The impact of conflict exposure and social support on posttraumatic growth among the young adults in Kashmir

Abstract This study examined the effect of social support and conflict exposure on posttraumatic growth (PTG) among the young adults who have been exposed to stressful experiences regarding the armed conflict in Kashmir. The aim of the study is to explore PTG in this population and its association with conflict exposure and perceived social support. This is a cross-sectional study involving 803 college students. The data were collected by four self-report instruments comprising of demographic data schedule, the exposure to Kashmir conflict checklist, the posttraumatic growth inventory and the multidimensional scale of perceived social support. The respondents reported relatively high levels of PTG and social support. Conflict exposure and total perceived social support were significantly associated with an increase in PTG. Formulation of programmes to sensitize people living in conflict zones about the importance of PTG and social support in buffering negative outcomes can help lessen their stress, increase their ability to withstand adversities and help them move towards personal growth.


PUBLIC INTEREST STATEMENT
The current study highlights a fact that traumatic experiences can have an adaptive value. There is overwhelming evidence that traumatic events have the potential to trigger positive psychological changes (i.e. PTG) among the individuals exposed to trauma. A wide range of research has suggested that there may be a number of factors that influence posttraumatic growth (PTG), including trauma exposure and social support. Given that trauma exposure and social support is linked to PTG, we explore PTG in this study and its association with conflict exposure and perceived social support. We found that the respondents reported relatively high levels of PTG and social support. Conflict exposure and total perceived social support were significantly associated with an increase in PTG. The current study enables each reader to perceive the value of social support in fostering positive psychological growth (i.e. PTG) when encountered by traumatic life experiences.

Introduction
Kashmir is considered to be one of the most likely places on the earth to witness a potential breakout of major conflict at any point of time (Scobell, 2001). When India was partitioned in 1947, it heralded an era of dispute between the divided nations over the control of Kashmir (Ganguly, 1996(Ganguly, , 1997. Presently, India, Pakistan and China each govern one of three parts into which Kashmir remains divided today. The conflict was mainly an interstate affair between India and Pakistan until 1988, when Kashmiri militants in the Indian part of Kashmir started a liberation movement which resulted in militancy. This conflict between the liberation movement and the Indian army has spiralled into a long cycle of armed conflict (de Jong et al., 2008a(de Jong et al., , 2008b. The counter-insurgency movement led by the Indian forces was extremely traumatic for the civilian population which was often trapped in this disturbing atmosphere of conflict. Current literature emerging on this issue underscores that Kashmir remains a battlefield between militants and the security forces today with its people experiencing traumatic violence, injury and death. (Dar, 2011;Kashani, Kanth, Fazili, & Husain, 2003;Wani & Margoob, 2006;Yaswi & Haque, 2008), Attendant concerns of poor mental health and traumatic reactions to stress are extremely common occurrences.
The devastating consequences of a conflict situation involve multiple psychological, social, economic and environmental challenges to integrity of an individual and to public life (Pedersen, 2006). Living under conditions of prolonged conflict and organized violence disrupts with individual's sense of identity (Das, 2007) and stifles his or her psychological integrity (Baker & Shalhoub-Kevorkkian, 1999;Giacaman et al., 2007;Punamaki, Kanninen, Qouta, & Sarraj, 2004). Before the outbreak of armed insurgency, the proportion of people living with psychiatric problems in Kashmir was no different from the surrounding regions (Yaswi & Haque, 2008). However, an article by Dar (2011) reported that the cumulative death toll arising out of the insurgency and counter-insurgency moves, as estimated by human rights groups and new agencies, was about 70,000 (47,000 as per Indian official claims). Similarly, the study reported that over 8,000 (4,000 as per Indian official claims) enforced disappearances have occurred. Civilians constituted a majority of these groups in both cases.
Violence affects nearly everybody in Kashmir. In one survey, Margoob et al. (2006), found a lifetime prevalence of traumatic events experienced by the inhabitants of four districts of the Indian part of Kashmir and the most frequently reported traumatic events were witnessing firing and explosions (81%) and exposure to combat zones (74%). A community survey done by de Jong et al. (2008a) found a high level of ongoing violence across the region with civilians being caught in the crossfire. The majority of people surveyed stated having been exposed to crossfire (86%) and round-up raids (83%). A significant proportion of people reported being subjected to maltreatment (44%), forced labour (33%), kidnapping (17%), torture (13%) and sexual violence (12%).
In the general process of growth, the individual's social system in the form of family, friends and significant others play an important role in the experience of PTG particularly through the empathetic acceptance of disclosures about the traumatic event and by providing a sense of being highly valued (Schroevers, Kraaij, & Garnefski, 2011;Tedeschi & Calhoun, 2004). Numerous studies have shown that individuals demonstrate better adjustment to traumatic events when perceived levels of social support are high (Halcomb, Daly, Davidson, Elliott, & Griffiths, 2005;Keane, Marshall, & Taft, 2006;McIntosh, Silver, & Wortman, 1993). Thus, social support is a well-known predictor of positive change after a trauma or life crisis (McMillen, Smith, & Fisher, 1997;Schroevers, Helgeson, Sanderman, & Ranchor, 2010;Schulz & Mohamed, 2004;Tedeschi & Calhoun, 1996. Findings regarding the relationship between social support and psychological adjustment are mixed. For example, Helgeson (1993) found that perceived available support had a beneficial effect on adjustment to heart attack, whereas received support from significant others appeared to have a harmful effect. Given the consistent evidence that social support availability protects people from the effects of stressful life experiences (Cohen, 1992;Cohen & Wills, 1985;Hobfoll & Vaux, 1993;Stroebe & Stroebe, 1996;Wills, 1991), but the studies have found that received support do not consistently improve adjustment to stressful experiences (Barrera, 1986;Bolger, Zuckerman, & Kessler, 2000;Coyne & Bolger, 1990). According to Linley and Joseph (2004), the overall literature on PTG and social support suggests a weak relationship between both the variables. While the role of social support has been extensively studied as a possible protective factor that lowers PTSD symptoms (Stephens & Long, 1999), however, the role of social support in developing PTG is less studied and requires further research.
In view of these findings, the aim of the current study was to explore PTG among the young adult population comprising of college students who have been exposed to stressful experiences in relation to the armed conflict in Kashmir. In addition, the present study also explored how PTG was associated to conflict exposure and social support in this study.

Design
The study was a descriptive study and utilized a cross-sectional design.

Sample
A cross-sectional sample of 803 students in the age group of 19-24 years was obtained using the purposive sampling technique. The sample was drawn from colleges in three districts (Baramulla, Bandipora and Kupwara) of North Kashmir.

Procedure
The researcher approached the college authorities and obtained permission to collect data from the students. The students were briefed about the study and their rights as participants. They were assured confidentiality and asked to participate only if they were willing to. They were requested to sign on the informed consent form prior to taking part in the study and a copy of informed consent form was provided to each student. The participants responded to the questionnaires in approximately 30 minutes of time.

Ethical considerations
Participants were treated in accordance to the ICMR/APA ethical guidelines. The study was reviewed and approved by the Institute Ethics Committee (Human Studies), Pondicherry University.

Demographic data schedule
A demographic data schedule was used to record the socio-demographic details of the respondents.

Exposure to Kashmir conflict checklist
This checklist was prepared by the researchers based on the traumatic events reported in previous studies on Kashmir armed conflict (Dar, 2011;de Jong et al., 2008a;Margoob et al., 2006;Yaswi & Haque, 2008). The final version of the checklist was subjected to a pilot study and comprised of 16 items. Every item that receives a response of "yes" is scored as 1 and the range of possible scores is 0-16. Higher scores reflect greater exposure to trauma. The respondent had to report whether or not a particular event had occurred, for instance, "have you been hit with a bullet? 'Or have your family members been killed?'".

Posttraumatic growth inventory (PTGI)
The PTGI is the most commonly used measure of positive psychological change that can result from coping with a traumatic experience (Shakespeare-Finch, Martinek, Tedeschi, & Calhoun, 2013). It was developed and standardized by Tedeschi & Calhoun in 1996. The reliability of the scale was established using a sample of university students and the authors reported that PTGI has an acceptable internal consistency coefficient (0.90) and adequate test-retest reliability over a two-month period (0.71). The PTGI has 21-items that are answered on a 6-point Likert type scale ranging from 0 (I did not experience this change as a result of my crisis) to 5 (I experienced this change to a very great degree as a result of my crisis). The range of possible scores on the test is 0-105 and higher scores on the PTGI indicate a greater degree of PTG. The PTGI has five subscales: (1) New possibilities,

Multidimensional scale of perceived social support
The multidimensional scale of perceived social support (MSPSS; Zimet, Dahlem, Zimet, & Farley, 1998) is a 12-item self-report measure of the amount of social support that an individual feels he or she receives from friends, family members and significant others. Each item is rated on a 7-point Likert-type scale ranging from "strongly disagree" to "strongly agree". The total score ranges from 12 to 84 for the entire 12-item questionnaire and from 4 to 28 for each of the three subscales. The reliability of the scale was established using a sample of university under graduates and the authors reported that MSPSS has an acceptable internal consistency coefficient (0.88) and adequate test-retest reliability over a 2-3 months period (0.85). The internal reliability and construct validity of this scale was confirmed by Tonsing, Zimet and Tse (2012) among South Asian migrants from Pakistani and Nepal, thereby sharing a common geographical location when compared to the sample of present study. In the current study, Cronbach's α were .79, .78 and .75 for significant others, family and friends subscales, respectively. Internal consistency of the global scale was .89. The reason why the reliability values differ by a margin in the current study could be that the tool is being used in a different culture and a very specific context, that is, trauma-affected populations. The MSPSS is a widely used social support tool because it is simple, precise and quick.

Data analysis
Descriptive analysis was conducted to show the distribution of PTG, perceived social support, conflict exposure and socio-demographic variables of the study. Prior to main analyses, correlation analysis was conducted to assess the relationship between the PTGI total and other study variables. For the main analysis, hierarchical regression analysis was performed in three steps to examine the linear and shared contribution of perceived social support, conflict exposure and the socio-demographic variables to the degree of PTG. Demographic characteristics (age, gender and income) were entered in the first step of the model, conflict exposure and MSPSS terms were entered in the second and third step of the model, respectively. All data analyses were conducted using the SPSS 20.0 statistical package.

Demographic characteristics
The participants comprised of a total of 803 students out of which 472 were males (58.8%) and 331 were females (41.2%). The mean age of the respondents was 19.99 years. Table 1 provides a socio-demographic profile of the study sample.

Description of exposure to conflict, PTG and perceived social support
The mean of exposure to conflict was 2.83 events (SD = 1.68). The findings of the study show that a very small fraction of the sample (0.7%) was not exposed to any traumatic event, about a quarter (23.7%) of the participants were exposed to one traumatic event, around half the sample (46.9%) was exposed to two or three traumatic events and another quarter (28.6%) reported witnessing four or more conflict-related events. The most prevalent incidents reported were being kept under a prolonged curfew (77%), witnessing a family member/friend being beaten or humiliated (36.2%) and smaller proportions reported being kidnapped (2.6%) and witnessing encounter between militants and security forces (2.2%).
The mean PTGI total score was 64.43 (SD = 16.14).    Table 2 shows the results of the correlation analysis which was conducted to examine relationship among all the study variables. Spearman's Rank-Order correlation was computed. The results showed that PTG was positively associated with conflict exposure, total perceived social support (i.e. family, friends and significant others). In addition, higher levels of age were significantly associated to higher PTG.

Predictors of PTG
The socio-demographic variables accounted for 2.1% of the variance in total PTGI in the first step of the equation, F (3, 799) = 5.75; p = .001. Exposure to conflict variable accounted for an additional 3.2% in variance in the second step, F (1,798) = 26.98; p = .000, and MSPSS term added an extra 5.3% significantly to the variance of the PTGI in the third step, F (1,797) = 47.00; p = .000. In the final model, shown in Table 3, the social support, conflict exposure and older age were positively associated with the overall level of PTGI. Family type and monthly family income were not associated with the levels of PTGI.

Discussion
The aim of the study was to explore PTG among the young adults who have been exposed to stressful experiences regarding the armed conflict in Kashmir and its association with perceived social support and conflict exposure. In this context, we examined the association between PTG, conflict  Note: N = 803. **p < 0.01.
3 Monthly family income (below 10,000 = 0, more than 10,000 = 1). exposure and perceived social support. We found that the respondents in the current study reported a higher degree of PTG which was positively associated to conflict exposure, perceived social support and being older in age.
Conflict exposure was positively associated with PTG. This finding is consistent with previous findings involving level of trauma exposure to PTG (Blix, Hansen, Birkeland, Nissen, & Heir, 2013;Linley & Joseph, 2004;McMillen et al., 1997;Tedeschi & Calhoun, 2004, 1996. Laufer and Solomon (2006) reported a similar finding among the Israeli youth wherein higher objective exposure was associated with more PTG.
Our findings also show that perceived social support was positively associated with PTG. This finding is in congruence with previous studies examining the role of social support in facilitating PTG (Cadell, Regehr, & Hemsworth, 2003;Janoff-Bulman, 1992;Park & Folkman, 1997;Siegel, Schrimshaw, & Pretter, 2005). Theory on PTG suggests that individuals who are able to share experiences with others and seek tangible support may be more likely to experience PTG Tedeschi & Calhoun, 1996. However, the general picture of the linkage between PTG and social support suggests a weak relationship between these variables (Linley & Joseph, 2004). We may understand the protective role of social support and its impact on PTG in this study better by looking at the cultural fabric of the society of Kashmir. Kaw (2010) describes the society of Kashmir as being very cohesive and socially connected-a feature that inculcates in them a sense of harmony and peace-provides them with a strong source of support in times when the conflict intensifies and facilitates resilience in the face of stress and loss.
Furthermore, the findings show that older respondents reported higher degree of PTG. With respect to age, the prevalent research on PTG has found mixed results. Some studies have found a positive relationship between PTG and age, with older individuals reporting increased level of growth (Kurtz, Wyatt, & Kurtz, 1995;Tallman, Altmaier, & Garcia, 2007). Antonovsky (1987) claimed that the ability to adjust to a stressor depends on the individual's experience and available resources. In this study, the higher degree of growth shown by the older respondents may imply that they have spent a significant part of their life living in conflict and this, in turn, has helped them to adjust better with the conflict situation in Kashmir when compared to the following generations.
To investigate the individual association of each of the variables with PTG, we fitted the hierarchical multiple regression in three steps. In the first step, demographic predictors were entered: gender, age and monthly family income. This model was statistically significant and explained 2.1% of the variance in PTG. After entry of exposure to conflict in second step, the total variance explained by the model was 5.3%. The introduction of exposure to conflict term explained an additional 3.2% variance in PTG, after controlling for demographic variables (gender, age and income). In the third step, perceived social support term explained the total variance of 10.6% in the whole model. The inclusion of perceived social support term added an extra 5.3% variance in PTG, after controlling for demographic variables and exposure to conflict term. In the final model, three out of five predictors were statistically significant with perceived social support term recording a higher contribution of 23.1% followed by exposure to conflict term with 19.8% and older age contributing 10.1% towards PTG. There is a possibility that an even larger variance in PTG would be noted if we were to include the pathogenic factors, subjective exposure to conflict, its effect and duration in the model.
The current study has certain limitations which may restrict its generalizability to an extent. Firstly, the sample was drawn from the northern part of Kashmir using purposive sampling technique and self-report measurement due to which the representativeness of its sample may be limited by this fact. Secondly, the study employed a cross-sectional research strategy which undermined the possibility of uncovering causal relationships. Additionally, conflict exposure was operationalized as the number of armed conflict-related events the respondents experienced or witnessed during the ongoing conflict in Kashmir. Measuring the degree of trauma exposure is a perplexing challenge involving diverse conflict-related events with a potential for varying degrees of impact perceived by different people. Lastly, this study focused closely on the salutogenic factors; a more comprehensive picture of the situation may be generated by combining both the pathogenic and salutogenic effects of trauma exposure.

Conclusion
We believe that findings of our study can contribute to the understanding of the role of social support in fostering PTG. This study, though comprised of non-clinical sample, has clinical implications for the traumatized civilians living in conflict zones. The study found that positive growth can co-occur among the individuals being exposed to situations marked by conflict. Accordingly, formulation of programmes to sensitize people living in conflict zones towards understanding the importance of PTG and social support could be effective in minimizing the negative outcomes of stressful experiences of the conflict situations.