Using Vignette Methodology as a Tool for Exploring Cultural Identity Positions of Language Brokers

Evaluating the validity of depression-related stigma measurement among diabetes and hypertension patients receiving depression care in Malawi: A mixed-methods analysis

Mental illness stigma research is sparse in Malawi. Our team previously analyzed the reliability and statistical validity of a quantitative tool to measure depression-related stigma among participants with depressive symptoms using quantitative psychometric methods. This analysis aims to further evaluate the content validity of the stigma tool by comparing participants' quantitative responses with qualitative data. The SHARP project conducted depression screening and treatment at 10 noncommunicable disease clinics across Malawi from April 2019 through December 2021. Eligible participants were 18-65 years with depressive symptoms indicated by a PHQ-9 score ≥5. Questionnaires at each study timepoint included a vignette-based quantitative stigma instrument with three thematic domains: disclosure carryover (i.e., concerns about disclosure), treatment carryover (i.e., concerns about external stigma because of receiving depression treatment), and negative affect (i.e., negative attitudes about people having depression). Sub-scores were aggregated for each domain, with higher scores indicating greater stigma. To better understand participants' interpretation of this quantitative stigma questionnaire, we asked a subset of six participants a parallel set of questions in semi-structured qualitative interviews in a method similar to cognitive interviewing. Qualitative responses were linked with participants' most recent quantitative follow-up interviews using Stata 16 and NVivo software. Participants with lower quantitative stigma disclosure sub-scores had qualitative responses that indicated less stigma around disclosure, while participants with higher quantitative stigma sub-scores had qualitative responses indicating greater stigma. Similarly, in the negative affect and treatment carryover domains, participants had parallel quantitative and qualitative responses. Further, participants identified with the vignette character in their qualitative interviews, and participants spoke about the character's projected feelings and experiences based on their own lived experiences. The stigma tool was interpreted appropriately by participants, providing strong evidence for the content validity of the quantitative tool to measure these stigma domains.

"Thandi should feel embarrassed": describing the validity and reliability of a tool to measure depression-related stigma among patients with depressive symptoms in Malawi

PURPOSE

There are no validated tools in Malawi to measure mental health stigma. Accordingly, this study evaluates the validity and reliability of a short quantitative instrument to measure depression-related stigma in patients exhibiting depressive symptoms in Malawi.

METHODS

The SHARP study began depression screening in 10 NCD clinics across Malawi in April 2019; recruitment is ongoing. Eligible participants were 18-65 years, had a patient health questionnaire (PHQ-9) score ≥ 5, and were new or current diabetes or hypertension patients. Participants completed a baseline questionnaire that measured depression-related stigma, depressive symptoms, and sociodemographic information. The stigma instrument included a vignette of a depressed woman named Thandi, and participants rated their level of agreement with statements about Thandi's situation in nine prompts on a 5-point Likert scale. Inter-item reliability was assessed with Cronbach's alpha. Exploratory factor analysis (EFA) was used to assess structural validity, and OLS regression models were used to assess convergent and divergent validity between measured levels of depression-related stigma and covariates.

RESULTS

The analysis of patient responses (n = 688) to the stigma tool demonstrated acceptable inter-item reliability across all scales and subsequent subscales of the instrument, with alpha values ranging from 0.70 to 0.87. The EFA demonstrated clustering around three domains: negative affect, treatment carryover, and disclosure carryover. Regression models demonstrated convergence with several covariates and demonstrated divergence as expected.

CONCLUSION

This study supports the reliability and validity of a short stigma questionnaire in this population. Future studies should continue to assess the validity of this stigma instrument in this population.

The Contact Zone and Dialogical Positionalities in “Non-Normative” Childhoods: How Children Who Language Broker Manage Conflict

This article examines the processes by which different dialogical positionalities are taken in the contact zone. The contact zone provides a framework for the consideration of potential confrontations and uncertainties during intercultural contacts between migrant children, their family, and another adult. The other adult is usually someone in a position of authority. For young people who language broker, managing the uncertainties and confrontations of conflictual situations highlighted three positionalities: (a) “conflict avoider,” (b) “the neutral or passive broker,” and (c) the “active broker.” The contact zone was a sphere of experience that opened up possibilities for agentic action as well as constraints. The contact zone had the potential to foreground different aspects of their status such as “the child,” “the immigrant,” or the second-language speaker. Equally, the young people took opportunities to utilize these statuses as part of their dialogical positionalities to get the best outcome for them and/or their families. We argue that further exploration of the contact zone within the framing of dialogical positionalities can enable better understanding of critical cultural-development childhoods.