2014.03.0041322-7696/© 2014 Australian College of Nursing Ltd. Published by Elsevier Ltd.

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Discussion: Quantitative data will be analyzed to determine the extent of psychosocial andenvironmental distress experienced by the participants. Qualitative data will be analyzed toexplain the variation among the participants. The results of the study will be used to developstrategies to support survivors in the future and to help ameliorate distress.© 2014 Australian College of Nurs

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Design

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here has been a proliferation of disasters in the lastew years including natural disasters, disasters associatedith climate-change, and human-made disasters (Simpson,eissbecker, & Sephton, 2011). One massive natural disas-

er that occurred in Indonesia in the last three years ishe eruption of Mount Merapi in the Yogyakarta region,ndonesia. This mountain is located on Java Island, on theorderlines of Sleman District, Yogyakarta Special Regionrovince and Magelang, Klaten, and Boyolali Districts, Cen-ral Java Province. In the last eruption of Mount Merapi,n October 26 and November 5, 2010, 386 people died, andver two hundred people were injured, mostly due to severeurns. The eruption forced more than 300,000 people fromour districts in Yogyakarta and Central Java to be evacu-ted to cramped emergency shelters (Surono et al., 2012).his disaster inflicted a financial loss up to US$400 million,esulted in the loss of a large area of fertile land, andmpacted many settlements (Wartatmo, 2010). This paperescribes a study protocol to explore the psychosocial dis-ress related to the volcanic eruption and the emotionalistress resulting from living in an environment damaged byhe volcano.

ackground

any scientists have conducted research on the psychosocialmpacts of natural disaster. However, research related to thesychosocial impact specifically related to volcanic erup-ions and the environmental distress resulting from theseisasters is limited.

From the research conducted to date, it is evidenthat a volcanic eruption causes several psychosocial prob-ems including depression and posttraumatic stress disorderPTSD) (Araki, Nakane, Ohta, & Kawasaki, 1998; Goto,ilson, Kahana, & Slane, 2006; Howard et al., 1999; Ohta

t al., 2003). Goto et al.’s (2006) research concluded thathe loss of goods and uncertainty related to the futurelays an important role in causing these symptoms. Mean-hile, survivors who undergo several relocations are more

ikely to suffer from psychosocial distress compared tohose who only experience it once. Some demographicata such as age, marital status, social economy, edu-ation, and duration of living around the mountain areelated highly to the occurrence of psychosocial prob-ems (Goto et al., 2006). This could be because eruptionso not occur over a short period of time like earth-uakes, and because of the frequency of eruptions by

Please cite this article in press as: Warsini, S., et al. Psychosoeruption: Study protocol. Collegian (2014), http://dx.doi.org/

ome active volcanoes which may burden the peopleiving around it and finally result in psychosocial prob-ems.

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ing Ltd. Published by Elsevier Ltd.

People living in damaged environments may feel dis-ressed by the changes they see. Studied to date by twoesearch teams (Connor, Albrecht, Higginbotham, Freeman,

Smith, 2004; Higginbotham, Connor, Albrecht, Freeman, Agho, 2007), the studies support Albrecht’s claim (2002),

hat people can feel ‘homesick’ at home when the land-cape around them is significantly changed or damaged.lbrecht defined the term ‘solastalgia’ that he proposed ishe distress or sadness a person feels when his or her homenvironment is negatively changed. Solastalgia may resultn people feeling unfamiliar in their own environment, evenhough they continue to live where they always have. Thisistinguishes solastalgia from nostalgia; that is, survivorsxperience a type of homesickness even though they haveot moved from their homes (Warsini, Mills, & Usher, 2014).lthough Albrecht (2005) hypothesized that solastalgia mayesult from the damage resulting from natural disasters, toate this has not been tested. The research that has beeneported about volcanic eruptions mostly discusses the sur-ivors’ responses to the disaster or to living in a relocationrea or a shelter. However, the fact that eruptions can have aasting impact on the environment and even trigger a secondisaster, has received little attention to date. In additiono that, research on the role of place attachment and itsmpact on the survivors’ experience in overcoming the envi-onmental change caused by an eruption, has not previouslyccurred.

he study

ims

he aims of the research are to measure the psychosocialnd environmental distress resulting from the 2010 eruptionf the Merapi volcano and explore the experience of livingn an environment damaged by a volcanic eruption.

Specifically, we aimed to answer the following researchuestions:

. How has the eruption of Merapi affected the psychosocialhealth of people who live near the volcano?

. What is the level of environmental distress caused byliving in an environment damaged by a volcanic eruption?

. What is the experience of living in the shadow of a very-active volcano and how does this impact on the mentalhealth of the local community?

cial and environmental distress resulting from a volcanic10.1016/j.colegn.2014.03.004

n explanatory mixed method design (Creswell & Planolark, 2011, p. 82) will allow the researcher to assess ahenomenon using a quantitative approach and then obtain

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Distress from volcanic eruption: Protocol

depth of information that cannot be examined quantita-tively, through a qualitative approach. Mixed method isconsidered appropriate to gain information about the psy-chosocial and environmental distress experienced by peoplewho live nearby the Merapi volcanic mountain. Integrationof the data, an important aspect of all well designed mixedmethod studies, will occur between the second and thirdphase of the study, where the results of phase two will drivethe questions in phase three, and in the final analysis whereall data will be merged to answer the research questions(Creswell & Plano Clark, 2011, p. 234).

Participants and setting

The research will be conducted in the Merapi community inIndonesia, primarily in Cangkringan and Pakem sub districtsof Jogjakarta province. Cangkringan sub district experi-enced the worst damage and the most deaths from theMerapi eruption in 2010 while Pakem sub district experi-enced several eruptions before the 2010 eruption but wasnot damaged in the 2010 eruption.

In the first phase of the research (quantitative), aconvenience sample will initially be used to test theappropriateness of the tools with a representative groupof participants (n = 30), and to perform a test retest(n = 80—110) of the tools. Once this has been completed,a larger stratified sample will be recruited to completethe questionnaire (n = 350). Systematic stratified samplingmeans the population will be divided into at least two differ-ent subgroups (or strata) that share similar characteristics(Triola, 2009). The advantages of systematic stratified samp-ling are ensuring of sampling representativeness and gaingreater accuracy (Schofield, 2003, pp. 181—182). A furthersample will target people not affected by the 2010 Merapieruption, living in areas not destroyed by the eruption, toget a baseline level of distress for the local population.

A group of 350 survivors will be recruited to participatein this survey from a total population of about 13,000 peo-ple residing in the area. A final sample of 350 is consideredsufficiently powered to answer the research questions. Thetarget sample size of 175 people from Cangkringan and 175from Pakem enables us to detect a mean difference of 1 unitin the EDS scale (assumed standard deviation (SD) 3 based onHigginbotham et al., 2007) with a power in excess of 80% andan overall level of significance of 0.05. Systematic stratifiedsampling will be used to recruit participants. The researcherwill stratify samples by sub-district (Cangkringan and Pakem)then chose two villages from each sub-district. Further clas-sification, according to gender and age groups (elderly andyoung adult) will be performed. Residents of every fifthhouse in the selected sub-districts will be approached toparticipate. The adult resident whose next birthday is clos-est will be invited to participate if they meet the inclusioncriteria.

In the third phase of the study, a smaller sampledrawn from the same individuals in the second phase ofthe research will be undertaken using purposive sampling.

Please cite this article in press as: Warsini, S., et al. Psychosoeruption: Study protocol. Collegian (2014), http://dx.doi.org/

Respondents with high and low EDS and IES-R scores fromthe quantitative result will be sought to help explain thephenomenon further (Creswell & Plano Clark, 2011, p. 235).The purpose of this sample is to enhance understanding

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f environmental distress and to understand the impact ofhe event in each group, and to determine if the groupsre typical or average in relation to their psychosocialesponse. Interviews will be continued until data saturationccurs, that is, where the same information is being heardStreubert, 2011). We expect that a sample of about 15—20ill be required to achieve this goal.

nclusion criteriahe respondents must meet the following inclusion criteria:

. lived in the area all of their life;

. experienced the eruption of Merapi in 2010 and now livein an area with environmental damage (study cohort);

. experienced the eruption before 2010 and now live inan area with no environmental damage (comparisoncohort);

. adult, over 18 years old;

. willing to consent to the study;

. able to communicate their experiences to theresearcher;

xclusion criteriahe exclusion criteria are as follows:

. evidence of a severe mental illness/disturbance;

. difficulty hearing or speaking;

ata collection

easures demographic section will be included in the survey. Par-icipants will be asked to complete a number of questionsuch as age, gender, education level, living arrangements,mployment, pre-disaster experiences, and post-disasterxperiences including losses experienced. The survey willlso have an area where the participant can indicate theirillingness to be interviewed.

The Environmental Distress Scale (EDS) is a 117 itemcale developed by Higginbotham et al. (2007). The EDSas designed to measure how people appraise the envi-

onmental degradation produced by activities of open-cutining industries. However, it has been suggested that this

ool can be adapted to measure distress arising in otherontexts such as climate change, and natural disaster. Thecale has been tested with populations in Upper Hunter Val-ey, Australia and demonstrated strong internal consistencyCronbach’s alpha = 0.79—0.96) and test retest reliabilityICC = 0.67—0.73) (Higginbotham et al., 2007). The tool willnitially undergo modification in preparation for use in a vol-ano setting as while Higginbotham et al. (2007) suggest theool may be useful for natural disasters. It has not previouslyeen used in this context. Translation and back translationrior to testing and dissemination will also be undertaken.

The Impact of Event Scale—–Revised is a self-report mea-ure of current subjective distress in response to a specificraumatic event and contains 22 items. The original scale,

cial and environmental distress resulting from a volcanic10.1016/j.colegn.2014.03.004

eveloped by Horowitz, Wilner, and Alvarev (1979), wasevised by Weiss and Marmar (1997) in order to better corre-pond with the Diagnostic and Statistical Manual for Mentalisorders-IV (DSM-IV) for the symptoms of Posttraumatic

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4 S. Warsini et al.

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tress Disorder (PTSD). The IES-R has recently been testednd has high internal consistency (alphas ranging from .87o .94) (Creamer, Bell, & Failla, 2003). However, the toolas not been translated and validated into an Indonesiananguage. Therefore, in this research the IES-R will be trans-ated into Bahasa Indonesia before it undergoes pilot andsychometric testing.

rocedure

he research will be divided into three phases over two yearssee Fig. 1).

hase 1he goal in this phase is to modify the Environmental Dis-ress Scale (EDS) (Higginbotham et al., 2007) to ensure itsppropriateness for use in Indonesia with residents of theerapi volcano area. An initial scoping exercise will assist

he researcher to understand the need for amendment ofhe tool. After the EDS scale content is modified it wille translated into Bahasa Indonesia and then back trans-ated as required by an authenticated person (Jones, Lee,hillips, Zhang, & Jaceldo, 2001). The IES-R scale will alsoe translated using the same process. Brislin’s (1986, p. 159)ranslation model requires three steps: (1) forward trans-ation of the tools into Bahasa and Jawa checked by twoilingual experts; (2) back translation (into English) by twoifferent bilingual experts; and (3) comparison of the orig-nal English version by two back-translation experts (Chent al., 2011; Jones et al., 2001). The aim of the translationrocess is to produce a version of the tool that is culturallynd setting specific yet as close as possible to the originalersion (Chen et al., 2011). The survey, which will includeoth measurement tools and a demographic section, willhen be pilot tested (sample n = 30), and followed by a test-

Please cite this article in press as: Warsini, S., et al. Psychosoeruption: Study protocol. Collegian (2014), http://dx.doi.org/

etest determination (sample n = 80) to assure the validitynd reliability of the survey tool (Bland & Altman, 1986; Gau,uettner, Usher, & Stewart, 2012). The final instrument willesult from these steps.

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hase 2he second phase is the conduct of the correlational surveyesearch. As many as 350 people living in the Cangkringannd Pakem sub district will be recruited to the study usingystematic stratified sampling. The researcher will stratifyamples by villages (hamlets), and then sample householdsystematically within villages/hamlets. The researcher willisit every fifth house in every lane in a village until theample for that area is fulfilled. The proportion of respon-ents according to age (adult and elderly), and sex (femalend male), are expected to be similar in both groups (Pakemnd Cangkringan sub district).

Data collection will be performed through researcher-ssisted interviews for elderly respondents who may find itifficult to fill out the tools themselves. Otherwise the toolill be self-administered. The survey tool is expected to

ake participants about 20 min to complete. See Fig. 2 forhe data collection procedure.

hase 3 descriptive exploratory qualitative study will be under-aken. The qualitative phase will aim to explore and explainhe particular characteristics and experiences of differentroups of respondents. For example, this phase will attempto unravel why some respondents score higher or lower onhe subscales of the survey tool, and why some respondentsave average score. The sample for the qualitative data col-ection phase will be chosen purposively from representativeespondents with the lowest and the highest scores on theDS and IES-R scores and who have indicated their willing-ess to be interviewed. Further, the information gatheredn the initial phase of the study will be used to develop theuestions to be explored in the qualitative phase. Interviewsill continue until the same information is being heard. Wexpect this to occur after interviewing approximately 15—20articipants. Interviews will be conducted at a time andlace of the participants choosing. A venue that is conducive

cial and environmental distress resulting from a volcanic10.1016/j.colegn.2014.03.004

o an interview and where privacy can be assured will beecommended.

During qualitative data collection, the interviews wille recorded and the researcher will take additional notes

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Distress from volcanic eruption: Protocol 5

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as required. The interviews will then be transcribed ver-batim ready for data analysis. The interviews will beconducted in Bahasa Indonesia, the transcriptions will be inBahasa Indonesia and the data analysis conducted in BahasaIndonesia. Approximately two transcripts will also be tran-scribed to English to allow for cross checking of analysis.

Data analysis

All quantitative data will be analyzed using the Statisti-cal Package for the Social Sciences (SPSS) version 21. Datafrom psychometric testing (phase 1) for both scales will beassessed using intra class correlation coefficients or concord-ance correlation coefficients. Internal consistency will bemeasured using Cronbach’s alpha test. Cronbach alpha andIntra Class Correlation scores of more than 0.6 will be set inthis research.

Data from the second phase (large survey) will be sub-jected to descriptive statistics and inferential statisticsconducted as required. Descriptive statistics will be used togain information about percentages, mean standard devia-tions and median values of EDS, IES-R score and demographicdata related to respondents such as age, and gender. Bivari-ate tests will be conducted using parametric tests such asun-paired t tests or non-parametric Mann—Whitney tests tocompare EDS and IES-R results among groups to addressthe main research questions. Further, bivariate statistics

Please cite this article in press as: Warsini, S., et al. Psychosoeruption: Study protocol. Collegian (2014), http://dx.doi.org/

will also be used to compare EDS and IES-R results accord-ing to respondent demographic characteristics (such as age,gender, education, pre and post disaster experienced). Mul-tivariate linear regression analyses will be conducted in

wtsd

ection process.

ases where groups are compared (i.e. people who expe-ienced the Merapi eruption and people who did not; peopleho live in Merapi eruption damaged area and people whoo not).

Qualitative data will be analyzed using NVivo software.he data will be searched for codes and themes in order tonswer the qualitative research questions arising from theuantitative data. Thematic analysis is a process wherebyhe data is examined and searched for recurring patternsRebar, Gersch, Macnee, & McCabe, 2011). For example, inhis case the data will be searched for themes that help tolluminate the answers to questions raised from phase 2 ofhe study.

Finally, both the quantitative and qualitative data wille merged to unravel the complexities of the phenomenonnder study. Integration is an essential component of thenalytic phase of a mixed method study (Kroll & Neri, 2009,. 38).

thical issues

thical approval has been obtained from the Universityuman Research Ethics Committee (HREC) and Institutionaleview Board of Medicine Faculty, Universitas Gadjah Mada,ndonesia. All participation in the study will be voluntarynd participants will be informed of their right to withdrawrom the study at any time. Participants will be provided

cial and environmental distress resulting from a volcanic10.1016/j.colegn.2014.03.004

ith an information sheet for each phase of the study andhose who agree to participate will be asked to sign a con-ent form. The participant information sheet will containetails of local support services should a participant become

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istressed due to the completion of the survey question-aire. Local support services will be made aware of theesearch study and asked to provide support to participantshould this be required. The researcher will also return tohe villages over the following 12 months and continue toeet with local health services to determine the need for

ny ongoing support for participants. An agreement for theonduct of the study has been organized with the local vil-age leaders. As the researcher (Warsini) is a local of therea, she is aware of the local cultural customs and willnsure these are respected in the conduct of the study.esearch assistants will be trained and supervised by theesearcher (Warsini) and will be provided with support fromocal agencies should they become distressed as a result ofonducting the data collection. The researcher will ensurehe confidentiality of participant data throughout the study.ll resulting reports and publications will be de-identifiednd pseudonyms used to protect the confidentiality of thearticipants.

alidity and reliability

he validity and reliability of the measurement tools for useith the population will be determined prior to data collec-

ion. The rigor and trustworthiness of the qualitative phasef the study will be addressed by following the guidelinesstablished by Lincoln and Guba (1985, p. 301).

issemination strategies

n easy to read report will be prepared for participatingommunities and distributed widely. Papers will also berepared for relevant scholarly journals and presentationselivered to relevant nursing and health conferences.

unding

he researcher was supported by a James Cook Universitynternational Postgraduate Research Scholarship (JCUIPRS)nd James Cook University Graduate Research School fundso conduct data collection.

iscussion

t is expected that the results of this mixed methodstudy will provide unique insights into the psychosocialnd environmental distress resulting from a volcanic erup-ion. Translated and tested measurement tools will providensight into the extent of the psychosocial and environ-ental distress experienced by the participants while theualitative phase of the study will help to unravel some ofhe unexplained results from the quantitative phase of the

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tudy. Results of the study may be used in the future toetter support survivors after a volcanic eruption or simi-ar natural disaster. As nurses make up the majority of firstesponders after a disaster and are also those who workith communities during periods of recovery, this research

s potentially significant for nursing practice and education.

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PRESSS. Warsini et al.

imitations

he study will be conducted in one region of Indonesia.herefore, the results of the study may not be generaliz-ble to other volcano or natural disaster affected areas ofndonesia or the world. In addition, the IES-R only predictshe extent of psychosocial distress. To accurately determinehe level of psychosocial distress and/or the existence ofosttraumatic stress requires a clinical assessment.

onclusion

he article describes a mixed method study designed toxplore the level and experience of psychosocial and envi-onmental distress resulting from a volcanic eruption. Asittle is currently known of these phenomena, the find-ngs from the study will be used to guide future education,ractice and research.

onflict of interest

o conflict of interest has been declared by the authors.

uthor contributions

ll authors have agreed on the final version and meet at leastne of the following criteria [recommended by the ICMJEhttp://www.icmje.org/ethical 1author.html)]:

substantial contributions to conception and design, acqui-sition of data, or analysis and interpretation of data;

drafting the article or revising it critically for importantintellectual content.

cknowledgement

he researcher is supported by an international studentcholarship and research support from James Cook Univer-ity.

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