The Sewol ferry disaster caused shock and grief in South Korea. The aim of this study was to identify the factors associated with symptoms of complicated grief (CG) among the surviving students 20 months after that disaster.
This study was conducted using a cross-sectional design and a sample of 57 students who survived the Sewol ferry disaster. Data were collected using the following instruments: Inventory of Complicated Grief (ICG), the Lifetime Incidence of Traumatic Events-Child, the Child Report of Post-Traumatic Symptoms (CROPS), KIDSCREEN-27, Family Adaptability and Cohesion Evaluation Scales-III, the Peri-traumatic Dissociation–Post-traumatic Negative Beliefs–Post-traumatic Social Support scale, and the Strengths and Difficulties Questionnaire. A generalized linear model using a log link and Poisson distribution was performed to identify factors associated with symptoms of CG.
The mean score on the ICG was 15.57 (standard deviation: 12.72). Being born in 1999, a higher score on the CROPS and a lower score in autonomy and relationship with parents on the KIDSCREEN-27 were related to higher levels of CG.
Twenty months after the Sewol ferry disaster, 24.5% of surviving students were suffering from CG. This study uncovered a vulnerable population of bereaved children at high risk for CG.
On April 16, 2014, the Sewol ferry sank in the West Sea off South Korea. Only 181 of the 476 passengers survived. A total of 325 Danwon high school students were on a school trip, and 250 of them died. The Sewol ferry disaster caused negative emotional reactions in the public, including anger, sadness, and anxiety [
A study that evaluated the mental health effects of this disaster on the community of Ansan, where most victims and survivors resided, showed that residents there had a significantly higher prevalence of psychiatric disturbances than those in control communities [
Students who survived the Sewol ferry disaster experienced not only a life-threatening traumatic event but also loss of their close friends. It is now generally agreed that grief refers to a wide variety of emotional, cognitive, and behavioral responses that normally follow the death of a loved one [
However, few studies are available on CG among disasterbereaved South Koreans after the ferry disaster. Bereaved people were at high risk for CG, which may have led to significant distress and impairment in their health. Understanding factors associated with CG is important to identify bereaved individuals who are at high risk and to provide targeted interventions and treatments.
The aim of this study was to identify factors associated with symptoms of CG among the surviving students 20 months after the Sewol ferry disaster. We hypothesized that the symptoms of CG among the surviving students would be severe and that demographic characteristics and psychological variables would be associated with symptoms of CG in this population. Thus, the aims of this study were to 1) investigate symptoms of CG in surviving students 20 months after the Sewol ferry disaster and 2) identify factors (demographic characteristics and psychological variables) associated with symptoms of CG.
This study was performed with Danwon high school students who survived the Sewol ferry disaster in South Korea. We initially distributed questionnaires to the 75 students and obtained responses from 57 students, after excluding four with insufficient responses. This cross-sectional study was conducted in December 2015, 20 months after the Sewol ferry disaster.
Socioeconomic variables including sex, birth year, birth order position, household income, type of residence, and type of medical insurance were included. Participants also completed the Inventory of Complicated Grief (ICG), Lifetime Incidence of Traumatic Events-Child (LITE-C), Child Report of Post-traumatic Symptoms (CROPS), KIDSCREEN-27, Family Adaptability and Cohesion Evaluation Scales (FACES-III), Peri-traumatic Dissociation-Post-traumatic Negative Beliefs-Post-traumatic Social Support (PTD-PTNB-PTSS) scale, and the Strengths and Difficulties Questionnaire (SDQ).
Birth year was categorized as 1997, 1998, and 1999. Birth order position was classified as first born, second born, and third born, or younger. Household income was based on South Korean Won (KRW) per annum and classified into three categories <30,000,000 KRW (approximately 25,000 USD), 30,000,000–60,000,000 KRW, and >60,000,000 KRW. Type of residence was categorized as self-occupied, deposit-basis rent, and monthly-basis rent. Type of medical security was classified as National Health Insurance, Medical Aid recipient, and the National Basic Livelihood Act (NBLA) recipient. The NBLA program was launched in October 2000 to support households with less than a designated minimum cost of living per month (approximately 1,500 USD for a household of four people as of 2016). The program is often considered a proxy measure of economic status in South Korea.
The dependent variable, ICG, is a self-report measure that assesses the severity of CG symptoms [
The LITE-C is a checklist assessing trauma or losses that children have experienced; it also assesses the age at which the trauma occurred, how many times it occurred, and how bad the child felt at the time. The items on the LITE-C include car accidents, house fires, death of a family member, exposure to threats, sexual assaults, witness to violence, and other potentially upsetting events. The test-retest reliability of the LITE has an r-value of 0.80 (p<0.001). The child completes the LITE-C measure on their own, and a clinician reviews it to rate the entire set of responses as 1 (no trauma or loss), 2 (possible trauma/loss), 3 (probable trauma/loss), or 4 (trauma/loss) [
CROPS [
The KIDSCREEN (KIDSCREEN-52) instrument assesses the subjective health and wellbeing (health-related quality of life) of children and adolescents. The tool was developed as a self-report measure applicable for healthy and chronically ill children and adolescents aged 8–18 years. The KIDSCREEN-27 was developed as a shorter version of the KIDSCREEN-52 with minimum information loss and good psychometric properties. The resulting KIDSCREEN-27 has five dimensions. All five dimensions are Rasch scales: Physical Wellbeing (five items), Psychological Wellbeing (seven items), Autonomy & Parents (seven items), Peers & Social Support (four items), and School Environment (four items) [
FACES III was developed to assess two major dimensions on the circumflex model: adaptation and cohesion of the family. The measure can be used with families across the life-cycle from newlyweds with no children to retired couples. The authors report that children >12 years old can complete the FACES III to allow for comparisons between family members. Family cohesion assesses the degree of separation or connection of family members to the family. There are four levels of family cohesion ranging from extreme low cohesion to extreme high cohesion: disengaged, separated, connected, and enmeshed. Similarly, there are four levels of adaptability: rigid, structured, flexible, and chaotic. Family members answer 20 statements (e.g., family members ask each other for help; it is hard to identify the leaders in our family) by estimating the relative truth of the statement. A second scale measures what the family member would like in an ideal situation (e.g., family members would ask each other for help; we would know who the leader is in our family) [
The SDQ is a brief behavioral screening questionnaire for 3–16-year-olds. The SDQ asks about 25 attributes, some positive and others negative. It exists in several versions to meet the needs of researchers, clinicians, and educators. The 25 items are divided among 5 scales: 1=emotional symptoms; 2=conduct problems; 3=hyperactivity/inattention; 4=peer relationship problems; 5=prosocial behavior; dimensions 1 to 4 can be added together to generate a total difficulties score. This self-report version is suitable for young people aged 11–16 years, depending on their level of understanding and literacy.
The PTD-PTNB-PTSS is a shortened version of the Post-trauma Risk checklist (PRC) [
The study was approved by the Ethics Committee of the National Medical Center (IRB No. H-1505-054-002). Written informed consent was obtained from all participants. All participants were informed that they could withdraw from the study at any time.
Descriptive analyses of the data were performed to examine the subjects’ general characteristics, and frequencies, percentages, means, and standard deviations were calculated. The dependent variable, ICG score, had a marked positive skew, which violated the distributional assumption of normality, making a normal regression inappropriate. Therefore, we assumed that distress had a Poisson distribution, such that the conditional mean was roughly equivalent to the variance. A generalized linear model using a log link and Poisson distribution was performed [
Result of sociodemographic and health-related characteristics of the study participants are summarized in
The results of the clinical classification of the study population are summarized in
About 24.5% of surviving children were suggested to be suffering from CG 20 months after the Sewol ferry disaster. This study uncovered a vulnerable population of bereaved individuals at high risk for CG.
The percentage of CG cases in this study was higher than that in a general population-based bereavement study. A prevalence study of CG in a representative population-based sample reported that the conditional likelihood of developing CG after major bereavement was 6.7%; the prevalence of CG in the general sample was 3.7% [
Second, the percentage of CG among participants of this study was lower than that in some studies of disaster-bereaved individuals. For instance, the percentage of CG among disaster-bereaved individuals was 47.7% at 2 years after the 2004 South-East Asian tsunami [
Third, 26.29% of the participants suffered from PTSD after the tragic disaster, and the severity of PTSD was correlated with the level of CG. Higher scores on the CROPS were significantly associated with higher ICG scores. Raphael [
Fourth, note that nearly half of the participants reported a low quality of life (lower than the 16th percentile), especially in the dimensions of Psychological Wellbeing, Peers & Social Support, and Autonomy & Parents. This finding is explained by a previous study in which children who were exposed to trauma reported a poorer quality of life than non-exposed children [
Lastly, the SDQ classified from 5.26 to 14.03% of the participants into various clinical groups: 5.26%, emotional symptoms; 8.77%, hyperactivity/inattention; 8.77%, peer relationship problems; 12%, prosocial behavior; and 14.03%, conduct problems. This finding was similar to the 13.6% prevalence of the SDQ clinical range for all difficulties among children who survived the 2011 Great East Japan Earthquake [
The results of the present study were limited by some factors. First, the cross-sectional design makes it difficult to identify causal relationship among factors. As a result, a longitudinal study is recommended. Second, some sampling bias may have occurred, as only 75% of the surviving students participated in the study; therefore, the results should be interpreted with caution. Third, although the demographic characteristics and psychological variables were accounted for in the analysis, some additional factors, such as social support, self-efficacy, and coping style should be included in future studies.
In conclusion, despite these limitations, our study has provided multiple insights. This study identified factors associated with symptoms of CG among surviving students after the Sewol ferry accident. The results have unique implications for relief work with the bereaved population of the Sewol ferry accident and other disasters. According to our findings, the symptoms of CG among the surviving students were higher 20 months after Sewol ferry disaster than in a study of the general bereaved population. Being an older student, having more PTSD symptoms, and having a lower quality of life in the dimension of autonomy and parent relations were associated with symptoms of CG. The results of the study also inform strategies suitable for bereaved individuals after the Sewol ferry accident, including early assessment for those at high risk for CG, targeted intervention programs for the survivors with CG or PTSD, and education for the survivors’ parents.
This study was supported by a grant from the Korean Mental Health Technology R&D Project, Ministry of Health & Welfare, Republic of Korea (HM15C1054).
General characteristics of the study population
Variable | Subcategory | N (%) | M (SD) |
---|---|---|---|
Sex | Male | 29 (50.88) | |
Female | 28 (49.12) | ||
Birth year | 1998 | 9 (15.79) | |
1997 | 47 (82.46) | ||
1999 | 1 (1.75) | ||
Birth order position | First | 21 (36.84) | |
Second | 27 (47.37) | ||
Third or younger | 4 (7.02) | ||
Not answered | 5 (8.77) | ||
Household income (ten thousand KRW) | Less than 3,000 | 14 (24.56) | |
3,000 to 6,000 | 13 (22.81) | ||
More than 6,000 | 6 (10.53) | ||
Not answered | 24 (42.11) | ||
Type of residence | Self-occupied | 27 (47.37) | |
Deposit basis rent | 16 (28.07) | ||
Monthly basis rent | 4 (7.02) | ||
Not answered | 10 (17.54) | ||
Type of medical insurance | National health insurance | 21 (36.84) | |
Medical aid recipients | 2 (3.51) | ||
NBLA recipients | 3 (5.26) | ||
Not answered | 31 (54.39) | ||
LITE-C | (min=0, max=8) | 3.14 (1.98) | |
KIDSCREEN-27 | Total score (min=64, max=135) | 93.36 (19.48) | |
Physical well-being (min=8, max=25) | 16.21 (4.19) | ||
Psychological well-being (min=12, max=35) | 24.91 (5.56) | ||
Peers & social support (min=6, max=20) | 14.12 (3.36) | ||
Autonomy & parents (min=14, max=35) | 23.91 (5.82) | ||
School environment (min=4, max=20) | 12.88 (3.89) | ||
FACES | Total score (min=35, max=100) | 67.98 (15.88) | |
Cohesion (min=10, max=50) | 33.37 (8.61) | ||
Adaptability (min=10, max=50) | 33.14 (8.30) | ||
PTD-PTNB-PTSS | Total score (min=15, max=56) | 22.96 (8.99) | |
Peritraumatic dissociation (min=3, max=15) | 5.51 (2.93) | ||
Post-traumatic negative beliefs (min=10, max=33) | 16.54 (6.34) | ||
Post-traumatic social support (min=5, max=15) | 6.18 (2.31) | ||
SDQ (difficulties) | (min=1, max=27) | 11.27 (5.92) | |
SDQ (strengths) | (min=3, max=10) | 6.64 (1.93) | |
ICG | (min=0, max=47) | 15.57 (12.72) | |
CROPS | (min=0, max=37) | 12.51 (9.49) |
LITE-C: Lifetime Incidence of Traumatic Events for Student, FACES: Family Adaptability and Cohesion Evaluation Scales, PTD-PTNBPTSS: Peritraumatic dissociation-Post-Traumatic Negative Beliefs-Post-Traumatic Social Support, SDQ: Strength and Difficulties Questionnaire, ICG: Inventory of Complicated Grief, CROPS: Child Report of Post-traumatic Symptoms
Clinical classification of study population
Variable | Subcategory | Non-clinical group, N (%) | Clinical group, N (%) |
---|---|---|---|
KIDSCREEN-27 | Physical well-being | 48 (84.21) | 9 (15.79) |
Psychological well-being | 32 (56.14) | 25 (43.86) | |
Peers & social support | 32 (56.14) | 25 (43.86) | |
Autonomy & parents | 32 (56.14) | 25 (43.86) | |
School environment | 45 (78.95) | 12 (21.05) | |
SDQ | Prosocial behavior | 50 (87.72) | 7 (12.28) |
Emotional symptoms | 54 (94.74) | 3 (5.26) | |
Conduct problems | 49 (85.96) | 8 (14.04) | |
Hyperactivity/inattention | 52 (91.23) | 5 (8.77) | |
Peer relationship problems | 52 (91.23) | 5 (8.77) | |
ICG | 43 (75.44) | 14 (24.56) | |
CROPS | 42 (73.68) | 15 (26.32) |
SDQ: Strength and Difficulties Questionnaire, ICG: Inventory of Complicated Grief, CROPS: Child Report of Post-traumatic Symptoms
Result from generalized linear models evaluating the impact of quality of life in the area of autonomy & parental relationship, posttraumatic negative beliefs and difficulties on ICG
Variables | Subcategory | Coef. | Robust SE | p | 95% CI |
---|---|---|---|---|---|
Sex | M | 0.000 | (reference) | ||
F | 0.021 | 0.185 | 0.910 | -0.342–0.384 | |
Birth year | 1998 | 0.000 | (reference) | ||
1997 | 0.096 | 0.237 | 0.686 | -0.369–0.561 | |
1999 | 0.884 | 0.327 | 0.007 | 0.244–1.524 | |
LITE-C | 0.007 | 0.026 | 0.790 | -0.043–0.057 | |
KIDSCREEN-27 | Physical well-being | 0.015 | 0.037 | 0.692 | -0.058–0.088 |
Psychological well-being | -0.003 | 0.022 | 0.883 | -0.046–0.039 | |
Peers & social support | 0.019 | 0.042 | 0.647 | -0.063–0.102 | |
Autonomy & parents | -0.051 | 0.024 | 0.032 | -0.098–-0.004 | |
School environment | 0.011 | 0.028 | 0.702 | -0.044–0.065 | |
FACES | Cohesion | -0.013 | 0.033 | 0.696 | -0.077–0.051 |
Adaptability | 0.020 | 0.029 | 0.488 | -0.037–0.078 | |
PTD-PTNB-PTSS | Peritraumatic dissociation | 0.000 | 0.040 | 0.998 | -0.078–0.078 |
Post-traumatic negative beliefs | 0.030 | 0.017 | 0.074 | -0.003–0.063 | |
Post-traumatic social support | -0.003 | 0.057 | 0.964 | -0.114–0.109 | |
SDQ | Difficulties | 0.017 | 0.016 | 0.295 | -0.015–0.049 |
Strengths | 0.125 | 0.079 | 0.113 | -0.030–0.279 | |
CROPS | 0.030 | 0.013 | 0.017 | 0.005–0.054 | |
AIC=9.759; BIC=128.680 |
AIC: akaike information criterion, BIC: bayesian information criterion, LITE-C: Lifetime Incidence of Traumatic Events for Student, FACES: Family Adaptability and Cohesion Evaluation Scales, PTD-PTNB-PTSS: Peritraumatic dissociation-Post-Traumatic Negative Beliefs-Post-Traumatic Social Support, SDQ: Strength and Difficulties Questionnaire, CROPS: Child Report of Post-traumatic Symptoms